Professional Claims
This endpoint sends 837P (professional) claims to payers. Visit Submit claims for a full how-to guide.
- Call this endpoint with a JSON payload.
- Stedi translates your request to the 837 X12 EDI format and sends it to the payer.
- The endpoint returns a response from Stedi in JSON format containing information about the claim you submitted and whether the submission was successful.
This endpoint is a direct replacement for the Change Healthcare (CHC) Claim Submission API.
Enable clearinghouse
Before you can send claims, you must enable the Stedi clearinghouse in your account. Go to EDI Settings and click Enable Stedi Clearinghouse.
Stedi automatically configures the necessary settings to send test and production claims and receive 277 and 835 payer responses.
Send test claims
All claims you submit through this endpoint are sent to the payer as production claims unless you explicitly designate them as test data.
To send test claims:
- Set the
usageIndicatorfield in the test claim toT. This allows you to filter for test claims on the Transactions page in the Stedi app.
Note that you will receive a 277 Claim Acknowledgment in response to test claims, allowing you to test your workflow end to end, but you will not receive a test 835 (ERA) response.
Basic claim submission
The content of your claim submission depends on your use case and the payer’s requirements. However, a basic claim submission includes the following information in the request body:
| Information | Description |
|---|---|
tradingPartnerServiceId | This is the Payer ID. Visit the Payer Network for a complete list. You can also use the same payer IDs you used for CHC eligibility checks. |
tradingPartnerName | This is the payer’s business name, like Cigna or Aetna. |
submitter object | Information about the entity submitting the healthcare claim. This can be either an individual or an organization, such as a doctor, hospital, or insurance company. |
receiver object | Information about the payer, such as an insurance company or government agency. |
subscriber and/or dependent objects | Information about the patient who received the medical services. Note that if a dependent has their own, unique member ID for their health plan, you should submit their information in the subscriber object and omit the dependent object from the request. You can check whether the dependent has a unique member ID by submitting an Eligibility Check to the payer for the dependent. The payer will return the member ID in the dependents.memberId field, if present. |
claimInformation object | Information about the claim, such as the patient control number, claim charge amount, and place of service code. It also includes information about each individual service line included in the claim. |
billing object | Information about the billing provider, such as the NPI, taxonomy code, and organization name. |
Character restrictions
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.
Identify service lines
A claim can contain multiple service lines. Since the payer may accept, reject, or pay a subset of those lines, you can receive an 835 response that references a patientControlNumber, but only pertains to some of the service lines.
However, the claimInformation.serviceLines.providerControlNumber serves as a unique identifier for each service line in your claim submission. This value appears in the 277CA and 835 ERA responses as the lineItemControlNumber, allowing you to correlate these responses to specific service lines from the original claim. If you don’t set the providerControlNumber for a service line, Stedi uses a random UUID.
Stedi returns service line identifiers in the claimReference.serviceLines object of the synchronous API response.
Conditional requirements
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 supervising object when the rendering provider is supervised by a physician.
Enhanced validation
You can optionally set the Stedi-Validation header to snip for enhanced validation on your claim submission.
Enhanced validation uses hundreds of additional edits (the industry term for validation rules) to increase claim acceptance rates. These include Strategic National Implementation Process (SNIP) validations. Stedi also automatically fixes common errors and monitors payer rejections to proactively build out new rules.
There is an additional cost per claim submission when you use enhanced validation. Please reach out to support for access and pricing information.
Authorizations
A Stedi API Key for authentication.
Headers
The outbound transaction setting ID. This option only needs to be specified if a non-default release of the Professional Claims guide needs to be used.
Set to snip for enhanced validation on this claim. Enhanced validation uses hundreds of additional 'edits' (the industry term for validation rules) to increase claims acceptance rates. Stedi also monitors your 277 rejections to proactively build rules based on previous failures. When possible, Stedi automatically fixes common errors (such as invalid date/time formats and character encoding issues) before sending the claim, reducing payer rejections. There is an additional cost per claim submission when you use enhanced validation. Please reach out to support for access and pricing information.
Body
Not currently used.
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.
The entity submitting the healthcare claim. This can be either an individual or an organization, such as a doctor, hospital, or insurance company.
The entity responsible for the payment of the claim, such as an insurance company or government agency.
The person or entity who is the primary policyholder for the health plan or a dependent with their own member ID. When a dependent has a unique, payer-assigned member ID, treat them as the subscriber for the claim submission - include their information here and omit the dependent object from the request.
Dependent who received the medical care associated with the claim. Note that if the dependent has their own member ID for the health plan, you should include the dependent's information in the subscriber object instead. To check whether a dependent has a member ID, submit an Eligibility Check to the payer. The payer returns the dependent's member ID in the dependents.memberId property in the response, if present.
Deprecated; please set all providers individually by type. For example, Referring.
Information about the healthcare claim. Note that the objects and properties marked as required are required for all claims, while others are conditionally required, depending on type of claim and claim circumstances. For example, you must always provide the patient's diagnosis codes in the healthCareCodeInformation object, but you only need to provide the otherSubscriberInformation object in coordination of benefits scenarios. When you include a conditionally required object, you must provide all of its required properties.
Use for subrogation payment requests. If you include this information, you must also set the claimInformation.otherSubscriberInformation.payerPaidAmount to the amount the payer (for example, Medicaid) actually paid.
Whether you want to send a test or production claim. This property corresponds to the Interchange Usage Indicator (ISA-15) in the X12 EDI file. It also allows you to filter claims in the Stedi app by production or test data. By default, this property is set to P for production data. Use T to desginate a claim as test data.
Information about the billing provider. For tax identification, you must include either the provider's Social Security Number (SSN) or their Employer Identification Number (EIN), but not both.
Information about the referring provider.
Information about the person or company (laboratory or other facility) who rendered the care. Use this object for all types of rendering providers including laboratories. When a substitute provider (locum tenens) was used, enter that provider's information here.
Deprecated; please use ClaimInformation.serviceLines.orderingProvider instead.
The entity responsible for supervising the healthcare services provided. Applies when the rendering provider is supervised by a physician.
This is the payer's business name, like Cigna or Aetna.
Response
The status of the claim submission.
An identifier for the transaction.
An ID for the payer you identified in the original claim. 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.
Information about the claim.
A list of errors. Currently not used.
A 200 response indicates that Stedi successfully generated the X12 EDI claim format required by the payer. It does not indicate whether the payer has accepted the claim - the payer will respond later with a 277CA containing this information. Learn more about 277CAs. A 400 response indicates one or more problems with the claim data in the request. Examples include missing required fields, invalid values, or incorrect data types. The response includes a message describing the problem.
200 OK, 400 BAD_REQUEST Metadata from Stedi about the request.
Currently not used.
Currently not used.
Information about the payer for the submitted claim.
Currently not used.
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