Policy & Contract Management Workflows

This document defines six core workflows for the Policy & Contract Management (policy-contract-mgmt) module. Each workflow includes process steps, decision points, integration hooks, exception handling, and the paperless transformation achieved by the HIS.

Regulatory context (UAE): UAE PDPL (Federal Decree-Law No. 45/2021) for processing payer and contract data; MOH, DOH (Abu Dhabi), and DHA (Dubai) regulations for payer licensing and tariff usage; DOH Shafafiya and DHA eClaimLink eClaims frameworks for payer connectivity; NABIDH (Dubai) and Malaffi (Abu Dhabi) HIE environments for consistent payer identifiers across systems.

WF-POLICYCONTRACTMGMT-001: Payer Onboarding

Process Flow

Actor: RCM Manager, Contract Analyst
Trigger: New insurance payer identified for contracting (e.g., new DHA-licensed insurer or TPA)
Pre-conditions:

• Facility has strategic approval to work with the payer
• DHA/DOH/MOH payer license details available
• At least one responsible internal owner assigned (RCM Manager)

1. RCM Manager opens Payer Master List (SCR-PCM-001) and clicks “Add New Payer”.
2. System checks if payer name, DHA/DOH license, or TPA name already exists in payers (to prevent duplicates).
3. If no duplicate found, Contract Analyst enters payer demographics on Payer Detail / Onboarding (SCR-PCM-002):
   - English/Arabic names, payer type (insurer/TPA/government), payer class (e.g., THIQA, private), DHA/DOH license numbers, TPA affiliation.
4. System validates mandatory fields and license formats (e.g., DOH payer code, DHA payer ID) and saves to payers (INSERT).
5. Contract Analyst records contact details and key roles (medical director, claims manager, IT contact) in payer_contacts (multiple INSERTs).
6. RCM Manager configures payer classification and network status (in-network, out-of-network, tier) and saves to payer_networks for each facility (INSERT).
7. System prompts to configure submission requirements:
   - eClaimLink / Shafafiya routing, submission channels (portal/API), batch size limits, resubmission rules → stored in payers (UPDATE) and related config tables (module-specific).
8. System calls System Administrator workflow (or config screen) to set up technical connectivity:
   - eClaimLink credentials, DOH eClaims credentials, endpoints, certificates (stored in secure config, not in business tables).
9. Contract Analyst defines high-level authorization and formulary constraints (e.g., “MRI requires auth”, “non-formulary biologics require prior auth”) as initial coverage_rules and prior_auth_rules (INSERT).
10. System runs a test eligibility transaction via eClaimLink or DOH eClaims using a test Emirates ID and plan code to validate connectivity (INT-PCM-004/005).
11. If test passes, RCM Manager marks payer as “Active for eligibility” and “Active for claims” in payers (UPDATE).
12. System notifies Billing & Claims and Patient Access modules via internal API (INT-PCM-001/002) that a new payer is available, pushing payer and plan metadata.
13. Contract Analyst uploads any supporting documents (e.g., payer manuals) to document repository and links them to the payer record (metadata INSERT in a payer_documents table if present).

Data Modified:

• payers — INSERT, then UPDATE
• payer_contacts — INSERT
• payer_networks — INSERT
• coverage_rules — INSERT (initial high-level rules)
• prior_auth_rules — INSERT (initial high-level rules)
• (Config tables for connectivity, e.g., payer_connectivity_settings — INSERT/UPDATE, if defined in this module)

Mermaid Flowchart

Decision Points

1. Duplicate payer check
   - If payer with same name/license exists → user must decide to edit existing or cancel onboarding.
   - If user edits existing → workflow becomes an update, not a new INSERT.

2. Validation of payer details
   - If mandatory fields missing or license format invalid → system blocks save and highlights fields.
   - If all valid → proceed to create payer record.

3. Connectivity test outcome
   - If eligibility test fails (timeout, authentication error, schema error) → system logs error, shows details, and allows retry after correction.
   - If test succeeds → payer can be activated for eligibility and claims.

Integration Points

• Billing & Claims module (billing-claims):
• Direction: Outbound (INT-PCM-001)
• Data: Payer master (payers), network status (payer_networks), submission requirements

• Trigger: Payer activated for claims.

• Patient Access module (patient-access):

• Direction: Outbound (INT-PCM-002)
• Data: Payer and plan metadata for eligibility checks

• Trigger: Payer activated for eligibility.

• DHA eClaimLink:

• Direction: Bidirectional (INT-PCM-004)
• Data: Eligibility requests/responses, connectivity configuration

• Trigger: Connectivity test, later eligibility checks.

• DOH eClaims (Shafafiya):

• Direction: Bidirectional (INT-PCM-005)
• Data: Eligibility requests/responses, connectivity configuration
• Trigger: Connectivity test, later eligibility checks.

Exception Handling

• Duplicate payer detected:
• System prevents creation of a new row; user can only update existing payer or cancel.

• Audit log records attempted duplicate creation (user, timestamp, values).

• Validation failures:

• Missing license numbers, invalid email/phone formats, or unsupported payer type → inline error messages; no DB write.

• Connectivity test failure:

• System captures error code and message from eClaimLink/DOH eClaims.
• Payer remains in “Draft” status; cannot be used for eligibility or claims.

• System suggests checking credentials/endpoints; allows re-run.

• PDPL-related issues:

• If user attempts to store personal contact data without consent flag (if modeled) → system prompts to confirm lawful basis (contractual necessity / legitimate interest) and logs consent/legal basis.

Paperless Transformation

Remaining Paper Touchpoints: Some payers may still send original signed letters or stamps; these can be scanned and attached, but originals may be retained for legal purposes.

Inputs and Outputs

Inputs:

Outputs:

Post-conditions:

• Payer record exists with status "Active" for both eligibility and claims
• Connectivity to DHA eClaimLink or DOH eClaims validated via test transaction
• Billing & Claims and Patient Access modules notified of new payer availability
• Initial coverage and prior auth rules configured and ready for use

SLA and Timing

State Transition Diagram

WF-POLICYCONTRACTMGMT-002: Contract Negotiation & Creation

Process Flow

Actor: Contract Manager, Finance Director
Trigger: New contract period, service expansion, or payer request
Pre-conditions:

• Payer record exists and is active in payers
• Facilities participating in the contract are defined in facilities (from ehr-patient-mgmt)
• Strategic approval to negotiate with the payer

1. Contract Manager opens Contract Management (SCR-PCM-003) and clicks “New Contract”.
2. System prompts for payer, facilities, contract type (fee-for-service, per diem, case rate, capitation, % of tariff), and effective/expiry dates; user enters details.
3. System checks for overlapping active contracts for the same payer/facility/contract type in contracts.
4. If no conflicting contract, system creates a contract shell in contracts (INSERT) with status = Draft and version = 1.
5. Contract Manager opens Contract Detail / Editor (SCR-PCM-004) and defines:
   - Rate methodology, payment terms (days to pay), dispute resolution clauses, covered services, exclusions.
6. Fee Schedule Analyst imports or manually enters fee schedule:
   - Import DHA/DOH tariff or custom CSV → system maps CPT codes and creates contract_fee_schedules (INSERT) and fee_schedule_items (bulk INSERT).
7. System validates fee schedule (duplicate CPT codes, missing rates, invalid modifiers) and flags issues for correction.
8. Contract Manager configures service-specific modifiers and exceptions (e.g., weekend surcharge, ICU uplift) by updating fee_schedule_items and/or related exception tables (UPDATE/INSERT).
9. Contract Manager sets approval chain (e.g., Legal, RCM Manager, Finance Director) in an approval workflow table and routes contract for review (status → In Review).
10. Approvers review contract terms and fee schedules; they can request changes (status → Revision Requested) or approve. Each action is logged in contract_amendments or contract_approval_log (INSERT).
11. After internal approvals, Contract Manager generates a contract PDF from the system and sends to payer for signature (via secure email/portal).
12. Once payer signs (digitally or on paper), Contract Manager uploads signed document and records digital signature metadata or “wet signature received” in contracts (UPDATE: document_path, approved_by, approved_date, status = Pending Activation).
13. Finance Director performs final review; if acceptable, they set status to Active and confirm activation date in contracts (UPDATE).
14. System publishes associated fee schedules (contract_fee_schedules.status → Active) and notifies Billing & Claims module via INT-PCM-001 that new contracted rates are available.

Data Modified:

• contracts — INSERT, multiple UPDATEs
• contract_fee_schedules — INSERT, UPDATE
• fee_schedule_items — INSERT, UPDATE
• contract_amendments — INSERT (for negotiated changes before activation)
• contract_approval_log (if defined) — INSERT

Mermaid Flowchart

Decision Points

1. Overlapping contract detection
   - If overlapping active contract exists → user must decide to proceed (e.g., for specific services) or cancel.
   - If proceed → system may require justification and flags potential conflicts.

2. Fee schedule validation
   - If validation fails (duplicate CPT, missing rates, invalid dates) → user must correct before proceeding.
   - If passes → workflow continues to approval.

3. Internal and payer approvals
   - If any approver rejects or requests revision → contract returns to Draft/In Review with recorded amendment.
   - If all approve and payer signs → contract can move to Pending Activation and then Active.

Integration Points

• Billing & Claims module (billing-claims):
• Direction: Outbound (INT-PCM-001)
• Data: Active contracts (contracts), fee schedules (contract_fee_schedules, fee_schedule_items), payment terms.

• Trigger: Contract status changes to Active.

• Denial Analysis module (denial-analysis):

• Direction: Outbound (INT-PCM-003)
• Data: Contract terms and fee schedules for mapping denials to contract clauses.
• Trigger: Contract activation or amendment.

Exception Handling

• Overlapping contracts not allowed by policy:

• System can enforce hard stop based on facility configuration; user must end-date old contract or adjust dates.

• Fee schedule import errors:

• Malformed CSV, missing required columns → system rejects file and shows detailed error report; no partial imports.

• Approval workflow misconfiguration:

• If approval chain missing required role (e.g., Finance Director) → system prevents routing until fixed.

• Document upload failure:

• If signed PDF upload fails (network/storage error) → system keeps contract in Pending Activation and logs error; user can retry.

Paperless Transformation

Remaining Paper Touchpoints: Some payers may insist on wet signatures; originals may still be stored physically but are scanned and linked in the system.

Inputs and Outputs

Inputs:

Outputs:

Post-conditions:

• Contract exists with status "Active" and associated fee schedules published
• All internal approvals recorded with timestamps and approver identities
• Payer-signed document linked to contract record
• Billing & Claims and Denial Analysis modules notified of new rates

SLA and Timing

State Transition Diagram

WF-POLICYCONTRACTMGMT-003: Fee Schedule Management

Process Flow

Actor: Fee Schedule Analyst, RCM Manager
Trigger: Annual CPT update, DHA/DOH tariff revision, or contract renegotiation
Pre-conditions:

• Contract exists in contracts (status Draft, In Review, or Active)
• Latest DHA/DOH tariff files or CPT updates available

1. Fee Schedule Analyst opens Fee Schedule Editor (SCR-PCM-005) for a selected contract.
2. System displays existing contract_fee_schedules and fee_schedule_items for that contract, if any.
3. Analyst chooses to import base fee schedule (DHA tariff, DOH tariff, or custom) or create manually.
4. If importing, system parses the file, maps payer/service categories to CPT codes, and creates/updates contract_fee_schedules (INSERT/UPDATE) and fee_schedule_items (bulk INSERT).
5. System runs validation checks:
   - CPT code exists in CPT master
   - No duplicate CPT+modifier for same fee schedule
   - Rates are non-negative and within configured bounds.
6. Analyst applies rate adjustments according to contract methodology (e.g., 120% of DHA tariff, 90% of DOH tariff, or fixed rates) using bulk update tools; system updates fee_schedule_items (UPDATE).
7. Analyst configures bundling/unbundling rules (e.g., CCI-like edits) in a rules table or within coverage_rules (INSERT/UPDATE).
8. System generates an impact analysis report comparing old vs. new rates, showing expected revenue change per service category.
9. Analyst reviews impact; if acceptable, submits fee schedule for approval (status in contract_fee_schedules → Pending Approval).
10. RCM Manager reviews fee schedule details and impact report; they can approve or reject. Decision is logged in an approval log table.
11. If rejected, Analyst adjusts rates and resubmits; if approved, system sets contract_fee_schedules.status → Active and updates effective/expiry dates.
12. System notifies Billing & Claims module of updated rates via INT-PCM-001 and stores previous fee schedule version as historical (status → Archived).

Data Modified:

• contract_fee_schedules — INSERT, UPDATE
• fee_schedule_items — INSERT, UPDATE
• coverage_rules or bundling_rules (if separate) — INSERT, UPDATE
• fee_schedule_approval_log (if defined) — INSERT

Mermaid Flowchart

Decision Points

1. Import vs manual creation
   - If import fails due to mapping issues → user must correct mapping or choose manual entry.
   - If import succeeds → system pre-populates items for further adjustment.

2. Validation of fee schedule items
   - If validation fails (invalid CPT, negative rate, duplicate entries) → user must fix before proceeding.
   - If passes → proceed to rate methodology and impact analysis.

3. Approval decision
   - If RCM Manager rejects → Analyst must adjust and resubmit.
   - If approved → schedule becomes Active and previous versions are archived.

Integration Points

• Billing & Claims module (billing-claims):
• Direction: Outbound (INT-PCM-001)
• Data: Updated fee schedules and rates.

• Trigger: Fee schedule status changes to Active.

• Denial Analysis module (denial-analysis):

• Direction: Outbound (INT-PCM-003)
• Data: Updated rates for underpayment and denial pattern analysis.
• Trigger: Fee schedule activation.

Exception Handling

• File import errors:

• System provides row-level error report (e.g., unknown CPT, missing rate); partial imports can be rolled back to maintain consistency.

• Rate calculation overflow or extreme values:

• If calculated rate exceeds configured thresholds (e.g., > 500% of base tariff) → system flags as potential configuration error and requires explicit override.

• Concurrent edits:

• If two users edit the same fee schedule, system uses optimistic locking (version/timestamp); second user is prompted to reload.

Paperless Transformation

Remaining Paper Touchpoints: None — fully digital once tariff files are received in electronic format from DHA/DOH.

Inputs and Outputs

Inputs:

Outputs:

Post-conditions:

• Active fee schedule published with current effective dates
• Previous version archived with historical rates preserved
• Impact analysis report generated and stored
• Billing & Claims notified with updated CPT-to-rate mappings

SLA and Timing

State Transition Diagram

WF-POLICYCONTRACTMGMT-004: Coverage Rule Configuration

Process Flow

Actor: Contract Analyst, Utilization Management Lead
Trigger: Contract specifies coverage rules; payer updates coverage policies
Pre-conditions:

• Payer and relevant plans exist in payers and insurance_plans
• Contract and fee schedules defined for the payer
• Clinical coding standards (ICD-10-AM, CPT, SNOMED CT) available in master data

1. Contract Analyst opens Coverage Rule Builder (SCR-PCM-006) and selects payer and plan.
2. System loads existing coverage_rules and prior_auth_rules for that payer/plan.
3. Analyst chooses rule type (e.g., medical necessity, frequency limit, age/gender restriction, benefit limit).
4. Analyst defines criteria:
   - CPT codes or ranges, ICD-10-AM diagnosis codes, age range, gender, frequency limits (e.g., 1 MRI per 6 months), service category.
5. System validates codes against master tables and checks for conflicting rules (e.g., overlapping CPT+ICD combinations with different outcomes).
6. Analyst specifies whether prior authorization is required (requires_prior_auth flag) and links to prior_auth_rules where applicable.
7. Utilization Management Lead configures prior auth details: auth method (portal/phone/fax/auto-approve), turnaround days, valid duration, documentation required in prior_auth_rules (INSERT/UPDATE).
8. Analyst defines benefit limits (annual maximums, visit caps, lifetime maximums) and links them to plan coverage level in coverage_rules.
9. System provides a test claim feature: user enters sample patient demographics, CPT, ICD-10-AM codes, and plan; system simulates coverage decision using the configured rules.
10. If test results are not as expected, Analyst adjusts rules and re-tests until desired behavior is achieved.
11. Once validated, Analyst sets rule status to Active and effective date in coverage_rules and prior_auth_rules (UPDATE).
12. System publishes rules to Patient Access and CPOE modules via INT-PCM-002 and INT-PCM-006 for real-time eligibility and order-time decision support.

Data Modified:

• coverage_rules — INSERT, UPDATE
• prior_auth_rules — INSERT, UPDATE
• coverage_rule_test_log (if defined) — INSERT

Mermaid Flowchart

Decision Points

1. Rule validation and conflict detection
   - If conflicting rules exist (e.g., one rule says auth required, another says not required for same CPT/ICD/plan) → system prompts user to resolve conflict (prioritisation or consolidation).

2. Test claim outcome
   - If simulated claim result does not match payer policy → rules must be adjusted.
   - If correct → rules can be activated.

3. Prior auth requirement
   - If requires_prior_auth = true → prior auth details must be configured; system enforces completeness.
   - If false → prior auth rules may be disabled for that service.

Integration Points

• Patient Access module (patient-access):
• Direction: Outbound (INT-PCM-002)
• Data: Coverage rules and prior auth requirements for eligibility estimation and pre-registration.

• Trigger: Rule activation or update.

• CPOE module (cpoe):

• Direction: Outbound (INT-PCM-006)
• Data: Coverage and prior auth rules for order-time decision support (e.g., “MRI brain requires prior auth for this plan”).

• Trigger: Rule activation or update.

• Billing & Claims module (billing-claims):

• Direction: Outbound (INT-PCM-001/003)
• Data: Coverage rules for claim edits and pre-submission checks.
• Trigger: Rule activation or update.

Exception Handling

• Invalid or deprecated codes:

• If CPT/ICD-10-AM codes are not found or are expired, system blocks rule creation and suggests valid alternatives.

• Rule circularity or excessive complexity:

• If rule combinations create loops or unresolvable logic, system warns and prevents activation until simplified.

• PDPL considerations:

• Test claim simulations use anonymised or synthetic patient data where possible; if real data is used, access is logged and restricted by role.

Paperless Transformation

Remaining Paper Touchpoints: Some payers may still issue paper policy circulars; these are scanned and used as reference but rules are implemented digitally.

Inputs and Outputs

Inputs:

Outputs:

Post-conditions:

• Coverage rules active with correct effective dates
• Prior auth requirements linked to appropriate services and plans
• Test claim simulation validated expected behavior
• Patient Access, CPOE, and Billing modules have current rule sets

SLA and Timing

WF-POLICYCONTRACTMGMT-005: Contract Renewal / Amendment

Process Flow

Actor: Contract Manager, Finance Director
Trigger: Contract approaching expiration, rate adjustment needed, or scope change
Pre-conditions:

• Active contract exists in contracts with upcoming expiry date
• Payer performance data available from Billing & Claims and Denial Analysis

1. System runs a daily job to identify contracts expiring in 90/60/30 days and populates Contract Renewal Alerts (SCR-PCM-008).
2. Contract Manager reviews expiring contracts list with days to expiry and performance summary (volume, denial rate, reimbursement variance).
3. For a selected contract, system retrieves aggregated metrics from reimbursement_rates and denial data (via Denial Analysis integration).
4. Contract Manager generates a renewal proposal with recommended rate adjustments (e.g., +5% on imaging, +3% on inpatient per diem) using built-in tools.
5. System simulates financial impact of proposed changes and displays summary.
6. Contract Manager decides whether to proceed with amendment or full new contract version.
7. If amendment:
   - System creates a new record in contract_amendments (INSERT) capturing amendment type, description, old_value, new_value, effective_date.
   - Contract terms and relevant fee_schedule_items are updated (UPDATE).
8. If new version:
   - System creates a new contracts row with parent_contract_id referencing the previous contract, version incremented, status Draft.
   - Existing fee schedules are cloned to new contract_fee_schedules and fee_schedule_items (INSERT).
9. Contract Manager routes amendment or new version through the same approval workflow as WF-PCM-002 (internal approvals, payer negotiation).
10. Once approved internally and signed by payer, system updates contracts and/or contract_amendments with approved_by, approved_date, and status.
11. System sets new effective date and ensures old contract is end-dated appropriately (status → Expired or Superseded).
12. Updated fee schedules are activated (contract_fee_schedules.status → Active) and previous ones archived.
13. System notifies Billing & Claims and Denial Analysis modules of new terms and effective dates.

Data Modified:

• contracts — INSERT (new version), UPDATE (status, expiry)
• contract_amendments — INSERT, UPDATE
• contract_fee_schedules — INSERT (cloned), UPDATE
• fee_schedule_items — INSERT (cloned), UPDATE
• reimbursement_rates — may be recalculated downstream, not directly modified here

Mermaid Flowchart

Decision Points

1. Proceed with change vs monitor
   - If performance is acceptable and payer relationship strategic → may choose to renew as-is (no amendment).
   - If underpayment or high denial rate → proceed with amendment or new version.

2. Amendment vs new version
   - Minor changes (e.g., small rate adjustments) → amendment.
   - Major structural changes (contract type, facilities, methodology) → new contract version.

3. Approval outcome
   - If not approved internally or payer rejects → proposal must be revised or contract may lapse; system can escalate alerts.

Integration Points

• Billing & Claims module (billing-claims):
• Direction: Bidirectional (INT-PCM-001/003)
• Data Inbound: Claims data for performance metrics.
• Data Outbound: Updated contract terms and fee schedules.

• Trigger: Renewal analysis and post-approval activation.

• Denial Analysis module (denial-analysis):

• Direction: Bidirectional (INT-PCM-003)
• Data Inbound: Denial patterns and root causes.
• Data Outbound: Updated contract/amendment details for future analysis.
• Trigger: Renewal analysis and contract changes.

Exception Handling

• Missed renewal (contract expires):

• If contract reaches expiry without renewal → system sets status to Expired and flags all related encounters/claims as out-of-contract; alerts Billing & Patient Access.

• Incorrect effective dates:

• If new effective date overlaps with previous contract version → system warns and requires explicit override or adjustment.

• Amendment without approval:

• System prevents activation of amendment changes until all required approvals are recorded.

Paperless Transformation

Remaining Paper Touchpoints: Some payers may still sign paper addenda; originals may be stored physically but scanned into the system.

Inputs and Outputs

Inputs:

Outputs:

Post-conditions:

• Renewed or amended contract active with new effective dates
• Previous contract end-dated appropriately (Expired or Superseded)
• Updated fee schedules activated and previous versions archived
• All downstream modules notified of new terms

SLA and Timing

WF-POLICYCONTRACTMGMT-006: Payer Performance Monitoring

Process Flow

Actor: RCM Manager, Finance Director
Trigger: Monthly/quarterly review cycle or ad-hoc performance review request
Pre-conditions:

• Claims and payment data available in Billing & Claims module
• Contracts and fee schedules configured in this module
• Denial data available from Denial Analysis module

1. On a scheduled basis (e.g., monthly), system aggregates claims data by payer from Billing & Claims into reimbursement_rates (INSERT/UPDATE).
2. For each payer/contract/CPT, system calculates:
   - Expected rate (from fee_schedule_items)
   - Actual average rate (from paid claims)
   - Variance percentage, claim count, period_start, period_end.
3. RCM Manager opens Payer Performance Dashboard (SCR-PCM-007).
4. System displays payer scorecards: denial rate, average days to payment, reimbursement variance, volume trends, top denial reasons (via Denial Analysis integration).
5. User filters by period, payer, payer class (e.g., THIQA, private), and facility.
6. System highlights underperforming payers/contracts based on thresholds (e.g., variance < 98%, denial rate > 15%, average days to pay > contract terms).
7. RCM Manager drills down into a specific payer to view service-level performance (by CPT/service category) using reimbursement_rates.
8. System allows export of detailed data for further analysis (subject to PDPL and role-based access).
9. Finance Director reviews high-level dashboards and identifies payers requiring renegotiation or operational interventions.
10. For payers flagged as underperforming, RCM Manager can initiate a Contract Renewal / Amendment workflow (WF-PCM-005) directly from the dashboard.
11. System logs all dashboard views and exports for audit purposes.

Data Modified:

• reimbursement_rates — INSERT, UPDATE
• payer_performance_audit_log (if defined) — INSERT

Mermaid Flowchart

Decision Points

1. Threshold-based underperformance
   - If payer metrics fall outside configured thresholds → flagged as underperforming.
   - If within thresholds → monitored only.

2. Need for renegotiation
   - If variance is minor and operational issues (e.g., coding) are root cause → focus on internal process improvement.
   - If systemic underpayment or long days to pay → initiate contract renegotiation.

3. Data export
   - If user requests export → system checks role and PDPL permissions; may anonymise or restrict data for non-RCM roles.

Integration Points

• Billing & Claims module (billing-claims):
• Direction: Inbound (INT-PCM-001)
• Data: Claims, payments, and remittance information used to compute reimbursement_rates.

• Trigger: Scheduled aggregation job.

• Denial Analysis module (denial-analysis):

• Direction: Inbound (INT-PCM-003)
• Data: Denial codes, reasons, and patterns per payer.
• Trigger: Dashboard load and drill-down.

Exception Handling

• Missing or delayed claims data:

• If Billing & Claims data not available for the period → system marks metrics as incomplete and displays warning.

• Contract or fee schedule changes mid-period:

• System uses effective dates to align expected rates with claim dates; if misalignment detected, it flags potential configuration issues.

• Performance calculation errors:

• If division by zero or inconsistent data → system logs error and excludes affected records from KPIs, showing partial data warning.

Paperless Transformation

Remaining Paper Touchpoints: None — performance monitoring is fully digital; any printed reports are optional and generated from the system.

Inputs and Outputs

Inputs:

Outputs:

Post-conditions:

• reimbursement_rates current as of last aggregation job
• Underperforming payers flagged based on configured thresholds
• Dashboard reflects accurate payer scorecards for the selected period
• All data exports and dashboard views logged for audit

SLA and Timing