API Claims
See Claims for additional information.
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,
"PatNum": 23,
"DateSent": "2022-07-18",
"ClaimStatus": "R",
"DateReceived": "2022-07-29",
"ProvTreat": 1,
"ClaimFee": 250.0,
"InsPayEst": 200.0,
"InsPayAmt": 200.0,
"DedApplied": 0.0,
"IsProsthesis": "N",
"PriorDate": "0001-01-01",
"ReasonUnderPaid": "",
"ClaimNote": "Insurance payment of $200",
"ProvBill": 1,
"PlaceService": "Office",
"AccidentRelated": "",
"AccidentDate": "0001-01-01",
"AccidentST": "",
"IsOrtho": "True",
"OrthoDate": "2021-03-10",
"WriteOff": 0.0,
"ClaimForm": "4",
"PriorAuthorizationNumber": "",
"OrthoTotalM": 20
},
{
"ClaimNum": 2,
"PatNum": 23,
"DateSent": "0001-01-01",
"ClaimStatus": "W",
"DateReceived": "0001-01-01",
"ProvTreat": 1,
"ClaimFee": 90.0,
"InsPayEst": 0.0,
"InsPayAmt": 0.0,
"DedApplied": 0.0,
"IsProsthesis": "N",
"PriorDate": "0001-01-01",
"ReasonUnderPaid": "",
"ClaimNote": "",
"ProvBill": 5,
"PlaceService": "OtherLocation",
"AccidentRelated": "A",
"AccidentDate": "2022-05-20",
"AccidentST": "OR",
"IsOrtho": "False",
"OrthoDate": "0001-01-01",
"WriteOff": 0.0,
"ClaimForm": "4",
"PriorAuthorizationNumber": "6128612926",
"OrthoTotalM": 0
},
{
"ClaimNum": 3,
"PatNum": 23,
"DateSent": "0001-01-01",
"ClaimStatus": "S",
"DateReceived": "0001-01-01",
"ProvTreat": 2,
"ClaimFee": 49.5,
"InsPayEst": 0.0,
"InsPayAmt": 0.0,
"DedApplied": 0.0,
"IsProsthesis": "R",
"PriorDate": "2016-01-15",
"ReasonUnderPaid": "",
"ClaimNote": "",
"ProvBill": 1,
"PlaceService": "Office",
"AccidentRelated": "",
"AccidentDate": "0001-01-01",
"AccidentST": "",
"IsOrtho": "False",
"OrthoDate": "0001-01-01",
"WriteOff": 0.0,
"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.
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. Will overwrite existing note.
ReasonUnderPaid: (Added in version 22.3.31) Note on a patient's statement explaining why the insurance does not pay as much as expected. Will overwrite existing note.
ProvBill: ProvNum of billing provider.
PlaceService: Service location. Usually "Office". See Database 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":"R",
"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":"true",
"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.
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 Claims GET and ClaimProcs GET to obtain ClaimNum and ProcNums of 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]
}
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.
ClaimNum: Required in the URL.
Example Requests:
DELETE /claims/26
Example Response:
200 OK
400 BadRequest (with explanation)
404 NotFound