Dental Predetermination and Prior Authorization Workflows

Do not treat an estimate as a payment guarantee

A pre-treatment response can help an office and patient understand anticipated benefits, but coverage can still depend on eligibility, plan limits, treatment actually performed, documentation, and other plan rules at the time of service.

Keep the response with the treatment record

Retain authorization or predetermination reference numbers, dates, plan responses, requested attachments, and any conditions. When the final claim is prepared, compare the completed treatment with what was previously submitted or approved.

Update the claim when treatment changes

If the actual procedure, tooth, date, or treatment plan differs from the pre-treatment request, do not blindly copy the earlier record into the final claim.

Dental-claim review

• Distinguish a predetermination/preauthorization request from a claim for completed services.
• Keep the payer’s response and authorization number with the treatment record.
• If the treatment plan, dates, provider, or coverage changes, confirm whether a prior determination still applies.

Sources and verification

Use the ADA source below for the current 2024 Dental Claim Form and completion guidance, together with the dental plan’s requirements.

• American Dental Association: 2024 ADA Dental Claim Form

Related guides

• Diagnosis Information on Dental Claims
• What Is the 2024 ADA Dental Claim Form?
• Patient Information on the ADA Dental Claim Form