Quick Answers: Predetermination and prior authorization are not the same thing, even though patients and even some front-desk teams use the terms interchangeably. A predetermination is a voluntary cost estimate, the insurer tells you what a treatment will likely cost before you commit to it. A prior authorization is a mandatory approval, the insurer confirms coverage before the service happens, and skipping it can mean an outright denial. Confusing the two is one of the most common (and most expensive) mistakes in dental and medical billing.
Have you had to wait several weeks just to find out that your patient’s treatment or crown wasn’t covered? You know how frustrating it is. Here in this blog of I-Med Dental, we will provide clear information about what predetermination and prior authorization really mean and when each of them should be applied to avoid denials and unhappy clients.
What Is a Predetermination?
A predetermination is a request sent to an insurance payer before treatment begins, asking them to estimate what they’ll cover. Your provider submits the treatment plan, procedure codes, tooth numbers (for dental), and fees, and the insurer responds with a written breakdown of covered amounts, patient responsibility, and any exclusions.
It’s essentially a “coverage preview.” Nothing is approved or denied at this stage. It’s an estimate, not a decision.
Key things to know about a predetermination:
- It is usually optional, though most payers recommend it for procedures above a set dollar threshold (commonly $300–$500).
- It typically takes one to two weeks to process, since insurers don’t treat it as urgent.
- Estimates are usually valid for 90 days, after which coverage or eligibility may have changed.
- It is not a guarantee of payment, plan limitations, waiting periods, or a lapse in eligibility can still change the final outcome.
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What Is Dental Predetermination?
Dental predetermination works the same way, but it’s far more common in dentistry than in medical care. Because dental treatment plans (crowns, bridges, implants, orthodontics) often involve significant out-of-pocket costs, both patients and practices want cost clarity before work begins.
Predetermination of a dental procedure involves:
- Patient and subscriber details.
- Procedure codes (CDT codes) and tooth numbers.
- Supporting narrative (e.g., X-ray, periodontal charts, etc.)
- Provider fee for treatment.
The payer reviews the plan and returns an Explanation of Benefits (EOB)-style estimate showing the percentage covered, the patient’s estimated share, and any plan exclusions. This lets the practice discuss financing and treatment options with the patient before the drill ever touches a tooth, which reduces billing disputes and improves case acceptance. Still interested then avail our services which are designed just for you so that you can focus on attending more patients, see what our specialities are.
What Is Prior Authorization?
Prior authorization (also called preauthorization or precertification) is a required approval process. Unlike a predetermination, it isn’t optional when the payer mandates it, treatment provided without it can be denied entirely, leaving the practice or patient to absorb the cost.
Approval/denial of the procedure based on its adherence to the guidelines and policy of medical necessity occurs prior to the delivery of services by the payer. Such prior authorizations occur for:
- MRIs, CT scans, and other expensive imaging
- Surgeries and specialty procedures
- Certain specialty medications
- Oral surgery and Medicaid dental services
Prior authorization is also more consequential when it’s skipped: <br>a missed predetermination just means no cost estimate but a missed required prior authorization usually means a denied claim.
Comparison between predetermination vs prior authorization
| Factor | Predetermination | Prior Authorization |
| Purpose | Assesses cost and insurance cover | Confirms medical necessity and approval |
| Required or optional | Generally optional (suggested) | Mandatory where the plan demands it |
| Decision | Cost projection, not the actual decision | Official approval or rejection |
| Average processing time | 1-2 weeks | 5 to 30 days, depending on the payor/urgency |
| Most common applications | Dental crowns, bridges, implants | Radiology, surgery, specialty medications |
| Not doing so would result in | No cost projection, treatment will still be done | Claim rejected right away |
| Validity period | Usually 90 days | Dependent on the payor and procedure |
| Guarantee of payment? | No | No, still subject to eligibility at time of service |
When Do You Need Each One?
Not every procedure requires the same step. Here’s a quick reference your front desk can use:
| Situation | Action Suggested |
| Expensive dental procedure (crowns, implants, orthodontics) | Ask for predetermination |
| The payer’s plan requires preauthorization for the code | Send prior authorization request |
| Diagnostic imaging (MRI, CT scan) | Prior authorization (almost always required) |
| Routine cleanings, fillings, standard visits | Neither, usually not required |
| Oral surgery under a Medicaid plan | Prior authorization (frequently mandatory) |
| Patient wants to know their out-of-pocket cost in advance | Predetermination |
Rule of thumb: if you’re trying to answer “what will this cost the patient?”, that’s a predetermined goal. If you’re trying to answer “will this be covered at all?”, that’s a prior authorization.
The Dangers of Being Wrong
It is not merely an issue of paper work either. As the following statistics from the latest American Medical Association physician survey show:
- 95% of physicians report that prior authorization impedes access to necessary treatment.
- 79% note that patients stop their prescribed treatment because of problems with authorization.
- 32% indicate that authorizations are often denied.
- On average, physicians and staff spend 13 hours a week on authorization tasks.
For dental and medical practices, mixing up predetermination and prior authorization, or skipping a required authorization altogether, translates directly into unpaid claims, frustrated patients, and hours of rework for your billing team.
Common Mistakes Practices Make
- Tying predetermination to guarantees. It’s an estimate. Coverage eligibility may differ at the time of the estimate from the date of service.
- Confusing “optional” with “don’t do it.” For more costly cases, doing without predetermination usually ends up in billing problems and unhappy patients.
- Failing to meet a prior authorization deadline. Certain payers demand that authorizations be renewed if the start of treatment occurs after a certain time frame.
- Failure to note expiration dates. A three-month-old predetermination may be outdated.
- Relying on verbal confirmation only. Always get authorization and predetermination decisions in writing.
How the Right Billing Partner Makes This Easier
Manually tracking which procedures need a predetermination, which need prior authorization, and where each request stands in the payer’s queue is one of the most time-consuming parts of revenue cycle management. A dedicated billing team can:
- Procedure for flagging authorizations that need approval before scheduling.
- Make pro-active submissions for predetermination of expensive treatment procedures.
- Keep track of authorization and expiry details to avoid any lapse.
- Follow up with payers to reduce turnaround time.
- Appeal denials tied to missed or mishandled authorizations.
If your team is losing hours each week chasing payer responses, that’s usually a sign your authorization workflow needs support, not more staff hours.
Want fewer denied claims and shorter payer turnaround times? Talk to our billing team about how we manage predeterminations and prior authorizations for practices like yours.
Frequently Asked Questions
Is predetermination and prior authorization one and the same thing?
Not necessarily. The former is a voluntary cost estimate, while the latter is a mandatory requirement that needs to be fulfilled before some treatments or else the claim could be rejected.
Will a predetermination guarantee payment?
Not necessarily. It is an estimate according to the current coverage and plan. If any changes occur in eligibility or coverage prior to the date of service, the payment could be different from the estimate.
How long does a dental predetermination take?
Most dental predeterminations return within one to two weeks, though this varies by payer and case complexity.
What happens if I skip a required prior authorization?
The claim is likely to be denied, and the practice or patient may be responsible for the full cost of the service.
Does every insurance plan require prior authorization for the same services?
The answer is no; different insurance providers have different policies, which is why it is important to know the prior authorization policy of each individual patient covered by insurance before conducting an expensive and specialized procedure.
Final Takeaway
In predetermination vs prior authorization, predetermination and prior authorization both address different issues: one determines the cost, while the other determines whether or not a procedure is covered. Thinking that these concepts are equivalent leads practices to denied claims, unhappy patients, and unnecessary write-offs. Implementing a short pre-procedure checklist that consists of verifying insurance eligibility, authorizations rules, and getting predetermination for expensive procedures will protect you from losses on multiple fronts.
If your practice needs help with figuring out when and what kind of approval is needed, schedule a free billing process audit and find where your authorization processes may cause you trouble.
