Quick facts
- Price
- $599.00 USD
- Odoo versions
- 17, 18, 19
- Setup time
- 30 min
- License
- One-time perpetual
- Languages
- 11 languages
One-time Purchase
Clinical Insurance & TPA Claims
A made-to-order Odoo module that adds payer configuration, patient coverage, pre-authorization, and full TPA claim generation and reconciliation directly onto your patient invoices. ECOSIRE builds it to your payer contracts, installs it, and supports it after go-live.
$599.00USD
No payment now. This sends a quote request to our team — we'll follow up by email with pricing and next steps.
Key Features
Insurance payer and plan master with covered-service lines, exclusion lines, and per-plan coverage percentages, modeled as related `models.Model` records with `ir.model.access.csv` control
Patient coverage records holding policy number, plan link, validity date range, and remaining coverage limit, validated so expired or exhausted coverage cannot be claimed
Coverage-aware pricing rules that auto-split each invoice line into patient-payable and payer-payable via computed fields (`@api.depends` on service, plan, and coverage %)
Ordered co-pay, deductible, and coverage-percentage calculation applied on the patient invoice so the split is deterministic and auditable
Pre-authorization request workflow that captures the payer's approval reference and blocks services flagged as auth-required until a reference is recorded
Claim generation directly from a posted patient invoice with an itemized covered/uncovered split carried onto claim lines
TPA (third-party administrator) master with per-claim routing, so each claim is sent to the correct administrator for the patient's plan
Claim status pipeline — `draft`, `submitted`, `approved`, `partially_paid`, `denied` — enforced as a state machine with guarded transitions
Denial handling with configurable reason codes and a one-click resubmission workflow that clones the claim while preserving the audit trail
EOB (explanation of benefits) reconciliation screen comparing expected versus paid amounts line by line, flagging short-pays and write-off candidates
Batch claim export to CSV or a payer/TPA-specific structured layout for upload to external portals
Payer-mix and outstanding-claims reporting via QWeb reports plus filterable list/pivot views for the revenue-cycle manager
Automated actions to flag aged outstanding claims and stalled authorizations for follow-up
`XML-RPC`/`JSON-RPC` endpoints so an external clearinghouse or portal can push claim status and pull adjudication results
About this Product
Hospitals and clinics in insurance-heavy markets live or die on their revenue cycle, yet Odoo's native account module has no concept of a payer, a coverage limit, a co-pay, or a claim. Out of the box you can raise a patient invoice, but you cannot split it into a patient-payable and a payer-payable portion, you cannot record a pre-authorization reference against a procedure, and you have nowhere to track a claim through submission, adjudication, denial, and resubmission. Billing teams end up managing eligibility and TPA (third-party administrator) claims in spreadsheets and payer portals that never reconcile back to the ledger — so cash leaks through under-billed co-pays, missed authorizations, and denials that are never reworked.
Why Choose Clinical Insurance & TPA Claims
Insurance payer and plan master with covered-service lines, exclusion lines, and per-plan coverage percentages, modeled as related `models.Model` records with `ir.model.access.csv` control
Patient coverage records holding policy number, plan link, validity date range, and remaining coverage limit, validated so expired or exhausted coverage cannot be claimed
Coverage-aware pricing rules that auto-split each invoice line into patient-payable and payer-payable via computed fields (`@api.depends` on service, plan, and coverage %)
Ordered co-pay, deductible, and coverage-percentage calculation applied on the patient invoice so the split is deterministic and auditable
Pre-authorization request workflow that captures the payer's approval reference and blocks services flagged as auth-required until a reference is recorded
Claim generation directly from a posted patient invoice with an itemized covered/uncovered split carried onto claim lines
This is a build-to-order module ECOSIRE develops on top of your existing clinical-core-his-emr and account install. We add a set of ORM models — an insurance payer and plan master (models.Model with covered-service and exclusion lines), patient coverage records carrying policy number, validity dates, and coverage limits, and a claim object generated from a posted patient invoice. Coverage-aware pricing rules run as computed fields (@api.depends on service, plan, and coverage percentage) so every invoice line is automatically split into patient-payable versus payer-payable, with co-pay and deductible applied in the right order. Pre-authorization is a small approval workflow that captures the payer's authorization reference and blocks claimable services that require one. Claims move through a state pipeline — draft, submitted, approved, partially_paid, denied — with denial reason codes and a resubmission path, and an EOB (explanation of benefits) reconciliation screen that compares expected against paid line by line.
Everything is wired to real Odoo primitives your team already knows. Access is governed by ir.model.access.csv plus record rules so billing clerks, coders, and finance see only what their role allows; QWeb reports produce claim forms and payer statements; automated actions can flag aged outstanding claims; and batch claim export emits a structured CSV (or a payer-specific layout) for upload to TPA portals, while the XML-RPC/JSON-RPC API lets you push or pull claim status from an external clearinghouse. Payer-mix and outstanding-claims dashboards give the revenue-cycle manager a single view of what is billed, adjudicated, and stuck. The module is delivered for your target line — Odoo 17.0, 18.0, or 19.0 — and works on Community or Enterprise (Enterprise adds the studio-style report designer and OCR-assisted document capture, neither of which the claim logic depends on).
Delivery is build-to-order: we start with a scoping call, map your payer contracts, plan rules, and TPA layouts, then build, test on a staging copy of your database, run UAT with your billing team, and deploy with a rollback plan. Typical delivery is 2-4 weeks from confirmed scope. Pricing starts from $599 (indicative, single-company base scope); multi-company or multi-branch consolidation, additional payer/TPA export formats, and clearinghouse or portal integrations increase the quoted scope.
What you get
- Installable source code for your target Odoo version (17.0, 18.0, or 19.0) with a clean `__manifest__.py` and versioned dependencies
- Installation and configuration on your environment, including payer, plan, and TPA master setup from your contracts
- Technical documentation covering the data model, security rules, computed fields, and API endpoints
- End-user guide plus a live training session for billing, coding, and finance staff
- UAT on a staging copy of your database with a documented rollback plan before production cutover
- Post-go-live support window for defect fixes and configuration adjustments
- Git repository handover with full commit history and branch tags per Odoo version
- Payer/TPA export templates and sample reconciliation workbooks configured to your formats
Who this is for
Revenue-Cycle / Billing Manager
Owns cash collection across a mixed cash-and-insurance patient base. Needs claims, authorizations, and denials tracked inside Odoo accounting so nothing leaks between the EMR, the ledger, and the payer portal.
Hospital Finance Controller (GCC / multi-payer)
Answers to management for payer-mix, outstanding receivables, and short-pays. Wants coverage-aware invoice splits and reconciliation that tie every claim back to a posted invoice and a bank receipt.
Insurance Coordinator / TPA Desk
Processes pre-authorizations and routes claims to the correct third-party administrator. Needs auth-reference capture, per-TPA routing, and batch export that matches each administrator's upload format.
Medical Coder / Claims Clerk
Prepares and resubmits claims day to day. Needs covered/uncovered line splits, denial reason codes, and a clean resubmission path that preserves the original claim's audit trail.
Installation overview
Download from ECOSIRE
Buy the license on ecosire.com and download the Clinical Insurance & TPA Claims module ZIP from your account dashboard.
Upload to Odoo
Extract the ZIP into your Odoo custom addons folder on the server (or upload via Apps > Install from file on Odoo.sh / runbot).
Install the module
Activate Developer Mode, open Apps, click Update Apps List, search for Clinical Insurance & TPA Claims, and press Install.
Configure settings
Open the new menu, paste your ECOSIRE license key, connect any external credentials (Shopify, Amazon, Stripe, etc.), and save.
Verify & go live
Run the built-in connection test, sync your first 10 records, and schedule the recurring cron. Contact support if anything fails.
How Clinical Insurance & TPA Claims Compares
| Criterion | ECOSIRE | Custom Build | Competitor | Odoo Native |
|---|---|---|---|---|
| Fit to your payer contracts & TPA formats | Built to your exact plans, coverage rules, and export layouts | Fully bespoke but you carry all the analysis and risk | Generic payer model you must bend to fit | |
| Invoice coverage split (co-pay/deductible/%) | Automatic patient vs payer split via computed fields | Possible if your developer designs it correctly | Often partial; ordering of co-pay/deductible varies | |
| Pre-authorization workflow | Auth-reference capture that blocks auth-required services | Whatever you specify and pay to build | Sometimes present, rarely enforced on services | |
| Claim pipeline & denial/resubmission | Full draft→denied state machine with reason codes & rework | Buildable but time-consuming to get states right | Basic statuses; denial rework often missing | |
| EOB reconciliation (expected vs paid) | Line-by-line reconciliation flagging short-pays | Custom scope, custom cost | Usually absent or spreadsheet-based | |
| Delivery model & timeline | Build-to-order, 2-4 weeks from confirmed scope | Weeks to months depending on your team | Instant install but generic and unsupported-fit | |
| Support & version upgrades | Post-go-live window + optional 17/18/19 upgrade path | Depends on retaining your developer | Vendor forum/tickets, no fit guarantee | |
| Ownership & lock-in | Full git repo handover, no lock-in | You own it but also maintain it alone | Licensed code, limited control |
Frequently Asked Questions about Clinical Insurance & TPA Claims
Is this an existing app I can download and install today?
No. This is a build-to-order module. ECOSIRE develops it to your payer contracts, plan rules, and TPA export formats, then installs and supports it. There is no instant download — the value is that it fits your revenue cycle rather than forcing you into a generic template.
How long does delivery take?
Typical delivery is 2-4 weeks from confirmed scope. The clock starts once we have agreed the payer/plan configuration, coverage rules, TPA layouts, and the target Odoo version. Complex multi-company or clearinghouse integrations can extend that, and we will tell you before you commit.
How does pricing and scoping work?
Pricing starts from $599 as an indicative from-price for a single-company base scope. After a short scoping call we issue a fixed written quote. Drivers that change the quote include multi-company or multi-branch consolidation, extra payer/TPA export formats, clearinghouse or portal integrations, and the volume of historical claim data to migrate.
Which Odoo versions and editions are supported?
We build for Odoo 17.0, 18.0, or 19.0 on either Community or Enterprise. The claim, coverage, and reconciliation logic runs the same on both editions; Enterprise simply adds conveniences like the studio-style report designer and OCR document capture, which the module does not depend on.
What support and updates come after go-live?
Every engagement includes a post-go-live support window for defect fixes and configuration tweaks. Beyond that we offer optional annual support and version-upgrade services — for example carrying the module forward when you move from Odoo 17.0 to 18.0 or 19.0. You receive the full git repository, so you are never locked in.
Will it split invoices correctly between the patient and the insurer?
Yes. Coverage-aware pricing rules compute each invoice line's patient-payable and payer-payable portions using the plan's coverage percentage, co-pay, and deductible in a defined order. The split is a computed field tied to the invoice, so it is auditable and recalculates if coverage or plan data changes.
Can it integrate with our TPA or clearinghouse portal?
Yes, within the quoted scope. We provide batch export in CSV or a payer-specific structured layout, and the module exposes `XML-RPC`/`JSON-RPC` endpoints so an external clearinghouse can push claim status and pull adjudication results. Direct API integrations are scoped per portal since each has its own format and credentials.
Related Modules
Request a quote
Clinical Insurance & TPA Claims
A made-to-order Odoo module that adds payer configuration, patient coverage, pre-authorization, and full TPA claim generation and reconciliation directly onto your patient invoices. ECOSIRE builds it to your payer contracts, installs it, and supports it after go-live.
- Insurance payer and plan master with covered-service lines, exclusion lines, and per-plan coverage percentages, modeled as related `models.Model` records with `ir.model.access.csv` control
- Patient coverage records holding policy number, plan link, validity date range, and remaining coverage limit, validated so expired or exhausted coverage cannot be claimed
- Coverage-aware pricing rules that auto-split each invoice line into patient-payable and payer-payable via computed fields (`@api.depends` on service, plan, and coverage %)
- Ordered co-pay, deductible, and coverage-percentage calculation applied on the patient invoice so the split is deterministic and auditable