> ## Documentation Index
> Fetch the complete documentation index at: https://dso.getlemma.com/llms.txt
> Use this file to discover all available pages before exploring further.
# Weeks 1–4: Build the billing rhythm
> Set up daily and weekly dental billing routines for benefits verification, predeterminations, claim attachments, denial follow-up, and hygiene scheduling.
Use the first four weeks of live billing to establish routines that will still work as volume grows. This tutorial sets the daily and weekly checklists, assigns owners, and builds the first dashboard.
## What Bluebird did
Sam put the daily checklist in a shared document during Bluebird's first week and asked the biller to time-stamp each item. The process was easy to test while the schedule was light, and the same checklist remained usable as visit volume increased.
## Week 1: install the daily loop
Assign every item an owner by name, not by role.
### Morning (45 minutes)
* [ ] Pull tomorrow's schedule; run **eligibility (270/271)** on every patient
* [ ] For each plan, **capture the plan design, not just "active"**: remaining annual maximum, deductible status, coverage tiers, and the frequency limits for scheduled services. Confirm whether the patient is due for the prophylaxis, bitewings, fluoride, or other planned care.
* [ ] Flag coverage problems and have the front desk call those patients today
* [ ] Check the status of outstanding **predeterminations** for treatment-planned major work
* [ ] Check the clearinghouse for overnight **999 / 277CA rejections**
* [ ] Work each rejection promptly and record when it was resubmitted
Review rejections early in the day. They have not reached adjudication, may still be running against the timely-filing limit, and are usually faster to correct while the source information is easy to find.
Dental verification needs more than an active-coverage response. Capture the annual maximum, frequency limits, waiting periods, missing-tooth clauses, and downgrade provisions that apply to the planned services. Record the verified details in the PMS so the estimate and later visits use the same information. See [Verify eligibility and benefits](/guides/billing/verify-eligibility).
### Afternoon (60 minutes)
* [ ] Enter charges for **yesterday's** completed visits
* [ ] Confirm every completed visit has either a charge or a documented reason it doesn't
* [ ] **Attach required documentation to the initial claim.** Examples include radiographs for crowns, periodontal charting for scaling and root planing, and payer-required narratives.
* [ ] Run the scrubber; clear every edit
* [ ] Submit the batch
* [ ] Post any **835s** received; work the exception queue
* [ ] Confirm each deposit ties to its remittance via **TRN**
Keep a payer-specific list of the procedures that require attachments and add reliable rules to the scrubber. Current workflows may use a service such as Vyne's FastAttach (the "NEA number" workflow) or a clearinghouse's integrated attachment tool. CMS finalized the X12 275 standard for claims attachments in March 2026, with a **May 26, 2028 compliance date**, so vendors should also provide a transition plan.1 See [Dental attachments](/reference/edi/dental-attachments).
### End of day (10 minutes)
* [ ] Record the day's numbers: visits, production, claims submitted, rejections, payments posted
* [ ] Record the **hygiene reappointment number**: of today's hygiene patients, how many left with their next visit booked?
* [ ] Note anything unresolved for tomorrow
Review the unbilled-encounter report every day. Each completed visit should have charges or a documented reason why no charge is expected. A short daily review is easier than reconstructing several weeks of encounters later.
## Week 2: install the weekly loop
Pick a fixed day. Bluebird used Tuesday.
* [ ] **Adverse-835 triage:** separate true denials from downgrades, frequency-limit reductions, and exhausted maximums. Route each item according to the payer contract and patient-responsibility rules. Set a review deadline inside the applicable appeal window.
* [ ] **AR aging**. Review the 60+ bucket line by line, the 90+ bucket with the ops lead
* [ ] **Credit balances**. Review the report; anything over 30 days gets resolved
* [ ] **Hygiene schedule:** review the weekly reappointment rate and open hygiene time over the next two weeks, then work the recall list against those gaps
* [ ] **Predetermination pipeline:** record whether each applicable crown, periodontal surgery, or orthodontic case has a response, is pending, or has a documented decision to proceed without one
* [ ] **Credentialing grid:** update statuses and follow up according to the payer's process and the application's age
* [ ] **Patient balances**. Confirm statements went out on schedule
* [ ] **Root-cause tagging:** record why each true denial occurred as well as how it was resolved
A predetermination uses claim-like information to request a pre-treatment estimate, often with the same documentation the final claim will need. It is voluntary and **does not guarantee payment** because final adjudication applies eligibility, the remaining maximum, and frequency limits on the date of service.2 It can still give the patient a better estimate before major treatment. See [Get predeterminations](/guides/billing/get-predeterminations).
Root-cause tags show which upstream process to review, rather than only recording how the individual denial was resolved. See [Work the denial queue](/guides/billing/work-the-denial-queue).
## Week 3: build the dashboard
Use one page or dashboard that is updated weekly. Start with seven metrics and one denial table.
| Metric | Source | Target |
| -------------------------------------- | -------------------------------- | ------------- |
| Clean claim rate | Clearinghouse acceptance reports | 95%+ |
| Days in AR | PMS | Trending down |
| True denial rate (downgrades excluded) | 835 data | Under 5–10% |
| Net collection rate | PMS | 95%+ |
| AR over 90 days | AR aging | Under 15–20% |
| Hygiene reappointment rate | PMS schedule data | 85%+ |
| Unbilled encounters | PMS | 0 |
Add a table of **true denials by CARC**, sorted by dollar value. Use it to choose the next process problem to investigate.
Track each metric **by payer** as soon as you have more than one, and the write-off percentage **by plan** once the close produces it monthly.
## Week 4: close the prevention loop
Use the denial data to make one measurable process change at a time:
Use a fixed taxonomy: eligibility, missing or mismatched attachment, preauthorization (Medicaid/DHMO), coding, credentialing, timely filing, coordination of benefits, demographic error, payer error. Free text defeats the purpose.
Not by count. Ten $40 denials matter less than one $900 crown denial.
One per week. If missing attachments top the list, build the per-payer attachment requirements into the scrubber. If frequency surprises top it, fix the plan-design capture at verification.
Check whether the tagged cause declined. If it did not, reassess the change before adding another control.
Preventing a recurring error avoids repeated correction and appeal work. See [Denials vs downgrades](/concepts/payments/denials-vs-downgrades).
## Documenting who does what
Document the assignment so another team member can cover the workflow when needed.
| Function | Owner | Backup |
| ------------------------------------- | ----------- | -------------------- |
| Eligibility and benefits verification | Front desk | Biller |
| Point-of-care collection | Front desk | No standing backup |
| Hygiene reappointment and recall list | Front desk | Ops lead |
| Charge entry | Biller | Ops lead |
| Attachments and predeterminations | Biller | Ops lead |
| Claim submission | Biller | Ops lead |
| Rejection resolution | Biller | Ops lead |
| Payment posting | Biller | Bookkeeper |
| Denial appeals | Biller | Outsourced partner |
| Patient statements | Biller | No standing backup |
| **Code assignment** | **Dentist** | **Covering dentist** |
Keep the last row's boundary clear. Billing staff are DSO employees; **coding decisions belong to the PC.** The DSO provides the people and the systems; it does not determine what procedure codes are assigned or what treatment is diagnosed. California's SB 351 names billing and coding among the functions a management entity may not control, and it covers dental practices.3 See [Run a CPOD self-audit](/guides/compliance/run-a-cpod-self-audit).
## Day-30 operating checks
* Zero unbilled encounters older than two business days
* Every 277CA rejection worked the day it arrives
* Attachments going out with initial claims, not in response to requests
* A denial queue with a named owner, downgrades routed out of it, nothing older than 14 days
* A hygiene reappointment rate someone watches weekly
* At least one upstream process changed because of denial data
## Next
Compare an alternate-benefit downgrade with a correctable documentation denial.
## Sources
1. Administrative Simplification: Adoption of Standards for Health Care Claims Attachments Transactions, 91 FR 14350 (final rule, March 24, 2026; compliance date May 26, 2028), adopting X12N 275 and 277 RFAI. [Federal Register](https://www.federalregister.gov/documents/2026/03/24/2026-05676/administrative-simplification-adoption-of-standards-for-health-care-claims-attachments-transactions). Current NEA-number workflow: Vyne Dental, [FastAttach](https://vynedental.com/fastattach/).
2. ADA, [Pre-authorizations and predeterminations](https://www.ada.org/resources/practice/dental-insurance/pre-authorizations).
3. Cal. S.B. 351 (2025), effective January 1, 2026. Summary: Benesch, [California Enacts SB 351: New Restrictions on Private Equity and Hedge Fund Involvement in Physician and Dental Practices](https://www.beneschlaw.com/insight/california-enacts-sb-351-new-restrictions-on-private-equity-and-hedge-fund-involvement-in-physician-and-dental-practices/).