Other API Questions

Do you bill for a failed claim due to technical error?

Every transaction that makes it to the clearinghouse is billable. All errors at the API level, and some errors at the ingress of the clearinghouse, are considered non-billable.

What's the difference between a Professional claim and an Institutional claim?

Professional billing typically uses the 837p transaction (or the CMS-1500 form in hardcopy); Institutional billings use the 837i transaction. We support both types of electronic claims and transactions. Institutional billing also sometimes encompasses collections while Professional claims and billing typically don't. Professional billing controls the billing of claims generated for work performed by physicians, suppliers, and other non-institutional providers for both outpatient and inpatient services. People handling Professional claims typically understand both billing and insurance coding. Our APIs help support and automate insurance coding.

A provider has two different teams; one enters the claim and the other verifies and submits it. Before submitting, can they enter the claim, save it and have it released when ready?

Our APIs don't have a cache/drafting feature. Customers can develop and automate this feature. Customers should hold the claims on their end, and programmatically set up a console to separate working on claims from submitting them.

How many line items can be on a single claim?

A single professional claim supports up to 50 service line items (serviceLine.)

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.