What is the biggest value-add from using this API?

For all Integrated Rules Institutional API applications, be familiar with the term Edits, which has a specific meaning in this context.

Payers control their own claims edit specifications. Edit specifications govern how medical practices must submit correct claims information for payer processing and claim adjudication. Claims Edits can change at any time, and these changes may or may not reach you before you submit an institutional claim, much less be integrated into your claims submission software.

Because of this likelihood, you may encounter unexpected errors and incur delays when filing claims, even when you think your software and processes are up to date.

These issues can occur at any time. Some medical practices may subscribe to continuous payer updates and submission edits. They receive their Claim edits notifications from the payer. Others may not do so, finding the costs prohibitive. The Integrated Rules Services team monitors regulatory requirements from Medicare and from industry organizations of many different types, and develops the Integrated Rules Knowledge Packs based upon the Packs' medical disciplines and the Rules/Edits that apply to them.

We continuously track and follow the Rules/Edits changes so you don't have to. Using the Knowledge Packs that you order as a match for your business, we tailor your Institutional Claims Integrated Rules API to your specific needs. Currently available Knowledge Packs for Institutional Claims include the following:

  • General Billing
  • Ambulance
  • Dialysis/End Stage Renal Disease (ESRD) (Institutional claims only)
  • Medicare
  • Post Acute Care
  • Prior Authorization
  • Rural FQHC (Institutional claims from Rural Health Clinics and Federally Qualified Health Centers)
  • Medical Necessity
  • National Correct Coding Initiative (NCCI)
  • Therapy (Institutional claims with Therapy Revenue Code, HCPCS/CPT-4 codes)
  • Validation Codes

Providers of each of the various Edit/Rule types select the Knowledge Pack that fits their needs. Rules within each category also may apply to specific Payers. For example, rules within the Durable Medical Equipment pack may be applicable for Aetna or for Medicare.

Another benefit: not all fields in an Institutional Claim request will be applicable for every service. A single claim may be a very substantial request body. Our Rules and Knowledge Packs enable you to narrow your claims down to the bodies of information that are only necessary for your claim type.

NOTE: Edits are directly comparable to individual validation rules in our API, hence we use the term Integrated Rules for our API.

The majority of Integrated Rules Claims Edit categories support both Professional and Institutional claims. Some Edit/Rule categories are supported only through Institutional claims; others are supported only by Professional claims and hence are not listed here.

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