A pre-determination of benefits (or pre-treatment estimate) is a helpful tool that allows you and your patient to know estimated benefits, eligibility and financial responsibility in advance of completed treatment. We encourage pre-determinations for extensive treatments like implants, TMJ, prosthetic and orthodontic procedures, veneers, crowns, gold restorations, surgical periodontics, endodontics, and oral surgery (except for simple extraction of a single tooth.)
Requests for pre-determinations are made by submitting a proposed treatment the same way you would a regular claim (excluding the dates of service and the dentist’s signature). You can also easily submit a pre-determination online through your dentist account. For step-by-step instructions on how to submit claims/pre-d's online, visit the Quick Links: Documents & Dentist Handbook section to access the Dentist Briefcase. Pre-determinations are valid for 6 months.
A Treatment Plan with Multiple Treatment Options
When submitting pre-determinations with multiple treatment options for your patient, submit each different treatment option on a separate claim form so that each pre-determination is processed independently. It is helpful to add comments in the remarks section, box #35, of the claim form noting treatment option #1, treatment option #2, etc. When you receive your pre-determinations back from us, you should see reference code 937 – Multiple treatment plans were submitted. Please note only one of the treatment plans received will be allowed.
A Treatment Plan with Multiple Sequential Phases
In order for a treatment plan with multiple phases to process chronologically, submit the different phases of the treatment plan on separate claim forms indicating the phase number in the remarks section, box #35 (i.e. Phase 1 of 3, Phase 2 of 3, etc.). If you submit a multi-phase treatment all on one claim form, the procedures will automatically reorganize in numerical order by ADA codes instead of the intended treatment order.
If the services are performed prior to the pre-determination expiration date, you can add the service date(s), sign and return the predetermination form to Delta Dental for payment. You can accomplish this by submitting the pre-determination as an in-for-payment claim to firstname.lastname@example.org. If submitting through your clearinghouse, include the original valid pre-d number in remarks box #35 to reference the approved pre-d. This will expedite payment.
If a new claim is submitted (electronic or paper), it is subject to the normal processing procedures including requests for attachments such as radiographs, chart notes or a written rationale.
Following these helpful tips should lead to a more efficient and accurate predetermination experience for your office. For more information, please check out the Delta Dental Participating Dentist Handbook by logging in to your dentist account at DeltaDentalKS.com.