Thrizer Pay Rules
Last Updated: 2026-03-24 Status: CanonicalPurpose: Defines the complete operational rules governing Thrizer Pay, including eligibility conditions, payment flow, fee behavior, reimbursement routing, and risk allocation. Use this file when determining:
- whether Thrizer Pay is available for a client or session
- how payments are split between client, Thrizer, and therapist
- how fees are calculated, retained, or refunded
- how and where insurance reimbursements are routed
- what happens when claims are approved, denied, or applied to deductible
- how coverage calibration and claim history impact eligibility
- how financial adjustments are handled post-reimbursement
- what guarantees and protections apply to therapist payments
- estimating reimbursement amounts or benefit details
- insurer-specific policies or claim approval (adjudication) logic
- general insurance definitions or terminology
Normalized Condition Inputs
Claim Status
- Approved
- Denied
Claim Outcome Type
- Reimbursed
- Applied_to_Deductible
- Denied
Coverage Calibration Status
- Established
- Not_Established
Coverage Calibration Definition
Coverage Calibration Status = Established when:- insurer allowed amount is known
- coinsurance behavior is known
- Any allowed amount used before claim approval (adjudication) is an estimate generated by Thrizer
- Final financial outcomes may vary based on insurer-determined allowed amount
Deductible Status
- Met
- Not_Met
Estimated Responsibility
Client’s expected out-of-pocket cost based on available benefit information at time of session.Successful Claim Definition
Successful claim = Claim Status = Approved Clarification:- A successful claim may result in:
- reimbursement, or
- deductible application
- Deductible application is represented as:
- Claim Status = Approved
- Claim Outcome Type = Applied_to_Deductible
Payment Model
Rule 1 — Client Payment
Client pays Estimated Responsibility at time of session.Rule 2 — Thrizer Pay Fee
Client pays 5% of therapist full session fee at time of session.Rule 3 — Fee Base
Fee is calculated on therapist full session fee.Rule 4 — Thrizer Advance
Thrizer pays remaining portion of therapist full session fee.Rule 5 — Claim Submission
Thrizer submits claim to insurance carrier.Rule 6 — Reimbursement Routing
Insurance reimbursement is paid to Thrizer.Therapist Payment Rules
Rule 7 — Full Payment Guarantee
Therapist receives full session fee.Rule 8 — No Clawback
Therapist payment is not reduced after payout.Eligibility Rules
Thrizer Pay is allowed only if all conditions are met:Rule 9 — Insurance Requirement
Primary insurance must be present.Rule 10 — Deductible Requirement
Deductible Status = MetRule 11 — Claim History Requirement
At least one Successful Claim must exist. System behavior:- The coinsurance value from the approved claim is used for:
- Thrizer Pay eligibility
- client responsibility estimation
Fee Rules
Rule 14 — Fee Retention
If Claim Status = Approved → Fee is retained.Rule 15 — Fee Refund
If Claim Status = Denied → Fee is refunded.Reimbursement Rules
Rule 16 — Standard Routing
All reimbursements are routed to Thrizer.Rule 17 — Client Does Not Receive Initial Reimbursement
Client does not receive reimbursement directly from insurer.Adjustment Rules
Rule 18 — Pre-Calibration Adjustment
If Coverage Calibration Status = Not_Established→ Thrizer Pay is not available to the client
Rule 19 — Post-Calibration Adjustment
If Coverage Calibration Status = Established→ Adjustment may result in:
- additional client charge
- client refund
Rule 20 — Therapist Protection
Therapist payment is unaffected by reimbursement differences.Reimbursement Variance Rules
Rule 21 — Excess Reimbursement
If reimbursement > estimated amount→ excess amount is returned to client.
Risk Boundary
Rule 22 — Risk Allocation
Thrizer assumes reimbursement risk relative to therapist.Rule 23 — Estimate Limitation
Estimated Responsibility is not a guarantee of final reimbursement.Rule 24 — Insurer Authority
Insurance carrier determines final claim outcome and reimbursement amount.Availability Limits
Rule 25 — Disable Condition
Thrizer Pay may be disabled if reimbursement behavior is unreliable.Rule 26 — Examples of Unreliable Behavior
- repeated claim denials
- inconsistent reimbursement patterns
Rule 27
— Fallback Behavior If Thrizer Pay is disabled→ standard claim submission flows remain available.