Insurance Predetermination Services

21+

Years of Experience

98%

Claim Submission Accuracy

25%

Decrease in Outstanding AR

Predetermination for Health Insurance for Hassle-Free Coverage Approvals

Insurance predetermination is a review of a patient’s requested medical care to assess its medical necessity and coverage under their insurance plan. It is a key aspect of medical and dental billing.

The predetermination request is usually submitted to the insurance company by a physician. Once the predetermination is received, the patient can make an informed decision about whether they want to proceed with the treatment, or discuss alternate options with their physician/dentist. Our expert team helps physicians navigate the complexities of the medical and dental insurance predetermination process.

What is Insurance Predetermination?

Insurance predetermination is a review process where details of a proposed medical or dental procedure are submitted to the insurance company before treatment. This determines if the procedure meets medical necessity requirements and is likely to be covered. If approved, the insurance payment and the patient’s financial responsibility are confirmed in advance, helping avoid coverage surprises. However, predetermination does not guarantee final approval.

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Why Predetermination Matters

Reduces denials

By verifying coverage in advance, we help prevent denials or underpayments that may arise from lack of authorization or insufficient documentation.

Ensures financial clarity

Patients are given upfront visibility into their insurance coverage and potential costs, allowing them to make better and more informed decisions.

Speeds up the revenue cycle

With prior approval or clarification, your practice can avoid delays in payments, leading to quicker reimbursements and smoother financial operations.

Enhances patient satisfaction

By offering a clear and transparent process, you reduce patient anxiety about unexpected costs, helping to build trust and satisfaction.

Simplifying the Insurance Predetermination Process

With years of experience in the medical and dental revenue cycle management space, our team understands the complexities of insurance predetermination across a wide range of providers. We specialize in both medical and dental insurance predetermination processes, ensuring that each service is thoroughly reviewed and documented for optimal coverage.

Predeterminations for health insurance and dental insurance is easier with expert support. We streamline the process to help ensure that patients’ procedures are covered by their insurance providers, reducing the likelihood of payment delays and unexpected costs. Our expert team works closely with healthcare providers to assess medical necessity, confirm coverage, and provide clarity before services are rendered.

Simplifying the Insurance Predetermination Process

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We serve all 50 states

Steps in the Predetermination Process

The key steps are as follows:

1

Insurance Eligibility Verification

2

Pre-determination Request Submission

3

Request
Review

4

Decision
Notification

5

Service Delivery and Payment Collection

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Insurance Eligibility Verification

We first verify the patient’s insurance coverage and eligibility for the proposed medical service.

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Pre-determination Request Submission

We help the provider submit a detailed request to the insurance company, including the diagnosis, treatment plan, and estimated costs.

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Request Review

The insurance company evaluates the request, typically by consulting medical professionals or reviewing records to determine the medical necessity of the service.

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Decision Notification

After making a decision, the insurance company informs both the provider and patient about the coverage and approved payment amount.

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Service Delivery and Payment Collection

Once the pre-determination approved, the provider delivers the service and bills the insurance company. The patient is responsible for any remaining balance not covered by insurance.

Predetermination of Medical and Dental Insurance Benefits: How We Can Help

Navigating insurance predeterminations can be complex. Our team simplifies the process and ensures you understand patient coverage before providing treatment.

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Thorough coverage review

We verify your patient’s insurance policy to ensure that the proposed services or treatments meet the requirements for coverage.

Predetermination of Medical and Dental Insurance Benefits: How We Can Help

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Medical necessity assessment

Our team works closely with your office to ensure that each procedure is backed by appropriate clinical documentation, meeting the insurance company’s medical necessity criteria.

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Timely submissions

We promptly submit predetermination requests to insurers, ensuring you get a timely response to avoid treatment delays.

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Clear communication

We provide clear, detailed responses from the insurance company, outlining the coverage decision and any specific conditions or limitations.

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Cost transparency

Our process helps clarify potential out-of-pocket costs for patients, reducing the risk of financial surprises.

Medical and Dental Procedures that May Need Predetermination

Medical Procedures

Surgical Procedures:

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Bariatric surgery (e.g., gastric bypass, sleeve gastrectomy)

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Orthopedic surgeries (e.g., joint replacement, spinal fusion)

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Reconstructive surgeries (e.g., breast reconstruction after mastectomy)

Advanced Diagnostic Tests:

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MRI, CT scans, and PET scans

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Genetic testing for hereditary conditions

Therapies and Treatments:

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Chemotherapy and radiation therapy

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Infertility treatments (e.g., IVF)

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Specialized injections (e.g., Botox)

Medical Devices and Equipment:

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Durable medical equipment (e.g., wheelchairs, CPAP machines)

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Prosthetic devices and implants

Dental Procedures

Major Restorative Work:

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Crowns, bridges, and dentures

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Full-mouth reconstruction

Orthodontic Treatments:

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Braces (metal or clear aligners)

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Palate expanders

Periodontal and Surgical Treatments:

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Dental implants

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Bone grafts and sinus lifts

Cosmetic Procedures (if covered):

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Veneers (if deemed medically necessary)

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Teeth whitening (rarely covered)

Flexible Pricing Plans Tailored to Your Needs

Full-Time Equivalent

In this model, services are billed based on the equivalent cost of a full-time employee (FTE) for a specified duration, usually monthly or annually.

Per Verification Billing

Like an FTE model, a person is dedicated to your practice. Perfect for a practice that is busy. They work as an extension to your business.

FTE/Per Verification Billing

This option is ideal for a practice that is unsure about their work requirements. This can have per request pricing for eligibility and other functions.

AR is only FTE

In this model, you will be charged a fixed monthly or annual fee based on the number of full-time equivalent staff required to manage your practice’s AR follow-up activities.

Get Started Today

Our insurance predetermination services are designed to ensure smooth and timely approvals for your patient’s treatments. We also provide comprehensive support for medical and dental insurance eligibility verification and prior authorizations. Our services are designed to allow you to focus on providing top-quality care without worrying about insurance coverage issues.

Healthcare and Dental Revenue Cycle Management Process

Ensure Accurate and Smooth Insurance Predeterminations

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FAQs

What is insurance predetermination?

It is a process where healthcare providers submit details of a proposed medical or dental procedure to the insurance company before treatment. This helps determine if the procedure is covered, the approved payment amount, and the patient’s financial responsibility.

Is predetermination the same as prior authorization?

No, predetermination is an estimate of coverage and costs, while prior authorization is a mandatory approval required before certain treatments can be performed.

Does predetermination guarantee insurance coverage?

No, predetermination provides an estimate but does not guarantee payment. Final coverage depends on the insurance company’s policies at the time of claim processing.

Why is insurance predetermination important?

It helps patients and providers understand expected coverage, reducing unexpected costs and billing disputes.

How long does the process take?

Processing times vary by insurance company but typically range from a few days to several weeks, depending on the complexity of the procedure.

What information is needed for a predetermination request?

The request usually includes patient details, insurance information, procedure codes, diagnosis, treatment plan, and estimated costs.

Who is responsible for submitting the predetermination request?

Healthcare providers usually handle submission, but patients should verify with their provider that the request has been made.

Can a patient request a predetermination directly?

Some insurance companies allow patients to request predeterminations, but it is generally done by the healthcare provider.

What happens if a procedure is denied after predetermination?

If a procedure is denied, patients can appeal the decision or explore alternative treatment options recommended by their provider.

Does predetermination apply to all medical and dental procedures?

No, it typically applies to more complex, costly, or elective procedures where coverage may be uncertain. Patients should check their insurance policy for specific requirements.