Coverage determination → Patient decision → Approved care → Payment → Benefits & trusted history updated
BOCA PRIME · PROPOSED
A Different Way for Dental Coverage to Work
BOCA Prime is the proposed model of dental coverage Cadmus Labs is working toward.
The project begins with a simple question: If we were designing dental coverage today, what would we intentionally build differently?
The system we have inherited performs difficult and necessary work. Coverage requires decisions about participation, benefits, risk, reserves, clinical evidence, financial responsibility, payment, and the responsible use of shared resources.
But over time, those responsibilities have become surrounded by layers of administration and complexity. Patients can struggle to understand what their coverage will actually provide when they need care. Dental practices spend significant time verifying benefits, interpreting rules, submitting information, following payments, and resolving uncertainty. Benefits can lose purchasing power as the cost of care changes. And resources intended to support coverage are also consumed by the work required to administer it.
BOCA Prime asks whether we can preserve the responsibilities that meaningful coverage requires while organizing the system around them differently.
That means reconsidering how dental coverage works from beginning to end—who participates, what is covered, how decisions are made, how financial responsibility is established, and how care gets paid for.
Prime is being designed around several objectives: clearer and more dependable financial expectations before treatment decisions are made; less unnecessary administrative work for dental practices; greater room for dentists to exercise clinical judgment; benefits that can respond more intelligently to changing economic conditions; and better use of the resources entering the system so more of their value can support care.
It also asks a longer-term question. As a coverage system grows, how can it remain accountable to the patients and practices that depend upon it—even as leadership, ownership, economic pressures, and institutional priorities change?
The proposed architecture brings together conventional, emerging, and proprietary technologies to pursue those objectives. The technology follows the requirements of the system: conventional software where it works best, and newer capabilities where they can improve verification, privacy, continuity, execution, or accountability.
BOCA Prime is not available today. Cadmus has developed a working design for Prime and proposed approaches to many of the major questions the model must resolve. That work provides the starting point for further legal, actuarial, economic, clinical, technical, governance, regulatory, and real-world validation—and for refining the decisions that remain open.
Coverage Should Be Understandable Before Care Begins
Imagine a patient sitting in the chair after an examination, discussing a recommended treatment plan with their dentist.
Before deciding whether to proceed, they naturally want to know:
Will my coverage apply? How much will it contribute? What will I owe? Can my dentist recommend the treatment they believe is best, or will coverage rules affect the options available to me?
Today, answering those questions can require benefit verification, manual interpretation, phone calls, estimates, and assumptions. Even after that work, the final financial responsibility may not become fully clear until treatment has been delivered and the claim has been processed.
BOCA Prime is designed around a different experience.
Where the necessary information can be established reliably before care, the patient and practice should have a clearer understanding of what the coverage system will contribute and what responsibility may remain with the patient before the treatment decision is made.
That determination should also mean something. When its stated conditions remain satisfied and the approved care is provided, the earlier financial determination should carry forward toward payment rather than beginning another complete review capable of producing a different answer.
For the dental practice, that could mean less time spent repeatedly verifying benefits, interpreting coverage, submitting the same information, following claims, reconciling unexpected payments, and explaining uncertainty to patients.
For the patient, it means making a decision with better information.
And for the dentist, the clinical relationship remains where it belongs:
The dentist recommends treatment. The patient decides whether to proceed. BOCA Prime determines the financial support available under its rules.
But earlier clarity is only one part of what Prime is intended to change.
Prime also explores different ways to structure the coverage itself. The goal is for coverage to remain useful as a patient needs more extensive or expensive care, rather than exhausting its value too quickly. Dentists would continue to set their own fees, while Prime would establish clear rules and reasonable limits around what the coverage system contributes. And as the cost of dental care changes over time, Prime is being designed so its benefits can change with it rather than steadily losing purchasing power.
Reducing unnecessary administrative work is another part of that effort. If fewer resources are consumed simply operating the system, more may remain available for care.
The goal is a coverage experience that becomes clearer when decisions are being made, requires less work to administer, preserves the patient-dentist relationship, and makes better use of the resources available for care.
The next question is how Prime would actually do it.
How BOCA Prime Would Work
Making coverage clearer before care requires more than producing an earlier estimate. Prime has to establish enough trustworthy information to make a dependable coverage determination in the first place.
It needs to know who is participating, what benefits are available, which rules apply, whether the required clinical evidence supports the request, and what financial support the system is responsible for providing.
Prime is being designed to automate more of that routine work when the necessary information can be established reliably. Cases involving incomplete or conflicting information, unusual circumstances, exceptions, or other uncertainty would receive additional review rather than being forced through an automated process.
And when a determination can be made reliably, the system needs to be capable of carrying that decision through—so an answer established before treatment can become the basis for payment afterward rather than the beginning of another administrative process.
BOCA Prime is being designed around four complementary functions that work together to make that possible.
Prime Core
What do the coverage rules require?
Prime Core coordinates the coverage, participation and financial logic of the system. It applies the rules governing eligibility, benefits, limits, available resources, and other conditions that determine what financial support Prime provides.
To make that determination reliably, Prime Core needs trustworthy information about who is participating and whether the requirements for coverage have been satisfied. Rootprint, DentAI, and human review provide different parts of that support.
Rootprint™
Who is participating, and what relevant history can be trusted?
Rootprint is Cadmus Labs’ framework for identity and continuity—designed to help establish who is participating and which relevant information can be trusted over time. Within Prime, it would help establish the relevant patient and provider relationships and allow useful facts or history to remain verifiable, while giving the individual greater control over what information is shared and with whom.
Where possible, the system could verify what it needs to know without requiring the underlying sensitive information itself to be broadly exposed.
DentAI
Does the evidence satisfy the coverage requirements?
DentAI is the proposed verification and intelligence layer. It would evaluate whether submitted clinical evidence meets defined coverage requirements, identify missing or inconsistent information, detect anomalies and potential fraud, waste, or abuse, and distinguish routine cases from those requiring additional scrutiny.
DentAI would support coverage verification and system integrity. The dentist remains responsible for diagnosis and treatment recommendations.
Human Review
What cannot be resolved reliably by the system?
Not every case belongs in an automated process. Incomplete or conflicting evidence, unusual circumstances, exceptions, appeals, suspected misuse, and ambiguous rules may require human judgment.
Those cases would move to an accountable review process with authority to investigate, decide, explain, and correct. Automation cannot depend on pretending uncertainty does not exist.
Participation & coverage rules→Dentist recommends care→Identity, permissions & clinical evidence evaluated→Prime Core + Rootprint + DentAI
Human review → Determination → Return to the appropriate point in the process
When the necessary conditions can be established before treatment, the patient and practice can understand what benefit remains available, what Prime will contribute, and what responsibility may remain with the patient—without the same amount of back-and-forth, manual interpretation, and administrative work often required to reach an answer today. The goal is to provide that information earlier and with greater confidence, while it can still help inform the treatment decision.
The dentist recommends treatment. The patient decides whether to proceed. Prime determines the financial support available under its rules.
Once that determination has been established, it is intended to carry forward. If its stated conditions remain satisfied and the approved care is provided, payment can follow the earlier determination without requiring the same financial question to be decided again.
The completed event can then update the participant's benefits and relevant history. Information that remains useful can remain available for future interactions, subject to the permissions and privacy protections established around it.
Prime is designed to establish what coverage will do, carry that determination through, and allow relevant verified information to remain useful so the next interaction is easier to coordinate and does not have to start from the beginning.
Better Coordination Should Create Value Across the System
BOCA Prime is intended to create value for the patients using coverage, the dental practices providing care, and the system they collectively sustain.
The test is whether a different way of organizing coverage can improve that relationship for all three.
For Patients
Patients should have greater clarity about what their coverage will provide when they are deciding about care, with fewer financial surprises afterward.
That information should also be easier to access. Prime is being designed so patients can see relevant information about their coverage directly—including available benefits, proposed treatment, what Prime is expected to contribute, and what responsibility may remain with them. Clear explanations and accessible digital tools should make that information easier to understand without requiring the dental practice to retrieve and interpret it for them.
But clarity is only part of the opportunity. A substantial amount of clerical and administrative work is currently required to coordinate coverage—from verifying benefits and interpreting rules to processing claims and reconciling payments. If Prime can reduce some of that repetitive work, more of the resources entering the coverage system may remain available to support care and benefits.
That does not make dental care inexpensive or mean that every treatment will qualify for financial support or be affordable for every patient. It means trying to make better use of the resources already available.
For Dental Practices
Dental practices absorb a substantial amount of the work required to make today's coverage function. Staff spend time verifying benefits, interpreting rules, repeatedly supplying information, responding to additional requests, following claims, reconciling payments, and explaining coverage uncertainty to patients.
Prime is being designed to reduce that burden by moving more routine coordination into the system itself and making useful coverage information more directly accessible to patients. That would mean fewer administrative steps, fewer repeated requests for information, clearer financial answers, and less time spent resolving coverage questions on the patient's behalf.
Practices should spend less time administering coverage and more time running their practices and caring for patients.
When financial obligations can be established with greater confidence and carried through toward payment, practices may also gain greater predictability around what Prime will contribute and when payment should occur. That can make financial conversations with patients easier and reduce the uncertainty the front office is left to manage.
Prime is also intended to preserve greater professional and economic autonomy for participating practices. Dentists remain responsible for diagnosis and treatment recommendations and continue to establish their own fees. Prime's responsibility is to make its financial contribution clear and dependable while leaving clinical judgment with the dentist and practice fees with the practice.
For the Coverage System
Every coverage system has finite resources. Some support care and benefits. Others are required for reserves, people, technology, compliance, risk management, and the operations needed to keep the system functioning responsibly.
Those responsibilities do not disappear simply because a system becomes more automated.
Many individual functions within today's coverage systems are already automated. Even so, substantial work can still be required to coordinate coverage across patients, dental practices, payers, and separate systems. Practices may need to track down information, verify what applies to a particular plan, provide information more than once, respond to additional requests, follow claims, and reconcile what was expected with what was ultimately paid.
That remaining coordination is where Prime sees an opportunity.
By designing coverage rules, patient access, identity, verification, financial determination, and payment to work together from the beginning, Prime is exploring whether more routine work can happen within the system itself and less administrative effort has to occur around it.
The economic hypothesis is straightforward:
If Prime can perform the necessary functions of coverage with less overall administrative effort, fewer resources may be required simply to operate and coordinate the system.
That has to be demonstrated. Prime cannot assume savings into existence, and efficiency cannot create money.
If meaningful savings are achieved, however, they create choices. Depending on the actual economics of the system, those resources could support care and benefits, stronger reserves, necessary capabilities, sustainable practice participation, lower pressure on contributions, greater financial resilience, or some combination of those priorities.
Those choices involve real tradeoffs. More resources directed toward one purpose can mean fewer available for another. What Prime can responsibly provide will ultimately depend on contributions, utilization, reserves, care costs, operating expenses, risk, and the efficiencies the model actually demonstrates.
The same discipline applies over time. As the cost of dental care changes, Prime is being designed so its benefits can change with it rather than steadily losing purchasing power.
Shared Value Is the Test
Efficiency alone is not the objective.
A system is not meaningfully improved if patients benefit only because practices absorb more cost or work. Practices do not benefit if improvement simply means patients pay more. And reducing administrative burden and expense across the system has limited value if all of the benefit ultimately remains with the organization operating it.
Prime's goal is to create more usable value across the relationship.
Patients should receive clearer and more useful coverage. Practices should face less administrative burden, greater predictability, and sustainable terms of participation. The coverage system must retain the resources and institutional capacity required to meet its obligations and remain viable.
The exact balance cannot be predetermined. It has to emerge from evidence about what Prime actually costs, saves, and delivers.
Shared value is the test: whether better organization can create a better and more sustainable relationship among the people receiving care, the professionals providing it, and the system supporting them.
Technology Follows Purpose
Prime requires technology capable of doing more than processing a claim faster.
It has to establish information the system can rely upon, protect sensitive information while allowing necessary facts to be verified, apply coverage rules consistently, recognize when human judgment is needed, and carry an established financial obligation through toward payment.
Some of that can be accomplished with conventional software. Some of it may be better served by newer technologies.
Cadmus starts with what BOCA needs to accomplish, then asks which technologies can actually help accomplish it. The experience and protections we want the system to provide come first. The architecture follows from those requirements.
Artificial intelligence is one example. DentAI could help evaluate clinical evidence, identify missing or inconsistent information, and detect anomalies, including potential fraud, waste, and abuse. That creates an opportunity to automate more routine verification while directing uncertain cases toward people who can actually evaluate them.
Rootprint addresses a different problem. Identity and useful history should not have to be reconstructed every time someone interacts with the system. At the same time, making information easier to use should not require making sensitive information easier to expose. Digital identity and privacy-preserving technology create the possibility of allowing patients to carry useful, verifiable information with them while maintaining greater control over what they share and with whom.
Other technologies could help connect rules to execution. Once Prime has established what it will contribute, programmable systems may allow that obligation to move more directly toward payment instead of beginning another round of interpretation and reconciliation.
But there is another reason Cadmus is exploring this architecture—one that matters more as BOCA grows.
Systems change over time.
Leadership changes. Ownership changes. Financial pressures change. The people running an institution twenty years from now may have very different priorities from the people who created it.
That does not require anyone to behave badly. A successful institution develops obligations of its own—to employees, investors, regulators, partners, and its continued survival. Over time, those pressures can compete with the interests of the people the institution was originally created to serve.
BOCA is being designed with that possibility in mind.
Where an important rule can be made visible, we want to explore making it visible. Where something important can be independently verified instead of simply taken on trust, we want to explore making it verifiable. Where identity or useful history can remain with the individual rather than being trapped inside one organization's system, we want to explore making it portable. And where control can responsibly be shared among the people participating in BOCA, we want the architecture to leave room for that possibility.
That is where blockchain and decentralization become particularly interesting.
Prime will likely begin as a hybrid system. Building something that can operate responsibly today means working within existing regulation and relying on accountable institutions, conventional systems, financial partners, and human judgment where they remain necessary.
But today's constraints do not have to become tomorrow's architecture.
As BOCA develops, Cadmus intends to investigate how much further decentralization can responsibly go. Technology, regulation, economics, security, governance, and real-world evidence will determine what is possible.
The longer-term ambition extends beyond using blockchain for selected functions within an otherwise conventional system. It is to explore whether parts of the trust and control traditionally concentrated inside an institution can gradually be built into an architecture that the people participating in the system can verify and, where appropriate, share.
Where can we replace promises with rules, private control with verifiability, and dependence on a single institution with a system shared among the people who actually use it?
We do not yet know how far that question can take BOCA.
We intend to find out.
A Model That Has to Earn Its Right to Exist
Cadmus has developed a working design for Prime and proposed approaches to many of the questions the model creates.
That is the beginning of the work.
Prime still has to demonstrate that it can operate legally, sustain itself economically, manage risk responsibly, evaluate evidence appropriately, protect sensitive information, perform reliably, attract willing participants, and deliver meaningful improvement in the real world.
A coherent design earns the opportunity to be tested. It does not earn the right to be built unchanged.
Direct Creates Experience. Prime Retains Its Own Burden of Proof.
BOCA Direct gives Cadmus a practical place to begin. If it earns adoption, Cadmus can build relationships with independent dental practices, learn from real workflows and membership programs, develop operating experience, and replace some assumptions with evidence grounded in how practices and patients actually behave.
That can make Cadmus better prepared to pursue Prime.
It cannot prove Prime.
Direct cannot establish whether Prime's eventual legal structure will work, whether its contributions and benefits can be actuarially sustainable, whether the coverage model can operate at the costs assumed, whether its technology will perform reliably, or whether patients, practices, employers, and other potential participants will adopt it at the scale required.
Prime has to earn advancement on its own terms.
Can the model operate within an appropriate legal and regulatory structure?
Can contributions, benefits, utilization, reserves, and risk support durable coverage?
Can Prime finance its obligations and create enough value to sustain participation and responsible operations?
Will patients, practices, purchasers, and other participants actually choose it and remain engaged?
Can coverage requirements and clinical evidence be evaluated appropriately while preserving professional judgment?
Can the architecture perform reliably, securely, affordably, and at the required scale?
Can Prime establish what it needs while appropriately protecting sensitive information and individual control?
Can important decisions evolve responsibly while reducing the risk of capture or unchecked control?
Does Prime actually work for the people who have to use it?
Evidence Can Change Prime
Testing Prime is not simply a process for confirming the design Cadmus already prefers.
Legal analysis may change where or how Prime can operate. Actuarial and economic evidence may change contributions, benefits, reserves, or participation requirements. Clinical validation may change the role of DentAI. Technical evidence may show that a conventional solution performs a proposed function better than a newer one. Governance research may change how authority is distributed. Experience with patients and practices may reveal needs the current architecture does not anticipate.
Some ideas will become stronger. Some will change. Some may disappear entirely.
That is what the evidence is for.
A compelling idea earns investigation. Evidence earns implementation.
Cadmus is publishing evidence and analysis that inform BOCA, giving others a way to examine the reasoning, assumptions, limitations, alternatives, and unresolved questions shaping the project.
Cadmus believes the problems are worth solving, the hypotheses are worth testing, and the design is developed enough to begin putting its most important assumptions under serious scrutiny.
The next stage is proof.
The ambition is intentional. So is the burden of proof.