Dental claim documentation requirements by payer

The SRP pocket-depth threshold nobody publishes

The 4 mm rule circulating in billing content is not a payer requirement. The ADA records that dentistry and the dental literature differ on pocket depths as benchmarks, so payers establish their own criteria — criteria that can differ from payer to payer and, inside one payer's book of business, from one customer to another. Two claims to the same payer with similar charts can be adjudicated differently because the patients sit under different employer group policies. What the documents below do publish is the evidence a reviewer wants: the charting method and its date, the radiographic findings, and the chart notes.

Procedure families, and what each payer asks to see

Where each payer publishes its rules

• Aetna Public — no login

  44 Dental Clinical Policy Bulletins (DCPBs), a per-code Dental and Oral Surgery Claim Documentation Guidelines PDF, the DMO/PCD Dental Office Guide procedure-guidelines section, and public claim-submission pages — all readable without a provider login. The Dental Office Guides that carry plan frequency limits are the part behind the login.

  DCPBs carry rolling per-bulletin dates: DCPB003 and DCPB012 updated March 13, 2026; DCPB004, DCPB008, DCPB041 and DCPB043 reviewed March 24, 2025; DCPB013 and DCPB015 May 15, 2025. The claim-documentation guidelines were last updated July 21, 2025 at aetna.com; the older /families/ path still serves the superseded September 30, 2019 edition, which is stamped Proprietary on every page and is not cited here. The DMO procedure guidelines are stamped revised December 15, 2025, and the downcoding-and-bundling page carries no date at all.

  Aetna Dental Clinical Policy Bulletins index (44 bulletins)Aetna Dental and Oral Surgery Claim Documentation Guidelines, last updated July 21, 2025 (PDF)Aetna DMO/PCD Dental Office Guide, Section VIII — Procedure Guidelines, revised December 15, 2025 (PDF)

• Cigna Public — no login

  Complete Dental Clinical Coverage Determination Guidelines for DPPO/indemnity and DHMO plans, published as public PDFs with named per-family policies (PERIO-16, PERIO-19, PERIO-20, REST-03, REST-06, IMPLNT-01, FPROS-01), plus a dental office reference guide. None of it requires a provider login; CignaforHCP is an additional access path, not the only one.

  Annual editions with in-year re-issues: the DPPO guidelines carry doc 928339 for the January 2026 edition and form 999493 05/26 for the May 2026 re-issue, whose policy inventory is identical. The DHMO guidelines are form 999492 and carry no restorative or prosthodontic section at all. The DPPO office reference guide is form 988135 12/25.

  Cigna Dental Clinical Coverage Determination Guidelines — DPPO, 2026 edition, doc 928339 (PDF)Cigna Dental Clinical Coverage Determination Guidelines — DPPO, May 2026 re-issue, form 999493 05/26 (PDF)Cigna Dental Clinical Coverage Determination Guidelines — DHMO, 2026 edition, form 999492 (PDF)Cigna Dental PPO dental office reference guide, form 988135 12/25 (PDF; also via CignaforHCP.com › Resources › Reference Guides)

• Delta Dental (Delta Dental Ins. enterprise) Public — no login

  Clinical Criteria / utilization-management document covering Delta Dental of California, New York, Pennsylvania, Delaware, DC, and West Virginia, with a Procedure Codes that Require Documentation Submission table; the national Dentist Handbook is posted publicly by several member companies in annual editions.

  The Clinical Criteria document is Section 4 of the 2025 Claims Processing Policies and Procedures, and its cover reads effective January 1, 2025 pending state regulatory approval — so the date is not uniformly in force across the seven companies it binds. The national Dentist Handbook publishes annual January editions. Delta Dental is 39 independent member companies and criteria vary — Delta Dental of Washington, for example, routes claims documentation through its provider portal with no public criteria document.

  Delta Dental Ins. Clinical Criteria / Utilization Management, Section 4, effective January 1, 2025 pending state regulatory approval (PDF)Delta Dental FYI — claim tips for core buildups and crown lengthening, December 2, 2022Delta Dental Federal Government Programs Dental Office Handbook 2026 (PDF)Delta Dental of North Carolina — Dentist Handbook, January 1, 2026 (PDF)

• Delta Dental of New Jersey Public — no login

  A public participating-dentist handbook that republishes Delta Dental national processing policies, a required-documentation chart covering New Jersey and Connecticut, and plan-level DeltaCare USA copayment schedules.

  The handbook Dentovio read is the 2023 participating-dentist edition (© 2022 Delta Dental of New Jersey); the required-documentation chart is the 2026 edition; the DeltaCare USA schedule read is plan 18B, version V24.

  Delta Dental of New Jersey Participating Dentist Handbook, 2023 edition (PDF)Delta Dental NJ & CT Required Documentation Chart 2026 (PDF)

• Delta Dental of Arkansas (Delta Dental Smiles, Arkansas Medicaid) Public — no login

  A public 117-page Delta Dental Smiles provider manual covering the ARKids First children's program through age 20 and the adult Arkansas Medicaid dental program.

  Version 12, effective December 1, 2023. Revisions 13 and 14 were not found at the same path, so treat V12 as the newest verified edition rather than a guaranteed current one.

  Delta Dental Smiles Provider Manual V12, Delta Dental of Arkansas (PDF)

• MetLife Provider portal login required

  MetLife's provider criteria, guides and fee schedules sit behind the dentalprovider.metlife.com single sign-on. No MetLife-hosted provider criteria document is publicly readable, so this record carries the gating fact and one MetLife-authored plan document a sponsor republished — nothing else.

  On 2026-08-30 metdental.com was a stub redirecting to dentalprovider.metlife.com, whose single-sign-on wall returns an authentication redirect even for robots.txt and a 401 for its sitemap; the legacy content paths return 404. The eforms.metlife.com copy of the Preferred Dentist Program Resource Manual returned an unavailable-form page on four attempts and could not be read, so nothing is attributed to it.

  MetLife dental provider portal (current criteria; single sign-on required)MetLife PDP Plus plan language republished by a plan sponsor — Lumen Technologies Dental Plan summary plan description, effective January 1, 2026, p. 14 (PDF)

• United Concordia Public — no login

  A public 59-page United Concordia Dental Clinical Policy for PPO plans, reachable through a no-login click-through acknowledgement, plus provider-education documents, help-center policy pages, a public DE/PA/WV Medical Assistance dental reference guide, and the federal FEDVIP brochure. The commercial Dentist Reference Guides are the part that requires a Dental Hub login.

  The PPO clinical policy is footer-stamped 'Last update: 5.1.26' and states it is reviewed at least annually; the DE/PA/WV Medical Assistance guide is Volume 2026, Issue 1; the FEDVIP brochure is the 2025 plan year. Provider-education transcripts are undated — confirm those against the current help-center pages.

  United Concordia Dental Clinical Policy (PPO), last update 5.1.26 — public behind a no-login acknowledgement (PDF)United Concordia Dental Reference Guide — Medical Assistance DE, PA, WV, Volume 2026 Issue 1 (PDF)United Concordia — Scaling and Root Planing Claims: Getting It Right (PDF)United Concordia Dental FEDVIP brochure, 2025 plan year — Section 5, Periodontal Services (OPM)

• Guardian Public — no login

  Guardian's public provider toolkit links directly to its Dental Clinical Guidelines 2026, including sections for scaling and root planing, indirect restorations and crowns, and core buildups and post-and-core procedures.

  The 13-page 2026 guidelines were updated August 12, 2026 and state an effective period of January 1 through December 31, 2026.

  Guardian provider toolkit — public clinical-guidelines linkGuardian Dental Clinical Guidelines 2026, updated August 12, 2026 (PDF)Guardian DentalGuard Preferred network dentist manual, stamped 08.25.2025 (PDF)

• DentaQuest (Medicaid/CHIP administrator) Public — no login

  Per-state Office Reference Manuals (ORMs) with numeric clinical criteria, publicly downloadable (e.g., Colorado Health First, Indiana via Humana, Kentucky via Anthem, Medi-Cal via Health Net).

  ORMs carry sub-annual effective dates (the Colorado ORM is stamped July 1, 2026). Criteria are state- and program-specific — always open the ORM for your state.

  DentaQuest Colorado Health First Office Reference Manual (PDF)DentaQuest Indiana ORM via Humana (PDF)DentaQuest Kentucky Medicaid manual via Anthem (PDF)DentaQuest Texas Authorization Catalog — prior-authorization and pre-payment-review code table (PDF)DentaQuest Texas HHSC Medicaid/CHIP Office Reference Manual, © January 1, 2026 — Exhibit A and clinical criteria (PDF)Virginia DMAS Medicaid bulletin — Clarification for adults enrolled in dental Medicaid, last updated 09/05/2024

• MCNA Dental (Medicaid/CHIP administrator) Public — no login

  Public, versioned per-state provider manuals. The Texas Medicaid and CHIP manual carries the full fee schedule with age bands, authorization flags, frequency limits and documentation requirements, in separate Medicaid and CHIP chapters.

  Manuals version several times per year: the Texas manual is v1.31, effective March 1, 2026, with a portal release date of April 14, 2026; the v1.29 edition cited in earlier research is superseded. State Medicaid criteria (TMHP, AHCA) apply alongside the manual.

  MCNA Texas Medicaid and CHIP Provider Manual v1.31, effective March 1, 2026MCNA Texas dentist resources

Which code is it? Common questions

Before the attachment question comes the coding question, and the same four pairs cause most of it. The coding half of each answer is the ADA's own free reporting guidance; the payer half is in the tables above.

The cleaning took 45 minutes and bled the whole time — is that D4346?

Not on time or difficulty. The ADA's free guide to reporting D4346 says the code is based on the diagnosis rather than the intensity of the treatment required, and answers no where a hard prophy is being defined strictly by how long the procedure took. The guide positions D4346 as a therapeutic procedure for a patient in a diseased state — generalized moderate or severe gingival inflammation where periodontitis is not present. Where there is attachment or bone loss, the question is scaling and root planing instead, and the payer criteria for that sit in the tables above. One number to leave out of the chart note: the ADA does not publish a percentage-of-teeth threshold as a code criterion. The 30% figure circulating in billing content is a periodontitis definition the ADA describes as reasonable to extend to gingivitis, not a bright line the ADA has drawn.

Can D4346 and a prophy be billed on the same day?

The ADA's guidance is that D4346 should not be reported alongside a prophylaxis, scaling and root planing, or a debridement — but it does not treat that as absolute. The same guide says that in an exceptional situation the dentist could submit a claim for both services with an explanatory narrative. Payment is a separate question from coding: the ADA states plainly that the benefit plan, not the ADA, determines the guidelines, policies, and exclusions, so a payer denial is not by itself proof the code was wrong.

The extraction took 45 minutes because of a stubborn root — does that make it D7210?

No. The ADA's free guide to extractions is explicit that the extraction codes carry no simple-or-difficult wording in their nomenclatures or descriptors, and that D7250 in particular is not intended to document a difficult extraction. D7210 turns on whether bone had to be taken or the tooth had to be cut apart, not on how long the appointment ran; raising the gum flap alone does not make it surgical. The bone removal does not have to be planned: the ADA describes reporting D7210 where the crown and root separated during the procedure for any reason and removing the root tip required bone removal. Two corrections worth carrying with that: a simple extraction can still involve smoothing bone at the socket, and that alone does not make it D7210 — and no ADA source requires the note to name a bur or handpiece. What the payers do require is in the extraction tables above.

Can we bill D4910 for a patient who has never had SRP?

Not on the code's own terms. Periodontal maintenance is a follow-up code: it presumes active periodontal treatment has already happened, and the ADA's own comparison table names active periodontal therapy — scaling and root planing, gingival flap, or osseous surgery — as its precursor procedure. Payer history and frequency rules then sit on top of that and differ sharply, as the periodontal maintenance records above show: Cigna allows it on a history of active therapy or a previously allowed maintenance visit and leaves frequency to the plan, while Aetna's DMO plans have their own history condition and pay a prophylaxis allowance where none exists.