Hospital RCM Integration

Guide for hospital Revenue Cycle Management (RCM) teams integrating Turquoise for front-desk authorization and guaranteed settlement.

Overview: A New RCM Paradigm

Turquoise fundamentally changes hospital cash flow and bad debt exposure:

Traditional RCM	Turquoise RCM
Pre-service estimate from leased network	Guaranteed Direct Contract rate
Patient responsible for estimate verification	System verifies guarantee before service
30-45 day payment cycle (slow)	48 hour settlement (Stripe)
Patient collection risk (bad debt)	Plan sponsor guarantees payment
835 coordination (slow)	Real-time webhooks (fast)
Contractual adjustments (reconciliation)	Zero adjustments needed
DSO 40-50 days	DSO 2-3 days

info

Plan sponsors cover the Turquoise 0.5% settlement fee. Hospitals receive 100% of contracted gross amount, with zero patient collection risk.

Pre-Service Guarantee Flow

1. Front Desk Verification

When patient arrives for procedure:

# POST /patient-guarantees/verify
curl -X POST \
  https://api.turquoise.health/tpa-api/v1/patient-guarantees/verify \
  -H "X-API-Key: $HOSPITAL_API_KEY" \
  -d '{
    "member_id": "SHP00123456",
    "plan_id": "SHARP-HMO-2024",
    "provider_npi": "1234567890",
    "procedure_code": "43235",
    "facility_npi": "9876543210"
  }'

Response:

{
  "guarantee_id": "GUAR-20240310-001",
  "status": "active",
  "member_id": "SHP00123456",
  "member_name": "John Doe",
  "plan_name": "Sharp Health Plan",
  "procedure_code": "43235",
  "procedure_description": "Esophagogastroduodenoscopy",
  "guaranteed_rate": 1200.00,
  "member_responsibility": 100.00,
  "hospital_receives": 1100.00,
  "guarantee_expires": "2024-03-12T17:00:00Z",
  "turquoise_confirms": "Plan sponsor guarantees payment if service provided by 5pm PT on Mar 12, 2024",
  "ehr_integration_token": "token_abc123xyz"
}

Print the guarantee and give to patient. This is their pre-service EOB.

tip

Keep the guarantee_id and ehr_integration_token for later claim submission. This eliminates pricing disputes.

2. Service Delivery

Proceed with service. No pricing uncertainty.

3. Claim Submission

After service, submit FHIR claim with guarantee reference:

curl -X POST \
  https://api.turquoise.health/tpa-api/v1/claims/submit \
  -H "X-API-Key: $HOSPITAL_API_KEY" \
  -H "Content-Type: application/fhir+json" \
  -d '{
    "resourceType": "Claim",
    "id": "CLM-20240310-001",
    "status": "active",
    "type": { "coding": [{ "code": "institutional" }] },
    "patient": { "identifier": { "value": "SHP00123456" } },
    "provider": { "identifier": { "value": "1234567890" } },
    "facility": { "identifier": { "value": "9876543210" } },
    "insurer": { "identifier": { "value": "SHARP-HMO-2024" } },
    "created": "2024-03-11T10:00:00Z",
    "servicedDate": "2024-03-10",
    "extension": [{
      "url": "https://turquoise.health/guarantee-id",
      "valueString": "GUAR-20240310-001"
    }],
    "item": [{
      "sequence": 1,
      "productOrService": { "coding": [{ "code": "43235" }] },
      "servicedDate": "2024-03-10",
      "unitPrice": { "value": 1200.00, "currency": "USD" },
      "net": { "value": 1200.00, "currency": "USD" }
    }]
  }'

The claim references the pre-service guarantee, eliminating disputes.

Stripe-Based Settlement

How Settlement Works

Claim Submitted
       ↓
Adjudicated by Turquoise
       ↓
Plan sponsor approves (via TPA)
       ↓
Stripe initiates ACH transfer
       ↓
48 hours later: Money in your bank account

No invoice to plan. No EOB back-and-forth. Fully automated.

Settlement Flow Example

Event 1: Claim adjudicated

{
  "event": "claim.adjudicated",
  "claim_id": "CLM-20240310-001",
  "claim_response_id": "CLMR-20240310-001",
  "status": "approved",
  "approved_amount": 1100.00,
  "timestamp": "2024-03-11T10:30:00Z"
}

Event 2: Settlement initiated

{
  "event": "settlement.initiated",
  "settlement_id": "SETTLE-20240310-001",
  "claim_response_id": "CLMR-20240310-001",
  "provider_npi": "1234567890",
  "amount": 1100.00,
  "stripe_transfer_id": "tr_abc123xyz",
  "expected_arrival": "2024-03-12T09:00:00Z"
}

Event 3: Settlement completed

{
  "event": "settlement.completed",
  "settlement_id": "SETTLE-20240310-001",
  "stripe_transfer_id": "tr_abc123xyz",
  "amount": 1100.00,
  "arrived_at": "2024-03-12T09:45:00Z",
  "bank_deposit_amount": 1100.00,
  "stripe_trace_id": "trace_0311_abc123xyz"
}

info

Stripe transfers appear in your bank as "TURQUOISE HEALTH INC" with a reference code. The stripe_trace_id ties each deposit to the original claim.

Stripe-to-835 Translator

For hospitals with legacy RCM systems that expect EDI 835 EOBs, Turquoise provides automated translation:

Enabling 835 Generation

curl -X POST \
  https://api.turquoise.health/tpa-api/v1/edi-config \
  -H "X-API-Key: $HOSPITAL_API_KEY" \
  -d '{
    "edi_generation": true,
    "edi_format": "835",
    "edi_transmission": "sftp",
    "sftp_endpoint": "sftp.yourhospital.com",
    "sftp_path": "/incoming/edi/835",
    "daily_transmission": true
  }'

Turquoise automatically generates standard 835 EOBs and delivers them to your SFTP daily:

ST~835~001
BPR~C~1100.00~C~ACH~PPD~...
TRN~0~SETTLE-20240310-001~...
CLP~CLM-20240310-001~1~1100.00~1100.00~...
SVD~1234567890~SETTLE-20240310-001~1100.00~...

Your RCM system can ingest these 835s and post payments automatically.

Data Mapping Reference

Map Turquoise API fields to your hospital billing system:

Turquoise Field	Type	RCM Equivalent	Mapping
`claim_id`	string	Claim Number	ClaimInfo.ClaimNumber
`member_id`	string	Member ID	ClaimInfo.PatientID
`provider_npi`	string	Provider NPI	ClaimInfo.ProviderID
`facility_npi`	string	Facility NPI	ClaimInfo.FacilityID
`procedure_code`	string	CPT/HCPCS	LineItem.ProcedureCode
`billed_amount`	decimal	Billed Charge	LineItem.ChargeAmount
`negotiated_rate`	decimal	Allowed Amount	LineItem.AllowedAmount
`settlement_id`	string	EOB Number	EOB.EOBNumber
`stripe_trace_id`	string	Reference ID	EOB.ReferenceID
`arrived_at`	timestamp	Payment Date	EOB.PaymentDate

Python Mapping Example

def map_turquoise_to_rcm(settlement_record):
    return {
        'claim_number': settlement_record['claim_id'],
        'patient_id': settlement_record['member_id'],
        'provider_id': settlement_record['provider_npi'],
        'facility_id': settlement_record['facility_npi'],
        'cpt_code': settlement_record['procedure_code'],
        'billed_charge': settlement_record['billed_amount'],
        'allowed_amount': settlement_record['negotiated_rate'],
        'eob_number': settlement_record['settlement_id'],
        'reference_id': settlement_record['stripe_trace_id'],
        'payment_date': settlement_record['arrived_at'],
        'payment_method': 'ACH',
        'payment_status': 'COMPLETED'
    }

Net vs. Gross Reconciliation

Payment Composition

Negotiated Rate (Gross):        $1,200.00
  ├─ Plan sponsor receives:     $1,000.00
  ├─ Deductible/copay:          $100.00
  └─ Turquoise fee (0.5%):      $6.00

Hospital receives (Net):        $1,100.00

Key point: Hospital always receives the full negotiated gross rate for contracted procedures. The 0.5% fee is paid by the plan sponsor, not deducted from the hospital payment.

Calculation in Your System

def calculate_payment(claim):
    negotiated_rate = claim['negotiated_rate']  # $1,200

    # Deductible/copay goes to patient collection
    patient_responsibility = claim['member_responsibility']  # $100

    # Hospital receives the difference (gross minus patient responsibility)
    hospital_payment = negotiated_rate - patient_responsibility  # $1,100

    # Turquoise fee is paid by plan sponsor (not shown here)
    turquoise_fee = negotiated_rate * 0.005  # $6 (paid by plan)

    return hospital_payment

warning

Never double-count the Turquoise fee. It's deducted from plan sponsor reimbursement, not from hospital payment.

True-Up Handling: No More Contractual Adjustments

Traditional Approach (Problematic)

Hospital bills $1,200 (billed charge)
Plan pays $1,000 (allowed amount)
Hospital records $200 write-off as "contractual adjustment"
CFO asks: "Why are we losing $200 per procedure?"
Manual true-up process (slow, error-prone)

Turquoise Approach (Simple)

Hospital gets rate guarantee: $1,200
Plan pays $1,200 through Turquoise (minus patient responsibility)
Zero contractual adjustments
No reconciliation needed

Rare Case: Rate Disagreement

If a rate discrepancy occurs (plan and hospital disagree on contract rate):

Webhook event:

{
  "event": "adjustment.initiated",
  "adjustment_id": "ADJ-20240311-001",
  "settlement_id": "SETTLE-20240310-001",
  "claim_id": "CLM-20240310-001",
  "original_amount": 1100.00,
  "disputed_amount": 50.00,
  "reason": "contract_rate_discrepancy",
  "action_required": "review",
  "contact_support": "disputes@turquoise.health"
}

Turquoise works with the plan sponsor to resolve. This is rare (< 0.1% of claims).

When resolved, a true-up is processed automatically:

{
  "event": "adjustment.completed",
  "adjustment_id": "ADJ-20240311-001",
  "adjustment_amount": 50.00,
  "resolved_at": "2024-03-12T14:00:00Z"
}

Benefits Summary

Reduced Days Sales Outstanding (DSO)

Metric	Traditional	Turquoise	Improvement
Payment cycle	30-45 days	48 hours	95% faster
DSO	40-50 days	2-3 days	90% reduction
Cash flow predictability	Unpredictable	Guaranteed	✓
Bad debt write-off	2-5% of revenue	0%	Eliminated

Zero Patient Collection Risk

No more "patient balance" tracking. Plan sponsor guarantees payment.

Pre-service guarantees eliminate disputes
Stripe settlements are automatic
Patient responsibility handled by TPA/plan
Hospital focus: clinical care, not collections

Clean Auditing

Every claim is traceable end-to-end:

Guarantee ID → Claim ID → ClaimResponse ID → Settlement ID → Stripe Trace ID
                                                           ↓
                                                  Bank deposit record

Full audit trail for compliance, no PHI in settlement records.

Webhook Integration

Listening for Settlement Events

from flask import Flask, request

app = Flask(__name__)

@app.route('/webhooks/settlements', methods=['POST'])
def handle_settlement_webhook():
    event = request.json

    if event['event'] == 'settlement.completed':
        # Post payment to RCM system
        settlement_id = event['settlement_id']
        amount = event['amount']
        stripe_trace_id = event['stripe_trace_id']

        post_payment_to_rcm(
            settlement_id=settlement_id,
            amount=amount,
            reference_id=stripe_trace_id,
            method='ACH'
        )

        return {'status': 'processed'}, 200

    return {'status': 'ignored'}, 200

Example Webhook Payload

{
  "webhook_id": "wh_abc123xyz",
  "event": "settlement.completed",
  "created_at": "2024-03-12T09:45:00Z",
  "settlement_id": "SETTLE-20240310-001",
  "claim_response_id": "CLMR-20240310-001",
  "claim_id": "CLM-20240310-001",
  "member_id": "SHP00123456",
  "provider_npi": "1234567890",
  "facility_npi": "9876543210",
  "amount": 1100.00,
  "currency": "USD",
  "stripe_transfer_id": "tr_abc123xyz",
  "stripe_trace_id": "trace_0312_abc123xyz",
  "arrived_at": "2024-03-12T09:45:00Z",
  "bank_deposit_amount": 1100.00
}

Comparing Integration Options

Option 1: Webhook-Only (Recommended for most hospitals)

Turquoise sends webhook when payment arrives
Your RCM system posts payment
Minimal integration complexity
Real-time posting (within minutes of deposit)

POST /webhooks/settlements → Read event → Post to RCM → Done

Option 2: Polling (for legacy systems)

If webhooks aren't available, poll for settlement status:

# Every hour, check for new settlements
curl -X GET \
  https://api.turquoise.health/tpa-api/v1/settlements?status=completed&created_since=2024-03-12T08:45:00Z \
  -H "X-API-Key: $HOSPITAL_API_KEY"

Response:

{
  "settlements": [
    {
      "settlement_id": "SETTLE-20240310-001",
      "status": "completed",
      "amount": 1100.00,
      "arrived_at": "2024-03-12T09:45:00Z"
    }
  ]
}

Option 3: EDI 835 Integration (for full legacy systems)

Turquoise generates standard 835 EOBs and delivers via SFTP daily. Your RCM can auto-ingest.

Next Steps

Set up pre-service guarantees: Configure front-desk endpoint
Enable webhooks: Subscribe to settlement.completed events
Configure EDI 835 (if using legacy RCM)
Test with pilot provider: Start with one facility
Train billing staff: Pre-service guarantee workflow
Monitor DSO: Measure improvement after 4 weeks
Full rollout: Expand to all eligible facilities

Support

Implementation: rcm-support@turquoise.health
Technical: api-support@turquoise.health
Billing questions: finance-support@turquoise.health

Overview: A New RCM Paradigm​

Pre-Service Guarantee Flow​

1. Front Desk Verification​

2. Service Delivery​

3. Claim Submission​

Stripe-Based Settlement​

How Settlement Works​

Settlement Flow Example​

Stripe-to-835 Translator​

Enabling 835 Generation​

Data Mapping Reference​

Python Mapping Example​

Net vs. Gross Reconciliation​

Payment Composition​

Calculation in Your System​

True-Up Handling: No More Contractual Adjustments​

Traditional Approach (Problematic)​

Turquoise Approach (Simple)​

Rare Case: Rate Disagreement​

Benefits Summary​

Reduced Days Sales Outstanding (DSO)​

Zero Patient Collection Risk​

Clean Auditing​

Webhook Integration​

Listening for Settlement Events​

Example Webhook Payload​

Comparing Integration Options​

Option 1: Webhook-Only (Recommended for most hospitals)​

Option 2: Polling (for legacy systems)​

Option 3: EDI 835 Integration (for full legacy systems)​

Next Steps​

Support​