pVerify Eligibility

pVerify validates insurance coverage before we invest clinical time. The eligibility workflow runs automatically on enrollment and on a rolling schedule for active panels.

Flow

1. Enrollment triggers verify-insurance with the patient’s demographics and payer information.
2. The edge function calls pVerify’s API using our BAA-backed credentials.
3. Responses populate billing.eligibility_checks with coverage level, copay, and deductible data.
4. Failures queue retries and notify Partner Ops for manual outreach.

Data Mapping

Source	Destination	Notes
EligibilityStatus	billing.eligibility_checks.status	ACTIVE, INACTIVE, PENDING
PlanType	billing.coverage.plan_type	Normalized to HMO, PPO, etc.
CopayAmount	billing.coverage.copay	Stored as cents to avoid floating point errors.

Scheduling

• Initial check: immediately upon enrollment approval.
• Recertification: every 30 days or when a new encounter is scheduled.
• Manual override: Partner Ops can trigger a recheck via the portal; actions are audit logged.

Error Handling

• pVerify outages fall back to a cached eligibility status (max age 14 days) and flag the patient for follow-up.
• Responses lacking subscriber data escalate to the Partner Ops queue; the BHCM is notified to clarify during outreach.

Security

• API keys reside in Infisical and never appear in logs.
• Requests include correlation IDs for traceability across billing, enrollment, and partner communication.

Accurate eligibility data underpins reliable revenue capture for CoCM billing codes.