Predetermination
A predetermination is a payer's advance, usually non-binding review of whether a service would be covered — an estimate of coverage rather than a required approval.
Updated
A predetermination is a voluntary request asking a payer, before a service, how it would likely be covered under the plan. It commonly returns an assessment of coverage and expected patient responsibility, and it is frequently described by payers as non-binding — an estimate, not a guarantee of payment.
It is most often used for elective or higher-cost services where the practice and patient want a coverage read in advance, and for services where coverage is uncertain but prior authorization is not mandatory.
In practice
The distinction that matters is binding versus advisory. A required prior authorization, once obtained, is the payer's advance approval to proceed; a predetermination is guidance that can still be overtaken by the facts on the actual claim — eligibility on the date of service, medical necessity as documented, and the plan terms in effect. Whether a given payer offers predeterminations, and how much weight its response carries, is set in that payer's own policy.
Commonly confused with
- Prior authorization: Prior authorization is a required approval a payer can deny; a predetermination is usually a voluntary, non-binding estimate of coverage.
- Eligibility verification: Eligibility verification confirms that coverage is active; a predetermination asks how a specific service would be covered under that coverage.