This is the authoritative glossary for the Patient Billing System. It contains only domain term definitions — no implementation details, file paths, or code.
All agents, engineers, and tools working on this project must use these terms consistently.
| Term | Definition |
|---|---|
| Patient | A person who receives care. Has demographics (name, DOB, contact) and optionally an insurance policy on file (provider, policy number, group number). |
| Claim | A formal request submitted to an InsurancePayer to reimburse a set of services rendered to a Patient. Has a lifecycle (Draft → Submitted → Under Review → Approved / Denied → Closed) managed by ClaimWorkflow. |
| ClaimLineItem | A single billable procedure on a Claim. Contains a CPT procedure code, description, quantity, and unit price. |
| InsurancePayer | The insurance company or government program to whom Claims are submitted for adjudication. |
| Invoice | A bill issued directly to a Patient for self-pay amounts (not covered by insurance). Has a lifecycle (Draft → Sent → Partially Paid → Paid / Overdue / Voided) managed by InvoiceWorkflow. |
| InvoiceLineItem | A single billable item on an Invoice (description, quantity, unit price). |
| Payment | A recorded cash or card payment applied against an Invoice. Captures payment date, amount, method, and reference number. |
| ClaimWorkflow | The state machine governing a Claim’s lifecycle. Controls which roles may trigger which transitions. |
| InvoiceWorkflow | The state machine governing an Invoice’s lifecycle. |
| ClaimValidator | An AI agent that verifies a Claim is complete and correct before submission. Checks required fields, validates ICD-10 diagnosis codes, suggests missing CPT codes, and returns a completeness score. |
| DenialAnalyzer | An AI agent that receives a denial reason code from a rejected Claim and produces a root-cause analysis and corrective action recommendations. Runs concurrently with AppealDrafter. |
| AppealDrafter | An AI agent that writes a formal insurance appeal letter for a denied Claim. Runs concurrently with DenialAnalyzer. |
| AI Insights | The combined surfaced output of ClaimValidator, DenialAnalyzer, and AppealDrafter, displayed on the Claim detail page in a dedicated tab. |
| BillingStaff | A system role. Can create and edit Patients, Claims, and Invoices; record Payments; view AI Insights. Cannot approve, deny, or void. |
| BillingManager | A system role. All BillingStaff permissions plus: approve/deny Claims, void Invoices, access the Dashboard. |
| ICD-10 code | International Classification of Diseases (10th revision) diagnosis code required on every Claim. |
| CPT code | Current Procedural Terminology code identifying a specific medical procedure on a ClaimLineItem. |
| Denial reason code | A standardized code (e.g. CO-4, PR-96) returned by an InsurancePayer when a Claim is rejected, indicating why it was not paid. |