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Program coverage

Nine first-class program categories.

Program-type coverage is canonical-by-design, not per-program code. Each category is modelled in the canonical layer; the differences are in seed data — codes, modifiers, rate bands, EVV configuration — not in application code.
Deep-modelled states

Four states modelled deeply; five with rate-code seed.

Deep modelling means pre-submit scrubbers, companion guides, modifier injection, group-size rate bands, and EVV configuration are seeded for the state. Rate-code seed means the master state-rate-code table is populated and ready for fee-schedule pricing.
Deep modelling 4 states
OHNYNJPA

Pre-submit + companion guide + modifier injection + group-size + EVV config. The four states the platform has been hardened against in production.

Rate-code seed 5 states
TXCANYFLPA

State rate codes loaded into the master DB. Fee-schedule pipeline wires up next; Pennsylvania is the announced pilot.

Interactive matrix

Program × state at a glance.

The matrix below renders the full coverage surface. Click any cell to inspect the seeded codes, default unit, auth model, EVV posture, and notes for that program × state combination.
Interactive · 9 × 7 matrix

Program × state coverage.

Click any cell to inspect the seeded codes and configuration depth for that program in that state. Tap the legend for the visual language.

Deep cells23
Partial cells1
General cells14
DeepPartialGeneralExtension
ProgramOHNYNJPATXCAFL
Behavioral Health (BH · IOP · PHP)MENTAL_HEALTH
I/DD (HCBS Waivers)IDD
ABA — Applied Behaviour AnalysisABA
Adult Day CareADULT_DAY
ICF / ICF-IIDICF
Home Care · HCBS · Personal CareHOMECARE
OTP / SUD — MAT enforcedOTP
PRTF — Psychiatric ResidentialRESIDENTIAL
CCBHC — Certified Community BH Clinic(extension via config)
Per-program detail

What's seeded, in full.

The same data the matrix renders, laid out as per-program cards for skim-readability.
Heavy EVV optional

Behavioral Health (BH · IOP · PHP)

MENTAL_HEALTH
Unit
varies
Auth model
varies

Seeded codes

11 BH codes (H2019, H0015, 90837, 96151-96155, T1017, H0036, H0038); IOP/PHP revenue 0905/0906/0912/0913.

Notes

Pre-submit + companion guides seeded for OH / NY / NJ / PA.

OHNYNJPA
First-class EVV required

I/DD (HCBS Waivers)

IDD
Unit
15-MIN
Auth model
DATE_RANGE

Seeded codes

H2016, H2017, T2021, H2014, T2020. Max 10 per group.

Notes

Ohio rate codes deeply modeled; multi-state TX/CA/NY/FL/PA rate-code seed.

OHTXCANYFLPA
Heavy EVV optional

ABA — Applied Behaviour Analysis

ABA
Unit
15-MIN
Auth model
UNIT

Seeded codes

97151-97158, H2019; HO/HN credential injection.

Notes

Most-developed program. Modifier injection + group-size rate bands (1-4=100%, 5-7=95%, 8+=80%).

OHNYNJPA
First-class EVV required

Adult Day Care

ADULT_DAY
Unit
DAY
Auth model
PER_DIEM

Seeded codes

2 HCPCS today; expansion plan covers S5101/S5102/T2025/T2026/T2027.

Notes

Taxonomy 251C00000X anchor; EVV required for personal care components.

OHNYNJPA
First-class EVV n/a

ICF / ICF-IID

ICF
Unit
DAY
Auth model
PER_DIEM

Seeded codes

Revenue 0100-0160, LOA 0180/0183, subacute, BH 1001-1009. UB-04 master.

Notes

Full institutional billing with condition/occurrence/value codes; occurrence code 74 anchor.

OHNYNJPA
Heavy EVV required

Home Care · HCBS · Personal Care

HOMECARE
Unit
HOUR
Auth model
VISIT

Seeded codes

27 codes — broadest seed of any vertical (S5125, S5126, S5130, S5131, T1019, G0156, G0299, companion services).

Notes

OH EVV config + global EVV.

OHNYNJPA
First-class EVV optional

OTP / SUD — MAT enforced

OTP
Unit
DAY
Auth model
EPISODE

Seeded codes

7 codes (H0020, H0033, H0004, H0005, J0571, J0572, H2033).

Notes

MAT NDC enforcement; OH SUD residential includes +14-day PA.

OH
First-class EVV n/a

PRTF — Psychiatric Residential

RESIDENTIAL
Unit
DAY
Auth model
PER_DIEM

Seeded codes

Revenue 1001-1009 seeded.

Notes

First-class via UB-04 master; state-specific seed pending.

Extension path EVV —

CCBHC — Certified Community BH Clinic

(extension via config)
Unit
—
Auth model
—

Seeded codes

Not seeded.

Notes

Extension path: add a `canonical_program` row + state-scoped YAML rule set; no code change.
Program-type coverage is canonical-by-design, not per-program code.
Program Coverage
Extension path

Adding a new program is a row + a YAML.

The platform's extension path for a new program category — say, an emerging waiver service definition — is mechanical. There is no code path that says “if program = X”.
  1. 1

    Add a canonical_program row

    One row in the master DB defines the new program key, its display name, and its service-line classification.

  2. 2

    Seed the codes

    HCPCS / CPT codes + state rate codes go into the existing master catalogs — the same tables every other program reads.

  3. 3

    Author the rule artifacts

    State-scoped YAML for the rule kinds that matter — typically PRE_SUBMIT_VALIDATE, CHARGE_DERIVE, and (if applicable) EVV_CONFIG.

  4. 4

    Publish

    Draft → in-review → approved → published. No code change. No release cycle. No DBA.
Keep going

Coverage is downstream of the canonical model.
Substrate

Master Data

The canonical model + catalogs that program coverage rides on.

 Engine

Configuration & Rules

The eight rule kinds that encode per-state, per-program behaviour.

 SME recap

For RCM experts

The deep-form summary in one read — for the people who'll scrutinize this.