Using the Professional Claims v3 APIs

The Professional Claims endpoints consist of the following:

Request Method: POST

API endpoint: /professionalclaims/v3

Validation endpoint: /professionalclaims/v3/validation

Healthcheck endpoint: /professionalclaims/v3/healthcheck

Raw-X12 endpoints:
/professionalclaims/v3/raw-x12-validation
/professionalclaims/v3/raw-x12-submission

Operation Mode: real-time, one request

Consumes: Application/json

Produces: Application/json

URLs:

Sandbox:

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

Production:

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

The Professional Claims API is designed for medical providers to submit insurance claims to payers. It contains a series of JSON objects that use various important elements for completing submission of claims, including but not limited to the following:

claimReference - Contains important values such as the payerId, customerClaimNumber, the claimType, and other values that mostly will be managed programmatically;
submitter - Identitication of the provider, including information such as the organizationName,
subscriber - includes the patient's insurance member ID and insurance policyNumber,
dependent - if necessary, information the insurance policy holder's dependent who received the medical services;
providers - The 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 Validation endpoint

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

The following Validation result is from the Sandbox API:

{
    "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"
    }
}

Using the Healthcheck endpoint

You can use the /healthcheck endpoint to verify that the service is running before submitting the claim. When you do so, you should see the following result:

{
    "version": "v3",
    "status": "ok"
}