Non-Reimbursable Dental Services

Policy No: 70
Originally Created: 04/01/2018
Section: Miscellaneous
Last Reviewed: 05/30/2023
Last Revised: 06/01/2021
Approved: 06/22/2023
Effective: 07/01/2023

This policy applies to all dental providers.

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

Providers will not be reimbursed for Non-Reimbursable Services.

The following are not eligible for reimbursement and a participating provider may not bill the member.

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
• Separate lab charges in addition to crown
• 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
• Local or regional anesthetic in addition to operative procedures
• Alveoloplasty (alveolectomy) in conjunction with fewer than three extractions
• 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, D4342, D4355, D4346, D4910
• Any services normally considered part of overhead (e.g., sterilization, infection control, asepsis, personal protective equipment).
• Charges for advanced technology including but not limited to laser, robotics, computer assistance, etc., in addition to the charge for the procedure.
• Claims (original or corrected) that are not submitted within the timely filing limits set forth in the participating agreement.
• Services or procedures considered not clinically appropriate are not reimbursable by the plan. Services or procedures considered not clinically appropriate are not billable to the member without signed prior consent

American Dental Association, Current Dental Terminology (CDT®)

None