Created: 2026-06-26
CRSHCS should not position Promise, STEDI, or its historical corpus as separate data assets. The strategic asset is the combined eligibility intelligence layer:
The GTM message is: CRSHCS helps providers convert fragmented Medicaid and payer data into actionable coverage, revenue, discharge, and access intelligence.
“All data points” cannot be asserted as one fixed list without authenticated Promise access, the applicable state Medicaid portal configuration, payer enrollment status, and STEDI production payer support. The map below is the practical field universe: the data families CRSHCS should inventory, normalize, and align to its provider-facing offers.
Access classification:
| Question | Confirmed answer | GTM/build implication |
|---|---|---|
| Promise portal/state instance | Pennsylvania PROMISe / Penn | Pennsylvania is the first state operating model. Build PA-specific code tables, workflows, and payer/MCO mapping first. |
| Provider authority | UHS | UHS becomes the first proof environment and first enterprise-account expansion story. |
| Promise access mode | Playwright automation over human portal access | Build a controlled browser-automation evidence collector before assuming direct API/export access. Preserve screenshots/logs/audit trail. |
| STEDI access mode | API | Build STEDI ingestion as a direct API service with raw payload storage plus normalized canonical records. |
| STEDI production transactions | All enabled | Phase 1 can include eligibility, claim status, claim submission, acknowledgments, remittance, payer list, and enrollment data rather than a narrow eligibility-only proof. |
| Priority Pennsylvania MCOs | AmeriHealth, Geisinger, UnitedHealthcare Community Plan, Jefferson Health Plans, UPMC for You | First payer matrix should be Pennsylvania Medicaid managed care and UHS facility coverage. |
| Priority DMV MCOs | AmeriHealth, MedStar Family Choice, Wellpoint DC | Second-state expansion proof should model PA-to-DMV portability. |
| AI/NLP authorization | CRS BAA includes AI/NLP extraction; AWS BAA/data storage includes AI/NLP extraction | Historical corpus mining is in scope for operational workflows, subject to minimum-necessary controls and auditability. |
| Analytics privacy posture | Identified operational workflow under BAA; BAA cites 45 CFR 164.514(a)-(c) | Treat identified use as operational workflow under BAA. 45 CFR 164.514(a)-(c) specifically governs de-identification and re-identification. For market-facing analytics outside an identified operational workflow, require a separate de-identification decision: Expert Determination or Safe Harbor. |
| Data family | Data points to catalog | Access class | CRSHCS GTM use |
|---|---|---|---|
| Provider identity | PROMISe ID, 13-digit provider number, NPI, EIN/SSN registration basis, provider type, specialty, service location, billing location, pay-to address, enrollment status, revalidation/reactivation status, alternate user authorization | Confirmed public workflow / state dependent | Reduce enrollment and billing denials; provider readiness score; facility onboarding audit |
| Eligibility verification | Member/recipient eligibility status, MA coverage active/inactive, effective dates, program/category, managed-care plan, benefit package, service restrictions, EVS error codes, eligibility inquiry date/time, verification method | Confirmed public workflow / state dependent | Point-of-admission coverage confirmation; Medicaid eligibility recovery; denial prevention |
| Claim submission | Claim type, institutional/professional/dental/pharmacy where supported, ICN/internal control number, dates of service, billing provider, service provider, diagnosis/procedure/revenue codes, place of service, billed amount, attachments, submission timestamp | Confirmed public workflow / state dependent | Claim readiness analytics; documentation gap detection; avoid preventable claim fallout |
| Claim inquiry/status | ICN, claim status, claim type, date range, adjudication stage, paid/denied/suspended indicators, denial/error status code, region code, claim adjustment/void status | Confirmed public workflow / state dependent | Revenue leakage detection; aging claims work queue; payer friction intelligence |
| Remittance advice | RA statement, paid amount, denied amount, adjustment reason, ESC/error status code, NCPDP reject code where applicable, payment cycle, EFT/RA enrollment, banner page notices | Confirmed public workflow / state dependent | Denial-pattern intelligence; facility-level revenue risk dashboard |
| Attachments | Attachment control number, attachment request, supporting documentation status, upload/submission evidence | Confirmed public workflow / state dependent | Case evidence completeness; automation-ready document chase |
| Portal/user operations | User IDs, alternate user IDs, authorization scope, location access, role delegation, registration state | Confirmed public workflow / state dependent | Compliance-controlled workflow design; auditability of who touched what |
| Policy/reference data | Provider handbooks, fee schedules, MA bulletins, region codes, place-of-service crosswalk, EVS/ESC code tables | Confirmed public workflow | Rules engine; claim edit library; state-specific Medicaid playbooks |
| STEDI rail | Data points to catalog | Access class | CRSHCS GTM use |
|---|---|---|---|
| Payer network/list payers | Payer ID, payer alias, supported transactions, enrollment requirement, payer routing metadata | Confirmed public workflow / payer dependent | Determine which provider targets can be activated fastest; payer readiness matrix |
| Eligibility 270 request | Subscriber/member ID, patient/subscriber demographics, dependent data where supported, provider identifiers, trading partner service ID, service type codes, dates, trace/control IDs | Confirmed public workflow / payer dependent | Clean intake requirements; first-pass eligibility success improvement |
| Eligibility 271 response | Active/inactive coverage, benefits, service type, plan/coverage details, payer returned errors, AAA validation errors, raw X12, generated eligibility PDF | Confirmed public workflow / payer dependent | Coverage truth layer; admission/visit decision support; Medicaid churn/coverage-gap detection |
| Batch eligibility | Batch ID, per-check processing status, active/inactive summary, full eligibility check results when polled | Confirmed public workflow / payer dependent | Census-wide eligibility sweep; daily facility coverage monitor |
| Claim submission 837I | Attending provider, billing/rendering providers, subscriber/patient, claim dates, admission/discharge, diagnosis codes, procedure/revenue/service lines, billed charges, attachments/references, transaction response | Confirmed public workflow / payer dependent | Institutional claim quality scoring; pre-submission claim completeness |
| Claim submission 837P | Rendering/billing/referring provider, patient/subscriber, service lines, procedure/modifier/diagnosis, charges, place of service, transaction response | Confirmed public workflow / payer dependent | Professional claim readiness where CRSHCS expands beyond institutional workflows |
| Claim acknowledgment 277CA | Accepted/rejected acknowledgment, rejection reason, transaction ID, syntax/business errors, claim correlation | Confirmed public workflow / payer dependent | Immediate rejection work queue; root-cause analytics |
| Claim status 276 request | Patient/subscriber/dependent data, provider identifier, service date range, billing type, patient account number, payer claim number, clearinghouse claim number | Confirmed public workflow / payer dependent | Missing-835 escalation; claim aging check automation |
| Claim status 277 response | Claim status, claim status category code, status code description, payer claim number, patient account number, service date, paid amount, check issue date, check/EFT trace number, warnings, raw X12 | Confirmed public workflow / payer dependent | Revenue status intelligence; collections prioritization; claim bottleneck visibility |
| ERA 835 | Payment details, service-line payments, adjustment/denial explanations, transaction ID, JSON ERA, PDF ERA | Confirmed public workflow / enrollment dependent | Denial and underpayment intelligence; revenue cycle feedback loop |
| Transactions/events | Transaction ID, input/output document, event/webhook notifications, processed status, raw/normalized payloads | Confirmed public workflow | Audit trail; data lake ingestion; reconciliation |
| Transaction enrollment | Enrollment status by transaction type, requested effective date, payer enrollment constraints | Confirmed public workflow / enrollment dependent | Activation plan per provider/payer; implementation risk score |