Clean Architecture & DDD Design
Built on Domain-Driven Design (DDD) and Clean Architecture principles, the Medical Billing & RCM System cleanly isolates core business rules from infrastructure and UI presentation layers.
PharmacyBilling.Domain
Pure business entities (Claim, MedicalCode, Patient, Doctor), Enums (ClaimStatus), and Value Objects (ClaimScrubResult).
PharmacyBilling.Application
CQRS Query handlers, ClaimScrubberService, ClaimRemittanceService, and PatientResponsibilityCalculator.
The 5 Pillars of Medical Billing
1. Medical Coding Catalog
ICD-10 / CPT / NDCHigh-speed searchable catalog for ICD-10 diagnosis codes, CPT procedure codes, and NDC drug identifiers linked directly to clinical claims.
2. Pre-Submission Claim Scrubber
Clearinghouse Rules EngineAutomated validation engine verifying patient demographics, policy numbers, rendering doctor NPI credentials, ICD-10 links, and charge totals prior to submission.
3. Co-Pay & Financial Split Engine
POS Financial BreakdownInstant calculations splitting gross charge amounts into Insurance Covered Share vs Patient Co-Pay, Co-Insurance percentage, and Deductible liabilities.
4. Denial & ERA Remittance Manager
EDI 835 / ERA AdjudicationTracks full claim status lifecycle (Draft → Scrubbed → Submitted → Paid / Denied → Appealed), handles denial codes (CO-45, PR-1), and logs one-click clinical appeals.
5. RCM Executive Analytics & Financial KPIs
Real-time Financial Health MonitoringFinancial Calculation Engine
The system implements precise financial formulas at point-of-sale and ERA posting:
Patient Co-Pay = Gross Amount × (Co-Pay % / 100)
Insurance Covered Share = Gross Amount - Patient Co-Pay
Medical Billing & RCM
- On-Premise Desktop/Server Installation
- Pre-Submission Claim Scrubber Engine
- ICD-10, CPT & NDC Coding Catalog
- EDI 835 / ERA Payment Adjudication
- Claim Denial Recording & Appeals
- Real-Time Executive RCM Analytics
- Default 30-Day Evaluation Trial