Key Takeaways
- ⚖️ Prior authorization = required pre-approval for coverage (binding decision)
- 🔮 Predetermination = voluntary coverage estimate (non-binding, informational)
- 📋 Both can be denied, but appeal processes differ slightly
- ✅ Prior auth denials MUST be appealed; predeterminations can be appealed OR ignored
- ⏰ Different timelines: prior auth urgent (72h) or standard (30d); predetermination ~15 days
The Critical Difference
Prior Authorization
Definition:
Required pre-approval from insurance before specific medications, treatments, or procedures will be covered. Doctor CANNOT provide treatment without it (or you pay full cost).
Characteristics:
- Mandatory: Insurance requires it before covering treatment
- Binding decision: Approval = coverage, denial = no coverage
- Blocking: Cannot receive covered treatment without approval
- Time-sensitive: Often delays urgently needed care
- Common for: Expensive medications (biologics, GLP-1s), specialty treatments, imaging (MRI, CT), surgeries, physical therapy
Appeal Rights:
- ✅ Formal appeal process required by law
- ✅ Urgent appeals: 72-hour decision timeline
- ✅ Standard appeals: 30-day decision timeline
- ✅ External review available if denied
- ✅ State insurance department complaints allowed
Predetermination
Definition:
Voluntary estimate of coverage BEFORE treatment is provided. You (or your doctor/dentist) asks, "Will you cover this if we do it?" Insurance gives non-binding answer.
Characteristics:
- Voluntary: Not required, you request it for planning purposes
- Non-binding: Estimate only, actual coverage decided when claimed
- Informational: Helps you understand potential out-of-pocket costs
- Planning tool: Used before expensive elective procedures
- Common for: Dental work (crowns, implants, orthodontics), elective surgeries, cosmetic procedures with medical component
Appeal Options:
- ⚠️ Can be appealed, but not always required
- ⚠️ May proceed with treatment anyway (risk: might not be covered)
- ⚠️ Final coverage determined when actual claim is submitted
- ⚠️ Timelines vary by insurer (typically 15-30 days)
- ✅ Can request formal coverage review instead
When Each Is Used
Prior Authorization (Required Pre-Approval)
💊 Medications
- Expensive drugs (>$500/month): biologics, specialty medications
- GLP-1 drugs (Ozempic, Wegovy, Mounjaro)
- Brand-name drugs with generic alternatives
- Controlled substances (opioids, stimulants)
- Off-label medication uses
🏥 Medical Procedures
- Imaging: MRI, CT scans, PET scans
- Surgeries (especially elective or bariatric)
- Specialty referrals and consultations
- Physical therapy (beyond initial visits)
- Durable medical equipment (wheelchairs, CPAP machines)
🔬 Specialty Treatments
- Infusion therapies
- Genetic testing
- Experimental or investigational treatments
- Home health care
- Skilled nursing facility stays
Predetermination (Voluntary Coverage Estimate)
🦷 Dental Work
- Crowns, bridges, implants
- Orthodontics (braces, Invisalign)
- Periodontal surgery
- Dentures and partials
- Root canals (complex cases)
🏥 Elective Procedures
- Reconstructive surgery (after trauma, cancer)
- Cosmetic procedures with medical justification
- Fertility treatments (IVF, IUI)
- Weight loss surgery (sometimes predetermination, sometimes prior auth)
📊 High-Cost Services
- Transplant evaluations
- Multiple procedures in one visit
- Extensive rehabilitation programs
- Complex diagnostic workups
How to Tell Which You Have
Look for These Clues in Your Letter/Notification
🔴 Prior Authorization Language
- "Prior authorization required for coverage"
- "This service must be pre-approved"
- "Coverage denied - prior authorization not obtained"
- "You must submit prior authorization before receiving service"
- "This is a final determination of coverage"
Action: MUST appeal if denied
🔵 Predetermination Language
- "Estimated coverage"
- "This is not a guarantee of payment"
- "Benefit estimate based on information provided"
- "Actual coverage determined when claim is submitted"
- "This is informational only"
Action: Can appeal OR proceed with treatment and appeal claim denial later
Still Unsure?
Ask yourself:
- Did I (or my doctor) request this review BEFORE scheduling treatment? → Likely predetermination
- Did insurance require this approval BEFORE allowing treatment? → Likely prior authorization
- Can I still receive the treatment without approval (I just pay out-of-pocket)? → Prior authorization
- Is this estimating future coverage for planned treatment? → Predetermination
How to Appeal Each Type
Prior Authorization Denial Appeal
Full Appeal Process Required
- Gather evidence: Medical records, clinical guidelines, doctor's letter
-
Submit internal appeal: Within 180 days of denial
- Urgent cases: 72-hour decision timeline
- Standard cases: 30-day decision timeline
-
If denied again: External review by independent medical expert
- Request within 4 months of internal denial
- Decision is binding on insurer
- Additional options: State insurance department complaint, legal action
Success rates:
- Internal appeal: 39% industry average, 82% with AppealArmor
- External review: 52% industry average, 78% with AppealArmor
Predetermination Rejection Appeal
Two Options Available
Option 1: Appeal the Predetermination
Similar process to prior authorization, but:
- Less formal - insurers may not have structured appeal process
- Timelines vary (typically 15-30 days, not regulated like prior auth)
- May require requesting "formal coverage determination" instead
- Submit same evidence: medical records, clinical necessity, guidelines
Use this when: Treatment is planned but not yet done, you want coverage certainty before proceeding
Option 2: Proceed with Treatment, Then Appeal Claim Denial
Ignore predetermination, receive treatment, submit claim, appeal if denied:
- Predetermination was just an estimate, not binding
- Actual coverage decided when real claim is processed
- If claim denied, use standard claims appeal process
- More evidence available (actual treatment provided, outcomes documented)
Use this when: Treatment is medically necessary NOW, you're confident in medical justification, willing to appeal claim later if needed
Predetermination denials are often based on incomplete information. You might have better success appealing the actual claim AFTER treatment, when you have:
- Complete medical records from the procedure
- Outcome documentation showing medical necessity was correct
- Complications or findings discovered during treatment
Risk: You might be responsible for full cost if claim is also denied.
Special Case: Prior Authorization vs. Predetermination for Same Service
Some services can involve BOTH prior authorization AND predetermination, creating confusion:
Example: Bariatric Surgery
Surgeon submits predetermination to estimate coverage before committing to surgery. Insurance says "estimated 80% coverage if medically necessary criteria met."
This is non-binding - just an estimate.
Surgeon submits prior authorization with full medical records, BMI history, comorbidities, supervised weight loss attempts. Insurance reviews and approves or denies.
This is binding - must have approval to proceed.
After surgery, hospital submits claim. Insurance reviews actual services provided and processes payment based on prior authorization approval.
Key Point: Predetermination approval doesn't guarantee prior authorization approval. You need the prior authorization for coverage, not just the predetermination estimate.
Common Mistakes to Avoid
❌ Confusing Predetermination Approval with Coverage Guarantee
Mistake: Patient gets predetermination approval for $2,000 dental crown, thinks coverage is guaranteed, proceeds with treatment.
Reality: When actual claim is submitted, insurance denies due to "not medically necessary" (cosmetic). Patient owes full $2,000.
Solution: Understand predeterminations are estimates only. Request prior authorization (if available) for binding decision.
❌ Not Appealing Prior Authorization Because It Seems "Informational"
Mistake: Patient receives prior authorization denial but thinks it's just a coverage estimate they can ignore.
Reality: Prior authorization denials are binding. Without approval, treatment won't be covered. Must appeal.
Solution: If letter says "prior authorization required" or "coverage denied", you MUST appeal for coverage.
❌ Proceeding with Treatment After Prior Auth Denial (Assuming You Can Appeal Later)
Mistake: Doctor says "just get the treatment, we'll appeal the claim after."
Reality: If prior authorization was REQUIRED and denied, claim will be automatically rejected for "no prior auth." Appeal must happen BEFORE treatment.
Solution: Always appeal prior authorization denials before receiving treatment.
Quick Reference Chart
| Feature | Prior Authorization | Predetermination |
|---|---|---|
| Purpose | Required pre-approval for coverage | Voluntary coverage estimate |
| Binding? | ✅ Yes - approval required for coverage | ❌ No - estimate only |
| Required? | ✅ Yes - by insurance plan | ❌ No - patient/provider requests |
| Timeline | 72 hours (urgent) or 30 days (standard) | Varies, typically 15-30 days |
| Appeal Rights | ✅ Formal process, external review, state complaints | ⚠️ Less formal, varies by insurer |
| If Denied | MUST appeal before treatment or pay full cost | Can appeal OR proceed and appeal claim later |
| Common For | Expensive drugs, imaging, specialty treatments | Dental work, elective procedures, high-cost planning |
Not Sure Which Type You Have? We'll Figure It Out
Upload your denial letter or coverage determination. Our AI identifies whether it's prior authorization or predetermination and generates the correct appeal strategy automatically.
✅ Free classification • ✅ Correct appeal pathway • ✅ Evidence-based strategy