{"openapi":"3.0.0","info":{"title":"Claim ACTIONS api","description":"Claim Actions api","version":"1.0.0"},"servers":[{"url":"https://sandbox-apigw.optum.com"}],"paths":{"/oihub/claim/actions/v1":{"post":{"security":[{"oAuth":["read_healthcheck"]}],"parameters":[{"name":"providerTaxId","in":"header","description":"Provider Tax ID","required":true,"schema":{"example":"123456789","type":"string"}},{"name":"x-optum-consumer-correlation-id","in":"header","description":"Unique UUID to track the transaction","required":false,"schema":{"example":"4d4a8964-e5fa-42dc-a37d-12345789","type":"string"}},{"name":"environment","in":"header","description":"Environment","required":false,"schema":{"example":"sandbox","type":"string"}}],"operationId":"claimActions","summary":"Call Claim Actions API","responses":{"200":{"description":"Successful response","content":{"application/json":{"schema":{"properties":{"errors":{"type":"array","description":"List of errors that occurred during Claim Actions","items":{"properties":{"description":{"description":"Detailed error message","type":"string"},"code":{"description":"Error code identifying the specific error","type":"string"}},"type":"object"}},"data":{"properties":{"claimSubmissionResponse":{"$ref":"#/components/schemas/ClaimSubmissionResponse","description":""},"claimTicketResponse":{"$ref":"#/components/schemas/ClaimTicketResponse","description":""}},"type":"object"}},"type":"object"},"examples":{"SubmitClaimWithPreCheck":{"value":{"data":{"claimSubmission":{"transactionId":"8841512345678901","x12ResponseData":"ISA*00*          *00*          *ZZ*87726          *ZZ*B00099999805   *250911*1927*^*00501*000000000*0*P*:~GS*FA*87726_B2B*B00099999805*20250911*1927*0*X*005010X231A1~ST*999*0001*005010X231A1~AK1*HC*1*005010X222A1~AK2*837*0001*005010X222A1~IK5*A~AK9*A*1*1*1~SE*6*0001~GE*1*0~IEA*1*000000000~","responseType":"837999","x12Response277CA":"ISA*00*          *00*          *ZZ*87726          *ZZ*B00099999805   *250911*1927*^*00501*000000000*0*P*:~GS*HN*87726_B2B*B00099999805*20250911*192706*0*X*005010X214~ST*277*0001*005010X214~BHT*0085*08*AB829992000298311665.1*20250911*192706*TH~HL*1**20*1~NM1*AY*2*INGENIXENS*****46*87726~TRN*1*AB829992000298311665.1~DTP*050*D8*20250911~DTP*009*D8*20250911~HL*2*1*21*1~NM1*41*2*B00099999805*****46*ENS~TRN*2*1~STC*A1:19*20250911*WQ*170~QTY*90*1~AMT*YU*170~HL*3*2*19*1~NM1*85*2*COVENANT MULTISPECIALTY GROUP, LLC*****XX*1942376918~TRN*1*1~QTY*QA*1~AMT*YU*170~HL*4*3*PT~NM1*QC*1*BROWN*ZIA****MI*963997463~TRN*2*CMG.126559~STC*A3:21*20250911*U*170********Prior auth validation could not be completed due to service failure~STC*A1:19*20250911*WQ*170********[BTH-V106 LOB Filters applied, ace was not called-Bypassing claim edits]~REF*D9*P3QAVH0FGU03H4~DTP*472*RD8*20241008-20241008~SE*26*0001~GE*1*0~IEA*1*000000000~","message":"Claim submitted successfully. Refer 277CA for validation outcomes.","statusCode":"000"}}},"summary":"Claim Submission With Pre-Check Response"},"SubmitClaimTicket":{"value":{"data":{"submitClaimTicket":{"ticketNumber":"PIQ-12345678","ticketStatus":"Under Review","preSignedUrl":"https://AWS-pre-signed-url"}}},"summary":"Claim Ticket Submission Response"},"SubmitClaimAttachment":{"value":{"data":{"submitClaimAttachment":{"attachmentId":"1234-1111-46a9-111-11117Cu_prov_attch_2021-11"}}},"summary":"Submit Attachment Response"}}}}},"400":{"description":"Bad Request","content":{"application/json":{"example":{"errors":[{"extensions":{"classification":"ValidationError"},"locations":[{"line":1,"column":87}],"message":"Validation error (FieldUndefined@[claimSubmission/transactionId]) : Field 'transactionId' in type 'ClaimSubmissionResponse' is undefined"}]}}}},"401":{"description":"Unauthorized","content":{"application/json":{"example":{"message":"Unauthorized","statusCode":401}}}},"500":{"description":"Internal Server Error","content":{"application/json":{"example":{"message":"Internal server error","statusCode":500}}}}},"tags":["Claim Actions"],"requestBody":{"required":true,"content":{"application/json":{"schema":{"type":"object","properties":{"query":{"description":"GraphQL query or mutation","example":"mutation SubmitClaimWithPreCheck($input: ClaimSubmissionInput!) { claimSubmission(input: $input) { transactionId x12ResponseData responseType x12Response277CA message statusCode } }\n","type":"string"},"variables":{"properties":{"input":{"$ref":"#/components/schemas/ClaimSubmissionInput","description":""},"claimTicketInput":{"$ref":"#/components/schemas/ClaimTicketInput","description":""}},"type":"object","description":"Variables for the GraphQL query"},"operationName":{"description":"Name of the GraphQL operation to execute (optional)","type":"string"}},"required":["query","variables"],"description":"GraphQL queries to fetch Claims information"},"examples":{"SubmitClaim":{"value":{"mutation":"mutation claimSubmission($input: ClaimSubmissionInput!) { claimSubmission(input: $input) { transactionId x12ResponseData responseType x12Response277CA message statusCode } }","variables":{"input":{"x12RequestData":"ISA*00*          *00*          *ZZ*BRT219996150   *ZZ*87726          *250625*0826*^*00501*888251331*1*P*:~GS*HC*BRT219996150*87726*20250625*0826*525620842*X*005010X222A1~ST*837*101770887*005010X222A1~BHT*0019*00*25062588055*20250625*0826*CH~NM1*41*2*RTS*****46*223832302~PER*IC*LORAINE GOETSCH*TE*7328735133~NM1*40*2*UNITED HEALTHCARE 1500*****46*87726~HL*1**20*1~NM1*85*2*MERCY GILBERT MEDICAL CENTER*****XX*1992735088~N3*3555 S VAL VISTA DR~N4*EDWARDSVILLE*IL*620253776~REF*EI*352263845~PER*IC*DAVIS, SARAH*TE*6185094866*FX*6185094866~HL*2*1*22*0~SBR*P*18*******ZZ~NM1*IL*1*LNLAMDA*FNTIMDA****MI*990313643~N3*201 MONTGOMERY STREET*APT 539~N4*JERSEY CITY*NJ*07302~DMG*D8*19800605*F~NM1*PR*2*UNITED HEALTH CARE*****PI*87726~N3*PO BOX 30555~N4*SALT LAKE CITY*UT*841300555~CLM*9283712345*330***11:B:1*Y*A*Y*Y~DTP*435*D8*20250624~HI*ABK:B351*ABF:D649*ABF:R600~NM1*82*1*BOLES*STEVEN*J***XX*1114031507~PRV*PE*PXC*363LA2200X~LX*1~SV1*HC:99214*165*UN*1***1:2:3~DTP*472*D8*20250624~LX*2~SV1*HC:99214*165*UN*1***1:2:3~DTP*472*D8*20250624~REF*6R*9287481400~SE*33*101770887~GE*1*525620842~IEA*1*888251331~","payerId":"P123"}},"operationName":"claimSubmission"},"summary":"Submit Claim With Pre-check Request"},"SubmitClaimTicket":{"value":{"mutation":"mutation submitClaimTicket($claimTicketInput: ClaimTicketInput!) { submitClaimTicket(claimTicketInput: $claimTicketInput) { ticketNumber ticketStatus preSignedUrl } }","variables":{"claimTicketInput":{"lineDetails":[{"lineKey":"lrlspg8hgksv971756148162162","lineAmountOwed":"450.00"}],"claimActionIdentifier":"fd00e249-fb5f-4601-a392-1ee032df61d0-1756148161470","ticketType":"RECON","ticketAction":"Create","ticketNumber":"PIQ-12345678","providerComments":"Reconsideration request","hasAttachment":true,"isAttachmentUploaded":true,"operator":{"operatorEmailId":"john.doe@gmail.com","operatorFirstName":"John","operatorLastName":"Doe","operatorPhoneNumber":"512-888-9999","operatorCity":"Minneapolis","operatorState":"MN","operatorStreet":"1555 lex ave","operatorZip":"12345"},"claimAmountOwed":"1000.00","requestReconsiderationReason":"INCORRECT_PAYMENT","placeOfServiceState":"MN","isAppealOnBehalfOfMember":false,"isExternalReviewAppeal":false,"payerId":"00123"}},"operationName":"submitClaimTicket"},"summary":"Submit Claim Ticket"}}},"multipart/form-data":{"schema":{"required":["operations","map","0"],"type":"object","properties":{"0":{"type":"string","description":"The attachment file to upload","format":"binary"},"operations":{"type":"string","description":"GraphQL mutation with variables","format":"json"},"map":{"type":"string","description":"Maps file fields in 'operations' to the file form fields","format":"json"}}}}}}}}},"components":{"schemas":{"AttachmentInput":{"type":"object","description":"Represents the input for submitting a claim attachment.","properties":{"documentTypeCode":{"type":"string","description":"edi837 PWK01 report type code: M1 (Medical Recs), CK (Consent Form) etc","example":"M1"},"documentName":{"type":"string","description":"document name or attachment control number","example":"attachment-control-number"},"claimReceiptLocatorNumber":{"type":"string","description":"claim FLN/claimReceiptLocatorNumber from claim inquiry","example":"9162500112345"},"claimNumber":{"type":"string","description":"claim ICN/claimNumber from claim inquiry (required for Unsolicited claim attachments)","example":"FE12345678"},"editCode":{"type":"string","description":"edit code applied to the claim","example":"EDIT123"},"expiryDate":{"type":"string","description":"expiry date","example":"2025-12-31"},"claimActionIdentifier":{"type":"string","description":"claimActionIdentifier key from claim inquiry (Required when a new ticket is being created)","example":"fd00e249-fb5f-4601-a392-1ee032df61d0-1756148161470"},"ticketNumber":{"type":"string","description":"ticket number (Required when updating an existing ticket)","example":"PIQ-12345678"},"payerId":{"type":"string","description":"payer ID","example":"00123"}},"required":["payerId","documentTypeCode"]},"ClaimSubmissionInput":{"type":"object","description":"Input data for the Claim Actions operation","properties":{"x12RequestData":{"type":"string","description":"EDI837 X12 formatted claim data","example":"ISA*00*          *00*          *ZZ*BRT219996150   *ZZ*87726          *250625*0826*^*00501*888251331*1*P*:~GS*HC*BRT219996150*87726*20250625*0826*525620842*X*005010X222A1~ST*837*101770887*005010X222A1~BHT*0019*00*25062588055*20250625*0826*CH~NM1*41*2*RTS*****46*223832302~PER*IC*LORAINE GOETSCH*TE*7328735133~NM1*40*2*UNITED HEALTHCARE 1500*****46*87726~HL*1**20*1~NM1*85*2*MERCY GILBERT MEDICAL CENTER*****XX*1992735088~N3*3555 S VAL VISTA DR~N4*EDWARDSVILLE*IL*620253776~REF*EI*352263845~PER*IC*DAVIS, SARAH*TE*6185094866*FX*6185094866~HL*2*1*22*0~SBR*P*18*******ZZ~NM1*IL*1*LNLAMDA*FNTIMDA****MI*990313643~N3*201 MONTGOMERY STREET*APT 539~N4*JERSEY CITY*NJ*07302~DMG*D8*19800605*F~NM1*PR*2*UNITED HEALTH CARE*****PI*87726~N3*PO BOX 30555~N4*SALT LAKE CITY*UT*841300555~CLM*9283712345*330***11:B:1*Y*A*Y*Y~DTP*435*D8*20250624~HI*ABK:B351*ABF:D649*ABF:R600~NM1*82*1*BOLES*STEVEN*J***XX*1114031507~PRV*PE*PXC*363LA2200X~LX*1~SV1*HC:99214*165*UN*1***1:2:3~DTP*472*D8*20250624~LX*2~SV1*HC:99214*165*UN*1***1:2:3~DTP*472*D8*20250624~REF*6R*9287481400~SE*33*101770887~GE*1*525620842~IEA*1*888251331~"},"payerId":{"type":"string","description":"Payer ID","example":"87726"}},"required":["payerId","x12RequestData"]},"ClaimSubmissionResponse":{"type":"object","description":"Response model for Claim Submission operations","properties":{"transactionId":{"type":"string","description":"unique transactionID created by the payer for the claim submission request","example":"8841512345678901"},"x12ResponseData":{"type":"string","description":"EDI x12-999 acknowledgement for the claim","example":"ISA*00*          *00*          *ZZ*BRT21345676150   *ZZ*87726          *250625*0826*^*00501*888234331*1*P*:~GS*HC*BRT2123496150*87726*20250625*0826*525620842*X*005010X222A1~ST*837*101770887*005010X222A1~BHT*0019*00*25062588055*20250625*0826*CH~NM1*41*2*RTS*****46*223832302~PER*IC*ABCD*TE*7328735133~NM1*40*2*UNITED HEALTHCARE 1500*****46*87726~HL*1**20*1~NM1*85*2*ABCD*****XX*1992735088~N3*3555 S VAL AA DR~N4*EDWARDSVILLE*IL*620253776~REF*EI*352263845~PER*IC*NAME, LAST*TE*6185094866*FX*6185094866~HL*2*1*22*0~SBR*P*18*******ZZ~NM1*IL*1*LNLAMDA*ABCD****MI*990313643~N3*201 STREET STREET*APT 123~N4* CITY*NJ*07302~DMG*D8*19800605*F~NM1*PR*2*UNITED HEALTH CARE*****PI*87726~N3*PO BOX 30555~N4*CITY*UT*841300555~CLM*9283712345*330***11:B:1*Y*A*Y*Y~DTP*435*D8*20250624~HI*ABK:B351*ABF:D649*ABF:R600~NM1*82*1*BOLES*STEVEN*J***XX*1114034507~PRV*PE*PXC*3634AL2200X~LX*1~SV1*HC:99214*165*UN*1***1:2:3~DTP*472*D8*20250624~LX*2~SV1*HC:99214*165*UN*1***1:2:3~DTP*472*D8*20250624~REF*6R*9287481400~SE*33*101770887~GE*1*525620842~IEA*1*888251331~"},"responseType":{"type":"string","description":"value describing x12ResponseData type","example":"837999"},"x12Response277CA":{"type":"string","description":"EDI x12-277 claim acknowledgement","example":"ISA*00*          *00*          *ZZ*BRT21345676150   *ZZ*87726          *250625*0826*^*00501*888234331*1*P*:~GS*HC*BRT2123496150*87726*20250625*0826*525620842*X*005010X222A1~ST*837*101770887*005010X222A1~BHT*0019*00*25062588055*20250625*0826*CH~NM1*41*2*RTS*****46*223832302~PER*IC*ABCD*TE*7328735133~NM1*40*2*UNITED HEALTHCARE 1500*****46*87726~HL*1**20*1~NM1*85*2*ABCD*****XX*1992735088~N3*3555 S VAL AA DR~N4*EDWARDSVILLE*IL*620253776~REF*EI*352263845~PER*IC*NAME, LAST*TE*6185094866*FX*6185094866~HL*2*1*22*0~SBR*P*18*******ZZ~NM1*IL*1*LNLAMDA*ABCD****MI*990313643~N3*201 STREET STREET*APT 123~N4* CITY*NJ*07302~DMG*D8*19800605*F~NM1*PR*2*UNITED HEALTH CARE*****PI*87726~N3*PO BOX 30555~N4*CITY*UT*841300555~CLM*9283712345*330***11:B:1*Y*A*Y*Y~DTP*435*D8*20250624~HI*ABK:B351*ABF:D649*ABF:R600~NM1*82*1*BOLES*STEVEN*J***XX*1114034507~PRV*PE*PXC*3634AL2200X~LX*1~SV1*HC:99214*165*UN*1***1:2:3~DTP*472*D8*20250624~LX*2~SV1*HC:99214*165*UN*1***1:2:3~DTP*472*D8*20250624~REF*6R*9287481400~SE*33*101770887~GE*1*525620842~IEA*1*888251331~"},"message":{"type":"string","description":"message describing the final outcome of the claim submission process","example":"Claim submitted successfully. Refer 277CA for validation outcomes."},"statusCode":{"type":"string","description":"status code for the submission process","example":"000"}}},"ClaimTicketInput":{"type":"object","description":"Input for submitting a claim ticket (Pend, Recon, Appeal)","properties":{"lineDetails":{"type":"array","items":{"$ref":"#/components/schemas/LineDetailInput"},"description":"selection of lineKeys from claim inquiry, to be submitted for rework"},"claimActionIdentifier":{"type":"string","description":"claimActionIdentifier key from claim inquiry (required for new ticket creation)","example":"fd00e249-fb5f-4601-a392-1ee032df61d0-1756148161470"},"ticketType":{"type":"string","description":"ticket (rework) type: PEND, RECON or APPEAL","example":"RECON"},"ticketAction":{"type":"string","description":"allowable action for the ticket (from claim inquiry): Create, Resubmit/Update","example":"Create"},"ticketNumber":{"type":"string","description":"ticket number (required if updating an existing ticket)","example":"PIQ-12345678"},"providerComments":{"type":"string","description":"provider comments elaborating claim ticket submission","example":"Reconsideration request"},"hasAttachment":{"type":"boolean","description":"boolean flag: provider intent to submit attachments substantiating the request","example":"true"},"isAttachmentUploaded":{"type":"boolean","description":"boolean flag: is/are attachments uploaded using submitClaimAttachment action","example":"true"},"operator":{"$ref":"#/components/schemas/OperatorInput","description":"details of the person submitting rework request"},"claimAmountOwed":{"type":"string","description":"expected claim amount owed by payer for reimbursement","example":"1000.00"},"requestReconsiderationReason":{"type":"string","description":"reason for submitting a Recon (select a value from claim inquiry response)","example":"INCORRECT_PAYMENT"},"placeOfServiceState":{"type":"string","description":"place of service state - required for Appeal submission","example":"MN"},"isAppealOnBehalfOfMember":{"type":"boolean","description":"boolean flag: to check if Appeal is submitted on behalf of the member","example":"false"},"isExternalReviewAppeal":{"type":"boolean","description":"boolean flag: external review Appeal","example":"false"},"payerId":{"type":"string","description":"payer ID","example":"00123"}},"required":["payerId","claimActionIdentifier","lineDetails","ticketType","ticketAction"]},"ClaimTicketResponse":{"type":"object","description":"Claim Ticket Response","properties":{"ticketNumber":{"type":"string","description":"payer generated unique identifier for the rework ticket","example":"PIQ-12345678"},"ticketStatus":{"type":"string","description":"status of the rework ticket","example":"Under Review"},"preSignedUrl":{"type":"string","description":"pre-signed URL link to upload bulk documents (as zip file) related to the rework ticket","example":"https://AWS-pre-signed-url"}}},"LineDetailInput":{"type":"object","description":"Details for a single claim line","properties":{"lineKey":{"type":"string","description":"unique line identifier for the service line from the claimStatusInquiry api","example":"lrlspg8hgksv971756148162162"},"lineAmountOwed":{"type":"string","description":"expected line amount owed by payer for reimbursement","example":"450.00"}}},"OperatorInput":{"type":"object","description":"Operator details for claim ticket","properties":{"operatorEmailId":{"type":"string","description":"operator email Id","example":"john.doe@gmail.com"},"operatorFirstName":{"type":"string","description":"operator first name","example":"John"},"operatorLastName":{"type":"string","description":"operator last name","example":"Doe"},"operatorPhoneNumber":{"type":"string","description":"operator phone number","example":"512-888-9999"},"operatorCity":{"type":"string","description":"operator city","example":"Minneapolis"},"operatorState":{"type":"string","description":"operator state","example":"MN"},"operatorStreet":{"type":"string","description":"operator street address","example":"1555 lex ave"},"operatorZip":{"type":"string","description":"operator zip code","example":"12345"}}}},"securitySchemes":{"oAuth":{"type":"oauth2","description":"This API uses OAuth 2 with the client_credentials grant flow.","flows":{"clientCredentials":{"tokenUrl":"/apip/auth/sntl/v1/token","scopes":{"read_txn":"read transactions","create_txn":"submit a new transaction request","read_coveragediscovery":"read coverage discovery tasks","create_coveragediscovery":"submit a new coverage discovery task","read_healthcheck":"check the status of the system"}}}}}},"x-readme":{"explorer-enabled":true,"proxy-enabled":true}}