Pre-determination of Benefits Task Group

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    Reply # 7230260 on 6420891
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  • 7 Aug 2018 10:23 AM
    Message # 6420891
    Anonymous

    This task group is researching dental provider and payer perspectives for three types of inquiries:

    • Pre-determination of benefits, which includes a clinical review
    • Estimate for a patient's treatment plan (at times called a pre-treatment estimate) without a clinical review
    • Prior authorization for proposed procedures

    The scope of the information requested and response received, the transactions being used, and commitment to the payer’s response are being discussed. In most cases, these are done in a batch mode, but payers are considering a migration to a real-time model. The task group’s goal is to develop a best practices guide on how these transactions should be completed.

    Chair: Kevin Moore, Delta Dental of Washington

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