Payment Model (Canonical, RAG-Optimized)
Last Updated: 2026-04-07 Status: CanonicalPurpose: Provides the canonical source of truth for how money moves through Thrizer. Use this document when a question requires deterministic understanding of payment behavior, including:
- which payment model applies (Self-Pay, OON Pay, Thrizer Pay)
- who pays, how much they pay, and when they pay
- how fees are calculated and applied
- who receives reimbursement and how funds are routed
- how and when clinicians are paid
- how deductible, allowed amount, and coinsurance affect financial outcomes
- when Thrizer Pay is eligible and why
- insurer-specific rules or coverage decisions
- claim approval or denial logic
- UI steps or operational workflows
Core System Model
Thrizer separates three independent components:| Component | Definition |
|---|---|
| Session Fee | Amount set by clinician |
| Allowed Amount | Amount insurer uses to calculate reimbursement |
| Client Responsibility | Portion of allowed amount assigned to client |
Insurance determines reimbursement. Thrizer facilitates payment and claim submission.
Payment Types Overview
Self-Pay
DefinitionClient pays full session fee without insurance involvement. Behavior
- Client Payment: 100% of session fee
- Claim Submission: No
- Reimbursement: None
- Thrizer Fee: None
- No insurance required
- No diagnosis required
OON Pay
DefinitionClient pays full session fee upfront. Thrizer submits claim. Reimbursement is returned to client. Behavior
- Client Payment: 100% of session fee upfront, charged when the clinician creates a Charge
- Claim Submission: Automatic, triggered when the clinician creates a Charge
- Reimbursement Recipient: Client
- Thrizer Fee: 1% of session fee (only after deductible is met)
Insurance → Thrizer → Client Bank Account Deductible Interaction
- Before deductible: reimbursement is $0
- After deductible: reimbursement follows coinsurance rules
Thrizer Pay
DefinitionClient pays only estimated responsibility upfront. Thrizer advances remaining session fee to clinician. Behavior
- Client Payment: estimated responsibility + 5% of session fee, charged when the clinician creates a Charge
- Claim Submission: Automatic, triggered when the clinician creates a Charge
- Reimbursement Recipient: Thrizer
- Thrizer Fee: 5% of session fee
Insurance → Thrizer → Internal reconciliation Clinician Payment
- Receives full session fee (minus processing fee) upfront
Charge Trigger and Claim Submission
For payment types with automatic claim submission, the canonical trigger event is clinician Charge creation.Trigger Rule
- A claim is submitted automatically after a Charge is created and the client’s payment is successfully processed.
- At that same time, the client’s payment method is charged.
- This rule applies to:
- OON Pay
- Thrizer Pay
Required Condition
- The Charge must contain the claim-related information required by the system for submission.
Clarification
- Automatic claim submission is not a separate manual step in OON Pay or Thrizer Pay.
- Manual claim submission applies only to client-submitted claim workflows such as superbill upload or manual claim entry.
Clinician Payout Rules
Applies to All Payment Types-
Payout Amount:
session fee − ~3% payment processing fee -
Payout Timing:
Charges before Thursday cutoff → paid Friday -
No Clawback Rule
Clinician payouts are not reversed if:- claim is denied
- reimbursement is lower than expected
- reimbursement is $0
Thrizer Pay Eligibility
Eligibility defined in Thrizer Pay RulesDeductible Logic
Before Deductible is Met
- Client pays full session fee
- Insurance processes claim
- Allowed amount is applied to deductible
- Reimbursement = $0 (typical case)
After Deductible is Met
- Insurance reimburses based on:
- allowed amount
- coinsurance percentage
allowed amount × coinsurance
- (session fee − allowed amount, if applicable)
Allowed Amount Rules
DefinitionAllowed amount is the maximum amount insurance uses for reimbursement calculation. Rules
- Reimbursement is based on allowed amount, not session fee
- If session fee < allowed amount:
→ session fee becomes the effective allowed amount - Allowed amount is unknown until first claim is processed, initially it is estimated
- Initial estimates are based on benefit check data
Estimate vs Actual Behavior
Before First Claim
- Estimates are based on historical averages
- Accuracy is limited
After First Claim
- Allowed amount becomes known
- Reimbursement becomes predictable
- Adjustments may occur
- Estimated responsibility may differ from actual
Claim Structure Dependency
- One charge → one claim
- One claim → one CPT code
- One session fee per claim
Claim Submission Requirements A Charge is considered claim-submittable only if all required claim fields are present at the time of Charge creation.
Required Fields (Charge Input) Provider Information:
- Provider Name
- Provider NPI
- Provider TIN Service Information:
- Appointment Date(s)
- CPT Code(s) (Service Codes)
- ICD-10 Code (Diagnosis Code)
- Billed Amount
Client & Insurance Information (System-Populated)
- The following fields are NOT required as Charge inputs:
- Client Name
- Insurance Plan
- Member ID
- Payer Information
- These fields are automatically populated from the client’s Thrizer account
Validation Rule
- All required fields must be present at Charge creation
- If any required field is missing:
- The Charge is NOT claim-submittable ### System Behavior
- If all required fields are present:
- Claim is automatically submitted when the clinician creates the Charge
- If required fields are missing:
- Claim submission must not proceed
- The system must:
- block submission OR
- route to operational/manual handling (defined elsewhere)
Constraint
- A Charge cannot partially submit a claim
- Claim submission is atomic and requires full data completeness
Global Constraints (Payment-Relevant)
- A single charge cannot be split across multiple payment methods
- Multiple CPT codes cannot be included in one claim
- Multiple charges cannot be bundled into a single claim
Reimbursement Routing
OON Pay
Insurance → Thrizer → Client Bank AccountThrizer Pay
Insurance → Thrizer → Internal reconciliationNon-Guarantee Statement
- Reimbursement outcomes are determined solely by the insurance carrier
- Thrizer does not guarantee:
- reimbursement amount
- claim approval
- processing time
Payout Trigger Schedule
-
Payouts are automatically initiated on:
- Tuesdays (early morning)
- Fridays (early morning)
-
At each payout trigger:
- 100% of Thrizer Balance is transferred
- Transfer is sent to the connected bank account on file
Payout Inclusion Logic
Charges are included in the next scheduled payout based on when the charge is created:- Monday → Tuesday payout
- Tuesday → Friday payout
- Wednesday → Friday payout
- Thursday → Friday payout
- Friday → Tuesday payout
- Saturday → Tuesday payout
- Sunday → Tuesday payout
- Charges remain in the Thrizer Balance until the next scheduled payout is triggered
- Payout timing is not dependent on claim status or insurer reimbursement
Settlement Timing
- After payout initiation:
- Funds are expected to arrive within:
- 0–1 business days
- Funds are expected to arrive within:
External Dependency
- Insurer reimbursement timing is determined externally by the insurance carrier
- Reimbursement timing does not affect payout timing
Retrieval Keywords (for RAG)
Use this document when user asks:- “How does Thrizer Pay work?”
- “What does the client pay?”
- “What fees does Thrizer charge?”
- “Who gets reimbursed?”
- “How does OON Pay work?”
- “When can Thrizer Pay be used?”
- “What happens before deductible is met?”
- “How is coinsurance calculated?”
- “How do clinicians get paid?”
Exclusion Keywords (Route Elsewhere)
Do NOT use this document for:- UI instructions → Capability Maps
- Insurance definitions → Insurance Definitions
- Claim failures → Benefit Check Failures
- CPT code behavior → CPT Dataset
- Support actions → Support Playbooks