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CO-204
Recoverability: Low
This service/equipment/drug is not covered under the patient's current benefit plan
The member's specific plan design does not include this service. It differs from a general non-covered denial in that it points at the current plan's benefit package rather than a blanket exclusion.
Why this happens on dental claims
- Employer groups that purchased a dental package without major, orthodontic, or implant riders
- Patients who changed plans mid-treatment and lost coverage the old plan included
- Adult orthodontic or implant services on plans that cover them only for dependents, or not at all
How to appeal CO-204
- Request the specific benefit provision: which category the plan places the service in and why it is absent from this member's package
- Verify against the member's benefit summary, since front-desk verification sometimes reads a different plan tier
- Check for alternate benefit provisions, such as a partial denture allowance applied toward an implant-supported case
- If a mid-treatment plan change caused the gap, submit to the prior plan under its incurred-date rules
- Move the balance to the patient with documentation when the gap in benefits is real
How to prevent it
- Verify category-level benefits, including major, prosthetics, orthodontics, and implants, rather than just active coverage before large cases
Related codes
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