A predetermination estimate (PDE) is used to estimate a patient's expected benefit coverage before the procedures are performed. Predetermination estimates are submitted just like any other claim except the Service Date for predetermination lines are left blank. A claim may contain both in-for-pay and predetermination claim lines. Benefits, as well as fees and other time-sensitive attributes, for claim lines without a date of service are determined as if the service date were the date the predetermination estimate is processed.
After the predetermination estimate has been submitted, it can be re-submitted as a predetermination-in-for-pay (PDIFP). The outcome of the PDIFP may be different from the outcome of the original predetermination estimate, due to any changes in member benefits, etc., that may have occurred since the PDE was processed. Any changes to the claim information may also result in a different outcome. Therefore, the predetermination estimate is not guaranteed; it is an estimate only, based on current data.
Related Topics
Adding a claim or predetermination estimate
Locating a claim
Submitting a predetermination in for pay