Request Contents - Professional Claims

📘

NOTE

The JSON attributes in our APIs use snake-case, with the first letter of the attribute in lower case as in tradingPartnerServiceId. Our APIs are case-sensitive and your JSON request body must observe this convention.

Professional Claims request body elements

```json
{
  "controlNumber": "000000001",
  "tradingPartnerServiceId": "9496",
  "submitter": {
    "organizationName": "REGIONAL PPO NETWORK",
    "contactInformation": {
      "name": "SUBMITTER CONTACT INFO",
      "phoneNumber": "123456789"
    }
  },
  "receiver": {
    "organizationName": "EXTRA HEALTHY INSURANCE"
  },
```
AttributeDescription
controlNumberA single arbitrary value that the requestor defines in the initial Eligibility API transaction request, perhaps by a random number generator. All parties to the Eligibility transaction refer to this number to ensure accurate responses and completion of the exchange.

📝 Control Numbers must be defined as a nine-digit unsigned numeric value.
tradingPartnerServiceIdPayer ID; you can use the payer’s ConnectCenter real-time Payer ID as the tradingPartnerServiceId. The Legacy Change Healthcare (LCHC) Payer List originates this value.
serviceIdA 5-digit alphanumeric value that identifies the Eligibility service from the payer. Also listed as the “Eligibility ID” for payers in the searchable Change Healthcare Payer List.
submitterContact information for the provider's submitting organization.
receiverBasic identification field for the payer (example, insurance company) that will receive and process the claim.

Providers object

```json
  "providers": [{
    "providerType": "BillingProvider",
    "npi": "1760854442",
    "employerId": "123456789",
    "organizationName": "HAPPY DOCTORS GROUPPRACTICE",
    "address": {
      "address1": "000 address1",
      "city": "city2",
      "state": "tn",
      "postalCode": "372030000"
    },
    "contactInformation": {
      "name": "janetwo doetwo",
      "phoneNumber": "0000000001"
    }
  },{
    "providerType": "ReferringProvider",
    "npi": "1942788757",
    "firstName": "johntwo",
    "lastName": "doetwo",
    "employerId" : "123456"
  },{
    "providerType": "RenderingProvider",
    "npi": "1942788757",
    "firstName": "janetwo",
    "lastName": "doetwo",
    "middleName": "middletwo",
    "ssn" : "000000000"
  }],
```

Professional claims may have several different providers involved with a claim:

Provider TypeDescription
Billing providerRequired Provider who submits the claim to the payer. They may or may not be the same as the rendering provider.
This record is required as part of the Professional Claims request.
Referring providerRequired Record of a provider who directed the patient for care to a second provider rendering the services described in the claim. Typical cases involve a general practitioner who refers the patient to a specialist, or an orthodontist referring to an oral surgeon.
This record is required if a referral was made.
Rendering providerRequired Provider who performed the medical care or a particular medical service as part of the care, such as anesthesia.
This record is required whether or not a referral was made. If no referral was made, the billing provider will most likely be in this field.

Other required attributes

Other providers object required parameters include the following:

  • Each provider in a claim has an NPI (npi)
  • Basic provider identification including firstName, lastName, and other patient information
  • All provider records must have either an employerId or ssn included in their records

Subscriber object

AttributeDescription
subscriber JSON objectRequired Medical insurance subscriber. The object contains a number of straightforward data fields identifying the insurance policyholder, including memberId, firstName, lastName, dateOfBirth, gender, ssn and idCard( the subscriber’s insurance plan card number).
```json
    "subscriber": {
        "memberId": "0000000000",
        "firstName": "johnOne",
        "lastName": "doeOne",
        "gender": "M",
        "dateOfBirth": "18800102",
        "ssn": "000000000",
        "idCard": "card123"
    },
```

Dependents object

AttributeDescription
dependentsOptional An array of one or more records describing the dependents of the subscriber who are the recipients of medical care for the claim.
```json
  "dependents": {
    "memberId": "0000000002",
    "paymentResponsibilityLevelCode": "P",
    "firstName": "janeone",
    "lastName": "doeOne",
    "gender": "F",
    "dateOfBirth": "19800102",
    "policyNumber": "00002",
    "relationshipToSubscriberCode": "01",
    "address": {
      "address1": "123 address1",
      "city": "city1",
      "state": "wa",
      "postalCode": "981010000"
    }
```

📘

NOTE

The encounter for the claim submission may involve the subscriber or a dependent. If a dependent is not involved in the encounter, you can omit the dependent information.

The dependents object is subordinate to the subscriber.

ClaimsInformation object

Parameter
claimInformationRequired Core body of information in the submission. It contains all of the diagnosis and procedure information associated with the medical claim. All objects, parameters, and arrays in the claimInformation object are required.
```json
  "claimInformation": {
    "claimFilingCode": "CI",
    "patientControlNumber": "12345",
    "claimChargeAmount": "28.75",
    "placeOfServiceCode": "11",
    "claimFrequencyCode": "1",
    "signatureIndicator": "Y",
    "planParticipationCode": "A",
    "benefitsAssignmentCertificationIndicator": "Y",
    "releaseInformationCode": "Y",
    "claimSupplementalInformation": {
      "repricedClaimNumber": "00001",
      "claimNumber": "12345"
    },
    "healthCareCodeInformation": [{
      "diagnosisTypeCode": "BK",
      "diagnosisCode": "496"
    },{
      "diagnosisTypeCode": "BF",
      "diagnosisCode": "25000"
    }],
    "serviceFacilityLocation": {
      "organizationName": "HAPPY DOCTORS GROUP",
      "address": {
        "address1": "000 address1",
        "city": "city2",
        "state": "tn",
        "postalCode": "372030000"
      }
      },
    "serviceLines":[ {
      "serviceDate": "20050514",
      "professionalService": {
        "procedureIdentifier": "HC",
        "lineItemChargeAmount": "25",
        "procedureCode": "E0570",
        "measurementUnit": "UN",
        "serviceUnitCount": "1",
        "compositeDiagnosisCodePointers": {
          "diagnosisCodePointers": ["1","2"]
        }
      }
      },
      {
        "serviceDate": "20050514",
        "professionalService": {
          "procedureIdentifier": "HC",
          "lineItemChargeAmount": "3.75",
          "procedureCode": "A7003",
          "measurementUnit": "UN",
          "serviceUnitCount": "1",
          "compositeDiagnosisCodePointers": {
            "diagnosisCodePointers": ["1" ]
          }
        }
        }
    ]

  }
```

📘

NOTE

The JSON objects described in the following section are all required for professional claim submissions; all of their respective fields except where noted, are also required. For more details on individual JSON data fields in these objects, including optional fields that do not appear in the API request bodies for our Postman collections but that can be used in your requests, see the Claims Submission Professional API attachment document.

Key ClaimInformation attributes

The important, required attributes for the leading elements of the claimInformation object include the following:

Required AttributesDescription
patientControlNumberIdentifier used to track a claim from its creation by the health care provider through payment.
claimFilingCodeSubscriber claim filing code: describes the type of payment. In the preceding claimInformation object, example, CI indicates that the payment is through commercial insurance.
claimChargeAmountThe total cost of all line items in the claim.
planParticipationCodeUsed by a health plan to show that the provider does or does not accept the assignment of benefits.
benefitsAssignmentCertificationIndicatorA code showing whether the provider has a signed form authorizing the third-party payer to pay the provider.
releaseInformationCodeIndicates whether the patient has agreed to share personal health information (PHI). Normally, answers in this attribute will be:
O for "On file with payer"
"Y"
*Claim risks rejection by the payer
repricedClaimNumberIdentification number, assigned by a repricing organization to identify an adjusted claim. The values are governed by the Washington Publishing Company and are not available without payment.
claimNumberAssigned claim number.

Claim filing payment codes

Claim Filing payment codes are limited to the following (this table is from the United States Health Information Knowledge-base):

CodeDefinition
09Self-pay
11Other non-federal programs
12Preferred Provider Organization (PPO)
13Point-of-service
14Exclusive Provider Organization (EPO
15Indemnity Insurance
16Health Maintenance Organization (HMO) Medicare Risk
17Dental Maintenance Organization
AMAutomobile Medical
IBLBlue Cross/Blue Shield
CHCHAMPUS
CICommercial Insurance Co.
DSDisability
FIFederal Employees Program
HMHealth Maintenance Organization
LMLiability Medical
MAMedicare Part A
MBMedicare Part B
MCMedicaid
OFOther Federal Program
TVTitle V
VAVeterans Affairs Plan
WCWorkers' Compensation Health Claim
ZZMutually Defined

HealthCareCodeInformation object

Required

This object contains the alphanumeric Healthcare Common Procedure Coding System (HCPCS) codes that the provider enters. The codes are associated with the procedures rendered for the patient. The healthCareCodeInformation object also contains other vital code values required for accurate billing and claims settlement. A full description of the HCPCS is beyond the scope of this document, but the coding definitions are available free of charge from the Centers for Medicare and Medicaid Services.

ServiceLines object

Required

The serviceLines object describes one or more line items, each listed in the object as a serviceDates record. Each serviceLine procedure must be unique, but they may share the same date or different dates, as anyone would be aware after the visit to the doctor.

Each serviceDates record describes a procedure (procedureCode) carried out with the patient, using standard HCPCS codes. In the preceding claimsInformation object example, two serviceDates records describe two procedures, each with a code: E0570 and A7003. Each also has a lineItemChargeAmount. Both take place on the same date.

Providers code only for the specific service lines in which the provider specializes, so procedureIdentifier and procedureCode codes will typically use only a small range of values. These codes come out of a very large set of insurance codes that are managed and updated by the Centers for Medicare and Medicaid (CMS) and mandated by Health Insurance Portability and Accountability Act (HIPAA). Diagnosis codes may be more complex, so ensure that your API implementation accounts for the ability to look up the relevant codes for the practice.