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A predetermination, also called a pre-treatment estimate, is a voluntary claim-shaped inquiry sent before treatment. The payer returns an estimate of coverage for the proposed work. It does not guarantee payment. A preauthorization is different because some payers require it before specified procedures are payable.

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Prerequisites

  • Benefits verified, with the full breakdown; see Verify eligibility and benefits
  • A PMS field where the predetermination or preauthorization number lives
  • An attachment workflow for radiographs, periodontal charting, and narratives; see Dental attachments

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Predetermination vs preauthorization

A predetermination is adjudicated at the date of service, not the date of the estimate. Final payment reflects eligibility, the remaining annual maximum, frequency limits, and coordination of benefits when the work is performed.1 If a patient uses 800ofa800 of a 1,500 maximum between the estimate and crown seat, the final payment may differ substantially. Submit predeterminations close to the planned treatment date and identify the response as an estimate in the written financial consent.
Missing a required preauthorization can make the service unpayable. There may be no adjudication error to appeal, and Medicaid patients generally cannot be billed for the service. Record which payers require preauthorization and for which procedures before treatment begins.

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When to submit a predetermination

For high-cost, documentation-heavy work where the coverage answer changes the patient’s decision: crowns, periodontal surgery, fixed and removable prosthodontics, implants, and orthodontics. The ADA’s guidance frames predetermination as the tool for producing a reliable patient cost estimate on exactly this class of work.1 You may not need a predetermination for routine restorative work on a verified plan. The response can take weeks, while a complete benefits verification may already answer the coverage question. Set criteria so staff do not delay every filling by default.

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What to attach

The predetermination is the same 837D (or 2024 ADA claim form) with the predetermination/preauthorization indicator marked, and it adjudicates on its documentation:2
  • Radiographs: current periapicals or bitewings showing the tooth in question, with a prior full-mouth series where replacement rules apply
  • Periodontal charting: pocket depths for periodontal surgery and scaling and root planing
  • Narrative: why the crown was selected instead of a filling, the date and history of the existing restoration, and any trauma or fracture documentation
  • Intraoral photos where they support the request
Send what the payer will demand anyway. A predetermination that comes back “additional information requested” bought you a second round trip instead of an answer.

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Steps

1

Build the per-payer requirements list

For each payer, record which procedures require preauthorization, which merit predetermination, and what documentation is expected. Start with Medicaid administrators and DHMOs. Review the matrix at least yearly and whenever a payer changes its manual.
2

Trigger the submission when treatment is planned

Send the predetermination after diagnosis while the patient is considering treatment. Time it so the response remains current on the planned treatment date.
3

Submit the marked 837D with the documentation attached

Through your clearinghouse like any other claim, attachments riding with it.
4

Track it to an answer

Keep a log with the patient, procedures, payer, submission date, status, and response amount. For preauthorizations, also record the approval number and validity window. Follow up before scheduled treatment.
5

Present the estimate to the patient with the caveat

Put the coverage estimate, expected downgrade treatment, remaining maximum, and projected patient share in writing. State that the final benefit is determined at the date of service.
6

Capture the number in the PMS structured field

The approval or reference number must reach the field the claim pulls from, so it rides the 837D. A number living only in a sticky note or clinical note is a denial waiting to adjudicate.
7

Re-verify at the date of service

Recheck eligibility and the remaining maximum, especially if several weeks have passed. For preauthorizations, confirm that the validity window covers the treatment date. An expired approval may be treated the same as no approval.

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Verify it worked

  • Per-payer list distinguishes required preauth from optional predetermination
  • Predeterminations submitted for major work, timed near treatment
  • Documentation attached on first submission
  • Tracking log with validity windows
  • Patient estimates carry the date-of-service caveat in the financial consent
  • Numbers in the structured PMS field, not the clinical note
  • Eligibility and maximum re-verified at the date of service

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Common failure modes

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Sources

  1. ADA, Pre-authorizations and pre-treatment estimates. A predetermination is optional and not a guarantee; final adjudication applies eligibility and the remaining maximum at the time of service. California Dental Association, preauthorization versus predetermination.
  2. The 837D carries a predetermination/preauthorization request indicator; see CDT & the 837D for the transaction detail.
Last modified on August 21, 2026