Claims Lifecycle AI v2

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Overview

Claims Lifecycle AI aims to drive insight, guidance, direction, and root causes for any predicted outcome of a claim. Results can provide substantial administrative and operational cost savings.

API Onboarding

See the Security and Authorization section in this portal to learn more about using our APIs. Most of our APIs are private and require credentials to gain access.

After receiving your client_id and client_secret for our sandbox environment, you can test the API from within our interactive documentation, using an application such as Postman, or from your own stack.

Try our Postman Collection Run in Postman

How does Claims Lifecycle AI compare with other solutions in the industry?

Claims Lifecycle AI is built to deliver real-time value with the customer in mind. Change Healthcare has one of the largest healthcare networks in the country which puts it at an advantage to leverage billions of transactions of data in order to provide more accurate results. Our solution is driven by machine learning and artificial intelligence, eliminating manual effort spent creating rules and edits.

What kind of data is expected to be supplied to get a prediction?

Submit all the values found on the full claim in JSON and the API will make a prediction based on the relevant attributes.

What can I expect the response to tell me?

Here is a list of what you can expect to see in the response:

  • The API supplies predictions on two levels: the propensity to deny at the claim and line levels

  • Top three subcategories for denial, along with a confidence score

  • Top three ERA CARC codes, along with a confidence score

For more in-depth information, see the Open API spec.

What does a typical API call look like?

This API uses a POST HTTPS call. You will provide the input as JSON in the body of the request.

{
  "precisionThreshold": 0.95,
  "billerId": "",
  "billing": {
    "address": {
      "address1": "",
      "address2": "",
      "city": "",
      "postalCode": "029193228",
      "state": ""
    },
    "commercialNumber": "",
    "contactInformation": {
      "email": "",
      "faxNumber": "",
      "name": "",
      "phoneNumber": "",
      "validContact": true
    },
    "employerId": "",
    "firstName": "",
    "lastName": "",
    "locationNumber": "",
    "middleName": "",
    "npi": "",
    "organisationName": "",
    "providerType": "",
    "providerUpinNumber": "",
    "ssn": "",
    "stateLicenseNumber": "",
    "taxonomyCode": "225100000X",
    "validBillingProvider": true,
    "validProvider": true
  },
  "claimInformation": {
    "benefitsAssignmentCertificationIndicator": "Y",
    "claimChargeAmount": "",
    "claimContractInformation": {
      "contractAmount": "",
      "contractCode": "",
      "contractPercentage": "",
      "contractTypeCode": "",
      "contractVersionIdentifier": "",
      "termsDiscountPercentage": ""
    },
    "claimDateInformation": {
      "accidentDate": "",
      "acuteManifestationDate": "",
      "admissionDate": "",
      "assumedAndRelinquishedCareBeginDate": "",
      "assumedAndRelinquishedCareEndDate": "",
      "authorizedReturnToWorkDate": "",
      "disabilityBeginDate": "",
      "disabilityEndDate": "",
      "dischargeDate": "",
      "firstContactDate": "",
      "hearingAndVisionPrescriptionDate": "",
      "initialTreatmentDate": "",
      "lastMenstrualPeriodDate": "",
      "lastSeenDate": "",
      "lastWorkedDate": "",
      "lastXRayDate": "",
      "repricerReceivedDate": "",
      "symptomDate": ""
    },
    "claimFilingCode": "CI",
    "claimFrequencyCode": "1",
    "claimSupplementalInformation": {
      "carePlanOversightNumber": "",
      "claimControlNumber": "",
      "claimNumber": "",
      "cliaNumber": "",
      "demoProjectIdentifier": "",
      "investigationalDeviceExemptionNumber": "",
      "mammographyCertificationNumber": "",
      "medicalRecordNumber": "",
      "medicareCrossoverReferenceId": "",
      "priorAuthorizationNumber": "",
      "referralNumber": "",
      "reportInformation": {
        "attachmentControlNumber": "",
        "attachmentReportTypeCode": "",
        "attachmentTransmissionCode": ""
      },
      "repricedClaimNumber": "",
      "serviceAuthorizationExceptionCode": ""
    },
    "healthCareCodeInformation": [
      {
        "diagnosisCode": "S76111D",
        "diagnosisTypeCode": ""
      },
      {
        "diagnosisCode": "M25551",
        "diagnosisTypeCode": ""
      }
    ],
    "patientAmountPaid": "",
    "patientControlNumber": "",
    "patientWeight": "",
    "placeOfServiceCode": "11",
    "planParticipationCode": "",
    "propertyCasualtyClaimNumber": "",
    "releaseInformationCode": "",
    "serviceFacilityLocation": {
      "address": {
        "address1": "",
        "address2": "",
        "city": "",
        "postalCode": "",
        "state": ""
      },
      "organizationName": ""
    },
    "serviceLines": [
      {
        "assignedNumber": "1",
        "professionalService": {
          "compositeDiagnosisCodePointers": {
            "diagnosisCodePointers": [
              ""
            ]
          },
          "description": "",
          "lineItemChargeAmount": "",
          "measurementUnit": "",
          "placeOfServiceCode": "11",
          "procedureCode": "97110",
          "procedureIdentifier": "HC",
          "procedureModifier1": "GP",
          "serviceUnitCount": ""
        },
        "providerControlNumber": "",
        "serviceDate": ""
      },
      {
        "assignedNumber": "2",
        "professionalService": {
          "compositeDiagnosisCodePointers": {
            "diagnosisCodePointers": [
              ""
            ]
          },
          "description": "",
          "lineItemChargeAmount": "",
          "measurementUnit": "",
          "placeOfServiceCode": "11",
          "procedureCode": "97140",
          "procedureIdentifier": "HC",
          "procedureModifier1": "GP",
          "serviceUnitCount": ""
        },
        "providerControlNumber": "",
        "serviceDate": ""
      },
      {
        "assignedNumber": "3",
        "professionalService": {
          "compositeDiagnosisCodePointers": {
            "diagnosisCodePointers": [
              ""
            ]
          },
          "description": "",
          "lineItemChargeAmount": "",
          "measurementUnit": "",
          "placeOfServiceCode": "11",
          "procedureCode": "97035",
          "procedureIdentifier": "HC",
          "procedureModifier1": "GP",
          "serviceUnitCount": ""
        },
        "providerControlNumber": "",
        "serviceDate": ""
      },
      {
        "assignedNumber": "4",
        "professionalService": {
          "compositeDiagnosisCodePointers": {
            "diagnosisCodePointers": [
              ""
            ]
          },
          "description": "",
          "lineItemChargeAmount": "",
          "measurementUnit": "",
          "placeOfServiceCode": "11",
          "procedureCode": "97110",
          "procedureIdentifier": "HC",
          "procedureModifier1": "GP",
          "serviceUnitCount": ""
        },
        "providerControlNumber": "",
        "serviceDate": ""
      },
      {
        "assignedNumber": "5",
        "professionalService": {
          "compositeDiagnosisCodePointers": {
            "diagnosisCodePointers": [
              ""
            ]
          },
          "description": "",
          "lineItemChargeAmount": "",
          "measurementUnit": "",
          "placeOfServiceCode": "11",
          "procedureCode": "97140",
          "procedureIdentifier": "HC",
          "procedureModifier1": "GP",
          "serviceUnitCount": ""
        },
        "providerControlNumber": "",
        "serviceDate": ""
      },
      {
        "assignedNumber": "6",
        "professionalService": {
          "compositeDiagnosisCodePointers": {
            "diagnosisCodePointers": [
              ""
            ]
          },
          "description": "",
          "lineItemChargeAmount": "",
          "measurementUnit": "",
          "placeOfServiceCode": "11",
          "procedureCode": "97035",
          "procedureIdentifier": "HC",
          "procedureModifier1": "GP",
          "serviceUnitCount": ""
        },
        "providerControlNumber": "",
        "serviceDate": ""
      }
    ],
    "signatureIndicator": ""
  },
  "controlNumber": "EP031618788465567",
  "date": "",
  "dependent": {
    "dateOfBirth": "",
    "firstName": "",
    "gender": "F",
    "lastName": "",
    "middleName": "",
    "relationshipToSubscriberCode": "18",
    "ssn": "",
    "address": {
      "state": "RI"
    }
  },
  "providers": [
    {
      "address": {
        "address1": "",
        "address2": "",
        "city": "",
        "postalCode": "",
        "state": ""
      },
      "commercialNumber": "",
      "contactInformation": {
        "email": "",
        "faxNumber": "",
        "name": "",
        "phoneNumber": "",
        "validContact": true
      },
      "employerId": "",
      "firstName": "",
      "lastName": "",
      "locationNumber": "",
      "middleName": "",
      "npi": "",
      "organisationName": "",
      "providerType": "",
      "providerUpinNumber": "",
      "ssn": "",
      "stateLicenseNumber": "",
      "taxonomyCode": "",
      "validBillingProvider": true,
      "validProvider": true
    }
  ],
  "receiver": {
    "organizationName": "",
    "taxId": ""
  },
  "referring": {
    "address": {
      "address1": "",
      "address2": "",
      "city": "",
      "postalCode": "",
      "state": ""
    },
    "commercialNumber": "",
    "contactInformation": {
      "email": "",
      "faxNumber": "",
      "name": "",
      "phoneNumber": "",
      "validContact": true
    },
    "employerId": "",
    "firstName": "",
    "lastName": "",
    "locationNumber": "",
    "middleName": "",
    "npi": "",
    "organisationName": "",
    "providerType": "",
    "providerUpinNumber": "",
    "ssn": "",
    "stateLicenseNumber": "",
    "taxonomyCode": "",
    "validBillingProvider": true,
    "validProvider": true
  },
  "rendering": {
    "address": {
      "address1": "",
      "address2": "",
      "city": "",
      "postalCode": "",
      "state": ""
    },
    "commercialNumber": "",
    "contactInformation": {
      "email": "",
      "faxNumber": "",
      "name": "",
      "phoneNumber": "",
      "validContact": true
    },
    "employerId": "",
    "firstName": "",
    "lastName": "",
    "locationNumber": "",
    "middleName": "",
    "npi": "",
    "organisationName": "",
    "providerType": "",
    "providerUpinNumber": "",
    "ssn": "",
    "stateLicenseNumber": "",
    "taxonomyCode": "",
    "validBillingProvider": true,
    "validProvider": true
  },
  "segmentCount": "",
  "submitter": {
    "contactInformation": {
      "email": "",
      "faxNumber": "",
      "name": "",
      "phoneNumber": "",
      "validContact": true
    },
    "organizationName": "",
    "taxId": ""
  },
  "submitterId": "",
  "subscriber": {
    "address": {
      "address1": "",
      "address2": "",
      "city": "",
      "postalCode": "",
      "state": "RI"
    },
    "dateOfBirth": "",
    "firstName": "",
    "gender": "",
    "groupNumber": "",
    "lastName": "",
    "memberId": "",
    "middleName": "",
    "paymentResponsibilityLevelCode": "",
    "policyNumber": "",
    "ssn": "",
    "standardHealthId": ""
  },
  "time": "",
  "tradingPartnerId": "",
  "tradingPartnerName": "",
  "tradingPartnerServiceId": "60054",
  "validSubscriber": true
}


What does a typical API Response look like?

The response is an object containing the version of the model that scored the claims on the request, an array of claims and lines along with predictions, and advice about the subcategories of denials per line and suggested ERA response codes. Probabilities are numbers between 0 and 1 (representing least likely and most likely respectively).

{
  "requestId": "string",
  "modelVersion": "string",
  "claims": [
    {
      "claimId": "string",
      "claimDenied": true,
      "daysToPay": "string",
      "drg": true,
      "lines": [
        {
          "lineId": "string",
          "lineDenied": true,
          "allowedAmount": 0,
          "denialReasons": [
            {
              "reason": "string",
              "eraCarcCodes": [
                {
                  "code": "string",
                  "probability": 0
                }
              ],
              "probability": 0
            }
          ]
        }
      ],
      "missingRevenueCodes": {
        "missing": true,
        "codes": [
          "string"
        ]
      },
      "missingProcedureCodes": {
        "missing": true,
        "codes": [
          "string"
        ]
      },
      "errors": [
        {
          "code": "string",
          "detail": "string"
        }
      ]
    }
  ]
}

What does the precision threshold represent?

The precision threshold can be throttled as you determine your tolerance for false positives. For example, a 95% precision threshold allows for 5% of false positive results. We define false positive as the likelihood that a given scenario is true when in fact, it’s not.

Do certain fields impact the accuracy of predictions more than others?

These attributes have the greatest impact on an accurate prediction if missing in the request:

  • Trading Partner Service ID (also known as Payer ID)

  • Subscriber Claim Filing Ind Cd

  • Patient State

  • Facility Code

  • Claim Frequency Code

  • Benefits Assign Cert Indicator

  • Procedure Code

  • Procedure Code Qualifier

HTTP Response Errors

200 – Success

400 – Bad request

500 – Internal server error

X12 to JSON Mappings

Reference a mapping of the X12 Loop and Segment to the API Schema:

X12 Loop X12 Segment Medical Network Claim Schema Attributes
2300 CL101 controlNumber
2300 CLM08 claimInformation.benefitsAssignmentCertificationIndicator
2000A PRV03 billing.taxonomyCode
2010AA N403 billing.address.postalCode
2300 CLM05-3 claimInformation.claimFrequencyCode
2300 CLM05-1 claimInformation.placeOfServiceCode
2300 HI01-2 claimInformation.healthCareCodeInformation[1].diagnosisCode
2300 HI01-2 claimInformation.healthCareCodeInformation[2].diagnosisCode
2300 HI01-2 claimInformation.healthCareCodeInformation[3].diagnosisCode
2300 HI01-2 claimInformation.healthCareCodeInformation[4].diagnosisCode
2300 HI01-2 claimInformation.healthCareCodeInformation[5].diagnosisCode
2010CA DMG03 subscriber.gender, dependent.gender
2000C PAT01 dependent.relationshipToSubscriberCode
2010CA N402 subscriber.address.state, dependent.address.state
2010BB NM109 tradingPartnerServiceId
2300 HI01-2 claimInformation.healthCareCodeInformation[0].diagnosisCode
2300 REF02 claimInformation.claimSupplementalInformation. priorAuthorizationNumber
2310B,A PRV03 rendering.taxonomyCode
2300 CLM12 claimInformation.specialProgramIndicator
2000B SBR09 claimInformation.claimFilingCode
2010BA N402 subscriber.state, claimInformation.serviceLines[].assignedNumber
2400 SV501-2 claimInformation.serviceLines[].dmeService.procedureCode
2400 LIN03 claimInformation.serviceLines[].drugIdentification.nationalDrugCode
2400 SV101-2 (P), SV202-02 (I) claimInformation.serviceLines[].professionalService.procedureCode
2400 SV101-1 (P), SV202-01 (I) claimInformation.serviceLines[].professionalService.procedureIdentifier
2400 SV101-3 (P), SV202-03 (I) claimInformation.serviceLines[].professionalService.procedureModifier1
2400 SV101-4 (P), SV202-04 (I) claimInformation.serviceLines[].professionalService.procedureModifier2
2400 SV101-5 (P), SV202-05 (I) claimInformation.serviceLines[].professionalService.procedureModifier3
2400 SV201 (I) claimInformation.serviceLines[].institutionalService.revenueCode
2400 SV105 (P), CLM05-01 (I) claimInformation.serviceLines[].professionalService.placeOfServiceCode

Error Codes: https://developers.changehealthcare.com/apis/error_info

Change Log

API Name API Version Date Introduced Available Until
Claims Lifecycle AI v2 11/01/19 TBD

Release Notes:

v1

  • Initial offering of Claims Lifecycle AI