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FILE: canonical_terms.md

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Thrizer Canonical Terms

Last Updated: 2026-04-07 Status: Canonical

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Purpose: Use this file to resolve the precise meaning of any Thrizer-specific term or insurance-related concept referenced in a query. Route here when: A question depends on the definition of a term (e.g., “What is Allowed Amount?”). Multiple terms could be confused or need disambiguation (e.g., Provider Fee vs Allowed Amount). A response requires consistent, canonical wording of a concept. A downstream answer depends on understanding a term before applying logic. Do not route here when: The query requires workflows, calculations, eligibility rules, or system behavior. The query asks “how,” “when,” or “why” something happens rather than “what it means.” This file is the single source of truth for terminology only.

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Payment Types

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Thrizer Pay

A payment type where the client payment at time of service is based on an estimated out-of-pocket responsibility.

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OON Pay

A payment type where services are processed as out-of-network insurance claims.

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Self-Pay

A payment type where no insurance claim is submitted.

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Financial Terms

This file defines terminology only. All financial concept definitions (including Provider Fee, Allowed Amount, Deductible, and Coinsurance) are governed by: → Thrizer Insurance Definitions (Canonical) Routing Rule:

• If a query requires meaning or interpretation of a financial insurance concept, route to Thrizer Insurance Definitions.
• This file must not redefine or restate financial calculation concepts.

Constraint:

• Do not duplicate definitions from Insurance Definitions in this file.
• This file may reference financial terms but must not define their calculation logic or behavior.

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Estimated Values

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Estimated Reimbursement

A predicted insurance payment amount based on available information.
This value is not guaranteed.

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Estimated Out-of-Pocket Responsibility

A predicted client payment amount for a service.
This value is not guaranteed.

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Claims

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Claim Status

The processing state of an insurance claim.
A claim has exactly one status at any given time.

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Canonical Values

• Processing
• Investigating
• Approved
• Denied

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Claim Result

The outcome of claim processing, including financial components such as reimbursement amount or deductible credit.

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Reimbursement

The amount paid by an insurance carrier after claim processing.

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Primary Insurance On File

• Indicates that the client’s insurance has been verified within the Thrizer system.

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Eligibility

Eligibility indicates that a client’s insurance is confirmed via benefit check to use Thrizer. Eligibility means the benefit check is usable. It is a binary state. Eligibility does not determine:

• coverage details
• reimbursement amounts
• payment type availability

These are determined by other system rules.

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Claim Outcome Type

Definition
Claim Outcome Type is a normalized classification of the financial result of a processed claim. This field standardizes interpretation across systems and prevents ambiguity between status and financial outcome. Canonical Values:

• Reimbursed
• Applied to Deductible
• Denied

Mapping Rules:

• Claim Status = Approved AND reimbursement > 0 → Reimbursed
• Claim Status = Approved AND reimbursement = 0 AND deductible applied → Applied to Deductible
• Claim Status = Denied → Denied

Constraint:

• “Approved_Applied_To_Deductible” is not a canonical status.
• Deductible application must be represented using:
  • Claim Status = Approved
  • Claim Outcome Type = Applied to Deductible

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Verification States

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Usable Benefit Check

A benefit check is usable when benefit information is successfully returned and is sufficient for Thrizer claim workflows and reimbursement estimates.

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eligibility_verified

eligibility_verified = true when a usable benefit check exists. This is a pre-claim verification state.

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Successful Claim

A successful claim is a processed claim that results in either:

• reimbursement, or
• deductible application

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coverage_verified

coverage_verified = true when at least one successful claim exists. This is a post-claim verification state.

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Distinction

• eligibility_verified must not be used to mean post-claim confirmation
• coverage_verified must not be used to mean benefit-check usability

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FILE: insurance_definitions.md

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Thrizer Insurance Definitions

Last Updated: 2026-04-02 Status: Canonical

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Purpose: Provides canonical definitions for insurance terms used across Thrizer. Use this file when a query requires precise meaning, interpretation, or disambiguation of insurance terminology (e.g., deductible, allowed amount, coinsurance, claim status, reimbursement). Route here for: Term definitions or clarification of insurance concepts Understanding relationships between financial inputs (provider fee, allowed amount, deductible, coinsurance) Interpreting claim statuses, outcomes, or result types Explaining how estimates (reimbursement, out-of-pocket) are constructed at a conceptual level Do not use this file for: Product behavior, workflows, or user actions Pricing rules, fee calculations, or payout timing Insurer-specific policies or plan details Determining actual claim outcomes or guarantees All interpretations derived from this file must respect global constraints: insurance carriers control claim decisions, reimbursement amounts, and deductible application; all estimates are non-guaranteed.

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Global Constraints

• Insurance carriers determine claim outcomes.
• Insurance carriers determine reimbursement amounts.
• Insurance carriers determine deductible application.
• Insurance carriers determine claim approval or denial.
• Coverage estimates and reimbursement estimates are not guarantees.

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Core Financial Inputs

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Provider Fee

Definition
The provider fee is the therapist’s full session rate charged for a service.

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Allowed Amount

Definition
The maximum amount recognized by the insurer for a covered service. Source

• Determined by the insurer after claim adjudication

System Usage (Thrizer):

• Thrizer may estimate the allowed amount prior to claim submission for pricing and reimbursement estimates
• These estimates are replaced with actual allowed amounts after adjudication

Rule
Insurance reimbursement calculations are based on the allowed amount, not the provider fee. Rule
If provider_fee > allowed_amount, the client may be responsible for the difference between provider_fee and allowed_amount.

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Deductible

Definition
The deductible is the cumulative amount a client must pay out of pocket before insurance begins reimbursing eligible claims. Rule
When deductible_status = Unmet, the allowed_amount may be applied toward the deductible. Rule
When deductible_status = Unmet, reimbursement_amount may equal 0 even if the claim is approved. Rule
When deductible_status = Unmet, client responsibility may include:

• allowed_amount applied to deductible
• any difference between provider_fee and allowed_amount

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Deductible Status

Definition
Deductible status indicates whether the client has met the deductible at the time of claim processing. Canonical Values

• Met
• Unmet

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Coinsurance Rate

Definition
The coinsurance rate is the percentage of the allowed amount assigned to the client after the deductible is met.

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Derived Financial Concepts

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Coinsurance

Definition
Coinsurance is the portion of the allowed amount the client is responsible for after the deductible is met. Condition
Applies only when deductible_status = Met Rule
Coinsurance is calculated from the allowed amount, not the provider fee.

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Estimated Reimbursement

Definition
Estimated reimbursement is a predicted insurance payment amount for a service. Normalized Inputs

• allowed_amount
• deductible_status
• coinsurance_rate

Constraint
Estimated reimbursement is not guaranteed.

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Estimated Out-of-Pocket Responsibility

Definition
Estimated out-of-pocket responsibility is the predicted amount the client pays for a service. Formula
provider_fee − estimated_reimbursement Constraint
Estimated out-of-pocket responsibility is not guaranteed.

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Coverage

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Out-of-Network Benefits

Definition
Out-of-network benefits are insurance coverage for services provided by non-contracted providers. Constraint
The presence of out-of-network benefits does not guarantee reimbursement. Constraint
Out-of-network benefits vary by insurance plan.

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Coverage Estimates

Definition
Coverage estimates are predicted reimbursement and cost values based on benefit information available at the time of verification. Constraint
Coverage estimates are not guarantees.

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Claims

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Insurance Claim

Definition
An insurance claim is a submission requesting reimbursement or deductible credit for a healthcare service.

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Claim Data Elements

Definition
An insurance claim contains structured data required for processing. Typical Fields

• client_identifier
• provider_identifier
• service_code
• billed_amount
• diagnosis_code
• insurance_plan_identifier

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Claim Status

Definition
Claim status represents the processing state of a claim. Canonical Status Values

• Processing
• Investigating
• Approved
• Denied

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Claim Result

Definition
Claim result represents the financial outcome of a processed claim. Possible Outputs

• reimbursement_amount
• deductible_applied_amount
• payment_method

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Claim Outcome Types

Definition
Claim outcome types represent final financial classifications of a processed claim.

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Reimbursed

Definition
Insurance pays a portion of the allowed amount.

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Applied to Deductible

Definition
Reimbursement amount = 0 and allowed_amount is applied to deductible. Condition
Typically occurs when deductible_status = Unmet

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Denied

Definition
No reimbursement is issued and no deductible application occurs.

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Claim Outcome Rules

Rule
Approved means the insurance carrier approved the claim for processing. Approved does not by itself determine whether the claim was reimbursed or applied to deductible. Deductible application and reimbursement are separate financial outcomes. Rule
A claim may be approved and still result in reimbursement_amount = 0.

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Deductible Status Source

Deductible status is initially determined using benefit check data prior to claim submission. After a claim is approved, deductible status must be updated based on insurer-reported claim results. The insurer determines final deductible application.

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Deductible Update Trigger

Deductible status is updated after an approved claim using insurer-reported results. This update is typically system-driven but may be performed manually if required.

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FILE: practioner_eligibility_reference.md

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Practitioner Eligibility Reference (Canonical)

Last Updated: 2026-04-07 Status: Canonical

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Purpose: Use this file when determining whether a practitioner can be considered eligible or supported at a classification level, based on license validity, supervision status, legal permissibility, and general reimbursement possibility. This file should be referenced when: The question involves whether a specific practitioner type is supported or unsupported The question involves license types, supervision status, or practitioner categories The chatbot needs to apply eligibility constraints (license valid, legal, reimbursable) The chatbot must classify a provider as supported, conditionally supported, or unsupported The chatbot needs to handle uncertainty for supervised or variable-support practitioners This file should NOT be used when: Determining actual reimbursement amounts, claim outcomes, or insurer decisions Evaluating plan-specific coverage or benefits Explaining payment flows, claim submission, or timing Providing guarantees of reimbursement or eligibility This file provides structural eligibility logic and practitioner classification only, not outcome determination.

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2. Normalized Inputs

The following inputs are required for eligibility evaluation:

• provider_license_type
• provider_license_valid (boolean)
• provider_supervision_status (independent | supervised)
• service_legally_permitted (boolean)
• service_reimbursement_possible (boolean)
• client_location

Eligibility requires all of the following:

• provider_license_valid = true
• service_legally_permitted = true
• service_reimbursement_possible = true

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3. Eligibility Rules

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Rule 1 — License Requirement

A provider is not eligible if:

• provider_license_valid = false

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Rule 2 — Legal Service Requirement

A provider is not eligible if:

• service_legally_permitted = false

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Rule 3 — Reimbursement Possibility

A provider must not be described as eligible if:

• service_reimbursement_possible = false

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Rule 4 — Supervised Providers

If:

• provider_supervision_status = supervised

Then:

• reimbursement eligibility is uncertain
• chatbot must not guarantee reimbursement

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4. Practitioner Support Classification

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4.1 Supported Practitioner Types

These practitioner types are recognized and commonly supported.

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Mental Health Clinicians

• Licensed Clinical Social Worker (LCSW, LICSW, LMSW)
• Licensed Marriage and Family Therapist (LMFT, AMFT)
• Licensed Professional Counselor (LPC, LPCC, LCPC, LMHC)
• Psychologist (PhD, PsyD)
• Psychiatrist (MD, DO)
• Psychiatric Mental Health Nurse Practitioner (PMHNP)

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Behavioral Health Practitioners

• Board Certified Behavior Analyst (BCBA)
• Addiction Counselors (CADC, Licensed Substance Use Counselor)

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Healthcare Practitioners

• Physician (MD, DO)
• Nurse Practitioner
• Physician Assistant (PA)

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4.2 Conditional / Variable Support

These practitioner types may be supported depending on reimbursement conditions:

• Occupational Therapist (OT)
• Physical Therapist (PT)
• Speech Language Pathologist (SLP)
• Registered Dietitian (RS, RDN)
• Medical specialists

Chatbot behavior:

• Do not guarantee reimbursement
• Indicate variability based on insurance

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Clarification — Variable Practitioner Validation

For practitioner types under conditional or variable support:

• Compatibility may require CPT-level validation
• Practitioner classification alone is not sufficient to determine support

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4.3 Unsupported Practitioner Types

These practitioner types are not supported:

• Chiropractor
• Massage Therapist

Chatbot behavior:

• Clearly state unsupported status
• Do not suggest eligibility

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4.4 Supervisory Claims (Incident-to Billing)

If a clinician is not independently licensed but is working under supervision, claims may be submitted under the supervising clinician’s NPI. This is typically done for associate-level clinicians, residents, or interns.

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Rendering vs Supervising Provider

• The rendering provider is the individual delivering care
• The supervising provider may be used for claim submission where applicable

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Reimbursement and Insurer Variability

• Supervisory (incident-to) billing is not uniformly accepted across insurers
• Some insurers may reimburse services delivered under a supervising provider’s NPI
• Others may deny claims or apply different rules

Constraints:

• Thrizer does not determine or enforce whether a specific insurer supports supervisory billing
• Reimbursement outcomes are determined externally by the insurer

Chatbot behavior:

• Do not guarantee reimbursement for supervised providers
• Do not assume uniform insurer behavior across plans

Support Guidance:

• If reimbursement is not supported by a client’s plan:
  • claims may be denied
  • alternative workflows (e.g., superbill submission) may be used

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5. License Categories

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5.1 Independent License

Definition:

• provider_supervision_status = independent

Examples:

• LCSW
• LMFT
• LPC
• Psychologist
• Psychiatrist
• Nurse Practitioner

Behavior:

• May submit claims under own license

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5.2 Supervised License

Definition:

• provider_supervision_status = supervised

Examples:

• AMFT
• APCC
• Associate therapist
• Intern
• Resident
• Limited license clinician

Behavior:

• Reimbursement varies by insurance
• Chatbot must not guarantee eligibility

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Clarification — Platform Support vs Insurer Acceptance

• Thrizer does not restrict or block usage based on supervised or associate license status alone.
• Practitioner types classified as supported (e.g., AMFT, LMSW, APCC) may:
  • use Thrizer workflows
  • submit claims through supported payment flows
• However:
  • reimbursement eligibility is determined externally by the insurer
  • insurer policies may vary regarding supervised or associate providers
• The chatbot must:
  • distinguish between platform support and insurer reimbursement
  • avoid implying that supported practitioner types are guaranteed reimbursement

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5.3 Supervisory Claims for Pre-Licensed Clinicians

If a clinician is in a pre-licensed or supervised status (e.g., associate, intern, resident), insurer requirements for supervising provider information may still apply.

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Standard Thrizer Submission Behavior

• Claims are submitted using the NPI of the clinician associated with the Thrizer account.
• Thrizer uses a single provider NPI for claim submission.
• Thrizer does not support:
  • entering a supervising provider NPI
  • dual provider representation (rendering + supervising)

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Representation Constraint

• Claims should reflect the provider who actually delivered care.

Implications:

• Provisionally licensed clinicians (with their own NPI):
  • If they are the Thrizer account holder, their NPI is used
  • The rendering provider is correctly represented
• Unlicensed interns:
  • If an intern delivers care but the claim is submitted under a supervising clinician’s NPI:
    • the rendering provider on the claim does not reflect the individual who performed the service

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Risk

• Misalignment between the actual rendering provider and the submitted NPI may result in:
  • claim denial
  • post-payment recoupment by the insurer

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Supervising Provider Requirements

• Insurer requirements for supervising provider information may still apply.
• Thrizer does not currently support entering supervising provider information in standard workflows.

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Denied Claim Handling

• If an insurer requires supervising provider information and denies the claim:
  • follow-up may require manual collection of supervisor details

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Constraint

• Thrizer does not guarantee insurer acceptance for supervised or pre-licensed clinicians.

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External Determination

• Requirements for supervising provider involvement and claim structure are determined externally by the insurer.

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6. Jurisdiction Constraint

Licenses are issued by jurisdiction. Valid jurisdictions include:

• U.S. states (50 states)
• District of Columbia
• U.S. territories (PR, GU, VI, AS, MP)

Rule:

• provider_license_valid must reflect jurisdiction validity

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7. Telehealth Constraint

Eligibility depends on:

• client_location

Rule:

• Insurance reimbursement may depend on client location at time of service
• Chatbot must not generalize across states

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8. Practitioner Usage Bias

• Mental health clinicians are the most common practitioner type using the system

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9. Service Edge Cases

Music-based therapy services may be supported when:

• billed under a reimbursable therapeutic CPT code

Constraint:

• CPT definitions are external to this file

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10. Support Variability Signal

Some non-mental-health practitioners may have:

• higher variability in reimbursement outcomes

Constraint:

• variability is driven by insurance coverage differences

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11. Chatbot Response Constraints

The chatbot must:

• Not guarantee eligibility or reimbursement
• Require license + legal + reimbursement conditions
• Clearly distinguish supported vs unsupported practitioners
• Treat supervised providers as uncertain eligibility
• Avoid assumptions when inputs are missing

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Rule — Benefit Check Scope Limitation (Practitioner Types)

• Benefit checks confirm plan-level out-of-network benefits only.
• Benefit checks do NOT:
  • confirm whether a specific practitioner type (e.g., associate, supervised provider) will be reimbursed
  • validate insurer acceptance of a provider’s license level
• The chatbot must:
  • clearly separate plan-level benefit confirmation from provider-level reimbursement eligibility

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