Dear ADA: Noncovered services

Coverage typically defined by benefit eligibility, not payment

Dental insurance issues are often rated as one of dentists’ biggest challenges.

In response to an ADA Health Policy Institute poll in late 2025, more than half of dentists reported that one of their top concerns looking ahead to 2026 was related to insurance, including low insurance reimbursement rates and delayed or denied payments.

This ADA News series aims to address some of those challenges. Dear ADA will feature answers to common insurance-related questions the American Dental Association receives from members to help provide clarity and direct members to additional resources.

The answer to this month’s question is provided by Liz Papineau, D.D.S., a member of the ADA Council on Dental Benefit Programs.

Dear ADA: If a plan denies a procedure as a noncovered service, why am I still required to accept the contracted PPO fee instead of my full fee?

Dr. Papineau: The short answer is: It depends on language in your state regulations and your PPO contracts, and whether the plan is subject to state regulation or claims exemption. Forty-four states have noncovered services laws prohibiting plans from dictating a provider’s fee for procedures that are not covered under the plan; however, if a service is covered but not paid because plan conditions were not met, you may still be bound to the contracted fee based on the definition of a covered service in your state. In the remaining six states — South Carolina, Delaware, New York, Michigan, Massachusetts and Hawaii — your PPO contract is key to determining the fees that can be charged to a patient covered by a dental benefit plan.

Let’s do a deeper dive into those states with laws on noncovered services. How your state law defines a covered service is a key factor in determining the fee the dentist may collect. Many dentists assume “covered” means “paid.” In most state laws, however, a covered service is defined by benefit eligibility, not by whether a claim was ultimately paid. But in some states, like Iowa for example, covered services are defined as services that are actually reimbursed to some extent. In Nebraska, covered services are not defined, so they can either be interpreted as services where payment was made (with noncovered services being ones where no payment was made) or as services that are contractually covered under the plan, regardless of payment. Understanding the interpretation of a covered service in your state and the difference between noncovered and nonpayable is the key.

With such variation in the language and interpretation of state laws, you can see there is no perfect answer on what a covered service is or what exactly an office is able to charge when services are not covered by a plan. In states that define a covered service as being one that is paid, the answer is more straightforward: If no payment is made, it is considered a noncovered service and the office may charge their full fee. However, more states define a covered service based on benefit eligibility, regardless of payment. In these states, plans may limit billing to the PPO fee for covered services even when no payment is made by the plan.

Examples of conditions when covered services may not be paid by the plan include:

• Annual maximum reached: The plan still recognizes the procedure as a benefit category, but $0 is paid because the maximum is exhausted.

• Frequency limitation exceeded: The service is still a covered benefit in concept but not payable again within the same period.

• Deductible not met: The plan would pay if the deductible were satisfied.

• Waiting period in effect: The service category is covered but not payable until the waiting period ends.

If a service is truly not covered, that means the plan never recognizes the procedure as a benefit, the service is expressly excluded in the plan, and you may be able to charge your full fee, subject to your PPO contract terms.

Examples of truly noncovered services include:

• Cosmetic veneers when the plan excludes cosmetic services entirely.

• Implants when the plan excludes them.

• Orthodontics when the plan excludes orthodontic procedures.

A quick question you can ask yourself to help determine if a service is covered but not payable or truly noncovered is: If the patient had not hit the maximum (or if the waiting period were over or the deductible were met, etc.), would this service have been paid under the plan? If yes, the service is covered but not currently payable and the PPO fee applies. If no, the service is likely noncovered, and you can often bill your full fee in states with noncovered services laws.

Another complicating factor is CDT code-level processing policy. When a plan applies a least expensive alternative treatment clause, downcoding or bundling, that typically indicates that the plan recognizes the service as a benefit but applies payment edits — for example, paying the equivalent of an amalgam restoration when the claim was submitted for a composite restoration. Because there are coverage edits, the service is typically still covered under the plan.

Additionally, if a payer were to introduce de minimis payments, or very small reimbursements that could be interpreted as nominal coverage, such payments could risk reclassifying an otherwise noncovered service as covered, thereby triggering contractual fee limits unless state law expressly prevents such manipulation. State legislation serves as the primary safeguard ensuring that token or de minimis payments cannot be used to undermine dentists’ ability to bill appropriately for services the plan does not meaningfully cover.

When considering whether or not the plan is subject to state law or if it claims exemptions, you have to know whether the plan is fully insured or self-funded. State noncovered services laws typically apply to fully insured plans regulated by the state’s department of insurance. However, self‑funded plans are typically governed by the Employee Retirement Income Security Act and may claim exemption from state insurance laws.

In fully insured, state-regulated plans, noncovered services laws often prevent the plan from setting your fee on truly noncovered services. Self‑funded, ERISA-governed plans may still require the discounted/contracted PPO fee for noncovered services. You should always attempt to determine if a patient’s plan is fully insured or self-funded. The ID card or summary plan description may name the employer as the plan sponsor or reference ERISA. If you’re unsure, contact the plan administrator directly and document the call.

What does this mean for billing? You should always bill for services you actually performed and documented. Always report your full fee on the claim form and let the payer adjust to the contracted amount when returning the explanation of benefits. Your collectible amount may still be limited to the contracted fee because the service category remains covered. If a service is truly noncovered under the plan terms, then noncovered services laws may let you collect your full fee. If you accept a payment for a least expensive alternative treatment, make sure you have patient consent acknowledging that a plan may pay for a less expensive alternative and the patient is responsible for paying the difference when state law and the plan contract allow.

Dentists can appeal payer decisions when appropriate. If a service was misclassified, submit a concise appeal with supporting plan language and your documentation. If you believe a plan violated a state noncovered services law, you can report the violation to your state department of insurance for a fully insured plan and follow U.S. Department of Labor/Employee Benefits Security Administration complaint pathways for a self-funded plan.

In your patient ledgers and correspondence, be sure to distinguish between services that are noncovered (not covered; patient is responsible for full fee) versus nonpayable (covered but not paid by plan; patient is responsible up to allowed amount). That documentation will be one of your strongest tools if appealing a payer decision or reporting a potential violation. You will also want to train your front desk and billing staff to explain these differences to patients. Consider providing them with scripts for various scenarios.

If you choose to advocate for policy change related to noncovered services in your state, share real-world examples with legislators that clarify the distinction between noncovered and nonpayable and why dentists need transparent plan disclosures. For fully insured plans, encourage your state’s department of insurance to issue clear guidance distinguishing these two types of services. For self-funded plans, promote plain-language plan documents dental offices and patients can use to see when a service is excluded versus limited.

So, how is the ADA helping members?

Over the last decade, the ADA has diligently supported states in ensuring passage of the noncovered services laws that we now have in 44 states across the nation. The ADA continues to help states refine these laws to protect dentists’ ability to collect fees appropriately. The ADA has introduced federal bills such as the Dental and Optometric Care Access Act, which seeks to prevent self-funded plans from dictating fees for noncovered services. Most recently, the ADA introduced the Improving Dental Administration Act, which would require state insurance reform laws applying to fully insured dental plans to also apply to self-funded dental plans, closing the ERISA preemption loophole carriers interpret as allowing them to avoid state law.  

The ADA also offers detailed guidance on understanding payer contracts.

These efforts emphasize fairness in insurer‑provider contracting and reducing interference in the doctor‑patient relationship.