Lumina Dental Network Billing

The challenge

Before

Lumina Dental runs nine branches across Metro Manila with roughly 18,000 monthly patient visits split across PhilHealth, six HMO networks, and self-pay. Billing was the most fragile part of the operation — each HMO had a different claim format, PhilHealth submissions slipped because procedure-coding mistakes were caught only at rejection, and patient statements went out late because billing staff were swamped with payer reconciliation. The group had four full-time billing staff and an obvious ceiling on branch growth without proportional headcount.

• 18,000 monthly visits routed across PhilHealth, six HMOs, and self-pay
• Each HMO claim format different, prepared manually per submission
• PhilHealth procedure-coding mistakes caught only at rejection, weeks later
• Patient statements sent late as billing staff drowned in payer reconciliation
• Branch-level claim status invisible to clinic managers
• HMO eligibility verification done by phone, often per-visit
• Denied claims followed up manually with inconsistent persistence
• Four-person billing team capping further branch expansion

The solution

What we built

We built a billing automation layer over the existing dental practice management system. Every patient visit flows through structured procedure-code capture at the chairside. Eligibility verification against PhilHealth and HMO portals runs automatically at appointment booking and is re-checked the morning of the visit. Claim packets generate in each payer's required format and submit through API or RPA depending on payer. Rejections route back into a structured queue with reason coding so billing staff fix root causes, not symptoms. Patient statements generate on a defined cycle without human assembly. Branch-level dashboards show claim status, AR aging, and payer mix in real time. The agent does not make clinical or coverage judgments — it removes the assembly, follow-up, and chasing work that was consuming the team.

How the system flows

1. Visit Booked→Eligibility Verified→Coverage Confirmed
2. Morning Re-check→Eligibility Refresh→Patient Notified if Changed
3. Visit Completed→Procedure Codes Captured→Claim Packet Drafted
4. Claim Submission→API or RPA→Confirmation Tracked
5. Rejection→Reason Coded→Fix Queue→Resubmission
6. Patient Statement Cycle→Generation→Channel Delivery
7. Branch Dashboard→Claim Status + AR Aging + Payer Mix
8. Denied Claim Follow-up→Structured Persistence→Escalation

• Multi-payer formatting handled per payer requirement
• Clinical and coverage judgments retained by clinicians and billing leads