Contents of the Professional Claims Request

The JSON attributes that comprise the leading elements of the Professional Claims request body are as follows:

{
  "controlNumber": "000000001",
  "tradingPartnerServiceId": "9496",
  "submitter": {
    "organizationName": "REGIONAL PPO NETWORK",
    "contactInformation": {
      "name": "SUBMITTER CONTACT INFO",
      "phoneNumber": "123456789"
    }
  },
  "receiver": {
    "organizationName": "EXTRA HEALTHY INSURANCE"
  },

• ControlNumber – a 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.

• TradingPartnerServiceId – the Payer ID. You can use the payer’s ConnectCenter Realtime Payer ID value as the tradingPartnerServiceId. The Legacy Change Healthcare (LCHC) Payer List originates this value.
• ServiceId – 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.
• Submitter – Contact information for the provider's submitting organization.
• Receiver – Basic identification field for the payer (e.g., insurance company) that will receive and process the claim.

The Providers object

  "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:

Billing provider - the 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 provider - The 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 provider - the 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 is 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.

The Subscriber Object

Required

Subscriber JSON object – the 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, which is the subscriber’s insurance plan card number.

    "subscriber": {
        "memberId": "0000000000",
        "firstName": "johnOne",
        "lastName": "doeOne",
        "gender": "M",
        "dateOfBirth": "18800102",
        "ssn": "000000000",
        "idCard": "card123"
    },

The dependents Object

Optional

Dependents – an array of one or more records describing the dependents of the subscriber who are the recipients of medical care for the claim.

  "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"
    }

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 dependent information.

The dependents object is subordinate to the subscriber.

The claimsInformation Object

Required

ClaimInformation is the 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 within the claimInformation object are required.

  "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" ]
          }
        }
        }
    ]

  }

Key Claim Information Attributes

Important attributes for the leading elements of the claimInformation object include the following:

• patientControlNumber - Identifier used to track a claim from its creation by the health care provider through payment.
• claimFilingCode - Subscriber claim filing code. It describes the type of payment. In the example above, CI indicates payment is through commercial insurance.
• claimChargeAmount - The total cost of all line items in the claim.
• planParticipationCode - Used by a health plan to show that the provider does or does not accept assignment of benefits.
• benefitsAssignmentCertificationIndicator - A code showing whether the provider has a signed form authorizing the third party payer to pay the provider.
• releaseInformationCode - Indicates whether the patient has agreed to share personal health information (PHI). Normally, answers in this attribute will be O for "On file with payer" or "Y", or the claim risks rejection by the payer.
• repricedClaimNumber - Identification number, assigned by a repricing organization, to identify an adjusted claim. Values are governed by the Washington Publishing Company and are not available without payment.
• claimNumber - the assigned claim number.

Claim Filing payment codes are limited to the following (table is from the United States Health Information Knowledgebase):

The healthCareCodeInformation Object

Required

This object contains the alphanumeric HCPCS codes (Healthcare Common Procedure Coding System) that are entered by the provider. 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.

The 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 take place on different dates, as anyone who's been to the doctor knows.

Each serviceDates record describes a procedure (procedureCode) carried out with the patient, using standard HCPCS codes. In the example above, 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 procedureIdentifiers, and procedureCodes 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 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.