predetermination

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predetermination

Managed care A requirement for prior approval from a health insurer before it will pay for a proposed treatment. See Red tape rationing.

pre·de·ter·mi·na·tion

(prē'dĕ-tĕr'mi-nā'shŭn)
Determination of the reimbursement amount from a third-party payor before a health care service is performed. It does not guarantee coverage.

pre·de·ter·mi·na·tion

(prē'dĕ-tĕr'mi-nā'shŭn)
Determination of the reimbursement amount from a third-party payor before a health care service is performed. It still does not guarantee coverage.

predetermination,

n an administrative procedure whereby a dental professional submits a treatment plan to the carrier before treatment is initi-ated. Then the carrier returns the treat-ment plan, indicating the patient's eligibility, covered service amounts payable, application of appropriate deductibles, copayment factors, and maximums. Under some programs, predetermination by the carrier is required when covered charges are expected to exceed a certain amount, commonly $100. Also known as
preauthorization, precertification, preestimate of cost, and
pretreatment estimate.