Common Member Complaint Drivers – 2025

Cigna Dental strives to improve the quality of care and services provided to our members by our network of affiliated providers, as described in our Quality Management Program. As part of this program, Cigna Dental is committed to partnering with you to improve the delivery of quality dental care and services by informing you of findings from member complaints.

Cigna Dental reviews all complaints regularly in order to identify complaint trends. Through this review, we have identified common issues that drive most member complaints. Many of these issues are related to our network providers not adhering to some administrative and clinical policy guidelines as described in the Dentist Office Reference Guide(s).  Please note the following common complaint drivers on both our Cigna Dental Care (DHMO) and Cigna Dental PPO (DPPO) plans:

1. Up-charging for Brand Name Crowns

Please note that the CDT Code from the ADA does not distinguish between a “name-branded” crown and a “standard” crown. All dentists should use the appropriate crown and bridge codes listed in the current CDT Code based on the fundamental material of restoration and charge appropriate copays/fees based on the CDT code.

Based on the current CDT Coding:

• Crowns including, but not limited to, Captek, Bio2000, and Occlusal Goldare are to be reported using procedure code D2750 (crown–porcelain fused to high noble metal).
• Crowns including, but not limited to, Cerec, Lava, Empress, andBruxzir are to be reported using procedure code D2740 (crown – porcelain/ceramic substrate).
• According to the Questions and Answers section in the ADA’s “CDT Coding Companion,” zirconia is an oxide considered chemically ceramic. The procedure code that should be used to report zirconia or porcelain fused to Zirconiumsubstrate crowns is code D2740 (crown – porcelain/ceramic substrate).

Cigna Dental PPO Plans (DPPO)—Cigna members should only be charged the difference between the provider’s contracted rate for the covered applicable crown procedure(s) provided and the amount paid by the dental benefit plan.

Cigna Dental Care Plans (DHMO) – Crown and bridge procedure codes are listed as covered services under most plans with an applicable Patient Charge. No additional fees can be charged to Cigna members unless this is specifically outlined in the Patient Charge Schedule. Some specific plans may allow charges for using specific metals or for porcelain on molars. Please refer to the Patient Charge Schedule At A Glance.

2. Up-charging for Brand Name Prostheses

Please note that the CDT Code from the ADA does not distinguish between a “name-branded” denture and a “standard” denture. All dentists should use the appropriate removable prosthesis codes listed in the current CDT Code based on the fundamental material of the prosthesis and charge appropriate copays/fees based on the CDT code.
Based on the current CDT Coding:

• Flexible base partial dentures, including Valplast or Flexite ones, are reported using procedure code D5225 or D5226.
• If the Valplast or Flexite resin is used in combination with a cast metal framework (often referred to as “Combo” partials), these partial dentures are reported using procedure codes D5213 or D5214.

Cigna Dental PPO Plans (DPPO)—Cigna members should only be charged the difference between the provider’s contracted rate for the covered applicable denture procedure(s) provided and the amount paid by the dental benefit plan.

Cigna Dental Care Plans (DHMO) – Denture procedure codes are listed as covered services under most plans with an applicable Patient Charge.  No additional fees can be charged to Cigna members unless specifically outlined in the Patient Charge Schedule. Some specific plans may allow charges for the characterization of dentures. Please reference the Patient Charge Schedule At A Glance.

3. Charges for Use of Equipment, Laser/Cerec

Please review the Cigna Dental Use of Equipment policy in the Dental Office Reference Guide. You may not charge Cigna Dental members for the specific use of equipment or technology (including, but not limited to, handpieces, air abrasion, lasers, and CAD/CAM technology) used in the provision of dental services. The use of equipment to complete a procedure is considered inclusive of the procedure.

Cigna Dental PPO Plans (DPPO)—Cigna Dental members should only be charged the difference between the provider’s contracted rate for the covered applicable procedure(s) provided and the amount paid by the dental benefit plan.

Cigna Dental Care Plans (DHMO)—Cigna Dental members may only be charged the applicable Patient Charge for the dental procedure(s) provided. Note: Some specific plans may allow charges for using CAD/CAM. Please refer to the Patient Charge Schedule At A Glance.

4. Charges for Infection Control/PPE

Please review the Cigna Dental Infection Control policy contained in the Dental Office Reference Guide. Cigna considers sterilization, infection control, personal protective equipment (PPE), tray/setup, and the handling/disposal of biohazardous waste to be included in the delivery of dental services and patient care. Therefore, Cigna Dental members may not be charged separately for these types of operatory preparation procedures.

5. Request for Records

As you know, Cigna Dental members can file complaints as needed. When Cigna Dental receives a member complaint involving a dentist, we may contact the dentist by mail or phone to request relevant records and other information pertinent to the case. Network dentists are contractually required to cooperate with Cigna Dental in resolving member complaints, including timely response to requests for records. 

If your office receives a letter from the Cigna Dental complaint department requesting records in response to a member complaint, it is very important that you reply promptly with all relevant requested records and information. Responding within the noted timeframe will ensure a timely resolution of the member’s concern and can aid you in maintaining your relationship with that patient. Patient records requests and Quality Management Programs are considered part of Treatment, Payment, and Health Care operations, as defined by the HIPAA Privacy Rule. As a result, patient authorization is not required to comply with Cigna’s requests for chart records.

6. Offering Covered Benefits/Alternatives (Cigna Dental Care DHMO only)

Please review the Cigna Dental Comprehensive Treatment Plan policy contained in the Cigna Dental Care General Dentist Office Reference Guide.

It is important that the member is presented with covered alternatives for necessary treatment and informed of non-covered and elective services. Cigna Dental expects all network providers to make available a covered option for any class of service they provide.  If a network provider offers/recommends only a non-covered option for any class of service, the member can only be responsible for the applicable co-payment for a reasonably covered option. 

Treatment plans should be itemized, contain relevant ADA codes for recommended services, and be signed by the member (or the parent or legal guardian) in acknowledgment of the dentist’s recommendations. They should also clearly show whether the member chose a covered or a non-covered service.

In the event that a member obtains a service that is not covered for a necessary condition and there is no documentation to confirm that reasonable covered options were offered, Cigna will determine the covered allowance for the non-covered procedure, and the member will only be responsible for the applicable co-payment.

7. Encounter Submission (Cigna Dental Care DHMO only)

Cigna Dental requires submitting patient encounter data for covered procedures you render to Cigna Dental Care members. Please reference the Patient Encounter Data policy in the General Dentist Dental Office Reference Guide for more information on submitting patient encounter data to Cigna Dental. Patient encounter data should be sent using the ADA claim form. Submission of patient encounter data is extremely important because it is used in the following ways:

• COMPENSATION—Patient encounter data submitted to Cigna Dental are the basis for compensation in the form of supplemental and office visit payments, as applicable.
  • STATISTICAL REPORTS – Cigna Dental sends monthly statistical reports to each network office. These reports are based on patient encounter data and contain the following information:
    • number of chair hours for procedures performed by each network dentist and the total chair hours for procedures performed at the office
    • procedures performed listed by major dental procedure categories and by an individual network dentist
    • income generated from fixed monthly payments, patient charges, and supplemental payments (if applicable) for procedures performed by the office.
  • UTILIZATION/REFERRAL PATTERNS—Our utilization review program routinely monitors Practice patterns and procedures. Specifically, we review the number of procedures an individual dentist reports and compare that with the norm for that particular area.