Coverage, claims, and payments
Insurance coverage, claims with versions, manual payments, and refunds.
Needs canManageBilling.
Coverage
recordPatientCoverage stores payer, member ID, group, and effective date. unverified → active, inactive, or rejected.
Claims
/dashboard/platform/claims. prepareInsuranceClaim needs active coverage matching the patient and facility, and an encounter. Billed amounts are non-negative integer cents. Every change adds an immutable ClaimVersion.
draft → prepared → submitted → external_acknowledged or external_rejected → corrected; cancelled. Recording external_* results can also arrive from the payer through the inbound webhook (claim.acknowledged, claim.rejected).
Payments and refunds
These are on the billing tab of /dashboard/platform/operational-fabric.
| Record | Methods and states |
|---|---|
PatientPayment | Methods cash, check, card_external, bank_external. pending → succeeded, failed, cancelled |
PatientRefund | pending → succeeded, failed, cancelled. Tracks refundedAmountCents on the payment |
Payments are recorded against money received outside the app. Add an externalReference when you mark one succeeded.