Policy No: 70
Originally Created: 04/01/2018
Last Reviewed: 05/01/2020
Last Revised: 05/01/2020
This policy applies to all dental providers.
Services that are not eligible for reimbursement.
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