Integrated Rules Institutional FAQs

The Integrated Rules Institutional API is an enabling tool for making complex provider claims more accurate, and more likely to be accepted and adjudicated by the pay.

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The Integrated Rules Institutional API requires the use of the Institutional Claims API for submission of claims to the payer; or, if you have another workflow for claims submissions, you may use that instead.

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See the API Examples section on the left panel in the developer portal.

How do I submit my edited claims?

Please see example in Submit Edited Claims.

What do Integrated Rules Institutional submissions look like?

Please see example in Integrated Rules Institutional Submission and Response.

The Integrated Rules Institutional API uses the POST request. You simply submit the institutional claim to the Integrated Rules API. It goes to work on your claim data, using the Knowledge Packs you have chosen for your account. It does not submit your claim to the payer. Institutional claims can contain up to 999 service line entries, so using the Integrated Rules API can be very helpful in this context.

Our APIs translate back and forth between JSON and X12 EDI when the information departs into and returns from the medical network. All fields and JSON objects conform to the EDI 837i transaction standard.

Integrated rules institutional submission example

See API Examples section.

What does a typical Integrated Rules Institutional API response look like?

After the Integrated Rules Institutional /institutionalclaims/advanced/v1/validation endpoint successfully evaluates an institutional claim, you will get a summary message stating so, with core claim reference information and a Metadata for troubleshooting. Please see example in Integrated Rules Institutional Submission and Response.

Claim Reference information

The claimReference object contains a number of tracking values. You can expect to see results similar to the following:

JSON Response ObjectDescription
json { "status": "SUCCESS", "controlNumber": "000000001", "tradingPartnerServiceId": "9496", "claimReference": { "correlationId": "210322R999898~66684261175841", "submitterId": "009998", "customerClaimNumber": "000000001", "patientControlNumber": "12345", "timeOfResponse": "2021-03-22T19:34:08.85-05:00", "claimType": "PRO", "formatVersion": "5010", "rhclaimNumber": "2108151508527" }, [meta object here] }, "editStatus": "SUCCESS", "payer": { "payerName": "Unknown", "payerID": "9496" }, The first response you get back from the clearinghouse does not indicate whether the claim is being paid; it indicates that the clearinghouse has accepted the claim and is getting ready to forward it to the payer.
claimReference is the response's main object.

Key values include the following:
customerClaimNumber: An additional claim tracking number assigned by the Change Healthcare clearinghouse.
submitterId: Describes the entity that submitted the claim. Value is in Loop 1000A, element NM109.
patientControlNumber: Echoes the Patient controlNumber back from the original request.
timeOfResponse: Date and time of the response from the clearinghouse.
formatVersion: describes the X12 EDI version to which the claim conforms.
claimType: "PRO" for Professional or "INST" for Institutional.
rhClaimNumber - Unique claim number to track the claim at the Change Healthcare clearinghouse. You can use this value to search for the claim in ConnectCenter and check for updates.
If the Integrated Edits evaluation was successful, it reports an editStatus of "SUCCESS" and the claim will be forwarded to the payer.

Does the Integrated Rules Institutional API have a Submission endpoint?

No, it does not. When you finish evaluating and correcting your claim through the Integrated Rules Institutional API, you can submit your corrected claim through the standard Institutional Claims API institutionalclaims/v1/submission endpoint or through your accustomed workflow for that task.

The Integrated Rules Institutional API is designed as a complementary product for use with the Institutional Claims API.

How do Raw-X12 Validation requests and responses work?

See X12 EDI 270 Request & 271 Response.

What is the biggest value-add from using this API?

See biggest value-add from using this API.

Does your API support HIPAA Validations?

See HIPAA Validations support.

If you use a different claim submission workflow, you can also submit your claim that way. Consult your Optum representative for more information.

What is the difference between an Institutional claims and a Professional claims?

See difference between a Professional claim and an Institutional claim?.

What's the difference between this API and the regular Institutional Claims API?

See difference between Integrated Rules Institutional API and the regular Institutional Claims API.

Are there guidelines for predicting the rate of unique claims submitted for a practice?

Rates of unique claims are isolated to each individual provider. Every provider is different. Whenever you render a medical service, file a claim.

The Institutional Claims API FAQs topic discusses about many informative items that describe the various features and reasons to use the Institutional Claims API.

How do Raw-X12 Validation requests and responses work?

Please see example in X12 EDI 270 Request & 271 Response.

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When your EDI formatted request is corrected and validated, use your normal claim submission workflow to submit the claim. The Institutional Claims v1 API does not directly support the X12 EDI submissions.

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