In the Medicare program, electronic and paper insurance claims may be rejected (formally denied) because the medical service was not covered, medical necessity was not met, the service was bundled with other services, the diagnosis was not covered, the claim was payable only in certain locations (e.g., outpatient only), prior approval was not obtained, or so on.

Alpha, numerical, or alphanumerical system used by insurance companies to explain partial or complete denials of insurance claims. Denial codes usually appear on documents such as explanation of benefits (EOBs).

1. Rejection of a medical service due to insurance coverage policy or insurance program issues. 2. Rejection of all or part of an insurance claim. Application of contractual copayments and deductibles is not considered a denial of a claim. 3. Official Medicare decision that services will not be approved for payment. This may be due to a decision that the service is not an approved service, not being provided in the proper setting for the level of care, not provided by an approved participating provider, or not medically necessary.

Medical claim submitted to an insurance company in which payment has been rejected due to a technical error or because of medical coverage policy issues. Also called denied paper claim or denied electronic claim .

1. Optional benefit offered by commercial insurance or managed care plans. Dental benefits may be combined with a health insurance plan or may be a separate policy with a different insurance company. 2. Insurance coverage for basic dental services such as cleanings, cavity repair, and necessary dental surgery including preventive care. Most dental plans do not cover the cost of orthodontia.

Outpatient facility that provides dental services by a group of dentists practicing together and assumes dental care responsibility for patients (e.g., examination of teeth and gums, cleaning of teeth, diagnostic x-rays for caries, educational services for prevention of diseases of the teeth and gums).

Organization endorsed by the American Dental Association that maintains the data content specifications for dental billing. Under the Health Insurance Portability and Accountability Act (HIPAA), this committee acts as a consultant for all transactions affecting dental health care services.

Managed care plan similar to a health maintenance organization (HMO) that provides only dental care.