Prof. Claims Request and Response
The Professional Claims API uses a POST request. Responses to our Medical Network APIs can be lengthy due to the many data points that a payer or trading partner provides in the query response. Professional claims can have up to fifty line items (Loop 2400) in the claimInformation object (Loop 2300 in the EDI spec), each of which, reflects payer decisions on payment.
Our APIs translate back-and-forth between JSON and X12 EDI when the information departs into and returns from the medical network. All fields and JSON objects conform to the EDI 837p transaction standard.
```javascript
POST ${api_basepath}/[validation|submission] HTTP/1.1
Host: ${apigee_host}
Authorization:Bearer <Your-Access-Token>
Content-Type: application/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": "ABK",
"diagnosisCode": "S93401A"
},{
"diagnosisTypeCode": "ABF",
"diagnosisCode": "S72044G"
}],
"serviceFacilityLocation": {
"organizationName": "HAPPY DOCTORS GROUP",
"address": {
"address1": "000 address1",
"city": "city2",
"state": "tn",
"postalCode": "372030000"
}
},
"serviceLines":[ {
"serviceDate": "20180514",
"professionalService": {
"procedureIdentifier": "HC",
"lineItemChargeAmount": "25",
"procedureCode": "E0570",
"measurementUnit": "UN",
"serviceUnitCount": "1",
"compositeDiagnosisCodePointers": {
"diagnosisCodePointers": ["1","2"]
}
}
},
{
"serviceDate": "20180514",
"professionalService": {
"procedureIdentifier": "HC",
"lineItemChargeAmount": "3.75",
"procedureCode": "A7003",
"measurementUnit": "UN",
"serviceUnitCount": "1",
"compositeDiagnosisCodePointers": {
"diagnosisCodePointers": ["1" ]
}
}
}
]
}
}
```
As shown below, the sample claim contains the JSON objects:
| JSON Object | Description |
|---|---|
submitter | Provider submitting the claim. |
receiver | Payer. |
subscriber | Medical insurance policy holder. |
dependent | Dependent of the insurance policyholder receiving the care. |
providers | List of one or more providers involved in the medical care. |
claimInformation | Complete breakdown of the medical encounter and its associated charges. |
serviceLines and serviceDate | serviceLines is an array of one or more medical services, procedures, or products for the encounter each of which, is specified as a serviceDate record in the array. |
A successful validation of a professional claim gives a response similar to the following
```json
{
"status": "SUCCESS",
"controlNumber": "000000001",
"tradingPartnerServiceId": "9496",
"claimReference": {
"correlationId": "201210R999898~2014364838718969",
"submitterId": "009998999898",
"customerClaimNumber": "000000001",
"patientControlNumber": "12345",
"timeOfResponse": "2020-12-10T20:07:05.4-06:00",
"claimType": "PRO",
"formatVersion": "5010"
}
}
```
After the API validates the claim, it is ready to submit to the payer unless you want to make further changes and run the checks.
```json
{
"status": "SUCCESS",
"controlNumber": "000000001",
"tradingPartnerServiceId": "9496",
"claimReference": {
"correlationId": "201113R999898~2634061369394033",
"submitterId": "009998999898",
"customerClaimNumber": "000000001",
"patientControlNumber": "12345",
"timeOfResponse": "2020-11-13T09:30:33.29-06:00",
"claimType": "PRO",
"formatVersion": "5010",
"rhclaimNumber": "2031851503057"
}
}
```
✍️ In the sandbox request, using value: test00005 (lower case and not uppercase), for
fieldName: patientControlNumber returns a EDITS canned response.
Updated 3 months ago