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# PM-48: Patient Cost Estimation & Financial Clearance — Integration Documentation

> Status: \U0001F4DD Planned Created: 2026-04-07

# Patient Cost Estimation & Financial Clearance — Integration Documentation

**Spec:** [PM-48](../../../specs/pm/specs/PM-48-patient-cost-estimation-financial-clearance.md)
**Status:** 📝 Planned
**Created:** 2026-04-07

***

## 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.

***

## Platform Foundation Dependencies

| PF Feature                    | Integration Type           | Usage                                                                                             |
| ----------------------------- | -------------------------- | ------------------------------------------------------------------------------------------------- |
| PF-01 (Organizations & Sites) | Direct dependency          | Multi-tenant scoping; site-level estimates                                                        |
| PF-02 (RBAC)                  | Direct dependency          | Permission checks: `pm.cost-estimates.*`, `pm.financial-clearance.*`, `pm.clearance-metrics.view` |
| PF-10 (Notifications)         | Platform Integration Layer | Notify patient of estimate availability; alert staff of pending clearances                        |
| PF-11 (Documents)             | Platform Integration Layer | Store generated cost estimate PDFs                                                                |
| PF-96 (Jurisdiction Profiles) | Platform Integration Layer | Jurisdiction-scoped financial counseling referral threshold                                       |

***

## PM Internal Dependencies

| PM Feature                      | Integration Type  | Data 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)     | Boundary          | PM-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/trigger     | PM-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 |

***

## Event Contracts

### Events Published

#### 1. `pm_cost_estimate_generated`

* **Publisher:** PM-48
* **Subscribers:** PM-32 (conditional — when threshold exceeded), PM-11
* **Payload Schema:**
  ```typescript theme={null}
  {
    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

#### 2. `pm_financial_clearance_completed`

* **Publisher:** PM-48
* **Subscribers:** PM-11, Admission workflow
* **Payload Schema:**
  ```typescript theme={null}
  {
    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

### Events Consumed

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

***

## API Contracts

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

***

## 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

***

## 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.

***

## Validation Checklist

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

***

## References

* [PM-48 Spec](../../../specs/pm/specs/PM-48-patient-cost-estimation-financial-clearance.md)
* [EVENT\_CONTRACTS.md](./EVENT_CONTRACTS.md)
* [CROSS\_CORE\_INTEGRATIONS.md](./CROSS_CORE_INTEGRATIONS.md)
* [PM-20 Integration](./good-faith-estimate-price-transparency-integration.md)
* [PM-23 Integration](./contract-fee-schedule-integration.md)
* [PM-11 Integration](./revenue-cycle-dashboard-analytics-integration.md)
* [PM-32 Integration](./patient-financial-counseling-integration.md)