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.

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Endpoints

Create claim for an appointment
POST
/v1/{practiceid}/appointments/{appointmentid}/claim

Create a new claim record for an appointment

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Input Parameters

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❙ required

practiceid integer practiceid
appointmentid integer appointmentid
Content-Type string Content type of the payload

❙ Request Body

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claimcharges array List of charges for this claim. This should be a JSON string representing an array of charge objects. A primary ICD-10 code (e.g. ICD10CODE1) is required. ICD-9 codes may also be passed, in the rare case that the payer for the claim still needs that information. The /feeschedules/checkprocedure call may be used to verify a particular PROCEDURECODE is valid for a practice before attempting claim creation. Claims can only be created for appointments that do not already have a claim, are not already in status 4, and have already been checked in.
supervisingproviderid integer The supervising provider ID. Defaults to the supervising provider of the appointment.

Output Parameters

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claimids array If the operation succeeded, this will contain the IDs of any claims that were created.
errormessage string If the operation failed, this will contain any error messages.
success string Whether the operation was successful.
Example Code
Create new financial claim
POST
/v1/{practiceid}/claims

Create a new claim

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Input Parameters

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❙ required

practiceid integer practiceid
Content-Type string Content type of the payload

❙ Request Body

Expand all
claimcharges array List of charges for this claim. This should be a JSON string representing an array of charge objects. A primary ICD-10 code (e.g. ICD10CODE1) is required. ICD-9 codes may also be passed, in the rare case that the payer for the claim still needs that information. The /feeschedules/checkprocedure call may be used to verify a particular PROCEDURECODE is valid for a practice before attempting claim creation.
customfields array A list of custom field JSON objects to populate on creation of a claim.
departmentid integer The department ID.
orderingproviderid integer The ordering provider ID. 'Ordering Provider' service type add-on must be enabled. Default is no ordering provider ID.
patientid integer The patient ID.
primarypatientinsuranceid integer The athena primary patient insurance ID. Defaults to the patient's active primary insurance.
referralauthid integer The referral authorization ID.
referringproviderid integer The referring provider id. Default is no referring provider ID.
renderingproviderid integer The rendering provider ID. Defaults to value passed for supervising provider ID.
reserved19 string Text to include in the Reserved 19 field. Limited to 48 characters. Default is an empty string.
secondarypatientinsuranceid integer The athena secondary patient insurance ID. Defaults to the patient's active secondary insurance.
servicedate string A date string that corresponds with when the patient was seen. The date must be today or in the past. By default we will use today's date.
supervisingproviderid integer The supervising provider ID.

Output Parameters

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claimids array If the operation succeeded, this will contain the IDs of any claims that were created.
errormessage string If the operation failed, this will contain any error messages.
success string Whether the operation was successful.
Example Code
Get list of claim details
GET
/v1/{practiceid}/claims

Retrieves a list of claims filtered by combination of date range, appointmentID ProviderID, and DepartmentID

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Input Parameters

Expand all

❙ required

practiceid integer practiceid
createdstartdate string The claim creation date, start of range, inclusive.
patientid integer The patient ID associated with the claims to search for
procedurecodes array One or more procedure codes
appointmentid array One or more appointment IDs.
serviceenddate string The service date, end of range, inclusive.
providerid integer Will match either the provider or the supervising provider.
departmentid integer The department ID of the service department for the claims being searched for.
createdenddate string The claim creation date, end of range, inclusive.
servicestartdate string The service date, start of range, inclusive.
showcustomfields boolean Include custom fields for the claims.
limit integer Number of entries to return (default 1500, max 5000)
offset integer Starting point of entries; 0-indexed

Output Parameters

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appointmentid string The appointment ID associated with this claim.
billedproviderid integer The provider ID of the billing provider for this claim.
billedservicedate string The billed date of service.
chargeamount string The total amount billed for all services from this claim.
claimcreateddate string The date the claim was created.
claimid string athenaNet's internal ID for this claim, specific to the practice.
customfields array The claim custom field values may or may not be the same between departments.
departmentid integer The department ID associated with this claim.
diagnoses object

Diagnoses 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:
patientid integer The patient ID associated with this claim.
patientpayer object The status and notes of a responsible payer. This payer is the patient.
primaryinsurancepayer object The status and notes of a responsible payer. This payer is the primary insurace.
procedures object

Procedures is an array of all procedures. /ccda is a better clinical representation. These fields are:
referralauthid integer The referral authorization ID for this claim.
referringproviderid integer The referring provider ID for this claim. See /referringproviders. This is not the same as the ID from the /providers call.
reserved19 string The text in the Reserved 19 field.
secondaryinsurancepayer object The status and notes of a responsible payer. This payer is the secondary insurace.
transactiondetails object A hash of ids ("transactionid") to amounts; these should sum to the chargeamount.
transactionid string A unique ID for the primary transaction this claim represents. May be useful for debugging.
Example Code
Get individual claim details
GET
/v1/{practiceid}/claims/{claimid}

Retrieves information for a specific claim

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Input Parameters

Expand all

❙ required

practiceid integer practiceid
claimid integer claimid
showcustomfields boolean Include custom fields for the claim.

Output Parameters

Expand all
appointmentid string The appointment ID associated with this claim.
billedproviderid integer The provider ID of the billing provider for this claim.
billedservicedate string The billed date of service.
chargeamount string The total amount billed for all services from this claim.
claimcreateddate string The date the claim was created.
claimid string athenaNet's internal ID for this claim, specific to the practice.
customfields array The claim custom field values may or may not be the same between departments.
departmentid integer The department ID associated with this claim.
diagnoses object

Diagnoses 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:
patientid integer The patient ID associated with this claim.
patientpayer object The status and notes of a responsible payer. This payer is the patient.
primaryinsurancepayer object The status and notes of a responsible payer. This payer is the primary insurace.
procedures object

Procedures is an array of all procedures. /ccda is a better clinical representation. These fields are:
referralauthid integer The referral authorization ID for this claim.
referringproviderid integer The referring provider ID for this claim. See /referringproviders. This is not the same as the ID from the /providers call.
reserved19 string The text in the Reserved 19 field.
secondaryinsurancepayer object The status and notes of a responsible payer. This payer is the secondary insurace.
transactiondetails object A hash of ids ("transactionid") to amounts; these should sum to the chargeamount.
transactionid string A unique ID for the primary transaction this claim represents. May be useful for debugging.
Example Code
Update individual claim details
PUT
/v1/{practiceid}/claims/{claimid}

Modifies information for a specific claim

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Input Parameters

Expand all

❙ required

practiceid integer practiceid
claimid integer claimid
Content-Type string Content type of the payload

❙ Request Body

Expand all
claimcharges array List of charges for this claim whose allowable values should be updated. This should be a JSON string representing an array of charge objects.
customfields array A list of custom field JSON objects to populate on creation of a claim.
orderingproviderid integer The ordering provider ID. 'Ordering Provider' service type add-on must be enabled. Default is no ordering provider ID.
referralauthid integer The referral authorization ID to associate with this claim.
referringproviderid integer The referring provider ID (not the same from /providers) associated with this claim.

Output Parameters

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customfields integer Number of custom fields updated.
success string Whether the operation was successful.
transactions integer Number of transactions updated.
Example Code
Get list of patient's closed claims
GET
/v1/{practiceid}/patients/{patientid}/claims/patientclosed

Retrieves a list of claims for a specific patient whose claim status is "Closed"

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Input Parameters

Expand all

❙ required

practiceid integer practiceid
patientid integer patientid
procedurecodes array One or more procedure codes
departmentid integer The department ID of the service department for the claims being searched for

Output Parameters

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closedclaims array All the closed claims held by the patient, grouped by provider group.
totalcount number The total number of closed claims for the patient.
Example Code
Get list of patient's outstanding claims
GET
/v1/{practiceid}/patients/{patientid}/claims/patientoutstanding

Retrieves outstanding claims for a specific patient

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Input Parameters

Expand all

❙ required

practiceid integer practiceid
patientid integer patientid
procedurecodes array One or more procedure codes
departmentid integer The department ID of the service department for the claims being searched for

Output Parameters

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openclaims array All the open claims held by the patient, grouped by provider group.
totalcount number The total number of open claims for the patient.
Example Code
View all claim transactions
GET
/v1/{practiceid}/claims/{claimid}/claimtransactions

Retrieves a list of claims transactions for a specific claim

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Input Parameters

Expand all

❙ required

practiceid integer practiceid
claimid integer claimid

Output Parameters

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adjustments integer Adjustments to the original value of this claim
amount integer The original value of this transaction before adjustments or transfers
customtransactioncode string The Custom Transaction Code for the transaction, which is only present for Adjustments
lastbilleddate string The date this transaction was last billed to a payer
outstandingamount integer The oustanding amount requiring payment for this charge line
parenttransactionid integer The ID of the parent transaction
payer string The payer associated with this transaction
payments integer Payments made on this transaction
procedurecode string The procedure code for this transaction
transactiondate string The date this transaction was created
transactionid integer The ID of this transaction
transactiontype string The type associated with this transaction
units integer The number of appropriate units associated with this transaction
Example Code
Get list of change events for claims
GET
/v1/{practiceid}/claims/changed/subscription/events

Retrieve list of all events that can be input for this subscription

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Input Parameters

Expand all

❙ required

practiceid integer practiceid
showadditionalevents boolean Include non-default events

Output Parameters

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status string Will return one of following statuses: ACTIVE, INACTIVE, or PARTIAL. The PARTIAL status means that not all events are subscribed to. In the event of a problem, UNKNOWN may be returned.
subscriptions array List of events you are subscribed to.
Example Code
Subscribe to all/specific change events for claims
POST
/v1/{practiceid}/claims/changed/subscription

Subscribes for changed claims events

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Input Parameters

Expand all

❙ required

practiceid integer practiceid
Content-Type string Content type of the payload

❙ Request Body

Expand all
eventname string By default, you are subscribed to all possible events. If you only wish to subscribe to an individual event, pass the event name with this argument.
showadditionalevents boolean If this is set, we will include additional events that aren't normally included in the default list of events.

Output Parameters

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success string Returns if the call to manipulate subscriptions for claim was successful.
Example Code
Get list of subscribed events for changes in claims
GET
/v1/{practiceid}/claims/changed/subscription

Retrieves list of events applicable for claims

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Input Parameters

Expand all

❙ required

practiceid integer practiceid
showadditionalevents boolean If this is set, we will include additional events that aren't normally included in the default list of events.

Output Parameters

Expand all
status string Will return one of following statuses: ACTIVE, INACTIVE, or PARTIAL. The PARTIAL status means that not all events are subscribed to. In the event of a problem, UNKNOWN may be returned.
subscriptions array List of events you are subscribed to.
Example Code
Get list of changes in claims
GET
/v1/{practiceid}/claims/changed

Retrieves list of modified claims records

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Input Parameters

Expand all

❙ required

practiceid integer practiceid
leaveunprocessed boolean For testing purposes, do not mark records as processed
departmentid array Department ID. Multiple departments are allowed, either comma separated or with multiple values.
showprocessedenddatetime string See showprocessedstartdatetime
patientid array Patient ID. Multiple Patient IDs are allowed, either comma separated or with multiple values.
showprocessedstartdatetime string Show already processed changes. This will show changes that you previously retrieved at some point after this datetime mm/dd/yyyy hh24:mi:ss (Eastern). Can be used to refetch data if there was an error, such as a timeout, and records are marked as already retrieved. This is intended to be used with showprocessedenddatetime and for a short period of time only. Also note that all messages will eventually be deleted.
limit integer Number of entries to return (default 1500, max 5000)
offset integer Starting point of entries; 0-indexed

Output Parameters

Expand all
appointmentid string The appointment ID associated with this claim.
billedproviderid integer The provider ID of the billing provider for this claim.
billedservicedate string The billed date of service.
chargeamount string The total amount billed for all services from this claim.
claimcreateddate string The date the claim was created.
claimid string athenaNet's internal ID for this claim, specific to the practice.
customfields array The claim custom field values may or may not be the same between departments.
departmentid integer The department ID associated with this claim.
diagnoses object

Diagnoses 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:
patientid integer The patient ID associated with this claim.
patientpayer object The status and notes of a responsible payer. This payer is the patient.
primaryinsurancepayer object The status and notes of a responsible payer. This payer is the primary insurace.
procedures object

Procedures is an array of all procedures. /ccda is a better clinical representation. These fields are:
referralauthid integer The referral authorization ID for this claim.
referringproviderid integer The referring provider ID for this claim. See /referringproviders. This is not the same as the ID from the /providers call.
reserved19 string The text in the Reserved 19 field.
secondaryinsurancepayer object The status and notes of a responsible payer. This payer is the secondary insurace.
transactiondetails object A hash of ids ("transactionid") to amounts; these should sum to the chargeamount.
transactionid string A unique ID for the primary transaction this claim represents. May be useful for debugging.
Example Code
Unsubscribe to all/specific events for changes in claims
DELETE
/v1/{practiceid}/claims/changed/subscription

Deletes a specific event which is no longer required

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Input Parameters

Expand all

❙ required

practiceid integer practiceid
eventname string By default, you are unsubscribed from all possible events. If you only wish to unsubscribe from an individual event, pass the event name with this argument.
showadditionalevents boolean If this is set, we will include additional events that aren't normally included in the default list of events.

Output Parameters

Expand all
success string Returns if the call to manipulate subscriptions for claim was successful.
Example Code