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Eligibility & RCM

Eligibility & full Mod-RCM

Full revenue cycle ships with pollenix.health — eligibility check, claim submission, acknowledgments, ERA ingest, denial worklist with AI appeals, all on X12 standards.

Eligibility (X12 270/271)

/admin/eligibility — real-time eligibility check against the clearinghouse. Round-trip through the configured eligibility provider (Stedi by default; mock provider available for demos).

Each check returns benefits + copays + deductibles + network status, persisted to a benefit-snapshot row tied to the patient + payer + date. Snapshot informs the OOP estimator before service.

Claim encode (X12 837P / 837I)

Encounter sign-off triggers an 837 build:

  1. Pull billable services from the encounter — Procedure, MedicationAdministration, Observation (point-of-care labs), any AI-charge-capture suggestions the coder accepted.
  2. Build the loops — 2300 (claim), 2400 (service line), 2310 ( rendering / billing provider), 2420 (referring provider).
  3. Validate against the predictive scrubber before submission. Failures land in the scrub queue with the gap list (NCCI / prior-auth / required-Dx / historical-risk).
  4. Submit through the clearinghouse adapter.

Acknowledgments (X12 277CA + 999)

/admin/rcm-ops — incoming ack messages parsed and matched against submitted claims. 999 = syntactic accept/reject; 277CA = clearing- house level + payer level status.

Each ack updates the claim’s status (accepted / rejected / accepted_with_warnings) and surfaces the underlying error if any — typically before the 835 lands.

ERA ingest (X12 835)

Inbound ERAs from the clearinghouse parse to:

  • claim_adjudications — per-claim, per-service-line CARC + RARC codes, paid amount, write-off, adjusted amount.
  • Auto-generated denials worklist rows for adjudications with denial CARCs.
  • Auto-generated underpayment_alerts when paid amount < contract-fee-schedule expected.
  • patient_ledger_entries updated per-claim.

Denial worklist + AI appeal letters

/admin/denials — open denials sorted by impact (denied $ × payer volume). Per-row actions: appeal, write off, correct + resubmit.

AI appeal letter generates a payer-specific appeal letter citing the original CARC, the supporting clinical evidence (FHIR resource ids), and the applicable medical-policy clause. Drafter is advisory — a biller reviews + signs.

Corrected resubmission (Frequency-7)

When a claim was accepted but adjudicated incorrectly, the Frequency-7 button rebuilds the 837 with a corrected-claim indicator and the original payer claim id attached. One-click resubmit; the original isn’t voided.

NCCI bundle

The CMS Quarterly Practitioner PTP edits bundle (NCCI) drives the scrubber’s bundle-rule check. Loaded by an admin via /admin/rcm-ops → Upload NCCI bundle — quarterly cadence. Updates apply globally for the tenant.