Request Body Parameters
NOTE
The JSON attributes in our APIs use snake-case, with the first letter of the attribute in lower case as in
tradingPartnerServiceId
(is the Payer ID; this will vary based on the payer you want to connect to). Our APIs are case-sensitive and your JSON request body must observe this convention.
Professional Claims request body elements
See examples, Prof. Claims Request and Response.
```json
{
"controlNumber": "000000001",
"tradingPartnerServiceId": "9496",
"submitter": {
"organizationName": "REGIONAL PPO NETWORK",
"contactInformation": {
"name": "SUBMITTER CONTACT INFO",
"phoneNumber": "123456789"
}
},
"receiver": {
"organizationName": "EXTRA HEALTHY INSURANCE"
},
```
Attribute | Description |
---|---|
controlNumber | A single arbitrary value that the requestor defines in the initial Claims API transaction request, perhaps by a random number generator. All parties to the Claims transaction refer to this number to ensure accurate responses and completion of the exchange. 📝 ControlNumbers must be defined as a nine-digit unsigned numeric value. |
tradingPartnerServiceId | Payer ID; you can use the payer’s ConnectCenter real-time Payer ID as the tradingPartnerServiceId . The Legacy Change Healthcare (LCHC) Payer List originates this value. |
serviceId | A 5-digit alphanumeric value that identifies the claims service from the payer. Also listed as the “Payer ID” for payers in the searchable Optum Payer List. |
submitter | Contact information for the provider's submitting organization. |
receiver | Basic identification field for the payer (example, insurance company) that will receive and process the claim. |
Providers object
```json
"providers": [{
"providerType": "BillingProvider",
"npi": "1760854442",
"employerId": "123456789",
"organizationName": "HAPPY DOCTORS GROUPPRACTICE",
"address": {
"address1": "000 address1",
"city": "city2",
"state": "tn",
"postalCode": "372030000"
},
"contactInformation": {
"name": "janetwo doetwo",
"phoneNumber": "0000000001"
}
},{
"providerType": "ReferringProvider",
"npi": "1942788757",
"firstName": "johntwo",
"lastName": "doetwo",
"employerId" : "123456"
},{
"providerType": "RenderingProvider",
"npi": "1942788757",
"firstName": "janetwo",
"lastName": "doetwo",
"middleName": "middletwo",
"ssn" : "000000000"
}],
```
Professional claims may have several different providers involved with a claim:
Provider Type | Description |
---|---|
Billing provider | Required Provider who submits the claim to the payer. They may or may not be the same as the rendering provider. This record is required as part of the Professional Claims request. |
Referring provider | Required Record of a provider who directed the patient for care to a second provider rendering the services described in the claim. Typical cases involve a general practitioner who refers the patient to a specialist, or an orthodontist referring to an oral surgeon. This record is required if a referral was made. |
Rendering provider | Required Provider who performed the medical care or a particular medical service as part of the care, such as anesthesia. This record is required whether or not a referral was made. If no referral was made, the billing provider will most likely be in this field. |
Other required attributes
Other providers
object required parameters include the following:
- Each provider in a claim has an NPI (
npi
) - Basic provider identification including
firstName
,lastName
, and other patient information - All provider records must have either an
employerId
orssn
included in their records
Subscriber object
Attribute | Description |
---|---|
subscriber JSON object | Required Medical insurance subscriber. The object contains a number of straightforward data fields identifying the insurance policyholder, including memberId , firstName , lastName , dateOfBirth , gender , ssn and idCard ( the subscriber’s insurance plan card number). |
```json
"subscriber": {
"memberId": "0000000000",
"firstName": "johnOne",
"lastName": "doeOne",
"gender": "M",
"dateOfBirth": "18800102",
"ssn": "000000000",
"idCard": "card123"
},
```
Dependents object
Attribute | Description |
---|---|
dependents | Optional An array of one or more records describing the dependents of the subscriber who are the recipients of medical care for the claim. |
```json
"dependents": {
"memberId": "0000000002",
"paymentResponsibilityLevelCode": "P",
"firstName": "janeone",
"lastName": "doeOne",
"gender": "F",
"dateOfBirth": "19800102",
"policyNumber": "00002",
"relationshipToSubscriberCode": "01",
"address": {
"address1": "123 address1",
"city": "city1",
"state": "wa",
"postalCode": "981010000"
}
```
NOTE
The encounter for the claim submission may involve the subscriber or a dependent. If a dependent is not involved in the encounter, you can omit the dependent information.
The
dependents
object is subordinate to thesubscriber
.
ClaimsInformation object
Parameter | |
---|---|
claimInformation | Required Core body of information in the submission. It contains all of the diagnosis and procedure information associated with the medical claim. All objects, parameters, and arrays in the claimInformation object are required. |
```json
"claimInformation": {
"claimFilingCode": "CI",
"patientControlNumber": "12345",
"claimChargeAmount": "28.75",
"placeOfServiceCode": "11",
"claimFrequencyCode": "1",
"signatureIndicator": "Y",
"planParticipationCode": "A",
"benefitsAssignmentCertificationIndicator": "Y",
"releaseInformationCode": "Y",
"claimSupplementalInformation": {
"repricedClaimNumber": "00001",
"claimNumber": "12345"
},
"healthCareCodeInformation": [{
"diagnosisTypeCode": "BK",
"diagnosisCode": "496"
},{
"diagnosisTypeCode": "BF",
"diagnosisCode": "25000"
}],
"serviceFacilityLocation": {
"organizationName": "HAPPY DOCTORS GROUP",
"address": {
"address1": "000 address1",
"city": "city2",
"state": "tn",
"postalCode": "372030000"
}
},
"serviceLines":[ {
"serviceDate": "20050514",
"professionalService": {
"procedureIdentifier": "HC",
"lineItemChargeAmount": "25",
"procedureCode": "E0570",
"measurementUnit": "UN",
"serviceUnitCount": "1",
"compositeDiagnosisCodePointers": {
"diagnosisCodePointers": ["1","2"]
}
}
},
{
"serviceDate": "20050514",
"professionalService": {
"procedureIdentifier": "HC",
"lineItemChargeAmount": "3.75",
"procedureCode": "A7003",
"measurementUnit": "UN",
"serviceUnitCount": "1",
"compositeDiagnosisCodePointers": {
"diagnosisCodePointers": ["1" ]
}
}
}
]
}
```
NOTE
The JSON objects described in the following section are all required for professional claim submissions; all of their respective fields except where noted, are also required. For more details on individual JSON data fields in these objects, including optional fields that do not appear in the API request bodies for our Postman collections but that can be used in your requests, see the Claims Submission Professional API attachment document.
Key ClaimInformation attributes
The important, required attributes for the leading elements of the claimInformation
object include the following:
Required Attributes | Description |
---|---|
patientControlNumber | Identifier used to track a claim from its creation by the health care provider through payment. ✍️ In the sandbox request, using value: test00005 (lower case and not uppercase), forfieldName: patientControlNumber returns EDITS canned response. |
claimFilingCode | Subscriber claim filing code: describes the type of payment. In the preceding claimInformation object, example, CI indicates that the payment is through commercial insurance. |
claimChargeAmount | The total cost of all line items in the claim. |
planParticipationCode | Used by a health plan to show that the provider does or does not accept the assignment of benefits. |
benefitsAssignmentCertificationIndicator | A code showing whether the provider has a signed form authorizing the third-party payer to pay the provider. |
releaseInformationCode | Indicates whether the patient has agreed to share personal health information (PHI). Normally, answers in this attribute will be:O for "On file with payer""Y" * Claim risks rejection by the payer |
repricedClaimNumber | Identification number, assigned by a repricing organization to identify an adjusted claim. The values are governed by the Washington Publishing Company and are not available without payment. |
claimNumber | Assigned claim number. |
Claim filing payment codes
Claim Filing payment codes are limited to the following (this table is from the United States Health Information Knowledge-base):
Code | Definition |
---|---|
09 | Self-pay |
11 | Other non-federal programs |
12 | Preferred Provider Organization (PPO) |
13 | Point-of-service |
14 | Exclusive Provider Organization (EPO |
15 | Indemnity Insurance |
16 | Health Maintenance Organization (HMO) Medicare Risk |
17 | Dental Maintenance Organization |
AM | Automobile Medical |
IBL | Blue Cross/Blue Shield |
CH | CHAMPUS |
CI | Commercial Insurance Co. |
DS | Disability |
FI | Federal Employees Program |
HM | Health Maintenance Organization |
LM | Liability Medical |
MA | Medicare Part A |
MB | Medicare Part B |
MC | Medicaid |
OF | Other Federal Program |
TV | Title V |
VA | Veterans Affairs Plan |
WC | Workers' Compensation Health Claim |
ZZ | Mutually Defined |
HealthCareCodeInformation object
Required
This object contains the alphanumeric Healthcare Common Procedure Coding System (HCPCS) codes that the provider enters. The codes are associated with the procedures rendered for the patient. The healthCareCodeInformation
object also contains other vital code values required for accurate billing and claims settlement. A full description of the HCPCS is beyond the scope of this document, but the coding definitions are available free of charge from the Centers for Medicare and Medicaid Services.
ServiceLines object
Required
The serviceLines
object describes one or more line items, each listed in the object as a serviceDates
record. Each serviceLine
procedure must be unique, but they may share the same date or different dates, as anyone would be aware after the visit to the doctor.
Each serviceDates
record describes a procedure (procedureCode
) carried out with the patient, using standard HCPCS codes. In the preceding claimsInformation
object example, two serviceDates
records describe two procedures, each with a code: E0570 and A7003. Each also has a lineItemChargeAmount
. Both take place on the same date.
Providers code only for the specific service lines in which the provider specializes, so procedureIdentifier
and procedureCode
codes will typically use only a small range of values. These codes come out of a very large set of insurance codes that are managed and updated by the Centers for Medicare and Medicaid (CMS) and mandated by Health Insurance Portability and Accountability Act (HIPAA). Diagnosis codes may be more complex, so ensure that your API implementation accounts for the ability to look up the relevant codes for the practice.
Updated 12 days ago