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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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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Request Body

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Example Code
Create new financial claim
POST
/v1/{practiceid}/claims

Create a new claim

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Input Parameters

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Request Body

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Example Code
Get list of claim details

Output Parameters

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Example Code
Get individual claim details
GET
/v1/{practiceid}/claims/{claimid}

Retrieves information for a specific claim

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Output Parameters

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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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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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Output Parameters

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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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Output Parameters

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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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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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Example Code
Get list of changes in claims

Output Parameters

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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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