Claims Responses and Reports V2 FAQs

The Claims Responses and Reports API provides a direct connection to your mailbox where payers send their responses and reports to your claims. Use this API to access your mailbox for claim payments, claim status updates, and other communications regarding the revenue cycle from the payer.

📘

NOTE

Please see the API FAQs section for tips and solutions to some of the most common questions asked by customers, developer community, and internal staff about the use of the Change Healthcare API.

This API enables you to obtain files of the following types:

  • EDI 277 Claim Status report files — responses to EDI 276 Claim Status inquiries, that you can send using our Claim Status APIs;

  • EDI 835 Claim Payment/Advice reports — provide detailed payment information for submitted Professional or Institutional claims. 835 Transactions can be returned for Professional (837p) and
    Institutional (837i) Claim electronic submissions, and for paper and electronic CMS 1500 and
    UB04 claims submissions.

Change Healthcare Medical Network Claims Responses and Reports v2 API endpoint

https://apigw.changehealthcare.com/medicalnetwork/reports/v2/

If you run this endpoint, you will see a list of all 277 files (X3 prefix) and 835 files (*R5** prefix). The contents of these files are in EDI format.

How do I access the Claims Responses and Reports v2 production APIs?

Search for a specific file

https://apigw.changehealthcare.com/medicalnetwork/reports/v2/

Endpoint to translate a 277 EDI report file to JSON

https://apigw.changehealthcare.com/medicalnetwork/reports/v2/277

Endpoint to translate an 835 EDI report file to JSON

https://apigw.changehealthcare.com/medicalnetwork/reports/v2/835

Delete HTTP endpoint

You can delete files from your mailbox using the DELETE HTTP endpoint.

DELETE https://apigw.changehealthcare.com/medicalnetwork/reports/v2/

What types of files does this API get from the mailbox?

277 transaction is claim status response to an EDI 276 transaction.
276 transaction is a request for the status of a health care claim. It is submitted by a provider, a health care/services recipient, or an authorized agent (any of these could be the consumer of our APIs).
A 277 might be a solicited response or an unsolicited one, in which case you need to proactively use our API to check your mailbox for any new 277 claim responses. 277 files use the phrase "X3" as the prefix in the file name for any 277 claim status response.

835 responses are claims remittance notifications letting the recipient know what the payer has approved and by what percentage coverage is approved for medical services. 835 files begin with the prefix "R5". These files are returned in EDI format by default. You can open such files in JSON using our /835 API endpoint.

What information needs to go in the request header?

See API FAQs.

What does a typical Reports API request and response look like?

The core request does not send a request body, and simply queries for the entire contents of the customer's mailbox:

https://apigw.changehealthcare.com/medicalnetwork/reports/v2

The API returns a complete listing of all documents available to a customer:

```json
{
    "reports": [
        "X3000000.XX",
        "R5000000.XY",
        "R5000000.XX",
        "X3000000.AB",
        "X3000000.AC",
        "X3000000.ZZ",
        "R5000000.XZ",
        "R5000000.YZ",
        "R5000000.WA",
        "R5000000.WB"
        ...
    ]
}
```

By appending the X3 or R5 filename to the request, you will see the X12 EDI contents of the file (the following is an example; your documents will show different information):

https://apigw.changehealthcare.com/medicalnetwork/reports/v2/R5000000.XZ
13661366

X12 EDI Contents Example

What does the filename structure mean?

The API returns a list of file names with the following structure:

AAnnnnnn.XX

where:

  • AA = the two-character prefix that designates the type of file
  • nnnnnn = the six-digit submitter ID
  • XX = the two-character extension that separates files. Files begin with the prefix AA, AB, AC….A0, A1, A2…..BA, BB, BC…..ending with W9 before rolling back to AA (excluding the AU, BK, DB, DV, GI, GW, HT, JS, QT, RA, RP and WM prefixes as these are reserved).

The most common reports are the Claim Status Response (X3) and the Claim Remittance (R5). Electronic reports also exist to support all available transactions, including medical statements and Electronic Remittance Advice (ERA).

How does EDI to JSON translation work?

By appending an X3 or R5 filename to the request, you will see the X12 EDI contents of the file:

https://apigw.changehealthcare.com/medicalnetwork/reports/v1/R5000000.XZ
11811181

X12-EDI-Example

Add the 835 suffix to the path, and the API translates the same content to a more-readable JSON:

https://apigw.changehealthcare.com/medicalnetwork/reports/v1/R5000000.XZ/835
```JSON
{
    "transactions": [
        {
            "detailInfo": [
                {
                    "assignedNumber": "1",
                    "paymentInfo": [
                        {
                            "claimPaymentInfo": {
                                "claimFilingIndicatorCode": "12",
                                "claimFrequencyCode": "1",
                                "claimPaymentAmount": "500",
                                "claimStatusCode": "1",
                                "facilityTypeCode": "11",
                                "patientControlNumber": "5554555444",
                                "patientResponsibilityAmount": "300",
                                "payerClaimControlNumber": "94060555410000",
                                "totalClaimChargeAmount": "800"
                            },
                            "claimSupplementInformation":  
 (...)
```

What's the difference between Claim Status and Claim Responses and Reports?

These two APIs are complementary to one another.

Claim Status main task is to check the status of a claim in the payer’s system. If a provider has not received a payer report on a claim, or if they have not received payment, they can run a claim status request to find out the most recent state of that claim. When a claim is paid, the claim status response from the payer provides only basic payment details, and excludes the details such as payer adjustments to the total charge, the patient copays and coinsurance, and other payer adjudication details. It produces a status summary instead of a complete breakdown.

Claim Responses and Reports is a tool to fetch claims information files from your mailbox. You can get your complete claims adjudication results here. The Reports files provide deeper details on the payments for individual Service Lines, the individual amounts the payer agreed on for each, and all other relevant adjudication details.

For more information about the Claim Status API, go to the Claim Status API Reference page and the Claim Status API.

How do I convert an EDI Reports file to JSON?

You specify the Report file in the request URL, including its two-letter extension, along with the correct endpoint type. The endpoint will always be either /277 or /835.

  • Example using our sandbox test values:
https://apigw.changehealthcare.com/medicalnetwork/reports/v2/X3000000.XX/835

The file, which is available in the sandbox API implementation, is for a relatively brief single-claim 277 claim status response.

```json
{
    "transactions": [
        {
            "controlNumber": "0001",
            "referenceIdentification": "000000001",
            "transactionSetCreationDate": "20201201",
            "transactionSetCreationTime": "120558",
            "payers": [
                {
                    "organizationName": "PREMERA",
                    "payerIdentification": "430",
                    "claimStatusTransactions": [
                        {
                            "provider": {
                                "organizationName": "CHC3",
                                "etin": "000000000"
                            },
                            "claimStatusDetails": [
                                {
                                    "serviceProvider": {
                                        "organizationName": "HAPPY DOCTORS GROUP",
                                        "npi": "1111111111"
                                    },
                                    "patientClaimStatusDetails": [
                                        {
                                            "subscriber": {
                                                "lastName": "DOEONE",
                                                "firstName": "JOHNONE",
                                                "memberId": "0000000000"
                                            },
                                            "claims": [
                                                {
                                                    "claimStatus": {
                                                        "referencedTransactionTraceNumber": "000000001",
                                                        "informationClaimStatuses": [
                                                            {
                                                                "statusInformationEffectiveDate": "20200613",
                                                                "totalClaimChargeAmount": "100",
                                                                "claimPaymentAmount": "80",
                                                                "adjudicatedFinalizedDate": "20200609",
                                                                "remittanceDate": "20200613",
                                                                "remittanceTraceNumber": "1111111",
                                                                "informationStatuses": [
                                                                    {
                                                                        "healthCareClaimStatusCategoryCode": "F1",
                                                                        "healthCareClaimStatusCategoryCodeValue": "Finalized/Payment-The claim/line has been paid.",
                                                                        "statusCode": "65",
                                                                        "statusCodeValue": "Claim/line has been paid."
                                                                    }
                                                                ]
                                                            }
                                                        ],
                                                        "tradingPartnerClaimNumber": "AAAAAAAAAAA1",
                                                        "patientAccountNumber": "00000",
                                                        "clearinghouseTraceNumber": "111111111111111",
                                                        "claimServiceBeginDate": "20200214",
                                                        "claimServiceEndDate": "20200214"
                                                    },
                                                    "serviceLines": [
                                                        {
                                                            "service": {
                                                                "serviceIdQualifierCode": "HC",
                                                                "serviceIdQualifierCodeValue": "Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes",
                                                                "procedureCode": "97161",
                                                                "procedureModifiers": [
                                                                    "95"
                                                                ],
                                                                "chargeAmount": "100",
                                                                "amountPaid": "80",
                                                                "submittedUnits": "1"
                                                            },
                                                            "serviceClaimStatuses": [
                                                                {
                                                                    "effectiveDate": "20200613",
                                                                    "serviceStatuses": [
                                                                        {
                                                                            "healthCareClaimStatusCategoryCode": "F1",
                                                                            "healthCareClaimStatusCategoryCodeValue": "Finalized/Payment-The claim/line has been paid.",
                                                                            "statusCode": "65",
                                                                            "statusCodeValue": "Claim/line has been paid."
                                                                        }
                                                                    ]
                                                                }
                                                            ],
                                                            "beginServiceLineDate": "20200214",
                                                            "endServiceLineDate": "20200214"
                                                        }
                                                    ]
                                                }
                                            ]
                                        }
                                    ]
                                }
                            ]
                        }
                    ]
...
```

The lengthy example is a completed record for a single claim in a multiple-claim report.

You can determine how many claims the current 277 file contains by looking for the following three JSON attributes in a group:

```json
                    "organizationName": "PREMERA",
                    "payerIdentification": "430",
                    "claimStatusTransactions": [
```

Each of these attributes is a complete claims entry in the transactions list.

What are the most important contents of the 277 and 835 Reports?

Key JSON attributes of any list of multiple payouts in an 835 report include the following:

Attribute

Definition

claimPaymentInfo

Multiple instances, each for a different patient claim, all of which are unique in the report. This line defines the beginning of each completed claim within the report.

payee

One for each report. This is the provider or institution receiving the payments.

payer

One medical insurance payer for each 835 report. Any single Reports file, no matter how many claim records in the transaction list, will have only one Payer. The Payer is unique for each file.

serviceLines

Array containing all medical services rendered by the medical provider(s) for the individual patient in each claim. This is arranged just under the patientName and renderingProvider identifying information. Also watch the serviceDate attribute instances, which illustrate each individual procedure giving rise to medical service payment requests to the Payer in a claim. Each of these contain the insurance-adjusted payments agreed to by the Payer.

Here is a somewhat typical serviceLines array record for a dental encounter:

```json

                            "serviceLines": [
                                {
                                    "serviceDate": "20190313",
                                    "servicePaymentInformation": {
                                        "productOrServiceIDQualifier": "AD",
                                        "productOrServiceIDQualifierValue": "American Dental Association Codes",
                                        "adjudicatedProcedureCode": "D4342",
                                        "lineItemChargeAmount": "125",
                                        "lineItemProviderPaymentAmount": "0"
                                    },
                                    "serviceAdjustments": [
                                        {
                                            "claimAdjustmentGroupCode": "CO",
                                            "claimAdjustmentGroupCodeValue": "Contractual Obligations",
                                            "adjustmentReasonCode1": "45",
                                            "adjustmentAmount1": "125"
                                        }
                                    ]
                                },
                                {
                                    "serviceDate": "20190313",
                                    "servicePaymentInformation": {
                                        "productOrServiceIDQualifier": "AD",
                                        "productOrServiceIDQualifierValue": "American Dental Association Codes",
                                        "adjudicatedProcedureCode": "D4381",
                                        "lineItemChargeAmount": "43",
                                        "lineItemProviderPaymentAmount": "0"
                                    },
                                    "serviceAdjustments": [
                                        {
                                            "claimAdjustmentGroupCode": "PR",
                                            "claimAdjustmentGroupCodeValue": "Patient Responsibility",
                                            "adjustmentReasonCode1": "3",
                                            "adjustmentAmount1": "33"
                                        },
                                        {
                                            "claimAdjustmentGroupCode": "CO",
                                            "claimAdjustmentGroupCodeValue": "Contractual Obligations",
                                            "adjustmentReasonCode1": "45",
                                            "adjustmentAmount1": "10"
                                        }
                                    ]
                                },
...
```

Each line item specifies whether the payer agrees to pay any cash for each line item. In the preceding example, the lineItemProviderPaymentAmount for each indicates that the provider did not apply any discounts or on-site payments towards the procedure. Each individual adjudicatedProcedureCode denotes the procedure line item. The 'serviceAdjustments` object describes the payment that the payer agrees to pay for each individual line item.

For 277 reports, look for the following:

  • payers: One for each report. Any single 277 Reports file, regardless of how many claim records are in the transaction list, it will have only one Payer. The Payer is unique for each file.

  • You can quickly determine how many claims the current 277 file contains by looking for the following three JSON attributes in a group:

```json
    "organizationName": "PREMERA",
    "payerIdentification": "430",
    "claimStatusTransactions": [
```

Each of these sets of attributes is the beginning of a complete claim in the transactions list:

Attribute

Definition

claims

This attribute, which is a bit deeper into each claims record in a list of transactions, describes the completed state of the claim, including the totalClaimChargeAmount and the claimPaymentAmount along with the remittanceDate.

serviceLines

As with 835s, the serviceLines objects describe the details of each procedure payment for the individual claims. Added up, the cumulative amounts in the serviceLines go into the totalClaimChargeAmount and the claimPaymentAmount along with other totals.

Values in Common

Values, such as totalClaimChargeAmount and claimPaymentAmount are common to both types of reports.


Did this page help you?