Benefits Predetermination

What you need to know

What is a benefit predetermination?

A predetermination of benefits is a form or letter that is sent from your medical or treatment provider to your insurer before undergoing treatment. Your insurer can then review the proposed treatment and determine how much will be reimbursed by your plan.

Why request one?

Whenever you’re about to undergo new or expensive medical treatments or dental procedures, this letter gives you the ability to financially plan ahead.

By receiving a predetermination of benefits response, you can find out how much your treatment will cost, how much your insurance plan will cover, and whether you’ll have any out of pocket expenses.

What to expect

  • request a predetermination of benefits through your medical or dental treatments provider

  • treatments provider will submit a predetermination or claim form listing proposed treatments, tests, or required medical equipment

  • receive a response statement from your insurer outlining the amounts you will be reimbursed for

How do you benefit?

When you submit a predetermination of benefits, your insurer gets notice of your pending claim. Having this information onhand will save time in the adjudication process and can result in a shorter waiting period, and quicker payment of your claim.

You also save your rainy day fund by avoiding surprise out of pocket expenses.

Tip:

If you find that there is a significant disparity between the estimated costs and your reimbursement amounts, you can discuss the issue with your insurer and your treatment provider to see if there are any alternatives for you.