Automated Billing Eligibility Engine
ABI's engine integrates with PointClickCare to read chart data directly, evaluating each patient against a facility's custom billing eligibility profiles as a deterministic rules flowchart. Additional EHR integrations are in development.
A rules engine that reads directly from EHR data
ABI connects to the EHR in read-only mode, runs chart data through a configurable rule flowchart, and logs every decision with its inputs. An optional AI layer can advise on documentation sufficiency and denial risk — it never makes the determination.
Read-only ingestion & normalization
Scheduled sync from your EHR, designed to plug into any FHIR/REST source — live on PointClickCare today. Raw payloads are archived immutably so every decision can be reconstructed from the exact data it saw.
Your rulebook as a flowchart
Every chart is walked through your billing playbook as a configurable flowchart. Deterministic nodes handle the clear-cut checks. An optional AI advisory layer flags documentation gaps and denial risk — logged alongside each determination, never replacing the human decision.
Review queue & decision log
Billers work from a queue organized by outcome — eligible, needs review, ineligible. Each item shows the rule path taken and the inputs evaluated. Every override is logged, and every decision is replayable against the exact data that produced it.
How a workflow gets built
Document the rules
We capture the existing billing rules — written policy, payer requirements, and institutional knowledge — and organize them into a structured rulebook.
Encode & connect
We translate the rulebook into a configurable flowchart, stand up a read-only EHR connection, and validate the logic against historical charts.
Run in parallel
The engine runs alongside existing reviewers. Each chart produces a decision and a full trace, compared against reviewer outcomes to verify accuracy.
Extend to new workflows
New service lines and payer types plug into the same infrastructure. The EHR connection and data layer stay shared — only the rules change.
Median and P90 durations for each pipeline stage, from chart sync through final determination, broken down per facility.
View report →Eligibility outcomes by profile, facility, and review cycle. Spot drift in determination rates before it affects collections.
View report →Agreement rate between the deterministic flowchart and the advisory AI layer. Surfaces nodes where the two disagree most often.
View report →How the system is built
ABI is built on four properties that carry across every workflow it runs: consistent rule execution, a complete decision log, HIPAA-aware data handling, and infrastructure that scales without proportional reviewer headcount.
Consistency
Every chart runs through the same rule flowchart. The same inputs produce the same output, regardless of who is reviewing or when.
Auditability
Every decision is stored with its inputs, the rule path it took, and any AI reasoning. The full decision can be reconstructed at any point from the logged data.
Data handling
Encrypted in transit and at rest. Tenant-scoped access and facility-isolated storage. Record changes are archived under HIPAA versioning, never deleted. The system operates independently of the EHR and fails safely if connectivity is lost.
Volume independence
The rule engine processes charts the same way at any volume. Adding facilities or increasing case load doesn't require proportionally more review staff.
Custom patient-profile eligibility running on PointClickCare
ABI is live in skilled nursing facilities through the PointClickCare Marketplace. Each facility's custom patient profiles — the criteria that define who qualifies, what evidence is required, and what timing windows apply — are encoded as a flowchart that runs against read-only FHIR and REST data from PCC.
Per-resident eligibility review against facility-defined patient profiles
Each review cycle evaluates coverage status, census data, profile-specific criteria, reassessment windows, and documentation sufficiency for every resident. The engine encodes those steps as a flowchart connected to PCC's FHIR and REST feeds, producing a decision and an evidence set for every case.
Constraints of Manual Billing Eligibility Reviews
Billing eligibility reviews are largely manual. Reviewers apply eligibility criteria to chart data, assess compliance windows, and document decisions — a process that varies by reviewer, organization, and service line.
Manual review
Eligibility determinations are made by individual reviewers working through chart data, payer rules, and documentation requirements case by case.
Compliance windows
Documentation, assessments, and orders each carry their own deadlines. Missing any one of them can invalidate an otherwise eligible claim.
Audit reconstruction
When a claim is denied, reconstructing the original eligibility determination often requires reviewing chart notes and applying judgment after the fact.
Review capacity
The volume of reviews a billing team can complete is tied directly to headcount. Adding facilities typically means adding reviewers.
ABI is live on PointClickCare, automating eligibility review against each facility's custom patient profiles. Additional EHR integrations are in development. If you're working on an eligibility automation problem in healthcare, we're open to a conversation.
Frequently Asked Questions
If yours isn't listed, please feel free to reach out directly.