Claims Submission Workflow

1. Find your tradingPartnerServiceId through Payer Tools >> Payer Searching in the ConnectCenter.

2. Request for a bearer token using the v2/token/ endpoint.

3. Depending on the type of claims (Professional or Institutional, build your claim using the request parameters.

4. Submit the claim using the submission endpoint for claims (Institutional or Professional) to send to the payer and receive the real time response.

5. 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. 

6. 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

• Claims API best practices and workflow