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

Description

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

Policy/criteria

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.

Disclaimer

Your use of this Dental Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Dental Policy Disclaimer.