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Version: 1.0.0
Status: 📝 Planned
Last Updated: 2026-02-23
Spec: PM-17 Provider Credentialing & Enrollment Verification
Constitution Reference: Section 1.3 (Integration Patterns), Section 2.1 (Integration points documented in /docs/architecture/integrations/)

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Overview

PM-17 provides provider payer-enrollment tracking, NPI/taxonomy validation, re-credentialing deadlines and alerts, and claim-scrub integration for enrollment verification. It consumes HR provider/credential context via the Platform Integration Layer (no direct PM→HR imports). Integration points: PM-08 (claim scrub), PM-15 (clearinghouse readiness), HR (provider identity/credential context), PF-10 (alerts).

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Quick Reference

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Decision Tree

  1. Is provider enrollment status eligible for payer submission?
    • enrolled → proceed.
    • pending/denied/inactive → enforce PM-08/PM-15 hold or override policy.
  2. Is NPI/credential validation current?
    • Yes → continue.
    • No → run validation flow and re-check before submission.
  3. Is re-credentialing deadline approaching?
    • Yes → trigger PF-10 alerts and assign follow-up.

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Pattern Library

  • Platform integration layer pattern: consume HR provider context via contracts only.
  • Enrollment-state gating pattern: use PM-17 status as hard/soft stop in PM-08/PM-15 workflows.
  • Deadline-alert pattern: route expiring enrollment events/notifications through PF-10.

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Common Mistakes

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Pre-Flight Checklist

  • organization_id scoping and RLS policies validated on PM-17 tables.
  • Permission keys seeded and mapped for view/manage/validate/override.
  • PM-08 and PM-15 consuming contracts verified against PM-17 status model.
  • Re-credentialing alert flow validated through PF-10.

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Integration Points

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API / Event Contracts

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Inbound (consumed by PM-17)

  • Provider/credential context: Consumed via Platform Integration Layer contract from HR (provider identity, credential attributes). Request/response schema TBD in HR–PM integration contract.
  • PM-08: Reads enrollment status for claim scrub (query or shared types). Contract: enrollment status per provider/payer for given claim context.

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Outbound (provided by PM-17)

  • Enrollment status: PM-08 and PM-15 consume enrollment state (enrolled/pending/denied/inactive) and validation results for scrub and submission readiness.
  • Alerts: PF-10 receives enrollment/re-credential deadline events for alert generation (event or API TBD).

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Planned Events (Deferred)

pm_enrollment_expiring — Planned but deferred from v1. V1 uses direct PF-10 notification insert for re-credentialing alerts. Domain event will be added if downstream consumers (PM-08 automation, GR compliance) need to subscribe.

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Security & Tenant Isolation

  • All PM-17 tables are scoped by organization_id; RLS and SECURITY DEFINER helpers enforce isolation per constitution §5.
  • Provider and enrollment data are operationally sensitive; access via permission keys below.
  • No PHI sent to external AI; HR integration uses platform contract only.

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Permission Keys

AHCCCS NPI: pm.credentialing.validate and pm.credentialing.manage tie to AHCCCS NPI requirements: NPI must be present on submission forms and active for date of service.

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References