What is the term for finding out the maximum dollar amount an insurance will pay for a procedure?

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The term for finding out the maximum dollar amount an insurance will pay for a procedure is "predetermination." This process involves the insurance company reviewing the proposed treatment and confirming the coverage and the extent of the payment prior to the actual procedure being performed. It provides both the healthcare provider and the patient with clarity on the expected out-of-pocket costs, which can help in financial planning for the medical treatment.

Predetermination is particularly important in ensuring that the patient is aware of their coverage limits and helps to avoid unexpected bills after receiving services. It creates a more transparent path for treatment, allowing for informed decisions based on financial responsibilities.

While preauthorization also closely relates to insurance processes, it generally refers to obtaining approval for a specific service or procedure rather than establishing the maximum payment amount. Medicare is a federal health insurance program and does not specifically denote the process of determining payment limits, and a referral is the act of directing a patient to another healthcare provider for further treatment, which is unrelated to payment determinations.

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