{"version":"0.38.0","built_at":"2026-10-24T19:53:00.313Z","license":"CC BY 4.0 © Mike Reams","canonical":"https://catalog.mikereams.com","capability":{"id":"BC-1870.60","name":"Payment Integrity","level":2,"parent_id":"BC-1870","l1_id":"BC-1870","industry":"healthcare","macro_id":null,"path":["Health Plan Operations","Payment Integrity"],"description":"Pay each claim once, at the right amount and only when the plan truly owes it, by catching errors, fraud, waste and abuse before payment where possible, recovering overpayments after, and pursuing other parties who should pay first. Employee misconduct is compliance.","aliases":["Program Integrity","Cost Containment","Payment Accuracy"],"in_scope":["Prepayment claim edits and reviews","Postpayment audits and overpayment recovery","Fraud, waste and abuse investigations","Coordination of benefits and subrogation"],"out_of_scope":["Coding compliance audits on the provider side (see BC-1840.20)","Capturing a patient's other coverage at registration (see BC-1810.30)","Employee ethics and conduct (see BC-140.30)","Litigation against providers or members (see BC-150.40)"],"csdm_note":"Record as a Business Capability realized by claim editing, payment integrity analytics and investigation case Business Applications around the core claims system; align it to the internal payment integrity Business Service.","status":"active","successor_id":null,"child_ids":["BC-1870.60.10","BC-1870.60.20","BC-1870.60.30","BC-1870.60.40","BC-1870.60.50"]},"crosswalk":{"realized_by":[{"product_id":"PR-100","product":"ServiceNow","pc_id":"PC-100.98","pc":"Healthcare and Life Sciences Service Management","maturity":"partial","via":"BC-1870.60.30"},{"product_id":"PR-670","product":"HealthEdge","pc_id":"PC-670.50","pc":"Payment Accuracy Edge","maturity":"strong","via":"BC-1870.60.10"}],"used_in":[{"vs_id":"VS-530","vs":"Claim-to-Payment","stage_id":"VS-530.40","stage":"Screen Payment","order":4,"via":null},{"vs_id":"VS-530","vs":"Claim-to-Payment","stage_id":"VS-530.60","stage":"Recover & Settle","order":7,"via":null}],"patterns":[],"stacks":[],"books":[],"technology":[],"frameworks":[],"principles":[],"data_concepts":[],"domain_events":[]},"ancestors":[{"id":"BC-1870","name":"Health Plan Operations","level":1}],"children":[{"id":"BC-1870.60.10","name":"Prepayment Claim Review","level":3,"child_count":0},{"id":"BC-1870.60.20","name":"Postpayment Recovery","level":3,"child_count":0},{"id":"BC-1870.60.30","name":"Fraud, Waste & Abuse Investigation","level":3,"child_count":0},{"id":"BC-1870.60.40","name":"Benefit Coordination & Subrogation","level":3,"child_count":0},{"id":"BC-1870.60.50","name":"Payment Integrity Analytics","level":3,"child_count":0}]}