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CO-254 Denial Code: Dental Plan, Bill Medical Plan

CO-254 means the dental plan received the claim, but benefits are not available under that plan. The services should be submitted to the patient's medical plan for further consideration. The dental plan did not forward the claim.

Quick facts

Code
CO-254 (CARC 254)
Status
Active In use since June 2, 2013; last modified November 1, 2017.
Code set
Claim Adjustment Reason Codes (CARC)
Group codes
  • CO (Contractual Obligation): The dental plan will not pay. The provider should bill the medical plan; the amount is not a patient balance at this stage.
  • OA (Other Adjustment): Some dental plans report it as OA because they are neither paying nor assigning the amount to the patient.
Official description
Claim received by the dental plan, but benefits not available under this plan. Submit these services to the patient's medical plan for further consideration.
X12 Claim Adjustment Reason Codes, retrieved September 25, 2026
Last verified
against the official X12 list.

What CO-254 means

CARC 254 says the claim was received by the dental plan, but benefits are not available under this plan. Submit these services to the patient’s medical plan for further consideration. X12’s note adds that if the dental plan forwarded the claim to the medical plan, it should use CO-290 instead.

So CO-254 is a routing instruction. The dental plan is telling you these services belong under medical coverage and that it did not send them over for you. You need to create and submit a medical claim.

This comes up when dental offices, oral surgeons, or hospital dental departments treat conditions that sit on the boundary between dental and medical care.

Common causes

  • Accident-related oral injuries, which many plans cover under medical benefits.
  • Oral surgery that the dental plan classifies as medical, such as some jaw procedures or biopsies.
  • Treatment tied to a medical condition, such as dental care required before certain medical treatments.
  • Hospital or facility charges for dental procedures, which dental plans usually do not cover.
  • Sleep apnea appliances and other items that some plans cover under medical benefits.

How to fix it

  1. Get the patient’s medical insurance details, including subscriber, member ID, and payer address.
  2. Verify medical coverage and any prior authorization requirements for the service.
  3. Convert the claim to the medical format: ICD-10-CM diagnoses in box 21, medical procedure codes in box 24D, and the right place of service in box 24B. A direct CDT-to-medical crosswalk may not exist for every service; code what was actually documented.
  4. Attach the dental plan’s EOB if the medical plan requires proof that the dental plan denied.
  5. Submit within the medical plan’s timely filing limit, which runs separately from the dental claim.
  6. Hold patient billing until the medical plan responds.

How to prevent it

  • Screen treatment plans for services likely to fall under medical coverage and verify both plans in advance.
  • Collect medical insurance information for every patient, not just dental.
  • Train staff on medical claim formats and diagnosis coding for cross-coded services.
  • Obtain medical prior authorization when required before scheduling.

Specialty notes

Oral and maxillofacial surgeons and hospital dentistry programs see CO-254 most often. General dental practices may see it for trauma cases. See eligibility and COB denials for guidance on handling multiple coverages.

Remark codes that may appear with CO-254

  • N216 (We do not offer coverage for this type of service or the patient is not enrolled in this portion of our benefit package.): The plan does not cover this type of service, or the patient is not enrolled in the relevant benefit.
  • N130 (Consult plan benefit documents/guidelines for information about restrictions for this service.): Points to plan documents describing dental versus medical coverage.
  • CO-290 (Claim received by the dental plan, but benefits not available under this plan.): The dental plan forwarded the claim to the medical plan itself, so you should not rebill.
  • CO-109 (Claim/service not covered by this payer/contractor.): The claim was sent to the wrong payer or contractor.
  • PR-204 (This service/equipment/drug is not covered under the patient's current benefit plan): The service is not covered under the patient's current benefit plan.

CO-254 FAQ

What is the difference between CO-254 and CO-290?

With CO-254, the dental plan did not forward the claim, so you must submit it to the medical plan. With CO-290, the dental plan forwarded it for you.

Which dental services go to medical insurance?

Examples often include treatment of oral injuries from accidents, some oral surgery, biopsies, and treatment related to medical conditions. Coverage varies widely by plan, so verify with the medical plan.

Do I need a different claim form for the medical plan?

Usually yes. Medical plans typically require a professional (CMS-1500 or 837P) or institutional claim with ICD-10-CM diagnoses and medical procedure codes, rather than a dental claim form with CDT codes.