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 based on these scenarios:

  • Balance transferred to patient
  • Balance paid off completely by payer
  • Patient balance paid in full
  • Patient balance partial pay
  • Balance transfer to patient voided (e.g. because the payer reprocessed saying the patient no longer owes)
  • Patient balance written off (e.g. to bad debt or collections)
  • Patient payment voided, increasing the outstanding amount (e.g. void to unapplied credit)
  • Initial claim creation

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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Submit

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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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

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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

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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
showservicetypeaddons boolean Include service type add-ons for the claim. The functionality behind this parameter is toggled by COLDEN_CLAIM_STAO_MDP_API. It is part of a feature that is scheduled to rollout in or before March 2023.
procedurecodes array One or more procedure codes
appointmentid array One or more appointment IDs.
serviceenddate string The service date, end of range, inclusive.
departmentid integer The department ID of the service department for the claims being searched for.
providerid integer Will match either the provider or the supervising provider.
createdenddate string The claim creation date, end of range, inclusive.
showsupervisingprovider boolean Include supervising provider ID and name for the claim.
claimfilters array Array, pass one or more options to filter claims.
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.
servicetypeaddons array Array of service type add-ons (STAOs) for the claim. This is toggled by COLDEN_CLAIM_STAO_MDP_API. It is part of a feature that is scheduled to rollout in or before March 2023.
supervisingproviderid integer The supervising provider ID for this claim.
supervisingprovidername string The supervising provider name for this claim.
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
showservicetypeaddons boolean Include service type add-ons for the claim. The functionality behind this parameter is toggled by COLDEN_CLAIM_STAO_MDP_API. It is part of a feature that is scheduled to rollout in or before March 2023.
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.
servicetypeaddons array Array of service type add-ons (STAOs) for the claim. This is toggled by COLDEN_CLAIM_STAO_MDP_API. It is part of a feature that is scheduled to rollout in or before March 2023.
supervisingproviderid integer The supervising provider ID for this claim.
supervisingprovidername string The supervising provider name for this claim.
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

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required

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

Request Body

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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

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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

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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

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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

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required

practiceid integer practiceid
showadditionalevents boolean Include non-default events

Output Parameters

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departmentids array List of Departmentids subscribed
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

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required

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

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

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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

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departmentids array List of Departmentids subscribed
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

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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.
showservicetypeaddons boolean Include service type add ons for the claim. The functionality behind this parameter is toggled by COLDEN_CLAIM_STAO_MDP_API. It is part of a feature that is scheduled to rollout in or before March 2023.
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.
servicetypeaddons array Array of service type add-ons (STAOs) for the claim. This is toggled by COLDEN_CLAIM_STAO_MDP_API. It is part of a feature that is scheduled to rollout in or before March 2023.
supervisingproviderid integer The supervising provider ID for this claim.
supervisingprovidername string The supervising provider name for this claim.
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

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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

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