{"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 276 Claim Status requests to payers in raw X12 EDI format. This is ideal if you have an existing system that generates X12 EDI files and you want to send them through Stedi’s API.
Stedi validates the EDI and sends the status request to the payer.
The endpoint returns a synchronous response from the payer in JSON format. The response contains information about the claims matching the criteria you provided in the request and their 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.
Supply 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.
We also 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.
Providing too much information in a claim status request can negatively affect the results. That’s why we recommend first sending a request with only the following information:
Loop 2100C: NM109 (National Provider Identifier) and NM103 (Provider Last Name or Organization Name)
Loop 2000D or 2000E: DMG02 (Subscriber/Patient Birth Date)
Loop 2100B: NM1 (Information Receiver Name)
Loop 2100D: NM103 (Subscriber Last Name), NM103 (Subscriber First Name), and NM109 (Member Identification Number)
Loop 2200D: DTP03 (Claim Service Period) that is plus or minus 7 days from the date of service listed in the claim
Loop 2200D or 2200E: TRN (Claim Status Tracking Number)
If this base request fails to return results, try adding in other information like Loop 2200D REF02 (Payer Claim Control Number).
You will eventually learn payer-specific nuances and can build logic in your system to supply additional information to specific payers. For example, some payers may have better success rates when you include the claim number.
Only use the following characters as delimiters: ~, *, : and ^. The X12 format doesn’t support using escape sequences, so you can’t include delimiters or special characters as part of the request data. Stedi returns a 400 error if you include restricted characters as anything other than delimiters in the 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:
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.
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 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.
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 (NCPDP) Reject/Payment Code, when the status is related to pharmacy claims.
Code identifying the organizational entity, physical location, property, or individual associated with the statusCode. For example 1G - Oncology Center.
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 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.
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 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.
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 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 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 code identifying the organizational entity, physical location, property, or individual associated with the statusCode. For example, 4H - Emergency Department.
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.
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.
{"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"}
