> ## 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.

# Step 9: Pick your billing stack

> Choose the minimum viable combination of practice management system, dental clearinghouse, and billing labor that can get an 837D out the door and a remittance back in.

Your **billing stack** has three parts: a **practice management system (PMS)** for scheduling, charting, and the patient ledger; a **clearinghouse** that exchanges claims and remittances with payers; and the **people** who operate both. Evaluate the clearinghouse workflow and payer reach when selecting the PMS rather than assuming the bundled option will fit.

## What Bluebird did

Bluebird chose a cloud PMS, because the growth plan is acquisition and Sam did not want a Windows server in the closet of every office they buy. Before signing, Sam confirmed two things in writing: that the PMS's data could be exported without a punitive fee, and that its claims pipeline handled the **837D, dental attachments, and real-time eligibility as one workflow**, with Bluebird's Delta member company on the payer list. One experienced dental biller joined as a DSO employee.

## The three layers

```mermaid theme={null}
graph LR
    A[PMS<br/>scheduling, charting,<br/>ledger, treatment plans] --> B[Clearinghouse<br/>scrub, translate,<br/>route, attach, acknowledge]
    B --> C[Payers]
    C --> B
    B --> D[835 remittances<br/>back to the PMS]
    E[Biller / RCM<br/>the humans] -.operates.-> A
    E -.operates.-> B
```

If the distinction is unclear, read [Clearinghouse vs RCM vs PMS](/concepts/payments/clearinghouse-vs-rcm-vs-pms) before choosing a vendor. A product in one layer may not solve a workflow problem that belongs in another.

## Layer 1: the PMS

The practice management system (PMS) is dentistry's main system of record. It commonly holds scheduling, clinical charts, imaging integrations, treatment plans, insurance information, charges, and claim status.

Start by comparing the product's architecture and multi-location design:<sup>1</sup>

|                             | Server-based legacy                                            | Cloud                                                            |
| --------------------------- | -------------------------------------------------------------- | ---------------------------------------------------------------- |
| **The names**               | Dentrix (Henry Schein One), Eaglesoft (Patterson), Open Dental | Denticon (Planet DDS), Dentrix Ascend, Curve, Fuse, tab32, Archy |
| **Where data lives**        | A Windows server in each office                                | A central multi-tenant database                                  |
| **Multi-location**          | Per-office databases; consolidation is an integration project  | Central patient records, cross-location scheduling and reporting |
| **Cost shape**              | License plus per-office server hardware on a 5–7 year refresh  | Subscription per location                                        |
| **Acquisition integration** | Each acquired office is a data conversion onto your copy       | Each acquired office is a data conversion onto one platform      |

Three vendor details are useful before demos. **Dentrix Ascend is a separate cloud product from Dentrix**, so moving between them requires a conversion rather than a version upgrade.<sup>1</sup> **Denticon** was designed for multi-location groups and uses a multi-tenant architecture.<sup>2</sup> **Open Dental** remains server-based and provides database access, although its license changed from open-source GPL to proprietary at version 24.4.<sup>3</sup>

Beyond architecture, weigh in order:

1. **Imaging.** Radiographs are both clinical record and claim attachment. Check whether imaging is native, a first-party module, or a third-party bridge, and who owns the images in an export.
2. **Data export rights.** Read the contract. Confirm the available formats, included data, delivery time, and fees for analytics, migrations, and transaction diligence.
3. **ERA auto-posting quality.** This determines how many hours a week your biller spends on manual posting. Ask for a demo using a real 835 that includes a downgrade.
4. **Eligibility checking.** Integrated 270/271 at scheduling, plus fields to capture what dental verification actually needs: remaining annual maximum, frequency history, downgrade behavior.
5. **Clearinghouse flexibility**. See below.
6. **Reporting.** Days in AR, denial rate, net collection rate, hygiene reappointment rate, and write-off percentage by payer, without exporting to a spreadsheet.
7. **Pricing model.** Per location, per provider, or percentage of collections. Percentage-of-collections pricing from a software vendor deserves scrutiny.

<Note>
  🦷 **Orthodontics** bills differently: banding date, months of treatment remaining, and contract/installment billing rather than per-visit claims. If ortho is anywhere in your plan, verify the PMS handles ortho contracts before signing; it is a common gap in general-dentistry systems.
</Note>

See [Choose a PMS](/guides/billing/choose-a-pms) and the [PMS directory](/reference/vendors/pms-directory).

## Layer 2: the clearinghouse

A **clearinghouse** translates your claim into the X12 **837D** format each payer expects, validates it against payer-specific edits, routes it, and brings back acknowledgments (999, 277CA) and remittances (835). See [What is a clearinghouse?](/concepts/payments/what-is-a-clearinghouse).

### The dental test: three transactions, one workflow

A dental clearinghouse should be tested across three connected workflows:<sup>4</sup>

* **837D claims**, with tooth, surface, and quadrant data intact
* **Attachments:** radiographs, periodontal charts, and narratives required by the payer for services such as crowns, scaling and root planing, and implants
* **Real-time 270/271 eligibility**

Dental-focused vendors such as **DentalXChange** (ClaimConnect) and **Vyne Dental** (the Tesia clearinghouse plus NEA FastAttach) offer claims, attachments, and eligibility through a connected workflow. Optum (Change Healthcare) and Availity carry the 837D, while attachment support may require a separate product or process.<sup>4</sup> Test the complete workflow against the group's payer mix.

Two more questions before you commit:

* **Concentration risk.** The February 2024 Change Healthcare cyberattack disrupted claim traffic for weeks, and the ADA publicized emergency funding for affected dentists.<sup>5</sup> Document a fallback path for high-volume payers.
* **The 275 roadmap.** The 2026 HIPAA attachments rule replaces today's proprietary NEA-number workflow with the X12 275 transaction, compliance due May 2028. Ask any clearinghouse and PMS vendor how they will carry it before signing a multi-year contract.<sup>6</sup> See [CDT & the 837D](/reference/edi/cdt-and-837d).

### Confirm whether you can choose the clearinghouse

Some PMS products embed a clearinghouse or limit the alternatives. Before signing, confirm whether the practice can select and later change its clearinghouse, including any interface or termination fees. Verify coverage for the actual payer mix, including the relevant Delta member company, by payer and transaction type.

For the full comparison, see [The clearinghouses, compared](/reference/vendors/clearinghouse-comparison).

## Layer 3: the people

Three viable shapes at launch:

| Model                              | Cost shape                            | Fits when                                                                  |
| ---------------------------------- | ------------------------------------- | -------------------------------------------------------------------------- |
| **In-house biller** (DSO employee) | Loaded salary                         | You have enough volume to keep one busy, and you want visibility           |
| **Outsourced dental RCM**          | Typically a percentage of collections | You want to start without hiring, or lack billing management capacity      |
| **Hybrid**                         | Salary + percentage                   | In-house front end (verification, charge entry), outsourced denials and AR |

The right labor model depends on claim volume, front-desk capacity, internal supervision, and the complexity of the payer mix. Whichever model you use, assign responsibility for benefit verification, attachments, predeterminations, rejection work, posting, denials, and downgrades. See [In-house billing vs outsourced RCM](/guides/billing/in-house-vs-outsourced-billing) and [Hire your first biller](/guides/billing/hire-a-biller).

The employer for each billing worker and the division of authority between the DSO and professional entity depend on state law and the actual operating model. The management company may provide staff and systems, but the licensed practice should retain the clinical judgment required for code selection. California's SB 351 expressly restricts management-entity control over specified billing and coding decisions for covered dental practices.<sup>7</sup> Document the applicable boundary in the management services agreement (MSA) and operating policies. See [MSA clause anatomy](/reference/legal/msa-clause-anatomy).

## Minimum viable stack

To submit one claim you need, at minimum:

* A PMS that can produce a charge with current-year CDT codes, tooth/surface/quadrant data, and provider identifiers
* A clearinghouse connection with EDI enrollment complete for your payer
* An attachment workflow live (NEA FastAttach or your clearinghouse's attachment service)
* ERA delivery configured to that clearinghouse
* One person who knows how to read a 277CA rejection

Analytics, automated eligibility, patient statements, and membership-plan tools can be added during the first 90 days.

## Your artifact from this step

* Signed PMS contract, with export rights confirmed in writing
* Clearinghouse selected and connected, with submitter ID issued
* Attachment service account live
* EDI enrollment submitted for your first payer
* ERA delivery pointed at the correct receiver
* Billing labor in place, with the coding-responsibility question settled in the MSA

## Checklist

* [ ] Cloud vs server decided against the growth plan, not the demo
* [ ] PMS chosen on imaging, auto-posting, and data portability
* [ ] Confirmed whether the PMS permits your choice of clearinghouse, before signing
* [ ] Clearinghouse handles 837D + attachments + 270/271 as one workflow
* [ ] Payer coverage verified for your actual payer mix, Delta member company first
* [ ] Vendor asked for its X12 275 attachments roadmap
* [ ] Submitter/receiver IDs issued and recorded
* [ ] EDI and ERA enrollment submitted for payer #1
* [ ] Billing labor model decided and staffed
* [ ] MSA reflects that coding responsibility sits with the PC

## Next

<Card title="Step 10: Submit your first claim" icon="arrow-right" href="/start/zero-to-paid/submit-your-first-claim">
  Prepare, scrub, transmit, and confirm acceptance of an 837D claim.
</Card>

## Sources

1. Henry Schein One, [Dentrix or Dentrix Ascend](https://www.dentrix.com/about-us/dentrix-or-dentrix-ascend/); Patterson Dental, [Eaglesoft](https://www.pattersondental.com/cp/software/dental-practice-management-software/eaglesoft) and [Fuse](https://www.pattersondental.com/cp/software/dental-practice-management-software/fuse). Vendor lineups
2. Planet DDS, [Denticon](https://www.planetdds.com/denticon/); vendor-reported multi-location penetration; treat scale claims as the vendor's.
3. Open Dental, [license](https://www.opendental.com/site/license.html) (proprietary as of v24.4; GPL before).
4. DentalXChange, [ClaimConnect services](https://payconnect.dentalxchange.com/provider/claimconnect/ClaimServices); Vyne Dental, [FastAttach](https://vynedental.com/fastattach/) and [payer connectivity](https://vynedental.com/payers/); BCBSM, [companion guide noting 837D via Availity (PDF)](https://www.bcbsm.com/amslibs/content/dam/public/providers/documents/hipaa-transaction-standard-companion-transactions.pdf).
5. ADA News, [Funding assistance available to dentists impacted by Change Healthcare cyberattack](https://adanews.ada.org/ada-news/2024/april/funding-assistance-available-to-dentists-impacted-by-change-healthcare-cyberattack/) (April 2024).
6. Administrative Simplification: Adoption of Standards for Health Care Claims Attachments Transactions and Electronic Signatures, 91 Fed. Reg. 14350 (Mar. 24, 2026), compliance May 26, 2028. [Federal Register](https://www.federalregister.gov/documents/2026/03/24/2026-05676/administrative-simplification-adoption-of-standards-for-health-care-claims-attachments-transactions).
7. Cal. S.B. 351 (2025), effective January 1, 2026; applies to dental as well as medical practices; see [California](/reference/legal/states/california). Summary: Quarles, [California Cracks Down](https://www.quarles.com/newsroom/publications/california-cracks-down-new-laws-governing-the-corporate-practice-of-medicine-and-pe-deals).