API Claims

See API Specification

Claims GET

Version Added: 22.2

Gets all claims for a specific patient.

PatNum: Required in the URL.

Example Request:
GET /claims?PatNum=23

Example Response:
[
{
"ClaimNum": 1,
"DateSent": "2022-07-18",
"ClaimStatus": "R",
"DateReceived": "2022-07-29",
"ProvTreat": 1,
"ClaimFee": 250.0,
"InsPayEst": 200.0,
"InsPayAmt": 200.0,
"IsProsthesis": "N",
"PriorDate": "0001-01-01",
"ClaimNote": "Insurance payment of $200",
"ProvBill": 1,
"PlaceService": "Office",
"AccidentRelated": "",
"AccidentDate": "0001-01-01",
"AccidentST": "",
"IsOrtho": "True",
"OrthoDate": "2021-03-10",
"ClaimForm": "4",
"PriorAuthorizationNumber": "",
"OrthoTotalM": 20
},
{
"ClaimNum": 2,
"DateSent": "0001-01-01",
"ClaimStatus": "W",
"DateReceived": "0001-01-01",
"ProvTreat": 1,
"ClaimFee": 90.0,
"InsPayEst": 0.0,
"InsPayAmt": 0.0,
"IsProsthesis": "N",
"PriorDate": "0001-01-01",
"ClaimNote": "",
"ProvBill": 5,
"PlaceService": "OtherLocation",
"AccidentRelated": "A",
"AccidentDate": "2022-05-20",
"AccidentST": "OR",
"IsOrtho": "False",
"OrthoDate": "0001-01-01",
"ClaimForm": "4",
"PriorAuthorizationNumber": "6128612926",
"OrthoTotalM": 0
},
{
"ClaimNum": 3,
"DateSent": "0001-01-01",
"ClaimStatus": "S",
"DateReceived": "0001-01-01",
"ProvTreat": 2,
"ClaimFee": 49.5,
"InsPayEst": 0.0,
"InsPayAmt": 0.0,
"IsProsthesis": "R",
"PriorDate": "2016-01-15",
"ClaimNote": "",
"ProvBill": 1,
"PlaceService": "Office",
"AccidentRelated": "",
"AccidentDate": "0001-01-01",
"AccidentST": "",
"IsOrtho": "False",
"OrthoDate": "0001-01-01",
"ClaimForm": "4",
"PriorAuthorizationNumber": "",
"OrthoTotalM": 0
}
]

200 OK
400 BadRequest (With explanation)
404 NotFound "Patient not found."

Claims PUT (update)

Version Added: 21.4

All fields are optional and it is common to only set one or two fields. ClaimNote will overwrite any existing note. Use either Queries POST or Queries PUT ShortQuery to obtain the ClaimNum of the desired claim.

ClaimNum: Required in the URL.
ClaimStatus: Single character. "U" for Unsent, "H" for Hold until pri received, "W" for Waiting in queue, "S" for Sent or "R" for Received.
DateReceived: Date the claim was received. String in "yyyy-MM-dd" format.
ProvTreat: ProvNum of treating provider for dental claims.
IsProsthesis: Single character. "N" for No, "I" for Initial or "R" for Replacement.
PriorDate: Date prior prosthesis was placed. This is only for paper claims. E-claims have a date field on each individual procedure. String in "yyyy-MM-dd" format.
ClaimNote: Note to be sent to insurance. E-Claims have notes on each procedure.
ProvBill: ProvNum of billing provider.
PlaceService: Service location. Usually "Office". See schema for other options.
AccidentRelated: Type of accident. "No" for No, "A" for Auto, "E" for Employment, or "O" for Other.
AccidentDate: (added in version 22.1) Date of accident. String in "yyyy-MM-dd" format.
AccidentST: Accident state. Two characters.
IsOrtho: Either "true" or "false".
OrthoDate: Date the ortho appliance was placed. Cannot change date if "Use the first ortho procedure date as Date of Placement" pref is enabled during Ortho Setup. String in "yyyy-MM-dd" format.
ClaimForm: FK to claimform.ClaimFormNum. Is 0 if not assigned to use the claimform for the insplan.
PriorAuthorizationNumber: (Rare) Also called the preauthorization number. Typically used for medical claims. This is NOT the predetermination of benefits number.
OrthoTotalM: Estimated months of ortho. Valid values are 1-36.

Example Request:
PUT /claims/21

{
"ClaimStatus":"W",
"DateReceived":"2021-05-25",
"ProvTreat":1,
"IsProsthesis":"N",
"PriorDate":"2020-06-26",
"ClaimNote":"Existing RCT from 2019-05-14.",
"ProvBill":1,
"PlaceService":"Office",
"AccidentRelated":"O",
"AccidentDate":"2021-05-15",
"AccidentST":"MO",
"IsOrtho":"false",
"OrthoDate":"2021-05-25",
"ClaimForm":0,
"PriorAuthorizationNumber":"6549848516",
"OrthoTotalM":36
}

Example Response:
200 OK
400 BadRequest (with explanation)
404 NotFound (with explanation)

Claims PUT Status

Version Added: 21.3

Sets the ClaimStatus of a claim to "Sent" and automatically creates an Etrans entry. Use either Queries POST or Queries PUT ShortQuery to obtain the ClaimNum of the desired claim.

ClaimNum: Required in the URL.
DateSent: Required. Date the claim was most recently sent. String in "yyyy-MM-dd" format."
DateSentOrig: Optional. String in "yyyy-MM-dd" format. Defaults to DateSent. Will be ignored for claims that have been marked as "Sent" previously.

Example Requests:
PUT /claims/26/Status

{
"DateSent": "2021-09-13"
}

{
"DateSent": "2021-09-13",
"DateSentOrig": "2021-09-01"
}

Example Response:
200 OK
400 BadRequest (Missing or invalid fields)
404 NotFound "Claim not found"

Claims PUT Split

Version Added: 22.1

Splits an existing claim. Moves the specified procedure(s) sent with the request from the original claim to a newly created one. Use either Queries POST or Queries PUT ShortQuery to obtain the ClaimNum of the desired claim and the ProcNums of the desired procedures.

ClaimNum: Required in the URL.
ProcNums: Required. An array of ProcNums, in [1,2,3] format.

Example Requests:
PUT /claims/26/Split

{
"ProcNums": [153, 154, 155]
}

Example Response:

{
"ClaimNum": 27,
"ProcNums": [153, 154, 155]
}

201 Created
400 BadRequest (Missing or invalid fields)
404 NotFound

Claims DELETE

Version Added: 22.1

Deletes a claim. Will not delete claims with insurance payments/checks attached or have a status of Received. If the claim is attached to at least one ERA it will unassociate from the ERA(s) before deleting. Use either Queries POST or Queries PUT ShortQuery to obtain the ClaimNum of the desired claim.

ClaimNum: Required in the URL.

Example Requests:
DELETE /claims/26

Example Response:
200 OK
400 BadRequest (with explanation)
404 NotFound