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.
Was this information helpful?
Yes | No
Thank you for your feedback!
What went wrong?
Incomplete or incorrect information |
Irrelevant Content
| Others
Submit
Endpoints
- Primary
- Subscription
Create claim for an appointment
POST
/v1/{practiceid}/appointments/{appointmentid}/claim
Create a new claim record for an appointment
Was this information helpful?
Yes | No
Thank you for your feedback!
What went wrong?
Incomplete or incorrect information |
Irrelevant Content
| Others
Submit
Input Parameters
Expand all❙ required
practiceid
integer
practiceid
appointmentid
integer
appointmentid
Content-Type
string
Content type of the payload
❙ Request Body
Expand allOutput Parameters
Expand all
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
Was this information helpful?
Yes | No
Thank you for your feedback!
What went wrong?
Incomplete or incorrect information |
Irrelevant Content
| Others
Submit
Input Parameters
Expand all❙ required
practiceid
integer
practiceid
Content-Type
string
Content type of the payload
❙ Request Body
Expand allOutput Parameters
Expand all
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
Was this information helpful?
Yes | No
Thank you for your feedback!
What went wrong?
Incomplete or incorrect information |
Irrelevant Content
| Others
Submit
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
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
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
Get individual claim details
GET
/v1/{practiceid}/claims/{claimid}
Retrieves information for a specific claim
Was this information helpful?
Yes | No
Thank you for your feedback!
What went wrong?
Incomplete or incorrect information |
Irrelevant Content
| Others
Submit
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
Was this information helpful?
Yes | No
Thank you for your feedback!
What went wrong?
Incomplete or incorrect information |
Irrelevant Content
| Others
Submit
Input Parameters
Expand all❙ required
practiceid
integer
practiceid
claimid
integer
claimid
Content-Type
string
Content type of the payload
❙ Request Body
Expand allOutput Parameters
Expand all
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"
Was this information helpful?
Yes | No
Thank you for your feedback!
What went wrong?
Incomplete or incorrect information |
Irrelevant Content
| Others
Submit
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
Expand all
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
Was this information helpful?
Yes | No
Thank you for your feedback!
What went wrong?
Incomplete or incorrect information |
Irrelevant Content
| Others
Submit
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
Expand all
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
Was this information helpful?
Yes | No
Thank you for your feedback!
What went wrong?
Incomplete or incorrect information |
Irrelevant Content
| Others
Submit
Input Parameters
Expand all❙ required
practiceid
integer
practiceid
claimid
integer
claimid
Output Parameters
Expand all
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
Was this information helpful?
Yes | No
Thank you for your feedback!
What went wrong?
Incomplete or incorrect information |
Irrelevant Content
| Others
Submit
Input Parameters
Expand all❙ required
practiceid
integer
practiceid
showadditionalevents
boolean
Include non-default events
Output Parameters
Expand all
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
Was this information helpful?
Yes | No
Thank you for your feedback!
What went wrong?
Incomplete or incorrect information |
Irrelevant Content
| Others
Submit
Input Parameters
Expand all❙ required
practiceid
integer
practiceid
Content-Type
string
Content type of the payload
❙ Request Body
Expand allOutput Parameters
Expand all
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
Was this information helpful?
Yes | No
Thank you for your feedback!
What went wrong?
Incomplete or incorrect information |
Irrelevant Content
| Others
Submit
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
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
Was this information helpful?
Yes | No
Thank you for your feedback!
What went wrong?
Incomplete or incorrect information |
Irrelevant Content
| Others
Submit
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.
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
Was this information helpful?
Yes | No
Thank you for your feedback!
What went wrong?
Incomplete or incorrect information |
Irrelevant Content
| Others
Submit
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