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Version: 1.0.0 Last Updated: 2026-05-15 Spec: PM-15-P2-EN-01 Plan: PM-15-P2-EN-01-PLAN Tasks: PM-15-P2-EN-01-TASKS Context: PM-15-P2-EN-01-CONTEXT Implementation Log: specs/pm/IMPLEMENTATION_LOG.md → PM-15-P2-EN-01 entry Sign-Off: PM-15-P2-EN-01-COMPLIANCE-SIGNOFF.md Regulations:
  • 45 CFR 162 — X12 5010 transaction continuity
  • 45 CFR 164.308(b)(1), 164.502(e) — Business Associate Agreement (BAA) controls
  • 45 CFR 164.312(a)(2)(iv) — Credential encryption at rest
  • 45 CFR 164.312(b) — Audit controls
  • 45 CFR 164.312(e)(2)(ii) — PHI encryption in transit

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1. Scope

PM-15-P2-EN-01 extends the PM-15-P2 single-vendor (Waystar) baseline with:
  • Secondary clearinghouse adapters (Availity, Change Healthcare) gated behind a recorded BAA approval per organization.
  • Per-payer route overrides (pm_payer_clearinghouse_routes).
  • Health-aware failover with a configurable degradation threshold (pm_clearinghouse_config.failover_*).
  • Audited failover transitions (config changes + runtime route flips) written to pm_audit_log.
The PM-15-P2 X12 5010 transaction inventory (837P, 835, 270/271, 999, 277CA) is unchanged and remains the canonical evidence for transport conformance.

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2. Vendor Adapter Inventory

VendorAdapterSourceStatus
WaystarWaystarClearinghouseAdaptersrc/cores/pm/services/clearinghouse/waystar-adapter.ts✅ Production (PM-15-P2)
AvailityAvailityClearinghouseAdaptersrc/cores/pm/services/clearinghouse/availity-adapter.ts🟡 Stub — gated by BAA
Change HealthcareChangeHealthcareClearinghouseAdaptersrc/cores/pm/services/clearinghouse/change-healthcare-adapter.ts🟡 Stub — gated by BAA
Stubs MUST NOT carry PHI until the secondary’s BAA gate (§4) is satisfied and transport hardening is signed off.

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3. Routing Precedence (Continuity — 45 CFR 162)

Implemented by resolveVendorRoute() (src/cores/pm/services/clearinghouse/router.ts). Pure, deterministic, unit-tested.
  1. Per-payer override (pm_payer_clearinghouse_routes.preferred_vendor).
  2. Configured primary vendor (pm_clearinghouse_config.clearinghouse_provider).
  3. Configured secondary vendor — only when failover is enabled, secondary is configured, and the primary has been continuously unhealthy for ≥ failover_threshold_minutes.
In-flight transactions are never re-routed; the router is consulted at submission time only. Tests: src/cores/pm/services/clearinghouse/router.test.ts (6 cases — payer override, disabled failover, no secondary, healthy primary, threshold-not-met, threshold-met failover).

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4. BAA Gate (45 CFR 164.308(b)(1), 164.502(e))

  • The Failover Settings UI (src/cores/pm/components/clearinghouse/FailoverSettingsCard.tsx) reads pm_clearinghouse_config.custom_fields.baa_approved_vendors: string[].
  • The Save action and the failover-enabled toggle are blocked when the chosen secondary vendor is not present in the approved list.
  • User-visible copy when blocked: “This vendor cannot be enabled until compliance approval is recorded.” (per PM-15-P2-EN-01-CONTEXT.md §Example Phrasing).
  • Storage location is interim — a dedicated pm_clearinghouse_baa_approvals table is tracked as a follow-up in specs/pm/IMPLEMENTATION_LOG.md.

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5. Audit Controls (45 CFR 164.312(b))

Two complementary audit paths, both PHI-free:
TriggerActionSource
Admin saves failover settingspm_audit_log.action = 'failover_config_change' with prior/new secondary_vendor, failover_enabled, failover_threshold_minutesuseUpdateFailoverConfig() in src/cores/pm/hooks/useClearinghouseFailover.ts
Runtime router flips vendor for an (org, payer) scopepm_audit_log.action = 'clearinghouse_route_failover' with prior vendor, new vendor, routing reason, payer scope, actorresolveVendorRouteWithAudit() in src/cores/pm/services/clearinghouse/audit.ts
Runtime emission is deduplicated by an in-memory (org, payer) cache so steady-state routing does not spam the audit log; only transitions are written. Failures are sent to Sentry and never block transaction submission. Tests: src/cores/pm/services/clearinghouse/audit.test.ts (4 cases — first decision, dedupe on no-op, transition row, payer scoping).

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6. Credential & Transport Security (45 CFR 164.312(a)(2)(iv), 164.312(e)(2)(ii))

Inherits all PM-15-P2 controls. No additional credential surface is introduced by EN-01:
  • Vendor credentials remain in Edge Function Secrets (Deno.env.get); no credentials in DB, logs, or app state.
  • All vendor traffic is HTTPS (TLS 1.2+); REST-only transport (SFTP deferred).
  • Failover settings store only vendor codes, booleans, and integer thresholds — no credentials, no PHI.

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7. Tenant Isolation (Constitution §5.1)

  • pm_clearinghouse_config, pm_payer_clearinghouse_routes, and pm_audit_log are all organization_id-scoped with FORCE ROW LEVEL SECURITY.
  • All hooks scope reads/writes by useOrganization() and filter mutations on organization_id.
  • RLS test: tests/rls/pm/pm-clearinghouse-failover.test.ts.

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8. Test Inventory

LayerPath
Router unitsrc/cores/pm/services/clearinghouse/router.test.ts
Runtime audit unitsrc/cores/pm/services/clearinghouse/audit.test.ts
RLS / tenant isolationtests/rls/pm/pm-clearinghouse-failover.test.ts

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9. Seed Test Data

Synthetic, PHI-free fixtures scoped to NorthSight Recovery: supabase/seeds/pm/pm-15-p2-en-01-test-data.sql (Test-PM-15-P2-EN-01-Normal, -Edge, -Empty). Apply via Supabase Studio SQL editor against the dev project.

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10. Open Follow-Ups

Tracked in specs/pm/IMPLEMENTATION_LOG.md → PM-15-P2-EN-01:
  • Mobile Sheet variant for PayerRoutesTable add/edit flows.
  • Replace ad-hoc empty-state copy with shared <EmptyState />.
  • Edge-function (server-side) clearinghouse transport for the secondary adapters.
  • Dedicated pm_clearinghouse_baa_approvals table to replace the JSONB interim store.
  • Server-side router-driven audit emission once submission moves to edge functions (current emission is client-side only).

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Sign-Off Status

See PM-15-P2-EN-01-COMPLIANCE-SIGNOFF.md for the compliance officer checklist.