Before sending claims for certain treatments, some dental plans need dentists to receive preauthorization, which “provides written advance approval for the planned service, which is generally valid for 60 days” (“Dental Benefits 101: Preauthorization versus predetermination” 2017). Some dental insurance policies may require additional elements for preauthorization, such as diagnostic notes, radiographs, codes, x-rays, periodontal charting, narratives, etc. (“Dental Benefits 101: Preauthorization versus predetermination” 2017; Tekavec 2000; “The Importance of Getting Preauthorization” 2015). Otherwise, insurance companies could deny the claims (“Dental Benefits 101: Preauthorization versus predetermination” 2017). Although dentists must fulfill an extra step for claim approval, depending on the insurance policy, preauthorizations may guarantee coverage for patients.
Some insurance companies require preauthorizations for a variety of reasons. Preauthorizations allow dental plans to check whether the procedures “are medically necessary” and may recommend other treatments and services, instead (“Dental Benefits 101: Preauthorization versus predetermination” 2017). Some treatments that require preauthorization include those categorized under “major,” scaling, root planning, etc. (“The Importance of getting Preauthorization” 2015). Though, Melissa Dunham, “owner of Reign Dental Accounts Control LLC and the office administrator at the Centre for Dental Excellence in Virginia Beach,” recommends “that all treatment plans, excluding prophies, perio maintenance, and films, should be preauthorized for the protection of the office income and to assist patients in making informed financial decisions regarding treatment” (Tuinei 2018). Without preauthorization, the patient loses coverage, regardless of whether the procedure is an included benefit in his or her policy (“The Importance of getting Preauthorization” 2015).
Preauthorizations may help patients receive coverage, depending on the policy and state. Not all health plans provide coverage after giving preauthorization to dentists, but depending on their state, such as California, they must give coverage for any preauthorized treatments (“Dental Benefits 101: Preauthorization versus predetermination” 2017; Tuinei 2018). Due to these state laws, many insurance companies omit preauthorization requirements from their policies (Jolly 2018). Plans that do need them usually include “Medicare, Medicaid, or managed care plans…” (Jolly 2018). Despite preauthorization, dental plans may not provide coverage in cases where the beneficiary leaves the plan before the treatment date, the beneficiary ran out of his or her annual maximum limit, or “other factors such as subsequent claims for the same procedure from a different provider” (“Dental Benefits 101: Preauthorization versus predetermination” 2017). Despite these caveats, they can still predict coverage and the patient’s financial responsibility (“Dental Benefits 101: Preauthorization versus predetermination” 2017; Tekavec 2000). They can also include information regarding “[plan] limitations (noncovered services), patient out-of-pocket costs, downgrades, and exclusions…” (Tuinei 2018).
Preauthorizations could lead to more approved and reimbursed claims, increased treatment plan acceptance, more guaranteed payments, etc. (Tuinei 2018). Even though many insurance companies may not need preauthorizations anymore, preauthorizations can still help patients gain coverage in order to access and pay for any necessary dental treatments and services.
Works Cited
“Dental Benefits 101: Preauthorization versus predetermination.” cda, July 5, 2017.
https://www.cda.org/news-events/dental-benefits-101-preauthorization-versus-predetermination.
Jolly, Sheri. “Pre-Authorization vs. Predetermination.” dentaltown, February 2, 2018.
https://www.dentaltown.com/blog/post/8738/pre-authorization-vs-predetermination.
Tekavec, Carol. “Preauthorizing inlays, onlays.” Dental Economics, April 1, 2000.
https://www.dentaleconomics.com/articles/print/volume-90/issue-4/departments/dental-insurance/preauthorizing-inlays-onlays.html.
“The Importance of Getting Preauthorization.” Monongalia County Health Department,
November 16, 2015. https://www.monchd.org/mchd-dentistry-blog/the-importance-of-getting-preauthorization.
Tuinei, Benjamin. “The art of war: Reducing time spent on insurance administration.” Dental
Economics, November 1, 2018. https://www.dentaleconomics.com/articles/print/volume-108/issue-11/macroeconomics/the-art-of-war-reducing-time-spent-on-insurance-administration.html.
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