Request and Response

Please be aware that payers require time to process the claims before the Claim Status may be available. Here is a sample Claim Status request that is used for the majority of payers. Please update your request format to match that of the following example.

curl --request POST \
     --url https://sandbox-apigw.optum.com/medicalnetwork/claimstatus/v2/ \
     --header 'Authorization: Bearer eyJraWQiOiIxIiwidHlwI....' \ //your Bearer token
     --header 'accept: application/json' \
     --header 'content-type: application/json' \
     --data '
{
    "controlNumber": "000000001",
    "tradingPartnerServiceId": "serviceId",
    "providers": [
        {
            "organizationName": "TestProvider",
            "taxId": "0123456789",
            "providerType": "BillingProvider"
        },
        {
            "organizationName": "happy doctors group",
            "npi": "1760854442",
            "providerType": "ServiceProvider"
        }
    ],
    "subscriber": {
        "memberId": "0000000000",
        "firstName": "johnone",
        "lastName": "doeone",
        "gender": "M",
        "dateOfBirth": "18800102",
        "groupNumber": "0000000000"
    },
    "dependent": {
        "firstName": "janeone",
        "lastName": "doeone",
        "gender": "F",
        "dateOfBirth": "18800101",
        "groupNumber": "0000000000"
    },
    "encounter": {
        "beginningDateOfService": "20100101",
        "endDateOfService": "20100102",
        "trackingNumber": "ABCD"
    }
}

The claimstatus/v2/raw-x12/enhanced endpoint provides additional information above the claimstatus/v2/ endpoint response information currently available to submitters.

curl --request POST \
     --url https://sandbox-apigw.optum.com/medicalnetwork/eligibility/v3/raw-x12 \
     --header 'Authorization: Bearer eyJraWQiOiIxIiwidHlwIjoiSldUIi...' \ //your Bearer token
     --header 'accept: application/json' \
     --header 'content-type: application/json' \
     --data '
ISA*00*          *01*password  *ZZ*something      *ZZ*EMDEON         *200729*0835*^*00501*000000001*0*P*:~GS*HR*LCX1210000*MTEXE*20200729*0835*000000001*X*005010X212~ST*276*000000001*005010X212~BHT*0010*13*000000001*20200729*0835~HL*1**20*1~NM1*PR*2*Unknown*****PI*serviceId~HL*2*1*21*1~NM1*41*2*TestProvider*****46*0123456789~HL*3*2*19*1~NM1*1P*2*happy doctors group*****XX*1760854442~HL*4*3*22*1~DMG*D8*18800102*M~NM1*IL*1*doeone*johnone****MI*0000000000~HL*5*3*23*0~DMG*D8*18800101*F~NM1*QC*1*doeone*janeone~TRN*1*ABCD~REF*6P*0000000000~DTP*472*RD8*20100101-20100102~SE*18*000000001~GE*1*000000001~IEA*1*000000001~

A few notes about this example in the X12 transmission payload:

The ISA, GS, and ST control segments are used as envelopes to encapsulate the medical transaction data and confidentially manage its transmission.
The GS header ends with the Version ID code (005010X212), which describes the EDI standard used in the transaction.
The ST header states the type of medical transaction, which is 276 in this example (Claim Status submission).

When the envelope headers are complete:
- The Beginning of Hierarchical Transaction (BHT) field shows the start of the data that forms the Claim Status medical transaction.
- The end of the claim status request body carries the TRN (Claim Tracking Number) and REF (Payer Claim Control Number) segments.

{
  "x12": "ISA*00*          *01*password  *ZZ*EMDEON         *ZZ*something      *200729*0835*^*00501*000000001*0*T*:~GS*HN*MTEXE*LCX1210000*20131015*2219*000000001*X*005010X212~ST*277*000000001*005010X212~BHT*0010*08*000000001*20200729*0835*DG~HL*1**20*1~NM1*PR*2*Unknown*****PI*serviceId~HL*2*1*21*1~NM1*41*2*TestProvider*****46*0123456789~HL*3*2*19*1~NM1*1P*2*happy doctors group*****XX*1760854442~HL*4*3*22*0~NM1*IL*1*doeone*johnone****MI*0000000000~TRN*2*000000001~STC*F1:65:1E*20170415**1229*219*20170415**20170415*1111111~REF*1K*AAAAAAAAAAA1~DTP*472*D8*20160722~TRN*2*C1234567891028297LL~STC*F3:101:1E*20170412**1229*184.05~REF*1K*AAAAAAAAAAA2~DTP*472*D8*20160722~TRN*2*C1234567891028297LL~STC*F3:101:1E*20161201**1229*219~REF*1K*AAAAAAAAAAA3~DTP*472*D8*20160722~SE*23*000000001~GE*1*000000001~IEA*1*000000001~",
  "meta": {
    "senderId": "MN_Internal_DEV_APP",
    "traceId": "a09ce024-f333-7261-b65b-ab2e51effc9b",
    "applicationMode": "sandbox"
  }
}

Core claim information consists of the STC segment; the STC segment contains 3 iterations of the Health Care Claim Status (C043) composite within STC01, STC10 and STC11 (STC10 and STC11 are used to convey states of the entire claim or a specific service line), which vary by loop, based on the entities receiving the status information:

Information Receiver status information
Provider status information
Claim Level status information
ServiceLine status information

Claim Level status information and service line status information can include monetary amounts.
The second and third STC segments in the response above show monetary amounts of $184.05 and $219.
Responses might not provide monetary amounts, based on the current claim status. Also, payers may or may not support service line reporting. See page 138 of the ASC X12 276/277 Implementation Guide for Claim Level Status Information and page 160 for Service Lines Status Information.


"secondaryStatusCategoryCode": {
                        "type": "string",
                        "default": "##default",
                        "description": "Segment: STC, Element: STC10-1, Notes: Status Category Code"
                    },
                    "secondaryStatusCategoryCodeValue": {
                        "type": "string",
                        "default": "##default",
                        "description": "Segment: STC, Element: STC10-1, Notes: Status Category Code value"
                    },
                    "secondaryStatusCode": {
                        "type": "string",
                        "default": "##default",
                        "description": "Segment: STC, Element: STC10-2, Notes: Status Code"
                    },
                    "secondaryStatusCodeValue": {
                        "type": "string",
                        "default": "##default",
                        "description": "Segment: STC, Element: STC10-2, Notes: Status Code value"
                    },
                    "secondaryEntityCode": {
                        "type": "string",
                        "default": "##default",
                        "description": "Segment: STC, Element: STC10-3, Notes: Entity Code"
                    },
                    "secondaryEntity": {
                        "type": "string",
                        "default": "##default",
                        "description": "Segment: STC, Element: STC10-3, Notes: Entity Code value"
                    },
                    "tertiaryStatusCategoryCode": {
                        "type": "string",
                        "default": "##default",
                        "description": "Segment: STC, Element: STC11-1, Notes: Status Category Code"
                    },
                    "tertiaryStatusCategoryCodeValue": {
                        "type": "string",
                        "default": "##default",
                        "description": "Segment: STC, Element: STC11-1, Notes: Status Category Code value"
                    },
                    "tertiaryStatusCode": {
                        "type": "string",
                        "default": "##default",
                        "description": "Segment: STC, Element: STC11-2, Notes: Status Code"
                    },
                    "tertiaryStatusCodeValue": {
                        "type": "string",
                        "default": "##default",
                        "description": "Segment: STC, Element: STC11-2, Notes: Status Code value"
                    },
                    "tertiaryEntityCode": {
                        "type": "string",
                        "default": "##default",
                        "description": "Segment: STC, Element: STC11-3, Notes: Entity Code"
                    },
                    "tertiaryEntity": {
                        "type": "string",
                        "default": "##default",
                        "description": "Segment: STC, Element: STC11-3, Notes: Entity Code value"
                    },

STC10 and STC11 are situational and provide additional status information (secondary and tertiary) when needed. These should be within the same status category code (i.e., Acknowledgments, Pending, Finalized) as used in STC01, but need not be the same category code, for example, if STC01 uses P0 - Pending: Adjudication/Details, STC10 and STC11 must use category codes from the Pending list but not necessarily the P0 value.

{
 "claims": [
  {
   "claimStatus": {
    "claimServiceDate": "20201203-20201204",
    "effectiveDate": "20201203",
    "entityCode": "PR",
    "secondaryEntity": "Third-Party Administrator",
    "secondaryEntityCode": "2B",
    "secondaryStatusCategoryCode": "A4",
    "secondaryStatusCategoryCodeValue": "Acknowledgement/Not Found-The claim/encounter can not be found in the adjudication system.",
    "secondaryStatusCode": "127",
    "secondaryStatusCodeValue": "Entity's Communication Number. Usage: This code requires use of an Entity Code.",
    "statusCategoryCode": "A1",
    "statusCategoryCodeValue": "Acknowledgement/Receipt-The claim/encounter has been received. This does not mean that the claim has been accepted for adjudication.",
    "statusCode": "19",
    "statusCodeValue": "Entity acknowledges receipt of claim/encounter. Usage: This code requires use of an Entity Code.",
    "submittedAmount": "8513.88",
    "tertiaryEntity": "Dependent",
    "tertiaryEntityCode": "03",
    "tertiaryStatusCategoryCode": "P5",
    "tertiaryStatusCategoryCodeValue": "Pending/Payer Administrative/System hold",
    "tertiaryStatusCode": "46",
    "tertiaryStatusCodeValue": "Internal review/audit.",
    "trackingNumber": "17baa6f3-e070-40de-bd1e-0fced3420723"
   }
  }
 ],
 "controlNumber": "000000001",
 "meta": {
  "applicationMode": "dev",
  "senderId": "test",
  "traceId": "17baa6f3-e070-40de-bd1e-0fced3420723"
 },
 "payer": {
  "organizationName": "Unknown",
  "payerIdentification": "00001"
 },
 "providers": [
  {
   "organizationName": "TestProvider",
   "providerType": "BillingProvider",
   "taxId": "0123456789"
  },
  {
   "npi": "0123456777",
   "organizationName": "TestProvider2",
   "providerType": "ServiceProvider"
  }
 ],
 "reassociationKey": "000000001",
 "status": "success",
 "subscriber": {
  "firstName": "johnone",
  "lastName": "doeone",
  "memberId": "123456789"
 },
 "tradingPartnerServiceId": "00001"
}