Coordination of Benefits & Secondary Claims — Integration Documentation

Documentation Index

Fetch the complete documentation index at: https://docs.encoreos.io/llms.txt

Use this file to discover all available pages before exploring further.

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Overview

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Integration Points

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PM-01 — Patient Registration & Demographics

• Type: Data (same-core)
• Usage: Patient identity and insurance policy records. PM-30 reads pm_insurance_policies (with new priority_order column) and pm_patients (with new dual_eligible column). PM-30 does not write to PM-01-owned tables except via extension columns added by PM-30’s own migration.
• Data Flow: PM-30 reads → PM-01 data; PM-01 does not consume PM-30 data directly.

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PM-02 — Insurance & Eligibility Verification

• Type: Data (same-core) / UI trigger
• Usage: When cob_order_change_triggers_reverification is enabled in pm_module_settings, changing priority_order on a policy prompts staff to re-run PM-02 eligibility verification for the affected policy. PM-30 does not call PM-02 directly; it surfaces a prompt that directs staff to the PM-02 eligibility workflow for the policy.
• Data Flow: PM-30 → user prompt → PM-02 eligibility UI (no direct function call).

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PM-07 — Charge Capture & Fee Schedules

• Type: Data (same-core, read)
• Usage: Secondary claim lines reference the same charge items as the primary claim. PM-30 reads charge data from PM-07 tables to populate secondary claim lines; amounts are overridden by primary EOB adjudication data (paid amount, CARC/RARC adjustments, patient responsibility).
• Data Flow: PM-30 reads pm_charges → populates pm_secondary_claims lines.

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PM-08 — Claims Management & Submission

• Type: Data (same-core)
• Usage: Secondary and tertiary claims are rows in pm_claims (with cob_sequence and frequency_type_code indicating secondary/tertiary). PM-30 creates pm_claims rows for secondary/tertiary claims and links them via pm_secondary_claims. PM-08 claim status lifecycle (draft → submitted → paid/denied) applies to secondary claims. PM-08 claim scrubbing (PM-18) applies to secondary claims.
• Data Flow: PM-30 inserts → pm_claims (secondary row) + pm_secondary_claims (link record).

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PM-09 — Payment Posting & ERA Processing

• Type: Data (same-core) / trigger
• Usage: Primary ERA posted by PM-09 is the trigger for secondary claim generation (auto or manual). PM-09 provides primary payment data (paid amount, CARC/RARC adjustments, patient responsibility) used to populate X12 COB2300/COB2400 loops in the secondary 837. Secondary ERA is posted by PM-09 to the secondary claim row; patient responsibility and patient balance are updated accordingly.
• Data Flow: PM-09 (primary ERA) → trigger → PM-30 secondary claim creation; PM-09 (secondary ERA) → updates pm_secondary_claims status + pm_claims balance.

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PM-15 — Clearinghouse Integration

• Type: Data (same-core)
• Usage: Secondary and tertiary 837P/837I claims with COB segments are submitted via PM-15. PM-15 handles 837 batch assembly and submission to the clearinghouse. PM-30 produces the claim record; PM-15 transmits it.
• Data Flow: PM-30 creates pm_claims (secondary) → PM-15 batches and submits 837 with COB segments.

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PM-16 — Patient Statement Generation & Billing Communications

• Type: Data (same-core, downstream)
• Usage: After secondary/tertiary ERA is posted, updated patient responsibility and patient balance feed PM-16 for patient statement generation. PM-16 reads the updated balance from PM-09/PM-30’s posting workflow; PM-30 does not call PM-16 directly.
• Data Flow: PM-30 (via PM-09 ERA posting) updates patient balance → PM-16 reads updated balance for statements.

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Events Published

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Events Consumed

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API Contracts

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Platform Integration Layer Usage

• PF-01 (Organizations / Sites): organization_id tenant isolation on all PM-30 tables.
• PF-30 (RBAC): Permission keys pm.cob.view and pm.cob.manage enforced via useHasPermission and RLS.

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Pending Contracts

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Security

• All pm_secondary_claims access is scoped by organization_id via pm_has_org_access SECURITY DEFINER function.
• COB data (payer names, claim amounts, patient IDs) is PHI; no PHI in logs or AI prompts.
• UPDATE RLS policy includes WITH CHECK to prevent organization_id modification.

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References

• PM-30 Spec
• PM-08 Claims Management Integration
• PM-09 Payment Posting & ERA Integration
• PM-15 Clearinghouse Integration
• PM-16 Patient Statement Integration
• CROSS_CORE_INTEGRATIONS.md