Dental Plans: Pre-determination

Click on the questions below for the answer.

What is a pre-determination?

A pre-determination is an estimate of what treatment your dental plan will cover and what you will be responsible for. Your dental office will submit an outline of the proposed treatment to your dental plan provider prior to proceeding with treatment. It is an estimate only and does not guarantee the final costs you will be responsible for paying.

It is important for you to be well informed on your plan coverage. Check with your dental plan provider to clarify when a pre-determination is required. Some plans may only reimburse some services if a pre-determination is received in advance of treatment. Also be aware that pre-determinations may be valid for a limited time; what is covered can change if you reach the financial limits of your plan; and/or other changes can occur to your plan before treatment is completed.

The final treatment coverage is determined by your dental plan carrier. Any costs not covered are your responsibility.

My dental office tried to get a pre-determination for treatment; why did my dental plan provider decline it?

There are many reasons why a pre-determination may be declined. You may have reached the coverage limits in your plan or the treatment outlined may not be covered by your plan—the treatment plan is based on your health needs, not your plan coverage.

It is important to understand that even if a pre-determination is approved, this is not a guarantee of coverage. Any costs not covered are your responsibility to pay. Review your plan coverage, and speak to your dental plan provider if you have any concerns.

What can I do to avoid any unforeseen dental costs?

Understand your dental plan. Know what coverage you have so that you can make informed decisions on what dental treatment services are covered and what treatment costs you are responsible for. Speak to your dentist about the treatment options and the importance to your health so you can make an informed choice for your health needs.

Your dental office can work with you to provide an estimate and obtain a pre-determination prior to proceeding with treatment; however, they are not experts on your plan. Ensure you are aware of any changes and/or limits to your coverage and have let your dental provider know.

Prevention is the best way to maintain good dental health and reduce the need for more costly and complex treatment in the future. Practice good oral hygiene at home and visit the dentist regularly to identify issues early.