Back to all terms

Pre-Determination of Benefits

Pre-determination of benefits is the process of submitting a treatment plan or cost estimate to your insurance provider before receiving care to confirm how much of the expense will be covered. This step helps you understand your expected reimbursement and out-of-pocket cost before proceeding with services that may be costly or complex.

Pre-determination is most common for major dental procedures such as crowns, bridges, dentures, and orthodontics, but it may also apply to expensive medical equipment or surgeries under extended health coverage. The insurer reviews the proposed treatment, checks eligibility, and responds with a detailed estimate showing what portion will be paid under your plan and what you will owe.

Submitting a pre-determination is not a claim, so it does not reduce your annual maximum. It simply provides clarity before you commit to treatment.

Example:

If your dentist submits a treatment plan for a crown costing $1,200, the insurer may confirm that your plan will cover 50 percent up to $600, letting you know you will be responsible for the remaining $600.

What to Watch For:

Always request pre-determination before major procedures to avoid unexpected costs. Ensure that your dentist or healthcare provider includes diagnostic codes, X-rays, and any supporting information your insurer requires. Approval is based on current eligibility and coverage rules, which may change if the procedure is delayed too long after the estimate.

Related Terms

Paramedical Disciplines

Paramedical disciplines refer to regulated health professionals who provide therapy or rehabilitation services outside of hospital settings. Common examples include physiotherapists, chiropractors, massage therapists, acupuncturists, naturopaths, osteopaths, psychologists, and speech-language pathologists.

Pay-Direct card / Drug card

A pay-direct card, also known as a drug card, is a plastic or digital card issued by your health insurance provider that allows pharmacies to bill your insurer directly for eligible prescription drugs. Instead of paying the full cost upfront and submitting a claim later, you pay only your portion - such as a deductible or coinsurance - at the point of sale.

Per Incident

Per incident refers to the way certain insurance benefits are calculated or limited based on each separate event, illness, or accident rather than by year or lifetime. When a benefit is paid “per incident,” it means you are eligible for reimbursement each time a new, distinct occurrence happens, up to the maximum amount specified for that type of claim.

Per Person / Per Family

Per person and per family describe how benefit limits, deductibles, or maximums are applied within a health or dental insurance plan. A per person limit means the specified amount applies individually to each insured member, while a per family limit represents the total combined coverage for all members under one policy.

Per-Practitioner Annual Maximum (Paramedical)

The per-practitioner annual maximum is the total amount your plan will reimburse for services from one specific type of provider in a single benefit year. For example, if your plan pays up to $500 for massage therapy annually, once that amount is reached, additional treatments from that provider type are no longer covered until the next year.

Have questions about your insurance coverage?

Our licensed advisors can help you understand your options and find the right plan for your needs.

Contact Us