Non-Reimbursable Dental Services
Policy No: 70
Originally Created: 04/01/2018
Last Reviewed: 01/01/2019
Last Revised: 04/01/2018
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.