Billing & claims · Last verified 2026-08-28
Major dental payers publish real, different documentation rules for the most-reviewed procedures — and most denials in these families trace back to a submission that missed the specific payer's published threshold. Aetna, Cigna, the Delta Dental Ins. enterprise, United Concordia, and DentaQuest all publish their criteria openly (no provider login); MetLife's current guides and Guardian's criteria sit behind provider portals. This hub compares the published scaling-and-root-planing, crown, and core-buildup requirements payer by payer, with a direct link to every source document.
The single highest-leverage fact in dental claim documentation: the pocket-depth and bone-loss standards for scaling and root planing are payer-specific, and each payer publishes its own. Submitting to Aetna's standard on a DentaQuest claim (or vice versa) is how well-documented care still gets denied.
| Payer | Published SRP threshold | Policy access |
|---|---|---|
| Aetna | Aetna's claim-documentation guidelines state that, in general, documented 5–8 mm pockets determine D4341/D4342 benefits | Public — no login |
| Cigna | Pocket depths 4 mm or deeper, plus radiographic bone loss | Public — no login |
| Delta Dental (Delta Dental Ins. enterprise) | Radiographic alveolar crest loss beyond the normal 1–1.5 mm CEJ distance | Public — no login |
| MetLife | Published charting and radiograph rules; no numeric threshold stated | Archived public copy; current rules gated |
| United Concordia | Radiographically demonstrable bone loss | Public — no login |
| DentaQuest (Medicaid/CHIP administrator) | Radiographic bone loss ≥ 2.5 mm from the CEJ | Public — no login |
SRP is among the most-reviewed procedure families in dental claims. Payers deny or downcode it when the submitted periodontal charting does not show their pocket-depth threshold, when radiographs do not demonstrate bone loss, or when the quadrant does not contain enough qualifying teeth.
Requirements by payerCrown claims fail when the pre-operative radiograph is missing, undated, or panoramic-only, when the submitted evidence does not show enough structural loss to rule out a filling, or when a replacement crown lacks the prior placement date and reason.
Requirements by payerPayers routinely bundle D2950 into the crown fee. Without pre-operative evidence that the tooth lost enough structure to need a separate buildup, the bundle is usually final — this is the classic denial that documentation must prevent at submission, because it is rarely winnable afterward.
Requirements by payerAetna Public — no login
44 Dental Clinical Policy Bulletins (DCPBs) plus a per-code Dental and Oral Surgery Claim Documentation Guidelines PDF, both public with no provider login.
DCPBs carry rolling per-bulletin review dates (DCPB041 reviewed March 24, 2025); the claim-documentation PDF has been static since September 30, 2019.
Aetna DCPB041 — Scaling and Root PlaningAetna Dental Clinical Policy Bulletins indexAetna Dental and Oral Surgery Claim Documentation Guidelines (PDF)
Cigna Public — no login
Complete Dental Clinical Coverage Determination Guidelines for DPPO and DHMO plans, published as annual-edition PDFs with named per-family policies (PERIO-16, REST-03).
Annual editions; the 2026 edition is current.
Cigna Dental Coverage Determination Guidelines — DPPO, 2026 edition (PDF)Cigna Dental Coverage Determination Guidelines — DHMO, 2026 edition (PDF)
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.
Clinical Criteria effective January 1, 2025; 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 (PDF)Delta Dental Federal Government Programs Dental Office Handbook 2026 (PDF)Delta Dental of North Carolina — Dentist Handbook, January 1, 2026 (PDF)
MetLife Archived public copy; current rules gated
The Preferred Dentist Program Resource Manual with a per-code Supporting Information table was historically served publicly; MetLife's current guides and fee schedules live behind the metdental.com provider login.
The public manual is static (circa 2018 print code); treat its specifics as historical and confirm current rules on metdental.com.
MetLife Preferred Dentist Program Resource Manual (archived public PDF)MetLife dental provider portal (current rules; login required)
United Concordia Public — no login
Public provider-education documents and help-center policy pages, including a dedicated scaling-and-root-planing claims guide.
Provider-education documents are undated transcripts; confirm against the current help-center policy pages.
United Concordia — Scaling and Root Planing Claims: Getting It Right (PDF)United Concordia help center — SRP claims policy
Guardian Provider portal login required
No public clinical-criteria or documentation-requirements document; the provider toolkit routes to the mydental.guardianlife.com portal login.
Requirements must be confirmed inside the provider portal or with provider relations.
Guardian provider toolkitGuardian dental provider portal (login required)
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)
MCNA Dental (Medicaid/CHIP administrator) Public — no login
Public, versioned per-state provider manuals (Texas Medicaid and CHIP Provider Manual; Florida Healthy Kids manual).
Manuals version several times per year (Texas v1.29 effective September 1, 2025). State Medicaid criteria (TMHP, AHCA) apply alongside the manual.
MCNA Texas Medicaid and CHIP Provider ManualMCNA Texas dentist resources
