API Example Professional Claims
- Request and Response
- CMS1500/UB04 Claims Forms
- Test Production Data without Submitting for Processing
- Test Prof. and Inst. Claims for PatientControlNumber
- Test Rejected/Denied Claim
- Resubmit a Denied Claim
- Test different Professional Claims Validation and Submission Responses
Submit rejected claims
A correct claim is only submitted when the payer has actually adjudicated the submission and processed the claim for payment.
claimFrequencyCode
'1' is used for all original submissions even if a claim has been rejected
claimFrequencyCode
'7' is used specifically if a payer denies a claim and corrections need to be made
If a claim submission response is received with status EDIT, use claimFrequencyCode
'7', that is, if a claim is denied at the payer and a '0' dollar or incomplete payment is received. Almost all other situations would require a claimFrequencyCode
'1'.
Corrected claims appeals and denials
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.
The same process would need to be followed for voided claims, but using a frequency code '8'. Here is a sample corrected claim. To include additional documents, use the Attachment Submission API. See also Attachments Submission V1 Getting Started.
{
"controlNumber": "000000001",
"tradingPartnerServiceId": "9496",
"submitter": {
"organizationName": "REGIONAL PPO NETWORK",
"contactInformation": {
"name": "SUBMITTER CONTACT INFO",
"phoneNumber": "123456789"
}
},
"receiver": {
"organizationName": "EXTRA HEALTHY INSURANCE"
},
"subscriber": {
"memberId": "0000000001",
"paymentResponsibilityLevelCode": "P",
"firstName": "johnone",
"lastName": "doeOne",
"gender": "M",
"dateOfBirth": "19800102",
"policyNumber": "00001",
"address": {
"address1": "123 address1",
"city": "city1",
"state": "wa",
"postalCode": "981010000"
}
},
"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"
}],
"claimInformation": {
"claimFilingCode": "CI",
"patientControlNumber": "12345",
"claimChargeAmount": "28.75",
"placeOfServiceCode": "11",
"claimFrequencyCode": "7",
"signatureIndicator": "Y",
"planParticipationCode": "A",
"benefitsAssignmentCertificationIndicator": "Y",
"releaseInformationCode": "Y",
"claimSupplementalInformation": {
"claimControlNumber": "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" ]
}
}
}
]
}
}
Handle multiple authorization numbers per claim
If the Institutional Claims required multiple authorization numbers, multiple claims need to be submitted. Submission through the Professional API allows for prior authorization information to be submitted at both the claim and line level Institutional Claims APIs allows for prior authorization information to be submitted at the claim level only. Here is an Open API Specs sample.
ServiceLineReferenceInformation:
type: object
properties:
repricedLineItemReferenceNumber:
type: string
description: 'Loop: 2400, Segment: REF, Element: REF02 Notes: When REF01=9B'
adjustedRepricedLineItemReferenceNumber:
type: string
description: 'Loop: 2400, Segment: REF, Element: REF02 Note: When REF01=9D'
priorAuthorization:
maxItems: 5
minItems: 0
type: array
description: Loop 2400 REF
items:
-->
Updated 5 days ago