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).
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.
Action: MUST appeal if denied
Action: Can appeal OR proceed with treatment and appeal claim denial later
Use when: Treatment is planned but not yet done, you want coverage certainty before proceeding
Use when: Treatment is medically necessary NOW, you're confident in medical justification
Strategic Consideration: 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, outcome documentation, and findings discovered during treatment. Risk: You might be responsible for full cost if claim is also denied.
| 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 |
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.
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.
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.
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Analyze My Denial — FreeComplete step-by-step guide to appealing a prior authorization denial with timelines and strategies.
Free prior authorization appeal letter template with clinical evidence sections that overturn PA denials.
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