PAYERS & REIMBURSEMENT CONNECTORS

Tariffs & Reimbursement Rules

4 of 7

Integrate payer eligibility, claims, reimbursement and reconciliation workflows without turning Mediloop into a payer or payment institution.

TariffsCNSNGAPCCAMRules EngineVersioningEstimate

Flexible & Configurable

Support payer-specific pricing models without hard-coding.

Versioned Rules

Track effective dates and historical rule versions.

Estimate Before Care

Estimate expected reimbursement and patient share.

Stay Compliant

Keep national rules, evidence and audit explicit.

Tariff Data Model

Entity	Purpose	Examples
Service concept	What was delivered	consultation, lab test, imaging
Tariff code	Payer/national billing code	CNS nomenclature, NGAP, CCAM
Rule version	Effective reimbursement policy	effectiveFrom/effectiveTo
Coverage condition	Eligibility/prior-auth constraint	age, frequency, authorization
Amount split	Estimated payer / patient share	covered amount, copay

Reimbursement Rules

Identify Service

Clinical/operational service delivered

Find Tariff

Map to payer/national nomenclature

Apply Rules

Coverage, conditions, co-pay and prior auth

Estimate

Expected reimbursement breakdown

Payer Adjudication

Authoritative final amount later

Service Mapping

Keep clinical service concept separate from payer billing code

Map by country, payer, contract and effective date

Preserve original source and target codes

Use versioned mapping sets

Require review for ambiguous or newly introduced codes

Examples

Service	System	Tariff mapping	Outcome
GP consultation	CNS LU	Applicable national act	Estimated covered + patient share
Nursing act	France	NGAP code	Rule-based estimate
Procedure	France	CCAM code	Rule-based estimate
Complementary coverage	Private payer	Contract-specific rule	Secondary estimate

APIs & Endpoints

httpCopy

# Illustrative reimbursement estimate
POST /v1/payers/reimbursement/estimate
Authorization: Bearer <token>

{
  "payer":"cpam-fr",
  "serviceCode":"CCAM:XXXX",
  "date":"2026-09-06",
  "coverageId":"cov_123"
}

Estimates are informational. The payer's adjudication remains authoritative and Mediloop does not guarantee reimbursement.

Error Handling

Unknown service mapping → explicit unmapped result

Expired tariff version → select rule by service date, never latest blindly

Missing eligibility input → estimate marked incomplete or blocked

Conflicting payer rules → require precedence/contract resolution

External rule source unavailable → return freshness/source status

Best Practices

Never hard-code national tariffs in application UI

Version rules with effective dates

Keep payer source and publication date

Separate estimate from adjudication

Regression-test high-volume services after rule updates

Audit manual overrides

Developer Integration Surface

Surface	Operation / resource	Use	Status
Tariff API	lookup tariff / estimate reimbursement	Pre-care estimate	Planned/versioned
Rules configuration	versioned payer rules	Calculation logic	Governed configuration
FHIR	ChargeItem / Claim-related resources	Interoperable representation where useful	FHIR
External sources	national/payer tariff feeds	Rule updates	Country-specific

Next Steps

Load authoritative tariff sources

Model effective-dated rules

Map services to payer codes

Test estimates against known examples

Set update/review governance