Claim
The Claim feature is a request for payment that patient or the health care provider submits to the health insurer when the patient gets items or services they think are covered. This feature allows the user to add a new claim, view an individual claims details, list of claims, or view a list of closed patient claims. Patient Claim feature allows the user to retrieve patient-facing claims for a patient. The Claim Changed Subscription feature will allow the user to retrieve changed claims (generally created, modified, deleted). For more information about subscriptions, please refer Changed Data Subscriptions.
Limitations:
• Partners can submit only one claim per call.
• Partners are not able to edit or delete a claim once it is submitted.
• A maximum of four diagnosis codes can be tied to a procedure code.
Partners can use an existing Claims API call to bypass using the fee schedule or allowable schedule at the time of claim creation. This is useful in cases where a single procedure code is used for multiple services/products that have various price points, such as ophthalmology, or for practices with discount programs.
Important: Be cautious when doing this since the functionality affects claims where the patient and/or insurer is a payer.
A Fee Schedule is a list of procedure codes and their corresponding fees charged by a practice under a contract with a particular insurer or allowable category. Fee schedules are created and managed in athenaNet by practice users.
An Allowable Schedule is a list of procedure codes and their corresponding reimbursement amounts that a practice expects to receive as payment from a particular payer. Allowable schedules are created and managed in athenaNet by practice users.
Endpoints
- Primary
- Subscription
Create claim for an appointment
Input Parameters
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❙ Request Body
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Expand allCreate new financial claim
Input Parameters
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❙ Request Body
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Expand allGet list of claim details
Input Parameters
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Output Parameters
Expand allDiagnoses is an array of all diagnoses. Each entry in the array is a hash with several fields. /ccda is a better clinical representation. These fields are:
Procedures is an array of all procedures. /ccda is a better clinical representation. These fields are:
Get individual claim details
Input Parameters
Expand all❙ required
Output Parameters
Expand allDiagnoses is an array of all diagnoses. Each entry in the array is a hash with several fields. /ccda is a better clinical representation. These fields are:
Procedures is an array of all procedures. /ccda is a better clinical representation. These fields are:
Update individual claim details
Input Parameters
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❙ Request Body
Expand allOutput Parameters
Expand allGet list of patient's closed claims
Input Parameters
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Output Parameters
Expand allGet list of patient's outstanding claims
Input Parameters
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Output Parameters
Expand allView all claim transactions
Input Parameters
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Output Parameters
Expand allGet list of change events for claims
Input Parameters
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Output Parameters
Expand allSubscribe to all/specific change events for claims
Input Parameters
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❙ Request Body
Expand allOutput Parameters
Expand allGet list of subscribed events for changes in claims
Input Parameters
Expand all❙ required
Output Parameters
Expand allGet list of changes in claims
Input Parameters
Expand all❙ required
Output Parameters
Expand allDiagnoses is an array of all diagnoses. Each entry in the array is a hash with several fields. /ccda is a better clinical representation. These fields are:
Procedures is an array of all procedures. /ccda is a better clinical representation. These fields are:
Unsubscribe to all/specific events for changes in claims
Input Parameters
Expand all❙ required