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Patient Cost Estimation & Financial Clearance — Integration Documentation

Spec: PM-48 Status: 📝 Planned Created: 2026-04-07

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Overview

PM-48 provides pre-admission cost estimation for insured patients and a financial clearance workflow that gates admission on cost transparency and payment arrangements. It integrates with several PM-internal specs and PF platform layers.

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Platform Foundation Dependencies

PF FeatureIntegration TypeUsage
PF-01 (Organizations & Sites)Direct dependencyMulti-tenant scoping; site-level estimates
PF-02 (RBAC)Direct dependencyPermission checks: pm.cost-estimates.*, pm.financial-clearance.*, pm.clearance-metrics.view
PF-10 (Notifications)Platform Integration LayerNotify patient of estimate availability; alert staff of pending clearances
PF-11 (Documents)Platform Integration LayerStore generated cost estimate PDFs
PF-96 (Jurisdiction Profiles)Platform Integration LayerJurisdiction-scoped financial counseling referral threshold

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PM Internal Dependencies

PM FeatureIntegration TypeData Flow
PM-02 (Insurance & Eligibility)Data (read)PM-48 reads benefit details (deductible remaining, coinsurance %, OOP max, copay) from PM-02 eligibility data
PM-20 (Good Faith Estimate)BoundaryPM-20 owns uninsured/self-pay GFEs; PM-48 handles insured cost estimation. Uninsured patients routed to PM-20.
PM-23 (Contract & Fee Schedule)Data (read)PM-48 reads contracted rates per payer per CPT/HCPCS code; falls back to org fee schedule
PM-32 (Financial Counseling)Event/triggerPM-48 auto-routes to PM-32 when patient responsibility exceeds configurable threshold
PM-11 (Revenue Cycle Dashboard)Data (source)PM-48 clearance metrics feed into PM-11 dashboards
PM-09 (Payment Posting & ERA)Data (write-back)PM-09 adjudicated posting writes actual_patient_responsibility back to PM-48 estimate records for accuracy tracking

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Event Contracts

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Events Published

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1. pm_cost_estimate_generated

  • Publisher: PM-48
  • Subscribers: PM-32 (conditional — when threshold exceeded), PM-11
  • Payload Schema: 
    {
  estimate_id: string;
  patient_id: string;
  organization_id: string;
  patient_estimated_responsibility: number;
  service_type: string;
}
  • Purpose: Notify downstream of new estimate; trigger financial counseling referral if threshold exceeded
  • Status: 📝 Planned

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2. pm_financial_clearance_completed

  • Publisher: PM-48
  • Subscribers: PM-11, Admission workflow
  • Payload Schema: 
    {
  estimate_id: string;
  patient_id: string;
  organization_id: string;
  clearance_status: 'cleared' | 'override';
  completed_by: string;
}
  • Purpose: Signal financial clearance complete for admission gate
  • Status: 📝 Planned

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Events Consumed

  • None (PM-48 reads data directly from PM-02, PM-23 tables; PM-09 writes back via adjudication pipeline)

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API Contracts

No external API contracts. PM-48 uses internal Supabase queries and frontend hooks only.

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Platform Integration Layer Usage

  • PF-10 (Notifications): @/platform/notifications — send estimate-ready notifications to patients, pending-clearance alerts to staff
  • PF-11 (Documents): @/platform/documents — store generated PDF cost estimates
  • PF-96 (Jurisdiction Profiles): @/platform/jurisdiction — useJurisdictionProfile() for jurisdiction-scoped financial counseling referral threshold

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Boundary Notes

  • PM-20 boundary: PM-48 does NOT generate GFEs for uninsured/self-pay; those are owned by PM-20. If a patient has no active insurance, PM-48 routes to PM-20.
  • PM-23 boundary: PM-48 reads contracted rates but does not modify them. Rate lookup includes fallback to org fee schedule.
  • PM-32 boundary: PM-48 creates the referral trigger; PM-32 owns the counseling workflow and charity care determination.
  • PM-11 boundary: PM-48 provides clearance metrics as a data source; PM-11 owns the dashboard UI. PM-48 US-3 may include a focused clearance metrics view, but comprehensive RCM analytics remain in PM-11.

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Validation Checklist

  • All integration points from spec documented
  • Event contracts have payload schemas
  • Boundary with adjacent specs documented
  • PF dependencies listed with integration type
  • Contract validation checklist passed (pending implementation)

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References