What is the response telling me?

Here is what you can expect to see in the response:

  • The API supplies predictions on two levels: the likelihood to deny at the claim level and at the line level in the claim.
  • It lists the top three reasons for denial, each with a confidence score. ("Confidence" is likelihood of denial.)
  • It lists the top three ERA CARC codes, each with a confidence score.

For example, consider the following snippet:

            "lines": [
                {
                    "lineId": "1",
                    "lineDenied": false,
                },
                {
                    "lineId": "2",
                    "lineDenied": false,
                },
                {
                    "lineId": "3",
                    "lineDenied": false,
                },
                {
                    "lineId": "4",
                    "lineDenied": true,
                    "denialReasons": [ ...

Each line of text in the claim gets examined by the API, and its status as a possible Accepted or Denied item appears. Above, line 1 ("lineId": "1") shows its "lineDenied" value as false meaning that this line item is likely to be approved by the payer. Conversely, line 4 ("lineId": "4") shows a "lineDenied" value as true, meaning that this line item for the claim is likely to be Denied by the payer.

To dig deeper into the same example:

                    "lineId": "4",
                    "lineDenied": true,
                    "denialReasons": [
                        {
                            "reason": "Registration/Eligibility",
                            "probability": 0.644,
                            "eraCarcCodes": [
                                {
                                    "code": "CO97",
                                    "probability": 0.662
                                },
                                {
                                    "code": "OA94",
                                    "probability": 0.316
                                },
                                {
                                    "code": "PI97",
                                    "probability": 0.01
                                }
                            ]
                        },

Whenever a line item gets a "lineDenied" value of true, the API gives the specific "reason" for the potential denial, the current likelihood for denial ("probability"), and an eraCarcCode that offers different updates you can make to the claim to improve the chances that the line item will be approved by the payer. The codes (such as "code": "CO97") are based specifically on the X12 EDI Claim Adjustment Reason Codes (CARC).


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