Non-Reimbursable Dental Services

Policy No: 70
Originally Created: 04/01/2018
Section: Miscellaneous
Last Reviewed: 01/01/2019
Last Revised: 04/01/2018
Approved: 04/01/2018
Effective: 04/01/2018


Non-Reimbursable Services
Services that are not eligible for reimbursement.


Providers will not be reimbursed nor allowed to bill the member for services considered to be Non-Reimbursable.

Services denied as Non-Reimbursable Services include, but are not limited to:

  • Denture insertion.
  • Periodontal charting.
  • Completion of claim forms.
  • Reports to referring providers.
  • Original soldering of bridge units.
  • Dressings by the treating dentist.
  • Duplication or submission of X-rays.
  • Indirect pulp caps, bases and liners.
  • Separate lab charges in addition to crown.
  • More than four pins per restoration (tooth).
  • Gold in addition to the cast gold restorations.
  • Finance charges on the amount paid by Regence.
  • Reline in addition to a separate charge for a rebase.
  • Bitewing X-rays in addition to a complete X-ray series.
  • Surgical procedure for isolation of a tooth with a rubber dam.
  • Local or regional anesthetic in addition to operative procedures.
  • Occlusal adjustment charges in addition to occlusal restorations.
  • Root canal culture (considered inclusive to the root canal procedure).
  • Alveoloplasty (alveolectomy) in conjunction with fewer than three extractions.
  • Individual periapical X-rays performed on the same day as a complete X-ray series.
  • Sedative or temporary fillings performed on the same day as permanent restorations.
  • Root recovery in addition to a charge for the extraction of the same tooth by the same dentist.
  • Charges for full or partial denture relines or adjustments done less than six months after the initial placement.
  • Acid etch or a light-cured restoration in addition to charges for restorative procedures on the same tooth.
  • Root planing and scaling if those procedures follow curettage, gingivectomy or osseous surgery done in the same area within one year.
  • Any combination of the following Current Dental Terminology (CDT) codes if performed on the same day: CDT D1110, D1120, D4210, D4211, D4260, D4261, D4341, D4910.
  • Any services normally considered part of overhead (e.g. sterilization, infection control, asepses).
  • Charges for advanced technology including but not limited to laser, robotics, computer assistance, etc, in addition to the charge for the procedure.
  • Billings (original or corrected) that are more than twelve months old after the date of service.


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