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 a new claim record for an appointment
Input Parameters
Expand all❙ Request Body
Expand allCreate a new claim
Input Parameters
Expand all❙ Request Body
Expand allRetrieves a list of claims filtered by combination of date range, appointmentID ProviderID, and DepartmentID
Input Parameters
Expand all❙ required
Output Parameters
Expand allRetrieves information for a specific claim
Input Parameters
Expand allOutput Parameters
Expand allModifies information for a specific claim
Input Parameters
Expand all❙ Request Body
Expand allRetrieves a list of claims for a specific patient whose claim status is "Closed"
Input Parameters
Expand allRetrieves outstanding claims for a specific patient
Input Parameters
Expand allRetrieves a list of claims transactions for a specific claim
Input Parameters
Expand allOutput Parameters
Expand allRetrieve list of all events that can be input for this subscription
Input Parameters
Expand allSubscribes for changed claims events
Input Parameters
Expand all❙ Request Body
Expand allOutput Parameters
Expand allRetrieves list of events applicable for claims
Input Parameters
Expand allRetrieves list of modified claims records
Input Parameters
Expand all❙ required
Output Parameters
Expand allDeletes a specific event which is no longer required
Input Parameters
Expand all❙ required