Dentovio public answer

dental claim denial codes

Dental denials arrive as CARC codes with CO/PR group codes, and they are not equally appealable: exclusions (the 96 family) and exhausted maximums (119) are structural, fix-and-resubmit codes (16, 18, 251) are not appeals at all, and documentation and necessity denials (50) are the winnable family when the record matches the payer's published criteria. The appeal route depends on plan funding: state prompt-pay law for fully-insured plans, 29 CFR 2560.503-1 for self-funded ERISA plans, and the 42 CFR 438 appeal-then-fair-hearing chain for Medicaid dental MCOs.