Provider Billing Tips

Listed below is information about common Medi-Cal Dental billing issues along with helpful tips and suggestions for preventing denials from occurring. Check back regularly for updates.

Top Five Denials

  • Reason Code 128 - Cast and prefabricated posts are benefits in endodontically treated devitalized permanent teeth only when crowns have been authorized and/or paid by the Medi-Cal Dental program.
  • Reason Code 113 - Tooth does not meet the Manual of Criteria for a laboratory processed crown. Please re-evaluate for alternative treatment. Refer to Restorative General Policies (D2000- D2999) in section 5 of the Provider Handbook.
  • Reason Code 081 - Periodontal procedures cannot be justified on the basis of pocket depth, bone loss, and/or degree of deposits as evidenced by the submitted radiographs and/or charting. Refer to Periodontal General Policies (D4000- D4999) in section 5 of the Provider Handbook.
  • Reason Code 048 - Extraction of a tooth is not payable when pathology is not demonstrated in the radiograph, or when narrative documentation submitted does not coincide with the radiographic evidence. Refer to Oral and Maxillofacial General Policies (D7000- D7999) in section 5 of the Provider Handbook.
  • Reason Code 326 - Procedures being denied on this document due to invalid response to the RTD or, if applicable, failure to provide radiographs/attachments for this EDI document.

Clinical Reasons for Denials:

  • Non-diagnostic radiographs
  • Missing or incomplete submission of radiographs
  • Radiographs/photographs fail to demonstrate medical necessity for restorative procedures
  • Poor prognosis for treatment:
    • Tooth/teeth/arch show severe bone loss
    • Gross destruction rendering the tooth/teeth/arch unrestorable

Clerical Reasons for Denials:

  • Other coverage claims for payment must have an EOB/RA attached showing action taken from prime carrier. Medi-Cal Dental is always the secondary carrier.
  • Failure to submit treating provider/NPI numbers.

Helpful Hints to Avoid Denials:

Medi-Cal Dental would like to offer the following to help offices avoid delays in payment and the denial of Claims and Treatment Authorization Requests (TARs).

  • Members 21 years and older;

    Authorized procedures on a Notice of Authorization (NOA):

    • Medi-Cal Dental authorized treatment on an NOA may be allowed even though the member's 21st birthday occurs before the expiration date on the NOA. Procedures requiring prior authorization will be payable as long as the member is eligible at the time services are rendered.
    • Orthodontic coverage is a benefit to age 21 for qualifying members. Authorized Ortho treatment may be rendered on an eligible member through the month of their 21st birthday.
  • All Medi-Cal Dental forms: i.e. claims/TARs/NOAs/RTDs/CIFs require a live signature from the provider or authorized staff member. Rubber stamps or "signature on file" cannot be accepted.
  • Use the existing NOA for a re-evaluation of a denied procedure by marking the re-evaluation box on the upper right corner and check the attachment box. Do not submit a Claim Inquiry Form (CIF).
  • Bite-wing radiographs are considered arch films and are considered current for a period of 36 months.
  • Anterior periapical radiographs and bite-wings are enough to establish arch integrity of the upper/lower arches.
  • Do not use x-ray envelopes for periodontal charts or any other type of documentation. X-ray envelopes are to be used for radiographs and photographs only. Staple all attachments to the back of the Claim/TAR form. Do not reuse X-ray envelopes that have been returned to you by Medi-Cal Dental.