Member Payment Status v1

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Member Payment Status

Overview

This API is used to allow members or other users to review the status of the member's remaining patient responsibility portion from the adjudicated claim (aka the ERA (electronic remittance advice or 835), before they submit a payment. Member Payment Status retrieves the payer's claim details which passed in the request for a member's claim. Claim details include the remaining balance and last payment information.

Member Payments Status is part of the Member Payments API suite. The Member Payments Status API allows consumers to pay their patient obligations to a provider using adjudicated claims.

Member Payments Status API is used to allow members or other users to review the status of the member's remaining patient responsibility portion from the adjudicated claim (aka the ERA–– electronic remittance advice––or 835), before they submit a payment. Member Payment Status retrieves the payer's claim details which passed in the request for a member's claim. Claim details include the remaining balance, last payment information, and whether additional payments are allowed.

FAQs

What will be returned for a request based on a Member ID?

A Member Payment Status API request sent with a member ID may be returned with an array of all claims associated with the member ID.

A request with Claim Number and Claim Number Source will be returned as an array but will typically include just one record for the requested claim.

What is the response for the Claim Number or MemberID not already in the Change Healthcare System?

System will create a claim record with a unique claimGUID and return a null value for last payment date, amount, remaining balance and claim status.

How is the remaining balance calculated?

Every claim record has an original patient obligation amount (see Claim API). All Payments, Refunds made against that claim are debited/ credited against that patient obligation amount to calculate the remaining balance in real time.

What is payment allowed?

Payment Allowed is a true/false flag that determines if a payment can be made on the obligation. Some reasons payments are disallowed include: the provider has been blocked, or the claim has a processed payment with a refund pending.

Why is a provider blocked? A provider can be blocked and unblocked only by Change Healthcare Customer Service. If the provider is blocked, then no further payments will be processed for that provider until they are unblocked.

A provider may be blocked for variety of reasons such as

  • Change Healthcare is unable to accurately locate and disburse funds to the provider.
  • Provider may choose not to receive payments from Change Healthcare
  • Compliance rules such as the provider being on the Office of Foreign Assets Control list

Change Log

API Name API Version Date Introduced Available Until
Member Payment Status v1 01/01/17 Current

Release Notes:

v1

  • Initial release