| A | B |
|---|
| A002 | Cannot Determine Location |
| 003 | This procedure is only payable when the primary code has been submitted and performed on the same date of service |
| 004 | Services are not covered when D0170 has been performed on the same date of service |
| 01 | Out of Network benefits are not covered under this plan. Member is responsible for payment.(Use OFFSET-ONCP) |
| 02 | The maximum dollar limit has been reached. (Used for the Benefit Strategy) There may not be Patient Responsibilty at the Benefit Strategy level |
| 02PA | The maximum dollar limit has been reached. This Remark Code is for UPMC's review for Radiograph Max per Provider. ($69 xray max) |
| 03 | This procedure is incidental to the primary procedure submitted on the same date of service |
| 04 | Services performed on previously extracted teeth are not covered |
| 05/05D | The patient doesn't meet the age requirement for the this benefit |
| 09 | Member responsibility reflects 25% discount. |
| 119/119D | Benefit maximum for this time period or occurrence has been reached. |
| 11N | This procedure is not covered for this tooth number. (USE OTN TO OFFSET to pay line) |
| 125 | Payment adjusted due to processing error(s). |
| 203 | Non-Covered Benefit. The member can not be billed for amounts exceeding the contracted rates for In-Network only. |
| 204 | The patient cannot be balance billed for any remaining balance. |
| 209 | This procedure code has been denied and reprocessed as D0272 on claim as per plan benefits. |
| 210 | This procedure code has been denied and reprocessed as D0274 on claim as per plan benefits. |
| 211 | D8660 is reimbursed only when an orthodontic case request has been denied. |
| 224 | The procedure code submitted has been changed to reflect the correct procedure code, identifying all surfaces for the same tooth number, on the same date of service. |
| 226 | Clinical information does not meet criteria for authorization of these services. |
| 227 | The procedure code submitted has been changed to reflect the correct procedure code, identifying all surfaces for the same tooth number, on the same date of service. |
| 228 | Denture adjustments are not covered when complete/immdediate dentures have been performed within a six month period. |
| 229 | Denture adjustments are not covered when full or partial dentures have not been performed. |
| 231 | Claim denied. Member information on radiograph received doesn't match the member information on submitted claim. |
| 232D | Conflicting service(s) filed on Same Day/Same Claim. (USE OBWX TO OFFSET THIS REMARK CODE TO PAY) |
| 29 | Receive Date is over timely filing limit. |
| 34D | Lifetime benefit maximum for this tooth number has been reached. |
| 35/35D | Lifetime benefit maximum has been reached. |
| 52 | The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed. |
| 62 | Payment denied/reduced for absence of, or exceeded, pre-certification/authorization. |
| 96/96D | Non-covered charge(s). |
| A12/A12D | Prior Authorization or Pre-Estimate Required. |
| A001 | Provider not found |
| A002 | Cannot determine location |
| A17 | D0140 is not covered when billed with other oral exams and preventative services on the same date of service |
| A34 | Receive Date is over timely filing limit. |
| A39 | Post review with x-rays and reports required. (OA39 IS USED BY Claim Processors TO OFFSET AND PAY LINE) |
| A54 | This service is only payable when other services have been performed and paid on the same day.(Use offset code OADJ to make line pay) |
| A56 | This claim requires further review. Please provide pre and post treatment x-rays, clearly labeled with the date and patient name along with chart notes. |
| A58 | Benefit not covered by same provider/provider group that placed the space maintainer. |
| A59 | Review Member Reimbursement Claims for Accuracy. |
| A62 | Periodic Orthodontic Treatment Visit is payable six months after a Comprehensive Orthodontic Treatment of the Adolescent Dentition has been performed. |
| A63 | Cephalometric Film is not payable when orthodontic treatment has been performed prior to service. |
| A64 | Alveoplasty for procedure code D7310 payable in conjunction with extractions. Alveoplasty for procedure code D7320 payable when not in conjunction with extractions. |
| A65 | This service requires a narrative report for pre-transplant cases for patients over the age of 21. |
| A72 | Lifetime benefit maximum for this procedure has been reached with this Provider/Dental Group. |
| A73 | Post and Core needs post review when a crown has been previously performed on same tooth number. Provider must send post operative x-rays for claim consideration. |
| A74 | Clinical documentation needed when services for fillings have been performed more than once on the same tooth, within a 12 month period. |
| A75 | Review required for bundling when fillings have been performed on the same tooth number, on the same date of service. |
| ADJC | Previously paid/denied service has been reprocessed. |
| ADJP | Remark code for Claim correction for proper vendor. |
| AZ12 | Prior Authorization is needed when more than two extractions have been performed on the same date of service. (For AZ BWY Extractions for 21+) |
| B13 | Fees will be reduced upon claim receipt and adjudication based on services previously reimbursed on another claim. |
| B7 | This provider was not certified/eligible to be paid for this procedure/service on this date of service. |
| BLU | Review Blue Cross Blue Shield, Out of Network claim submitted with In-Network fees. |
| CP1 | Member's responsibility reflects copay amount. |
| CP2 | Member's responsibility reflects coinsurance amount. |
| D012 | Avesis is not the dental carrier for this group. Please submit to the current dental carrier. |
| D03 | X-rays denied when billed with a Full Mouth Series on the same date of service. |
| D04 | Hospital Call denied when billed with a Comprehensive Exam or Palliative Treatment on the same date of service. |
| D06 | Periodontal Maintenance is payable when Gingivectomy/Gingivoplasty or Periodonatal Scaling and Root Planning have been performed previously. |
| D07 | Procedure code covered for Oral Surgeons only. |
| D22 | This procedure is not covered with any other service on the same date. |
| HCKY | CoventryCares Kentucky Medicaid Dental - Group Hold |
| HP12 | Prior Authorization or Pre-Estimate Required for HealthPartners/KidzPartners |
| I4 | Avesis is no longer the Carrier |
| I55 | A detailed office receipt is required displaying charges and any amounts paid. Please resubmit claim with documentation. |
| KY02 | The radiograph maximum has been reached for this provider/dental group. |
| KY03 | Procedure is incidental to another procedure submitted/performed prior to code submitted. |
| KY04 | Services performed on previously extracted teeth are not covered. |
| KY05 | The patient doesn't meet the age requirement for this benefit. |
| KY06 | Procedure payable only when primary procedure has been performed on same day of service. |
| KY07 | Emergency exams inclusive when billed with other services on the same date of service. |
| KY08 | Procedure code incidental to restorations when an occlusal surface has been performed on a restoration for the same tooth number. |
| KY12 | Prior Authorization or Pre-Estimate Required for Coventry Care of KY |
| KY12 | Authorization Required. |
| KY19 | Ok to pay Frequency Limitation for EPSDT claims. |
| KY39 | Review for Post Review. |
| KYCC | Claim is payable under Continuation of Care for Kentucky. |
| KYEP | Ok to pay procedure. |
| KYFS | Review $0 fee amount for procedure code(s) to manually pay for amount approved. |
| KYNC | Non Contracted Dental Provider - KY Medicaid |
| KYPW | Review for Post Review. This procedure is covered for pregnant women only. |
| MM12 | Prior Authorization or Pre-Estimate Required for Molina |
| N37 | Missing/incomplete/invalid tooth number/letter. |
| N39 | Procedure code is not compatible with tooth number/letter. |
| N40 | Missing X-Ray |
| N48 | Claim information does not agree with information received from other insurance carrier. |
| N75 | Missing/incomplete/invalid tooth surface information. |
| NCDP | Non Contracted Dental Provider |
| PD16 | Clinical information does not meet criteria for authorization of these services. (USED BY UM IN GA ONLY) |
| PD27/MM27 | Provider must include a signed Patient Responsibility form with all PTE requests. (USED BY UM DEPT.) For Molina $1000 Plan, if the provider bills for more than $500 per day. |
| PVR/D108 | Services billed in error. This service is being denied at the request of the provider |
| PW12 | Prior Authorization required. This procedure is covered for pregnant women only. |
| SSCR | SSC Review for AZ-BWY (2 per General Dentist) and (4 per PEDO) |
| S001 | Price Stragety not found - varies reasons for this code to appear on claim but normally it means procecedure code is not covered. |
| DD02 | Duplicate claim - Please re-evaluate (The EOB to the provider reads: |
| 119v | Benefit maximum for this time period or occurrence has been reached |
| PD23 | Supporting documents were not of a diagnostic quality and could not be used to approve these services. |
| MD | Manually Denied Service |
| A33 | No Provider NPI Number |
| N19 | Procedure code incidental to primary procedure. |
