PM-48: 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

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PM Internal Dependencies

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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

• PM-48 Spec
• EVENT_CONTRACTS.md
• CROSS_CORE_INTEGRATIONS.md
• PM-20 Integration
• PM-23 Integration
• PM-11 Integration
• PM-32 Integration