Health · Chapter 13 · Dental
Predetermination of Benefits
Definition
A review — also called pre-certification or prior authorization — conducted to determine whether proposed services are medically necessary and covered, the approved amount, and the patient's financial responsibility. It does NOT authorize the procedure. Skipping it doesn't void coverage — services may still be covered, but neither dentist nor insured will know the benefit amount in advance.
In plain English
A price-and-coverage preview, not a permission slip.
Exam tip
⚠️ Trap answer: predetermination does NOT approve/authorize the procedure, and non-precertified services can still be covered.
Easy to confuse with
These are what this term gets tested against — if you can't tell them apart cold, drill the contrast.
Related terms