Create Claim

Creating and submitting an out-of-network vision claim

The claim object contains all the information required to send a claim to an insurer:

• insurer
• patient details
• primary member details (can be same as patient details)
• list of services

During claim submission, the API validates the claim payload against known insurer requirements and will reject claims that we know will be rejected by the insurer. However, this does not guarantee the opposite; a claim accepted by the API can still be rejected by the insurer.

Insurers can change their claim requirements without notifying us. When this happens, as soon as we understand the new requirements, we will update the validation rules and inform you. It is advisable to be prepared to adopt the updated rules as quickly as possible.

Request Example

{
    "patient": {
        "dob": "1998-02-11",
        "first_name": "Max",
        "last_name": "Smith",
        "type": "child",
        "address": {
            "line1": "String name",
            "city": "City",
            "zipcode": "12332",
            "state": "CA",
        },
    },
    "primary_member": {
        "address": {
            "city": "City",
            "line1": "String name",
            "state": "CA",
            "zipcode": "12332"
        },
        "dob": "1988-10-11",
        "first_name": "John",
        "insurer_code": "insurer:demo:vision",
        "last_name": "Smith",
        "member_id": "A123455",
        "phone": "0987654321",
        "ssn_last_four": "1242"
    },
    "services": [{
        "codes": ["S0504"],
        "cost": "12.22",
        "date": "2022-02-11",
        "quantity": "2"
        "diagnosis_codes": ["H52.10"],
    }, {
        "codes": ["V2781"],
        "cost": "44.21",
        "date": "2022-02-11",
        "quantity": "1"
    }],
    "paid_amount": "68.65"
}

200

{
    "code": "CLM21T",
    "patient": {
        "address": {
            "city": "City",
            "line1": "String name",
            "line2": null,
            "recipient": null,
            "state": "CA",
            "zipcode": "12332"
        },
        "dob": "1998-02-11",
        "email": null,
        "first_name": "Max",
        "last_name": "Smith",
        "member_id": null,
        "phone": null,
        "sex": null,
        "ssn_last_four": null,
        "type": "child"
    },
    "primary_member": {
        "address": {
            "city": "City",
            "line1": "String name",
            "line2": null,
            "recipient": null,
            "state": "CA",
            "zipcode": "12332"
        },
        "dob": "1988-10-11",
        "email": null,
        "employer": null,
        "first_name": "John",
        "individual_plan_name": null,
        "insurer_code": "insurer:demo:vision",
        "last_name": "Smith",
        "member_id": "A123455",
        "phone": "0987654321",
        "sex": null,
        "ssn_last_four": "1242"
    },
    "services": [{
        "codes": ["S0504"],
        "cost": "12.2200",
        "date": "2022-02-11",
        "quantity": 2
        "diagnosis_codes": ["H52.10"],
    }, {
        "codes": ["V2781"],
        "cost": "44.2100",
        "date": "2022-02-11",
        "quantity": 1
    }],
    "status": "ready",
    "paid_amount": "68.6500"
}

Request Parameters

The main fields of claim are:

• patient: JSON object, representing patient details
• primary_member: JSON object, representing primary patient member
• services: list of JSON objects, representing services that can be reimbursed

Both patient and primary_member must be provided even if the claim is created for a primary member. In this case, both the patient object and primary_member object must contain the same data.

Authorizations

Authorization · string · header · required

Your API token prefaced with an "Api" prefix. Example value: "Api B3F4242424E3FDB4242424242A9C7642"

Body

application/json

Response

200 - application/json

The response is of type object.