Understanding pre-treatment estimate pricing

A pre-treatment estimate is used to estimate a patient's expected benefit coverage before the procedures are performed. Pre-treatment estimates are submitted just like any other claim except the Service Date for pre-treatment estimate lines are left blank. A claim may contain both in-for-pay and pre-treatment estimate 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 pre-treatment estimate is processed.

After the pre-treatment estimate has been submitted, it can be re-submitted as a pre-treatment estimate-in-for-pay (PEIFP). The outcome of the PEIFP may be different from the outcome of the original pre-treatment estimate, due to any changes in member benefits, etc., that may have occurred since the pre-treatment estimate was processed. Any changes to the claim information may also result in a different outcome. Therefore, the pre-treatment estimate is not guaranteed; it is an estimate only, based on current data.