Professional Claims FAQs
NOTE
Please see API FAQs 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.
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.
- API environments](doc:testing-environments)
- Try our APIs
- API URLs and endpoints
- Use the
/professionalclaims/v3/validationendpoint to check your request:
The /validation endpoint 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 must separately ensure that the claim is complete and accurate before submission.
NOTE
The
/validationand/submissionendpoints use the same request model. Avoid sending any claims until you have tested your submission process and validated your claim!
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 /professionalclaims/v3/healthcheck endpoint checks the operating status of the Professional Claims API engine. See API Health Check.
Do you have a sandbox that I can test with before signing a contract?
Yes, we do. See API FAQ and API environments.
What does a typical Professional Claims API request look like?
The Professional Claims API uses a POST request. 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.
Professional Claims API request example
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" ]
}
}
}
]
}
}
```
Example Claim JSON objects
As shown below, the sample claim contains the JSON objects:
| JSON Object | Description |
|---|---|
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 make further changes and run the checks.
What is the claimReference field in the Submission response?
The claimReference field is an object containing the list of identifiers that you 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
claimReference object fields| Fields | Description |
|---|---|
correlationId | ID used by the support team 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. |
If the Primary claims are sent electronically, will the Secondary/Tertiary claims be sent electronically as well all the time?
For the secondary claim to be paid electronically, the primary payer must accept secondary claim.
These payers can be reviewed in the Change Healthcare [Payer Finder tool](https://payerfinder.changehealthcare.com/npd or https://payerfinder.changehealthcare.com/cap). The âAccepts Secondaryâ column is not automatically displayed.
- Click the gear (highlighted below) at the top-right of the list.
Payer Finder Tool
- From the menu that shows, select the Accepts Secondary checkbox.
Column Settings
- Save your settings.
This will display an additional column. Those with a âYâ designation, accept secondary claims.
However, the secondary payer must also process claims electronically and the appropriate payer ID must be included within the claim for the process to be fully electronic.
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 caching/drafting feature. Customers can develop and automate this feature. Customers should hold the claims at 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.
Where can we include the information about the primary claim on the API request for the secondary claim?
Send any payer-specific information in the otherPayerName object. Use otherSubscriberInformation to convey details for the member specifically. For more information see.
Are there any other fields in the request body of the Professional Claims to be aware of?
Yes, see request contents. Every API topic in the developer portal includes examples of request and response contents.
If I wanted to send an EOB from the primary payer with the claim, how would I go about doing that?
Secondary claim information goes in to loop 2320. We do not have any documentation on what is required for secondary claims since that is a billing-specific question. Also, if you want to send the EOB to the payer you need to work with them directly to determine how you want those submitted. To learn more about Billing or Invoice Assistance, check out the last page of the Support & Escalation Guide.
What would be the correct co-insurance amount for Professional (Physician) Visit â Office, for example, for Professional (Physician) Visit â Office but one says 0% and the other says 10%?
serviceTypes: Professional (Physician) Visit â Office is the correct amount. The other serviceType codes are not Professional Visit and would have a higher % based on that payer's response.
Why is the Claim Submission API is giving 400 error for the test values?
Error 400 means, there is a missing or invalid data or parameters in the request. Here is a listing of HTTP error responses.
Does Change Healthcare support appeals for denials? Are there any APIs through which these appeals can be submitted?
If a claim is denied or partially paid by a payer, a corrected claim should be sent for additional review. Submitting a corrected claim would require the claim frequency code '7', and the payer claim controlNumber must be included on the claim in the claimControlNumber field in the claimSupplementalInformation.
The claimControlNumber is the number assigned by the payer to identify a claim. Once submitted, the payer will review the claim and make any changes based on their internal review. The claimControlNumber is found on the payer 277 report.
The same process would need to be followed for voided claims, but using a frequency code '8.' Here is a sample corrected claim.
{ "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" } }, "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": "7", "signatureIndicator": "Y", "planParticipationCode": "A", "benefitsAssignmentCertificationIndicator": "Y", "releaseInformationCode": "Y", "claimSupplementalInformation": { "claimControlNumber": "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" ] } } } ] } }
How do you re-submit a claim that was denied â Appeal & Denial
If a claim is denied or partially paid by a payer, a corrected claim would need to be sent for additional review. Submitting a corrected claim would require the claim frequency code '7', and the payer claim controlNumber must be included on the claim in the claimControlNumber field in the claimSupplementalInformation.
The claimControlNumber is the number assigned by the payer to identify a claim. Once submitted, the payer will review the claim and make any changes based on their internal review. The claimControlNumber is found on the payer 277 report.
The same process would need to be followed for voided claims, but using a frequency code '8.' Here's a sample corrected claim. To include additional documents, use the Attachment Submission API. See also Attachment Submission API FAQ.
{
"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"
}
},
"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": "7",
"signatureIndicator": "Y",
"planParticipationCode": "A",
"benefitsAssignmentCertificationIndicator": "Y",
"releaseInformationCode": "Y",
"claimSupplementalInformation": {
"claimControlNumber": "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" ]
}
}
}
]
}
}
Is it possible to submit multiple claims at once, in batches?
We do offer batch submissions through SFTP only, our current API does not allow for batch submissions. These would have to be 5010-compliant EDI files. Please reach out to your sales representative to discuss pricing options for SFTP submissions.
When a claim is submitted via the API, the API returns a change healthcare claim ID. What API can I use to fetch the payer's claim number before we receive the ERA, ideally the next day after the claim is submitted successfully?
The payer-assigned claim ID would be returned through the SF and SD reports we provide through the responses and reports API. Additionally, you may be able to check the provider portal for the payer for this information.
Can we make multiple claims in one API call? If so, which endpoint should we use?
This is not possible through the current APIs. Only single submission is allowed. You can submit batch through SFTP but the batch file would need to be in X12 formats. Here is documentation that describes the available reports.
I am developing an application that will replace the old paper forms and start using the Professional Claim API. I cannot find the Prior Authorization Number.
- Open the Professional Claims OpenAPI spec.
- Do a Ctrl + F and search for priorAuthoriationNumber (under ClaimSupplementalInformation) in the spec shown as below.
"priorAuthorizationNumber":{"type":"string","description":"Loop: 2300, Segment: REF, Element: REF02 and REF01=G1"}
How to handle multiple authorization numbers per claim?
If the Institutional Claims required multiple authorization numbers, multiple claims need to be submitted. Submission through the Professional API allows for prior authorization information to be submitted at both the claim and line level Institutional Claims APIs allows for prior authorization information to be submitted at the claim level only. Here is a sample from our Open API Specs.
Professional Claims mapping:
ServiceLineReferenceInformation:
type: object
properties:
repricedLineItemReferenceNumber:
type: string
description: 'Loop: 2400, Segment: REF, Element: REF02 Notes: When REF01=9B'
adjustedRepricedLineItemReferenceNumber:
type: string
description: 'Loop: 2400, Segment: REF, Element: REF02 Note: When REF01=9D'
priorAuthorization:
maxItems: 5
minItems: 0
type: array
description: Loop 2400 REF
items:
Institutional Claims mapping:
ClaimSupplementalInformation:
type: object
properties:
reportInformation:
$ref: '#/components/schemas/ReportInformation'
priorAuthorizationNumber:
type: string
description: 'Loop 2300; Segment: REF; Element: REF02 when REF01 = G1'
I sometimes get back errors from the payer like: "Loop 2310B (rendering provider name) is missing, it is expected to be used when loop 2420A is used with the same value in every loop 2400". How can I send the rendering provider in loop 2310B?
See Provider object.
For EDI claims, where can I put the session times in Loop 2400 for each individual line in the claim request when using the claims API?
In the developers portal's JSON-to-EDI mapping, scroll down to Loop 2400 to view different SV segments.
How to avoid the error "Other Payer Primary ID# is Ming or Invalid" when the other payer doesn't have a payor ID and for which the claims are set up to be sent by paper?
The CPID for paper claims are listed here:
Professional 1500 form (Medical Claims):
- Commercial CPID 4320
- Medicaid CPID 4322
- BCBS CPID 4323
Institutional UB-04 form (Hospital Claims):
- Commercial CPID 4350
- Medicaid CPID 4352
- BCBS CPID 4353
What is Professional Claims API and what is it used for?
The Professional Claims API allows for the creation and submission of claims so that your providers can be reimbursed for their services. This API takes the standard established in the X12 EDI 837P transaction and translates this standard to JSON so it is more accessible to developers and easily integrated into users' applications.
The ASC X12N Health Care Claim: Professional (837P) transaction allows healthcare providers to submit healthcare claims for a service or encounter. A healthcare claim includes patient information, related diagnoses, procedures performed or services provided, and any related charges.
This service includes the /validation endpoint to check and verify your claim prior to submission to the payer. This endpoint checks for the correct well-formed syntax of the submission as well as correctly summing service line charges and verifying codes in order to minimize the chance of rejection by the payer.
I am trying to test out a scenario where the clinic would enter a specific service type code and want to get patient benefits for that specific service code?
All of our sandbox Eligibility responses are real payer responses that have been de-identified and emulated. The only value that affects the response in sandbox is the "tradingPartnerServiceId". You can receive different responses by switching that out, but the responses will not vary if you change other values like the "serviceTypeCode".
Is a list of Eligibility AAA errors with a description available?
Yes, here is a list of AAA error codes.
- AAA Rejection codes are part of the Eligibility standard, but since that standard is licensed, we are limited in what we can show. Most are clear when they are defined, such as AAA 72 for Invalid/Missing Subscriber/Insured ID. That basically means that the memberId in the request does not have a match with the payer.
A couple others that might be nuclear:
-
AAA 41 â Authorization/Access Restrictions: This is an enrollment issue where the NPI in the request needs to be recognized by the payer. You can check enrollment requirements on our payer list, and complete the enrollment form through Enrollment Central. This may also be represented with AAA 79 for Invalid Participant Identification.
-
AAA 42/80 â These indicate something is wrong like a transaction time out or an exception that does not fit in other AAA codes. Most of the time, these are temporary and will resolve on their own. If you continue to get this error on a request, you should open a support ticket.
The complete list of AAA codes and Eligibility request and response codes can be purchased here.
Does the Revenue Performance Advisor work with claims submitted with the API as well as claims submitted through the revenue advisor interface?
Only the Eligibility API works with Revenue Performance Advisor. Our claims APIs currently route to another one of our switches, this will be considered for a future enhancement.
My client would be billing her clients for the visit which is not a professional/specialist visit but more like evaluation and management services that come under CPT 99214. Other than 98 (Professional physician visit-office), any other code I can use?
Include service type code 30 to pull back all benefit information.
What is the Claim submission Flow in Change Healthcare?
Please see Claim Submission Workflow.
Do we need to use same control ID for a claim in submission and checking its claim status?
The controlNumber should be unique for each individual submission.
How can I add modifiers to the services/procedures/other codes of a claim? How can you express that a CPT code had to be added to a claim so that the payer have sufficient support or their adjudication?
The following are the mapping for submitting modifiers. In an instance where a code needs to be added to a claim, a corrected claim should be submitted. This would require the claim frequency code '7' to be submitted, and the payer claim control number must be included on the claim in the claimControlNumber field in the claimSupplementalInformation. The claimControlNumber is the number assigned by the payer to identify a claim. Once submitted, payers will review the claim and make any changes based on their internal review.
ProfessionalService:
required:
- compositeDiagnosisCodePointers
- lineItemChargeAmount
- measurementUnit
- procedureCode
- procedureIdentifier
- serviceUnitCount
type: object
properties:
procedureIdentifier:
type: string
description: >-
Loop: 2400, Segment: SV1, Element: SV101-01, Notes: Allowed Values are:
- 'ER' Jurisdiction Specific Procedure and Supply Codes,
- 'HC' Health Care Financing Administration Common Procedural Coding System
(HCPCS) Codes, 'IV' Home Infusion EDI Coalition (HIEC) Product/Service Code,'WK' Advanced Billing Concepts (ABC) Codes
example: HC
enum:
- ER
- HC
- IV
- WK
procedureCode:
- type: string
- description: 'Loop 2400, Segment: SV1, Element: SV101-02'
- example: E0570
procedureModifiers:
- maxItems: 4
- minItems: 0
- type: array
- description: >-
Loop 2400, Segment: SV1, Elements: SV101-03 to SV101-06, Notes:
Required when modifier clarifies or improves the reporting accuracy
of the associated procedure code. If not required then do not send
items:
- type: string
description:
- type: string
- description: >-
Loop 2400, Segment: SV1, Element: SV101-07, Notes: A free form
description to clarify teh related data elements and their content
Can the modifier code be added to the first submission or I need to submit another claim with frequency code 7, just to add the modifier?
We are not able to say if a code would be 'required'; it will vary payer-to-payer. However, you can add a modifier to the initial claim in the professionalService object from the Professional Claims JSON to EDI Mapping Guide's procedureModifier.
Provide the source to obtain the master list related to CMS1500/UB04 Claims forms.
A 1500 is a medical claim (Professional) and UB04 is hospital claim (Institutional). And 837P is a 1500 Medical Claims and 837I is a UB04 Hospital claims. When paper is sent, they use a 1500 form for Medical claims and UB04 for Hospital. Change Healthcare does not have a master list of information. The information is common across the medical industry and there are many crosswalks or sites you can find that map the paper claim locations to a 837.
Is there any field other than the patient_control_number field in claims payload that can associate the Claims to the ERA? I need the field to come back in the ERA.
The Patient Control number is typically the main identifier that is used in tracking claims through to payment. The Patient Control number can be up to 38 alphanumeric characters, and should be unique per submission. Additionally, you can submit a providerControlNumber (API KEY)/LINE ITEM CONTROL NUMBER (5010 X12). The providerControlNumber must be unique within a patient control number. Payers are required to return this number in the remittance advice transaction (835) if the provider sends it to them in the 837. However, please note this is dependent on the claim adjudication being done on a service line level basis.
Are the address1 and City fields, which are part of the payerAddress object necessary when submitting the claim? Where can the address information be obtained for the payers listed in the ConnectCenter Payer list?
The payer address is not required when submitting claims electronically. The payer address information would only be required if a claim was intended to be submitted through paper. We route transactions based on the CPID, which is the tradingPartnerServiceId that is submitted in the request.
Do we need to be enrolled at Remitter to receive 277 Claim Status? We have enrolled through ConnectCenter as a Submitter, is 277 claim status response dependent on us being enrolled as the Remitter for a payer?
Claim Status responses are not dependent on being enrolled for Remittance.
There are two types of 277 Claim Status responses, solicited and unsolicited:
A solicited 277 would be a response from the payer to a submitted claim status request through the API. Depending on the payer, this can either be returned in a real-time response or it would be received in a batch file. If the 277 is received through batch, the response would be returned through the Response and Reports API as an X3 file-277 Claim Status Response Data File (x12 format, JSON conversion available) &endash; this report returns the solicited claim status x12 raw data that matches exactly what is returned by the payer and can be translated into JSON. This file is received from payers when claim status is requested and not returned in realtime.
An unsolicited 277 response would be returned through the Response and Reports API in a SF file-Payer Report Data File (Pipe Delimited) &endash; this report is a proprietary pipe delimited file that returns claim level payer acceptance and rejections.
The SR you received is the human-readable version of the SF report mentioned above.
Please keep in mind that 277s will only provide information up to the point when the claim has been processed. Most payers will not provide payment details through Claim Status. Find more information here.
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Updated about 2 months ago