Claims Submission Workflow
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Find your
tradingPartnerServiceId
through Payer Tools >> Payer Searching in the ConnectCenter. -
Request for a bearer token using the
v2/token/
endpoint. -
Depending on the type of claims (Professional or Institutional, build your claim using the request parameters.
-
Submit the claim using the submission endpoint for claims (Institutional or Professional) to send to the payer and receive the real time response.
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Or, use the
/validation
endpoint (Institutional or Professional) to test the submitted data against the same edits without submitting the claims.- Address any errors if an "EDITS" response is received.
- Allow the submitted claim to process for X number of days.
-
Pull the associated reports through the Responses and Reports API.
The submitter gets unsolicited claim status about the claim being in process. Once the claim is accepted for adjudication, a Remit (EOB) can be processed by the payer.
If a claim is rejected by the payer, make the requested changes and generate a new submission with a new patientControlNumber. The patientControlNumber would be the main value used in tracking specific submissions.
If a claim is denied by the payer, a corrected claim would be required. The claim frequency code should be submitted as a '7' and the payer claim control number must be included on the claim in the claimControlNumber field in the claimSupplementalInformation. The claimControlNumber is the number assigned by the payer to identify a claim. The patientControlNumber should be sent as a unique value. Once submitted, the payer will review the claim and make any changes based on their internal review.
Related Topic
Updated 5 months ago