What is a Pre-Determination of Benefits?

A pre-determination of benefits is an estimate from your dental insurance company of how much it will pay for a proposed dental procedure. It will also specify your share of the costs.

The insurance company will send it to you and your dentist before the proposed dental treatment starts.

Knowing in advance how much you will need to pay out-of-pocket will help you budget for dental procedures and decide how to proceed with treatment. 

Examples:

• After recommending that you get a crown, your dentist submits a pre-determination request to your insurance company detailing the proposed treatment and estimated costs. Your insurance company will review the request and issue a pre-determination of benefits that outlines what portion of the treatment will be covered and any out-of-pocket expenses for you.
• Make sure you receive a written (or digital) pre-determination of benefits prior to your dental treatment so you know what portion of the cost you will be responsible for.

FAQs

• Is a pre-determination of benefits a guarantee of payment? No, it’s an estimate and not a guarantee.
• Can my dentist tell me how much a recommended dental treatment will cost? Your dentist will probably not know all the details of your dental plan, including your deductible and annual maximum, so his/her estimate might be inaccurate.
• Can I get the recommended dental treatment even though I haven’t received the pre-determination of benefits? You can, but you won’t know in advance how much the insurance is likely to cover and how much you will have to pay out of pocket. A lot of people don’t like this uncertainty and might not have budgeted their co-insurance. If the date of your recommended dental treatment approaches and you haven’t received the pre-determination of benefits, contact your insurance’s customer service department.
• Is a pre-determination of benefits the same as an explanation of benefits? No. An explanation of benefits is a statement from your insurance company that details the costs it paid for the dental services you already received.

Example of a Pre-Determination of Benefits

This flowchart shows the steps from your dentist’s pre-determination request to your receipt of the estimate.

Delta Dental of Arkansas Offers Dental and Vision Insurance for Individuals and Groups

Are you interested in our dental coverage plans so you don’t have to pay the full dentist bill yourself? Check out our insurance options for individuals and families, and small, mid-size and large groups.

And while you’re browsing, take a look at our vision insurance, too.

More Dental Insurance Terms Explained

1. What is a premium?
2. What is a waiting period?
3. What is a network dentist?
4. What is a benefit period?
5. What are preventive/diagnostic, basic and major dental procedures?
6. What is a deductible?
7. What is a copay?
8. What is co-insurance?
9. What is an annual maximum?
10. What is a claim?
11. What is an explanation of benefits (EOB)?
12. What is a pre-determination of benefits?
13. What are out-of-pocket expenses?

Back to Dental Insurance Terms Explained: A Quick Guide

Are there additional dental insurance terms you’d like us to add to this series?

Email your requests to marketing@deltadentalar.com.