SAIF.Data business rules¶

This page captures business rules enforced by this library's query providers, HTTP clients, and model helpers.

SD-BR-001 Data client configuration created per SystemType and SystemName¶

Field	Value
Statement	Data client configuration is created per SystemType/SystemName and may be customized by caller action
Trigger	`AddDataClients` call
Enforcement	`ContainerBuilderExtensions.AddDataClients`
Outcome	Singleton config registered
Source	`Data/SAIF.Data/Configuration/ContainerBuilderExtensions.cs`
Operation(s)	Register data clients

SD-BR-002 GET responses cached via Polly unless caching disabled¶

Field	Value
Statement	GET responses are cached via Polly for `MaxCacheDuration` (default 30 s, originating `SAIF.Data.Guidewire`/`DataClientConfiguration`) unless `UseCache` is false
Trigger	Cached GET/POST
Enforcement	`HttpClientBase.GetAsyncCached<T>`
Outcome	Cached or NoOp execution
Source	`Data/SAIF.Data/Clients/HttpClientBase.cs`
Operation(s)	Register data clients, Authenticated/cached HTTP GET

SD-BR-003 Service base URL must come from environment configuration¶

Field	Value
Statement	Service base URL must come from environment configuration key (`UrlKey`)
Trigger	Client construction
Enforcement	`HttpClientBase` (lazy client)
Outcome	BaseAddress set
Source	`Data/SAIF.Data/Clients/HttpClientBase.cs`
Operation(s)	Authenticated/cached HTTP GET, Get e-bill EOB extract

SD-BR-004 Credentials retrieved from secure setting decrypted with system hash¶

Field	Value
Statement	Credentials retrieved from secure setting `AuthKey` decrypted with system hash; value format `user\\|password`
Trigger	`AuthKey` set
Enforcement	`HttpClientBase` handler creation
Outcome	NetworkCredential applied
Source	`Data/SAIF.Data/Clients/HttpClientBase.cs`
Operation(s)	Authenticated/cached HTTP GET, Get e-bill EOB extract

SD-BR-010 Claim is valid only if CC API returns HTTP 200¶

Field	Value
Statement	Claim is valid only if the Guidewire CC API returns HTTP 200
Trigger	`ValidateClaim`
Enforcement	`CCClaimApiService.ValidateClaim`
Outcome	true/false
Source	`Data/SAIF.Data/Queries/Claims/CCClaimApiService.cs`
Operation(s)	Validate claim / get claim

SD-BR-011 Id of 0 returns null without calling the API¶

Field	Value
Statement	An id of 0 returns null without calling the API
Trigger	`GetClaim`/`GetWorker*`
Enforcement	`CCClaimApiService`
Outcome	null
Source	`Data/SAIF.Data/Queries/Claims/CCClaimApiService.cs`
Operation(s)	Validate claim / get claim

SD-BR-012 Latest MCO selection precedence¶

Field	Value
Statement	Latest MCO = effective date on or before today and (expiration on or after today or unset), newest first; empty location if none match
Trigger	`GetLatestMco`
Enforcement	`CCClaimApiService.GetLatestMco`
Outcome	`McoLocation`
Source	`Data/SAIF.Data/Queries/Claims/CCClaimApiService.cs`
Operation(s)	Get latest MCO

SD-BR-013 Bill queue HTTP status mapping¶

Field	Value
Statement	Bill queue HTTP status mapping (200/404/500) to ReturnCode/ImageId; restore returns 1/0
Trigger	Queue calls
Enforcement	`CCClaimApiService.GetNextClaimBillFromQueue`, `RestoreClaimBillToQueue`
Outcome	Result codes
Source	`Data/SAIF.Data/Queries/Claims/CCClaimApiService.cs`
Operation(s)	Bill queue processing

SD-BR-020 Employee has claim security override only when override row matches claim and employee within EffDate to ExpDate window¶

Field	Value
Statement	Employee has a claim security override only when an override row matches the claim and employee and today falls within [EffDate, ExpDate]
Trigger	Access check
Enforcement	`ClaimSecurityOverrideProvider.HasClaimSecurityOverride`
Outcome	bool (data-level authorization)
Source	`Data/SAIF.Data/Queries/Claims/ClaimSecurityOverrideProvider.cs`
Operation(s)	Claim security override check
Tables	CL_SECURITY_OVERRIDE
SQL	SQL-073

SD-BR-021 Recoverable balance sums outstanding amount for non-amended overpayments¶

Field	Value
Statement	Recoverable balance = sum of OutstandingAmount for the worker, not amended, status 1 or 3
Trigger	Balance request
Enforcement	`OverpaymentQueryProvider.GetRecoverableBalance`
Outcome	decimal
Source	`Data/SAIF.Data/Queries/Claims/OverpaymentQueryProvider.cs`
Operation(s)	Recoverable overpayment balance
Tables	CL_OVERPAYMENT, CL_CLAIM_PERSON
SQL	SQL-190

SD-BR-030 Nurse review required if any audited service code flags it¶

Field	Value
Statement	Nurse review is required if any audited service's service code flags it
Trigger	Audit review
Enforcement	`AuditQueryProvider.IsNurseReviewRequired`
Outcome	bool
Source	`Data/SAIF.Data/Queries/AuditQueryProvider.cs`
Operation(s)	Bill audit evaluation
Tables	CBP_AUDIT, CBP_BILL, CBP_NATIONAL_DRUG, CBP_SERVICE_CODE, CBP_AUDITED_SERVICE, CBP_SERVICE_PHYSICAL_MEDICINE, CBP_AUDIT_ADJUSTMENT_TYPE
SQL	SQL-013, SQL-014, SQL-015, SQL-016, SQL-017, SQL-018, SQL-019, SQL-020, SQL-021, SQL-022

SD-BR-031 Duplicate services excluded from count¶

Field	Value
Statement	Duplicate services (OriginalBillCode "D") are excluded from the count
Trigger	Count
Enforcement	`AuditQueryProvider.GetNonDuplicateServiceCount`
Outcome	int
Source	`Data/SAIF.Data/Queries/AuditQueryProvider.cs`
Operation(s)	Bill audit evaluation
Tables	CBP_AUDIT, CBP_BILL, CBP_NATIONAL_DRUG, CBP_SERVICE_CODE, CBP_AUDITED_SERVICE, CBP_SERVICE_PHYSICAL_MEDICINE, CBP_AUDIT_ADJUSTMENT_TYPE
SQL	SQL-013, SQL-014, SQL-015, SQL-016, SQL-017, SQL-018, SQL-019, SQL-020, SQL-021, SQL-022

SD-BR-032 Unset thru-date treated as open-ended¶

Field	Value
Statement	An unset thru-date is treated as open-ended (`DateTime.MaxValue`)
Trigger	Service query
Enforcement	`AuditQueryProvider.GetServices`
Outcome	Date range
Source	`Data/SAIF.Data/Queries/AuditQueryProvider.cs`
Operation(s)	Bill audit evaluation
Tables	CBP_AUDIT, CBP_BILL, CBP_NATIONAL_DRUG, CBP_SERVICE_CODE, CBP_AUDITED_SERVICE, CBP_SERVICE_PHYSICAL_MEDICINE, CBP_AUDIT_ADJUSTMENT_TYPE
SQL	SQL-013, SQL-014, SQL-015, SQL-016, SQL-017, SQL-018, SQL-019, SQL-020, SQL-021, SQL-022

SD-BR-033 Audit note save allowed only under optimistic concurrency match¶

Field	Value
Statement	Audit note save is allowed only if Id and UpdateNumber still match (optimistic concurrency); new notes are always allowed
Trigger	Save
Enforcement	`AuditNoteQueryProvider.IsAuditNoteNoContention`
Outcome	bool
Source	`Data/SAIF.Data/Queries/Claims/AuditNoteQueryProvider.cs`
Operation(s)	Audit note concurrency check
Tables	CBP_NOTE
SQL	SQL-012

SD-BR-034 Bill entry source classification¶

Field	Value
Statement	Bill entry source "R" means regenerated and "E" means e-bill
Trigger	Bill queries
Enforcement	`BillQueryProvider`
Outcome	Classification
Source	`Data/SAIF.Data/Queries/Claims/BillQueryProvider.cs`
Operation(s)	Bill queries
Tables	CBP_BILL, CBP_BILL_TYPE_CODE, CBP_BILL_STATUS_CODE, CBP_BILL_STATUS, CBP_BILL_ENTRY_SOURCE_CODE, CBP_AUDITED_SERVICE, CBP_DIAGNOSIS, CBP_DIAGNOSIS_TYPE_CODE
SQL	SQL-024, SQL-025, SQL-026, SQL-027, SQL-028, SQL-029, SQL-030, SQL-031, SQL-032, SQL-033

SD-BR-035 Bill allowed total treats null as zero¶

Field	Value
Statement	Bill allowed total treats a null amount as 0
Trigger	Totals
Enforcement	`BillQueryProvider.GetBillAmounts`
Outcome	decimal
Source	`Data/SAIF.Data/Queries/Claims/BillQueryProvider.cs`
Operation(s)	Bill queries
Tables	CBP_BILL, CBP_BILL_TYPE_CODE, CBP_BILL_STATUS_CODE, CBP_BILL_STATUS, CBP_BILL_ENTRY_SOURCE_CODE, CBP_AUDITED_SERVICE, CBP_DIAGNOSIS, CBP_DIAGNOSIS_TYPE_CODE
SQL	SQL-024, SQL-025, SQL-026, SQL-027, SQL-028, SQL-029, SQL-030, SQL-031, SQL-032, SQL-033

SD-BR-036 Service code current only when expiration date is null¶

Field	Value
Statement	A service code is current only when ExpirationDate is null
Trigger	Lookup
Enforcement	`BillQueryProvider.GetCbpServiceCodeNotExpired`
Outcome	Service code
Source	`Data/SAIF.Data/Queries/Claims/BillQueryProvider.cs`
Operation(s)	Bill queries
Tables	CBP_BILL, CBP_BILL_TYPE_CODE, CBP_BILL_STATUS_CODE, CBP_BILL_STATUS, CBP_BILL_ENTRY_SOURCE_CODE, CBP_AUDITED_SERVICE, CBP_DIAGNOSIS, CBP_DIAGNOSIS_TYPE_CODE
SQL	SQL-024, SQL-025, SQL-026, SQL-027, SQL-028, SQL-029, SQL-030, SQL-031, SQL-032, SQL-033

SD-BR-040 Physician without facility is invalid¶

Field	Value
Statement	A physician without a facility is invalid; location selection follows a facility/physician precedence
Trigger	Lookup
Enforcement	`ClaimQueryProvider.GetAttendingPhysician`
Outcome	Location or `ApplicationException`
Source	`Data/SAIF.Data/Queries/Claims/ClaimQueryProvider.cs`
Operation(s)	Attending physician resolution
Tables	PROVIDER_LOCATION
SQL	SQL-057

SD-BR-041 Latest claim status falls back to WCD status when no history¶

Field	Value
Statement	Latest claim status falls back to the WCD status when there is no history
Trigger	Lookup
Enforcement	`ClaimQueryProvider.GetLatestClaimStatus`
Outcome	Status
Source	`Data/SAIF.Data/Queries/Claims/ClaimQueryProvider.cs`
Operation(s)	Claim status and compensability
Tables	CL_CLAIM_STATUS_ACTIVITY, CL_CLAIM_REQUEST_DECISION, claim_status_code
SQL	SQL-058, SQL-061, SQL-062, SQL-063, SQL-071

SD-BR-042 Compensability status mapping¶

Field	Value
Statement	Compensability "Claim Denied" maps to "D"; otherwise the first letter, upper-cased
Trigger	Lookup
Enforcement	`ClaimQueryProvider.GetCompensabilityStatus`
Outcome	Code
Source	`Data/SAIF.Data/Queries/Claims/ClaimQueryProvider.cs`
Operation(s)	Claim status and compensability
Tables	CL_CLAIM_STATUS_ACTIVITY, CL_CLAIM_REQUEST_DECISION, claim_status_code
SQL	SQL-058, SQL-061, SQL-062, SQL-063, SQL-071

SD-BR-043 Original acceptance requires request type I with decision A¶

Field	Value
Statement	Original acceptance = request type "I" with decision "A"
Trigger	Lookup
Enforcement	`ClaimQueryProvider.GetOriginalAcceptance`
Outcome	Decision
Source	`Data/SAIF.Data/Queries/Claims/ClaimQueryProvider.cs`
Operation(s)	Claim status and compensability
Tables	CL_CLAIM_STATUS_ACTIVITY, CL_CLAIM_REQUEST_DECISION, claim_status_code
SQL	SQL-058, SQL-061, SQL-062, SQL-063, SQL-071

SD-BR-044 MCO enrollment date only when eligibility is Y¶

Field	Value
Statement	MCO enrollment date is returned only when the eligibility status is "Y" (obsolete)*
Trigger	Lookup
Enforcement	`ClaimQueryProvider.GetMcoEnrollmentDate`
Outcome	Date or null
Source	`Data/SAIF.Data/Queries/Claims/ClaimQueryProvider.cs`
Operation(s)	Claim status and compensability

SD-BR-045 Retired WCIS claim activity queries are unsupported¶

Field	Value
Statement	Retired WCIS claim-activity queries are unsupported and throw
Trigger	Call
Enforcement	`ClaimQueryProvider.GetWorkReleaseStatus`, `GetLatestClaimTypeActivity`, `GetClaimTypeActivity`, `GetClaimStatusActivity`, `GetClaimRequestDecisions`
Outcome	`NotImplementedException`
Source	`Data/SAIF.Data/Queries/Claims/ClaimQueryProvider.cs`
Operation(s)	Claim status and compensability

SD-BR-046 Time-loss financials filtered by check status and category¶

Field	Value
Statement	Time-loss financials = payments with issued/cleared check status and temporary-disability or voc-TD category, excluding legal-fee line items
Trigger	Query
Enforcement	`ClaimQueryProvider.GetFinancialTransactionsQuery`
Outcome	Filtered list
Source	`Data/SAIF.Data/Queries/Claims/ClaimQueryProvider.cs`
Operation(s)	Claim financial transactions

SD-BR-047 Guidewire category code must map to a legacy category¶

Field	Value
Statement	A Guidewire category code must map to a legacy category; an unmapped code throws
Trigger	Translate
Enforcement	`ClaimQueryProvider.TranslateCategoryCodeFromGw`
Outcome	Code or exception
Source	`Data/SAIF.Data/Queries/Claims/ClaimQueryProvider.cs`
Operation(s)	Claim financial transactions

SD-BR-048 Guidewire vocational status mapped to legacy code¶

Field	Value
Statement	A Guidewire vocational status code is mapped to a legacy code
Trigger	Translate
Enforcement	`ClaimQueryProvider.TranslateGWVocationalStatusCodeToLegacy`
Outcome	Code
Source	`Data/SAIF.Data/Queries/Claims/ClaimQueryProvider.cs`
Operation(s)	Claim financial transactions

SD-BR-049 Missing tax id identified by a single space¶

Field	Value
Statement	A missing tax id is identified by `PrimaryTaxId` equal to a single space
Trigger	Query
Enforcement	`ClaimQueryProvider.GetClaimsMissingTaxId`
Outcome	List
Source	`Data/SAIF.Data/Queries/Claims/ClaimQueryProvider.cs`
Operation(s)	Claim data-quality queries
Tables	CL_INJURY_CLAIM, CL_CLAIM_PERSON
SQL	SQL-060

SD-BR-050 E-bill status and assignment-rule code sets¶

Field	Value
Statement	E-bill status codes (ACCPT, ASSGN, COMPL, DLOAD, EOBDS, EOBRJ, IMAGE, INDEX, NEW, PEND, REJCT, SETUP, EXTR) and assignment rules (CONF, PROV, CLAIM, CLEAN) are fixed constants
Trigger	Queries
Enforcement	`EbillQueryProvider` constants
Outcome	Classification
Source	`Data/SAIF.Data/Queries/Claims/Ebilling/EbillQueryProvider.cs`
Operation(s)	E-bill processing queries
Tables	EBILL, EBILL_BATCH, EBILL_CLEARINGHOUSE, CBP_BILL, CBP_BILL_STATUS_CODE, EBILL_EOB, EBILL_RESPONSE_SET, EBILL_PATIENT
SQL	SQL-114, SQL-115, SQL-116, SQL-117, SQL-118, SQL-119, SQL-120, SQL-121, SQL-122, SQL-123

SD-BR-051 Bill included in clearinghouse response file by response-batch state¶

Field	Value
Statement	A bill is included in the clearinghouse response file if it has no first response batch, or no last response batch and its status is not "PEN"
Trigger	Response file build
Enforcement	`EbillQueryProvider.GetBillsForResponseFileForClearinghouse`
Outcome	List
Source	`Data/SAIF.Data/Queries/Claims/Ebilling/EbillQueryProvider.cs`
Operation(s)	E-bill processing queries
Tables	EBILL, EBILL_BATCH, EBILL_CLEARINGHOUSE, CBP_BILL, CBP_BILL_STATUS_CODE, EBILL_EOB, EBILL_RESPONSE_SET, EBILL_PATIENT
SQL	SQL-114, SQL-115, SQL-116, SQL-117, SQL-118, SQL-119, SQL-120, SQL-121, SQL-122, SQL-123

SD-BR-052 Multiple prescription numbers mark all NDC lines as compound drug¶

Field	Value
Statement	More than one distinct prescription number among NDC lines marks all of those lines as compound drug
Trigger	Bill processing
Enforcement	`EbillQueryProvider.SetCompoundDrugForAllServiceLinesForTheBill`
Outcome	Flags set
Source	`Data/SAIF.Data/Queries/Claims/Ebilling/EbillQueryProvider.cs`
Operation(s)	E-bill processing queries
Tables	EBILL, EBILL_BATCH, EBILL_CLEARINGHOUSE, CBP_BILL, CBP_BILL_STATUS_CODE, EBILL_EOB, EBILL_RESPONSE_SET, EBILL_PATIENT
SQL	SQL-114, SQL-115, SQL-116, SQL-117, SQL-118, SQL-119, SQL-120, SQL-121, SQL-122, SQL-123

SD-BR-053 E-bill batch type classification¶

Field	Value
Statement	Batch type 837 is e-bill and 835 is payment advice
Trigger	Batch queries
Enforcement	`EbillBatchQueryProvider`
Outcome	Filter
Source	`Data/SAIF.Data/Queries/Claims/Ebilling/EbillBatchQueryProvider.cs`
Operation(s)	E-bill processing queries
Tables	EBILL_BATCH, EBILL_CLEARINGHOUSE, EBILL_BATCH_TYPE_CODE, EBILL_BATCH_STATUS_CODE
SQL	SQL-078, SQL-079, SQL-080, SQL-081, SQL-082, SQL-083, SQL-084, SQL-085, SQL-086, SQL-087

SD-BR-054 Zero-pay EOB candidate criteria¶

Field	Value
Statement	Zero-pay EOB candidates require status COM, an existing audit, an allowed-amount sum of 0, and no existing EOB
Trigger	EOB build
Enforcement	`EbillEobQueryProvider.GetCompletedZeroPaymentBillsForEob`
Outcome	List
Source	`Data/SAIF.Data/Queries/Claims/Ebilling/EbillEobQueryProvider.cs`
Operation(s)	E-bill processing queries
Tables	EBILL, CBP_BILL, CBP_BILL_STATUS_CODE, CBP_AUDIT, EBILL_EOB, EBILL_BATCH, EBILL_CLEARINGHOUSE
SQL	SQL-100, SQL-101, SQL-102, SQL-103

SD-BR-055 DRG code identified by health information type¶

Field	Value
Statement	The DRG code is the health-information entry with type "DR"
Trigger	Lookup
Enforcement	`EbillHealthInformationQueryProvider.GetDrgCode`
Outcome	Code
Source	`Data/SAIF.Data/Queries/Claims/Ebilling/EbillHealthInformationQueryProvider.cs`
Operation(s)	E-bill processing queries
Tables	EBILL_HEALTH_INFORMATION, EBILL_HEALTH_INFO_TYPE_CODE, EBILL
SQL	SQL-104, SQL-105, SQL-106

SD-BR-056 Active clearinghouse has a null end date¶

Field	Value
Statement	The active clearinghouse is the one where `EndDate` is null
Trigger	Lookup
Enforcement	`EbillingQueryProvider.GetClearinghouse`
Outcome	Clearinghouse
Source	`Data/SAIF.Data/Queries/Claims/EbillingQueryProvider.cs`
Operation(s)	E-bill processing queries
Tables	EBILL_CLEARINGHOUSE
SQL	SQL-142

SD-BR-060 Case-to-claim resolution precedence¶

Field	Value
Statement	Case-to-claim resolution tries the CC API first, then falls back to WCB, BRB, DCBS, OALJ, and OWCP numbers in order
Trigger	Lookup
Enforcement	`LegalQueryProvider.GetClaimIdForCase`
Outcome	Claim id
Source	`Data/SAIF.Data/Queries/Legal/LegalQueryProvider.cs`
Operation(s)	Legal case queries
Tables	LEGAL_CASE, CASE_COST, LEGAL_BILL, SUBPOENA, APPEAL, ADP_EMPLOYEE, CASE_STATUS_CODE, ATTORNEY_PROFILE
SQL	SQL-152, SQL-153, SQL-154, SQL-155, SQL-156, SQL-157, SQL-158, SQL-159, SQL-160, SQL-161

SD-BR-061 Preferred employee name takes precedence¶

Field	Value
Statement	The preferred employee name takes precedence over the legal name
Trigger	Lookup
Enforcement	`LegalQueryProvider.GetAdpEmployeeName`
Outcome	Name
Source	`Data/SAIF.Data/Queries/Legal/LegalQueryProvider.cs`
Operation(s)	Legal case queries
Tables	LEGAL_CASE, CASE_COST, LEGAL_BILL, SUBPOENA, APPEAL, ADP_EMPLOYEE, CASE_STATUS_CODE, ATTORNEY_PROFILE
SQL	SQL-152, SQL-153, SQL-154, SQL-155, SQL-156, SQL-157, SQL-158, SQL-159, SQL-160, SQL-161

SD-BR-062 Location code and contact-type precedence¶

Field	Value
Statement	Location codes BUS/POL/CLM and contact-type precedence (CLM, then CON) determine the resolved location; Oregon business locations require `State == "OR"`
Trigger	Lookup
Enforcement	`LocationQueryProvider`
Outcome	Location
Source	`Data/SAIF.Data/Queries/Locations/LocationQueryProvider.cs`
Operation(s)	Location lookups
Tables	LOCATION, CONTACT, OFFICE_CODE
SQL	SQL-167, SQL-168, SQL-169, SQL-170, SQL-171, SQL-172, SQL-173, SQL-174, SQL-175

SD-BR-070 Output document status code set¶

Field	Value
Statement	Output document status codes are PEND, HELD, DELE, and RELE
Trigger	Queries
Enforcement	`OutputDocumentQueryProvider`
Outcome	Filter
Source	`Data/SAIF.Data/Queries/OutputDocuments/OutputDocumentQueryProvider.cs`
Operation(s)	Output document queries
Tables	document_status_code, POLICY, batch_process_log, policy_output_document, output_document_type_code, output_document_category_code
SQL	SQL-181, SQL-182, SQL-183, SQL-184, SQL-185, SQL-186, SQL-187, SQL-188, SQL-189

SD-BR-071 Document date defaults from batch process log¶

Field	Value
Statement	The document date comes from `BatchProcessLog`, defaulting to today when absent
Trigger	Query
Enforcement	`OutputDocumentQueryProvider`
Outcome	Date
Source	`Data/SAIF.Data/Queries/OutputDocuments/OutputDocumentQueryProvider.cs`
Operation(s)	Output document queries
Tables	document_status_code, POLICY, batch_process_log, policy_output_document, output_document_type_code, output_document_category_code
SQL	SQL-181, SQL-182, SQL-183, SQL-184, SQL-185, SQL-186, SQL-187, SQL-188, SQL-189

SD-BR-072 Agency sees only agency-viewable and inbox-viewable documents¶

Field	Value
Statement	An agency sees only documents flagged agency-viewable or agency-inbox-viewable
Trigger	Query
Enforcement	`PolicyOutputDocumentExtensions.AgencyViewable`, `AgencyInboxViewable`
Outcome	Filter
Source	`Data/SAIF.Data/Queries/OutputDocuments/PolicyOutputDocumentExtensions.cs`
Operation(s)	Output document queries

SD-BR-073 Blank or ALL category applies no filter¶

Field	Value
Statement	A category of "ALL" or blank applies no filter
Trigger	Query
Enforcement	`PolicyOutputDocumentExtensions.ForCategory`
Outcome	Filter
Source	`Data/SAIF.Data/Queries/OutputDocuments/PolicyOutputDocumentExtensions.cs`
Operation(s)	Output document queries

SD-BR-074 Policy-or-account filter returns policy docs only while account docs remain unused¶

Field	Value
Statement	The policy-or-account filter returns only policy documents; account documents are computed but the concatenation that would include them is unused, a probable defect*
Trigger	Query
Enforcement	`PolicyOutputDocumentExtensions.ForPolicyOrAccount`
Outcome	Filter
Source	`Data/SAIF.Data/Queries/OutputDocuments/PolicyOutputDocumentExtensions.cs`
Operation(s)	Output document queries

SD-BR-075 Child documents only retrievable for a released parent¶

Field	Value
Statement	Child documents are only retrievable when the parent document is released; otherwise the call throws
Trigger	Query
Enforcement	`OutputDocumentQueryProvider.GetReleasedAgencyViewableChildOutputDocuments`
Outcome	List or exception
Source	`Data/SAIF.Data/Queries/OutputDocuments/OutputDocumentQueryProvider.cs`
Operation(s)	Output document queries
Tables	document_status_code, POLICY, batch_process_log, policy_output_document, output_document_type_code, output_document_category_code
SQL	SQL-181, SQL-182, SQL-183, SQL-184, SQL-185, SQL-186, SQL-187, SQL-188, SQL-189

SD-BR-080 Provider identity relationship and address code sets¶

Field	Value
Statement	Provider identity codes NPI/ONPI, relationship type WRK, and address types PAY/PHY/COR are applied as fixed filters
Trigger	Queries
Enforcement	`ProviderQueryProvider`
Outcome	Filter
Source	`Data/SAIF.Data/Queries/Providers/ProviderQueryProvider.cs`
Operation(s)	Provider queries
Tables	PROVIDER_ADDRESS, PROVIDER, PROVIDER_TAX_ID, PROVIDER_LOCATION, CBP_BILL, CBP_BILL_STATUS_CODE, PROVIDER_IDENTITY
SQL	SQL-200, SQL-201, SQL-202, SQL-203, SQL-204, SQL-205, SQL-206, SQL-207, SQL-208, SQL-209

SD-BR-081 Provider updates stamped with a fixed audit user¶

Field	Value
Statement	Provider updates are stamped with the last-update user constant "CMN0140"
Trigger	Update
Enforcement	`ProviderQueryProvider`
Outcome	Audit user
Source	`Data/SAIF.Data/Queries/Providers/ProviderQueryProvider.cs`
Operation(s)	Provider queries

SD-BR-082 Dismissed bills excluded from provider location ids¶

Field	Value
Statement	Bills with status "DIS" are excluded from provider location ids
Trigger	Query
Enforcement	`ProviderQueryProvider.GetBillProviderLocationIds`
Outcome	List
Source	`Data/SAIF.Data/Queries/Providers/ProviderQueryProvider.cs`
Operation(s)	Provider queries
Tables	PROVIDER_ADDRESS, PROVIDER, PROVIDER_TAX_ID, PROVIDER_LOCATION, CBP_BILL, CBP_BILL_STATUS_CODE, PROVIDER_IDENTITY
SQL	SQL-200, SQL-201, SQL-202, SQL-203, SQL-204, SQL-205, SQL-206, SQL-207, SQL-208, SQL-209

SD-BR-083 Provider in MCO only within date window¶

Field	Value
Statement	A provider is in an MCO only within the MCO's effective/expiration date window
Trigger	Check
Enforcement	`ProviderQueryProvider.IsProviderInMco`
Outcome	bool
Source	`Data/SAIF.Data/Queries/Providers/ProviderQueryProvider.cs`
Operation(s)	Provider queries
Tables	PROVIDER_ADDRESS, PROVIDER, PROVIDER_TAX_ID, PROVIDER_LOCATION, CBP_BILL, CBP_BILL_STATUS_CODE, PROVIDER_IDENTITY
SQL	SQL-200, SQL-201, SQL-202, SQL-203, SQL-204, SQL-205, SQL-206, SQL-207, SQL-208, SQL-209

SD-BR-090 Superseded certificate holders excluded from search¶

Field	Value
Statement	Superseded certificate holders are excluded, and search runs a word match across name and address fields
Trigger	Search
Enforcement	`CertificateHolderQueryProvider`
Outcome	List
Source	`Data/SAIF.Data/Queries/Policies/Certificates/CertificateHolderProvider.cs`
Operation(s)	Other query providers
Tables	CERTIFICATE_HOLDER
SQL	SQL-051, SQL-052, SQL-053

SD-BR-091 Task codes compared case-insensitively¶

Field	Value
Statement	Task codes are matched case-insensitively
Trigger	Query
Enforcement	`TaskQueryProvider`
Outcome	Filter
Source	`Data/SAIF.Data/Queries/Tasks/TaskQueryProvider.cs`
Operation(s)	Other query providers
Tables	TASK_SOURCE_CODE, TASK_ACTION_CODE, TASK_PRIORITY_CODE, TASK_CATEGORY_CODE, TASK
SQL	SQL-231, SQL-232, SQL-233, SQL-234, SQL-235, SQL-236

SD-BR-092 Active support order has no termination date¶

Field	Value
Statement	An active support order is one with no termination date
Trigger	Count
Enforcement	`WorkerQueryProvider.GetActiveSupportOrderCount`
Outcome	int
Source	`Data/SAIF.Data/Queries/Claims/WorkerQueryProvider.cs`
Operation(s)	Other query providers
Tables	CL_CLAIM_SUPPORT_ORDER, CL_CLAIM_PERSON, cl_pref_contact_method_code, CL_INJURY_CLAIM
SQL	SQL-237, SQL-238, SQL-239

SD-BR-093 Active report record has a null expiration date¶

Field	Value
Statement	An active report record is one with a null `ExpirationDate`
Trigger	Query
Enforcement	`ReportQueryProvider`
Outcome	Filter
Source	`Data/SAIF.Data/Queries/Claims/Reports/ReportQueryProvider.cs`
Operation(s)	Other query providers
Tables	ATTENDING_PHYSICIAN, PROVIDER_LOCATION, CL_INJURY_CLAIM, CL_CLAIM_LEGAL_REPRESENTATIVE
SQL	SQL-218, SQL-219, SQL-220, SQL-221

SD-BR-094 MA code identifies medical audit payment type¶

Field	Value
Statement	The code "MA" identifies a medical-audit payment type
Trigger	Query
Enforcement	`PaymentsQueryProvider`
Outcome	Filter
Source	`Data/SAIF.Data/Queries/Payments/PaymentsQueryProvider.cs`
Operation(s)	Other query providers
Tables	PAYMENT_TRANSACTION_STAT, PAYMENT_TRANSACTION_TYPE_CODE
SQL	SQL-191, SQL-192, SQL-193

SD-BR-095 Medicare history match requires all fields equal¶

Field	Value
Statement	A Medicare beneficiary query history match requires all supplied fields to be equal
Trigger	Query
Enforcement	`MedicareQueryProvider`
Outcome	Match
Source	`Data/SAIF.Data/Queries/Claims/MedicareQueryProvider.cs`
Operation(s)	Other query providers
Tables	MEDICARE_BENEFICIARY_QUERY_BAT, MEDICARE_QUERY_HISTORY, MEDICARE_BENEFICIARY_QUERY
SQL	SQL-176, SQL-177, SQL-178, SQL-179, SQL-180

SD-BR-100 Child procedure and service ids auto-increment¶

Field	Value
Statement	Child procedure/service ids auto-increment when added to a bill
Trigger	Add child
Enforcement	`CbpBill.AddProcedure`, `CbpBill.AddService`
Outcome	Id assigned
Source	`Data/SAIF.Data/Model/Claims/Bills/CbpBill.cs`
Operation(s)	Model helper operations

SD-BR-101 Financial transaction detail must not be null¶

Field	Value
Statement	A financial transaction detail must not be null (enforced via the originating `SAIF.Framework.Core`/`Enforce` utility)
Trigger	Add detail
Enforcement	`FinancialTransaction.AddDetail`
Outcome	`ArgumentNullException`
Source	`Data/SAIF.Data/Model/Claims/Payments/FinancialTransaction.cs`
Operation(s)	Model helper operations

SD-BR-102 Subpoena classification helpers¶

Field	Value
Statement	Subpoena helpers classify witness type (Nonparties, OtherMedical, Parties), provider type (Claims, MedicalRecords), and zero-pay/no-mail status ("NOML" with a paid sum of 0)
Trigger	Evaluation
Enforcement	`Subpoena` properties (`IsWitnessType`, `IsProviderType`, `IsZeroPayNoMail`, `IsZeroPay`, `IsDoNotMail`)
Outcome	bool
Source	`Data/SAIF.Data/Model/Legal/Subpoenas/Subpoena.cs`
Operation(s)	Model helper operations

SD-BR-103 Claim cost category code lookups and aliases¶

Field	Value
Statement	Claim cost category codes (MED, TD, PPD, PTD, FTL, CHE, VSV, VTD, OTH) are fixed lookups; the descriptions "burial expenses" and "death benefits" map to FTL
Trigger	Lookup
Enforcement	`ClaimCostCategoryCode`
Outcome	Code
Source	`Data/SAIF.Data/Model/Claims/Payments/ClaimCostCategoryCode.cs`
Operation(s)	Model helper operations

SD-BR-104 Unknown show-only string defaults to Unread¶

Field	Value
Statement	An unrecognized show-only string defaults to `Unread`
Trigger	Conversion
Enforcement	`Enums.ConvertShowOnlyStringToEnum`
Outcome	Enum
Source	`Data/SAIF.Data/Model/OutputDocuments/Enums.cs`
Operation(s)	Model helper operations

Notes¶

Rule IDs follow the analyst's numbering scheme (SD-BR-NNN), grouped by originating query provider or operation, not strictly sequential.
Mark inferred statements with * and unknown statements with **. Do not use bold inline confidence labels.

Sources¶

Data/SAIF.Data/Configuration/ContainerBuilderExtensions.cs
Data/SAIF.Data/Clients/HttpClientBase.cs
Data/SAIF.Data/Clients/MedicalBillingApiService.cs
Data/SAIF.Data/Queries/Claims/CCClaimApiService.cs
Data/SAIF.Data/Queries/Claims/ClaimSecurityOverrideProvider.cs
Data/SAIF.Data/Queries/OverpaymentQueryProvider.cs
Data/SAIF.Data/Queries/AuditQueryProvider.cs
Data/SAIF.Data/Queries/Claims/AuditNoteQueryProvider.cs
Data/SAIF.Data/Queries/Claims/BillQueryProvider.cs
Data/SAIF.Data/Queries/Claims/ClaimQueryProvider.cs
Data/SAIF.Data/Queries/Claims/Ebilling/EbillQueryProvider.cs
Data/SAIF.Data/Queries/Claims/Ebilling/EbillBatchQueryProvider.cs
Data/SAIF.Data/Queries/Claims/Ebilling/EbillEobQueryProvider.cs
Data/SAIF.Data/Queries/Claims/Ebilling/EbillHealthInformationQueryProvider.cs
Data/SAIF.Data/Queries/Claims/Ebilling/EbillingQueryProvider.cs
Data/SAIF.Data/Queries/Legal/LegalQueryProvider.cs
Data/SAIF.Data/Queries/Policies/LocationQueryProvider.cs
Data/SAIF.Data/Queries/OutputDocuments/OutputDocumentQueryProvider.cs
Data/SAIF.Data/Queries/OutputDocuments/PolicyOutputDocumentExtensions.cs
Data/SAIF.Data/Queries/Providers/ProviderQueryProvider.cs
Data/SAIF.Data/Queries/Policies/Certificates/CertificateHolderProvider.cs
Data/SAIF.Data/Queries/Tasks/TaskQueryProvider.cs
Data/SAIF.Data/Queries/Claims/WorkerQueryProvider.cs
Data/SAIF.Data/Queries/Claims/Reports/ReportQueryProvider.cs
Data/SAIF.Data/Queries/PaymentsQueryProvider.cs
Data/SAIF.Data/Queries/MedicareQueryProvider.cs
Data/SAIF.Data/Model/Claims/Bills/CbpBill.cs
Data/SAIF.Data/Model/Claims/Payments/FinancialTransaction.cs
Data/SAIF.Data/Model/Legal/Subpoenas/Subpoena.cs

SAIF.Data business rules¶

SD-BR-001 Data client configuration created per SystemType and SystemName¶

SD-BR-002 GET responses cached via Polly unless caching disabled¶

SD-BR-003 Service base URL must come from environment configuration¶

SD-BR-004 Credentials retrieved from secure setting decrypted with system hash¶

SD-BR-010 Claim is valid only if CC API returns HTTP 200¶

SD-BR-011 Id of 0 returns null without calling the API¶

SD-BR-012 Latest MCO selection precedence¶

SD-BR-013 Bill queue HTTP status mapping¶

SD-BR-020 Employee has claim security override only when override row matches claim and employee within EffDate to ExpDate window¶

SD-BR-021 Recoverable balance sums outstanding amount for non-amended overpayments¶

SD-BR-030 Nurse review required if any audited service code flags it¶

SD-BR-031 Duplicate services excluded from count¶

SD-BR-032 Unset thru-date treated as open-ended¶

SD-BR-033 Audit note save allowed only under optimistic concurrency match¶

SD-BR-034 Bill entry source classification¶

SD-BR-035 Bill allowed total treats null as zero¶

SD-BR-036 Service code current only when expiration date is null¶

SD-BR-040 Physician without facility is invalid¶

SD-BR-041 Latest claim status falls back to WCD status when no history¶

SD-BR-042 Compensability status mapping¶

SD-BR-043 Original acceptance requires request type I with decision A¶

SD-BR-044 MCO enrollment date only when eligibility is Y¶

SD-BR-045 Retired WCIS claim activity queries are unsupported¶

SD-BR-046 Time-loss financials filtered by check status and category¶

SD-BR-047 Guidewire category code must map to a legacy category¶

SD-BR-048 Guidewire vocational status mapped to legacy code¶

SD-BR-049 Missing tax id identified by a single space¶

SD-BR-050 E-bill status and assignment-rule code sets¶

SD-BR-051 Bill included in clearinghouse response file by response-batch state¶

SD-BR-052 Multiple prescription numbers mark all NDC lines as compound drug¶

SD-BR-053 E-bill batch type classification¶

SD-BR-054 Zero-pay EOB candidate criteria¶

SD-BR-055 DRG code identified by health information type¶

SD-BR-056 Active clearinghouse has a null end date¶

SD-BR-060 Case-to-claim resolution precedence¶

SD-BR-061 Preferred employee name takes precedence¶

SD-BR-062 Location code and contact-type precedence¶

SD-BR-070 Output document status code set¶

SD-BR-071 Document date defaults from batch process log¶

SD-BR-072 Agency sees only agency-viewable and inbox-viewable documents¶

SD-BR-073 Blank or ALL category applies no filter¶

SD-BR-074 Policy-or-account filter returns policy docs only while account docs remain unused¶

SD-BR-075 Child documents only retrievable for a released parent¶

SD-BR-080 Provider identity relationship and address code sets¶

SD-BR-081 Provider updates stamped with a fixed audit user¶

SD-BR-082 Dismissed bills excluded from provider location ids¶

SD-BR-083 Provider in MCO only within date window¶

SD-BR-090 Superseded certificate holders excluded from search¶

SD-BR-091 Task codes compared case-insensitively¶

SD-BR-092 Active support order has no termination date¶

SD-BR-093 Active report record has a null expiration date¶

SD-BR-094 MA code identifies medical audit payment type¶

SD-BR-095 Medicare history match requires all fields equal¶

SD-BR-100 Child procedure and service ids auto-increment¶

SD-BR-101 Financial transaction detail must not be null¶

SD-BR-102 Subpoena classification helpers¶

SD-BR-103 Claim cost category code lookups and aliases¶

SD-BR-104 Unknown show-only string defaults to Unread¶

Notes¶

Related documentation¶

Sources¶