What is predetermination?

A predetermination is a formal review of a patient’s proposed medical care compared to their insurance’s medical and reimbursement policies.  Predeterminations are more extensive reviews, must be conducted in writing through the U.S. Postal Service rather than securely online, and may take up to 60 days, though they have been averaging about three weeks as of this writing.  Predeterminations are not required for services and drugs that require prior authorization.  Successful predetermination involves confirmation that the patient is a covered member of the insurance plan and that the treatment plan for the patient is a covered benefit, according to the health insurance policy.  In obtaining a predetermination judgement, a patient’s clinical information to support the need for the intended procedure is submitted by the provider’s office and the insurance company are to review the patient’s conditions against the insurance policy. As with prior authorization, predetermination requests may be given approval, denial, request for additional information, or preliminary denial pending additional information provided by your physician to a clinical provider employed by the insurance company in a “peer to peer” phone discussion, or an appeal.  A “peer to peer” call is set according to the insurer’s employed provider’s schedule in which a window of time during your physician’s normal clinic is set for the insurer to call your physician to discuss the case.  This conversation may end with approval or denial of the predetermination.  But, as with prior authorization, an approved predetermination still does not guarantee payment for the service rendered.  The reported aim is to determine if the intended care meets “medical necessity” requirements, though this term is defined by the patient’s insurance company in the policy contract between patient and insurer.

Services that are considered life threatening typically do not need predeterminations, though it is not clear to me what treatments for life threatening conditions require predeterminations.

Predetermination is promoted as a method of informing patients of a cost estimate for proposed services by verifying information regarding the patient’s insurance coverage, payable benefits, co-pays and co-insurance, details on the plan related to coverage, date of coverage, type of plan, exclusions, deductibles, and other key details about the insurance plan. While it may do these things, it can also delay medical care.