Claim Responses and Reports FAQs

Can Reports v2 handle large/data/reports files?

Yes, Claim Responses and Reports v2 performs real-time streaming of large amount of data. Our service will return a response with a 413 if the file size is too large for real-time retrieval and EDI 277 and EDI 835 stream larger files.

Other than the X3 and R5 report types, what are the other report types and in what format are this data?

Here is a complete list of available claim responses and reports.

How long are the finished/downloaded Claims files available in the mailbox?

The files are kept in the mailbox for a maximum of 30 days. For more information, please follow the recommended File Retrieval workflow, best practices, and retention rules.

Medical Network Claim Responses and Reports v2 API endpoint

Run the /reports/v2 endpoint to view a list of all 277 files (X3 prefix) and 835 files (*R5** prefix). The contents of these files are in EDI format. Please see API URLs and Endpoints.

How do I access the Claim Responses and Reports v2 production APIs?

Please see the production endpoints in Claim Responses and Reports Production Endpoints.

Search for a specific file

Please use the /reports/v2/ endpoint to search for a specific file.

Endpoint to translate a 277 EDI report file to JSON

Please use the /reports/v2/{ReportID}/277 endpoint to translate a 277 EDI report file to JSON.

Endpoint to translate an 835 EDI report file to JSON

Please use the /reports/v2/{ReportID}/835 endpoint to translate an 835 EDI report file to JSON.

Delete HTTP endpoint

You can delete files from your mailbox using DELETE in the /reports/v2/ endpoint.

What types of files does this API get from the mailbox?

276 transaction is a request for the status of a health care claim. It is submitted by a provider, a health care/services recipient, or an authorized agent (any of these could be the consumer of our APIs).
A 277 transaction is claim status response to an EDI 276 transaction. A 277 might be a solicited response or an unsolicited one, in which case you need to proactively use our API to check your mailbox for any new 277 claim responses. 277 files use the phrase X3 as the prefix in the file name for any 277 claim status response.

835 responses are claims remittance notifications letting the recipient know what the payer has approved and by what percentage coverage is approved for medical services. 835 files begin with the prefix R5. These files are returned in EDI format by default. You can open such files in JSON using our /835 API endpoint.

What information needs to go in the request header?

Please see example in API Request Header.

What does a typical Reports API request and response look like?

The core request does not send a request body, and simply queries for the entire content of the customer's mailbox. Please see example in Claim Responses and Reports Request & Response.

What does the filename structure mean?

The API returns a list of file names with the structure mentioned in file name structure in the Available Claim Responses and Reports V2 section.

How does EDI to JSON translation work?

By appending an X3 or R5 filename to the request, you will see the X12 EDI contents of the file. Please see example in EDI to JSON Translation.

What is the difference between Claim Status and Claim Responses and Reports?

These two APIs are complementary to each other.

Claim Status main task is to check the status of a claim in the payer’s system. If a provider has not received a payer report on a claim, or if they have not received payment, they can run a claim status request to find out the most recent state of that claim. When a claim is paid, the claim status response from the payer provides only basic payment details, and excludes the details such as payer adjustments to the total charge, the patient copays and coinsurance, and other payer adjudication details. It produces a status summary instead of a complete breakdown.

Claim Responses and Reports is a tool to fetch claims information files from your mailbox. You can get your complete claims adjudication results here. The Reports files provide deeper details on the payments for individual Service Lines, the individual amounts the payer agreed on for each, and all other relevant adjudication details.

For more information about the Claim Status API, see Claim Status API Reference and Claim Status API.

How do I convert an EDI Reports file to JSON?

Specify the Report file in the request URL, including its two-letter extension, along with the correct endpoint type. The endpoint will always be either reports/v2/{filename}/277 or reports/v2/{filename}/835. Please see example in Convert 277 or 835 Report.

What are the most important contents of the 277 and 835 Reports?

Please see example in Important Contents of the 277 and 835 Reports.

For 277 reports, look for the following

Please see description with example in Contents of 277 and 835 Reports.

Other than the X3 and R5 report types, what are the other report types and in what format is this data?

Here is a complete list of report types.

How many report names can the Claim Responses and Reports request include?

The report is generated by the clearinghouse, there is no limit to how many report names can be shown.

When I tried to request a token to the Responses and Reports/Eligibility API, I get an invalid access token error even though I am using the same access token that I used for the Claim Status request. Invalid access token for Claim Responses and Reports/Eligibility API (sandbox).

Please see some of the common reasons for this issue in the Invalid Access Token Error in Sandbox section.

I am working on a potential new project and I'm considering using the JSON format.

Do you have this mapping in a non-web form? CSV, DB table ... etc?

No, we do not have this in a non-web form. We provide this as a reference point, but the final authority is the TR3 documentation.

I am looking for mapping for 835s or 999s, do you have them?

Check out the Responses and Reports API, this goes well with the claims API. The responses will be the 999 reports. There are reports to show an 835. The actual 835 file stays in the format received from the payer. We also offer assistance in the workflow for the responses and reports API when you are in implementation.

Do you have any tools for transforming X12 — JSON and/or JSON X12?

We do not have any tools to do this. You can send the X12 format through API and JSON.

How do we know that our claim has been forwarded to payer?

Please see information in Know if a Claim is forwarded to Payer.

I want to make multiple requests with different service types to completely get mental health providers their coverage. Is there a way to reduce the number of requests by clubbing the service types together? Any idea which payers allow that and which don't?

We do not know which payers allow more than one service type code. However, we recommend no more than two in a single request. All payers might not accept two, but two have worked for most.

My client would be billing the clients for the visit, which is not a professional/specialist visit but more like evaluation and management services that come under CPT 99214. Other than serviceType 98, which other code can I use?

Include serviceType code 30 to pull back all the benefit information.

Should I be running multiple requests for 98, MH, and A6 for each patient to get their complete eligibility? Is there a better combo of service type codes that can yield me the results with lesser number of requests per patient?

98, MH, and A6 are good; add 30.

Do you have any API which sends electronic remittance notices regarding payments?

Check out our responses and reports API. We will also walk you through the best way to use these reports while you are in the implementation stage.

How to identify which reports relate to which patients?

Please see example in Identify which Reports relate to which Patients.

Which report (277, 835) contains information about successful adjudication and denial? Should we check all the reports or check only files with prefixes X (277)or R (835)?

Please see information in Get Adjudication Message after Submitting a Claim.

Instead of checking every file, can we go with the R5 Prefix file because it contains detailed information regarding the claim?

We cannot advise you to only check the R5 file as you would be missing anything related to rejected claims by using only that. Please review our Available Responses and Reports for processing the claims.

When a claim is submitted via the API, the API returns a claim ID, to fetch the payer's claim number before we receive the ERA, what API can I use?

The payer assigned claim ID would be returned in the SF and SD reports we provided through the responses and reports API. Additionally, you could check the provider portal for the payer for this information.

Which API to use to get the exact claim details of one particular claim, because it has multiple files in both X3 and R5?

Please see information in Get Exact Claim Details of Particular Claim.

How do we get the EOB files, explain the payment EOB files for the claims?

Please see this section for information Get EOB Files for Payment Received from Payer.

How to get the EOB Files for payment received from payer?

Please see this section for information Get EOB Files for Payment Received from Payer.

What is the expected timeline for receiving status updates regarding the validation process and submission? Are these notifications received immediately after sending the claim, or is there a specific timeframe for receiving them?

Please see information about this in Timeline for Validation and Submission Updates.

When to use Convert Report 277 or Report 835?

Please see the Convert 277 or 835 Report section for information.

Do you support appeals for denials? Are there any APIs through which these appeals can be submitted?

If a claim is denied or partially paid by a payer, a corrected claim should be sent for additional review. Submitting a corrected claim would require the claim frequency code '7', and the payer claim controlNumber 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. Once submitted, the payer will review the claim and make any changes based on their internal review. The claimControlNumber is found on the payer 277 report. Please see example in Corrected Claim in Appeals and Denials. More information can be found in API Examples section.

The same process would need to be followed for voided claims, but using a frequency code '8'.

How do you re-submit a claim that was denied – Appeal & Denial

If a claim is denied or partially paid by a payer, a corrected claim would need to be sent for additional review. Submitting a corrected claim would require the claim frequency code '7', and the payer claim controlNumber 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. Once submitted, the payer will review the claim and make any changes based on their internal review. The claimControlNumber is found on the payer 277 report. Please see Resubmit a Denied Claim. More information can be found in API Examples section.

The same process would need to be followed for voided claims, but using a frequency code '8'.

How can I map 835s or 999s?

Please information in the Map 835s or 999s section.

Why mismatch in Status Response with Claim Status v2 API and Claim Reports API Response for the same professional claim?

The first place you will want to look for responses is, within the reports returned via the Claim Responses & Reports API. Generally, if you do not see any response for a claim within 7 to 10 days, you need to use the Claim Status API. You use that API when seeking information about one particular claim (a solicited request). Sometimes there is a discrepancy between the two because the Claim Status API is updated when the payer wants to update it - hence, you may notice a mismatch of information.

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