Utilization Review Guidelines

Our Utilization Review Guidelines explain the criteria that Delta Dental of Rhode Island uses to determine whether a procedure qualifies for coverage. The UR guidelines are organized by dental procedure code and include any documentation needed to file a claim for a particular service (e.g. x-rays, periodontal charting, etc.). Please note that while services may be dentally appropriate and necessary, they may not be covered by a patient's specific dental plan.

These guidelines are subject to be revised as procedure codes are introduced or modified, or to reflect changes in materials, techniques and insurance industry practices. Log in to your online account to read our Utilization Review Guidelines.

Teledentistry exams are now available as a covered service in all member plans. See our Utilization Review Guidelines for more information.

You can also read more about Commonly Reviewed Procedures:
Guide for Commonly Reviewed Procedures

Complete Claim Standard

Providing Medically Necessary Orthodontics

As part of the Affordable Care Act, medically necessary orthodontics for children under the age of 19 is included in the Pediatric Dental Essential Health Benefit requirement.

To learn more about this benefit, click here.

Review our guidelines for medically necessary orthodontics coverage.

Scoring Form
For use by a dentist when evaluating a child's need for medically necessary orthodontic coverage.