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Predetermination of Benefits

Why it is best

In situations that require expensive medical or dental procedures – or perhaps even the purchase of specialized equipment – it is always best to know upfront how much of the cost will be covered by your insurance plan and how much you could pay out of your own pocket. When possible, it’s never a good idea to assume that a certain expense may be covered under your plan without confirmation from your insurer.

How to get Predetermination of Benefits…

This information is easily obtained via predetermination of benefits, a process which allows you to review projected costs and reimbursement levels with your insurer beforehand, letting you make informed decisions.

It all starts with submitting to your insurance company a statement listing proposed treatments, tests, or required medical equipment. Within a few weeks, the insurance company will generally respond with a statement of the amount of reimbursement the company typically provides for the treatments, tests, or equipment in question.

How this will benefit you…

The predetermination of benefits process can assist you in all non-emergency situations involving significant costs, including elective surgeries, expensive medical testing, and the outright purchase of medical equipment. Taking advantage of the predetermination of benefits process safeguards against a scenario that sees you caught between the medical provider and the insurer.

If through predetermination you find that there will be a significant disparity between estimated costs and reimbursement levels, you will still have the chance to discuss the issue with both your insurer and your medical practitioner to arrive at a favourable resolution.

How this will benefit your insurance provider…

Predetermination of benefits not only has advantages for the insured, but for the insurance provider as well. When predetermination of coverage is applied, the insurance provider has prior notification of your pending claim – this saves time and resources that would otherwise be spent on claim adjudication after the fact. This also means that you, the insured, will not suffer long waiting periods after your procedure for your adjudication because your insurer already possesses all the information necessary to process the claim.


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