dental claim denial codes

Sourced answer

Dental remittances pair a CARC reason number with a group code — CO, PR, OA, or PI — and the group code, not the CARC, assigns financial responsibility. X12 fixes the group code for only two of these codes: 18 may be used only with OA except where state workers' compensation law requires CO, and 45 only with PR or CO depending on liability. For every other code the payer chooses the group code under its own contract, so read the one on the remittance rather than assuming it from the number. This reference covers 39 codes with their registry dates and paired remark codes, each verified against a named payer crosswalk or the CAQH CORE combinations, with the absence stated where no source pairs them. Correction codes such as 16, 18, and 251 call for fixing the submission, plan exclusions and benefit limits turn on contract terms, and a documentation dispute can be contested when the record meets the payer's published criteria. The appeal route depends on plan funding: state law and plan terms for fully insured plans, 29 CFR 2560.503-1 for self-funded ERISA plans, and 42 CFR 438.402/438.408 for an enrollee's Medicaid managed-care benefit appeal. Provider payment and contract disputes follow the provider contract and state Medicaid process instead.