{"claims":[{"claimStatus":{"amountPaid":"95.55","claimServiceDate":"20240325","effectiveDate":"20240329","paidDate":"20240329","patientAccountNumber":"3333333","statusCategoryCode":"P5","statusCategoryCodeValue":"Pending/Payer Administrative/System hold","statusCode":"3","statusCodeValue":"Claim has been adjudicated and is awaiting payment cycle.","submittedAmount":"238.44","trackingNumber":"222222222","tradingPartnerClaimNumber":"5332034153-KK"},"serviceDetails":[{"service":{"amountPaid":"95.55","procedureId":"90837","serviceIdQualifier":"Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes","serviceIdQualifierCode":"HC","submittedAmount":"238.44","submittedUnits":"1"},"status":[{"effectiveDate":"20240329","statusCategoryCode":"P5","statusCategoryCodeValue":"Pending/Payer Administrative/System hold","statusCode":"3","statusCodeValue":"Claim has been adjudicated and is awaiting payment cycle."}]}]}],"controlNumber":"222222222","meta":{"applicationMode":"production","traceId":"bf27223e-46c3-451e-b2b4-46f3f0b6fe3b"},"payer":{"organizationName":"UNITEDHEALTHCARE","payerIdentification":"3429"},"providers":[{"organizationName":"Behavioral Services P.C.","providerType":"BillingProvider","taxId":"123456789"},{"npi":"1234567890","organizationName":"Behavioral Services P.C.","providerType":"ServiceProvider"}],"reassociationKey":"000000001","status":"success","subscriber":{"firstName":"JANE","lastName":"DOE","memberId":"111222333"},"tradingPartnerServiceId":"3429"}
This endpoint sends real-time 276 Claim Status requests to payers. You can use it to quickly check the status of an existing claim.
Call this endpoint with a JSON payload.
Stedi translates the JSON to the X12 276 EDI format and sends it to the payer.
The endpoint returns a synchronous response from the payer in JSON format. The response contains information about the referenced claim and its current status.
The response may contain information about more than one claim, if the payer has multiple claims on file that match the information you provided.
We recommend supplying a date range that is at least plus or minus 7 days from the date of the services listed in the claim. The payer may have stored a different date for the encounter than the one in your records, so providing a date range increases the likelihood that the payer will find a match.
Don’t include the following characters in your request data: ~, *, : and ^. They are reserved for delimiters in the resulting X12 EDI transaction, and X12 doesn’t support using escape sequences to represent delimiters or special characters. Stedi returns a 400 error if you include these restricted characters in your request.
Only use the X12 Basic and Extended character sets in request data. Using characters outside these sets may cause validation and HTTP 400 errors.
The X12 Basic character set includes uppercase letters, digits, space, and some special characters. Lowercase letters and special language characters like ñ are not included.
The following special characters are included:
The Extended character set includes the characters listed in Basic, plus lowercase letters and additional special characters, such as @.
The following additional special characters are included:
Note that objects marked as required are required for all requests, while others are conditionally required depending on the circumstances. When you include a conditionally required object, you must include all of its required properties.
For example, you must always include the subscriber object in your request, but you only need to include the serviceLineInformation object when you want to request the status for a specific service line.
Payers generally only allow a provider organization to check the status of the claims they submitted. This means that you likely won’t be able to check the status of a claim submitted by a different provider organization or by the patient themselves, even if you have all of the details about the claim. Payers impose these access controls to protect plan member privacy and confidential commercial data.
Payers also often archive claims older than 18 months, but this varies by payer. If you try to check the status of a claim from several years ago, the payer may return an error even if the information you submit matches a real historical claim.
Finally, we recommend keeping the dates of service range to 30 days or less. Some payers may reject requests with a date range that is too wide.
Information about the billing and/or service providers related to the referenced claim. For each provider, you must set the providerType and one of the following identifiers: npi, taxId, or etin.
- When the providerType = BillingProvider, you must include the provider's etin.
- When providerType = ServiceProvider, you must include the npi if the provider has one. Otherwise, include the taxId.
Identifies the type of provider related to the referenced healthcare claim. You can include both a billing provider and a service provider if both are relevant to the request.
The Electronic Transmitter Identification Number (ETIN). This identifier is preferred if the payer specifically assigned one for the provider. If not, most payers will accept the provider's NPI or TIN instead.
The National Provider Identification (NPI) number. The NPI is a unique, 10-digit identification number assigned to healthcare providers according to HIPAA standards.
Information about the subscriber listed in the referenced claim.
You must set the dateOfBirth and gender properties when the subscriber is the patient. Stedi determines that the subscriber is the patient when the dependent object is not included in the request.
If either dateOfBirth or gender is set, you must include both properties. You can either include both properties or neither within a single request.
This is the Payer ID. Visit the Payer Network for a complete list. You can send requests using the Primary Payer ID, the Stedi Payer ID, or any alias listed in the payer record.
Information about the dependent listed in the referenced claim. You must submit the dependent's firstName, lastName, dateOfBirth, and gender in the request.
Information about the referenced claim or claims for which you want to retrieve status information.
We recommend supplying a date range that is at least plus or minus 7 days from the date of the services listed in the claim, using the beginningDateOfService and endDateOfService properties. The payer may have stored a different date for the encounter than the one in your records, so providing a date range increases the likelihood that the payer will find a match.
The total charges submitted for the claim. Note that not all payer systems retain the original submitted charges; they are sometimes changed during processing.
This is the tracking number assigned to the claim status request. It is returned in the response as claims.trackingNumber. If the payer requires a tracking number and you do not supply one, Stedi generates a tracking number for you from a UUID.
An identifier for the service line. This matches the claimInformation.serviceLines.providerControlNumber submitted for the service line in the original claim.
The total amount paid for the claim. May be zero when no payment is being made. Some payers can provide the adjudicated payment amount before they issue the remittance.
The date the payer issued the check for payment, formatted as YYYYMMDD. This may also contain a non-payment remittance advice date, if available from the payer.
The check identification number or electronic funds transfer (EFT) trace number. This number is used to track the payment. This may also contain a non-payment remittance advice Trace Number (835 or paper), if available from the payer.
Either a single date (formatted as YYYYMMDD) or a range of dates (formatted as YYYYMMDD-YYYYMMDD) identifying the period of service related to the claim. This property is derived from the service level dates.
Code identifying the organizational entity, physical location, property, or individual associated with the statusCode. For example 1G - Oncology Center.
This is the date of denial or approval for the claim, formatted as YYYYMMDD. This date may or may not be the same as the issue date of the check, EFT, or non-payment remittance. Some payers can provide this date before they issue the remittance.
The patient account number provided by the service provider in the original claim. You can use this value to correlate the claim status response to the original claim.
The status code used to identify the status of an entire claim or a service line. For example, 20 - Accepted for Processing. This is either a Health Care Claim Status Code or a National Council for Prescription Drug Programs Reject/Payment Code, when the status is related to pharmacy claims.
The total charges submitted for the claim. The total claim charge may change from the submitted claim total charge based on claims processing instructions, such as claim splitting. Some payers may not store the original submitted charge. Some HMO encounters supply zero as the amount of original charges.
The amount submitted for the service line, expressed as a decimal. For example, 100.00. This is the line item total on the current claim service status.
The code identifying the organizational entity, physical location, property, or individual associated with the statusCode. For example, 4H - Emergency Department.
The status code used to identify the status of an entire service line. This is either a Health Care Claim Status Code or a National Council for Prescription Drug Programs Reject/Payment Code, when the status is related to pharmacy claims.
The syntax error code in the 999 Implementation Acknowledgment. It indicates the type of error (if present) in the EDI request syntax. Visit IK502 in the Implementation Acknowledgment specification for a complete list.
The payer's telephone number. Phone numbers are formatted as AAABBBCCCC, where AAA represents the area code, BBB represents the telephone number prefix, and CCCC represents the telephone number. Phone numbers are provided without separators, such as dashes or parentheses. For example, 5551123345 for 555-112-3345.
Identifies the type of provider related to the referenced healthcare claim. You can include both a billing provider and a service provider if both are relevant to the request.
The Electronic Transmitter Identification Number (ETIN). This identifier is preferred if the payer specifically assigned one for the provider. If not, most payers will accept the provider's NPI or TIN instead.
The National Provider Identification (NPI) number. The NPI is a unique, 10-digit identification number assigned to healthcare providers according to HIPAA standards.
Information about the subscriber listed in the referenced claim.
You must set the dateOfBirth and gender properties when the subscriber is the patient. Stedi determines that the subscriber is the patient when the dependent object is not included in the request.
If either dateOfBirth or gender is set, you must include both properties. You can either include both properties or neither within a single request.
An ID for the payer you identified in the original claim status request. This value may differ from the tradingPartnerServiceId you submitted in the original request because it reflects the payer's internal concept of their ID, not necessarily the ID Stedi uses to route requests to this payer.
The acknowledgment code in the 999 Implementation Acknowledgment, an EDI file generated by the payer to acknowledge receipt of the claim status request. It indicates whether the claim status request was accepted or rejected due to errors in the EDI request syntax.
{"claims":[{"claimStatus":{"amountPaid":"95.55","claimServiceDate":"20240325","effectiveDate":"20240329","paidDate":"20240329","patientAccountNumber":"3333333","statusCategoryCode":"P5","statusCategoryCodeValue":"Pending/Payer Administrative/System hold","statusCode":"3","statusCodeValue":"Claim has been adjudicated and is awaiting payment cycle.","submittedAmount":"238.44","trackingNumber":"222222222","tradingPartnerClaimNumber":"5332034153-KK"},"serviceDetails":[{"service":{"amountPaid":"95.55","procedureId":"90837","serviceIdQualifier":"Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes","serviceIdQualifierCode":"HC","submittedAmount":"238.44","submittedUnits":"1"},"status":[{"effectiveDate":"20240329","statusCategoryCode":"P5","statusCategoryCodeValue":"Pending/Payer Administrative/System hold","statusCode":"3","statusCodeValue":"Claim has been adjudicated and is awaiting payment cycle."}]}]}],"controlNumber":"222222222","meta":{"applicationMode":"production","traceId":"bf27223e-46c3-451e-b2b4-46f3f0b6fe3b"},"payer":{"organizationName":"UNITEDHEALTHCARE","payerIdentification":"3429"},"providers":[{"organizationName":"Behavioral Services P.C.","providerType":"BillingProvider","taxId":"123456789"},{"npi":"1234567890","organizationName":"Behavioral Services P.C.","providerType":"ServiceProvider"}],"reassociationKey":"000000001","status":"success","subscriber":{"firstName":"JANE","lastName":"DOE","memberId":"111222333"},"tradingPartnerServiceId":"3429"}
