Backend

Overview of Backend Architecture

This section documents the backend architecture and system workflows that support the Insurance and Claims Management module.

The backend is responsible for handling the core logic required to process insurance claims and maintain accurate claim records.

This includes:

• Managing insurance claim records
• Storing claim data snapshots
• Handling claim submission workflows
• Integrating with third-party insurance processors
• Tracking claim statuses
• Managing eligibility verification requests

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Core Responsibilities

The backend system performs several critical functions within the claim management lifecycle.

Claim Creation

When a claim is submitted, the backend generates claim records and stores claim-related data across multiple tables.

This includes:

• Claim-level information
• Provider information
• Test-level pricing details
• Bill-to-claim mappings

These records ensure that the claim data remains consistent even if billing information changes later.

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Claim Submission Processing

Once a claim is created, the backend prepares and submits claim data to external insurance processors when integrations are enabled.

This submission includes:

• Patient information
• Insurance details
• Billing information
• Test-level claim breakdown

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Claim Status Tracking

When the lab is integrated with an insurance processor, the backend periodically retrieves claim status updates.

These updates may include:

• Claim approval
• Claim rejection
• Partial approvals
• Additional processing remarks

The backend updates the claim status within the system based on the responses received from the external processor.

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Eligibility Verification

The backend also supports insurance eligibility verification workflows.

Eligibility verification allows the system to:

• Confirm insurance validity
• Retrieve coverage details
• Fetch copay and deductible values
• Validate patient demographic data

Currently the eligibility verification workflow is implemented for the Inmediata integration.

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Database Layer

The claims module introduces several new database tables to maintain claim information.

The major tables include:

• InsuranceClaim
• ClaimProviderInfo
• ClaimTestRelation
• BillClaimRelation

Each table plays a specific role in storing claim information and maintaining claim history.

Detailed descriptions of these tables are provided in the Claims Database Schema documentation.