X12 EDI Technical Design Document

ISA*00*          *00*          *ZZ*SENDER_ID      *ZZ*RECEIVER_ID    *YYMMDD*HHMM*^*00501*000000001*0*P*:~
  GS*HC*SENDER_ID*RECEIVER_ID*YYYYMMDD*HHMM*1*X*005010X222A1~
    ST*837*0001*005010X222A1~
      [Transaction-specific segments]
    SE*[segment_count]*0001~
  GE*1*1~
IEA*1*000000001~

Minutes → Units mapping (from PM-07):
  <8 min  = 0 units (not billable)
  8-22    = 1 unit
  23-37   = 2 units
  38-52   = 3 units
  53-67   = 4 units
  68-82   = 5 units
  (pattern: each additional 15 min = +1 unit)

1. Parse 835 file into CLP/SVC/CAS segments
2. For each CLP (claim-level):
   a. Match CLP01 to pm_claims.claim_number
   b. If no match: flag for manual review, continue
   c. Verify CLP03 (charged) matches pm_claims.total_charge
   d. If mismatch > threshold: flag for review
3. For each SVC (service line):
   a. Match to pm_claim_lines by CPT + date + provider
   b. Record paid amount
4. For each CAS (adjustment):
   a. Map CARC to adjustment category (CO/PR/OA/PI/CR)
   b. CO (contractual): auto-post adjustment
   c. PR (patient responsibility): create patient balance
   d. OA/PI: flag for review
   e. Store RARC remark for denial management
5. Create pm_payments record with check/EFT detail
6. Update pm_claims.status based on CLP02
7. If fully paid: status = 'paid'
8. If partial: status = 'partial_payment'
9. If denied: status = 'denied', trigger denial workflow

interface ClearinghouseAdapter {
  // Identity
  readonly providerId: string;
  readonly providerName: string;

  // Submission
  submitClaim(claim: X12Envelope<Claim837P | Claim837I>): Promise<SubmissionResult>;
  checkEligibility(request: X12Envelope<Eligibility270>): Promise<EligibilityResult>;
  submitPriorAuth(request: X12Envelope<Auth278>): Promise<AuthResult>;

  // Retrieval
  fetchRemittance(dateRange: DateRange): Promise<ERA835[]>;
  checkClaimStatus(claimId: string): Promise<ClaimStatus277>;

  // Configuration
  validateCredentials(): Promise<boolean>;
  getSubmissionWindow(): { start: string; end: string };
}

// Implementations
class AvailityAdapter implements ClearinghouseAdapter { ... }
class ChangeHealthcareAdapter implements ClearinghouseAdapter { ... }
class TrizettoAdapter implements ClearinghouseAdapter { ... }

-- See PM-15 Spec for authoritative DDL
-- specs/pm/specs/PM-15-clearinghouse-integration.md