PR-254: Dental Plan Benefits Not Available - Submit to Medical

What Does PR-254 Mean?

When paired with Group Code PR, CARC 254 shifts the financial responsibility to the patient. The adjustment for dental plan benefits not available - submit to medical is deemed the patient's responsibility. The provider should verify the PR designation is correct before billing the patient.

CARC 254 fires when a dental plan receives a claim and determines the billed services are not covered under the patient's dental benefits. The dental plan is explicitly directing the provider to resubmit the claim to the patient's medical insurance plan, where the services may be covered. This is not a statement that the services are non-covered entirely — it is a routing instruction.

This code applies to services that straddle the line between dental and medical coverage. Common examples include oral surgery procedures (jaw fracture treatment, cyst removal), TMJ/TMD treatment, oral biopsies, dental services related to trauma or accidents, and medically necessary extractions prior to radiation therapy. These services often have medical rather than dental insurance coverage, but providers may initially submit to the dental plan out of habit or because the service occurred in a dental setting.

CARC 254 appears with Group Code CO, making it a contractual adjustment on the dental plan side. The provider's next step is to obtain the patient's medical insurance information and rebill the claim to the medical plan using appropriate medical coding (CPT/ICD-10 rather than CDT codes). If the patient has no medical insurance or the medical plan also denies coverage, the patient may become financially responsible.

How to Resolve

1. Verify patient responsibility Confirm that the PR group code assignment is correct for the CARC 254 adjustment. Review the remittance advice and any RARC codes for context.
2. Review for potential errors Check whether the underlying denial reason can be corrected, which may eliminate the patient's responsibility. Verify coding accuracy and documentation completeness.
3. Appeal if designation is incorrect If the PR assignment appears incorrect or the denial is in error, file an appeal with supporting documentation before billing the patient.
4. Generate patient statement If the determination is correct, generate a patient statement for the amount and follow standard patient collection procedures.
5. Communicate with the patient Explain the charge to the patient, provide information about their financial responsibility, and discuss payment options.

How to Prevent PR-254

• Verify patient coverage and financial responsibility before rendering services
• Communicate potential out-of-pocket costs to patients proactively
• Review PR-254 adjustments before billing to confirm the designation is appropriate

Also Filed As

The same CARC 254 may appear with different Group Codes:

Related Denial Codes