Available Claim Responses and Reports V2

Our Responses and Reports API is your method to access your mailbox for claim payments, claim status updates, and other communications regarding the revenue cycle from the payer.

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NOTE

The finished/downloaded Claim files are not available permanently for retrieval. For more information, please follow the recommended file retrieval workflow, best practices, and retention rules.

File name structure

The API will return a list of file names with the following structure:

AAnnnnnn.XX where,

• AA = the two character prefix that designates the type of file
• nnnnnn = the six digit submitter ID
• XX = the two character extension that separates files. Files will start with AA, AB, AC….A0, A1, A2…..BA, BB, BC…..ending with W9 before rolling back to AA (excluding AU, BK, DB, DV, GI, GW, HT, JS, QT, RA, RP, and WM)

The most common reports are the Claim Status Response (X3) and the Claim Remittance (R5). Electronic reports also exist to support all available transactions, including medical statements and Electronic Remittance Advice (ERA).

Response files

Review the response files to ensure you are getting all claim updates, including any rejections. The following section provides additional information and specification.

• CF prefix-Claims Summary Data File (pipe-delimited) — this report is a pipe delimited, variable length clearinghouse response report. The response is returned for any acceptance/rejection processing completed after a claim is received from the API.
• UF prefix-Claims Summary Data File (recreates) — this report is the same as the CF response file (pipe-delimited, variable length), but it is only returned in circumstances where a Optum batch file to a payer fails and needs to be recreated. This report provides acceptance or rejection for any claims reprocessed due to a need for a file recreation.
• FX prefix-Notification Report — this report is a human-readable notification sent from our Audit team when we are notified by a payer directly of a processing issue for a provider’s claims.
• CN prefix-Notification Report — this report is a human-readable notification used to provide notification of a payer claim that could not be delivered to the intended address. The CN is primarily for paper carrier-direct claims that contain an invalid address and are returned to Optum as undeliverable.
• SD prefix-Payer Batch Data File (pipe-delimited) — this report is a pipe-delimited, variable length payer response report providing details about batch level payer rejections.

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NOTE

For information about accessing the SD reports through the ConnectCenter, see SD reports.

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NOTE

Since this is a batch level response, any data returned on the SD data file is not provided in the X3 or SF data files.

• SF prefix-Payer Report Data File (pipe-delimited) — this report is a proprietary pipe-delimited file that returns claim level payer acceptance and rejections.

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NOTE

For information about accessing the SF reports through the ConnectCenter, see SF reports.

• X3 prefix-277 Claim Status Response Data File (x12 format, JSON conversion available) — this report returns the solicited claim status x12 raw data that matches exactly what is returned by the payer and can be translated into JSON. This file is received from payers when claim status is requested and not returned in real time.
• R5 prefix-835 Claim Remittance Data File (x12 format, JSON conversion available) — provides payment and denial information from the payer. This report is an explanation of the claim payment sent by the payer and can be translated into JSON.

URL

This API can be accessed through a GET request to /medicalnetwork/reports/v2.
This endpoint will return a list of all the available reports. These can be opened by calling the same endpoint with the file name appended to the end.
Example: /medicalnetwork/reports/v2/{filename}

Reports beginning with the prefix “X3” are claim status responses (277) returned from the payer. These reports are returned in X12 EDI by default. If you want to open the file in JSON, open the file with the /277 endpoint, example: /medicalnetwork/reports/v2/{filename}/277.

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NOTE

In the Response 200 pop-up , the X12 segment in the payerIdentification is the same as that of the trandingPartnerServiceId.

Reports beginning with the prefix “R5” are remittances (835) returned from the payer explaining the claim payment. These reports are returned in X12 EDI by default. If you want to open the file in JSON, open the file with the /835 endpoint, example: /medicalnetwork/reports/v2/{filename}/835.

Headers

The following headers are required:

• Authorization: Bearer {Your-Access-Token}
• Content-Type: application/json

Custom headers

The following information must be sent in the headers of your request to identify your access. You should obtain these values from your implementation analyst. Users with multiple usernames or mailboxes should substitute those here.

Sandbox values

The GET request requires no values in the body of the request. In the response, there are three sample reports that you can use to test out the functionality outlined above.

Postman collection

For a quick start, you can download our Claim Responses and Reports API collection.