Preauthorization vs. predetermination: what dental clinics should know
Predetermination and preauthorization sound alike and often get swapped. They answer different questions, and sending the wrong one costs a clinic a round trip. Here’s how to tell them apart.
Two different questions
Predetermination and preauthorization sound alike but answer different questions: predetermination asks what a plan would pay; preauthorization asks whether the treatment may proceed before the plan pays.
Predetermination: the estimate
A predetermination gives the patient an idea of coverage in advance — what the plan would contribute and what the patient may owe. The clinic submits the treatment plan and gets a coverage estimate back before treatment starts.
Some plans use specific words for this step, and some regulate when a clinic may charge a fee for preparing one, so local and payer rules still apply.
Preauthorization: the approval in advance
Preauthorization is the go-ahead for the treatment itself. The clinic sends the clinical picture — plan, narrative, records — and the plan approves it before work begins. Under the CDCP and other plans, treatment preauthorization is required for some treatments before the plan pays.
Why the distinction matters to clinics
Sending the wrong one costs time: an estimate where a decision was needed, or a request where the plan wanted a review first. Knowing which question the plan is asking keeps requests — and paperwork — moving.
A few quick answers
Is a predetermination required before preauthorization?
Not always. Different plans handle the two differently; the clinic’s payer rules decide which step applies to a given treatment.
Do patients see the difference?
They experience it as the plan’s coverage decision. For the clinic the practical difference is which file to prepare and which process to run.
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