Category guide · 837P verify · evidence graph

How to verify an 837P claim against clinical evidence

POST a proposed professional claim with operative or progress note text. PrismClaim returns ACCEPT, REVIEW, or REFUSE with evidence_coverage, structured violations, and a versioned claim_hash — not a clearinghouse submission.

Open the PrismClaim landing Verify API Dashboard verify form

What you send

Inline clinical_note_text plus a proposed_claim object (CPT, ICD-10, laterality, units). Proposed Mode treats the client payload as authoritative; candidate extraction from the note is untrusted and used only for divergence checks.

Pipeline (v0.1 hosted slice)

PrismGuard

Note text passes a fail-closed guard before extraction (same pattern as PrismSQL ingress).

Policy YAML

Deterministic bundling and laterality rules — extensible bundles, not full national NCCI/LCD in v0.1.

Evidence graph

Coverage ratio and grounding status per field. UNGROUNDED spans surface in violations.

No auto-correct

Proposed vs extracted conflict → REVIEW + escalation_id. Humans resolve via API or dashboard.

Call the hosted verify API

POST /api/prismclaim/v1/claims/verify
Authorization: Bearer <JWT>
Content-Type: application/json

{
  "encounter_id": "enc_982431a",
  "clinical_note_text": "Operative report: Primary total left knee arthroplasty (CPT 27447)...",
  "proposed_claim": {
    "cpt_code": "27447",
    "icd10_code": "M17.12",
    "laterality": "RT"
  }
}

Outcomes

Decision	Meaning	Audit record
ACCEPT	Evidence and policy pass automated checks	`claim_hash_v1`
REVIEW	Human clearance required (conflict, low coverage, policy REVIEW tier)	Escalation + optional `claim_hash_v2` after resolve
REFUSE	Hard block — do not release to clearinghouse	Violations + hash for appeals packet

What v0.1 does not claim

Not institutional 837I or dental claims
Not SOC 2 certified — hashes support payer review, not compliance certification
Not VectorPrism medical ontology at production scale (stub adapter with honest gaps)
Not batch multi-claim ingress yet — single verify supports inline text or storage URIs (https presigned preferred)

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