Dental Provisions #19 Aug 2002

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August 2002: Dental Provisions #19

Regence BlueShield Message Codes (excluding FEP)

The following is an updated list of message codes used most frequently on your payment voucher to explain how a claim was paid or why it was rejected. Up to three message codes may be used per line item to explain processing.

Message Code	Description	Patient Responsibility
A02	Your claim has been reprocessed. Total amount paid has been increased.	-
A03	Prior payment deducted - patient responsible for charges.	Y
A04	Prior payment deducted - patient not responsible for charges.	N
A05	Charge processed incorrectly. Corrected claim in process.	N
A06	Entire payment credited to refund account.	Y
A10	Processing error adjusted - corrected patient responsibility indicated.	-
A14	Charge processed incorrectly. New claim in process.	N
C01	This claim has been coordinated with your primary insurance coverage.	-
C02	Benefits were coordinated with other Regence plan.	-
C03	Paid from coordination of benefits savings.	-
C04	Please send claims payment explanation from other carrier. Will reprocess when received.	Y
C05	Additional payment after coordination of benefits with other carrier.	-
C06	Multiple coverage letter not answered - will reprocess if received.	Y
C09	Please send claim processing explanation from your other carrier. Will reprocess when received.	Y
C10	Multiple coverage letter not answered - will reprocess if received.	Y
C16	We are unable to process this claim without the completed multiple coverage letter previously sent.	Y
D01	Duplicate charge - indicate if corrected bill or review requested & submit to claims review with notes/report.	N
D02	Duplicate charge currently in process.	N
D03	Duplicate charge - indicate if corrected bill or review requested & submit to claims review with notes/report.	N
E01	Coverage not in effect for date of service.	Y
E03	Procedure/treatment started prior to coverage.	Y
E13	Replacement of teeth extracted prior to coverage are not covered.	Y
E24	Dental procedure is subject to contract waiting period.	Y
I06	Required report or additional information requested not received. Claim will be adjusted upon receipt.	N
I40	Do not auto-reject claim as duplicate.	-
I56	The frequency of this service is beyond nationally accepted dental practice guidelines.	Y
I59	Columbia Dental Group referral. Please contact Columbia Dental Group for processing at 1-800-360-1909.	Y
I60	Columbia Dental Group out-of-network emergency service. Contact Columbia Dental Group at 1-800-360-1909.	Y
I75	Required reports/itemization and/or requested additional information not received.	N
I95	Resubmit with copy of general anesthesia or conscious sedation permit. Will reprocess when received.	Y
I96	X-ray and description relationship is inconsistent. Please resubmit with clarification.	Y
I97	Description or charting is missing or inadequate to determine benefit.	Y
M01	Maximum contract benefit expended.	Y
M06	Maximum contract benefit allowance.	Y
M42	Benefit exhausted. Scaling and root planing is limited to once per calendar year.	Y
M53	Orthodontia lifetime maximum has been exhausted.	Y
M54	Service exceeds benefit. Contract limits this dental procedure to twice every 1 calendar year.	Y
M55	Sealant exceeds once every 3 calendar year limitation and/or is covered on permanent bicuspid/molars.	Y
M56	Service exceeds benefit. Contract limits this dental procedure to once every 2 calendar years.	Y
M61	Procedure denied. Per contract, limit of one abutment tooth placed on each side of the missing tooth.	Y
M62	Service exceeds benefit. Contract limits this dental procedure to once every 3 calendar years.	Y
M63	Service exceeds benefit. Contract limits this dental procedure to once every 5 calendar years.	Y
M66	Service exceeds benefit. Full mouth scaling and root planing is limited to once every 2 calendar years.	Y
M67	Dental procedure has not met the 7 year replacement contract limitation.	Y
M68	Service exceeds benefit. Contract limits to one set of bitewing x-rays every 1 calendar year.	Y
M69	Sealant exceeds once every 4 calendar year limitation and/or is covered on permanent bicuspid/molars.	Y
NB6	Dental implants and associated surgical procedures are contract exclusions.	Y
NB7	Cosmetic dentistry is a contract exclusion.	Y
NC2	IV sedation is not covered for this dental procedure.	Y
NC3	Occlusal/Nightguard is a contract exclusion.	Y
NC5	Unable to process until general anesthesia or conscious sedation permit is received.	Y
N01	Not covered by contract.	Y
N03	This provider is not covered under this contract.	Y
N04	This provider is not covered for this procedure.	Y
N06	Payment cannot be made for incomplete treatment.	Y
N07	Condition not covered by contract.	Y
N08	This service/procedure is not a contract benefit.	Y
N13	Patient is over the contract age limit for fluoride treatment.	Y
N16	No orthodontic benefits provided by contract.	Y
N33	Dental services are not covered by your contract.	Y
N34	Procedure not covered following Dental Consultant's review.	Y
N50	Procedure code is not a valid ADA code. Please refer to the current CDT book.	Y
N55	Patient is over the contract age limitation for sealant treatment.	Y
N56	Treatment not covered. Contract requires treatment to be rendered at a Columbia Dental Group Clinic.	Y
N71	Services provided by a family member are not payable.	Y
N73	General anesthesia not covered for this dental procedure.	Y
P01	Paid at contract percentage of maximum allowable fee.	-
P03	Allowed amount paid at contract percentage.	Y
P05	Paid at contract percentage of maximum allowance.	Y
P07	Paid to contract percentage for non-preferred provider.	Y
P20	This service paid to your dental injury benefit.	Y
P28	Amalgam/gold material allowance provided for posterior teeth.	Y
P30	Amalgam or composite filling allowance provided per Dental Consultant review.	Y
P32	Inlay and gold foil are contract exclusions. Amalgam allowance provided for these procedures.	Y
P33	Paid to the Federal DentalBlue non-preferred network percentage.	Y
S24	Paid out of savings.	-
U04	Please submit medical necessity documentation for this procedure.	Y
WC4	Full mouth x-ray allowance provided when 10 or more periapical x-rays including bitewings are billed.	N
WC5	Debridement denied. Cleaning allowance provided.	Y
W05	Procedure not allowed or included in similar procedure.	N
W12	Claim not submitted within required time limits.	N
W20	Anesthesia is not paid to surgeon.	Y
W21	Allowance based on corrected code.	-
W66	Allowance reduced following dental consultants review. Number of teeth does not equal quadrant benefit.	-
W70	This service by this provider not within the scope of their license.	N
W75	Claim not submitted within required time limits.	N
X07	Subject to dental deductible.	-
X09	Subject to medical/dental deductible.

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