SAIF.Domain business rules¶

This page captures the business rules enforced by SAIF.Domain, drawn from the ebilling assignment, indexing, CBP generation, EDI, audit, certificate-holder, Guidewire claim-mapping, and document-packet logic in this library. Origin for every rule is SAIF.Domain; no rule on this page is imported from a dependency package.

DOM-BR-001 Bill assignment¶

Field	Value
Statement	Each pended error on a bill is recorded as an audit note with TypeCode "BE" and Category "B"
Trigger	Bill assignment
Enforcement	`BillAssignment.AssignBillResponsibility`
Outcome	`AuditNote` created
Source	`Domain/SAIF.Domain/Claims/Ebilling/BillAssignment.cs`
Operations	OP-DOM-01

DOM-BR-002 Assignment¶

Field	Value
Statement	Pended errors on a claim whose worker is a conflict worker go to the confidential assignment rule
Trigger	Assignment
Enforcement	`BillAssignment.GetBillAssignmentRule`
Outcome	Confidential responsible party and status
Source	`Domain/SAIF.Domain/Claims/Ebilling/BillAssignment.cs`
Operations	OP-DOM-01

DOM-BR-003 Assignment¶

Field	Value
Statement	Pended errors that are not all provider errors go to the claim-error assignment rule
Trigger	Assignment
Enforcement	`BillAssignment.GetBillAssignmentRule`
Outcome	Claim-error party and status
Source	`Domain/SAIF.Domain/Claims/Ebilling/BillAssignment.cs`
Operations	OP-DOM-01

DOM-BR-004 Assignment¶

Field	Value
Statement	All pended errors being provider errors triggers the provider-error assignment
Trigger	Assignment
Enforcement	`BillAssignment.GetBillAssignmentRule`
Outcome	Provider-error party and status
Source	`Domain/SAIF.Domain/Claims/Ebilling/BillAssignment.cs`
Operations	OP-DOM-01

DOM-BR-005 Assignment¶

Field	Value
Statement	No pended errors results in the clean assignment
Trigger	Assignment
Enforcement	`BillAssignment.GetBillAssignmentRule`
Outcome	Clean party and status
Source	`Domain/SAIF.Domain/Claims/Ebilling/BillAssignment.cs`
Operations	OP-DOM-01

DOM-BR-006 Assignment complete¶

Field	Value
Statement	After assignment the ebill status becomes Assigned
Trigger	Assignment complete
Enforcement	`BillAssignment.AssignBillsResponsibily`
Outcome	Ebill status Assigned
Tables	EBILL
SQL	SQL-024
Source	`Domain/SAIF.Domain/Claims/Ebilling/BillAssignment.cs`
Operations	OP-DOM-01

DOM-BR-007 Exception¶

Field	Value
Statement	Assignment failures are rethrown with the ebill id
Trigger	Exception
Enforcement	`BillAssignment.AssignBillsResponsibily`
Outcome	Exception "Ebill Id: {id}"
Source	`Domain/SAIF.Domain/Claims/Ebilling/BillAssignment.cs`
Operations	OP-DOM-01

DOM-BR-010 Patient indexing¶

Field	Value
Statement	Claim number "UNKNOWN" is not indexable
Trigger	Patient indexing
Enforcement	`PatientIndexer.IndexPatientToClaim`
Outcome	Error "No claim number"
Source	`Domain/SAIF.Domain/Claims/Ebilling/Indexing/PatientIndexer.cs`
Operations	OP-DOM-02

DOM-BR-011 Patient indexing¶

Field	Value
Statement	The claim number must be 7-8 characters, and an 8-character number must end in a letter
Trigger	Patient indexing
Enforcement	`PatientIndexer.IndexPatientToClaim`
Outcome	Error "Invalid claim number"
Source	`Domain/SAIF.Domain/Claims/Ebilling/Indexing/PatientIndexer.cs`
Operations	OP-DOM-02

DOM-BR-012 API exception¶

Field	Value
Statement	A ClaimCenter API failure is an indexing error
Trigger	API exception
Enforcement	`PatientIndexer.IndexPatientToClaim`
Outcome	Error "An error occurred in CCClaimDataApi"
Source	`Domain/SAIF.Domain/Claims/Ebilling/Indexing/PatientIndexer.cs`
Operations	OP-DOM-02

DOM-BR-013 Null claim¶

Field	Value
Statement	The claim must exist in ClaimCenter
Trigger	Null claim
Enforcement	`PatientIndexer.IndexPatientToClaim`
Outcome	Error "Claim not found"
Source	`Domain/SAIF.Domain/Claims/Ebilling/Indexing/PatientIndexer.cs`
Operations	OP-DOM-02

DOM-BR-014 Indexing¶

Field	Value
Statement	The worker's birth date must equal the patient's birth date
Trigger	Indexing
Enforcement	`PatientIndexer.IndexPatientToClaim`
Outcome	Error "Claim has a missing or unmatched birth date"
Source	`Domain/SAIF.Domain/Claims/Ebilling/Indexing/PatientIndexer.cs`
Operations	OP-DOM-02

DOM-BR-015 Post-index check¶

Field	Value
Statement	WCD status "void" or claim state "draft" is invalid
Trigger	Post-index check
Enforcement	`PatientIndexer.CheckIndexedPatientForClaimErrors`
Outcome	Error "Invalid claim status"
Source	`Domain/SAIF.Domain/Claims/Ebilling/Indexing/PatientIndexer.cs`
Operations	OP-DOM-02

DOM-BR-016 Post-index check¶

Field	Value
Statement	Non-complying-employer claims are flagged
Trigger	Post-index check
Enforcement	`PatientIndexer.CheckIndexedPatientForClaimErrors`
Outcome	Error "NCE claim"
Source	`Domain/SAIF.Domain/Claims/Ebilling/Indexing/PatientIndexer.cs`
Operations	OP-DOM-02

DOM-BR-020 Provider indexing¶

Field	Value
Statement	The billing provider's tax ID must exist
Trigger	Provider indexing
Enforcement	`ProviderIndexer` / `ProviderIndexerV2`
Outcome	Error "Provider Tax Id not found"
Source	`Domain/SAIF.Domain/Claims/Ebilling/Indexing/ProviderIndexer.cs`
Operations	OP-DOM-03, OP-DOM-04

DOM-BR-021 Provider indexing¶

Field	Value
Statement	A bill is institutional when any bill has SetType "INST"; institutional filtering uses provider types NU/HO/HH
Trigger	Provider indexing
Enforcement	`ProviderIndexer` / `ProviderIndexerV2`
Outcome	Filtered candidate list
Source	`Domain/SAIF.Domain/Claims/Ebilling/Indexing/ProviderIndexer.cs`
Operations	OP-DOM-03, OP-DOM-04

DOM-BR-022 Address match¶

Field	Value
Statement	Addresses match on Line1 and City (trimmed, case-insensitive) and on the zip padded to 5
Trigger	Address match
Enforcement	`ProviderIndexer`
Outcome	Match / no match
Source	`Domain/SAIF.Domain/Claims/Ebilling/Indexing/ProviderIndexer.cs`
Operations	OP-DOM-03

DOM-BR-023 Address match¶

Field	Value
Statement	The facility address takes precedence over the physical address; with no physical match the bill fails
Trigger	Address match
Enforcement	`ProviderIndexer`
Outcome	Error "Physical location not found for billing provider"
Source	`Domain/SAIF.Domain/Claims/Ebilling/Indexing/ProviderIndexer.cs`
Operations	OP-DOM-03

DOM-BR-024 Payment resolution¶

Field	Value
Statement	With no payment address, the matched location must have no active PAY address
Trigger	Payment resolution
Enforcement	`ProviderIndexer`
Outcome	Errors "Multiple physical locations found without a payment address" / "Physical location having no payment address not found"
Source	`Domain/SAIF.Domain/Claims/Ebilling/Indexing/ProviderIndexer.cs`
Operations	OP-DOM-03

DOM-BR-025 Payment resolution¶

Field	Value
Statement	With a payment address, the physical and payment matches must intersect by location
Trigger	Payment resolution
Enforcement	`ProviderIndexer`
Outcome	Errors "Multiple physical locations found with matching payment address" / "Payment address not found"
Source	`Domain/SAIF.Domain/Claims/Ebilling/Indexing/ProviderIndexer.cs`
Operations	OP-DOM-03

DOM-BR-026 V2 indexing¶

Field	Value
Statement	Correspondence and expired addresses are excluded from matching
Trigger	V2 indexing
Enforcement	`ProviderIndexerV2`
Outcome	Filtered list
Source	`Domain/SAIF.Domain/Claims/Ebilling/Indexing/ProviderIndexerV2.cs`
Operations	OP-DOM-04

DOM-BR-027 V2 indexing¶

Field	Value
Statement	Provider-type filter: Pharmacy=PH, Dental=DE, Hospital=HO/NU/HH, Professional=all others
Trigger	V2 indexing
Enforcement	`ProviderIndexerV2`
Outcome	Filtered list
Source	`Domain/SAIF.Domain/Claims/Ebilling/Indexing/ProviderIndexerV2.cs`
Operations	OP-DOM-04

DOM-BR-028 V2 indexing¶

Field	Value
Statement	A biller with physical, payment and facility addresses uses the PaymentAndFacility and ThreeAddressNoFacilityMatches rules; otherwise PaymentAndFacility, PhysicalAndPayment, PhysicalAndFacility, PhysicalOnly and PhysicalOnlyMatchPhysicalWithPayment
Trigger	V2 indexing
Enforcement	`ProviderIndexerV2`
Outcome	Rule set selected
Source	`Domain/SAIF.Domain/Claims/Ebilling/Indexing/ProviderIndexerV2.cs`
Operations	OP-DOM-04

DOM-BR-029 Matching¶

Field	Value
Statement	The first unique rule match wins; if none, retry with the Line1+Line2 concatenation when any Line2 exists
Trigger	Matching
Enforcement	`ProviderMatcher`
Outcome	Location chosen
Source	`Domain/SAIF.Domain/Claims/Ebilling/Indexing/ProviderMatcher.cs`
Operations	OP-DOM-04

DOM-BR-029a Matching¶

Field	Value
Statement	No match is an error
Trigger	Matching
Enforcement	`ProviderIndexerV2`
Outcome	Error "Provider location match not found"
Source	`Domain/SAIF.Domain/Claims/Ebilling/Indexing/ProviderIndexerV2.cs`
Operations	OP-DOM-04

DOM-BR-030 Status change¶

Field	Value
Statement	A bill status maps to a code (COM, ENT, PEN, AUD, APP, DIS, EXT, REV, SUS); an unknown status throws
Trigger	Status change
Enforcement	`Bill.ModifyStatus` → `BillStatusCode.GetStatusCode`
Outcome	Exception on an unknown status
Source	`Domain/SAIF.Domain/Model/Claims/Bills/Bill.cs`
Operations	OP-DOM-01, OP-DOM-13, OP-DOM-16

DOM-BR-040 Service indexing¶

Field	Value
Statement	For set type PHAR, use the NPI identity location, else the organizational NPI; take the max location ID
Trigger	Service indexing
Enforcement	`BillServiceIndexer`
Outcome	Rendering location set
Source	`Domain/SAIF.Domain/Claims/Ebilling/Indexing/BillServiceIndexer.cs`
Operations	OP-DOM-05

DOM-BR-041 Service indexing¶

Field	Value
Statement	For a service-provider-restricted provider type, use the billing location as the rendering location
Trigger	Service indexing
Enforcement	`BillServiceIndexer`
Outcome	Location set
Source	`Domain/SAIF.Domain/Claims/Ebilling/Indexing/BillServiceIndexer.cs`
Operations	OP-DOM-05

DOM-BR-042 Service indexing¶

Field	Value
Statement	Rendering lookup by NPI + works-for + date must return exactly one location
Trigger	Service indexing
Enforcement	`BillServiceIndexer`
Outcome	Errors "Multiple locations found for rendering provider" / "Rendering provider NPI or works-for relationship not found"
Source	`Domain/SAIF.Domain/Claims/Ebilling/Indexing/BillServiceIndexer.cs`
Operations	OP-DOM-05

DOM-BR-043 Service indexing¶

Field	Value
Statement	After service indexing the ebill status is Indexed
Trigger	Service indexing
Enforcement	`BillServiceIndexer`
Outcome	Status Indexed
Tables	EBILL
SQL	SQL-025
Source	`Domain/SAIF.Domain/Claims/Ebilling/Indexing/BillServiceIndexer.cs`
Operations	OP-DOM-05

DOM-BR-050 CBP generation¶

Field	Value
Statement	Ebill type is I if INST and a place of service is found, O if INST without one, otherwise S
Trigger	CBP generation
Enforcement	`GenerateCbpBills.Generate`
Outcome	BillTypeCode
Tables	CBP_BILL, CBP_BILL_SERVICE, EBILL
SQL	SQL-016, SQL-017, SQL-032
Source	`Domain/SAIF.Domain/Claims/Ebilling/GenerateCBPBills.cs`
Operations	OP-DOM-06

DOM-BR-051 CBP generation¶

Field	Value
Statement	Admit and discharge dates only apply to type I
Trigger	CBP generation
Enforcement	`GenerateCbpBills.Generate`
Outcome	Dates set or null
Tables	CBP_BILL, CBP_BILL_SERVICE, EBILL
SQL	SQL-016, SQL-017, SQL-032
Source	`Domain/SAIF.Domain/Claims/Ebilling/GenerateCBPBills.cs`
Operations	OP-DOM-06

DOM-BR-052 CBP generation¶

Field	Value
Statement	Statement from/thru dates default to the min/max service date
Trigger	CBP generation
Enforcement	`GenerateCbpBills.Generate`
Outcome	Dates set
Tables	CBP_BILL, CBP_BILL_SERVICE, EBILL
SQL	SQL-016, SQL-017, SQL-032
Source	`Domain/SAIF.Domain/Claims/Ebilling/GenerateCBPBills.cs`
Operations	OP-DOM-06

DOM-BR-053 CBP generation¶

Field	Value
Statement	Worker tax ID 999999999 becomes null; 9 digits are formatted xxx-xx-xxxx
Trigger	CBP generation
Enforcement	`GenerateCbpBills.Generate`
Outcome	WorkerTaxId
Tables	CBP_BILL, CBP_BILL_SERVICE, EBILL
SQL	SQL-016, SQL-017, SQL-032
Source	`Domain/SAIF.Domain/Claims/Ebilling/GenerateCBPBills.cs`
Operations	OP-DOM-06

DOM-BR-054 CBP generation¶

Field	Value
Statement	First name is truncated to 20 characters; claim-API worker names override the bill's
Trigger	CBP generation
Enforcement	`GenerateCbpBills.Generate`
Outcome	Names
Tables	CBP_BILL, CBP_BILL_SERVICE, EBILL
SQL	SQL-016, SQL-017, SQL-032
Source	`Domain/SAIF.Domain/Claims/Ebilling/GenerateCBPBills.cs`
Operations	OP-DOM-06

DOM-BR-055 CBP generation¶

Field	Value
Statement	PriorityNumber = 3 and IsRebill = false for generated bills
Trigger	CBP generation
Enforcement	`GenerateCbpBills.Generate`
Outcome	Values set
Tables	CBP_BILL, CBP_BILL_SERVICE, EBILL
SQL	SQL-016, SQL-017, SQL-032
Source	`Domain/SAIF.Domain/Claims/Ebilling/GenerateCBPBills.cs`
Operations	OP-DOM-06

DOM-BR-056 CBP generation¶

Field	Value
Statement	Service code: institutional selects revenue code, else service code; non-institutional selects NDC, else revenue code, else service code
Trigger	CBP generation
Enforcement	`GenerateCbpBills.Generate`
Outcome	Code chosen
Tables	CBP_BILL, CBP_BILL_SERVICE, EBILL
SQL	SQL-016, SQL-017, SQL-032
Source	`Domain/SAIF.Domain/Claims/Ebilling/GenerateCBPBills.cs`
Operations	OP-DOM-06

DOM-BR-057 CBP generation¶

Field	Value
Statement	A non-institutional service with an NDC is type Pharmacy
Trigger	CBP generation
Enforcement	`GenerateCbpBills.Generate`
Outcome	Service type
Tables	CBP_BILL, CBP_BILL_SERVICE, EBILL
SQL	SQL-016, SQL-017, SQL-032
Source	`Domain/SAIF.Domain/Claims/Ebilling/GenerateCBPBills.cs`
Operations	OP-DOM-06

DOM-BR-058 CBP generation¶

Field	Value
Statement	Quantity precision over 2 decimals is truncated and logged as a non-pending error
Trigger	CBP generation
Enforcement	`GenerateCbpBills.Generate`
Outcome	Error condition (not pended)
Tables	CBP_BILL, CBP_BILL_SERVICE, EBILL
SQL	SQL-016, SQL-017, SQL-032
Source	`Domain/SAIF.Domain/Claims/Ebilling/GenerateCBPBills.cs`
Operations	OP-DOM-06

DOM-BR-059 CBP generation¶

Field	Value
Statement	Dental ("D") services require a valid tooth code
Trigger	CBP generation
Enforcement	`GenerateCbpBills.Generate`
Outcome	Error condition
Tables	CBP_BILL, CBP_BILL_SERVICE, EBILL
SQL	SQL-016, SQL-017, SQL-032
Source	`Domain/SAIF.Domain/Claims/Ebilling/GenerateCBPBills.cs`
Operations	OP-DOM-06

DOM-BR-060 CBP generation¶

Field	Value
Statement	Service location: institutional inpatient vs outpatient; otherwise `UbBillTypeCode.Substring(1,2)`
Trigger	CBP generation
Enforcement	`GenerateCbpBills.Generate`
Outcome	Location code
Tables	CBP_BILL, CBP_BILL_SERVICE, EBILL
SQL	SQL-016, SQL-017, SQL-032
Source	`Domain/SAIF.Domain/Claims/Ebilling/GenerateCBPBills.cs`
Operations	OP-DOM-06

DOM-BR-061 CBP generation¶

Field	Value
Statement	Diagnosis pointers only for Standard (S) bills
Trigger	CBP generation
Enforcement	`GenerateCbpBills.Generate`
Outcome	Pointers set
Tables	CBP_BILL, CBP_BILL_SERVICE, EBILL
SQL	SQL-016, SQL-017, SQL-032
Source	`Domain/SAIF.Domain/Claims/Ebilling/GenerateCBPBills.cs`
Operations	OP-DOM-06

DOM-BR-062 CBP generation¶

Field	Value
Statement	The prescribing provider falls back to the rendering NPI
Trigger	CBP generation
Enforcement	`GenerateCbpBills.Generate`
Outcome	Provider set
Tables	CBP_BILL, CBP_BILL_SERVICE, EBILL
SQL	SQL-016, SQL-017, SQL-032
Source	`Domain/SAIF.Domain/Claims/Ebilling/GenerateCBPBills.cs`
Operations	OP-DOM-06

DOM-BR-063 Complete¶

Field	Value
Statement	After CBP generation the ebill status is CbpSetup
Trigger	Complete
Enforcement	`GenerateCbpBills.Generate`
Outcome	Status
Tables	CBP_BILL, CBP_BILL_SERVICE, EBILL
SQL	SQL-016, SQL-017, SQL-032
Source	`Domain/SAIF.Domain/Claims/Ebilling/GenerateCBPBills.cs`
Operations	OP-DOM-06

DOM-BR-064 CBP generation¶

Field	Value
Statement	Service type code is P/D/R/serviceType/U; an invalid NDC is flagged
Trigger	CBP generation
Enforcement	`GenerateCbpBills.GetCbpBillServiceTypeCode`
Outcome	Error "Nation Drug Code not Valid"
Tables	CBP_BILL, CBP_BILL_SERVICE, EBILL
SQL	SQL-016, SQL-017, SQL-032
Source	`Domain/SAIF.Domain/Claims/Ebilling/GenerateCBPBills.cs`
Operations	OP-DOM-06

DOM-BR-070 Error recording¶

Field	Value
Statement	Error-condition flags: provider errors are pended + provider-error; patient errors are pended + not provider-error; bill-service errors use the isPending parameter; bill-service-provider errors are pended + provider-error
Trigger	Error recording
Enforcement	`ErrorConditionHandler`
Outcome	`EbillErrorCondition` row
Tables	EBILL_ERROR_CONDITION
SQL	SQL-014
Source	`Domain/SAIF.Domain/Model/Claims/Ebilling/ErrorConditionHandler.cs`
Operations	OP-DOM-02..07

DOM-BR-080 Code lookup¶

Field	Value
Statement	Prefer a non-expired service code, then an expired one
Trigger	Code lookup
Enforcement	`ServiceCodeManager`
Outcome	Code
Source	`Domain/SAIF.Domain/Claims/Ebilling/ServiceCodeManager.cs`
Operations	OP-DOM-06, OP-DOM-08

DOM-BR-081 Code lookup¶

Field	Value
Statement	Type code is Unknown when there is no service date or the date is outside the effective/expiration range
Trigger	Code lookup
Enforcement	`ServiceCodeManager`
Outcome	Unknown type
Source	`Domain/SAIF.Domain/Claims/Ebilling/ServiceCodeManager.cs`
Operations	OP-DOM-08

DOM-BR-090 Batch create¶

Field	Value
Statement	New batches start with status "NEW"
Trigger	Batch create
Enforcement	`Batch`
Outcome	Status NEW
Tables	EBILL_BATCH
SQL	SQL-003, SQL-004, SQL-005, SQL-023
Source	`Domain/SAIF.Domain/Model/Claims/Ebilling/Batch.cs`
Operations	OP-DOM-09

DOM-BR-091 GetBatch¶

Field	Value
Statement	A retrieved batch must exist and match the expected status and type
Trigger	GetBatch
Enforcement	`Batch.GetBatch`
Outcome	`InvalidBatchException`
Tables	EBILL_BATCH
SQL	SQL-003, SQL-004, SQL-005, SQL-023
Source	`Domain/SAIF.Domain/Model/Claims/Ebilling/Batch.cs`
Operations	OP-DOM-09

DOM-BR-092 Status set¶

Field	Value
Statement	Batch statuses: COMP, EXTR, IMAGE, INDEX, EOB, DLOAD, ACK, SETUP
Trigger	Status set
Enforcement	`Batch` setters
Outcome	Status code
Tables	EBILL_BATCH
SQL	SQL-003, SQL-004, SQL-005, SQL-023
Source	`Domain/SAIF.Domain/Model/Claims/Ebilling/Batch.cs`
Operations	OP-DOM-09

DOM-BR-100 837 parse¶

Field	Value
Statement	The ISA date must equal the batch submission date
Trigger	837 parse
Enforcement	`File837Extractor.ProcessFile`
Outcome	File fails
Tables	EBILL_SERVICE
SQL	SQL-015
Source	`Domain/SAIF.Domain/Claims/Ebilling/File837Extractor.cs`
Operations	OP-DOM-10

DOM-BR-101 837 parse¶

Field	Value
Statement	A bill must have a PWK document
Trigger	837 parse
Enforcement	`File837Extractor.ProcessFile`
Outcome	Error "Error: Bill has no documents"
Tables	EBILL_SERVICE
SQL	SQL-015
Source	`Domain/SAIF.Domain/Claims/Ebilling/File837Extractor.cs`
Operations	OP-DOM-10

DOM-BR-102 837 parse¶

Field	Value
Statement	The LIN qualifier must be N4
Trigger	837 parse
Enforcement	`File837Extractor.ProcessFile`
Outcome	Error
Tables	EBILL_SERVICE
SQL	SQL-015
Source	`Domain/SAIF.Domain/Claims/Ebilling/File837Extractor.cs`
Operations	OP-DOM-10

DOM-BR-103 837 parse¶

Field	Value
Statement	An N4 segment must follow an N3
Trigger	837 parse
Enforcement	`File837Extractor.ProcessFile`
Outcome	Error
Tables	EBILL_SERVICE
SQL	SQL-015
Source	`Domain/SAIF.Domain/Claims/Ebilling/File837Extractor.cs`
Operations	OP-DOM-10

DOM-BR-104 837 parse¶

Field	Value
Statement	PRV "BI" creates the billing provider with default TaxId 999999999; taxonomy truncated to 10 characters
Trigger	837 parse
Enforcement	`File837Extractor.ProcessFile`
Outcome	Provider created
Tables	EBILL_SERVICE
SQL	SQL-015
Source	`Domain/SAIF.Domain/Claims/Ebilling/File837Extractor.cs`
Operations	OP-DOM-10

DOM-BR-105 837 parse¶

Field	Value
Statement	Recognised REF qualifiers: D9, EI, SY, Y4 (claim number truncated to 20), 1W, 6R, XZ
Trigger	837 parse
Enforcement	`File837Extractor.ProcessFile`
Outcome	Fields set
Tables	EBILL_SERVICE
SQL	SQL-015
Source	`Domain/SAIF.Domain/Claims/Ebilling/File837Extractor.cs`
Operations	OP-DOM-10

DOM-BR-106 837 parse¶

Field	Value
Statement	The first PWK document's type comes from the set type; an unknown document type fails the file
Trigger	837 parse
Enforcement	`File837Extractor.ProcessFile`
Outcome	File fails
Tables	EBILL_SERVICE
SQL	SQL-015
Source	`Domain/SAIF.Domain/Claims/Ebilling/File837Extractor.cs`
Operations	OP-DOM-10

DOM-BR-107 837 parse¶

Field	Value
Statement	For 005010X222A1, the bill is pharmacy when every LX has a LIN
Trigger	837 parse
Enforcement	`File837Extractor.ProcessFile`
Outcome	Pharmacy set type
Tables	EBILL_SERVICE
SQL	SQL-015
Source	`Domain/SAIF.Domain/Claims/Ebilling/File837Extractor.cs`
Operations	OP-DOM-10

DOM-BR-108 837 parse¶

Field	Value
Statement	Service code limited to 5 characters
Trigger	837 parse
Enforcement	`File837Extractor.ProcessFile`
Outcome	Truncation
Tables	EBILL_SERVICE
SQL	SQL-015
Source	`Domain/SAIF.Domain/Claims/Ebilling/File837Extractor.cs`
Operations	OP-DOM-10

DOM-BR-110 277 build¶

Field	Value
Statement	277 status: PEN maps to 2 (no claim) or 3; DIS maps to 4; otherwise 1
Trigger	277 build
Enforcement	`File277CaBuilder.Build277ResponseFile`
Outcome	Status category
Tables	EBILL
SQL	SQL-030
Source	`Domain/SAIF.Domain/Claims/Ebilling/File277CaBuilder.cs`
Operations	OP-DOM-11

DOM-BR-111 277 build¶

Field	Value
Statement	LastResponseBatch is set only when the status is not PEND
Trigger	277 build
Enforcement	`File277CaBuilder.Build277ResponseFile`
Outcome	Batch reference
Tables	EBILL
SQL	SQL-030
Source	`Domain/SAIF.Domain/Claims/Ebilling/File277CaBuilder.cs`
Operations	OP-DOM-11

DOM-BR-120 EOB generation¶

Field	Value
Statement	Non-payment EOBs are grouped by provider + status date with payment method "NON"
Trigger	EOB generation
Enforcement	`EobBuilder.GenerateEobs`
Outcome	EOB groups
Tables	EBILL_EOB_ADJUSTMENT, EBILL_EOB_REMITTANCE_ADVICE, PROVIDER_LOCATION, EBILL
SQL	SQL-010, SQL-011, SQL-012, SQL-013, SQL-020, SQL-021, SQL-029
Source	`Domain/SAIF.Domain/Claims/Ebilling/EobBuilder.cs`
Operations	OP-DOM-12

DOM-BR-121 EOB generation¶

Field	Value
Statement	Ebills load in chunks of 900 (Oracle 1000 IN-list limit)
Trigger	EOB generation
Enforcement	`EobBuilder.GenerateEobs`
Outcome	Chunked queries
Tables	EBILL_EOB_ADJUSTMENT, EBILL_EOB_REMITTANCE_ADVICE, PROVIDER_LOCATION, EBILL
SQL	SQL-010, SQL-011, SQL-012, SQL-013, SQL-020, SQL-021, SQL-029
Source	`Domain/SAIF.Domain/Claims/Ebilling/EobBuilder.cs`
Operations	OP-DOM-12

DOM-BR-122 EOB generation¶

Field	Value
Statement	A null PaymentMethodCode is logged and skipped
Trigger	EOB generation
Enforcement	`EobBuilder.GenerateEobs`
Outcome	Skipped
Tables	EBILL_EOB_ADJUSTMENT, EBILL_EOB_REMITTANCE_ADVICE, PROVIDER_LOCATION, EBILL
SQL	SQL-010, SQL-011, SQL-012, SQL-013, SQL-020, SQL-021, SQL-029
Source	`Domain/SAIF.Domain/Claims/Ebilling/EobBuilder.cs`
Operations	OP-DOM-12

DOM-BR-123 EOB generation¶

Field	Value
Statement	MCO fee adjustments use the clearinghouse MCO reason and group codes
Trigger	EOB generation
Enforcement	`EobBuilder.GenerateEobs`
Outcome	Adjustment rows
Tables	EBILL_EOB_ADJUSTMENT, EBILL_EOB_REMITTANCE_ADVICE, PROVIDER_LOCATION, EBILL
SQL	SQL-010, SQL-011, SQL-012, SQL-013, SQL-020, SQL-021, SQL-029
Source	`Domain/SAIF.Domain/Claims/Ebilling/EobBuilder.cs`
Operations	OP-DOM-12

DOM-BR-124 EOB generation¶

Field	Value
Statement	Service adjustments invert the amount; group code MA/PR maps to CO
Trigger	EOB generation
Enforcement	`EobBuilder.GenerateEobs`
Outcome	Adjustment rows
Tables	EBILL_EOB_ADJUSTMENT, EBILL_EOB_REMITTANCE_ADVICE, PROVIDER_LOCATION, EBILL
SQL	SQL-010, SQL-011, SQL-012, SQL-013, SQL-020, SQL-021, SQL-029
Source	`Domain/SAIF.Domain/Claims/Ebilling/EobBuilder.cs`
Operations	OP-DOM-12

DOM-BR-125 EOB generation¶

Field	Value
Statement	Remittance advices are grouped by service and RARC
Trigger	EOB generation
Enforcement	`EobBuilder.GenerateEobs`
Outcome	RA rows
Tables	EBILL_EOB_ADJUSTMENT, EBILL_EOB_REMITTANCE_ADVICE, PROVIDER_LOCATION, EBILL
SQL	SQL-010, SQL-011, SQL-012, SQL-013, SQL-020, SQL-021, SQL-029
Source	`Domain/SAIF.Domain/Claims/Ebilling/EobBuilder.cs`
Operations	OP-DOM-12

DOM-BR-126 EOB regenerate¶

Field	Value
Statement	Regenerating a rejected EOB sets its bills to Completed
Trigger	EOB regenerate
Enforcement	`EobBuilder.GenerateEobs`
Outcome	Status Completed
Tables	EBILL_EOB_ADJUSTMENT, EBILL_EOB_REMITTANCE_ADVICE, PROVIDER_LOCATION, EBILL
SQL	SQL-010, SQL-011, SQL-012, SQL-013, SQL-020, SQL-021, SQL-029
Source	`Domain/SAIF.Domain/Claims/Ebilling/EobBuilder.cs`
Operations	OP-DOM-12

DOM-BR-130 Audit routing¶

Field	Value
Statement	Audit queue is LEVEL2 when bill type is I, or type O with charges over 20000, or nurse review is required; otherwise LEVEL1
Trigger	Audit routing
Enforcement	`Bill.AuditQueue`
Outcome	Queue
Tables	CBP_BILL_STATUS
SQL	SQL-006
Source	`Domain/SAIF.Domain/Model/Claims/Bills/Bill.cs`
Operations	OP-DOM-13

DOM-BR-131 Send to audit¶

Field	Value
Statement	Sending to audit sets status Audited and adds a B/AU note
Trigger	Send to audit
Enforcement	`Bill.SendToAudit`
Outcome	Status and note
Tables	CBP_BILL_STATUS
SQL	SQL-006
Source	`Domain/SAIF.Domain/Model/Claims/Bills/Bill.cs`
Operations	OP-DOM-13

DOM-BR-132 Pend-approve¶

Field	Value
Statement	Pend and approve use responsible party "SYSTEM"
Trigger	Pend/approve
Enforcement	`Bill.SendPend`, `Bill.Approve`
Outcome	Status change
Tables	CBP_BILL_STATUS
SQL	SQL-006
Source	`Domain/SAIF.Domain/Model/Claims/Bills/Bill.cs`
Operations	OP-DOM-13

DOM-BR-133 Payment option change¶

Field	Value
Statement	Payment-option updates append "@" to the update user
Trigger	Payment option change
Enforcement	`Bill.ModifyPaymentOptions`
Outcome	UpdateUser
Source	`Domain/SAIF.Domain/Model/Claims/Bills/Bill.cs`
Operations	OP-DOM-13

DOM-BR-134 Generate EOB¶

Field	Value
Statement	EOB generation requires a claim
Trigger	Generate EOB
Enforcement	`Bill.GenrateEob`
Outcome	Exception when the claim is null
Source	`Domain/SAIF.Domain/Model/Claims/Bills/Bill.cs`
Operations	OP-DOM-13

DOM-BR-135 Duplicate check¶

Field	Value
Statement	A bill is a full duplicate when its non-duplicate service count is 0
Trigger	Duplicate check
Enforcement	`Bill.IsFullDuplicate`
Outcome	Boolean
Source	`Domain/SAIF.Domain/Model/Claims/Bills/Bill.cs`
Operations	OP-DOM-13

DOM-BR-140 Audit¶

Field	Value
Statement	Disallow-all sets every service's allowed amount to 0 with adjustments
Trigger	Audit
Enforcement	`Audit.DisallowAllServices`
Outcome	Allowed = 0
Source	`Domain/SAIF.Domain/Model/Claims/Bills/Audits/Audit.cs`
Operations	OP-DOM-14

DOM-BR-141 Audit¶

Field	Value
Statement	Allow-all reverses DB/MD/TC adjustments for services whose original bill code is not "D", and recomputes the MCO fee (rate, rounded away from zero)
Trigger	Audit
Enforcement	`Audit.AllowAllServices`
Outcome	Amounts
Source	`Domain/SAIF.Domain/Model/Claims/Bills/Audits/Audit.cs`
Operations	OP-DOM-14

DOM-BR-142 Audit totals¶

Field	Value
Statement	Adjustment = -(charged - allowed); paid = allowed - MCO fee
Trigger	Audit totals
Enforcement	`Audit`
Outcome	Totals
Source	`Domain/SAIF.Domain/Model/Claims/Bills/Audits/Audit.cs`
Operations	OP-DOM-14

DOM-BR-150 Note create¶

Field	Value
Statement	Category C notes attach to the claim and are added to the repository; category B notes attach to the bill
Trigger	Note create
Enforcement	`AuditNote`
Outcome	Note placement
Tables	CBP_NOTE
SQL	SQL-001, SQL-002, SQL-033
Source	`Domain/SAIF.Domain/Model/Claims/Bills/Notes/AuditNote.cs`
Operations	OP-DOM-15

DOM-BR-160 Regenerate¶

Field	Value
Statement	A regenerated bill starts at Entered with responsible party SYSTEM
Trigger	Regenerate
Enforcement	`BillRegenerator.Regenerate`
Outcome	Status Entered
Tables	CBP_BILL, CBP_BILL_SERVICE
SQL	SQL-007, SQL-008
Source	`Domain/SAIF.Domain/Claims/Bills/BillRegenerator.cs`
Operations	OP-DOM-16

DOM-BR-170 Holder save¶

Field	Value
Statement	Certificate-holder text has Unicode replaced with ASCII
Trigger	Holder save
Enforcement	`CertificateHolder`
Outcome	Normalised text
Tables	CERTIFICATE_HOLDER
SQL	SQL-009, SQL-026, SQL-027, SQL-028
Source	`Domain/SAIF.Domain/Model/Policies/Certificates/CertificateHolder.cs`
Operations	OP-DOM-17

DOM-BR-171 Holder save¶

Field	Value
Statement	State is set only when the address is non-empty
Trigger	Holder save
Enforcement	`CertificateHolder`
Outcome	State
Tables	CERTIFICATE_HOLDER
SQL	SQL-009, SQL-026, SQL-027, SQL-028
Source	`Domain/SAIF.Domain/Model/Policies/Certificates/CertificateHolder.cs`
Operations	OP-DOM-17

DOM-BR-172 Holder save¶

Field	Value
Statement	CountryCode is "US" unless the address is foreign
Trigger	Holder save
Enforcement	`CertificateHolder`
Outcome	Country
Tables	CERTIFICATE_HOLDER
SQL	SQL-009, SQL-026, SQL-027, SQL-028
Source	`Domain/SAIF.Domain/Model/Policies/Certificates/CertificateHolder.cs`
Operations	OP-DOM-17

DOM-BR-180 Read¶

Field	Value
Statement	Policy number below 18 means a non-policy account
Trigger	Read
Enforcement	`Claim.PolicyName`
Outcome	Name
Source	`Domain/SAIF.Domain/Model/Claims/Claim.cs`
Operations	OP-DOM-18

DOM-BR-181 Read¶

Field	Value
Statement	OccupationalDisease "D" means an OD claim
Trigger	Read
Enforcement	`Claim.IsOdClaim`
Outcome	Flag
Source	`Domain/SAIF.Domain/Model/Claims/Claim.cs`
Operations	OP-DOM-18

DOM-BR-182 Read¶

Field	Value
Statement	SaifPayrollSubCode "P" means a preferred worker
Trigger	Read
Enforcement	`Claim.IsPreferredWorker`
Outcome	Flag
Source	`Domain/SAIF.Domain/Model/Claims/Claim.cs`
Operations	OP-DOM-18

DOM-BR-183 Read¶

Field	Value
Statement	Jurisdiction "2" means inmate, "1" means state
Trigger	Read
Enforcement	`Claim`
Outcome	Flags
Source	`Domain/SAIF.Domain/Model/Claims/Claim.cs`
Operations	OP-DOM-18

DOM-BR-184 Read¶

Field	Value
Statement	OD injury date is the earlier of the disability date and the initial treatment date
Trigger	Read
Enforcement	`Claim.OdInjuryDate`
Outcome	Date
Source	`Domain/SAIF.Domain/Model/Claims/Claim.cs`
Operations	OP-DOM-18

DOM-BR-185 Read¶

Field	Value
Statement	DCS F means full, P means partial
Trigger	Read
Enforcement	`Claim`
Outcome	Flags
Source	`Domain/SAIF.Domain/Model/Claims/Claim.cs`
Operations	OP-DOM-18

DOM-BR-186 Read¶

Field	Value
Statement	Medical conditions exclude "not properly initiated"
Trigger	Read
Enforcement	`Claim.MedicalConditions`
Outcome	Filtered list
Source	`Domain/SAIF.Domain/Model/Claims/Claim.cs`
Operations	OP-DOM-18

DOM-BR-187 Read¶

Field	Value
Statement	Guidewire reserves drop legal/other non-chargeable expenses, merge burial into death benefits, and throw on an untranslated category
Trigger	Read
Enforcement	`Claim.GetGwReserves`
Outcome	Reserves or exception
Source	`Domain/SAIF.Domain/Model/Claims/Claim.cs`
Operations	OP-DOM-18

DOM-BR-188 Read¶

Field	Value
Statement	Last payment sums TD, VocTD and SupTD
Trigger	Read
Enforcement	`Claim.GetLastPayment`
Outcome	Amount
Source	`Domain/SAIF.Domain/Model/Claims/Claim.cs`
Operations	OP-DOM-18

DOM-BR-189 Read¶

Field	Value
Statement	First closure date is the first status C that has not been removed
Trigger	Read
Enforcement	`Claim.FirstClosureDate`
Outcome	Date
Source	`Domain/SAIF.Domain/Model/Claims/Claim.cs`
Operations	OP-DOM-18

DOM-BR-190 Read¶

Field	Value
Statement	"No row with the given identifier" is swallowed for the MyClaim last login
Trigger	Read
Enforcement	`Claim.MyClaimLastLogin`
Outcome	Null
Source	`Domain/SAIF.Domain/Model/Claims/Claim.cs`
Operations	OP-DOM-18

DOM-BR-191 Read¶

Field	Value
Statement	Overpayment means RecoverableBalance > 0
Trigger	Read
Enforcement	`Claim.IsOverpayment`
Outcome	Flag
Source	`Domain/SAIF.Domain/Model/Claims/Claim.cs`
Operations	OP-DOM-18

DOM-BR-193 Security attributes¶

Field	Value
Statement	IsConflictClaim = Worker.IsWorkerConflict; IsSecureClaim = IsSecured
Trigger	Security attributes
Enforcement	`Claim.BuildSecurityAttributes`
Outcome	`SecureClaimAttributes`
Source	`Domain/SAIF.Domain/Model/Claims/Claim.cs`
Operations	OP-DOM-18

DOM-BR-194 Mapping¶

Field	Value
Statement	Guidewire claim status NEW maps to N, OPEN/REOPEN to O, CLOSED to C, DENIED to D, VOID to V; anything else throws
Trigger	Mapping
Enforcement	`GuidewireToLegacyMapper`
Outcome	`InvalidDataException`
Source	`Domain/SAIF.Domain/Mappers/GuidewireToLegacyMapper.cs`
Operations	OP-DOM-18

DOM-BR-195 Mapping¶

Field	Value
Statement	MCO status Yes maps to Y, No to N, Pending to P, default B
Trigger	Mapping
Enforcement	`GuidewireToLegacyMapper`
Outcome	Code
Source	`Domain/SAIF.Domain/Mappers/GuidewireToLegacyMapper.cs`
Operations	OP-DOM-18

DOM-BR-200 Packet creation¶

Field	Value
Statement	Child policies (relationship not WRAP) exclude 312R, 412R, AUDIT and 312IR documents from packets
Trigger	Packet creation
Enforcement	`PacketManager.CreatePackets`
Outcome	Excluded docs
Tables	ENDORSE_CODE
SQL	SQL-022
Source	`Domain/SAIF.Domain/Tasks/Documents/Packets/PacketManager.cs`
Operations	OP-DOM-19

DOM-BR-201 Packet creation¶

Field	Value
Statement	Documents group by policy + document date + release date, then by period
Trigger	Packet creation
Enforcement	`PacketManager.CreatePackets`
Outcome	Groups
Tables	ENDORSE_CODE
SQL	SQL-022
Source	`Domain/SAIF.Domain/Tasks/Documents/Packets/PacketManager.cs`
Operations	OP-DOM-19

DOM-BR-202 Packet evaluation¶

Field	Value
Statement	A packet requires: minimum document count, market type, parent/child relationship, included relationship types, secondary code, the required parent document, the same source key text, and child document inclusion
Trigger	Packet evaluation
Enforcement	`PacketGenerator`
Outcome	Packet created or not
Tables	ENDORSE_CODE
SQL	SQL-022
Source	`Domain/SAIF.Domain/Tasks/Documents/Packets/PacketGenerator.cs`
Operations	OP-DOM-19

DOM-BR-203 Packet evaluation¶

Field	Value
Statement	38 packet definitions PKT001-PKT038 are hard-coded
Trigger	Packet evaluation
Enforcement	`PacketDefinition`
Outcome	Definitions
Tables	ENDORSE_CODE
SQL	SQL-022
Source	`Domain/SAIF.Domain/Tasks/Documents/Packets/PacketDefinition.cs`
Operations	OP-DOM-19

DOM-BR-210 Image conversion¶

Field	Value
Statement	Vignette IFN constants: 25362436 maps to "387/4", 25427970 maps to "388/2"
Trigger	Image conversion
Enforcement	`Image.ConvertIfnDs`
Outcome	Converted IDs
Source	`Domain/SAIF.Domain/Model/Imaging/Image.cs`
Operations	OP-DOM-20

DOM-BR-211 Employee load¶

Field	Value
Statement	An employee prefers the `IUserProfileService` application user, falling back to `WcisEmployee`
Trigger	Employee load
Enforcement	`Employee`
Outcome	Employee data
Source	`Domain/SAIF.Domain/Model/Employees/Employee.cs`
Operations	OP-DOM-20

Notes¶

DOM-BR-029a is a matcher/indexing edge-case rule numbered outside the main DOM-BR-029 sequence; the rule number 192 is not used (no Stage 1 rule was recorded for that number).
Rules DOM-BR-070, DOM-BR-080/DOM-BR-081, and DOM-BR-030 are shared across multiple operations (see the Operations column on each rule).
The Tables/SQL fields above are populated only for rules whose enforcement is directly tied to one or more of the 33 ORM operations cataloged in SQL catalog; rules enforced purely in memory (validation, derived-property, and mapping rules) omit these fields.

Sources¶

Domain/SAIF.Domain/Claims/Ebilling/BillAssignment.cs, GenerateCBPBills.cs, File837Extractor.cs, File835Builder.cs, File277CaBuilder.cs, File837AckBuilder.cs, EdiBuildSegments.cs, EobBuilder.cs, ServiceCodeManager.cs
Domain/SAIF.Domain/Claims/Ebilling/Indexing/PatientIndexer.cs, ProviderIndexer.cs, ProviderIndexerV2.cs, BillServiceIndexer.cs, ProviderMatcher.cs
Domain/SAIF.Domain/Claims/Bills/BillRegenerator.cs
Domain/SAIF.Domain/Model/Claims/Bills/Bill.cs, BillStatusCode.cs
Domain/SAIF.Domain/Model/Claims/Bills/Audits/Audit.cs
Domain/SAIF.Domain/Model/Claims/Bills/Notes/AuditNote.cs
Domain/SAIF.Domain/Model/Claims/Claim.cs
Domain/SAIF.Domain/Model/Claims/Ebilling/Batch.cs, ErrorConditionHandler.cs
Domain/SAIF.Domain/Model/Employees/Employee.cs
Domain/SAIF.Domain/Model/Imaging/Image.cs
Domain/SAIF.Domain/Model/Policies/Certificates/CertificateHolder.cs
Domain/SAIF.Domain/Mappers/GuidewireToLegacyMapper.cs
Domain/SAIF.Domain/Tasks/Documents/Packets/PacketManager.cs, PacketGenerator.cs, PacketDefinition.cs