SAIF.Business.Claim.MedicalBill business rules

This page captures business rules enforced by SAIF.Business.Claim.MedicalBill.

BR-MB-001: Exposure claims require ExposureClaim AD resource authorization

Field	Value
Statement	Exposure claims require ExposureClaim AD resource authorization
Trigger	Bill collection retrieval
Enforcement	clsMedicalBillCollection.HasExposureAccess
Outcome	Filters data based on authorization
Confidence	Source-backed
Source	Business\SAIF.Business.Claim.MedicalBill\clsMedicalBillCollection.vb — HasExposureAccess

---

BR-MB-002: Collateral health claims require CollateralHealthClaim AD resource authorization

Field	Value
Statement	Collateral health claims require CollateralHealthClaim AD resource authorization
Trigger	Bill collection retrieval
Enforcement	clsMedicalBillCollection.HasHealthIssueAccess
Outcome	Filters data based on authorization
Confidence	Source-backed
Source	Business\SAIF.Business.Claim.MedicalBill\clsMedicalBillCollection.vb — HasHealthIssueAccess

---

BR-MB-003: SAIF employee status affects data visibility

Field	Value
Statement	SAIF employee status affects data visibility
Trigger	Bill retrieval
Enforcement	clsMedicalBillCollection.IsSAIFEmployee — checks SecurityPrincipal.Domain = "SAIF"
Outcome	Domain-based filtering
Confidence	Source-backed
Source	Business\SAIF.Business.Claim.MedicalBill\clsMedicalBillCollection.vb — IsSAIFEmployee, AfterRetrieve

---

BR-MB-004: Optimistic concurrency on all CRUD operations

Field	Value
Statement	Optimistic concurrency on all CRUD operations
Trigger	All After* lifecycle methods
Enforcement	All business objects
Outcome	DB contention error on failure
Confidence	Source-backed
Source	Business\SAIF.Business.Claim.MedicalBill\clsNationalDrug.vb — AfterUpdate; Business\SAIF.Business.Claim.MedicalBill\clsNationalDrugPrice.vb — AfterUpdate, AfterDelete; Business\SAIF.Business.Claim.MedicalBill\clsNdcPriceHistory.vb — AfterInsert

---

BR-MB-005: Bill search claim number must resolve to a valid SAIF claim

Field	Value
Statement	When a claim number is entered on a bill search, it must resolve to a valid claim through claim security.
Trigger	clsBillSearchCriteria.IsValid evaluation of the ClaimNumber property.
Enforcement	clsBillSearchCriteria.IsValidClaim
Outcome	Search is blocked with a broken rule until the claim number is valid or cleared.
Confidence	Source-backed
Source	Business\SAIF.Business.Claim.MedicalBill\clsBillSearchCriteria.vb — IsValidClaim

---

BR-MB-006: Bill search provider location must be valid when entered

Field	Value
Statement	When a provider location is entered on a bill search, it must resolve to a valid provider location; resolving it also derives the associated provider identifier.
Trigger	clsBillSearchCriteria.IsValid evaluation of the ProviderLocID property.
Enforcement	clsBillSearchCriteria.IsValidProviderLocation
Outcome	Search is blocked with a broken rule when the location does not resolve; ProviderID is set as a side effect when it does.
Confidence	Source-backed
Source	Business\SAIF.Business.Claim.MedicalBill\clsBillSearchCriteria.vb — IsValidProviderLocation

---

BR-MB-007: Bill search worker last name is required when a first name is entered

Field	Value
Statement	A worker last name must be entered whenever a worker first name is entered on a bill search.
Trigger	clsBillSearchCriteria.IsValid evaluation of the WorkerFirstName property.
Enforcement	clsBillSearchCriteria.IsValidFirstName
Outcome	Search is blocked with a broken rule until a last name is also supplied.
Confidence	Source-backed
Source	Business\SAIF.Business.Claim.MedicalBill\clsBillSearchCriteria.vb — IsValidFirstName

---

BR-MB-008: Bill search service begin and end dates must both be entered together

Field	Value
Statement	A service begin date and a service end date must both be entered together on a bill search, or neither.
Trigger	clsBillSearchCriteria.IsValid evaluation of the ServiceBeginDate property.
Enforcement	clsBillSearchCriteria.IsValidDatesOfService
Outcome	Search is blocked with a broken rule when only one of the two dates is present.
Confidence	Source-backed
Source	Business\SAIF.Business.Claim.MedicalBill\clsBillSearchCriteria.vb — IsValidDatesOfService

---

BR-MB-009: Bill search service begin date may not be in the future

Field	Value
Statement	A bill search service begin date may not be later than today.
Trigger	clsBillSearchCriteria.IsValid evaluation of the ServiceBeginDate property.
Enforcement	clsBillSearchCriteria.IsFromDateNotFuture
Outcome	Search is blocked with a broken rule when the begin date is in the future.
Confidence	Source-backed
Source	Business\SAIF.Business.Claim.MedicalBill\clsBillSearchCriteria.vb — IsFromDateNotFuture

---

BR-MB-010: Bill search service end date may not precede the begin date

Field	Value
Statement	A bill search service end date may not be earlier than the service begin date.
Trigger	clsBillSearchCriteria.IsValid evaluation of the ServiceEndDate property.
Enforcement	clsBillSearchCriteria.IsValidThruDate
Outcome	Search is blocked with a broken rule when the end date precedes the begin date.
Confidence	Source-backed
Source	Business\SAIF.Business.Claim.MedicalBill\clsBillSearchCriteria.vb — IsValidThruDate

---

BR-MB-011: Bill search date range may not exceed six months unless an identifier is given

Field	Value
Statement	A bill search date range may not exceed six months unless a claim number, bill number, or check number is also entered.
Trigger	clsBillSearchCriteria.IsValid evaluation of the ServiceBeginDate property.
Enforcement	clsBillSearchCriteria.IsValidDateRange
Outcome	Search is blocked with a broken rule when the six-month window is exceeded without a qualifying identifier.
Confidence	Source-backed
Source	Business\SAIF.Business.Claim.MedicalBill\clsBillSearchCriteria.vb — IsValidDateRange

---

BR-MB-012: Bill search service end date may not be in the future

Field	Value
Statement	A bill search service end date may not be later than today.
Trigger	clsBillSearchCriteria.IsValid evaluation of the ServiceEndDate property.
Enforcement	clsBillSearchCriteria.IsThruDateNotFuture
Outcome	Search is blocked with a broken rule when the end date is in the future.
Confidence	Source-backed
Source	Business\SAIF.Business.Claim.MedicalBill\clsBillSearchCriteria.vb — IsThruDateNotFuture

---

BR-MB-013: Bill search worker birth date may not be in the future

Field	Value
Statement	A bill search worker birth date may not be later than today.
Trigger	clsBillSearchCriteria.IsValid evaluation of the WorkerBirthDate property.
Enforcement	clsBillSearchCriteria.IsValidDob
Outcome	Search is blocked with a broken rule when the birth date is in the future.
Confidence	Source-backed* (the rule's RuleData attribute text is copy-pasted from IsFromDateNotFuture, but the bound function and message describe a birth-date check)
Source	Business\SAIF.Business.Claim.MedicalBill\clsBillSearchCriteria.vb — IsValidDob

---

BR-MB-014: Internal bill search requires a claim number, bill number, or provider number

Field	Value
Statement	A non-external bill search must include a claim number, bill number, or provider location before it is considered valid.
Trigger	clsBillSearchCriteria.IsValid evaluation of the ClaimNumber property, when the criteria object was constructed as non-external.
Enforcement	clsBillSearchCriteria.IsValidSearchInfo
Outcome	Search is blocked with a broken rule when none of the three identifiers is present; external searches skip this check.
Confidence	Source-backed
Source	Business\SAIF.Business.Claim.MedicalBill\clsBillSearchCriteria.vb — IsValidSearchInfo

---

BR-MB-015: Bill search by check number requires a provider number

Field	Value
Statement	A bill search that includes a check number must also include a provider number.
Trigger	clsBillSearchCriteria.IsValid evaluation of the CheckNumber property.
Enforcement	clsBillSearchCriteria.IsValidCheckNum
Outcome	Search is blocked with a broken rule when a check number is entered without a resolved provider.
Confidence	Source-backed
Source	Business\SAIF.Business.Claim.MedicalBill\clsBillSearchCriteria.vb — IsValidCheckNum

---

BR-MB-016: Bill search starts-with option requires at least three characters

Field	Value
Statement	When the starts-with option is selected for worker last name, at least three characters must be entered.
Trigger	clsBillSearchCriteria.IsValid evaluation of the WorkerLastName property.
Enforcement	clsBillSearchCriteria.IsValidWildCard
Outcome	Search is blocked with a broken rule when fewer than three characters are entered with starts-with selected.
Confidence	Source-backed
Source	Business\SAIF.Business.Claim.MedicalBill\clsBillSearchCriteria.vb — IsValidWildCard

---

BR-MB-017: Medical bill search requires exactly one of worker ID or provider location

Field	Value
Statement	A medical bill search (IsMedicalBillSearch) must supply exactly one of WorkerID or ProviderLocID; supplying both or neither is invalid.
Trigger	clsBillSearchCriteria.IsValid evaluation of the IsMedicalBillSearch property.
Enforcement	clsBillSearchCriteria.IsValidMedicalBillSearch
Outcome	Search is blocked with a broken rule when zero or both identifiers are present.
Confidence	Source-backed
Source	Business\SAIF.Business.Claim.MedicalBill\clsBillSearchCriteria.vb — IsValidMedicalBillSearch

---

BR-MB-018: Active drug price selection prefers an unexpired row, falling back to the most recent effective date

Field	Value
Statement	The active national drug price is the first price row found with an expiration date equal to Date.MaxValue or Date.MinValue (treated as unexpired); if no such row exists, the price row with the latest effective date is used instead.
Trigger	Reading clsNationalDrug.ActivePrice.
Enforcement	clsNationalDrug.ActivePrice
Outcome	Callers receive a single "current" price row for pricing calculations without having to scan the full price collection themselves.
Confidence	Source-backed
Source	Business\SAIF.Business.Claim.MedicalBill\clsNationalDrug.vb — ActivePrice

---

BR-MB-019: Pending bill payment totals are suppressed during a medical bill search

Field	Value
Statement	TotalPaidAmt returns a null value for a pending bill when the bill belongs to a parent collection retrieved as a medical bill search (IsMedicalBillSearch), instead of the computed allowed-minus-admin-fee amount.
Trigger	Reading clsMedicalBill.TotalPaidAmt on a pending bill returned from a medical bill search.
Enforcement	clsMedicalBill.TotalPaidAmt
Outcome	Search result views do not display a misleading paid amount for bills that have not yet completed processing.
Confidence	Source-backed
Source	Business\SAIF.Business.Claim.MedicalBill\clsMedicalBill.vb — TotalPaidAmt

---

BR-MB-020: Audit and EOB detail retrieval is suppressed for bulk print views

Field	Value
Statement	When SuppressAuditDetail is set on a bill or propagated across a bill collection, lazy retrieval of audit services, EOB notes, and adjustment descriptions is skipped for the affected bill(s).
Trigger	clsMedicalBillCollection.SuppresAuditDetail setter (propagates to each item) or clsMedicalBill.SuppressAuditDetail directly.
Enforcement	clsMedicalBill.AuditServices, clsMedicalBill.EOBNotes, clsMedicalBill.AuditDescriptions, clsMedicalBillCollection.AuditDescriptions
Outcome	Avoids per-bill audit-detail round trips when printing bill search result reports.
Confidence	Source-backed
Source	Business\SAIF.Business.Claim.MedicalBill\clsMedicalBill.vb — SuppressAuditDetail, AuditServices, EOBNotes; Business\SAIF.Business.Claim.MedicalBill\clsMedicalBillCollection.vb — SuppresAuditDetail

---

BR-MB-021: Worker name is masked for confidential claims

Field	Value
Statement	WorkerName returns ** Confidential ** instead of the formatted worker name when the caller is internal (or is flagged as a SAIF employee) and the claim reports a worker conflict.
Trigger	Reading clsMedicalBill.WorkerName.
Enforcement	clsMedicalBill.WorkerName
Outcome	Confidential worker identity is withheld from views that would otherwise expose it.
Confidence	Source-backed
Source	Business\SAIF.Business.Claim.MedicalBill\clsMedicalBill.vb — WorkerName

---

BR-PROC-001: Service adjustments are sorted so code FT appears first, PA appears last, and all othe

Field	Value
Statement	Service adjustments are sorted so code FT appears first, PA appears last, and all other codes sort in the middle.
Trigger	CASE adj.AUDIT_ADJUSTMENT_CODE WHEN FT THEN 0 WHEN PA THEN 999 ELSE 1 END.
Enforcement	PK82396_MEDICAL_BILLS.GetServiceAdjustments
Outcome	Consumers receive a stable adjustment ordering for the bill audit UI.
Confidence	Source-backed
Source	PK82396_MEDICAL_BILLS.GetServiceAdjustments

---

BR-PROC-002: Service descriptions prefer bill service description text and fall back to generic drug na

Field	Value
Statement	Service descriptions prefer bill service description text and fall back to generic drug name when the service code is a national drug code.
Trigger	NVL(CD.SERVICE_DESCR_TEXT, DRG.GENERIC_NAME) with date-effective joins.
Enforcement	PK82396_MEDICAL_BILLS.GetAuditServices
Outcome	Audit-service retrieval returns the most specific available description.
Confidence	Source-backed
Source	PK82396_MEDICAL_BILLS.GetAuditServices

---

BR-PROC-003: EOB note retrieval is always restricted to the requested bill identifier

Field	Value
Statement	EOB note retrieval is always restricted to the requested bill identifier.
Trigger	WHERE bill_id = inBillId.
Enforcement	PK82396_MEDICAL_BILLS.GetEOBNotes
Outcome	Callers only receive note rows for the current medical bill.
Confidence	Source-backed
Source	PK82396_MEDICAL_BILLS.GetEOBNotes

Notes

• Procedure-derived rules are mirrored here so claim-domain readers do not have to open procedure pages to see active constraints.
• Rules without BOF rule attributes are enforced by lifecycle methods, helper methods, or stored-procedure contracts.

Related documentation

• Index
• Overview
• Architecture
• Dependencies
• Operations and processes
• Database tables
• SQL catalog
• Procedures
• Security and authorization
• API reference

Sources

• Business\SAIF.Business.Claim.MedicalBill\clsMedicalBill.vb
• Business\SAIF.Business.Claim.MedicalBill\clsMedicalBillCollection.vb
• Business\SAIF.Business.Claim.MedicalBill\clsAuditServiceCollection.vb
• Business\SAIF.Business.Claim.MedicalBill\clsEOBNoteCollection.vb
• Business\SAIF.Business.Claim.MedicalBill\clsServiceAdjustmentCollection.vb
• Business\SAIF.Business.Claim.MedicalBill\clsNationalDrug.vb
• Business\SAIF.Business.Claim.MedicalBill\clsNationalDrugPrice.vb
• Business\SAIF.Business.Claim.MedicalBill\clsNdcPriceHistory.vb
• Business\SAIF.Business.Claim.MedicalBill\packages.config
• Business\SAIF.Business.Claim.MedicalBill\SAIF.BOF.Business.Claim.MedicalBill.nuspec
• Business\SAIF.Business.Claim.MedicalBill\Pipelines\build-vars.yml
• Business\SAIF.Business.Claim.MedicalBill\clsAdjustmentCode.vb
• Business\SAIF.Business.Claim.MedicalBill\clsAdjustmentCodeCollection.vb
• Business\SAIF.Business.Claim.MedicalBill\clsNationalDrugPriceCollection.vb
• Business\SAIF.Business.Claim.MedicalBill\clsNdcPriceHistoryCollection.vb
• Business\SAIF.Business.Claim.MedicalBill\clsBillSearchCriteria.vb