This decision tree is part of the claim denial routing guide. Here the job is narrower: work out, for one company, who can say yes to a conversation about its routing rules, reason codes and resolved cases.
Who touches these records, and who can commit them
This history is spread across a whole team. Most people who can open it cannot decide what happens to it.
| Role | What they hold or know | Can they authorize a licensing discussion? |
|---|---|---|
| Rules analyst or rules owner | Why each rule changed, which reason codes go to which team | No: knows the logic, not an approver |
| Billing system administrator | Payment history, line-level reason codes, report and export rights | No: technical access only |
| Case management administrator | Case records, resolution codes, assignments, retention settings | No |
| Team leads | Manual exceptions and side spreadsheets kept outside the tool | No, but know where informal records sit |
| Head of revenue cycle or VP of billing operations | Volumes, coverage, system plans, who owns each record class | Sponsors and convenes; usually not alone |
| CEO | Company information as an asset, vendor and client contracts | Yes, and signs |
| Compliance officer or general counsel | Provider agreements, HIPAA obligations, de-identification | Sets the limits; approval sits with the CEO |
The rules read the standard adjustment reason codes on each paid or unpaid line. That is why the rules owner understands the records best: they translate payer codes into team assignments. Understanding is still not ownership.
The yes path: six questions in order
Ask these in sequence. The introduction is the first person who answers yes to question 4, with compliance aware by question 5.
- Does this person administer one system? If yes, they can say what the system stores and for how long. Ask who owns the process overall.
- Does this person own the end-to-end process? If yes, this is usually the head of revenue cycle. Ask them to sponsor the conversation and to bring in the CEO, who decides on company data.
- Is the company a provider billing for itself, or a billing company working for clients? The answer changes the branch on the tree. A provider generally controls its own history, subject to HIPAA. A billing company needs question 6.
- Can this person commit company records to an agreement? If yes, this is the introduction: the CEO.
- Is compliance or counsel in the loop? If not, suggest the sponsor brings them to the first call, because they decide scope.
- For a billing company: what do the client agreements say? HHS lists billing and claims processing among the functions that make a company a business associate, and a business associate may use or disclose protected health information only as its contract permits or the law requires. Counsel reads those contracts; the partner only flags that they exist.
The common mistake is stopping at question 2. The revenue cycle head is the right sponsor and the wrong signer.
Branches that need provider, compliance or legal sign-off
Some records sit behind someone else's permission. The partner names the branch and stops there.
| Record class | Why it needs review | Who decides | Typical outcome |
|---|---|---|---|
| Payment lines and case notes | Contain protected health information as they stand | Compliance and counsel | De-identified by Expert Determination or Safe Harbor, or excluded |
| Claim-level history worked for client providers | The provider is the covered entity; the agreement sets permitted uses | Counsel, against each provider agreement | Some clients in scope, some excluded |
| Routing rule sets with version history | Usually the company's own work, no patient data | CEO, with counsel checking client terms | Often the cleanest candidate |
| Cause taxonomy and queue work instructions | Internal know-how, no patient data | CEO | Often in scope |
| Cases under appeal or dispute | May be subject to hold | Counsel | Left alone |
Any licensed version of patient-level material would need de-identification under one of HIPAA's two methods. The rule sets, cause taxonomy and work instructions often name no patient at all, which is why licensing healthcare operational data without PHI is worth reading before the first call. For how billing companies split their own data from client data, see medical billing company data.
A provider group and a billing company: two paths (Illustrative)
Two fictional companies show how the same tree gives different answers. Neither describes a real organization or deal.
| Question on the tree | 600-person multi-specialty provider group | 350-person medical billing company |
|---|---|---|
| Who describes the records? | Director of patient financial services | VP of billing operations and the rules owner |
| Who sponsors? | Director of patient financial services | VP of billing operations |
| Whose data is it? | The group's own, subject to HIPAA | Each client provider's claims; the company's own rules |
| Who signs? | CEO, with the CFO preparing the case | CEO |
| Extra review | Compliance on de-identification | Counsel against roughly 40 client agreements |
| Likely starting scope | Rules, taxonomy and de-identified cases | Rules and taxonomy first; claim-level data client by client |
The provider path is short: one sponsor, one signer, one compliance review. The billing company path is longer because authority over claim-level records is shared with every client. Neither path rules the company in or out. The revenue cycle management page covers that sector in more depth.
What stays open until SourceX's rights review
When the CEO agrees to talk, a partner should be clear that these questions remain unanswered:
- Rights: which record classes, years and clients the company can license once provider agreements and HIPAA obligations are read.
- De-identification: which method applies and what it removes from cases and notes.
- Demand: whether any buyer wants routing histories when SourceX reviews them.
- Terms: whether an offer follows, and what payout and schedule it carries.
The introduced company needs 50+ full-time employees at peak (contractors excluded), documented operating history, rights to license and an authorized contact. Companies in the U.S., Canada and the EU qualify, as do companies in the UK, Australia, New Zealand, India, Singapore, South Africa, Latin America, the UAE and Saudi Arabia when at least 90% of the data is in English. Partners sign the Channel Partner Agreement before submitting introductions; the first valid introduction within the 90-day window is credited when the company submits a verified application, and one partner is credited per company. The system map helps the sponsor describe where records sit, and the referral brief template puts the answers on one page. Why data rights matter explains what the review establishes.
Next step
Refer a company. Earn up to $100,000. Default reward: 25% of Actual Supplier Payout, capped at $100,000 cumulatively per referred company. Eligibility and payment conditions apply, and a signed Schedule A or addendum can differ. A lead, meeting or signature alone does not trigger payment.
Once the revenue cycle head has agreed to bring in the CEO, who can say yes, and compliance knows about the conversation, register as a partner, check the company on who qualifies and read the program terms before you make the introduction.