Claims Responses and Reports V1 FAQs

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NOTE

Change Healthcare is deprecating the Claims Responses and Reports v1 API. If you use the v1 API, you should begin using the enhanced Report V2 Release at your earliest opportunity.

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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.

How do I access the Production APIs?

Change Healthcare Medical Network Claims Responses and Reports API endpoint

https://apigw.changehealthcare.com/medicalnetwork/reports/v1/

This endpoint shows a list of all 277 files (X3 prefix) and 835 files (R5 prefix). The contents of these files are in EDI format.

Search for a specific file

https://apigw.changehealthcare.com/medicalnetwork/reports/v1/

Endpoint to translate a 277 EDI report file to JSON

https://apigw.changehealthcare.com/medicalnetwork/reports/v1/X3000000.XX/

Endpoint to translate an 835 EDI report file to JSON

https://apigw.changehealthcare.com/medicalnetwork/reports/v1/R5000000.WA/

Delete HTTP endpoint

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

DELETE https://apigw.changehealthcare.com/medicalnetwork/reports/v1/R5000

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

277 transactions are a claim status response to an EDI 276 transaction. The 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. The 277 files use the phrase as the X3 prefix in the file name for any 277 claim status response.

The 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. The 835 files begin with the R5 prefix. These files are returned in EDI format by default. You can open such files in JSON using our /835 endpoint.

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NOTE

During the offline processing of large files/reports, because the large amount of data is being chunked during this process, it might take up to five minutes for our service to complete processing the large files/reports. Please be patient and observe the status change from "413 (processing)" to "200 (success)" before attempting the 'retry' operation.

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

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

https://apigw.changehealthcare.com/medicalnetwork/reports/v1

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

```javascript
{
    "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/v1/R5000000.XZ
13661366

X-12 EDI 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 guides.

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 environment, 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 sets of attributes is a complete claims entry in the transactions list.