Professional Claims (837P) JSON

Changelog

Overview

Payers & enrollment

Payers
Transaction enrollment

Eligibility & benefits

Eligibility checks
Insurance discovery
Coordination of benefits

Claims processing

EDI platform

Transaction
Interchange
File execution
Fragments
Mappings
Events

POST

change

medicalnetwork

professionalclaims

submission

curl --request POST \
  --url https://healthcare.us.stedi.com/2024-04-01/change/medicalnetwork/professionalclaims/v3/submission \
  --header 'Authorization: <api-key>' \
  --header 'Content-Type: application/json' \
  --data '{
  "usageIndicator": "T",
  "tradingPartnerServiceId": "6400",
  "submitter": {
    "organizationName": "Test Data Health Services, Inc.",
    "submitterIdentification": "<YOUR-SUBMITTER-ID>",
    "contactInformation": {
      "name": "Test Data Health Services, Inc.",
      "phoneNumber": "5552223333"
    }
  },
  "receiver": {
    "organizationName": "Cigna"
  },
  "subscriber": {
    "memberId": "U7777788888",
    "paymentResponsibilityLevelCode": "P",
    "subscriberGroupName": "Cigna",
    "firstName": "John",
    "lastName": "Anon",
    "gender": "M",
    "dateOfBirth": "20000101",
    "groupNumber": "3335555",
    "address": {
      "address1": "2222 Random St",
      "city": "A City",
      "state": "NY",
      "postalCode": "123450000"
    }
  },
  "billing": {
    "providerType": "BillingProvider",
    "npi": "1999999984",
    "employerId": "123456789",
    "taxonomyCode": "2084P0800X",
    "organizationName": "Therapy Associates",
    "address": {
      "address1": "123 Some St",
      "address2": "Floor 1",
      "city": "A City",
      "state": "NY",
      "postalCode": "123450000"
    },
    "contactInformation": {
      "name": "Test Data Health Services, Inc.",
      "phoneNumber": "5553334444"
    }
  },
  "claimInformation": {
    "claimFilingCode": "CI",
    "patientControlNumber": "<YOUR-PATIENT-ID>",
    "claimChargeAmount": "109.20",
    "placeOfServiceCode": "02",
    "claimFrequencyCode": "1",
    "signatureIndicator": "Y",
    "planParticipationCode": "A",
    "benefitsAssignmentCertificationIndicator": "Y",
    "releaseInformationCode": "Y",
    "healthCareCodeInformation": [
      {
        "diagnosisTypeCode": "ABK",
        "diagnosisCode": "F1111"
      }
    ],
    "serviceFacilityLocation": {
      "organizationName": "Smith Associates",
      "address": {
        "address1": "1234 Other St",
        "city": "A City",
        "state": "NY",
        "postalCode": "123450000"
      },
      "npi": "1999999984"
    },
    "serviceLines": [
      {
        "serviceDate": "20240101",
        "professionalService": {
          "procedureIdentifier": "HC",
          "procedureCode": "90837",
          "procedureModifiers": [
            "95"
          ],
          "lineItemChargeAmount": "109.20",
          "measurementUnit": "UN",
          "serviceUnitCount": "1",
          "compositeDiagnosisCodePointers": {
            "diagnosisCodePointers": [
              "1"
            ]
          }
        },
        "providerControlNumber": "111222333",
        "renderingProvider": {
          "providerType": "RenderingProvider",
          "npi": "1999999984",
          "taxonomyCode": "111YP2000X",
          "firstName": "Jane",
          "lastName": "Smith"
        }
      }
    ]
  },
  "tradingPartnerName": "Cigna"
}'

{
  "status": "SUCCESS",
  "controlNumber": "555123",
  "tradingPartnerServiceId": "6400",
  "claimReference": {
    "correlationId": "01HTCX97F6XS6F2K22D4KD59TK",
    "patientControlNumber": "22266555",
    "timeOfResponse": "2024-04-01T13:23:54.255Z",
    "payerId": "6400",
    "formatVersion": "5010",
    "rhclaimNumber": "01HTCX97F6XS6F2K22D4KD59TK",
    "serviceLines": [
      {
        "lineItemControlNumber": "111222333"
      }
    ]
  },
  "httpStatusCode": "200 OK",
  "meta": {
    "traceId": "a7f7c912-77f7-489d-96fc-c4ab3b5c33fc"
  },
  "payer": {
    "payerName": "Cigna",
    "payerId": "6400"
  }
}

This endpoint sends 837P (professional) claims to payers. Visit Submit professional claims for a full how-to guide.

Call this endpoint with a JSON payload.
Stedi translates your request to the X12 837 EDI format and sends it to the payer.
The endpoint returns a response from Stedi in JSON format containing information about the claim you submitted and whether the submission was successful.

Send test claims

All claims you submit through this endpoint are sent to the payer as production claims unless you explicitly designate them as test data.

To send test claims, set the usageIndicator property in the test claim body to T. This allows you to filter for test claims on the Transactions page in the Stedi portal.

Note that you will receive a 277 Claim Acknowledgment in response to test claims, allowing you to test your workflow end to end, but you will not receive a test 835 (ERA) response.

Basic claim submission

The content of your claim submission depends on your use case and the payer’s requirements. However, a basic claim submission includes the following information in the request body:

Information	Description
`tradingPartnerServiceId`	This is the Payer ID. Visit the Payer Network for a complete list.
`tradingPartnerName`	This is the payer’s business name, like Cigna or Aetna.
`submitter` object	Information about the entity submitting the healthcare claim. This can be either an individual or an organization, such as a doctor, hospital, or insurance company.
`receiver` object	Information about the payer, such as an insurance company or government agency.
`subscriber` and/or `dependent` objects	Information about the patient who received the medical services. Note that if a dependent has their own, unique member ID for their health plan, you should submit their information in the `subscriber` object and omit the `dependent` object from the request. You can check whether the dependent has a unique member ID by submitting an Eligibility Check to the payer for the dependent. The payer will return the member ID in the `dependents.memberId` field, if present.
`claimInformation` object	Information about the claim, such as the patient control number, claim charge amount, and place of service code. It also includes information about each individual service line included in the claim.
`billing` object	Information about the billing provider, such as the NPI, taxonomy code, and organization name.

Character restrictions

Don’t include the following characters in your request data: ~, *, : and ^. They are reserved for delimiters in the resulting X12 EDI transaction, and X12 doesn’t support using escape sequences to represent delimiters or special characters. Stedi returns a 400 error if you include these restricted characters in your request.

Only use the X12 Basic and Extended character sets in request data. Using characters outside these sets may cause validation and HTTP 400 errors.

Identify service lines

A claim can contain multiple service lines. Since the payer may accept, reject, or pay a subset of those lines, you can receive an 835 response that references a patientControlNumber, but only pertains to some of the service lines.

However, the claimInformation.serviceLines.providerControlNumber serves as a unique identifier for each service line in your claim submission. This value appears in the 277CA and 835 ERA responses as the lineItemControlNumber, allowing you to correlate these responses to specific service lines from the original claim. If you don’t set the providerControlNumber for a service line, Stedi uses a random UUID.

Stedi returns service line identifiers in the claimReference.serviceLines object of the synchronous API response.

Conditional requirements

Note that objects marked as required are required for all requests, while others are conditionally required depending on the circumstances. When you include a conditionally required object, you must include all of its required properties.

For example, you must always include the subscriber object in your request, but you only need to include the supervising object when the rendering provider is supervised by a physician.

Enhanced validation

You can optionally set the Stedi-Validation header to snip for enhanced validation on your claim submission.

Enhanced validation uses hundreds of additional edits (the industry term for validation rules) to increase claim acceptance rates. These include Strategic National Implementation Process (SNIP) validations. Stedi also automatically fixes common errors and monitors payer rejections to proactively build out new rules.

There is an additional cost per claim submission when you use enhanced validation. Please reach out to support for access and pricing information.

CMS-1500 Claim Form PDF

When you submit a claim, Stedi automatically generates a 1500 claim form PDF. Please review the behaviors and recommendations in the CMS-1500 claim form PDF documentation if you plan to send the generated PDFs to payers or retain them for your records.

Authorizations

Authorization

string

header

required

A Stedi API Key for authentication.

Headers

Stedi-Transaction-Setting-Id

string

The outbound transaction setting ID. This option only needs to be specified if a non-default release of the Professional Claims guide needs to be used.

Stedi-Validation

string

Set to snip for enhanced validation on this claim. Enhanced validation uses hundreds of additional 'edits' (the industry term for validation rules) to increase claims acceptance rates. Stedi also monitors your 277 rejections to proactively build rules based on previous failures. When possible, Stedi automatically fixes common errors (such as invalid date/time formats and character encoding issues) before sending the claim, reducing payer rejections. There is an additional cost per claim submission when you use enhanced validation. Please reach out to support for access and pricing information.

Body

application/json

tradingPartnerServiceId

string

required

This is the Payer ID. Visit the Payer Network for a complete list. You can send requests using the Primary Payer ID, the Stedi Payer ID, or any alias listed in the payer record.

Minimum length: 1

submitter

object

required

The entity submitting the healthcare claim. This can be either an individual or an organization, such as a doctor, hospital, or insurance company. You must submit at least organizationName or lastName properties and the contactInformation object. If you don't supply the submitterIdentification property, Stedi uses the value from billing.npi in the request.

receiver

object

required

The entity responsible for the payment of the claim, such as an insurance company or government agency.

subscriber

object

required

The person or entity who is the primary policyholder for the health plan or a dependent with their own member ID. The subscriber can be an individual or a business entity.

When a dependent has a unique, payer-assigned member ID, treat them as the subscriber for the claim submission - include their information here and omit the dependent object from the request. Stedi treats the subscriber as an individual when the request doesn't contain a value for the subscriber.organizationName property.
You must set the dateOfBirth and gender properties when the subscriber is the patient. Stedi determines that the subscriber is the patient when the dependent object is not included in the request.
If either dateOfBirth or gender is set, you must include both properties. You can either include both properties or neither within a single request.

subscriber.memberId

string

The member ID for the subscriber's insurance policy. This property is required if the subscriber is an individual.

Required string length: 2 - 80

subscriber.ssn

string

The subscriber's Social Security Number. This must be a string of exactly nine numbers with no separators. For example, send 111002222 instead of 111-00-2222.

subscriber.paymentResponsibilityLevelCode

enum<string>

Code identifying the insurance carrier's level of responsibility for a payment of a claim. Stedi sets this property to P - Primary by default.

You only need to include this property when you need to submit codes other than P. This can happen when the patient has multiple insurance policies. For example, if a patient is covered by both Medicare and an employer-sponsored commercial plan, you could bill the commercial plan first as P and then bill the Medicare payer second as S. Visit Claims code lists for a complete list of possible codes.

Available options:

A,

B,

C,

D,

E,

F,

G,

H,

P,

S,

T,

U

subscriber.organizationName

string

The business name of the entity submitting the claim. When the subscriber is an organization, you should identify the patient in the dependent object.

subscriber.insuranceTypeCode

enum<string>

Identifies the type of insurance policy within a specific insurance program. This property is required when sending claims to Medicare and Medicare is not the primary payer (paymentResponsibilityLevelCode is not set to P). Otherwise, don't include this property in the claim.

Visit Claims code lists for a complete list of insurance type codes.

Available options:

12,

13,

14,

15,

16,

41,

42,

43,

47

subscriber.subscriberGroupName

string

The name of the subscriber's health plan. For example, Cigna or Blue Cross Blue Shield.

Provide either this property OR the groupNumber, not both. If groupNumber is set, Stedi ignores this value and uses the value in groupNumber.

subscriber.firstName

string

The subscriber's first name. This property is recommended when the subscriber is an individual. Some payers reject requests without the firstName property.

subscriber.lastName

string

The subscriber's last name. This property is required if the subscriber is an individual.

Don't include the subscriber's name suffix, such as Jr. or III. Use the designated suffix property instead.

subscriber.middleName

string

The subscriber's middle name or initial.

subscriber.suffix

string

The suffix of the subscriber's name, such as Jr. or Sr. Only include the subscriber's personal name suffix - don't include professional or academic titles, such as M.D. or MBA.

subscriber.gender

enum<string>

Identifies the subscriber's gender. This property is required when the subscriber is the patient. Can be set to F - Female, M - Male, or U - Unknown.

You should set this property to U when the patient declines to answer or does not identify as male or female. Note that some payers may reject the claim if the patient's gender doesn't match the gender they have recorded in their member records.

Available options:

M,

F,

U

subscriber.dateOfBirth

string

The subscriber's date of birth. Expressed in format YYYYMMDD. This property is required if the subscriber is an individual.

subscriber.policyNumber

string

The subscriber's health plan policy number. You should provide either this property OR the groupNumber, not both.

subscriber.groupNumber

string

The subscriber's health plan group number.

Provide this property OR the policyNumber, not both.
Provide this property OR the subscriberGroupName, not both. If this property is set, Stedi ignores the subscriberGroupName property.

subscriber.address

object

The subscriber's address. Every claim must include address information in either the subscriber (when the patient is the subscriber) or dependent (when the patient is a dependent) object. You must include at least the address1 and city properties in this object. The state and postalCode properties are also required for all United States and Canadian addresses.

The address must be the patient's correct address at the time of service. Don't use placeholder values to complete unknown address information. Use of outdated or placeholder values could cause the payer to reject, deny, or delay the claim due to suspected fraud.
If you don't know the patient's address, you should first submit a Real-Time Eligibility Check for the patient and then copy the patient's address from either the subscriber or dependent object in the response.
If the patient doesn't have a current address, you can populate the address1 property with UNKNOWN and populate the city, state, and zip code with appropriate values based on your discretion. However, some payers may have explicit rules for how to handle this situation, so you should check the payer's specific requirements before using this approach.

subscriber.contactInformation

object

Only use this object for payer administrative contacts on property and casualty claims. Otherwise, you shoudn't include contact information here. If you include this object, you must supply at least one communication method (phone, fax, or email).

claimInformation

object

required

Information about the healthcare claim.

Note that the objects and properties marked as required are required for all claims, while others are conditionally required, depending on type of claim and claim circumstances. For example, you must always provide the patient's diagnosis codes in the healthCareCodeInformation object, but you only need to provide the otherSubscriberInformation object in coordination of benefits scenarios. When you include a conditionally required object, you must provide all of its required properties.

claimInformation.claimFilingCode

enum<string>

required

A code identifying the type of claim. For example DS - Disability.

Use OF when submitting Medicare Part D claims.
Use ZZ when you don't know the type of insurance.
Some payers reject claims with invalid codes. If you're not sure which code to use, we recommend running a real-time eligibility check and using the value returned in the most relevant benefitsInformation.insuranceTypeCode property. Note that the eligibility response uses a different code list than claims, so you may need to map that code value to the appropriate claim filing code.

Visit Claims code lists for a complete list.

Available options:

11,

12,

13,

14,

15,

16,

17,

AM,

BL,

CH,

CI,

DS,

FI,

HM,

LM,

MA,

MB,

MC,

OF,

TV,

VA,

WC,

ZZ

claimInformation.patientControlNumber

string

required

An identifier you assign to the claim. We strongly recommend submitting a unique value for this property so that you can use it to correlate this claim with responses from the payer, such as the 835 Electronic Remittance Advice (ERA).

Required string length: 1 - 20

claimInformation.claimChargeAmount

string

required

The total dollar amount charged for the services on this claim, expressed as a decimal. For example, 100.50. This is the total amount before any adjustments or payments. The amount must balance to the sum of the service line charges.

claimInformation.placeOfServiceCode

enum<string>

required

Code identifying the type of facility where the services were or may be performed. Visit Place of Service Codes for a complete list.

Available options:

01,

02,

03,

04,

05,

06,

07,

08,

09,

10,

11,

12,

13,

14,

15,

16,

17,

18,

19,

20,

21,

22,

23,

24,

25,

26,

27,

31,

32,

33,

34,

41,

42,

49,

50,

51,

52,

53,

54,

55,

56,

57,

58,

60,

61,

62,

65,

66,

71,

72,

81,

99

claimInformation.claimFrequencyCode

enum<string>

required

Code specifying the frequency of the claim. Can be set to 1 - Admit thru Discharge Claim, 7 - Replacement of Prior Claim, or 8 - Void/Cancel of Prior Claim. Visit the National Uniform Billing Committee for a complete code list and usage notes.

Available options:

1,

7,

8

claimInformation.signatureIndicator

enum<string>

required

Indicates whether the provider's signature is on file. Can be set to N - No or Y - Yes.

Available options:

N,

Y

claimInformation.benefitsAssignmentCertificationIndicator

enum<string>

required

A code indicating whether the patient or an authorized person has assigned benefits to the provider. Use W when the patient refuses to assign benefits. Can be set to N - No, Y - Yes, or W - Not Applicable (use when patient refuses to assign benefits).

Available options:

N,

W,

Y

claimInformation.releaseInformationCode

enum<string>

required

Indicates whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations. Can be set to Y - Yes, or I - Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statues. Use I when the provider has not collected a signature AND state or federal laws do not require a signature be collected.

Available options:

I,

Y

claimInformation.planParticipationCode

enum<string>

required

Code indicating whether the provider accepts assignment. This refers to whether the provider accepts assignment and/or has a participation agreement with the destination payer. It does not indicate whether the patient has assigned benefits to the provider. Can be set to A - Assigned, B - Assignment Accepted on Clinical Lab Services Only, or C - Not Assigned. Choose A when the provider accepts assignment and/or has a participation agreement with the destination payer, OR the provider does not accept assignment and/or have a participation agreement, but is advising the payer to adjudicate this specific claim under the participating provider benefits allowed under certain plans.

Available options:

A,

B,

C

claimInformation.healthCareCodeInformation

object[]

required

Details about the patient's healthcare diagnosis.

Don't submit the decimal for ICD codes; the decimal is implied.
Use ABK as the type for the principal diagnosis code and ABF for any other diagnosis codes you include.
One ABK code is required as the first object, and then you can submit up to 11 ABF codes as needed. If you need to submit more codes than this, you must create additional, separate claims.

claimInformation.serviceLines

object[]

required

Information about one or more services rendered to the patient. Each service line must be a unique procedure. Service lines can share the same dates of service if the patient received multiple services on the same day. You can include up to 50 service lines within a single claim.

claimInformation.serviceLines.serviceDate

string

required

The date the service was rendered (for services performed on a single day), expressed as YYYYMMDD. When you send this property with serviceDateEnd, it will be used as the start date for the date range in which the service was rendered.

claimInformation.serviceLines.professionalService

object

required

Information about the service rendered.

claimInformation.serviceLines.professionalService.procedureIdentifier

enum<string>

required

Code identifying the specific industry code list used for the procedureCode. Visit Claims code lists for a complete list.

Available options:

ER,

HC,

IV,

WK

claimInformation.serviceLines.professionalService.procedureCode

string

required

The procedure code.

claimInformation.serviceLines.professionalService.lineItemChargeAmount

string

required

The total charge amount for the service, including the provider's base charge and any applicable tax or postage. It is acceptable to set this to 0 (zero).

claimInformation.serviceLines.professionalService.measurementUnit

enum<string>

required

Code identifying the unit of measurement. Can be set to MJ - Minutes or UN - Unit. Minutes is required for anesthesia services. Note that anesthesia time is counted from the moment that the practitioner, having completed the preoperative evaluation, starts an intravenous line, places monitors, administers pre-anesthesia sedation, or otherwise physically begins to prepare the patient for anesthesia. Time continues throughout the case and while the practitioner accompanies the patient to the post-anesthesia recovery unit (PACU). Time stops when the practitioner releases the patient to the care of PACU personnel.

Available options:

MJ,

UN

claimInformation.serviceLines.professionalService.serviceUnitCount

string

required

The number of units of the service provided, formatted as a decimal.

claimInformation.serviceLines.professionalService.compositeDiagnosisCodePointers

object

required

Diagnosis code pointers in order of importance to this service line. These pointers are an index to the ICD-10-CM codes you included in the claimInformation.healthCareCodeInformation object array. The pointer values can be from 1 to 12 (integer numbers).

You must set at least one pointer for the primary diagnosis. Then, you can add up to three additional pointers (up to four in total).
The number of pointers cannot exceed the number of diagnosis codes in the claimInformation.healthCareCodeInformation object array. For example, if you only supplied one diagnosis code, then the only valid pointer value is 1.
Don't put ICD-10-CM codes here - they belong in claimInformation.healthCareCodeInformation.

claimInformation.serviceLines.professionalService.procedureModifiers

string[]

A modifier code that clarifies or improves the reporting accuracy of the associated procedure code. If not required, do not send.

claimInformation.serviceLines.professionalService.description

string

A free form description to clarify the procedure code and any procedure modifiers, as needed.

Required string length: 1 - 80

claimInformation.serviceLines.professionalService.placeOfServiceCode

string

A code identifying the location where services were rendered. Visit Place of Service Codes for a complete list.

claimInformation.serviceLines.professionalService.emergencyIndicator

enum<string>

Code indicating whether the service was related to an emergency. Can be set to Y - Yes. An emergency is when the patient requires immediate medical intervention as a result of severe, life threatening, or potentially disabling conditions.

Available options:

Y

claimInformation.serviceLines.professionalService.epsdtIndicator

enum<string>

Code indicating whether there was EPSDT involvement in the service. Can be set to Y - Yes. EPSDT is a program that provides comprehensive and preventive health care services for children under age 21 who are enrolled in Medicaid.

If this value is set to Y, you must also include the claimInformation.epsdtReferral object in your claim submission.

Available options:

Y

claimInformation.serviceLines.professionalService.familyPlanningIndicator

enum<string>

Code indicating whether the service was related to family planning. Can be set to Y - Yes.

Available options:

Y

claimInformation.serviceLines.professionalService.copayStatusCode

enum<string>

Code indicating whether co-payment requirements were met. Can be set to O - Copay exempt.

Available options:

0

claimInformation.serviceLines.assignedNumber

string

deprecated

Deprecated; Stedi computes this value for you. This shape is deprecated.

claimInformation.serviceLines.serviceDateEnd

string

The end date of the service period, expressed as YYYYMMDD. If you send this property, you must also send serviceDate.

claimInformation.serviceLines.providerControlNumber

string

A unique identifier for this service line within the claim. It appears in the 835 (ERA) response as lineItemControlNumber, allowing you to correlate ERAs to the specific service lines from the original claim. If you don't set this property, Stedi uses a random UUID. Stedi returns service line identifiers in the claimReference.serviceLines.lineItemControlNumber object of the synchronous API response.

claimInformation.serviceLines.durableMedicalEquipmentService

object

Information about durable medical equipment. For example, the rental and purchase price information.

claimInformation.serviceLines.serviceLineSupplementalInformation

object[]

Supporting documentation for the service line. Required when there is a paper attachment following this claim, when attachments are sent electronically, or when the provider needs to identify additional information that is being held at their office and is available upon request.

Required when there is a paper attachment following this claim, when attachments are sent electronically with the claim, or when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request.

claimInformation.serviceLines.durableMedicalEquipmentCertificateOfMedicalNecessity

object

Required on claims that include a Durable Medical Equipment Regional Carrier (DMERC) Certificate of Medical Necessity (CMN).

claimInformation.serviceLines.ambulanceTransportInformation

object

Information about the ambulance service provided to the patient.

claimInformation.serviceLines.durableMedicalEquipmentCertification

object

Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or a DMERC Information Form (DIF) or Oxygen Therapy Certification is included on this service line.

claimInformation.serviceLines.ambulanceCertification

object[]

Required when the claim involves ambulance transport services.

claimInformation.serviceLines.hospiceEmployeeIndicator

boolean

Whether the rendering provider is a hospice employee. Required on all Medicare claims involving physician services to hospice patients. Set to true if the rendering provider is a hospice employee, and false if they are not.

claimInformation.serviceLines.conditionIndicatorDurableMedicalEquipment

object

Required when a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN) or a DMERC Information Form (DIF), or Oxygen Therapy Certification is included on this service line and the information is necessary for adjudication.

claimInformation.serviceLines.serviceLineDateInformation

object

Identify specific dates related to the service rendered, formatted as YYYYMMDD.

claimInformation.serviceLines.ambulancePatientCount

number

The number of patients transported by the ambulance. Required when more than one patient is transported in the same vehicle for Ambulance or non-emergency transportation services.

claimInformation.serviceLines.obstetricAnesthesiaAdditionalUnits

number

The number of units reported by an anesthesia provider to reflect additional complexity of services.

claimInformation.serviceLines.testResults

object[]

Required on Dialysis related service lines for ESRD, or required on on DMERC service lines to report the Patient's Height from the Certificate of Medical Necessity (CMN). Use HT qualifier.

claimInformation.serviceLines.contractInformation

object

Required when the submitter is contractually obligated to supply this information on post-adjudicated claims.

claimInformation.serviceLines.serviceLineReferenceInformation

object

Additional identifiers for the service line.

claimInformation.serviceLines.salesTaxAmount

string

Sales tax, formatted as a decimal. When you include this property, the total lineItemChargeAmount for this service line must include this sales tax value.

claimInformation.serviceLines.postageTaxAmount

string

The amount of the postage, formatted as a decimal. When you include this property, the total lineItemChargeAmount for this service line must include this postage value.

claimInformation.serviceLines.fileInformation

string[]

Used to send additional data specifically requested by the payer. Not commonly used.

claimInformation.serviceLines.additionalNotes

string

Additional information the provider feels is necessary to substantiate the medical treatment that cannot be provided in other claim properties. Don't use this property to describe non-specific procedure codes.

claimInformation.serviceLines.goalRehabOrDischargePlans

string

The provider's goals, rehabilitation potential, or discharge plans for the patient.

claimInformation.serviceLines.thirdPartyOrganizationNotes

string

Required when the TPO/repricer needs to forward additional information to the payer. Providers shouldn't complete this property.

claimInformation.serviceLines.purchasedServiceInformation

object

Specify information about services that were purchased. Required on non-vision service lines when adjudication is known to be impacted by the charge amount for services purchased from another source OR when adjudication is known to be impacted by the acquisition cost of lenses.

claimInformation.serviceLines.linePricingRepricingInformation

object

Repricing information to be completed by repricers, not providers. For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim.

claimInformation.serviceLines.linePricingRepricingInformation.pricingMethodologyCode

enum<string>

required

Code indicating the pricing or repricing methodology. Visit Claims code lists for a complete list.

Available options:

00,

01,

02,

03,

04,

05,

06,

07,

08,

09,

10,

11,

12,

13,

14

claimInformation.serviceLines.linePricingRepricingInformation.repricedAllowedAmount

string

required

The dollar amount, expressed as a decimal. For example, 100.50.

claimInformation.serviceLines.linePricingRepricingInformation.repricedSavingAmount

string

The dollar amount, expressed as a decimal.

claimInformation.serviceLines.linePricingRepricingInformation.repricingOrganizationIdentifier

string

The identifier of the organization that repriced the claim.

claimInformation.serviceLines.linePricingRepricingInformation.repricingPerDiemOrFlatRateAmount

string

The pricing rate associated with per diem or flat rate repricing, expressed as a decimal.

claimInformation.serviceLines.linePricingRepricingInformation.repricedApprovedAmbulatoryPatientGroupCode

string

The code indicating the type of repricing.

claimInformation.serviceLines.linePricingRepricingInformation.repricedApprovedAmbulatoryPatientGroupAmount

string

The dollar amount, expressed as a decimal.

claimInformation.serviceLines.linePricingRepricingInformation.rejectReasonCode

enum<string>

Code indicating the rejection message returned from the third party organization. Visit Claims code lists for a complete list.

Available options:

T1,

T2,

T3,

T4,

T5,

T6

claimInformation.serviceLines.linePricingRepricingInformation.policyComplianceCode

enum<string>

Code indicating the policy compliance. Visit Claims code lists for a complete list.

Available options:

1,

2,

3,

4,

5

claimInformation.serviceLines.linePricingRepricingInformation.exceptionCode

enum<string>

Code specifying the exception reason for consideration of out-of-network health care services. This is the reason generated by the third-party health organization. Visit Claims code lists for a complete list.

Available options:

1,

2,

3,

4,

5,

6

claimInformation.serviceLines.drugIdentification

object

To report prescribed drugs and biologics.

claimInformation.serviceLines.renderingProvider

object

Information about the provider who rendered the services. This can be a individual or a company (a laboratory or other facility). This is where you should enter the substitute provider's (locum tenens physician) information, if applicable.

claimInformation.serviceLines.renderingProvider.providerType

string

required

Set to RenderingProvider.

claimInformation.serviceLines.renderingProvider.npi

string

The National Provider Identifier (NPI) assigned to the provider.

claimInformation.serviceLines.renderingProvider.ssn

string

deprecated

The provider's Social Security Number. The Social Security Number must be a string of exactly nine numbers with no separators. If you provider this value, you cannot include the provider's employerId. This shape is deprecated.

claimInformation.serviceLines.renderingProvider.employerId

string

deprecated

The provider's Employer Identification Number (EIN). The EIN is typically a string of exactly nine numbers with no separators, unless otherwise specified by the provider. If you include this value, you cannot include the provider's ssn. This shape is deprecated.

claimInformation.serviceLines.renderingProvider.commercialNumber

string

The provider's commercial number.

claimInformation.serviceLines.renderingProvider.locationNumber

string

The provider's location number.

claimInformation.serviceLines.renderingProvider.payerIdentificationNumber

string

The payer identification number.

claimInformation.serviceLines.renderingProvider.employerIdentificationNumber

string

deprecated

The provider's Employer Identification Number (EIN). This field is the same as employerId. The EIN is typically a string of exactly nine numbers with no separators, unless otherwise specified by the provider. If you include this value, you cannot include the provider's ssn. This shape is deprecated.

claimInformation.serviceLines.renderingProvider.claimOfficeNumber

string

deprecated

This shape is deprecated.

claimInformation.serviceLines.renderingProvider.naic

string

deprecated

The National Association of Insurance Commissioners (NAIC) code. This shape is deprecated.

claimInformation.serviceLines.renderingProvider.stateLicenseNumber

string

The provider's state license number.

claimInformation.serviceLines.renderingProvider.providerUpinNumber

string

deprecated

Deprecated; do not use. This shape is deprecated.

claimInformation.serviceLines.renderingProvider.taxonomyCode

string

Code from the National Uniform Claims Committee Health Care Provider Taxonomy Code Set. This identifies the provider's type and/or area of specialty.

Required string length: 10

claimInformation.serviceLines.renderingProvider.firstName

string

The provider's first name.

claimInformation.serviceLines.renderingProvider.lastName

string

The provider's last name. You should include either the lastName or organizationName property in this object.

claimInformation.serviceLines.renderingProvider.middleName

string

The provider's middle name or initial.

claimInformation.serviceLines.renderingProvider.suffix

string

The provider's name suffix, such as Jr. or III.

claimInformation.serviceLines.renderingProvider.organizationName

string

The provider's business name. You should include either the lastName or organizationName property in this object.

claimInformation.serviceLines.renderingProvider.address

object

This shape is deprecated.

claimInformation.serviceLines.renderingProvider.contactInformation

object

This shape is deprecated.

claimInformation.serviceLines.renderingProvider.otherIdentifier

string

claimInformation.serviceLines.renderingProvider.secondaryIdentifier

object[]

An identifier for the provider. The qualifier can be set to OB - State License Number, 1G - Provider UPIN Number, LU - Location Number, or G2 - Provider Commercial Number. Note that UPIN is deprecated and shouldn't be used for new claims.

claimInformation.serviceLines.purchasedServiceProvider

object

Information about the provider who performed the purchased service. A purchased service provider performs a service on a contractual or reassignment basis for the billing provider. Examples of purchased services include processing a laboratory specimen and performing diagnostic testing services (excluding clinical laboratory testing) subject to Medicare's anti-markup rule. Note that a substitute provider (a locum tenens physician) is not considered a purchased service provider.

claimInformation.serviceLines.purchasedServiceProvider.providerType

string

required

Set to PurchasedServiceProvider.

claimInformation.serviceLines.purchasedServiceProvider.npi

string

The National Provider Identifier (NPI) assigned to the provider.

claimInformation.serviceLines.purchasedServiceProvider.stateLicenseNumber

string

The provider's state license number.

claimInformation.serviceLines.purchasedServiceProvider.commercialNumber

string

The provider's commercial number.

claimInformation.serviceLines.purchasedServiceProvider.payerIdentificationNumber

string

The payer identification number. This must match the value you provided in claimInformation.otherSubscriberInformation.otherPayerName.otherPayerIdentifier.

claimInformation.serviceLines.purchasedServiceProvider.ssn

string

deprecated

This shape is deprecated.

claimInformation.serviceLines.purchasedServiceProvider.employerId

string

deprecated

This shape is deprecated.

claimInformation.serviceLines.purchasedServiceProvider.locationNumber

string

deprecated

This shape is deprecated.

claimInformation.serviceLines.purchasedServiceProvider.employerIdentificationNumber

string

deprecated

This shape is deprecated.

claimInformation.serviceLines.purchasedServiceProvider.claimOfficeNumber

string

deprecated

This shape is deprecated.

claimInformation.serviceLines.purchasedServiceProvider.naic

string

deprecated

This shape is deprecated.

claimInformation.serviceLines.purchasedServiceProvider.providerUpinNumber

string

deprecated

This shape is deprecated.

claimInformation.serviceLines.purchasedServiceProvider.taxonomyCode

string

deprecated

This shape is deprecated.

Required string length: 10

claimInformation.serviceLines.purchasedServiceProvider.firstName

string

deprecated

This shape is deprecated.

claimInformation.serviceLines.purchasedServiceProvider.lastName

string

deprecated

This shape is deprecated.

claimInformation.serviceLines.purchasedServiceProvider.middleName

string

deprecated

This shape is deprecated.

claimInformation.serviceLines.purchasedServiceProvider.suffix

string

deprecated

This shape is deprecated.

claimInformation.serviceLines.purchasedServiceProvider.organizationName

string

deprecated

This shape is deprecated.

claimInformation.serviceLines.purchasedServiceProvider.address

object

This shape is deprecated.

claimInformation.serviceLines.purchasedServiceProvider.contactInformation

object

This shape is deprecated.

claimInformation.serviceLines.purchasedServiceProvider.otherIdentifier

string

deprecated

This shape is deprecated.

claimInformation.serviceLines.purchasedServiceProvider.secondaryIdentifier

object[]

claimInformation.serviceLines.serviceFacilityLocation

object

Information about where the services were rendered. When reporting ambulance services, you should use the ambulancePickUpLocation and ambulanceDropOffLocation properties instead.

claimInformation.serviceLines.serviceFacilityLocation.organizationName

string

required

The laboratory or facility name. When services were rendered in the patient's home, we recommend setting this to Residence or something similar.

claimInformation.serviceLines.serviceFacilityLocation.address

object

required

The address of where services were rendered.

If the service facility location is in an area where there are no street addresses, enter a description of where the service was rendered. For example, 'crossroad of State Road 34 and 45'.

For United States addresses, you must include the full nine-digit zip code with no separators, such as 100031502. If you don't know the full zip code, you can find it using the USPS ZIP Code Lookup tool.

claimInformation.serviceLines.serviceFacilityLocation.npi

string

The organization National Provider Identifier (NPI) assigned to the service facility. Only include this property when the service facility is not a component or subpart of the billing provider. Don't include when the service facility is the patient's home.

claimInformation.serviceLines.serviceFacilityLocation.phoneName

string

deprecated

The full name of the person or office. This shape is deprecated.

claimInformation.serviceLines.serviceFacilityLocation.phoneNumber

string

deprecated

The phone number, formatted as AAABBBCCCC, where AAA represents the area code, BBB is the telephone number prefix, and CCCC is the telephone number. The phone number should only include the digits 0 to 9. Don't include separators, such as dashes, and don't include long distance access numbers, such as 1. For example, you would format the phone number 123-456-7890 as 1234567890. This shape is deprecated.

claimInformation.serviceLines.serviceFacilityLocation.phoneExtension

string

deprecated

The telephone extension, if applicable. Only submit the numeric extension. For example, don't include data that indicates an extension, such as 'ext.' or 'x-'. This shape is deprecated.

claimInformation.serviceLines.serviceFacilityLocation.secondaryIdentifier

object[]

Secondary identifier for the service facility location. Used when another identifier is needed for the claims processor to identify the facility or when the entity is not a healthcare provider and does not have an NPI. The qualifier can be set to OB - State License Number, LU - Location Number, or G2 - Provider Commercial Number. You can include up to three objects in this array.

claimInformation.serviceLines.supervisingProvider

object

Information about the provider who oversaw the rendering provider and the care reported in this service line. Include this object when the supervising provider is different than the one listed in the supervising object for the entire claim.

This should be an individual, not an organization, and you should supply at least the provider's lastName and an identifier, which is typically the npi.

claimInformation.serviceLines.supervisingProvider.providerType

string

required

Set to SupervisingProvider.

claimInformation.serviceLines.supervisingProvider.npi

string

The individual National Provider Identifier (NPI) assigned to the provider.

claimInformation.serviceLines.supervisingProvider.ssn

string

deprecated

The provider's organization name. This shape is deprecated.

claimInformation.serviceLines.supervisingProvider.employerId

string

deprecated

claimInformation.serviceLines.supervisingProvider.commercialNumber

string

The provider's commercial number.

claimInformation.serviceLines.supervisingProvider.locationNumber

string

The provider's location number.

claimInformation.serviceLines.supervisingProvider.payerIdentificationNumber

string

deprecated

The payer identification number. This shape is deprecated.

claimInformation.serviceLines.supervisingProvider.employerIdentificationNumber

string

deprecated

claimInformation.serviceLines.supervisingProvider.claimOfficeNumber

string

deprecated

This shape is deprecated.

claimInformation.serviceLines.supervisingProvider.naic

string

deprecated

The National Association of Insurance Commissioners (NAIC) code. This shape is deprecated.

claimInformation.serviceLines.supervisingProvider.stateLicenseNumber

string

The provider's state license number.

claimInformation.serviceLines.supervisingProvider.providerUpinNumber

string

deprecated

Deprecated; do not use. This shape is deprecated.

claimInformation.serviceLines.supervisingProvider.taxonomyCode

string

deprecated

Code from the National Uniform Claims Committee Health Care Provider Taxonomy Code Set. This identifies the provider's type and/or area of specialty. This shape is deprecated.

Required string length: 10

claimInformation.serviceLines.supervisingProvider.firstName

string

The provider's first name.

claimInformation.serviceLines.supervisingProvider.lastName

string

The provider's last name.

claimInformation.serviceLines.supervisingProvider.middleName

string

The provider's middle name or initial.

claimInformation.serviceLines.supervisingProvider.suffix

string

The provider's name suffix, such as Jr. or III.

claimInformation.serviceLines.supervisingProvider.organizationName

string

The provider's business name. You should include either the lastName or organizationName property in this object.

claimInformation.serviceLines.supervisingProvider.address

object

This shape is deprecated.

claimInformation.serviceLines.supervisingProvider.contactInformation

object

This shape is deprecated.

claimInformation.serviceLines.supervisingProvider.otherIdentifier

string

claimInformation.serviceLines.supervisingProvider.secondaryIdentifier

object[]

claimInformation.serviceLines.orderingProvider

object

Information about the provider who requested the services or items reported in this service line.

This should be an individual, not an organization, and you should supply at least the provider's lastName and an identifier, which is typically the npi.

claimInformation.serviceLines.orderingProvider.providerType

string

required

Set to OrderingProvider.

claimInformation.serviceLines.orderingProvider.npi

string

The individual National Provider Identifier (NPI) assigned to the provider.

claimInformation.serviceLines.orderingProvider.ssn

string

deprecated

This shape is deprecated.

claimInformation.serviceLines.orderingProvider.employerId

string

deprecated

This shape is deprecated.

claimInformation.serviceLines.orderingProvider.commercialNumber

string

claimInformation.serviceLines.orderingProvider.locationNumber

string

deprecated

This shape is deprecated.

claimInformation.serviceLines.orderingProvider.payerIdentificationNumber

string

claimInformation.serviceLines.orderingProvider.employerIdentificationNumber

string

deprecated

This shape is deprecated.

claimInformation.serviceLines.orderingProvider.claimOfficeNumber

string

deprecated

This shape is deprecated.

claimInformation.serviceLines.orderingProvider.naic

string

deprecated

This shape is deprecated.

claimInformation.serviceLines.orderingProvider.stateLicenseNumber

string

claimInformation.serviceLines.orderingProvider.providerUpinNumber

string

deprecated

This shape is deprecated.

claimInformation.serviceLines.orderingProvider.taxonomyCode

string

deprecated

This shape is deprecated.

Required string length: 10

claimInformation.serviceLines.orderingProvider.firstName

string

The provider's first name.

claimInformation.serviceLines.orderingProvider.lastName

string

The provider's last name.

claimInformation.serviceLines.orderingProvider.middleName

string

The provider's middle name or initial.

claimInformation.serviceLines.orderingProvider.suffix

string

The provider's name suffix, such as Jr. or III.

claimInformation.serviceLines.orderingProvider.organizationName

string

The provider's business name.

claimInformation.serviceLines.orderingProvider.address

object

claimInformation.serviceLines.orderingProvider.contactInformation

object

claimInformation.serviceLines.orderingProvider.otherIdentifier

string

claimInformation.serviceLines.orderingProvider.secondaryIdentifier

object[]

An identifier for the provider. The qualifier can be set to OB - State License Number, 1G - Provider UPIN Number, or G2 - Provider Commercial Number. Note that UPIN is deprecated and shouldn't be used for new claims.

claimInformation.serviceLines.referringProvider

object

Information about the provider who directed the patient to the rendering provider for care. For example, a primary care provider may refer patients to a specialist. Include this object when the referring provider is different than the one listed in the referring object for the entire claim.

This should be an individual, not an organization, and you should supply at least the provider's lastName and an identifier, which is typically the npi.

claimInformation.serviceLines.referringProvider.providerType

string

required

Set to ReferringProvider.

claimInformation.serviceLines.referringProvider.npi

string

The individual National Provider Identifier (NPI) assigned to the provider.

claimInformation.serviceLines.referringProvider.ssn

string

deprecated

claimInformation.serviceLines.referringProvider.employerId

string

deprecated

claimInformation.serviceLines.referringProvider.commercialNumber

string

The provider's commercial number.

claimInformation.serviceLines.referringProvider.locationNumber

string

deprecated

The provider's location number. This shape is deprecated.

claimInformation.serviceLines.referringProvider.payerIdentificationNumber

string

The payer identification number.

claimInformation.serviceLines.referringProvider.employerIdentificationNumber

string

deprecated

claimInformation.serviceLines.referringProvider.claimOfficeNumber

string

deprecated

This shape is deprecated.

claimInformation.serviceLines.referringProvider.naic

string

deprecated

The National Association of Insurance Commissioners (NAIC) code. This shape is deprecated.

claimInformation.serviceLines.referringProvider.stateLicenseNumber

string

The provider's state license number.

claimInformation.serviceLines.referringProvider.providerUpinNumber

string

deprecated

Deprecated; do not use. This shape is deprecated.

claimInformation.serviceLines.referringProvider.taxonomyCode

string

deprecated

Code from the National Uniform Claims Committee Health Care Provider Taxonomy Code Set. This identifies the provider's type and/or area of specialty. This shape is deprecated.

Required string length: 10

claimInformation.serviceLines.referringProvider.firstName

string

The provider's first name.

claimInformation.serviceLines.referringProvider.lastName

string

The provider's last name.

claimInformation.serviceLines.referringProvider.middleName

string

The provider's middle name or initial.

claimInformation.serviceLines.referringProvider.suffix

string

The provider's name suffix, such as Jr. or III.

claimInformation.serviceLines.referringProvider.organizationName

string

The provider's organization name.

claimInformation.serviceLines.referringProvider.address

object

This shape is deprecated.

claimInformation.serviceLines.referringProvider.contactInformation

object

This shape is deprecated.

claimInformation.serviceLines.referringProvider.otherIdentifier

string

claimInformation.serviceLines.referringProvider.secondaryIdentifier

object[]

claimInformation.serviceLines.ambulancePickUpLocation

object

The address where the ambulance picked up the patient. If the ambulance pickup location is in an area where there are no street addresses, enter a description of where the service was rendered. For example Exit near mile marker 123 on I-95.

claimInformation.serviceLines.ambulanceDropOffLocation

object

The address where the ambulance dropped off the patient.

claimInformation.serviceLines.lineAdjudicationInformation

object[]

Includes service line adjudication information for coordination of benefits between the initial payers of a health care claim and all subsequent payers.

claimInformation.serviceLines.lineAdjudicationInformation.otherPayerPrimaryIdentifier

string

required

The payer ID for the payer responsible for reimbursement.

claimInformation.serviceLines.lineAdjudicationInformation.serviceLinePaidAmount

string

required

The amount paid for this service line, expressed as a decimal. Zero (0) is an acceptable value.

claimInformation.serviceLines.lineAdjudicationInformation.procedureCode

string

required

The procedure code.

claimInformation.serviceLines.lineAdjudicationInformation.paidServiceUnitCount

string

required

The number of paid units from the remittance advice. expressed as a decimal. When paid units are not present on the remittance advice, use the original billed units. The maximum length for this property is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three.

claimInformation.serviceLines.lineAdjudicationInformation.adjudicationOrPaymentDate

string

required

The date the other payer adjudicated or paid the claim, formatted as YYYYMMDD.

claimInformation.serviceLines.lineAdjudicationInformation.serviceIdQualifier

enum<string>

required

Code identifying the type of procedureCode. Visit Claims code lists for a complete list.

Available options:

ER,

HC,

HP,

IV,

WK

claimInformation.serviceLines.lineAdjudicationInformation.procedureModifier

string[]

Modifiers that convey special circumstances related to the performance of the service. You can include up to four modifiers in this array.

claimInformation.serviceLines.lineAdjudicationInformation.procedureCodeDescription

string

The meaning of the procedure code.

claimInformation.serviceLines.lineAdjudicationInformation.bundledOrUnbundledLineNumber

string

The LX assigned number of the service line into which this service line is bundled. It's only used to bundle service lines.

claimInformation.serviceLines.lineAdjudicationInformation.claimAdjustmentInformation

object[]

Required when the payer made line level adjustments which caused the amount paid to differ from the amount originally charged. You can include up to five objects in this array.

claimInformation.serviceLines.lineAdjudicationInformation.remainingPatientLiability

string

The amount of the service line that the patient is still responsible for, expressed as a decimal.

claimInformation.serviceLines.formIdentification

object[]

Use this object to attach standardized supplemental information to the claim when required by the payer. One example is payer documentation requirements for home health services.

claimInformation.propertyCasualtyClaimNumber

string

The agency claim number for this transaction. Used when services included in this claim are part of a property and casualty claim.

Code identifying an accompanying cause of an illness, injury or an accident. Can be set to AA - Auto Accident, EM - Employment, or OA - Other Accident. You can include up to two codes in this array.

Code identifying an accompanying cause of an illness, injury or an accident. Can be set to AA - Auto Accident, EM - Employment, or OA - Other Accident.

Available options:

AA,

EM,

OA

claimInformation.autoAccidentStateCode

string

A code identifying the state or province in which the automobile accident occurred. Use this code when relatedCausesCode is set to AA.

claimInformation.autoAccidentCountryCode

string

The country code where the accident occurred. Use when relatedCausesCode = AA and the accident occurred in a country other than US or Canada.

claimInformation.delayReasonCode

enum<string>

Code indicating the reason for the delay in claim submission. Visit Claims code lists for a complete list.

Available options:

1,

2,

3,

4,

5,

6,

7,

8,

9,

10,

11,

15

claimInformation.patientAmountPaid

string

The total amount in dollars the patient or their representatives have paid on this claim. For example, 20.50. This includes any co-payments, co-insurance, or other amounts already collected from the patient.

If the patient has not paid anything, you should omit this property entirely - don't set it to 0.

claimInformation.fileInformation

string

Used to send additional data specifically requested by the payer. Not commonly used.

claimInformation.fileInformationList

string[]

Used to send additional data specifically requested by the payer. Not commonly used.

claimInformation.claimPricingRepricingInformation

object

claimInformation.serviceFacilityLocation

object

Required when the location for the service is different from the billing provider's address. The purpose of this object is to identify specifically where the service was rendered. This can be healthcare facilities, such as surgical centers or reference labs, OR the patient's address when services were rendered in their home.

Don't use this object when reporting ambulance services - use ambulancePickupLocation and ambulanceDropoffLocation instead.

claimInformation.serviceFacilityLocation.organizationName

string

required

The laboratory or facility name. When services were rendered in the patient's home, we recommend setting this to Residence or something similar.

claimInformation.serviceFacilityLocation.address

object

required

The address of where services were rendered.

If the service facility location is in an area where there are no street addresses, enter a description of where the service was rendered. For example, 'crossroad of State Road 34 and 45'.

claimInformation.serviceFacilityLocation.npi

string

claimInformation.serviceFacilityLocation.phoneName

string

The full name of the person or office.

claimInformation.serviceFacilityLocation.phoneNumber

string

claimInformation.serviceFacilityLocation.phoneExtension

string

The telephone extension, if applicable. Only submit the numeric extension. For example, don't include data that indicates an extension, such as 'ext.' or 'x-'.

claimInformation.serviceFacilityLocation.secondaryIdentifier

object

claimInformation.deathDate

string

The patient's date of death, formatted as YYYYMMDD.

claimInformation.patientWeight

string

The patient's weight in pounds, such as 150. You should only set this property if the payer specifically requests it, such as for some Medicare DME claims. Otherwise, including this property can trigger claim edits.

claimInformation.patientSignatureSourceCode

boolean

Code indicating how the patient or subscriber authorization signatures were obtained and how they are being retained by the provider. Can be set to true - Signature generated by provider because the patient was not physically present for services. This means the signature was generated by an entity other than the patient according to State or Federal law. This property is required for claims submitted to Medicare.

claimInformation.pregnancyIndicator

enum<string>

Code indicating whether the patient is pregnant. Can be set to Y - Yes.

Available options:

Y

claimInformation.claimDateInformation

object

You must provide at least one date related to the claim. For example, the date on which the patient was admitted to the hospital. All dates are formatted as YYYYMMDD.

claimInformation.claimDateInformation.symptomDate

string

The date the patient began experiencing acute symptoms for the current illness or condition. Required for the initial medical service or visit performed in response to a medical emergency when the date is available and is different than the date of service.

claimInformation.claimDateInformation.initialTreatmentDate

string

The date the patient first received treatment for the current illness or condition. Required when the Initial Treatment Date is known to impact adjudication for claims involving spinal manipulation, physical therapy, occupational therapy, speech language pathology, dialysis, optical refractions, or pregnancy.

claimInformation.claimDateInformation.lastSeenDate

string

The date that the patient was seen by the attending or supervising physician for the qualifying medical condition related to the services performed. Required when claims involve services for routine foot care and this date is known to impact the payer's adjudication process.

claimInformation.claimDateInformation.acuteManifestationDate

string

The date the patient first experienced acute symptoms for a chronic condition. Required when the patientConditionCode = A (Acute Condition) or M (Acute Manifestation of a Chronic Condition), the claim involves spinal manipulation, and the payer is Medicare.

claimInformation.claimDateInformation.accidentDate

string

The date of the accident related to this claim. Required when relatedCausesCode is set to AA - Auto Accident or OA - Other Accident. Also required when relatedCausesCode is set to EM - Employment and this claim is the result of an accident.

claimInformation.claimDateInformation.lastMenstrualPeriodDate

string

The date of the patient's last menstrual period. Required when the provider believes the services on this claim are related to the patient's pregnancy.

claimInformation.claimDateInformation.lastXRayDate

string

The date of the patient's last x-ray. Required when claim involves spinal manipulation and an x-ray was taken.

claimInformation.claimDateInformation.hearingAndVisionPrescriptionDate

string

The date of the patient's hearing and vision prescription. Required on claims where a prescription has been written for hearing devices or vision frames and lenses and it is being billed on this claim.

claimInformation.claimDateInformation.disabilityBeginDate

string

The start date of the patient's disability period. You can include this date without providing a disabilityEndDate if the patient is currently disabled and the end date is unknown. Used for claims involving disability where the provider judges that the patient was or will be unable to perform the duties normally associated with their work.

claimInformation.claimDateInformation.disabilityEndDate

string

The end date of the patient's disability period. You can include this date without including a disabilityStartDate if the patient is no longer disabled and the start date is unknown. Used for claims involving disability where the provider judges that the patient was or will be unable to perform the duties normally associated with their work.

claimInformation.claimDateInformation.lastWorkedDate

string

The date the patient last worked, related to disability claims. Required on claims where this information is necessary for adjudication, such as workers compensation claims.

claimInformation.claimDateInformation.authorizedReturnToWorkDate

string

The date the provider has authorized the patient to return to work. Required on claims where this information is necessary for adjudication, such as workers compensation claims.

claimInformation.claimDateInformation.admissionDate

string

The date the patient was admitted to the hospital. Required on ambulance claims when the patient was known to be admitted to the hospital. Also required on inpatient claims.

claimInformation.claimDateInformation.dischargeDate

string

The date the patient was discharged from the hospital. Required for inpatient claims when the patient was discharged from the facility and the discharge date is known

claimInformation.claimDateInformation.assumedAndRelinquishedCareBeginDate

string

The date the provider filing this claim assumed care from another provider during post-operative care. Required when providers share post-operative care (global surgery claims).

claimInformation.claimDateInformation.assumedAndRelinquishedCareEndDate

string

The date the provider filing this claim relinquished post-operative care to another provider. Required when providers share post-operative care (global surgery claims).

claimInformation.claimDateInformation.repricerReceivedDate

string

The date the repricing entity received the initial claim. Required when a repricer is passing the claim onto the payer.

claimInformation.claimDateInformation.firstContactDate

string

Date the patient first consulted the provider for their condition by any means. This is not necessarily the same as the initial treatment date. Required for Property and Casualty claims when state mandated.

claimInformation.claimSupplementalInformation

object

Additional information or documentation required for the claim.

claimInformation.claimSupplementalInformation.reportInformation

object

claimInformation.claimSupplementalInformation.priorAuthorizationNumber

string

Required when an authorization number is assigned by the payer or UMO and the services on this claim were preauthorized. The UMO (Utilization Management Organization) is generally the entity empowered to make a decision regarding the outcome of a health services review or the owner of information.

claimInformation.claimSupplementalInformation.referralNumber

string

Required when a referral number is assigned by the payer or Utilization Management Organization (UMO) and a referral is involved.

claimInformation.claimSupplementalInformation.claimControlNumber

string

Required when the claimFrequencyCode indicates this claim is a replacement or void to a previously adjudicated claim.

claimInformation.claimSupplementalInformation.cliaNumber

string

Required for all CLIA certified facilities performing CLIA covered laboratory services. When this claim contains both in-house and outsourced laboratory services, use the CLIA Number for laboratory services performed by the billing or rendering provider. You can report outsourced laboratory services in the serviceLines object.

claimInformation.claimSupplementalInformation.repricedClaimNumber

string

Required when the repricer believes this information is necessary. Providers should not complete this property.

claimInformation.claimSupplementalInformation.adjustedRepricedClaimNumber

string

Required when the repricer believes this information is necessary. Providers should not complete this property.

claimInformation.claimSupplementalInformation.investigationalDeviceExemptionNumber

string

Required when claim involves a Food and Drug Administration (FDA) assigned investigational device exemption (IDE) number. When more than one IDE applies, you must split into separate claims.

claimInformation.claimSupplementalInformation.claimNumber

string

The claim number assigned by clearinghouse, van, etc. Providers should not complete this property.

claimInformation.claimSupplementalInformation.mammographyCertificationNumber

string

Required when mammography services are rendered by a certified mammography provider.

claimInformation.claimSupplementalInformation.medicalRecordNumber

string

Required when the provider needs to identify the actual medical record of the patient for this episode of care.

claimInformation.claimSupplementalInformation.demoProjectIdentifier

string

Required when it is necessary to identify claims that are atypical in ways such as content, purpose, and/or payment. For example, claims made as the result of a demonstration or a clinical trial.

claimInformation.claimSupplementalInformation.carePlanOversightNumber

string

Required when the physician is billing Medicare for Care Plan Oversight (CPO). This is the number of the home health agency or hospice providing Medicare covered services to the patient.

claimInformation.claimSupplementalInformation.medicareCrossoverReferenceId

string

Required when the submitter is Medicare and the claim is a Medigap or COB crossover claim.

claimInformation.claimSupplementalInformation.serviceAuthorizationExceptionCode

enum<string>

Code indicating the reason for the service authorization exception. Visit Claims code lists for a complete list.

Available options:

1,

2,

3,

4,

5,

6,

7

claimInformation.ambulanceTransportInformation

object

Information about the ambulance service provided to the patient.

claimInformation.spinalManipulationServiceInformation

object

Information about a chiropractic service rendered to the patient. Required on chiropractic claims involving spinal manipulation when the information is known to impact the payer's adjudication process.

claimInformation.ambulanceCertification

object[]

Required when the claim involves ambulance transport services.

claimInformation.patientConditionInformationVision

object[]

Required on vision claims involving replacement lenses or frames when this information is known to impact reimbursement.

Required on vision claims involving replacement lenses or frames when this information is known to impact reimbursement. .

claimInformation.claimContractInformation

object

Required when the submitter is contractually obligated to supply this information on post-adjudicated claims.

claimInformation.specialProgramCode

enum<string>

Code indicating the Special Program under which the services rendered to the patient were performed. Used for Medicaid claims only. Can be set to 02 - Physically Handicapped Children's Program, 03 - Special Federal Funding, 05 - Disability, or 09 - Second Opinion or Surgery.

Available options:

02,

03,

05,

09

claimInformation.homeboundIndicator

boolean

Required for Medicare claims when an independent laboratory renders an EKG tracing or obtains a specimen from a homebound or institutionalized patient.

claimInformation.epsdtReferral

object

Required on Early & Periodic Screening, Diagnosis, and Treatment (EPSDT) claims when the screening service is being billed in this claim.

This is required if any of the claim service lines are for EPSDT services. That means you must include this object if any claimInformation.serviceLines.professionalService.epsdtIndicator properties are set to Y.

The surgical code. Required on claims where anesthesiology services are being billed or reported when the provider knows the surgical code and knows the adjudication of the claim will depend on provision of the surgical code.

claimInformation.conditionInformation

object[]

Required when condition information applies to the claim. You can include up to 24 codes in the array. Visit the National Uniform Claim Committee for a complete list of possible condition codes.

claimInformation.claimNote

object

Comments or special instructions related to the claim. Contains information required to substantiate the medical treatment that isn't provided elsewhere in the claim.

claimInformation.ambulancePickUpLocation

object

claimInformation.ambulanceDropOffLocation

object

The address where the ambulance dropped off the patient.

claimInformation.otherSubscriberInformation

object[]

Required when other payers are known to potentially be involved in paying on this claim. This object contains information about other health plans under which the patient has coverage. It's used for coordination of benefits scenarios.

claimInformation.otherSubscriberInformation.paymentResponsibilityLevelCode

enum<string>

required

Code identifying the insurance carrier's level of responsibility for a payment of a claim. Visit Claims code lists for a complete list. You may need to use other codes if the patient has multiple insurance policies. For example, if a patient is covered by both Medicare and an employer-sponsored commercial plan, you could bill the commercial payer first as P and then bill the Medicare payer second as S.

Available options:

A,

B,

C,

D,

E,

F,

G,

H,

P,

S,

T,

U

claimInformation.otherSubscriberInformation.individualRelationshipCode

enum<string>

required

Code identifying the relationship to the person insured. Visit Claims code lists for a complete list.

Available options:

01,

18,

19,

20,

21,

39,

40,

53,

G8

claimInformation.otherSubscriberInformation.claimFilingIndicatorCode

enum<string>

required

A code identifying the type of claim. For example DS - Disability. Use OF when submitting Medicare Part D claims. Use ZZ when you don't know the type of insurance. Visit Claims code lists for a complete list.

Available options:

11,

12,

13,

14,

15,

16,

17,

AM,

BL,

CH,

CI,

DS,

FI,

HM,

LM,

MA,

MB,

MC,

OF,

TV,

VA,

WC,

ZZ

claimInformation.otherSubscriberInformation.benefitsAssignmentCertificationIndicator

enum<string>

required

Code indicating whether whether or not the insured has authorized the plan to remit payment directly to the provider. Can be set to N - No, W - Not Applicable, or Y - Yes.

Available options:

N,

W,

Y

claimInformation.otherSubscriberInformation.releaseOfInformationCode

enum<string>

required

Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations. Can be set to I - Informed Consent to Release Medical Information or Y - Yes. Code I is required when the provider has not collected a signature AND state or federal laws do not require a signature be collected. Code Y is required when the provider has collected a signature OR when state or federal laws require a signature be collected.

Available options:

I,

Y

claimInformation.otherSubscriberInformation.otherSubscriberName

object

required

The person or entity who is the primary policyholder for the other payer's health plan.

claimInformation.otherSubscriberInformation.otherSubscriberName.otherInsuredQualifier

enum<string>

required

Code identifying the type of entity. Can be set to 1 - Person or 2 - Non-Person Entity.

Available options:

1,

2

claimInformation.otherSubscriberInformation.otherSubscriberName.otherInsuredLastName

string

required

The primary policyholder's last name or organizational name. Don't include the primary policyholder's name suffix, such as Jr. or III. Use the designated otherInsuredNameSuffix property instead.

claimInformation.otherSubscriberInformation.otherSubscriberName.otherInsuredIdentifierTypeCode

enum<string>

required

Code identifying the type of identifier. Can be set to II - Standard Unique Health Identifier for each individual in the United States or MI - Member Identification Number. The code MI should be the subscriber's identification number as assigned by the payer, such as their subscriber ID. You should also use MI in claims submitted to the Indian Health Service/Contract Health Services (IHS/CHS) Fiscal Intermediary for the purpose of reporting the Tribe Residency Code (Tribe County State). For IHS/CHS claims, you should also put the SSN in the otherInsuredAdditionalIdentifier property.)

Available options:

II,

MI

claimInformation.otherSubscriberInformation.otherSubscriberName.otherInsuredIdentifier

string

required

The identifier you specified in otherInsuredIdentifierTypeCode.

claimInformation.otherSubscriberInformation.otherSubscriberName.otherInsuredFirstName

string

The primary policyholder's first name, if they are an individual.

claimInformation.otherSubscriberInformation.otherSubscriberName.otherInsuredMiddleName

string

The primary policyholder's middle name or initial, if they are an individual.

claimInformation.otherSubscriberInformation.otherSubscriberName.otherInsuredNameSuffix

string

The primary policyholder's name suffix, such as Jr. or III. Only include the subscriber's personal name suffix - don't include professional or academic titles, such as M.D. or MBA.

claimInformation.otherSubscriberInformation.otherSubscriberName.otherInsuredAddress

object

The other subscriber's address.

claimInformation.otherSubscriberInformation.otherSubscriberName.otherInsuredAdditionalIdentifier

string

The primary policyholder's Social Security Number. The Social Security Number must be a string of exactly nine numbers with no separators. For example 123456789.

claimInformation.otherSubscriberInformation.otherPayerName

object

required

Details about the other payer.

claimInformation.otherSubscriberInformation.otherPayerName.otherPayerOrganizationName

string

required

The payer's organization name.

claimInformation.otherSubscriberInformation.otherPayerName.otherPayerIdentifierTypeCode

enum<string>

required

Code designating the type of identifier. Can be set to PI - Payor Identification or XV - Centers for Medicare/Medicaid Services PlanID. Use code value XV when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).

Available options:

PI,

XV

claimInformation.otherSubscriberInformation.otherPayerName.otherPayerIdentifier

string

required

The identifier specified in otherPayerIdentifierCode. When sending Line Adjudication Information for this payer, the identifier sent in lineAdjudicationInformation.otherPayerPrimaryIdentifier must match this value.

claimInformation.otherSubscriberInformation.otherPayerName.otherPayerAddress

object

The payer's address.

claimInformation.otherSubscriberInformation.otherPayerName.otherPayerAdjudicationOrPaymentDate

string

The date the other payer adjudicated the claim. Required when this payer has previously adjudicated the claim and you aren’t including a value for LineAdjudicationInformation.adjudicationOrPaymentDate.

claimInformation.otherSubscriberInformation.otherPayerName.otherPayerSecondaryIdentifier

object[]

An additional identification number to identify the other payer. The qualifier can be set to 2U - Payer Identification Number, EI - Employer Identification Number, FY - Claim Office Number, or NF - National Association of Insurance Commissioners (NAIC) Code.

claimInformation.otherSubscriberInformation.otherPayerName.otherPayerPriorAuthorizationNumber

string

The authorization number assigned by this payer.

claimInformation.otherSubscriberInformation.otherPayerName.otherPayerPriorAuthorizationOrReferralNumber

string

The referral number assigned by this payer.

claimInformation.otherSubscriberInformation.otherPayerName.otherPayerClaimAdjustmentIndicator

boolean

The only valid value is true. Required when Required when the claim is being sent in the payer-to-payer COB model AND the destination payer is secondary to this payer AND this payer has re-adjudicated the claim.

claimInformation.otherSubscriberInformation.otherPayerName.otherPayerClaimControlNumber

string

The claim control number assigned by this payer.

claimInformation.otherSubscriberInformation.insuranceGroupOrPolicyNumber

string

The group or policy number.

claimInformation.otherSubscriberInformation.otherInsuredGroupName

string

The name of the health plan.

claimInformation.otherSubscriberInformation.insuranceTypeCode

enum<string>

Code identifying the type of insurance policy within a specific insurance program. Visit Claims code lists for a complete list.

Available options:

12,

13,

14,

15,

16,

41,

42,

43,

47

claimInformation.otherSubscriberInformation.claimLevelAdjustments

object[]

Use this object to report prior payers' claim level adjustments that cause the amount paid to differ from the amount originally charged. Codes and associated amounts must come from either paper remittance advice or 835s (Electronic Remittance Advice) received on the claim. When the information originates from a paper remittance advice that does not use the standard Claim Adjustment Reason Codes, you must convert them to standard Claim Adjustment Reason Codes.

claimInformation.otherSubscriberInformation.payerPaidAmount

string

The total amount in dollars the payer has paid on this claim. It is acceptable to set this to 0 (Zero). This is required when you include the payToPlan object, and you should set it to the amount the Medicaid agency actually paid.

claimInformation.otherSubscriberInformation.nonCoveredChargeAmount

string

Required when the destination payer's cost avoidance policy allows providers to bypass claim submission to the otherwise prior payer identified in otherSubscriberInformation.otherPayerName. The amount must equal the total claim charge amount you reported in claimInformation.claimChargeAmount.

claimInformation.otherSubscriberInformation.remainingPatientLiability

string

This is the remaining amount (as determined by the provider) to be paid after the other payer identified in the otherPayerName object has adjudicated the claim.

claimInformation.otherSubscriberInformation.otherPayerReferringProvider

object[]

Information about the provider who directed the patient to the rendering provider for care. For example, a primary care physician may refer patients to a specialist.

claimInformation.otherSubscriberInformation.otherPayerRenderingProvider

object[]

Information about the rendering provider.

claimInformation.otherSubscriberInformation.otherPayerServiceFacilityLocation

object[]

Information about the service facility location.

claimInformation.otherSubscriberInformation.otherPayerSupervisingProvider

object[]

Information about the supervising provider.

claimInformation.otherSubscriberInformation.otherPayerBillingProvider

object[]

Information about the billing provider.

claimInformation.otherSubscriberInformation.patientSignatureGeneratedForPatient

boolean

claimInformation.otherSubscriberInformation.medicareOutpatientAdjudication

object

Claim-level data related to the adjudication of Medicare claims not related to an inpatient setting. Required when outpatient adjudication information is reported in the remittance advice or when you need to report remark codes.

billing

object

required

Information about the billing provider. For tax identification, you must include either the provider's Social Security Number (SSN) or their Employer Identification Number (EIN), but not both.

billing.providerType

string

required

Set to BillingProvider.

billing.npi

string

The billing provider's National Provider Identifier (NPI).

billing.ssn

string

The billing provider's Social Security Number. Must be a string of exactly nine numbers with no separators. If you include this value, you cannot include the employerId.

billing.employerId

string

The billing provider's Employer Identification Number. Typically a string of exactly nine numbers with no separators, unless otherwise instructed by the payer. If you include this value, you cannot include the ssn.

billing.stateLicenseNumber

string

The billing provider's state license number.

billing.providerUpinNumber

string

deprecated

Deprecated; do not use. This shape is deprecated.

billing.taxonomyCode

string

Code from the National Uniform Claims Committee Health Care Provider Taxonomy Code Set. This identifies the billing provider's type and/or area of specialty.

Required string length: 10

billing.firstName

string

The billing provider's first name, if the provider is an individual.

billing.lastName

string

The provider's last name, if the provider is an individual.

billing.middleName

string

The provider's middle name or initial, if the provider is an individual.

billing.suffix

string

The provider's name suffix, such as Jr. or III.

billing.organizationName

string

The provider's business name.

billing.address

object

The billing provider's address. For United States addresses, you must include the full nine-digit zip code with no separators, such as 100031502. If you don't know the full zip code, you can find it using the USPS ZIP Code Lookup tool.

billing.contactInformation

object

Contact information for the billing provider. You can include a maximum of two objects in this array.

controlNumber

string

Not currently used.

dependent

object

Dependent who received the medical care associated with the claim. Note that if the dependent has their own member ID for the health plan, you should include the dependent's information in the subscriber object instead. To check whether a dependent has a member ID, submit an Eligibility Check to the payer. The payer returns the dependent's member ID in the dependents.memberId property in the response, if present.

dependent.firstName

string

required

The patient's first name.

dependent.lastName

string

required

The patient's last name. Don't include the patient's name suffix, such as Jr. or III. Use the designated suffix property instead.

dependent.gender

enum<string>

required

Code indiciating the patient's gender. Can be set to F - Female, M - Male, or U - Unknown.

Available options:

M,

F,

U

dependent.dateOfBirth

string

required

The patient's date of birth, formatted as YYYYMMDD.

dependent.relationshipToSubscriberCode

enum<string>

required

Identifies the relationship of the patient to the subscriber. Can be set to 01 - Spouse, 19 - Child, 20 - Employee, 21 - Unknown, 39 - Organ Donor, 40 - Cadaver Donor, 53 - Life Partner, or G8 - Other Relationship.

Available options:

01,

19,

20,

21,

39,

40,

53,

G8

dependent.middleName

string

The patient's middle name or initial.

dependent.suffix

string

The patient's name suffix, such as Jr. or III. Only include the patient's personal name suffix - don't include professional or academic titles, such as M.D. or MBA.

dependent.ssn

string

The patient's Social Security Number. Only used for Property and Casualty claims. The Social Security Number must be a string of exactly nine numbers with no separators. For example 123456789.

dependent.memberId

string

The patient's identification number. Only used in Property and Casualty claims.

dependent.address

object

The dependent's address. Every claim must include address information in either the subscriber (when the patient is the subscriber) or dependent (when the patient is a dependent) object. You must include at least the address1 and city properties in this object. The state and postalCode properties are also required for all United States and Canadian addresses.

The address must be the patient's correct address at the time of service. Don't use placeholder values to complete unknown address information. Use of outdated or placeholder values could cause the payer to reject, deny, or delay the claim due to suspected fraud.
If you don't know the patient's address, you should first submit a Real-Time Eligibility Check for the patient and then copy the patient's address from either the subscriber or dependent object in the response.
If the patient doesn't have a current address, you can populate the address1 property with UNKNOWN and populate the city, state, and zip code with appropriate values based on your discretion. However, some payers may have explicit rules for how to handle this situation, so you should check the payer's specific requirements before using this approach.

dependent.contactInformation

object

providers

object[]

deprecated

Deprecated; please set all providers individually by type. For example, Referring. This shape is deprecated.

The entity responsible for overseeing the rendering provider and the care reported in this claim. Applies when the rendering provider is supervised by a physician. Use when the provider applies to the entire claim, not just a specific service line.

This should be an individual, not an organization, and you should supply at least the provider's lastName and an identifier, which is typically the npi.

providers.providerType

string

required

Set to SupervisingProvider.

providers.npi

string

The individual National Provider Identifier (NPI) assigned to the supervising provider.

providers.ssn

string

deprecated

This shape is deprecated.

providers.employerId

string

deprecated

This shape is deprecated.

providers.commercialNumber

string

The commercial number of the supervising provider.

providers.locationNumber

string

The location number of the supervising provider.

providers.stateLicenseNumber

string

The state license number of the supervising provider.

providers.providerUpinNumber

string

deprecated

Deprecated; do not use. This shape is deprecated.

providers.taxonomyCode

string

deprecated

This shape is deprecated.

Required string length: 10

providers.firstName

string

The first name of the supervising provider.

providers.lastName

string

The last name of the supervising provider.

providers.middleName

string

The middle name or initial of the supervising provider.

providers.suffix

string

The suffix of the supervising provider's name, such as Jr. or III.

providers.organizationName

string

The supervising provider's business name, when the provider is not an individual.

providers.address

object

This shape is deprecated.

providers.contactInformation

object

This shape is deprecated.

payToAddress

object

Use when the address for payment is different than that of the billing provider for this claim.

payToPlan

object

Use for subrogation payment requests. If you include this information, you must also set the claimInformation.otherSubscriberInformation.payerPaidAmount to the amount the payer (for example, Medicaid) actually paid.

payToPlan.organizationName

string

required

The last name of the individual, or the business name of the pay-to-plan organization.

payToPlan.primaryIdentifierTypeCode

enum<string>

required

Code identifying the type of identifier. Can be set to PI - Payor Identification or XV - Centers for Medicare/Medicaid Services PlanID. Use code value XV when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).

Available options:

PI,

XV

payToPlan.primaryIdentifier

string

required

The identifier you specified in primaryIdentifierTypeCode.

payToPlan.address

object

required

The address of the pay-to-plan organization.

payToPlan.taxIdentificationNumber

string

required

The Employer Identification Number (EIN). This must be a string of exactly nine numbers with no separators.

Required string length: 9

payToPlan.secondaryIdentifierTypeCode

enum<string>

Code identifying the type of secondary identifier. Can be set to 2U - Payer Identification Number, FY - Claim Office Number, or NF - National Association of Insurance Commissioners. You should only set this to 2U when you set the primaryIdentifierTypeCode to XV.

Available options:

2U,

FY,

NF

payToPlan.secondaryIdentifier

string

The secondary identifier you specified in secondaryIdentifierTypeCode.

payerAddress

object

usageIndicator

string

Whether you want to send a test or production claim. This property also allows you to filter claims in the Stedi portal by production or test data. By default, this property is set to P for production data. Use T to designate a claim as test data.

referring

object

Information about the provider who directed the patient to the rendering provider for care. For example, a primary care physician may refer patients to a specialist. Use when the referring provider applies to the entire claim, not just a specific service line.

This should be an individual, not an organization, and you should supply at least the provider's lastName and an identifier, which is typically the npi.

referring.providerType

string

required

Set to ReferringProvider.

referring.npi

string

The individual National Provider Identifier (NPI) assigned to the provider.

referring.commercialNumber

string

The provider's commercial number.

referring.stateLicenseNumber

string

The provider's state license number.

referring.providerUpinNumber

string

deprecated

Deprecated; do not use. This shape is deprecated.

referring.taxonomyCode

string

deprecated

This shape is deprecated.

Required string length: 10

referring.firstName

string

The provider's first name.

referring.lastName

string

The provider's last name.

referring.middleName

string

The provider's middle name or initial.

referring.suffix

string

The provider's name suffix, such as Jr. or III.

referring.organizationName

string

The provider's business name.

referring.address

object

This shape is deprecated.

referring.contactInformation

object

This shape is deprecated.

rendering

object

Information about the person or company (laboratory or other facility) who rendered the care. Use this object for all types of rendering providers including laboratories. When a substitute provider (locum tenens) was used, enter that provider's information here. Use when the provider applies to the entire claim, not just a specific service line.

rendering.providerType

string

required

Set to RenderingProvider.

rendering.npi

string

The National Provider Identifier (NPI) assigned to the provider.

rendering.commercialNumber

string

The provider's commercial number.

rendering.locationNumber

string

The provider's location number.

rendering.stateLicenseNumber

string

The provider's state license number.

rendering.providerUpinNumber

string

deprecated

Deprecated; do not use. This shape is deprecated.

rendering.taxonomyCode

string

Code from the National Uniform Claims Committee Health Care Provider Taxonomy Code Set. This identifies the provider's type and/or area of specialty.

Required string length: 10

rendering.firstName

string

The provider's first name, if the provider is an individual.

rendering.lastName

string

The provider's last name, if the provider is an individual. You must include either the lastName or organizationName property in this object.

rendering.middleName

string

The provider's middle name or initial, if the provider is an individual.

rendering.suffix

string

The provider's name suffix, such as Jr. or III.

rendering.organizationName

string

The provider's business name, if the provider is an organization. You must include either the lastName or organizationName property in this object.

rendering.address

object

This shape is deprecated.

rendering.contactInformation

object

This shape is deprecated.

ordering

object

deprecated

Deprecated; please use claimInformation.serviceLines.orderingProvider instead. This shape is deprecated.

ordering.providerType

string

required

ordering.npi

string

ordering.ssn

string

ordering.employerId

string

ordering.commercialNumber

string

ordering.locationNumber

string

ordering.payerIdentificationNumber

string

ordering.employerIdentificationNumber

string

ordering.claimOfficeNumber

string

ordering.naic

string

ordering.stateLicenseNumber

string

ordering.providerUpinNumber

string

ordering.taxonomyCode

string

Required string length: 10

ordering.firstName

string

ordering.lastName

string

ordering.middleName

string

ordering.suffix

string

ordering.organizationName

string

ordering.address

object

ordering.contactInformation

object

You must include at least one communication method (phone, fax, or email) in this object.

supervising

object

This should be an individual, not an organization, and you should supply at least the provider's lastName and an identifier, which is typically the npi.

supervising.providerType

string

required

Set to SupervisingProvider.

supervising.npi

string

The individual National Provider Identifier (NPI) assigned to the supervising provider.

supervising.ssn

string

deprecated

This shape is deprecated.

supervising.employerId

string

deprecated

This shape is deprecated.

supervising.commercialNumber

string

The commercial number of the supervising provider.

supervising.locationNumber

string

The location number of the supervising provider.

supervising.stateLicenseNumber

string

The state license number of the supervising provider.

supervising.providerUpinNumber

string

deprecated

Deprecated; do not use. This shape is deprecated.

supervising.taxonomyCode

string

deprecated

This shape is deprecated.

Required string length: 10

supervising.firstName

string

The first name of the supervising provider.

supervising.lastName

string

The last name of the supervising provider.

supervising.middleName

string

The middle name or initial of the supervising provider.

supervising.suffix

string

The suffix of the supervising provider's name, such as Jr. or III.

supervising.organizationName

string

The supervising provider's business name, when the provider is not an individual.

supervising.address

object

This shape is deprecated.

supervising.contactInformation

object

This shape is deprecated.

tradingPartnerName

string

This is the payer's business name, like Cigna or Aetna.

Response

200

application/json

ClaimsSubmission 200 response

status

string

The status of the claim submission.

controlNumber

string

An identifier for the transaction.

tradingPartnerServiceId

string

An ID for the payer you identified in the original claim. This value may differ from the tradingPartnerServiceId you submitted in the original request because it reflects the payer's internal concept of their ID, not necessarily the ID Stedi uses to route requests to this payer.

claimReference

object

Information about the claim.

errors

object[]

A list of errors. Currently not used.

warnings

object[]

A list of warnings.

Warnings indicate issues that may cause some payers to reject the claim. Stedi doesn’t reject claims with warnings only - a response with warnings but no errors means Stedi still submitted the claim.

If you receive warnings, we recommend closely monitoring 277CA responses from the payer for rejections. If the claim is rejected, we recommend fixing the issues identified in the warnings before resubmitting.

httpStatusCode

enum<string>

A 200 response indicates that Stedi successfully generated the X12 EDI claim format required by the payer. It does not indicate whether the payer has accepted the claim - the payer will respond later with a 277CA containing this information. Learn more about 277CAs. A 400 response indicates one or more problems with the claim data in the request. Examples include missing required fields, invalid values, or incorrect data types. The response includes a message describing the problem.

Available options:

200 OK,

400 BAD_REQUEST

Payers & enrollment

Eligibility & benefits

Claims processing

EDI platform

​Send test claims

​Basic claim submission

​Character restrictions

​Identify service lines

​Conditional requirements

​Enhanced validation

​CMS-1500 Claim Form PDF

Authorizations

Headers

Body

Response

Send test claims

Basic claim submission

Character restrictions

Identify service lines

Conditional requirements

Enhanced validation

CMS-1500 Claim Form PDF