Denial Code 290 means that a claim has been received by the dental plan, but benefits are not available under this plan. The claim has been forwarded to the patient’s medical plan for further consideration. In this article, we will provide a detailed description of denial code 290, common reasons for its occurrence, next steps to resolve the denial, tips on how to avoid it in the future, and examples of denial code 290 cases.
2. Description
Denial Code 290 is a specific claim adjustment reason code (CARC) that indicates the claim has been received by the dental plan, but the benefits are not available under that particular plan. As a result, the claim is forwarded to the patient’s medical plan for further consideration. This denial code is typically used when the dental plan does not cover the specific service or procedure being claimed.
2. Common Reasons
The most common reasons for denial code 290 are:
- Service Not Covered: Denial code 290 often occurs when the dental plan does not include coverage for the specific service or procedure being claimed. This could be due to limitations in the plan’s coverage, exclusions for certain treatments, or restrictions on the frequency or necessity of the service.
- Out-of-Network Provider: Another common reason for denial code 290 is when the provider is not in-network with the dental plan. Dental plans often have a network of preferred providers, and if the service is performed by an out-of-network provider, it may not be covered under the plan.
- Missing Preauthorization: Some dental plans require preauthorization for certain services or procedures. If the claim is submitted without obtaining the necessary preauthorization, it may be denied under code 290.
- Benefit Limitations: Denial code 290 may also occur if the claim exceeds the plan’s benefit limitations. Dental plans often have annual maximums or specific limits on coverage for certain services. If the claim amount exceeds these limits, it may be denied.
3. Next Steps
If you receive a denial with code 290, here are the next steps to resolve the issue:
- Review Plan Coverage: First, review the patient’s dental plan coverage to determine if the service or procedure being claimed is indeed not covered. Check the plan documents or contact the insurance company for clarification.
- Verify In-Network Status: If the service was performed by an out-of-network provider, confirm whether the dental plan covers out-of-network services. If not, consider discussing alternative options with the patient, such as seeking treatment from an in-network provider or exploring other coverage options.
- Check Preauthorization Requirements: If the denial is due to missing preauthorization, determine if the service or procedure requires preauthorization according to the dental plan’s guidelines. If so, work with the patient and the insurance company to obtain retroactive preauthorization or explore other options for coverage.
- Appeal the Denial: If you believe the denial was incorrect or unjustified, prepare an appeal. Gather any supporting documentation, such as clinical notes, treatment plans, or evidence of medical necessity, to demonstrate why the service should be covered. Follow the dental plan’s appeal process and submit the necessary documentation within the specified timeframe.
- Coordinate with Medical Plan: If the claim has been forwarded to the patient’s medical plan, communicate with the medical plan to ensure they have received the claim and understand the circumstances. Provide any requested information or documentation to support the claim’s consideration under the medical plan.
4. How To Avoid It
To avoid denial code 290 in the future, consider the following tips:
- Verify Coverage: Before providing any services, verify the patient’s dental plan coverage to ensure the service or procedure is covered. Review the plan’s limitations, exclusions, and network requirements to avoid potential denials.
- Obtain Preauthorization: If the dental plan requires preauthorization for certain services, make sure to obtain it before providing the treatment. Familiarize yourself with the preauthorization process and requirements to prevent denials due to missing preauthorization.
- Communicate with Patients: Clearly communicate with patients about their dental plan coverage, including any limitations or exclusions. Discuss treatment options, costs, and potential out-of-pocket expenses to manage expectations and minimize surprises.
- Stay In-Network: Whenever possible, encourage patients to seek treatment from in-network providers to ensure maximum coverage under their dental plan. If you are an out-of-network provider, inform patients about potential limitations or additional costs they may incur.
5. Example Cases
Here are two examples of denial code 290:
- Example 1: A patient submits a claim for cosmetic teeth whitening to their dental plan. However, the dental plan explicitly excludes coverage for cosmetic procedures, resulting in denial code 290.
- Example 2: A provider performs a dental implant procedure for a patient who has a dental plan with a maximum coverage limit of $2,000 per year for major services. The claim for the dental implant exceeds the plan’s coverage limit, leading to denial code 290.
