Thrizer Reimbursement Reasoning Rules
Last Updated: 2026-03-23 Status: CanonicalPurpose: Use this file when the question requires deterministic calculation or explanation of out-of-network reimbursement amounts based on known inputs. This includes:
- Calculating expected reimbursement for a claim
- Explaining why reimbursement is $0 vs partial vs full
- Determining how deductible affects reimbursement
- Breaking down client responsibility vs insurer payment
- Classifying claim outcomes (reimbursed, applied to deductible, denied)
- Explaining the impact of allowed amount vs provider fee
- provider_fee
- allowed_amount
- deductible_remaining
- coinsurance_client_percent
- claim_status
- Questions about how claims are submitted, processed, or tracked
- Questions about product behavior, UX, or system workflows
- Questions about insurer policies, approval criteria, or allowed amount determination
- Questions about timing of reimbursement or payments
Normalized Inputs
All reimbursement reasoning must use the following inputs:- provider_fee
- allowed_amount
- deductible_remaining
- coinsurance_client_percent
- claim_status (approved | denied)
Core Calculation Variables
Provider Fee
Definition: The therapist’s full session rate.Allowed Amount
Definition: The maximum amount recognized by the insurer for the service. Rule: Reimbursement calculations are always based on the lower of the allowed_amount or provider_fee.Coinsurance (Client Share)
Definition: coinsurance_client_percent represents the percentage of allowed_amount the client is responsible for after deductible. Derived: insurer_share_percent = 1 − coinsurance_client_percentReimbursement Determination Rules
Rule 1 — Claim Denied
Condition: claim_status = denied Outcome:- reimbursement = 0
- deductible_applied = 0
Rule 2 — Pre-Deductible (Full)
Condition: claim_status = approvedAND deductible_remaining ≥ allowed_amount Outcome:
- reimbursement = 0
- deductible_applied = allowed_amount
Rule 3 — Partial Deductible
Condition: claim_status = approvedAND deductible_remaining > 0
AND deductible_remaining < allowed_amount Calculation:
- deductible_applied = deductible_remaining
- remaining_allowed = allowed_amount − deductible_remaining
- reimbursement = remaining_allowed × insurer_share_percent
Rule 4 — Post-Deductible
Condition: claim_status = approvedAND deductible_remaining = 0 Calculation: reimbursement = allowed_amount × insurer_share_percent
Rule 5 — Client Responsibility
Calculation: client_responsibility = provider_fee − reimbursementAllowed Amount Gap
Definition: allowed_gap = provider_fee − allowed_amount Rule: allowed_gap is generally the client’s responsibility in out-of-network billing.Claim Outcome Classification
Outcome: Reimbursed
Condition: reimbursement > 0Outcome: Applied to Deductible
Condition: reimbursement = 0AND deductible_applied > 0
Outcome: Denied
Condition: claim_status = deniedCritical Clarifications
Rule: An approved claim may result in reimbursement = 0 when deductible_remaining > 0.Estimate vs Final Outcome
Rule: All estimates are based on input values available at the time of calculation. Final outcomes may differ due to changes in:- allowed_amount
- deductible_remaining
- claim_status
Allowed Amount Source of Truth ### Definition
- The allowed amount is the maximum amount recognized by the insurer for a given service.
Source and Timing
- Before claim submission:
- Allowed amount is estimated by Thrizer.
- After claim approval (adjudication):
- Allowed amount is determined by the insurer based on the processed claim.
System Behavior
- Thrizer uses estimated allowed amounts to:
- calculate expected reimbursement
- power Thrizer Pay pricing and client responsibility estimates
- After a claim is approved (adjudicated):
- Thrizer updates its internal understanding of the allowed amount using the insurer’s response
Estimate Accuracy Guidance
- Allowed amount estimates are based on historical patterns and available benefit data.
- These estimates are not guaranteed.
- A majority of actual allowed amounts fall within a narrow range of the initial estimate.
- However, variance may occur based on:
- provider
- location
- service type
- insurer-specific adjudication rules
- Do not represent allowed amount estimates as exact predictions.
- Do not guarantee any specific variance range.
- Final allowed amount is always determined by the insurer after claim adjudication.
Stability
- Allowed amounts are generally stable after the first approved (adjudicated) claim for a given context
- However, insurers may change allowed amounts, which are determined externally
Constraint
- Thrizer does not control the final allowed amount
- Final allowed amount is always determined by the insurer
Non-Deterministic Factors (External)
The following are determined by the insurer and are not defined in this file:- allowed_amount determination
- claim approval or denial
- deductible tracking across claims
- reimbursement timing
Reimbursement Variance Responsibility
Definition
- Reimbursement variance is the difference between:
- estimated reimbursement (pre-approval)
- actual reimbursement (post-apporoval)
Responsibility
- The client is fully responsible for all reimbursement variance
-
This includes:
- lower-than-expected reimbursement
- higher-than-expected reimbursement
System Behavior
- Estimates are provided for guidance only and are not guaranteed
-
The system does not:
- retroactively adjust clinician payment based on actual reimbursement
- shift financial responsibility to the clinician
Clinician Protection
- Clinicians are not impacted by differences between estimated and actual reimbursement
- Clinician earnings are not adjusted based on insurer approval (adjudication) outcomes
Constraint
- Final reimbursement is determined by the insurer
- All financial variance resulting from insurer behavior is borne by the client