Non-reimbursable Dental Services

Non-Reimbursable Dental Services

Policy No: 70
Originally Created: 04/01/2018
Section: Miscellaneous
Last Reviewed: 05/01/2020
Last Revised: 05/01/2020
Approved: 05/21/2020
Effective: 06/01/2020

This policy applies to all dental providers.


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

Policy Statement

Providers will not be reimbursed for Non-Reimbursable Services.

The following are not eligible for reimbursement and should not be billed to us or to 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
  • 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 Asuris
  • Reline in addition to a separate charge for a rebase
  • Bitewing or individual periapical 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
  • 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, 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 submitted more than twelve months after the date of service.
  • 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®)

Policy Cross References



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