4 Based on documentation received, this procedure does not meet the plan criteria to allow a benefit. 7 Service indicated is not a benefit. 12 Patient not eligible for service per contract limitation. 15 Service is not a covered benefit of the plan. 33 Tooth number or procedure has been changed. 60 Service was rendered after termination or prior to effective date. Therefore, patient is not eligible for benefits. 64 Patient not covered. 72 Maximum benefit of the dental plan has been reached. 84 Fee for completion of forms is not a benefit. 87 This service is considered a part of and included in the fee for a complete procedure. 89 Incomplete services are not covered. 94 To process claim, amount paid by other insurance carrier is required. 119 Processed as complete series. 120 Benefit frequency limit exceeded. 130 Duplicate service. 139 Dental procedures for the primary purpose of periodontal splinting are not a benefit of the dental plan. 142 This procedure was allowed as an alternate benefit. 144 Additional information requested for benefit determination. 146 The maximum allowed for this service has been paid for this benefit period. The patient is responsible for the approved amount. 150 Service is not a benefit. 152 Date of service is invalid claim was received prior to the date of service indicated. 165 The waiting period was not satisfied, therefore the patient is not eligible for benefits. 190 Benefit is limited by the age of the patient. 202 Restorations on the same tooth and surface(s) are a benefit once in a 24-month period. 206 Replacing tooth structure lost due to wear/attrition/abrasion/erosion/abfraction is not a benefit of the dental plan. 222 Dental procedures for the primary purpose of increasing/altering vertical dimension are not a benefit of the dental plan. 413 To be considered, a radiograph and tooth charting, which includes missing and present teeth, is required.
603 When more retainers/pontics are reported than customary, the additional retainers/pontics are considered optional. 707 Service considered a component of surgical extraction. 708 This procedure, when performed in conjunction with a surgical procedure, is not a payable benefit. 724 Services or supplies that are considered experimental or investigative are not covered benefits of the dental plan. 731 A tentative approval has been made. A pathology report is required for the final benefit determination. 732 Benefit has been approved as a pretreatment estimate. An operative report is required for final benefit determination. 736 A tentative approval has been made. A medical carrier statement is required for the final benefit determination. 807 Orthodontic services are not a covered benefit of the plan. 917 In order to determine the benefit for this procedure a copy of the pathology report is required. Benefit is disallowed. 951 Adjusted claim. 971 Other carrier explanation of benefits statement is required for payment. 972 In order to determine the benefit, documentation in the form of narrative/pocket depth/periodontal charting is required. 980 Services or supplies that are considered to have a poor prognosis are not covered benefits of the dental plan. 1015 Tooth number/surface/quadrant is required for this service. 1113 Carry Over Max has been used. 1303 This service is covered twice every twelve (12) months. 1310 Benefits were coordinated with another carrier. 1312 The plan has a Non-Duplication of Benefit Provision. No additional payment will be made. 1320 This procedure has been re-evaluated and the original decision has been upheld. 1330 Member dentists have agreed not to bill patients a separate charge for infection control. 1325 Participating dentists have agreed to not bill patients a separate charge for infection control. 1400 Benefit allowed as an Emergency Service. 1401 In order to determine the benefit for this procedure, a copy of the clinical record / chart notes is required. 1406 General Anesthesia and/or IV Sedation is not covered when done in conjunction with this procedure. 1408 Maximum allowance of the dental plan has been made. 1409 Radiograph is required for benefit consideration. 1410 Processed as a full mouth series. 1411 Based on documentation received, the criteria for a crown/onlay are not met.
1412 Documentation in the form of radiograph/diagnosis/narrative is required. 1415 Disallow as part of a complete procedure. 1416 Retention pin fee is considered to apply per tooth regardless of the number of pins placed. 1419 Procedures primarily for cosmetic purposes are not covered benefits of the plan. 1427 Documentation in the form of a detailed narrative and radiograph are required. 1428 Documentation in the form of a detailed narrative and diagnosis is required. 1430 Repair/reline/rebase/adjustment/tissue conditional within 6 months of delivery is disallowed. 1435 Lifetime maximum for this service has been reached. 1441 Alternate benefit applied. 1442 The allowance previously made for a related procedure has been deducted from the allowance of this procedure. 1444 Documentation in the form of periodontal charting with probing depth, amount of recession and keratinized tissue is required. 1445 In order to determine the benefit, documentation in the form of radiographs/periodontal charting/narrative/diagnosis is required. 1448 In order to determine the benefit for this procedure, documentation in the form of the Oral CDX lab report is required. 1449 Replacement/retreatment by the same dentist within 24 months is not a payable benefit. 1450 This service is a benefit only when done on an emergency basis. 1456 Criteria for benefit not met benefit denied. 1471 Benefit has been approved as a pretreatment estimate. No more than two quadrants are allowed on the same date of service. 1475 Benefit is payable on posterior primary teeth only. 1480 Appliances to correct harmful habits are not a benefit of the dental plan. 1508 In order to determine the benefit for this procedure a copy of the pathology report is required. 1511 Documentation does not meet criteria to allow benefit. Disallow service. 1520 This service is payable once (1) in a 12 month period. Benefit is disallowed. 1526 This service is covered once every twelve (12) months. 1527 This service is covered once every 24 months. 1529 This service is covered twice (2) in a benefit period. 1545 Disallowed when done in conjunction with treatment. 1551 This service is covered once every six (6) months. 1552 This service is covered once (1) in a benefit period.
1565 Non-emergency services performed by a non-contracted dentist are not covered. 1566 Services performed by a non-contracted dentist are not covered. 1580 For impacted teeth extractions, or accident-related services, the medical EOB is required. 1581 The medical EOB is required. 1595 Documentation in the form of radiographs and clinical record/chart notes are required. 1596 Documentation in the form of an operative/surgical report and radiograph is required. 1603 Service exceeds the frequency limit of the plan. 1604 This service is covered once every three (3) years. 1605 This service is covered once every five (5) years. 1606 This service is covered once (1) per lifetime. 1609 Verification of the patient's full time student status is required to determine eligibility. 1619 Contract limitation. 1620 Contract limitation. 1630 Records indicate this tooth has been previously extracted. 1675 Benefit is limited by the age of the patient. 1690 An alternate benefit was allowed and applied toward the implant related global allowance. 1691 Benefit has been approved as a pretreatment estimate. An x-ray and operative report are required for final benefit determination. 1695 Treatment does not meet criteria for benefit based on information received. Benefits are denied. 1697 No prior-authorization received. The hawk-i plan requires prior authorization for this service. Benefit is denied. 1702 Benefits for sealants are limited to restoration-free permanent molars, once per lifetime or to the limitation of the plan. 1704 This procedure has been re-evaluated and the original decision has been upheld. 1707 Incorrect patient. 1708 Orthodontic services are disallowed. 1709 Orthodontic services are denied. 1710 Benefit can be considered once the existing crown is removed and the missing structure is assessed with supporting documentation. 1711 Based on documentation received, crown/onlay benefits are not available for teeth that may fracture in the future. 1712 Documentation in the form of radiographs/clinical record/diagnosis/pertinent treatment history is required. 1713 This procedure can be considered after the healing process has been reported.
1714 The area/tooth to be considered is not visible on the radiograph received. 1715 Dental procedures to restore occlusion are not a benefit of the dental plan. 1716 In order to determine the benefit a pre-operative radiograph and clinical record/chart notes are required. 1717 A labeled and dated pretreatment intraoral photograph(s) is requested. 1718 A copy of the chart with specific information regarding testing used, diagnosis, duration and history of symptoms is required. 1719 Diagnosis along with chronological record of treatment and related charting documentation is required. 1720 This procedure is not payable when a prophylaxis was performed within the past 36 months. 1725 Documentation in the form of x-rays, diagnostic casts, photos, case type, treatment plan and type of appliance are required. 1750 Services are disallowed. Treating dentist is on a government excluded list. 1751 Services are denied. Treating dentist is on a government exclusion list. 1755 Services are disallowed. No payment due from patient. Claims for the treating dentist are under investigation. 1756 Only those services performed by a licensed dentist are a benefit of the dental plan. 1757 Claim cannot be processed because the treating dentist indicated on the claim is not on the Delta Dental National Provider file. 1760 Procedures to correct congenital or developmental malformations are not covered benefits of the plan. 1799 Service is not covered, you have not met your deductible, waiting period and/or have exceeded frequency or other plan limitation. 1800 Maximum allowance of the dental plan has been made 1801 This is a duplicate claim. An orthodontic schedule has been set up based on the initial claim and payments are being issued. 1815 Service provided by a participating hawk-i orthodontic provider. 1816 Services are not covered under the hawk-i orthodontic plan. 1817 Annual maximum has been reached for the hawk-i member. The emergency dental service has been approved. 1818 Documentation received does not meet the published handicapping malocclusion criteria as required by hawk-i. Benefits are denied. 1819 No prior-authorization received. The hawk-i plan requires prior-authorization for orthodontic services. Benefits are denied. 1820 Orthodontic treatment plan has been approved as Medically Necessary. 1821 Orthodontic treatment plan has been approved as Corrective. 1822 Replacement retainers are not covered under the hawk-i orthodontic benefits. 1823 In cases of emergency, hawk-i may benefit this code. Service may be considered with supporting documentation. 1824 Service exceeds the additional fluoride / bitewing benefit for high caries risk members. 1825 The provider is not a hawk-i orthodontic provider. Orthodontic services are denied.
1826 The information received does not indicate it is part of orthodontic comprehensive therapy. Benefits are denied. 1828 To determine benefits, dates of previous orthodontic treatment (banding date, length of treatment, and end date) are required. 1830 Coverage for this service is provided through your Evidence Based Integrated Care Plan. 1875 The electronic documentation number is not valid. 1900 Orthodontic treatment in process is not a covered benefit. 1951 This procedure was adjusted after a review of additional information. 2001 Maximum Out-of-Pocket limit is met for this benefit period. 2002 Maximum Out-of-Pocket has been met. 2003 Processed as orthodontia. 2050 Additional information will be required when the claim is submitted. 3070 Service not submitted within the timely filing limitation.