Claims Service — Epics
Service: claims-service Epic prefix: CLAIMS-EPIC Last updated: 2026-04-18
Epics
CLAIMS-EPIC-01 — Coverage and Eligibility Management
| Field | Value |
|---|---|
| Issue type | Epic |
| Summary | Create, manage, and verify patient insurance coverage and real-time eligibility |
| Status | To Do |
| Priority | Must |
| Labels | service:claims, domain:revenue-cycle, slice:S2 |
| Components | claims-service, registration-service |
| Fix version | M1 |
| FR references | FR-CLAIMS-008, FR-CLAIMS-009, FR-CLAIMS-010 |
| Legacy FR refs | FR-INS-001, FR-INS-002, FR-INS-003, FR-INS-004, FR-INS-005 |
| Dependencies | IDENT-EPIC-01, REG-EPIC-01 |
| Rollup status | Not started |
Business outcome: Registration and billing staff can create and manage patient insurance coverage records with priority ordering, and verify real-time eligibility before encounters to confirm active benefits.
Description: Covers the full coverage lifecycle: create, update, activate, deactivate, and priority management (primary/secondary/tertiary). Includes real-time eligibility verification via X12 270/271 and payer REST APIs, with responses stored and cached per tenant configuration. FHIR Coverage and CoverageEligibilityRequest/Response resources generated.
Stories: CLAIMS-US-001, CLAIMS-US-002, CLAIMS-US-003
CLAIMS-EPIC-02 — Prior Authorization
| Field | Value |
|---|---|
| Issue type | Epic |
| Summary | Request and track prior authorizations from payers for covered services |
| Status | To Do |
| Priority | Must |
| Labels | service:claims, domain:revenue-cycle, slice:S2 |
| Components | claims-service |
| Fix version | M1 |
| FR references | FR-CLAIMS-011, FR-CLAIMS-012 |
| Legacy FR refs | FR-INS-006, FR-INS-007, FR-INS-008 |
| Dependencies | CLAIMS-EPIC-01 |
| Rollup status | Not started |
Business outcome: Clinicians and billing staff can submit prior authorization requests and receive payer decisions with authorization numbers and validity dates; approved authorizations are linked to claim submission.
Description: Covers prior auth request creation, payer API/fax submission, and recording of payer decisions (approve/deny/modify). Tracks authorization numbers, approved units, validity dates. Links authorization to claim on submission. Alerts when authorization is expiring.
Stories: CLAIMS-US-004, CLAIMS-US-005
CLAIMS-EPIC-03 — Claim Assembly and Scrubbing
| Field | Value |
|---|---|
| Issue type | Epic |
| Summary | Assemble claims from encounter charges with coding validation and pre-submission scrubbing |
| Status | To Do |
| Priority | Must |
| Labels | service:claims, domain:revenue-cycle, slice:S2 |
| Components | claims-service, billing-service, terminology-service |
| Fix version | M1 |
| FR references | FR-CLAIMS-001, FR-CLAIMS-002 |
| Legacy FR refs | FR-CLM-001, FR-CLM-002 |
| Dependencies | CLAIMS-EPIC-01, BILLING-EPIC-01, TERM-EPIC-01 |
| Rollup status | Not started |
Business outcome: Billing staff and the billing-service can assemble a complete claim from encounter charges with validated ICD-10/CPT codes; scrubbing catches required-field errors and coding rule violations before submission, reducing denial rates.
Description: Covers claim assembly from encounter charges and charge items; coding validation via terminology-service; claim scrubbing rules engine (required fields, diagnosis pointer validation, modifier rules); duplicate claim detection within configurable window. Generates FHIR Claim resource.
Stories: CLAIMS-US-006, CLAIMS-US-007
CLAIMS-EPIC-04 — Electronic Claim Submission
| Field | Value |
|---|---|
| Issue type | Epic |
| Summary | Submit claims electronically via X12 837, payer REST APIs, or XML adapters |
| Status | To Do |
| Priority | Must |
| Labels | service:claims, domain:revenue-cycle, slice:S2, slice:S3 |
| Components | claims-service |
| Fix version | M1 |
| FR references | FR-CLAIMS-003, FR-CLAIMS-004 |
| Legacy FR refs | FR-CLM-003, FR-CLM-004 |
| Dependencies | CLAIMS-EPIC-03 |
| Rollup status | Not started |
Business outcome: Claims are submitted electronically to payers via their preferred channel (X12 837, REST, XML); acknowledgements (999/277) are processed automatically; submission status is tracked in real time.
Description:
Covers the pluggable IClaimSubmissionAdapter interface and concrete implementations: X12 837P/837I via clearinghouse SFTP/REST, payer REST APIs, and XML flat-file. Acknowledgement processing (999 functional ACK, 277 claim status). Circuit breaker and retry policy per adapter. Payer credentials managed in Vault.
Stories: CLAIMS-US-008, CLAIMS-US-009
CLAIMS-EPIC-05 — Remittance Processing and EOB Generation
| Field | Value |
|---|---|
| Issue type | Epic |
| Summary | Process ERA (X12 835) and generate FHIR ExplanationOfBenefit resources |
| Status | To Do |
| Priority | Must |
| Labels | service:claims, domain:revenue-cycle, slice:S2 |
| Components | claims-service, billing-service |
| Fix version | M1 |
| FR references | FR-CLAIMS-005 |
| Legacy FR refs | FR-CLM-005, FR-CLM-006 |
| Dependencies | CLAIMS-EPIC-04 |
| Rollup status | Not started |
Business outcome: ERA payments are automatically applied to claims with correct allocations; billing-service receives payment events; patient portal surfaces EOBs for patient review.
Description: Covers ERA ingest (X12 835 + payer REST equivalents), transactional allocation to claims, FHIR ExplanationOfBenefit generation per claim, and event publication. Handles partial payments, contractual adjustments (CARC codes), and COB (coordination of benefits) scenarios. ERA idempotency prevents double-posting.
Stories: CLAIMS-US-010, CLAIMS-US-011
CLAIMS-EPIC-06 — Denial Management and Appeals
| Field | Value |
|---|---|
| Issue type | Epic |
| Summary | Track claim denials, file appeals, and manage resubmission workflow |
| Status | To Do |
| Priority | Must |
| Labels | service:claims, domain:revenue-cycle, slice:S2 |
| Components | claims-service |
| Fix version | M1 |
| FR references | FR-CLAIMS-006, FR-CLAIMS-007 |
| Legacy FR refs | FR-CLM-007, FR-CLM-008 |
| Dependencies | CLAIMS-EPIC-05 |
| Rollup status | Not started |
Business outcome: Billing staff are notified of denials with CARC/RARC codes; they can file appeals with supporting documentation and track outcomes; corrected claims can be resubmitted as replacement claims.
Description: Covers denial recording with CARC/RARC codes and denial reason; appeal filing workflow with deadline tracking; appeal status updates (filed/pending/approved/denied); resubmission as corrected/replacement claim. Dashboard metrics for denial rates by code and payer.
Stories: CLAIMS-US-012, CLAIMS-US-013
CLAIMS-EPIC-07 — Multi-Country Payer Adapter Support
| Field | Value |
|---|---|
| Issue type | Epic |
| Summary | AFG and UAE payer-specific claim formats and eligibility adapters |
| Status | To Do |
| Priority | Should |
| Labels | service:claims, domain:revenue-cycle, slice:S3 |
| Components | claims-service |
| Fix version | M2 |
| FR references | FR-CLAIMS-013 |
| Legacy FR refs | — |
| Dependencies | CLAIMS-EPIC-04 |
| Rollup status | Not started |
Business outcome: Ghasi deployments in Afghanistan and UAE can submit claims to local payers and authorities using jurisdiction-required formats; core claim logic is unchanged.
Description:
Implements AFG Ministry of Public Health insurance adapter and UAE DHA (Dubai Health Authority) payer adapter as concrete IClaimSubmissionAdapter implementations. Tenant configuration maps to the correct adapter. Core domain model unchanged; adapters handle format translation.
Stories: CLAIMS-US-014
CLAIMS-EPIC-08 — Security, Licensing, and Compliance Gate
| Field | Value |
|---|---|
| Issue type | Epic |
| Summary | RLS enforcement, RBAC, audit trail completeness, and ehr.claims module gate |
| Status | To Do |
| Priority | Must |
| Labels | service:claims, domain:revenue-cycle, slice:S0, type:security, type:compliance |
| Components | claims-service, audit-service |
| Fix version | M1 |
| FR references | FR-CLAIMS-014, FR-CLAIMS-015 |
| Legacy FR refs | FR-CLM-001, FR-INS-001 |
| Dependencies | IDENT-EPIC-01, TENANT-EPIC-01 |
| Rollup status | Not started |
Business outcome: No cross-tenant claim data leakage; all PHI mutations audited; unlicensed tenants receive 403; security penetration test passed before production activation.
Description:
RLS policies on all claims tables; adversarial cross-tenant CI gate; module entitlement gate (ehr.claims) on all write operations; audit event coverage for all claim/coverage mutations; HIPAA-equivalent audit retention (7 years). Security penetration test required.
Stories: CLAIMS-US-015, CLAIMS-US-016