Billing Automation Pipeline (WORK IN PROGRESS)

How Bills Enter the Pipeline

The pipeline applies only to bills that are automatically imported from a third-party ePCR system. The following bill types do not enter the pipeline and are not affected by this feature: bills created manually in AIM Billing, bills manually imported by a user, and bills posted from AIM ePCR (V3).

When a qualifying bill is imported, it is programmatically moved into the pipeline and begins processing in the background. The biller does not need to take any action to initiate automation.

Pipeline Phases

Each bill moves through the following phases in order. If a phase completes successfully, the bill advances to the next phase automatically. If a phase cannot be completed, the bill is blocked at that phase for biller review.

Phase 1: PCR Receipt and Intake

The bill is imported from the NEMSIS XML and entered into the pipeline. The system runs a predictive patient lookup to determine if the patient already exists in AIM. If a single match is found, the patient account is automatically assigned and the bill advances. If no match is found and the patient qualifies as a new patient, a new patient record is created from the PCR data. If multiple matches are found, the bill is blocked because the system cannot determine which patient account is correct without human review.

Phase 2: Insurance Discovery and Eligibility

The system attempts to identify and verify payers for the bill. For existing patients, payers are first carried forward from a previous bill that has been paid. If no prior bill payers are found, the system checks the patient's account member payers. If neither source produces results, the system checks the ePayment.InsuranceGroup data from the NEMSIS XML as a last resort. Once payers are identified, the system runs an eligibility verification to confirm they are active. If the patient is 65 or older, Medicare eligibility is checked first. If no active payers are found through any source, the bill continues through the pipeline without payers. The existing Bills With No Payer report and patient outreach workflow are used to address these bills.

Phase 3: Medical Necessity and Documentation Review

The system maps NEMSIS XML data to ANSI 5010 837 fields, populating the bill with available clinical and transport data directly from the PCR. The system then evaluates the bill against configured Automation Profile Mappings. Profiles are evaluated in priority order, and the first profile whose conditions are all fully satisfied is applied. A profile can only be considered if the bill contains a payer that matches the linked Billing Profile's payer association. When a profile is applied, it populates data across the Charges, Diagnosis, Narrative, Transport, Transport Locations, and payer data entry screens per normal Billing Profile behavior. If no profile's conditions are fully satisfied, the bill continues through the pipeline without a profile applied.

Phase 4: Coding

The system suggests ICD-10 diagnosis codes based on NEMSIS XML data. If a Billing Profile already defaulted diagnosis codes during the previous phase, the suggestion engine does not run. A primary diagnosis code is suggested based on the system's analysis of the Chief Complaint, Primary Symptom, Primary Impression, Other Associated Symptoms, Secondary Impression, Patient Care Narrative, and CMS Service Level. The suggestion is only applied if it meets the configured confidence threshold. A secondary Z-code is also determined by scanning the Narrative and Chief Complaint for keywords that indicate a specific clinical scenario. Z781 (Physical Restraint Status) is the highest priority and is applied when keywords such as restraint, suicide, involuntary hold, or psychiatric hold are found. Z9989 (Dependence on Enabling Machines and Devices) is applied when keywords such as ventilator, oxygen dependent, CPAP, tracheostomy, or feeding tube are found. Z7401 (Bed Confinement Status) is applied when keywords such as bed confined, bedridden, non-ambulatory, paralyzed, or immobilized are found. Z743 (Need for Continuous Supervision) is applied as the default when no specific keywords are matched. If the primary diagnosis cannot be determined with sufficient confidence, the bill is blocked at this phase for manual coding.

Phase 5: Claim Scrubbing

The system validates the bill for completeness and compliance. This includes both mandatory print field validation and ANSI 5010 claim validation. If the bill passes all validations, it advances to Ready for Review. If validation fails, the bill is blocked at this phase so the biller can correct the issues.

Phase 6: Ready for Review

The bill has completed all pipeline phases and is ready for the biller to review before transmission. The biller should confirm that the populated data is accurate and complete before transmitting the claim.

Working with Pipeline Bills

While a bill is actively being processed by the pipeline, it is view-only. The biller can open and review the bill, but cannot enable edit mode until the pipeline has finished processing or the bill has been blocked.

When a bill is blocked at a pipeline phase, the biller can enable edit mode to make corrections. After making changes, when the biller saves the bill, a popup will ask whether to re-enter the bill into the automation pipeline. Selecting Yes will save the bill immediately, bypassing any mandatory entry validation errors, and re-enter the bill at the phase where it was blocked. Selecting No will perform a standard save where all mandatory entry validation errors must be resolved before the save completes, and the bill will exit the pipeline for the biller to complete manually.

Pipeline Tab

A new Pipeline tab is available on bills that have entered the automation pipeline. This tab is not present on manually created bills, manually imported bills, or bills posted from V3.

The Pipeline tab displays the full history of the bill's journey through the pipeline. Each phase the bill has passed through is listed with a timestamp, the phase name, whether it completed or was blocked, and a detail line describing what occurred. For example, the detail might indicate which patient was matched, which payers were carried forward, which profile was applied, or why a phase was blocked.

Pipeline Status Label

A pipeline status label is displayed in the bill header alongside the existing bill status fields. This label shows the bill's current pipeline phase and whether it is processing or blocked. For example, the label might read "Coding — Blocked" to indicate the bill is stopped at the Coding phase. This label is only visible when the bill is open.