Use the Professional Claims V3 API

The Professional Claims APIs are designed for medical providers to submit insurance claims to payers.

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NOTE

The JSON attributes in our APIs use snake-case, with the first letter of the attribute in lower case as in tradingPartnerServiceId. Our APIs are case-sensitive and your JSON request body must observe this convention.

Professional Claims endpoints

Task

Endpoint

Request Method

POST

Bearer Token

/apip/auth/v2/token

API endpoint

/professionalclaims/v3

Validation endpoint

/professionalclaims/v3/validation

Healthcheck endpoint

/professionalclaims/v3/healthcheck

Raw-X12

/professionalclaims/v3/raw-x12-validation
/professionalclaims/v3/raw-x12-submission

Operation Mode

Real-time, one request

Consumes

Application/json

Produces

Application/json

Sandbox URL

https://sandbox.apigw.changehealthcare.com/medicalnetwork/professionalclaims/v3

Production URL

https://apigw.changehealthcare.com/medicalnetwork/professionalclaims/v3

The Professional Claims API contains a series of JSON objects that use various important elements for completing submission of claims, including but not limited to the following:

Element

Description

claimReference

Contains important values, such as the payerId, customerClaimNumber, claimType, and other values that mostly will be managed programmatically.

submitter

Provider identification, including information, such as the organizationName.

subscriber

Includes the patient's insurance member ID and policyNumber.

dependent

If necessary, information about the insurance policy holder's dependent who received the medical services.

providers

Providers involved with the medical claim.

claimInformation

A key block of medical coding information that defines the actual procedures and services rendered for the medical encounter. It contains other JSON blocks including the serviceLines objects that contain the professionalService line item charges and diagnosis information. This section contains the standard charge entries that the provider(s) expect to receive for their services.

Using the Healthcheck endpoint

The /healthcheck endpoint verifies that the operating status of the Change Healthcare APIs is optimal and the APIs are running and are accessible. For more information, API Healthcheck.

Using the Validation endpoint

The /professionalclaims/v3/validation endpoint checks for the correct values of the claimReference object, which confirms that you will be sending the claim to the right place and it will not be rejected by the clearinghouse.

```json
{
    "status": "SUCCESS",
    "controlNumber": "000000001",
    "tradingPartnerServiceId": "9496",
    "claimReference": {
        "correlationId": "200715R999898~18620063139417176",
        "submitterId": "999898",
        "customerClaimNumber": "000000001",
        "patientControlNumber": "12345",
        "timeOfResponse": "2020-07-15T12:44:17.994-05:00",
        "claimType": "PRO",
        "formatVersion": "5010"
    },
    "editStatus": "SUCCESS",
    "payer": {
        "payerName": "EXTRA HEALTHY INSURANCE",
        "payerID": "9496"
    }
}
```

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