MANSOQ RCM & insurance
Resolve coverage, authorization, cost share and limits
Read the independent decisions behind a benefit outcome and a patient estimate.
Current source · source reviewed · 8 min read
Before you begin
- An applicable policy/class and source-backed benefit schedule.
- The correct service, date and clinical context.
1. Define the service conditions
Configure the benefit domain and selector against the clinical applicability. Record source, effective dates and explicit precedence.
2. Keep the decision dimensions separate
Establish coverage, authorization requirement, settlement mode and manual-review requirement independently. A single approved badge cannot answer all four questions.
3. Attach cost-share components and limits
Use separate copay, coinsurance and multi-limit definitions with explicit scopes. A visit cap must be shared across the visit’s eligible lines, not reapplied independently to every line.
4. Validate and preview
Resolve contradictory or equal-priority overlaps, then preview a representative member estimate. Inspect the selected and losing rules in the trace before publication.
Six coverage outcomes
Covered, conditionally covered, excluded, exhausted, unauthorized and unresolved each imply a different next action. Unknown evidence should produce review, not a guessed approval or exclusion.
Clinical care remains separate
The RCM control records financial uncertainty and work items. It does not authorize withholding a clinically recorded event. Benefit holds and clinical event capture are separate concerns.
Troubleshooting
A benefit appears covered but no amount can be calculated
Inspect tariff, cost-share components, limit scopes and their value states. Resolve missing evidence before interpreting an incomplete estimate as a zero.
Source evidence
References are pinned to the private MANSOQ source repository. Repository access is required to open these links.