Integrated Rules Professional FAQs

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The Integrated Rules Professional API requires the use of the Professional Claims API for submission of claims to the payer. If you have another workflow for claims submissions, you may use that instead.

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See the API Examples section on the left pane in the developer portal.

What does a typical Integrated Rules Professional API call look like?

The input is a complete professional claims that you submit as the request body, as you would with a standard professional claims submission. Please see example in Integrated Rules Professional Request & Response.

What does an Integrated Rules Professional API response look like?

After the Integrated Rules Professional /professionalclaims/advanced/v1/validation endpoint successfully evaluates a professional claim, you will get a summary message stating so, with core claim reference and a Metadata for troubleshooting information. Please see example in Integrated Rules Professional Request & Response.

Validation API issues in the claim evaluation example

When the validation API encounters issues in the claims evaluation, it will list each in the reply. Please see example in Validation Endpoint Issue. For more information, see Error types in Professional claims.

How do I submit my edited claims?

Please see example in Submit Edited Claims.

How do Raw-X12 Validation requests and responses work?

Please see example in X12 EDI 270 Request & 271 Response.

What is the biggest value-add from using the Integrated Rules Institutional API?

For all Integrated Rules Institutional API applications, be familiar with the term Edits, which has a specific meaning in this context.

Payers control their own claims edit specifications. Edit specifications govern how medical practices must submit correct claims information for payer processing and claim adjudication. Claims Edits can change at any time, and these changes may or may not reach you before you submit an institutional claim, much less be integrated into your claims submission software.

Because of this likelihood, you may encounter unexpected errors and incur delays when filing claims, even when you think your software and processes are up to date.

These issues can occur at any time. Some medical practices may subscribe to continuous payer updates and submission edits. They receive their Claim edits notifications from the payer. Others may not do so, finding the costs prohibitive. The Integrated Rules Services team monitors regulatory requirements from Medicare and from industry organizations of many different types, and develops the Integrated Rules Knowledge Packs based upon the Packs' medical disciplines and the Rules/Edits that apply to them.

We continuously track and follow the Rules/Edits changes so you do not have to. Using the Knowledge Packs that you order as a match for your business, we tailor your Institutional Claims Integrated Rules API to your specific needs.

Knowledge packs for Institutional Claims

Currently available Knowledge Packs for Institutional Claims include the following:

  • General Billing
  • Ambulance
  • Dialysis/End Stage Renal Disease (ESRD) (Institutional claims only)
  • Medicare
  • Post Acute Care
  • Prior Authorization
  • Institutional claims from Rural Health Clinics and Federally Qualified Health Centers (Rural FQHC)
  • Medical Necessity
  • National Correct Coding Initiative (NCCI)
  • Therapy (Institutional claims with Therapy Revenue Code, HCPCS/CPT-4 codes)
  • Validation Codes

Providers of each of the various Edit/Rule types select the Knowledge Packs that fits their needs. Rules within each category also may apply to specific Payers. For example, rules within the Durable Medical Equipment pack may be applicable for Aetna or for Medicare.

Another benefit: not all fields in an Institutional Claim request will be applicable for every service. A single claim may be a very substantial request body. Our Rules and Knowledge Packs enable you to narrow your claims down to the bodies of information that are only necessary for your claim type.

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Edits are directly comparable to individual validation rules in our API, hence we use the term Integrated Rules for our API.

The majority of Integrated Rules Claims Edit categories support both Professional and Institutional claims. Some Edit/Rule categories are supported only through Institutional claims; others are supported only by Professional claims and hence are not listed here.

Does your API support HIPAA Validations?

Our Institutional Claims Integrated Rules EDI supports the following Edit Types and compliance checking for HIPAA Types 1 through 7:

HIPAA TypeDescription
Type 1 EDI Standard Integrity TestingValidate basic syntactical integrity of the EDI submission.
Type 2 HIPAA Implementation Guide Requirement TestingValidate HIPAA requirement-guide-specific syntax requirement by checking limits on repeat counts, used or not used qualifiers, code, elements, and segments.
Type 3 HIPAA Balance TestingValidate that claim line items amounts are equal to total claim amount.
Type 4 HIPAA Inter-Segment Situation TestingValidate inter-segment relationship. For example, if element A exists, element B must be populated.
Type 5 HIPAA External Code Set TestingValidate specific code set values for HIPAA standards.
Type 6 Product Type/Type of Service TestingValidate that segments that differ based on certain Healthcare services are properly created and processed.
Type 7 Trading Partner-Specific TestingCompliance with payer specific requirement.

What does a typical Integrated Rules Institutional API response look like?

After the Integrated Rules Institutional /institutionalclaims/advanced/v1/validation endpoint successfully evaluates an institutional claim, you will get a summary message stating so, with core claim reference information see claim reference and Metadata for troubleshooting. Please example in, Integrated Rules Institutional Submission and Response.

Validation API issue

When the validation API encounters issues, it will list each in the reply. See example in Validation Endpoint Issue.

Claim Reference information

The claimReference object contains a number of tracking values. You can expect to see results similar to: ClaimReference Field in Submission Response.

How do Raw-X12 Validation requests and responses work?

See example in, RAW-12 Validation Requests & Responses.

What's the difference between the Integrated Rules API and the regular Institutional Claims API?

The standard /institutionalclaims/v1/validation endpoint uses a separate set of rules and logic for scrubbing an institutional claim, and is automatically applicable across a range of institutional specialties. The Integrated Rules Institutional API provides greater specialization through the selection of Knowledge Packs to support your provider's medical specialties. It can be considered complementary to the standard Institutional Claims API.

What's the difference between a Professional claim and an Institutional claim?

Professional billing typically uses the 837p transaction (or the CMS-1500 form in hard copy); Institutional billings use the 837i transaction. We support both types of electronic claims and transactions. Institutional billing also sometimes encompasses collections while Professional claims and billing typically do not. Professional billing controls the billing of claims generated for work performed by physicians, suppliers, and other non-institutional providers for both outpatient and inpatient services. People handling Professional claims typically understand both billing and insurance coding. Our APIs help support and automate insurance coding.

What's the difference between standard Professional Claims API and the regular Integrated Rules Professional Claims API?

The standard /professionalclaims/v3/validation endpoint uses a separate set of rules and logic for scrubbing a professional claim, and is applicable across a range of professional specialties. The Integrated Rules Professional API provides greater specialization through the selection of Knowledge Packs to support your provider's medical specialties.

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