Professional Claims FAQs

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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 APIs.

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NOTE

Medicare payers accept claims only for subscribers. If you want to submit a dependent claim with a Medicare payer, submit the dependent as a subscriber in the claim request.

How do I access the Professional Claims APIs?

Providers use the Professional Claims APIs to submit their medical procedure claims to their payers. To access them for testing, you can use Postman tool or your own API console. The best way to investigate our APIs is through our sandbox, which enables you to test our APIs without sending an actual claim to your payer.
.

  • Use the Professional Claims /professionalclaims/v3/validation endpoint to check your request:
https://apigw.changehealthcare.com/medicalnetwork/professionalclaims/v3/validation

Validation does not send your transaction to the payer. It checks for the correct well-formed syntax of your submission. It does not check the accuracy of the information included in your submission, so you will need to separately ensure that the claim is complete and accurate before submission.

  • The /professionalclaims/v3/submission endpoint submits your professional claim transaction to the payer:
https://apigw.changehealthcare.com/medicalnetwork/professionalclaims/v3/submission

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NOTE

The /validation and /submission endpoints use the same request model. Avoid sending any claim until you have tested your submission process and validated your claim!

  • The Professional Claims API /professionalclaims/advanced/v1/healthcheck service endpoint, checks the operating status of the API engine.

What information goes in the API Request header?

See API request header information.

How do I check the Operating Status of the API?

Change Healthcare's /healthcheck endpoint checks the operating status of our APIs. See API Health Check.

Do you have a sandbox that I can test with before signing a contract?

Yes, we do. See API FAQ

What does a typical Professional Claims API request look like?

The Professional Claims APIs use a POST HTTPS call. Responses to our Medical Network APIs can be lengthy due to the many data points that a payer or trading partner provides in the query response. Professional claims can have up to fifty line items (Loop 2400) in the claimInformation object (Loop 2300 in the EDI spec), each of which reflects payer decisions on payment.

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 837p transaction standard.

The following example is quite brief compared to what can apply in a real-world transaction.

```javascript
POST ${api_basepath}/[validation|submission] HTTP/1.1
Host: ${apigee_host}
Authorization:Bearer <Your-Access-Token>
Content-Type: application/json

{
  "controlNumber": "000000001",
  "tradingPartnerServiceId": "9496",
  "submitter": {
    "organizationName": "REGIONAL PPO NETWORK",
    "contactInformation": {
      "name": "SUBMITTER CONTACT INFO",
      "phoneNumber": "123456789"
    }
  },
  "receiver": {
    "organizationName": "EXTRA HEALTHY INSURANCE"
  },
  "subscriber": {
    "memberId": "0000000001",
    "paymentResponsibilityLevelCode": "P",
    "firstName": "johnone",
    "lastName": "doeOne",
    "gender": "M",
    "dateOfBirth": "19800102",
    "policyNumber": "00001",
    "address": {
      "address1": "123 address1",
      "city": "city1",
      "state": "wa",
      "postalCode": "981010000"
    }
  },
  "dependent": {
    "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"
    }
  },
  
  "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"
  }],
  "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": "ABK",
      "diagnosisCode": "S93401A"
    },{
      "diagnosisTypeCode": "ABF",
      "diagnosisCode": "S72044G"
    }],
    "serviceFacilityLocation": {
      "organizationName": "HAPPY DOCTORS GROUP",
      "address": {
        "address1": "000 address1",
        "city": "city2",
        "state": "tn",
        "postalCode": "372030000"
      }
      },
    "serviceLines":[ {
      "serviceDate": "20180514",
      "professionalService": {
        "procedureIdentifier": "HC",
        "lineItemChargeAmount": "25",
        "procedureCode": "E0570",
        "measurementUnit": "UN",
        "serviceUnitCount": "1",
        "compositeDiagnosisCodePointers": {
          "diagnosisCodePointers": ["1","2"]
        }
      }
      },
      {
        "serviceDate": "20180514",
        "professionalService": {
          "procedureIdentifier": "HC",
          "lineItemChargeAmount": "3.75",
          "procedureCode": "A7003",
          "measurementUnit": "UN",
          "serviceUnitCount": "1",
          "compositeDiagnosisCodePointers": {
            "diagnosisCodePointers": ["1" ]
          }
        }
        }
    ]

  }
}
```

As shown below, the sample claim contains the following JSON objects:

JSON Object

submitter

Provider submitting the claim.

receiver

Payer.

subscriber

Medical insurance policy holder.

dependent

Dependent of the insurance policyholder receiving the care.

providers

List of one or more providers involved in the medical care.

claimInformation

Complete breakdown of the medical encounter and its associated charges.

serviceLines and serviceDate

serviceLines is an array of one or more medical services, procedures, or products for the encounter, each of which is specified as a serviceDate record in the array.

What do Professional Claims Validation API responses look like?

A successful validation of a professional claim gives a response similar to the following:

```json
{
    "status": "SUCCESS",
    "controlNumber": "000000001",
    "tradingPartnerServiceId": "9496",
    "claimReference": {
        "correlationId": "201210R999898~2014364838718969",
        "submitterId": "009998999898",
        "customerClaimNumber": "000000001",
        "patientControlNumber": "12345",
        "timeOfResponse": "2020-12-10T20:07:05.4-06:00",
        "claimType": "PRO",
        "formatVersion": "5010"
    }
}
```

After the API validates the claim, it is ready to submit to the payer unless you want to run further changes and checks.

What is the claimReference field in the Submission response?

The claimReference field is an object containing the list of identifiers that you and others can use to track a claim. If questions arise about a claim, you can provide the information listed in the claimReference object to Change Healthcare support for troubleshooting purposes. It appears in all Submission responses for claims. The list of identifiers may differ depending on the context for the response.

```json
{
    "status": "SUCCESS",
    "controlNumber": "000000001",
    "tradingPartnerServiceId": "9496",
    "claimReference": {
        "correlationId": "201113R999898~2634061369394033",
        "submitterId": "009998999898",
        "customerClaimNumber": "000000001",
        "patientControlNumber": "12345",
        "timeOfResponse": "2020-11-13T09:30:33.29-06:00",
        "claimType": "PRO",
        "formatVersion": "5010",
        "rhclaimNumber": "2031851503057"
    }
}
```

claimReference object fields

Fields

Description

correlationId

ID used by support to locate a transaction at the clearinghouse.

submitterId

Customer's combined biller ID and submitter ID.

customerClaimNumber

ID set by the customer in the claim.

patientControlNumber

ID set by the customer in the claim for the patient.

timeOfResponse

Timestamp for the response.

claimType

Type of claim, Professional or Institutional.

formatVersion

EDI format version, will always be 5010 for the current version of the 837 claim.

rhclaimNumber

Number assigned by the clearinghouse. This value appears to search for the claim in ConnectCenter.

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 hard copy)
  • 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 do not.

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. One commonality: our APIs help support and automate insurance coding for both Institutional and Professional claims.

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 do not 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.


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