Request Body Parameters

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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"
  },
```

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:

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 or ssn included in their records

Subscriber object

```json
    "subscriber": {
        "memberId": "0000000000",
        "firstName": "johnOne",
        "lastName": "doeOne",
        "gender": "M",
        "dateOfBirth": "18800102",
        "ssn": "000000000",
        "idCard": "card123"
    },
```

Dependents object

```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"
    }
```

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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 the subscriber.

ClaimsInformation object

```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" ]
          }
        }
        }
    ]

  }
```

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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:

Claim filing payment codes

Claim Filing payment codes are limited to the following (this table is from the United States Health Information Knowledge-base):

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.