Your dentist has recommended treatment and given you a price. The next question is how much your dental plan might reimburse. A predetermination can help you check that before planned work begins.
This guide focuses on requesting and reviewing an estimate under an existing private dental plan. Your dentist remains the person to discuss treatment needs and timing with, especially when care is urgent.
Start with the dentist's written treatment estimate
Ask the dental office for an itemized estimate and an explanation of the proposed work. Useful questions include:
- What procedures and codes are included?
- Does the total include every planned stage and any laboratory charges?
- Are any costs still provisional?
- Who will submit the estimate, and how will I receive the response?
In Ontario, the Royal College of Dental Surgeons of Ontario’s guidance on discussing treatment costs says estimates should include applicable material and laboratory charges and additional treatment. It also stresses giving patients time to ask questions. This is Ontario dental-regulator guidance, not a national insurance rule.
Keep the estimate with your current benefits booklet. The office can explain the treatment; the insurer or plan administrator can explain how your contract applies. The Canadian Dental Association recommends asking your dentist to submit a predetermination when reimbursement is uncertain.
Request the assessment under your existing plan
A predetermination asks the insurer to assess proposed treatment against the coverage you already have. It is different from asking an advisor about a plan you are considering buying.
Follow your own insurer's submission instructions. For example, Alberta Blue Cross directs members to have their dental provider submit the request before treatment.
Manulife's CoverMe health-insurance FAQ calls for an estimate when proposed treatment is expected to cost more than $500. Its instructions use the dental benefit claim form, with the proposed treatment outlined and X-rays included if available. That dollar threshold belongs to this published guidance; it is not a Canada-wide rule.
Ask which supporting documents are needed and who will follow up if information is missing. Send treatment records through the insurer's or dental office's approved process.
Read the response beside the original estimate
Focus on the individual procedures, not just the total. Check these points with the insurer or dental office:
- Treatment match: Does the response cover the same procedures and stages the dentist proposed?
- Eligible charges: What amount is being used to calculate reimbursement?
- Your share: Which costs remain payable by you after reimbursement and any deductible?
- Available benefits: What maximums or treatment-frequency limits affect the estimate?
- Conditions: Are more documents, an updated submission or another approval step required?
If a line is unclear, ask for an explanation before treating it as covered. Write down the answer beside that item, including who explained it and whether the insurer needs anything further. Keep an unresolved question separate from a confirmed estimate.
A useful question is: "The dentist's estimate and the insurer's response show different amounts for this procedure. What explains the difference, and what could I need to pay?" This keeps the conversation focused on the particular item instead of assuming the full treatment is covered or excluded.
Check the assumptions before relying on the amount
A predetermination is an estimate, not a guarantee of payment, as the CDA's dental-plan fact sheet explains.
Ask the insurer what happens if the treatment, charges, timing or your coverage changes. Ask whether other claims could affect the amount remaining and whether the response has an expiry date. Do not assume the estimate reserves a benefit amount for you.
Keep the response and reference number. If something changes, ask whether a revised estimate is needed. After treatment, compare the actual invoice and claim statement with the earlier figures, and question any unexplained difference.
Insurance paperwork should not determine what care you need. Discuss clinical options and urgency with your dentist rather than postponing necessary care on the strength of an insurance estimate.
Comparing dental plans for future care?
Get Health Coverage is an independent comparison platform. If you are reviewing options for future care, compare the plans shown for your province, then check the policy wording with the insurer. Look at waiting periods, covered procedures, reimbursement percentages and benefit limits together.
You can also request a free call with an independent licensed advisor about comparing options. For an existing predetermination, contact the insurer or dental office handling it. Before sharing treatment records, ask for an appropriate secure route.
Your policy terms and the insurer's assessment determine coverage; your dentist advises on treatment. A shopping conversation can help identify questions about a proposed policy, but it cannot confirm that already-recommended treatment will qualify under a new plan.
Frequently asked questions
Is a predetermination the same as a claim?
No. A predetermination concerns proposed treatment. A claim reports services already provided. Receiving an estimate does not mean a claim has been paid or that the dentist has received payment.
Can I get one before buying dental insurance?
A formal predetermination assesses benefits under an existing plan. While shopping, you can ask about policy wording, exclusions and waiting periods. That discussion does not establish that already-recommended treatment will qualify under a new policy.
How long does a dental predetermination take?
Ask your insurer about the current process and what information is required. Confirm who will follow up on missing documents and how you will receive the response. Do not assume another insurer’s timeline applies to your request.