Integrated Rules Professional Request & Response
```json
{
"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"
}
},
"dependent": {
"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"
}
},
"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": "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" ]
}
}
}
]
}
}
```
```json
{
"status": "SUCCESS",
"controlNumber": "000000001",
"tradingPartnerServiceId": "9496",
"claimReference": {
"correlationId": "200925R639534~847432178458572",
"submitterId": "395795639534",
"customerClaimNumber": "000000001",
"patientControlNumber": "12345",
"timeOfResponse": "2020-09-25T18:13:48.136-05:00",
"claimType": "PRO",
"formatVersion": "5010"
},
"meta": {
"submitterId": "999898",
"senderId": "Xxxx.Xxxxxx",
"billerId": "009998",
"traceId": "900773a9-c0ba-6aa2-0f61-cfcc30a0200f",
"applicationMode": "pro"
}
}
```
Updated 7 months ago