Claim Creation Outside of an Appointment

With the POST /claims API, partners are able to create claims for events that are not associated with an appointment or encounter.

Note: If a claim needs to be associated with an appointment, please refer to workflow document ‘Appointment Based Claim Creation’.

Creating a claim

Creating a claim via the POST /claims call requires partners to input Practice ID, Patient ID, Claim Charges (as a valid JSON object), Department ID and Supervising Provider ID. Additionally, partners may input Rendering Provider ID, if different from Supervising Provider ID, and Primary Patient-Insurance ID or Secondary Patient-Insurance ID to denote any of the patient’s insurances as a primary and secondary for the claim being submitted.  

For successful claim creation, thorough validation is done on the input parameters. Partners should confirm the following when creating a claim outside of an appointment:

  • Patient is active and has at least one insurance.
  • Provider is active and is a of type person.
  • Department is active and is a billing/service department. (This information is returned in the GET /departments or GET /departments/{departmentid} API calls)
  • Chosen patient/provider(s)/department are all in the same provider group [for ProviderGroup-enterprise practices only]. (providergroup information is returned in GET /departments, GET /departments/{departmentid} and GET /providers, GET /providers/{providerid} API calls)
  • All diagnoses are valid.
  • The procedure code is valid and applicable per the practice’s fee schedule (API GET /feeschedules/checkprocedure can be used to verify if a procedure code is in a physician’s fee schedule)

Please refer 'Claims' document in ‘Insurance and Financial' section for technical documentation on this API.

What happens after a claim is created

The API response for a successfully generated claim will output ‘Success: True’ along with the ClaimID of the newly created claim. GET /claims/{claimid} allows for insight of individual claims which partners can use to check status/progress on various claims. Partners can also leverage the POST /claims/{claimid}/note to add a claim note to the newly created claim.

For each new claim that is added, the athenaNet rules engine scrubs the claim, identifies if any additional information is required, and adds the claim to claims queue. If the athenaNet rules engine finds a problem with the claim, it will obtain a HOLD status. Practice staff members review each claim, resolve any issues and set the claim to the proper status according to their claim workflow. Once the issues have been resolved (or if the rules engine found no issues in the first place), the claim will go into DROP status and be sent to the payer.

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 4 diagnosis codes can be tied to a procedure code.

Common Errors:

Creating claims for case policy insurance packages should be using InsuranceID, not InsuranceIDNumber, for the PrimaryPatientInsuranceID parameter. Calling GET /patients/{patientid}/insurances returns the InsuranceID number which stores insurance / case policy package information for a given PatientID.  

Partners should validate that a given procedure code, or codes, are in a physician's fee schedule using the GET /feeschedules/checkprocedure API. If a submitted procedure code is not in a physician's fee schedule, API will not create a claim and an error message will be returned ("One or more of the procedure codes specified are not valid.").

In addition, if partners want to include modifiers with a procedure code, append all modifiers with a comma after the procedure code (e.g. "99213,GT,26").  The GET /feeschedules/checkprocedure API can be used with modifiers included to be sure all modifiers are valid.

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