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

For all Integrated Rules Professional 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 approvals or disapprovals. Claims Edits can change at any time, and notifications of these changes may or may not reach you before you submit a professional claim, much less be integrated into your claims submission software.

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

These issues can occur at any time. Some medical practices may subscribe to continuous payer updates and submission edits, and receive their notifications from the payer. Others may not do so, finding the costs prohibitive. The Integrated Rules Professional Services team monitors regulatory requirements from Medicare and from industry organizations of many different types, and builds the Integrated Rules Knowledge Packs based upon the medical disciplines and the Rules/Edits that apply to them. Using the Knowledge Packs that you order as a match for your business, we tailor your Integrated Rules API to your specific needs. Available Knowledge Packs for Professional Claims include the following:

  • General Billing
  • Ambulance
  • Medicare
  • Durable Medical Equipment (Professional claims only)
  • Post Acute Care
  • Prior Authorization
  • Professional Radiology (Professional claims only)
  • Vision (Professional claims only)
  • Medical Necessity
  • National Correct Coding Initiative (NCCI)
  • 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 a Professional 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 Professional claims; others are supported only by Institutional claims and hence are not listed here.