The billing pipeline

Outcome

You understand the path a single charge takes from your EMR all the way to a posted, paid (or written-off) line. Every later chapter assumes this picture.

The big diagram

Stage-by-stage

1. Ingestion (upstream of you)

Your EMR (or another source — push API, SFTP file feed, HL7 v2 listener) delivers an inbound batch. The platform parses it against the configured mapping, validates it, and writes the result as service.charge rows. You see the result on /charges. The how of ingestion is the Tenant Admin's job; you only need to know what arrived and why anything failed.

Where to look	What it tells you
/charges?status=NEEDS_FIX	Validation failed; you have to repair upstream or correct in-app.
/charges?status=VALIDATED	Ready to bill.
/admin/ingestion/feeds/:id/artifacts	The most recent inbound batch — admins see this; you usually don't.

See 2.1 — Where charges come from for the upstream picture.

2. Charge prep

Before a charge is billable, the platform has to know:

• Active coverage for the member on the date of service. Eligibility cache may need a refresh — see 2.4 — Confirm eligibility.
• Active authorization if the program requires one. If the auth is missing, you can attach an existing one or request a new one — see 2.5 — Attach or request auth.
• Validated rate. The rate-resolver picks the highest-priority applicable rate (contract → fee schedule → state default).

The Charges page surfaces these checks as inline issues. A charge that fails any of them sits at NEEDS_FIX until you (or the clinical team) resolves it.

3. Build

Selecting validated charges and clicking Build claim creates a CREATED claim and runs the scrubber:

Scrubber stage	Job
Modifier injection	Adds modifiers per modifier_injection_rule (e.g. HQ for groups, 95 for telehealth).
Validation rules	Pre-submit checks (auth required, modifier valid, bundle conflicts, etc.) per the PRE_SUBMIT_VALIDATE rule set.
Bundling	CCI / MUE compaction.
Pricing	Applies contracted fee schedule + any group / per-diem / institutional bands.

If anything fails the claim stays CREATED with an issue list. Fix and re-validate; the platform re-runs the scrubber idempotently.

4. Submit

A clean CREATED claim accepts Submit. The platform:

• Routes to the right trading partner per the routing rules.
• Renders 837P or 837I based on filing type.
• Hands the file to the transport (SFTP / API / direct).
• Promotes the claim to BUILT → SUBMITTED once transport confirms.

5. Acknowledgment

Two acks come back:

Doc	When	Effect
999	Within minutes of the file arriving	Confirms the file parsed.
277CA	Hours later	Confirms the payer accepted (or rejected) the claim.

A clean 277CA flips the claim to ACCEPTED. A rejection generates an issue with the payer's reason; you fix and rebuild.

6. Adjudication & 835

The payer adjudicates — sometimes minutes, sometimes weeks. The result arrives as an 835 (electronic remittance advice). The receivable lands at /receivables/:id with six tabs: Auto-matched, Review, Unmatched, Exceptions, Adjustments, Trace.

You walk those tabs (chapter 4), then Post. Posting:

• Updates each claim's balance.
• Records remittance_adjustment rows (CARC / RARC).
• Routes patient liability (PR-1/2/3) to the patient AR.
• Auto-builds secondary / tertiary claims if COB applies.
• Emits denial rows for any DENIED lines, which appear on the worklist.

7. Denials → auto-correction → re-bill

A denial flows to the /denials worklist. The auto-correction engine has a registry of handlers keyed by CARC (CO-4, CO-16, CO-29, CO-18, CO-97, CO-197, etc.). It runs automatically; you review the result on the Auto-correction tab.

Engine outcome	Your move
SUCCESS	None — the rebill is in flight.
FAILED / SKIPPED	Manually decide: appeal, rebill, write off, or route back.
Not yet attempted	Wait, or trigger by hand.

8. AR management & timely filing

Anything outstanding lives on /ar/aging. You sort by age, by payer, by days-in-AR. The timely-filing watch (/ar/timely-filing) shows claims approaching their payer-specific filing deadline; the dashboard alert escalates as the window narrows.

9. Patient billing

Lines tagged PR-1/2/3 and any unbilled patient balance after secondary post route to patient AR. Statements (electronic + paper) generate on a configurable cadence.

Where each stage lives in this manual

Stage	Chapter
Ingestion + charge prep	2. From EMR to Claim
Build, submit, ack, COB	3. Claim Lifecycle
ERA posting	4. Receivables
Denials + appeals	5. Denials
Aging, timely filing	6. AR
Patient AR	7. Patient Billing
KPIs	8. Reporting

Where to next

• 1.3 — Day 1 as a billing clerk if you build and submit.
• 1.4 — Day 1 as a posting clerk if you post.
• 1.5 — Day 1 as an AR analyst if you do AR follow-up.