Institutional Claims Request & Response
The following example is brief compared to what can apply in a real-world transaction.
```javascript
POST https://sandbox-apigw.optum.com/medicalnetwork/institutionalclaims/v1/[validation|submission] HTTP/1.1
Host: ${apigee_host}
Authorization:Bearer <Your-Access-Token>
Content-Type: application/json
{
"controlNumber": "000000001",
"tradingPartnerServiceId": "9496",
"submitter" : {
"organizationName" : "happy doctors group",
"taxId":"12345",
"contactInformation": {
"name": "janetwo doetwo",
"phoneNumber": "123456789",
"email": "[email protected]",
"faxNumber": "123456789"
}
},
"receiver": {
"organizationName": "EXTRA HEALTHY INSURANCE",
"taxId":"67890"
},
"subscriber" : {
"memberId": "0000000001",
"paymentResponsibilityLevelCode": "P",
"firstName": "johnOne",
"lastName": "doeOne",
"gender": "M",
"dateOfBirth": "19800101",
"address": {
"address1": "123 address1",
"city": "city1",
"state": "wa",
"postalCode": "981010000"
}
},
"providers": [{
"providerType": "BillingProvider",
"npi": "1760854442",
"employerId": "123456789",
"organizationName": "HAPPY DOCTORS GROUPPRACTICE",
"address": {
"address1": "123 address1",
"city": "city1",
"state": "wa",
"postalCode": "981010000"
}
}],
"claimInformation" : {
"claimFilingCode": "CI",
"patientControlNumber": "12345",
"claimChargeAmount": "3.75",
"placeOfServiceCode": "11",
"claimFrequencyCode": "1",
"signatureIndicator": "Y",
"planParticipationCode": "A",
"releaseInformationCode": "Y",
"benefitsAssignmentCertificationIndicator": "Y",
"billingNote":"ADD",
"claimDateInformation": {
"statementBeginDate": "20181209",
"statementEndDate": "20181214",
"dischargeHour":"1130",
"admissionDateAndHour": "201810131242"
},
"claimCodeInformation": {
"admissionTypeCode": "1",
"patientStatusCode": "10",
"admissionSourceCode": "7"
},
"serviceLines":[{
"assignedNumber": "1",
"institutionalService": {
"serviceLineRevenueCode": "1",
"lineItemChargeAmount": "72.50",
"measurementUnit": "UN",
"serviceUnitCount": "1"
}
}],
"principalDiagnosis": {
"qualifierCode": "ABK",
"principalDiagnosisCode": "S93401A",
"presentOnAdmissionIndicator": "Y"
},
"admittingDiagnosis":{"qualifierCode": "ABJ",
"admittingDiagnosisCode": "S93401A"
},
"otherSubscriberInformation": {
"paymentResponsibilityLevelCode": "A",
"individualRelationshipCode": "19",
"benefitsAssignmentCertificationIndicator": "Y",
"claimFilingIndicatorCode": "11",
"releaseOfInformationCode": "Y",
"otherPayerName":{
"otherPayerOrganizationName": "ABC Insurance Co",
"otherPayerIdentifierTypeCode": "PI",
"otherPayerIdentifier": "11122333"
},
"otherSubscriberName": {
"otherInsuredQualifier": "1",
"otherInsuredLastName": "DOE",
"otherInsuredIdentifierTypeCode": "MI",
"otherInsuredIdentifier": "123456"
}
}
}
}
```
In its header section, the request body supports use of either the tradingPartnerServiceId or the serviceId as the required payer identification.
The submitter object describes the information for the medical institution submitting the transaction. The core claimInformation object follows the provider information. It contains the insurance coding for the claim.
The primary elements of a medical claims submission response consist of the aforementioned meta object and a claimReference object. It contains a number of tracking values.
```json
{
"status": "SUCCESS",
"controlNumber": "000000001",
"tradingPartnerServiceId": "9496",
"claimReference": {
"correlationId": "210322R999898~66684261175841",
"submitterId": "009998",
"customerClaimNumber": "000000001",
"patientControlNumber": "12345",
"timeOfResponse": "2021-03-22T19:34:08.85-05:00",
"claimType": "PRO",
"formatVersion": "5010",
"rhclaimNumber": "2108151508527"
},
"meta": {
"submitterId": "999898",
"senderId": "Xxxx.Xxxxxx",
"billerId": "009998",
"traceId": "900773a9-c0ba-6aa2-0f61-cfcc30a0200f",
"applicationMode": "pro"
},
"editStatus": "SUCCESS",
"payer": {
"payerName": "Unknown",
"payerID": "9496"
},
```
````
The first response you get back from the clearinghouse does not indicate whether the claim is being paid; it indicates that the clearinghouse has accepted the claim, and is getting ready to forward it to the payer.
| Institutional Claims API Response Example | Description |
|---|---|
json { "status": "SUCCESS", "controlNumber": "000000001", "tradingPartnerServiceId": "9496", "claimReference": { "correlationId": "210322R999898~66684261175841", "submitterId": "009998", "customerClaimNumber": "000000001", "patientControlNumber": "12345", "timeOfResponse": "2021-03-22T19:34:08.85-05:00", "claimType": "PRO", "formatVersion": "5010", "rhclaimNumber": "2108151508527" }, "meta": { "submitterId": "999898", "senderId": "Xxxx.Xxxxxx", "billerId": "009998", "traceId": "900773a9-c0ba-6aa2-0f61-cfcc30a0200f", "applicationMode": "pro" }, "editStatus": "SUCCESS", "payer": { "payerName": "Unknown", "payerID": "9496" }, | claimReference is the response's main object. Key values are:
|
Updated 2 months ago