Following a predetermination that never came back
Submitted for a crown, then silence. The answer often arrives on paper weeks later, posted to whichever location the payer holds on file, by which point the patient has either booked or drifted. Medical prior authorisation runs worse, because the 278 transaction meant to carry it has one of the lowest adoption rates of any HIPAA standard, so the real work happens inside whatever portal a benefit manager operates. What returns is a number with a span attached, and that number has to reach the claim or the claim denies for authorisation absent.
Electronic eligibility answers whether a patient is covered, and then somebody opens the payer portal anyway to find out what is actually payable.
There is a mandated electronic standard for eligibility, and it works. It confirms that a plan is active. What it routinely omits is the detail the front desk actually needs: frequency limitations, waiting periods, alternate benefit provisions and remaining annual maximum. That gap is the origin of most manual verification in this sector.
- Availity
- Open Dental
- Outlook
When this is the wrong thing to build
Pick something else if the work submitted rarely needs approval in advance, or if the payers involved answer electronically within days, because a tracking queue that empties itself before anyone opens it is one more screen to keep current for no return.
The constraint that shapes it
A practice is a covered entity, and any vendor that creates, receives, maintains or transmits protected health information on its behalf is a business associate, which requires a written agreement in place before any disclosure. More on how this sector works.
A list of things that are missing, worked until it is empty. Read what this shape is, or start from one of these.
- Chasing a compliance file to complete
- Chasing a referral fee through to a closing you cannot see
- Asking for the replenishment before the retainer runs to zero
- Chasing medical records until the set is complete
- Getting a deposition on the calendar of every party
- Chasing the warranty credit the distributor has not issued
- How long does a dental predetermination take to come back?
- Does a predetermination guarantee the payer will pay?
- How do I track outstanding prior authorisations across payers?
- Why was my claim denied for authorisation absent when I had approval?
- Where does the authorisation number go on a claim?
Back to medical and dental practices, or see how this is priced and scoped.