RCM & insurance

Capture and resolve patient insurance coverage

Retain real coverage evidence while policy, class or identity conflicts are being resolved.

Current source · source reviewed · 6 min read

Before you begin

Correct patient record and identity evidence.
Insurer, member identifier and card or discovery evidence when available.

1. Confirm the patient identity

Match the patient before linking coverage. Check member and dependent information against the evidence rather than relying only on similar names.

2. Record the coverage as received

Retain insurer, policy/member references and coverage dates. Preserve provisional coverage when local configuration is under review; do not create a fictitious policy or class.

3. Map the local policy and class

Resolve the canonical insurer and applicable active policy/class/network with the insurance master owner. Keep unmapped or conflicting discovery data visible as a work item.

4. Verify eligibility separately

Use the eligibility workflow for the service context and read the response, site statement, freshness and residual denial risks.

Discovery and determination

A member card, employer letter or portal can help discover a coverage. The enrollment API explicitly distinguishes discovery from an eligibility determination.

Newborn and border-number exceptions

A newborn remains a separate patient with its own provider MRN; the mother’s policy relationship does not permit reusing her patient identity. A border-only identifier may require an administrative queue rather than an unsupported outbound identity.

Troubleshooting

No matching class appears

Retain the received class code and request a source-backed mapping. Do not select an unrelated class merely to complete the form.

Source evidence

References are pinned to the private MANSOQ source repository. Repository access is required to open these links.