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Spec Reference: specs/pm/specs/PM-07-EN-14-payer-specific-modifier-rules-engine.md
Core: PM
Status: Draft
Last Updated: 2026-04-02

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Purpose

Define how payer-specific modifier rule evaluation is shared between PM-07 charge capture flows and PM-18 scrub processing while preserving deterministic precedence and tenant isolation.

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Integration Summary

  • Producer: PM payer modifier rules service (new PM-07-EN-14 capability)
  • Consumers: PM-07 charge workflow validation, PM-18-EN-06 scrub engine
  • Fallbacks: PF-96 jurisdiction profile defaults and system defaults
  • Tenancy: organization_id scoped reads/writes for all rule operations

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Resolution Contract

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Input

  • organizationId
  • payerId
  • modifierSet (array)
  • Optional encounterContext metadata needed by PM-18 scrub flow

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Output

  • decision (allow, warn, block)
  • matchedRuleLevel (payer, jurisdiction, system)
  • messages (user-facing validation details)
  • auditContext (rule id/version for traceability)

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API Surface (Planned)

  • Internal PM integration layer function:
    • resolvePayerModifierRules(input): RuleResolutionResult
  • No external public API endpoints introduced by this enhancement.

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Security and Compliance

  • No PHI in rule definitions, logs, or integration payloads.
  • All data access constrained by tenant scope and role permissions.
  • Rule version metadata retained for audit and compliance review.

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Testing Expectations

  • Unit tests for precedence and severity outcomes.
  • Integration tests proving parity between PM-07 and PM-18 decision outcomes.
  • Regression tests for jurisdiction fallback behavior when payer overrides are absent.