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Care Management Worklist — User Guide

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What Is the Worklist?

The Care Management Worklist is the billing review queue for monthly care-management charges that have passed all gate checks but are awaiting manual submission (when auto-post is OFF). It shows:
  • Patient name and enrollment program (CoCM / BHI / CCM / PCM)
  • Accrued minutes vs. threshold
  • CPT code selected by the engine
  • Gate status and any denial reasons
  • Payer policy and covered-code badge
Path: PM → Care Management → Worklist The default view shows the current month’s enrollments. Use the month picker to review prior months. Filters:
  • Program — filter by CoCM, BHI, CCM, or PCM
  • Gate Status — pass / fail / denied / pending
  • Provider — filter by billing provider
  • Payer — filter by payer name

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Actions

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Submit a Charge

  1. Select one or more rows with gate status Pass.
  2. Click Submit to Billing.
  3. The charge is created in pm_charges with the pre-evaluated CPT code and sent to the billing queue.

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Review a Denied Charge

  1. Click the row to expand the detail panel.
  2. The Denial Reason shows exactly why the gate failed (e.g., concurrent_billing:conflicting_code=99484, registry_membership_missing, credential_gate_fail).
  3. Coordinate with the clinical team or correct the underlying issue, then re-trigger evaluation from the Evaluate button.

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Void a Charge

Voiding cancels a previously auto-posted charge and records an immutable audit entry.
  1. Click the row for an auto-posted charge.
  2. Click Void Charge.
  3. Enter a void reason (required for audit trail).
  4. Confirm. The charge status becomes void and the billing period gate status becomes void.
Important: Void entries cannot be deleted. They satisfy NFR-audit-1 (100% evaluation coverage in the audit log).

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Understanding Gate Statuses

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Audit Trail

Every gate evaluation — pass, fail, or void — creates an immutable audit row in pm_care_mgmt_gate_audit. The audit row includes:
  • Verdict (pass / fail / void)
  • Denial reason if applicable
  • Rule snapshot (exact code-family rules, payer policy, credential check result used at evaluation time)
The audit log is insert-only. No row can be updated or deleted, satisfying NFR-audit-1 and SC-002.