Pre-Determination of Benefits
Pre-determination of benefits is the process of submitting a treatment plan or cost estimate to your insurance provider before receiving care to confirm how much of the expense will be covered. This step helps you understand your expected reimbursement and out-of-pocket cost before proceeding with services that may be costly or complex.
How It Works
A pre-determination of benefits is a form or letter sent from your medical or treatment provider to your insurer before you undergo treatment, allowing the insurer to review the proposed treatment and determine how much will be reimbursed by your plan. For a dental predetermination, your dental office completes either an electronic or paper dental claim form with the treatment plan estimate and clearly marks the form as a predetermination request, and may submit supporting documentation and dental x-rays through the insurer's portal. After the dentist submits the treatment plan, the insurer sends both the patient and the dentist a confirmation detailing the treatment plan, what the benefits pay, and an out-of-pocket estimate.
Submitting a pre-determination is not a claim, so it does not reduce your annual maximum. It simply provides clarity before you commit to treatment. Submitting one also gives the insurer notice of your pending claim, which can save time in the adjudication process, result in a shorter waiting period and quicker payment, and help you avoid surprise out-of-pocket expenses.
Example:
Before getting a crown, your dentist submits a treatment plan to your insurer marked as a predetermination, along with x-rays and supporting documentation. The insurer reviews your eligibility and remaining coverage and sends both you and your dentist a confirmation showing the portion your plan will reimburse and the share you would owe, letting you decide whether to proceed or discuss alternatives. Because it is not a claim, it does not draw down your annual maximum.
What to Watch For:
Pre-determination is most common for major dental procedures such as crowns, bridges, dentures, and orthodontics, but it may also apply to expensive medical equipment or surgeries under extended health coverage. Requesting a pre-treatment estimate from your provider before complex procedures is recommended to avoid unexpected bills. Note that some programs require it: under Health Canada's First Nations and Inuit Health Non-Insured Health Benefits (NIHB) program, certain dental services require predetermination (prior approval), and clients can contact the NIHB Dental Predetermination Centre to determine what is covered.
