What Is A Pre-Treatment Estimate?

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What is a Pre-Treatment Estimate?

When a patient goes in for an exam and the dentist determines work needs to be done, the dentist will develop a customized treatment plan for the patient. These treatment plans can often include major or extensive dental treatment, which, depending on how insurance pays, can end up being quite expensive for the patient.

To avoid any surprises, the dental office may submit this treatment plan to insurance prior to providing the actual services (pre-treatment) in order to see (or estimate) how insurance would pay for each procedure in the treatment plan.

What is the Difference Between Pre-Treatment Estimates and Prior Authorization?

Though pre-treatment estimates are not required, there are some dental services that may require Prior Authorization, depending on the patient?s insurance policy. Prior Authorization is similar to Pre-Treatment Estimates as they are submitted to insurance prior to the dental work being completed. However, Prior Authorization includes an additional step where a licensed dental professional looks at the requested treatment and patient's dental records to determine if the proposed service would be considered medically necessary or otherwise meet the insurance policy's criteria in order for the service to be paid.

The types of services for which most insurance policies require Prior Authorization tend to be extensive or major services, including oral surgery, periodontal treatment, endodontic treatment, crown/bridge/inlay/onlay work, implant/implant-related services, orthodontics, and dentures/partials.

Submitting and Processing Pre-Treatment Estimates and Prior Authorization

When submitting a Prior Authorization request to insurance, the dental office will include supporting documentation to show why they believe the treatment is necessary. This supporting documentation could include chart notes, x-rays, and photos.

Upon receipt, BCBS FEP Dental reviews submissions and sends the patient and dental office a Pre-Treatment Estimate of Benefits, outlining which of the planned procedures would be covered and even further explaining what the insurance payment and patient out-of-pocket expense would be.

A Pre-Treatment Estimation of Benefits, however, is not a guarantee of payment, as received treatment claims are based on current eligibility and contract benefits in effect at the time of the completed service. For example, if a Pre-Treatment Estimate was approved, but the patient's insurance policy was cancelled before receiving treatment, insurance will not pay on the claim, despite the Pre-Treatment Estimate approval.

BCBS FEP Dental members can log in to bcbsfepdental.com to review their benefits, check their deductibles, and view their claim/pre-treatment estimate history.

Are Dental Offices Required to Submit Pre-Treatment Estimates?

No, dental offices are not required to submit pre-treatment estimates. However, patients who are considering major or extensive dental treatment may request their dental office submit one in order to estimate what their out-of-pocket expense would be for the dental work, and help them make choices about which dental treatment options they wish to pursue. In fact, doing so can help patients avoid unexpected costs, so submission of a pre-treatment estimate is strongly recommended and encouraged.