Availity - Documentation

Introduction - Healthcare APIs

Availity web service API's are designed using a RESTful approach. Our REST API offers predictable, resource-oriented URLs and uses HTTP response codes to indicate API success and failure conditions. Availity REST APIs all return JSON and XML representations, including errors. Some API's have the ability to return CSV, PDF, PNG, and XLS representations.

We offer a trial package that allows you to begin exploring our APIs without completing a formal application process. Using demo data (without PHI information), you'll get up-to-speed quickly, and at no cost to you.

cURL SAMPLES

We use cURL for all samples in this guide so that you can try them. You can download cURL software if needed. Be sure to include your API key and specific IDs for calls.

Important: The sample requests in this guide are examples only and not runnable as is. Substitute all call-specific parameters (such as API Keys, access tokens, and IDs) with your own values.

Try an API:

Request:

Response:

Get an API Key

All requests to the Availity REST APIs must be authenticated with an Client ID (API Key) including demo endpoints.

  1. Sign Up here on https://migrate-developer.availity.com/partner/user/register. See Create an account in top menu on right.
  2. Log in to the Availity Developer Portal using the email address and password you used to create an account.
  3. Register an Application. Once logged in successfully, click Apps in top menu. Create separate applications for Demo vs. Standard rate plan for example.
  4. Take note of your Client Secret right away. You will not see it again.
  5. Select a Plan. See API Products in top menu. Drill down to view specific details about API Product. Select Demo Rate Plan for Mock data response and Standard Rate plan for Live data response.
  6. Click Subscribe to the plan you are interested in and select appropriate application previously registered.
  7. Demo plans subscribed to an application will automatically be approved for use right away.
  8. A notification will be sent to Availity API Support for all other subscribed plans. Once verified, your application will be approved.

Cross-Site Scripting Prevention

One of the most commonly exploited web security vulnerabilities is called Cross Site Scripting (XSS). Simply put, this type of attack tricks a company into serving malicious JavaScript to users' browsers. This is possible because browsers do not distinguish between text to show the user and scripts to execute.

There are three main categories of XSS attacks:

  1. Reflected XSS - When an XSS attack is "reflected" off of the web service and returned back to an end user, this is a Reflected XSS Attack. A common form of this is an error message. For example, if an attacker enters into a zip code URL parameter: &zipcode=20879<script>alert('Gotcha')</script> the web service code may check that it's a valid zip code, yet not output encode and sanitize it. The web service may respond with an error message saying: 20878<script>alert('Gotcha')</script> is not a valid Zip Code If this happens the attacker will now have full access control to that user's browser.
  2. Stored XSS - If the XSS is stored "permanently" on a target server this is a Stored XSS Attack. Classic examples of this would be comments in WordPress, forum posts, and contact forms.
  3. DOM XSS - This is the newest form of XSS and is when the "attacker's payload" is injected directly into the browser DOM creating a DOM XSS Attack. An example would be if such JavaScript code exists: var message = document.cookie; document.errorDiv.innerHTML = message This would expose the cookie value to an HTML section of the current page.

To learn more about Cross-Site Scripting visit the Open Web Application Security Project (OWASP) website, which has listed XSS Attacks as the #3 most critical security flaw that can exist in applications today. OWASP Top 10 2013-A3 Cross Site Scripting (XSS)

How Availity APIS help you prevent XSS Attacks

Availity continually works to keep your data and our data as secure as possible. We support two parts that will to help prevent XSS attacks:

  1. Input validation and sanitization.
  2. Encode resources specifically for their intended use context.

Input Validation and Sanitization

We have implemented whitelist rules for data validation that have been carefully designed to provide protection even against future vulnerabilities introduced by browser changes. What this means for you as a developer is, if you send a request to an API that contains characters which we've determined to not be safe, an HTTP 400 response is returned with an inbound injection error message. You are required to fix the data and re-submit your request. The best way for you to avoid receiving this error is to ensure that you use proper input validation and sanitization on your side before calling an API.

Response Resource Encoding

Encoding is a complicated process because there are different encoders for each given context. An HTML Body string encode isn't the same as a JavaScript string encode. This is where problems can arise as the attacks also vary from context to context. If encoding isn't done properly for the context you're displaying the data in, an attack can slip through.

By default, we do not provide response resource encoding for an API. If you wish to take advantage of encoding you must opt-in to it by sending an X-Response-Encoding-Context request header with one of the following values:

  • HTML - Performs encoding of data for use in HTML entities.
  • HTML_ATTRIBUTE - Performs encoding of data for use in HTML attributes values.
  • CSS - Performs encoding of data for use in stylesheets and style tags.
  • URL - Performs encoding of data for use in a URL.
  • JAVA_SCRIPT - Performs encoding of data for use in JavaScript data values.
  • XML - Performs encoding of data for use in XML entities.
  • XML_ATTRIBUTE - Performs encoding of data for use in XML attribute values.

We highly recommend that you use the appropriate response encoding context when using our API if you will be displaying API resources directly in your application.

Encoding Examples

Below is an example request to the Configurations service showing a partial resource that was returned using the HTML encoding context.

Notice the providerNpi.errorMessage object, the message contents that contained () characters is escaped for use in HTML.

curl -X "GET" "https://api.availity.com/availity/v1/configurations?type=270&payerId=700" -H "Authorization: Bearer abc12345" -H "X-Response-Encoding-Context : HTML"

configurations[0].providerNpi.errorMessage = "Enter a valid National Provider Identifier &#x28;NPI&#x29; containing 10 numeric digits and beginning with a 1, 2, 3, or 4."

Authentication

All Availity REST API's support OAuth2 over HTTPS for authentication including requests to Demo resources.

You may have multiple Client IDs active at one time. Your Client ID carry many privileges, so be sure to keep them secret. If you want to make a REST API request to Availity we will assume that you have already:

  1. Signed up for an account on the Availity developer portal.
  2. Obtained an Client ID for your application.

OAuth2

The Availity REST API supports the Application-only authentication method, which is based on the Client Credentials Grant flow of the OAuth 2.0 spec.

There are 2 steps required to make an initial API request. The following is an example for obtaining an access token and making a request to the Coverages resource:

1. Get an OAuth2 Access Token

This will return a response that contains an access token, token type, and expiration time. The access token is only valid for 5 minutes.

curl -i -X "POST" "https://api.availity.com/availity/v1/token" \
  -d "grant_type=client_credentials&client_id=$CLIENT_ID&client_secret=$CLIENT_SECRET&scope=hipaa"

->
HTTP/1.1 200 OK
Connection: Keep-Alive
Transfer-Encoding: chunked
Content-Type: application/json
Cache-Control: private, no-store, no-cache, must-revalidate
Pragma: no-cache

{ "token_type":"bearer", "access_token":"AAEkZGI1ZjRhYzgtYWViNy00NmRmLWE0YjYtND5NTliZDI0NTc2kPwma8ezU6mkghUoomSLMUbB8LMPc4NJFNkEyrrmFMZabZ67DHXL3gaCr01_mln8-qLDQWne-8stwXOpb2dObXP3SAt8yn1LDQehlNw_KTcZf1H1-FyAFyM5Nh4g0zNs9ATtj2l-H98FzXl9MoBA", "expires_in":300, "scope":"hipaa" }

The request body parameters are case sensitive. Make sure grant_type=client_credentials,client_id=your_client_id,client_secret=your_client_secret and scope=hipaa matches exactly how it is shown.

2. Call REST API with OAuth2 Access Token

We use the access token from step #1 and make requests to the Availity REST API's. The example below shows making a request to the Coverages API. This includes the Availity demo endpoints as well.

curl -i -H "Authorization: Bearer $ACCESS_TOKEN" -X "GET" "https://api.availity.com/availity/v1/coverages?payerId=BCBSF" \

Making Your First Call

With your applications Client ID available, you're now ready to make a request to a REST resource. Below is an example of a request to retrieve a collection of coverages.

The API Key is case sensitive.

 curl -i -H "Authorization: Bearer $ACCESS_TOKEN" -X GET "https://api.availity.com/availity/v1/coverages" 
->
{
  "totalCount": 5,
  "count": 5,
  "offset": 0,
  "limit": 50,
  "links": {
    "self": {
      "href": "https://api.availity.com/availity/v1/coverages"
    }
  },
  "coverages": [
    {
      "links": {
        "self": {
          "href": "https://api.availity.com/availity/v1/coverages/0001234821666577173234942038175340242587013739108497709963594997"
        }
      },
      "id": "0001234821666577173234942038175340242587013739108497709963594997",
      "customerId": "4321",
      "controlNumber": "9876543",
      "status": "Complete",
      "statusCode": "4",
      "createdDate": "2017-06-15T16:31:07.000+0000",
      "updatedDate": "2017-06-15T16:31:07.000+0000",
      "expirationDate": "2017-06-16T16:31:07.000+0000",
      "asOfDate": "2017-06-15T04:00:00.000+0000",
      "requestedServiceType": [
        {
          "code": "30",
          "value": "Health Benefit Plan Coverage"
        }
      ],
      "subscriber": {
        "firstName": "ZENA",
        "lastName": "MARDIN",
        "memberId": "H87654321",
        "gender": "Female",
        "genderCode": "F",
        "birthDate": "1942-09-15T04:00:00.000+0000"
      },
      "patient": {
        "firstName": "ZENA",
        "lastName": "MARDIN",
        "subscriberRelationship": "Self",
        "subscriberRelationshipCode": "18",
        "gender": "Female",
        "genderCode": "F",
        "birthDate": "1942-09-15T04:00:00.000+0000"
      },
      "payer": {
        "name": "HUMANA",
        "payerId": "HUMANA"
      },
      "requestingProvider": {
        "npi": "1234567893",
        "taxId": "123123123"
      },
      "plans": [
        {
          "status": "Active Coverage",
          "statusCode": "1",
          "groupNumber": "P1234567"
        }
      ]
    }
  ]
}

Demo Endpoints

Availity has created demo (mock response) versions of each endpoint that you can explore. Each has a number of demo responses available. You can choose which demo response you want by sending a header with your request. The name of the header is X-Api-Mock-Scenario-ID and the value is the id of the response scenario you want. For demo response confirmation, inspect response header for X-Api-Mock-Response: true. You can find supported response scenarios in the documentation of each endpoint.

$ curl -i -H "Authorization: Bearer $ACCESS_TOKEN" " -H "X-Api-Mock-Scenario-ID: Demo-Example1" -X GET "https://api.availity.com/availity/v1/coverages"
->
HTTP/1.1 200 OK
Connection: Keep-Alive
Transfer-Encoding: chunked
Content-Type: application/json
Date: Mon, 10 Jul 2017 13:56:47 GMT
X-Global-Transaction-ID: 2032325519
Cache-Control: private,no-store,max-age=0,must-revalidate
x-api-id: 1599f0e1-36a3-43de-a937-d2770beb6625
X-Api-Mock-Response: true
X-Session-ID: 1599f0e1-36a3-43de-a937-d2770beb6625
X-planid: healthcare-hipaa-transactions:1.0.0:demo
X-planname: demo

{
  "message": "This is an example."
}

HTTP Status Codes

CODE STATUS VERB DESCRIPTION
200 OK GET, PUT Successfully retrieved or updated an existing resource.
200 OK GET by ID Operation was successful and returns 0 or more resources. The metadata count property in the response body contains the number of resources returned.
200 OK PATCH Successfully updated field(s) in an existing resource.
201 Created POST Successfully created a new resource
202 Accepted GET, POST, PUT, DELETE, PATCH The request has been accepted for processing, but the processing has not been completed. The Location header contains the URI to monitor for status updates.
204 No Content DELETE The service fulfilled the request, which may have removed a resource from server cache, server DB or external resource. The API client can consider the resource no longer available.
303 See Other GET The response to the request can be found under a different URI provided in the Location header and should be retrieved using a GET method on the URI.
400 Bad Request GET by ID The request could not be understood by the service due to malformed query parameters.
400 Bad Request POST The request could not be understood by the service due to malformed syntax.
400 Bad Request PUT The request could not be understood by the service due to malformed syntax.
401 Unauthorized GET, POST, PUT, DELETE, PATCH The API client is not authorized to make this request. The request requires user authentication.
403 Forbidden GET, POST, PUT, DELETE, PATCH The server understood the request, but is refusing to fulfill it. This may be temporary or permanent, depending on the use case.
404 Not Found GET, PUT, DELETE, PATCH The service has not found anything matching the Request URI. No indication is given whether the condition is temporary or permanent.
405 Method Not Found GET, POST, PUT, PATCH, DELETE The method specified in the Request-Line is not allowed for the resource identified by the Request-URI.
406 Not Acceptable GET, POST, PUT, DELETE, PATCH The resource identified by the request is only capable of generating response entities that have content characteristics not acceptable according to the Accept headers sent in the request.
409 Conflict POST, PUT, PATCH, DELETE The service could not complete the request due to a conflict with the current state of the resource.
410 Gone GET, PUT, DELETE, PATCH The requested resource is no longer available and there is no forwarding URI known, this condition is permanent and you should not request the resource again in the future.
415 Unsupported Media Type GET, POST, PUT, DELETE, PATCH The server is refusing to service the request because the entity of the request is in a format not supported by the requested resource for the requested method.
422 Unprocessable Entity POST, PUT, PATCH, DELETE The JSON/XML request entity is properly formed and the media type is a supported media type for the resource; but validation has failed or the request entity is a different type or version than the service supports
500 Internal Server Error GET, POST, PUT, DELETE, PATCH The service encountered an unexpected condition that prevented it from fulfilling the request.

Collections

A Collection Resource is a resource containing other resources. It is known as a Collection Resource because it is itself a first class resource, it has its own attributes similar to any other resource in addition to the instances it contains.

If you want to interact with multiple resources, you must do so with a Collection Resource. They support additional behavior specific to collections, such as pagination, sorting, and searching.

Collection Resource Attributes

ATTRIBUTE DESCRIPTION MIN MAX DEFAULT TYPE
links Set of resource URI's - - - Object
offset The zero-based starting index in the collection of the first item to return 0 - 0 Integer
limit The maximum number of collection items to return for a single request 1 50 50 Integer
count The number of items returned 0 - - Integer
totalCount The total number of items available that match the parameters specified 0 - - Integer
resources An array containing the current page of resources, the attribute name will be the plural name of the resource type, such as coverages. The size of the array can be less than the requested limit. For example, if the limit requested is greater than the maximum allowed or if the response returned less than the limit amount. 0 - - Array

Pagination

If a Collection Resource contains a large number of resource instances, it will not include all of them in a single response. Instead, pagination is used to break up the results into one or more pages of data. You can request additional pages as separate requests.

Example Collection Resource Partial Response

{
  "totalCount": 19,
  "count": 5,
  "offset": 0,
  "limit": 5,
  "links": {
    "last": {
      "href": "https://api.availity.com/availity/v1/coverages?limit=5&offset=14"
    },
    "next": {
      "href": "https://api.availity.com/availity/v1/coverages?limit=5&offset=5"
    },
    "self": {
      "href": "https://api.availity.com/availity/v1/coverages?limit=5"
    }
  },
  "coverages": [
    {
      "customerId": "1194",
      "batchId": "14029438773180168889579000001660",
      "controlNumber": "1-1020",
      "status": "Communication Error",
      "statusCode": "14",
      "createdDate": "2017-07-16T18:38:12.000+0000",
      "updatedDate": "2017-07-16T18:38:12.000+0000",
      "expirationDate": "2017-07-16T19:07:23.000+0000",
      "asOfDate": "2017-02-03T05:00:00.000+0000"
    },
    {
        ...
    }
  ]
}
Query Parameters

The Availity API utilizes cursor-based pagination using two optional query parameters, if they aren't specified the default values are used:

offset The zero-based starting index in the collection of the first item to return. Default is 0.

limit The maximum number of collection items to return for a single request. Minimum value is 1, Maximum value is 50.

The links attribute will contain Link Relations depending on which page and the number of resources returned. If a Link Relation is not available you will receive a null value when trying to access it.

LINK RELATION PURPOSE HREF
self The URL used to retrieve the Collection Resources "https://api.availity.com/availity/v1/coverages?offset=50&limit=50"
first The URL to retrieve the first page of resources "https://api.availity.com/availity/v1/coverages?offset=0&limit=50"
last The URL to retrieve the last page of resources "https://api.availity.com/availity/v1/coverages?offset=251&limit=50"
next The URL to retrieve the next page of resources "https://api.availity.com/availity/v1/coverages?offset=100&limit=50"
prev The URL to retrieve the previous page of resources "https://api.availity.com/availity/v1/coverages?offset=0&limit=50"

Date Time Format

All date and time values used in the Availity API use the ISO 8601 format.

Example

"createdDate": "2014-06-16T18:38:12.000+0000"

Errors

REST API responses indicating an error or warning will return a response body with extended error information. Conventional HTTP status codes are used to indicate success or failure of an API request. In general, codes in the 2xx range indicate success; codes in the 4xx range could indicate missing required parameters or authentication/authorization failures; and codes in the 5xx range indicate an error within Availity's or downstream servers.

Example Error Response

{
    "statusCode": 404,
    "userMessage": "The coverage you specified cannot be found.",
    "developerMessage": "The specified coverage cannot be found. 
      If you accessed this url via a stale href reference,
      it's possible the coverage object has expired in our 
      system, you should acquire the members Coverage Collection 
      Resource again to obtain the current list of coverages.",
    "url": "https://api.availity.com/availity/v1/documentation/coverages",
    "errors": [
        {
            "code": 545,
            "errorMessage": "Some other extended error occurred"
        },
        {
            "code": 615,
            "errorMessage": "Some other extended error occurred"
        }
    ]
}

Error Response Attributes

Attribute Description Type
statusCode The HTTP status code Integer
reasonCode Internal error code (currently not used) Integer
userMessage Error message appropriate for display to end user String
developerMessage A more detailed error message appropriate for a developer String
url URL where more information can be found on the error String
errors A collection of extended error messages if available Array
errors.code Service-specific error code Integer
errors.errorMessage Service-specific error message for error code String

Supported Health Plans

Name ID

Coverages

This resource allows you to find and manage a member's coverage information.

Working with the DEMO endpoints

Availity allows you to specify the type of response you want when interacting with our Coverages demonstration service by sending a header (X-Api-Mock-Scenario-ID) with the appropriate response scenario id. The supported response scenarios are listed below.

Response Scenario ID Status Code Description
Coverages-Complete-i 200 Availity has successfully retrieved the member's coverage information from the health plan.
Coverages-PayerError1-i 200 The health plan has indicated that the provider is ineligible for inquiries.
Coverages-PayerError2-i 200 The health plan has indicated that the subscriber name is invalid.
Coverages-InProgress-i 202 Availity is in the process of retrieving the member's coverage information from the health plan.
Coverages-Retrying-i 202 The health plan did not respond so Availity is retrying the request.
Coverages-RequestError1-i 400 Your request failed Availity's input validation rules.
Coverages-RequestError2-i 400 Your request failed Availity's input validation rules.

Payer can return the following errors:

Code Description
04 Authorized Quantity Exceeded
15 Required Application Data Missing
33 Input Errors
35 Out of Network
41 Authorization/Access Restrictions
42 Unable to Respond at Current Time
43 Invalid/Missing Provider Identification
44 Invalid/Missing Provider Name
45 Invalid/Missing Provider Specialty
46 Invalid/Missing Provider Phone Number
47 Invalid/Missing Provider State
48 Invalid/Missing Referring Provider Identification Number
49 Provider is Not Primary Care Physician
50 Provider Ineligible for Inquiries
51 Provider Not on File
52 Service Dates Not Within Provider Plan Enrollment
53 Inquired Benefit Inconsistent with Provider Type
54 Inappropriate Product/Service ID Qualifier
55 Inappropriate Product/Service ID
56 Inappropriate Date
57 Invalid/Missing Date(s) of Service
58 Invalid/Missing Date-of-Birth
60 Date of Birth Follows Date(s) of Service
61 Date of Death Precedes Date(s) of Service
62 Date of Service Not Within Allowable Inquiry Period
63 Date of Service in Future
64 Invalid/Missing Patient ID
65 Invalid/Missing Patient Name
66 Invalid/Missing Patient Gender Code
67 Patient Not Found
68 Duplicate Patient ID Number
69 Inconsistent with Patient's Age
70 Inconsistent with Patient's Gender
71 Patient Birth Date Does Not Match That for the Patient on the Database
72 Invalid/Missing Subscriber/Insured ID
73 Invalid/Missing Subscriber/Insured Name
74 Invalid/Missing Subscriber/Insured Gender Code
75 Subscriber/Insured Not Found
76 Duplicate Subscriber/Insured ID Number
77 Subscriber Found, Patient Not Found
78 Subscriber/Insured Not in Group/Plan Identified
79 Invalid Participant Identification
80 No Response received - Transaction Terminated
97 Invalid or Missing Provider Address
98 Experimental service or procedure
AA Authorization number not found
AE Requires primary care physician authorization
AF Invalid/missing diagnosis code(s)
AG Invalid/missing procedure code(s)
AO Additional patient coordination information required
CI Certification information does not match patient
E8 Requires medical review
IA Invalid authorization number format
MA Missing authorization number
T4 Payer Name or Identifier Missing

GET /V1/COVERAGES

You can retrieve a snapshot of a member's health plan coverage by querying the coverages resource with the following parameters:

Parameter Required Type Description
payerId No String This is the Availity id of the health plan that the member has coverage with. You can view the list of payer id's by selecting the Coverage Resource from the Supported Health Plans link on the contents menu on the left side of this page.
providerType No String Certain health plans require that the submitter specify whether or not they are a professional or institutional provider. You can specify that using this optional field.
providerNpi No String Most health plans require that you send the provider's National Provider Identifier number to identify who is requesting to see a member's coverage information. Specify this value using this parameter.
providerTaxId No String Some health plans require that you send the provider's tax id. Please use this parameter to specify the requesting provider's tax id.
payerAssignedProviderId No String A few health plans allow you to specify a payer-assigned identifier for the requesting provider. If the requesting provider has been assigned a payer-assigned provider id, send it using this parameter.
providerSSN No String A few health plans allow you to specify a provider's SSN.
providerFirstName No String The provider's first name.
providerLastName No String The provider's last name.
providerCity No String Certain health plans require that you specify the city that the provider is located in. You can send that information using this parameter.
providerState No String Certain health plans require that you specify the state that the provider is located in. You can send that information using this parameter.
providerZipCode No String Certain health plans require that you specify the ZIP code that the provider is located in. You can send that information using this parameter.
providerSpecialty No String Certain health plans allow you to specify the provider's specialty using a taxonomy code.
placeOfService No String Certain health plans require that you identify the place of service.
submitterId No String Some health plans require that you identify yourself using a payer-assigned submitter identifier. Please send that information for health plans that require it using this parameter.
asOfDate No Date You can indicate the date of service or point in time you want to check coverage information for using this parameter.
toDate No Date Some health plans require that you provide an end date for your coverage information search period. If checking coverage for such a health plan, please use this parameter.
serviceType No String You can specify the type or types of service using this parameter.
memberId No String The patient's health plan member id.
medicaidId No String The Medicaid id of the patient or subscriber.
patientSSN No String The patient's SSN.
patientLastName No String The patient's last name.
patientFirstName No String The patient's first name.
patientMiddleName No String The patient's middle name.
patientGender No String The patient's gender.
patientBirthDate No Date The patient's birth date.
patientSuffix No String The patient's suffix.
patientState No String The subscriber's patient of residence.
groupNumber No String The patient's group number.
subscriberRelationship No String If the patient is not the subscriber, you can specify their relationship to the subscriber using this parameter.
externalTraceId No String If you would like to assign a trace id to one or more coverages, specify an externalTraceId. You will be able to filter your requests by this id when searching.
externalControlNumber No String If you would like to assign a unique identifier to a particular coverage, specify an externalControlNumber. You will be able to filter your requests by this id when searching.
providerOfficeId No String If you would like to tag one or more coverages with your own system's customer id, you can do so by sending this parameter.
providerUserId No String If you would like to tag a coverage with your own system's user id, you can do so by sending this parameter.

Sample Requests

When you make a valid request, the resource will return a status code of 200 and a coverage summary.

Note: The response has been truncated to conserve space.

$ curl -X GET "https://api.availity.com/availity/v1/coverages""
->
{
  "totalCount": 5,
  "count": 5,
  "offset": 0,
  "limit": 50,
  "links": {
    "self": {
      "href": "https://api.availity.com/availity/v1/coverages"
    }
  },
  "coverages": [
    {
      "links": {
        "self": {
          "href": "https://api.availity.com/availity/v1/coverages/0001234821666577173234942038175340242587013739108497709963594997"
        }
      },
      "id": "0001234821666577173234942038175340242587013739108497709963594997",
      "customerId": "4321",
      "controlNumber": "9876543",
      "status": "Complete",
      "statusCode": "4",
      "createdDate": "2014-10-15T16:31:07.000+0000",
      "updatedDate": "2014-10-15T16:31:07.000+0000",
      "expirationDate": "2014-10-16T16:31:07.000+0000",
      "asOfDate": "2014-10-15T04:00:00.000+0000",
      "requestedServiceType": [
        {
          "code": "30",
          "value": "Health Benefit Plan Coverage"
        }
      ],
      "subscriber": {
        "firstName": "ZENA",
        "lastName": "MARDIN",
        "memberId": "H87654321",
        "gender": "Female",
        "genderCode": "F",
        "birthDate": "1942-09-15T04:00:00.000+0000"
      },
      "patient": {
        "firstName": "ZENA",
        "lastName": "MARDIN",
        "subscriberRelationship": "Self",
        "subscriberRelationshipCode": "18",
        "gender": "Female",
        "genderCode": "F",
        "birthDate": "1942-09-15T04:00:00.000+0000"
      },
      "payer": {
        "name": "HUMANA",
        "payerId": "HUMANA"
      },
      "requestingProvider": {
        "npi": "1234567893",
        "taxId": "123123123"
      },
      "plans": [
        {
          "status": "Active Coverage",
          "statusCode": "1",
          "groupNumber": "P1234567"
        }
      ]
    }
  ]
}

This coverage summary contains high level information about the coverage.

Availity stores short-lived, local copies of each coverage (until the time specified by the expirationDate property). If we do not have a recent local copy of a particular coverage, we will request it from the health plan. This is an asynchronous process. You can track the current status using the status and statusCode properties of the coverage.

To search your recently requested coverages, in addition to the parameters above, you can also use the following parameters:

Parameter Required Type Description
status No String Search for coverages with a status of "In Progress", "Request Error", "Communication Error", or "Complete".
planStatus No String Search for coverages with a plan status of "Active" or "Inactive"
q Yes String Search for coverages that match free form search terms.
sortBy No String Sort the results by "lastUpdateDate", "asOfdate", or "patientLastName". The default is "lastUpdateDate".
sortDirection No String Sort the results in "asc" or "desc" order. The default is "desc".

Important: When performing a search query, you must specify the q parameter. If you do not require a free-form matching of terms you may leave it empty, q=

If you send invalid parameters, the resource will return a status code of 400 and an error response:

$ curl -X GET "https://api.availity.com/availity/v1/coverages?payerId=BCBSF"
->
{
    "userMessage": "This client system has made an invalid request.",
    "developerMessage": "Your request is not formed properly. Please check your request and the API documentation.",
    "documentation": "https://api.availity.com/availity/v1/documentation/coverages",
    "reasonCode": 0,
    "statusCode": 400,
    "errors": [
        {
            "field": "submitterId",
            "errorMessage": "Please enter a valid Submitter ID."
        },
        {
            "field": "serviceType",
            "errorMessage": "This field is required."
        },
        {
            "field": "patientBirthDate",
            "errorMessage": "Enter a valid date that is not in the future."
        },
        {
            "field": "memberId",
            "errorMessage": "Enter a patient ID containing letters, numbers, spaces, and any of the following special characters: ,;'-.?!&/\\#+=()"
        },
        {
            "field": "providerNpi",
            "errorMessage": "Enter a valid National Provider Identifier (NPI) containing 10 numeric digits and beginning with a 1, 2, 3, or 4."
        },
        {
            "field": "patientLastName",
            "errorMessage": "Enter a name containing letters, numbers, spaces, and any of the following special characters: ,;'-.?!&/\\#+=()"
        }
    ]
}

Hint: In general, sending as many fields as you can is a good approach. The rules vary according to the health plan and some have specific requirements. These rules are documented as a feature of our configurations resource.

If a coverage reports its statusCode and status properties as "0" and "In Progress" respectively, Availity is in the process of retrieving the coverage from the health plan. You should poll by either repeating your request or making a GET by id request periodically for the coverage until the statusCode and status properties change. "In Progress" coverages will include an etaDate property reporting the time we anticipate the refresh will be complete. The status property will change to one of several values:

Status Code Status Description
19 Request Error Indicates that the health plan has returned one or more validationMessages.
R1 Communication Error, Retrying Indicates that the health plan did not respond and we are retrying the request.
7 Communication Error Indicates that the health plan did not respond.
13 Communication Error Indicates that the health plan's response was invalid.
14 Communication Error The health plan did not respond.
15 Communication Error The health plan has indicated that they are down maintenance.
4 Complete Indicates that the refresh was completed successfully.
3 Complete (Invalid Response) Indicates that the refresh was completed successfully, but the health plan's response was partially invalid. Availity will still return all available information from the response, but some values may be missing.

When you make a search request, the resource will return a status code of 200 and the first page of matching coverage summaries:

$ curl -X "GET" "https://api.availity.com/availity/v1/coverages?payerId=BCBSF&providerNpi=1234567893&memberId=PBHR123456&patientLastName=Parker&patientFirstName=Peter&serviceType=98&patientBirthDate=1990-01-01&providerTaxId=123456789"
->
{
  "totalCount": 1,
  "count": 1,
  "offset": 0,
  "limit": 50,
  "links": {
    "self": {
      "href": "https://api.availity.com/availity/v1/coverages?payerId=BCBSF&providerNpi=1234567893&memberId=PBHR123456&patientLastName=Parker&patientFirstName=Peter&serviceType=98&patientBirthDate=1990-01-01&providerTaxId=123456789"
    }
  },
  "coverages": [
    {
      "links": {
        "self": {
          "href": "https://api.availity.com/availity/v1/coverages/0001234457589486807542108543870042194372034683103803500071606998"
        }
      },
      "id": "0001234457589486807542108543870042194372034683103803500071606998",
      "customerId": "1234",
      "status": "In Progress",
      "statusCode": "0",
      "createdDate": "2014-10-15T15:33:29.000+0000",
      "updatedDate": "2014-10-15T15:33:29.000+0000",
      "expirationDate": "2014-10-16T15:33:28.000+0000",
      "etaDate": "2014-10-15T15:33:29.000+0000",
      "asOfDate": "2014-10-15T04:00:00.000+0000",
      "requestedServiceType": [
        {
          "code": "30",
          "value": "Health Benefit Plan Coverage"
        }
      ],
      "subscriber": {
        "memberId": "111222333"
      },
      "patient": {
        "subscriberRelationship": "Self",
        "subscriberRelationshipCode": "18",
        "birthDate": "2001-01-10T05:00:00.000+0000"
      },
      "payer": {
        "name": "HUMANA",
        "payerId": "HUMANA"
      },
      "requestingProvider": {
        "taxId": "123123123"
      }
    }
  ]
}

When you request one or more summaries by id, the resource will return a status code of 200 and any requested unexpired coverage summaries:

$ curl -X GET "https://api.availity.com/availity/v1/coverages?id=0001194499098175762045868562105833796329766732695450956940743265&id=00011944990981757620458685621358337963297667326954509569407491523" 
->
{
    "coverages" : [
        {
            "links": {
                "self": {
                    "href": "https://api.availity.com/availity/v1/coverages/0001194499098175762045868562105833796329766732695450956940743265"
                }
            },
            "customerId": "1234",
            "requestedServiceType": [...],
            "subscriber": {...},
            "patient": {...},
            "payer": {...},
            "requestingProvider": {...},
            "plans": [...]
        },
        {
            "links": {
                "self": {
                    "href": "https://api.availity.com/availity/v1/coverages/00011944990981757620458685621358337963297667326954509569407491523"
                }
            },
            "customerId": "1234",
            "requestedServiceType": [...],
            "subscriber": {...},
            "patient": {...},
            "payer": {...},
            "requestingProvider": {...},
            "plans": [...]
        }
    ]
}

The coverage summary also contains demographics about the member, their overall plan status, and other information to help identify the coverage.

Availity will return the first 50 coverages that match your search. If there are more than 50 matching coverages, links to subsequent pages will be returned. For more information on paging of data, see pagination.

GET /V1/COVERAGES/:ID

You can retrieve the details about a member's coverage by requesting an individual coverage.

When you make a valid request, the resource will return a status code of 200 and a coverage:

$ curl -X GET "https://api.availity.com/availity/v1/coverages/0001194499098175762045868562105833796329766732695450956940743265"
->
{
    "id": "0001194499098175762045868562105833796329766732695450956940743265",
    "customerId": "1234",
    "batchId": "14121823232660172516451000001173",
    "controlNumber": "23337",
    "externalTraceId" : "12314",
    "externalControlNumber": "1",
    "providerOfficeId": "Office246810",
    "providerUserId": "UserOffice246810",
    "status": "Complete",
    "statusCode": "4",
    "createdDate": "2017-10-01T16:52:06.000+0000",
    "updatedDate": "2017-10-01T16:52:06.000+0000",
    "expirationDate": "2017-10-31T16:52:05.000+0000",
    "etaDate" : "2017-10-01T16:52:06.000+0000",
    "asOfDate": "2017-09-30T04:00:00.000+0000",
    "toDate": "2017-09-30T04:00:00.000+0000",
    "requestedServiceType": [...],
    "validationMessages": [...],
    "subscriber": {...},
    "patient": {...},
    "payer": {...},
    "requestingProvider": {...},
    "plans": [...],
    "supplementalInformation": {...},
    "reminders" : {...},
    "links": {...}
}

The subscriber object contains demographics about the health plan subscriber.

"subscriber" : {
    "firstName" : "JAMES",
    "middleName" : "T",
    "lastName" : "KIRK",
    "suffix" : "SR",
    "memberId" : "ASDF12345",
    "gender" : "Male",
    "genderCode" : "M",
    "ssn" : "123591122",
    "birthDate" : "1982-04-28T00:00:00.000+0000",
    "address" : {
        "line1" : "123 MAIN ST",
        "line2" : "SUITE 1",
        "city" : "JACKSONVILLE",
        "state" : "Florida",
        "stateCode" : "FL",
        "zipCode" : "23211"
    }
}

The patient object contains demographics about the patient. The patient might be the subscriber or a dependent. This is indicated by the subscriberRelationship and subscriberRelationshipCode properties. The updateYourRecords property indicates whether the demographics you sent to the health plan are out of date and should be updated with the demographics presented here.

"patient" : {
    "firstName" : "JANE",
    "middleName" : "C",
    "lastName" : "KIRK",
    "suffix" : "PMP",
    "patientAccountNumber" : "1232141-12",
    "memberId" : "ASDF12345",
    "familyUnitNumber" : "1",
    "subscriberRelationship" : "Spouse",
    "subscriberRelationshipCode" : "01",
    "gender" : "Female",
    "genderCode" : "F",
    "ssn" : "213329991",
    "birthDate" : "1983-04-28T00:00:00.000+0000",
    "deathDate" : "2017-05-01T00:00:00.000+0000",
    "address" : {
        "line1" : "123 MAIN ST",
        "line2" : "SUITE 1",
        "city" : "JACKSONVILLE",
        "state" : "Florida",
        "stateCode" : "FL",
        "zipCode" : "23211"
    },
    "updateYourRecords" : false
}

The payer object contains information about the health plan that returned this coverage information. The payerId property is the health plan's Availity id. We also return any known contact information for the health plan in the contactInformation array.

"payer" : {
    "payerId" : "BCBSF",
    "payerName" : "FLORIDA BLUE",
    "contactInformation" : [{
        "name" : "BILLING DEPT",
        "phone" : "1-800-123-4567",
        "workPhone" : "1-800-123-4567 x120",
        "fax" : "1-800-234-4321",
        "emailAddress" : "ASDF@EXAMPLE.COM",
        "url" : "WWW.EXAMPLE.COM",
        "ediAccessNumber" : "12341123"
    }]
}

The requestingProvider object contains information about the provider that requested this coverage information. This includes information sent on the request to the health plan and any additional information the health plan returned about that provider.

"requestingProvider" : {
    "name" : "Business Name",
    "lastName" : "LAST",
    "firstName" : "FIRST",
    "middleName" : "MIDDLE",
    "npi" : "1234567893",
    "taxId" : "111222333",
    "payerAssignedProviderId" : "U1283",
    "ein" : "111222333",
    "ssn" : "111222333",
    "payerId" : "12939",
    "pharmacyProcessorNumber" : "123123",
    "planId" : "2148124",
    "stateLicenseNumber" : "123129312",
    "medicareProviderNumber" : "1231243",
    "medicaidProviderNumber" : "891823",
    "facilityId" : "9127371",
    "pin" : "1112",
    "contractNumber" : "2391781-1",
    "electronicPin" : "1293",
    "submitterId" : "G1923",
    "payerAssignedUserId" : "E1231",
    "providerPlanNetworkId" : "19231-12",
    "facilityNetworkId" : "123123-312",
    "specialty" : "HOSPITAL",
    "specialtyCode" : "282N00000X",
    "role" : "Admitting",
    "roleCode" : "AD" 
}

The plans array contains any health plans returned for the member. Each plan has an overall status indicated by the status and statusCode properties. We also return any pertinent identifiers and dates tied to the plan.

"plans" : [{
    "status" : "Active",
    "statusCode" : "1",
    "groupNumber" : "12314",
    "groupName" : "EXAMPLE COMPANY",
    "policyNumber" : "219312",
    "planNumber" : "213124",
    "planName" : "BLUE OPTIONS",
    "planNetworkId" : "213123",
    "planNetworkName" : "EXAMPLE NETWORK",
    "contractClassCode" : "21312",
    "contractNumber" : "41257",
    "medicalRecordNumber" : "238124",
    "healthInsuranceClaimNumbe" : "184891",
    "identificationCardSerialNumber" : "12939123",
    "identityCardNumber" : "1239123",
    "issueNumber" : "1",
    "medicaidRecipientIdentificationNumber" : "123123",
    "priorIdentificationNumber" : "13141",
    "agencyClaimNumber" : "141",
    "caseNumber" : "189923-1",
    "admissionDate" : "2017-04-21T00:00:00.000+0000",
    "dischargeDate" : "2017-05-01T00:00:00.000+0000",
    "issueDate" : "2017-05-01T00:00:00.000+0000",
    "serviceDate" : "2017-05-01T00:00:00.000+0000",
    "coverageStartDate" : "2017-01-01T00:00:00.000+0000",
    "coverageEndDate" : "2017-12-31T00:00:00.000+0000",
    "planStartDate" : "2017-01-01T00:00:00.000+0000",
    "planEndDate" : "2017-12-31T00:00:00.000+0000",
    "planEnrollmentDate" : "2017-01-01T00:00:00.000+0000",
    "certificationDate" : "2017-01-01T00:00:00.000+0000",
    "eligibilityStartDate" : "2017-01-01T00:00:00.000+0000",
    "eligibilityEndDate" : "2017-12-31T00:00:00.000+0000",
    "policyEffectiveDate" : "2017-01-01T00:00:00.000+0000",
    "policyExpirationDate" : "2017-12-31T00:00:00.000+0000",
    "effectiveChangeDate" : "2017-01-01T00:00:00.000+0000",
    "cobraStartDate" : "2017-01-01T00:00:00.000+0000",
    "cobraEndDate" : "2017-12-31T00:00:00.000+0000",
    "lastUpdateDate" : "2017-01-01T00:00:00.000+0000",
    "addedDate" : "2017-01-01T00:00:00.000+0000",
    "premiumPaidToBeginDate" : "2017-01-01T00:00:00.000+0000",
    "premiumPaidToEndDate" : "2017-12-31T00:00:00.000+0000",
    "statusDate" : "2017-01-01T00:00:00.000+0000",
    "additionalPayers" : [...],
    "primaryCareProvider" : {...},
    "contacts" : [...],
    "payerNotes" : [...],
    "preexistingConditions" : {...},
    "benefits" : [...]
}]

A plan can contain information about other health plans in the additionalPayers array. This includes various identifiers, dates, and member information associated with the other healthplan. The primary, secondary, and tertiary properties indicate how this health plan participates in coordination of benefits for the member.

"additionalPayers" : [{
    "name" : "Example Insurance",
    "type" : "Commercial",
    "typeCode" : "C1",
    "planNumber" : "128318",
    "planName" : "Sample Plan",
    "groupNumber" : "81283",
    "groupName" : "Example Group",
    "policyNumber" : "8123",
    "planNetworkId" : "123",
    "planNetworkName" : "Example Network",
    "dischargeDate" : "2017-01-01T00:00:00.000+0000",
    "periodStartDate" : "2017-01-01T00:00:00.000+0000",
    "periodEndDate" : "2017-12-31T00:00:00.000+0000",
    "completionDate" : "2017-01-01T00:00:00.000+0000",
    "coordinationOfBenefitsBeginDate" : "2017-01-01T00:00:00.000+0000",
    "coordinationOfBenefitsEndDate" : "2017-12-31T00:00:00.000+0000",
    "coordinationOfBenefitsDate" : "2017-01-01T00:00:00.000+0000",
    "coverageStartDate" : "2017-01-01T00:00:00.000+0000",
    "coverageEndDate" : "2017-12-31T00:00:00.000+0000",
    "addedDate" : "2017-01-01T00:00:00.000+0000",
    "planStartDate" : "2017-01-01T00:00:00.000+0000",
    "benefitBeginDate" : "2017-01-01T00:00:00.000+0000",
    "benefitEndDate" : "2017-12-31T00:00:00.000+0000",
    "primaryCareProviderDate" : "2017-01-01T00:00:00.000+0000",
    "lastVisitDate" : "2017-01-01T00:00:00.000+0000",
    "eligibilityStartDate" : "2017-01-01T00:00:00.000+0000",
    "eligibilityEndDate" : "2017-01-01T00:00:00.000+0000",
    "admissionDate" : "2017-01-01T00:00:00.000+0000",
    "serviceDate" : "2017-01-01T00:00:00.000+0000",
    "lastUpdateDate" : "2017-01-01T00:00:00.000+0000",
    "statusDate" : "2017-01-01T00:00:00.000+0000",
    "payerNotes" : ["This is a note from the secondary payer."],
    "payerId" : "00590",
    "contactInformation" : [{
        "name" : "Billing Dept",
        "phone" : "1-800-234-1234 x12",
        "fax" : "1-800-345-1234 x12",
        "emailAddress" : "api@availity.com",
        "ediAccessNumber" : "1238",
        "url" : "www.availity.com",
        "workPhone" : "555-123-3122 x151
    }],
    "address" : {
        "line1" : "123 Main St",
        "line2" : "Suite 15",
        "city" : "Jacksonville",
        "state" : "Florida",
        "stateCode" : "FL",
        "zipCode" : "237812123"
    },
    "primary" : false,
    "secondary" : true,
    "tertiary" : false,
    "insuredLastName" : "",
    "insuredFirstName" : "",
    "insuredMiddleName" : "",
    "insuredMemberId" : "",
    "insuredContactInformation" : [{
        "name" : "Resident",
        "phone" : "9042312134 x12",
        "fax" : "5555554444 x12",
        "emailAddress" : "bob@example.com",
        "ediAccessNumber" : "1238",
        "url" : "www.example.com",
        "workPhone" : "555-123-3122 x152
    }],
    "insuredAddress" : {
        "line1" : "123 Main St",
        "line2" : "Suite 12",
        "city" : "Jacksonville",
        "state" : "Florida",
        "stateCode" : "FL",
        "zipCode" : "237812123"
    }
}]

The primaryCareProvider object contains any information returned by the health plan about the member's primary care provider. This information includes any known identifiers, pertinent dates, and contact information for that primary care provider.

"primaryCareProvider" : {
    "name" : "Medical Center",
    "lastName" : "Smith",
    "firstName" : "Joe",
    "middleName" : "D",
    "npi" : "1234567893",
    "taxId" : "111222333",
    "payerAssignedProviderId" : "G1234",
    "ein" : "128312314",
    "ssn" : "111222333",
    "etin" : "123123",
    "facilityId" : "21312",
    "suhi" : "4123",
    "memberId" : "12312",
    "naicId" : "123214",
    "payerId" : "44431",
    "pharmacyProcessorNumber" : "123123",
    "planId" : "123124",
    "address" : {
        "line1" : "123 Main St",
        "line2" : "Suite 1",
        "city" : "Jacksonville",
        "state" : "Florida",
        "stateCode" : "FL",
        "zipCode" : "612312341"
    },
    "specialty" : "HOSPITAL",
    "specialtyCode" : "282N00000X",
    "role" : "Admitting",
    "roleCode" : "AD",
    "contactInformation" : [{
        "name" : "Dr Smith",
        "phone" : "9042312134 x12",
        "fax" : "5555554444 x12",
        "emailAddress" : "bob@example.com",
        "ediAccessNumber" : "1238",
        "url" : "www.example.com",
        "workPhone" : "555-123-3122 x152
    }],
    "dischargeDate" : "2017-01-01T00:00:00.000+0000",
    "periodStartDate" : "2017-01-01T00:00:00.000+0000",
    "periodEndDate" : "2017-01-01T00:00:00.000+0000",
    "completionDate" : "2017-01-01T00:00:00.000+0000",
    "coordinationOfBenefitsBeginDate" : "2017-01-01T00:00:00.000+0000",
    "coordinationOfBenefitsEndDate" : "2017-01-01T00:00:00.000+0000",
    "coordinationOfBenefitsDate" : "2017-01-01T00:00:00.000+0000",
    "coverageStartDate" : "2017-01-01T00:00:00.000+0000",
    "coverageEndDate" : "2017-01-01T00:00:00.000+0000",
    "addedDate" : "2017-01-01T00:00:00.000+0000",
    "planStartDate" : "2017-01-01T00:00:00.000+0000",
    "benefitBeginDate" : "2017-01-01T00:00:00.000+0000",
    "benefitEndDate" : "2017-01-01T00:00:00.000+0000",
    "primaryCareProviderDate" : "2017-01-01T00:00:00.000+0000",
    "lastVisitDate" : "2017-01-01T00:00:00.000+0000",
    "eligibilityStartDate" : "2017-01-01T00:00:00.000+0000",
    "eligibilityEndDate" : "2017-01-01T00:00:00.000+0000",
    "admissionDate" : "2017-01-01T00:00:00.000+0000",
    "serviceDate" : "2017-01-01T00:00:00.000+0000",
    "lastUpdateDate" : "2017-01-01T00:00:00.000+0000",
    "statusDate" : "2017-01-01T00:00:00.000+0000",
    "policyNumber" : "2134",
    "familyUnitNumber" : "1",
    "groupNumber" : "1231",
    "referralNumber" : "12312",
    "alternateListId" : "32154",
    "coverageListId" : "78123",
    "healthInsuranceClaimNumber" : "12",
    "drugFormularyNumber" : "491123",
    "priorAuthorizationNumber" : "1238123",
    "medicalAssistanceCategoryId" : "2139123",
    "planNetworkId" : "19283",
    "medicaidRecipientId" : "123123",
    "deliveryInformation" : [{
        "quantityQualifier" : "Visits",
        "quantityQualifierCode" : "VS",
        "quantity" : "12",
        "amount" : "3",
        "per" : "Week",
        "perCode" : "WK",
        "timePeriod" : "Month",
        "timePeriodCode" : "34"
        "timePeriods" : "2",
        "pattern" : "Monday, Wednesday and Thursday",
        "patternCode" : "SY",
        "time" : "A.M.",
        "timeCode" : "D"
    }],
    "payerNotes" : ["The is a note from the payer about the primary care provider."]
}

The contacts array contains any other general contact information provided. This object contains any identifiers, pertinent dates, and contact information for the contact.

"contacts" : [{
    "name" : "Joe's Discount Health Plan",
    "lastName" : "Smith",
    "firstName" : "Joe",
    "middleName" : "D",
    "npi" : "1234567893",
    "taxId" : "111222333",
    "payerAssignedProviderId" : "G1234",
    "ein" : "128312314",
    "ssn" : "111222333",
    "etin" : "123123",
    "facilityId" : "21312",
    "suhi" : "4123",
    "memberId" : "12312",
    "naicId" : "123214",
    "payerId" : "44431",
    "pharmacyProcessorNumber" : "123123",
    "planId" : "123124",
    "address" : {
        "line1" : "123 Main St",
        "line2" : "Suite 1",
        "city" : "Jacksonville",
        "state" : "Florida",
        "stateCode" : "FL",
        "zipCode" : "612312341"
    },
    "specialty" : "HOSPITAL",
    "specialtyCode" : "282N00000X",
    "type" : "Prior Insurance Carrier",
    "typeCode" : "P4",
    "role" : "Admitting",
    "roleCode" : "AD",
    "contactInformation" : [{
        "name" : "Dr Smith",
        "phone" : "9042312134 x12",
        "fax" : "5555554444 x12",
        "emailAddress" : "bob@example.com",
        "ediAccessNumber" : "1238",
        "url" : "www.example.com",
        "workPhone" : "555-123-3122 x152
    }],
    "dischargeDate" : "2017-01-01T00:00:00.000+0000",
    "periodStartDate" : "2017-01-01T00:00:00.000+0000",
    "periodEndDate" : "2017-01-01T00:00:00.000+0000",
    "completionDate" : "2017-01-01T00:00:00.000+0000",
    "coordinationOfBenefitsBeginDate" : "2017-01-01T00:00:00.000+0000",
    "coordinationOfBenefitsEndDate" : "2017-01-01T00:00:00.000+0000",
    "coordinationOfBenefitsDate" : "2017-01-01T00:00:00.000+0000",
    "coverageStartDate" : "2017-01-01T00:00:00.000+0000",
    "coverageEndDate" : "2017-01-01T00:00:00.000+0000",
    "addedDate" : "2017-01-01T00:00:00.000+0000",
    "planStartDate" : "2017-01-01T00:00:00.000+0000",
    "benefitBeginDate" : "2017-01-01T00:00:00.000+0000",
    "benefitEndDate" : "2017-01-01T00:00:00.000+0000",
    "primaryCareProviderDate" : "2017-01-01T00:00:00.000+0000",
    "lastVisitDate" : "2017-01-01T00:00:00.000+0000",
    "eligibilityStartDate" : "2017-01-01T00:00:00.000+0000",
    "eligibilityEndDate" : "2017-01-01T00:00:00.000+0000",
    "admissionDate" : "2017-01-01T00:00:00.000+0000",
    "serviceDate" : "2017-01-01T00:00:00.000+0000",
    "lastUpdateDate" : "2017-01-01T00:00:00.000+0000",
    "statusDate" : "2017-01-01T00:00:00.000+0000",
    "policyNumber" : "2134",
    "familyUnitNumber" : "1",
    "groupNumber" : "1231",
    "referralNumber" : "12312",
    "alternateListId" : "32154",
    "coverageListId" : "78123",
    "healthInsuranceClaimNumber" : "12",
    "drugFormularyNumber" : "491123",
    "priorAuthorizationNumber" : "1238123",
    "medicalAssistanceCategoryId" : "2139123",
    "planNetworkId" : "19283",
    "medicaidRecipientId" : "123123",
    "authorizationRequired" : true,
    "deliveryInformation" : [{
        "quantityQualifier" : "Visits",
        "quantityQualifierCode" : "VS",
        "quantity" : "12",
        "amount" : "3",
        "per" : "Week",
        "perCode" : "WK",
        "timePeriod" : "Month",
        "timePeriodCode" : "34"
        "timePeriods" : "2",
        "pattern" : "Monday, Wednesday and Thursday",
        "patternCode" : "SY",
        "time" : "A.M.",
        "timeCode" : "D"
    }],
    "payerNotes" : ["The is a note from the payer about the primary care provider."]
}]

The payerNotes array contains general disclaimers and messages from the health plan.

"payerNotes" : [{
    "type" : "Disclaimer",
    "typeCode" : "D",
    "message" : "This is a disclaimer!"
}]

The preexistingConditions contains any general information about coverage of pre-existing conditions returned by the health plan. This object is organized by network with each network array containing detailed benefit information (see benefit detail object below).

"preexistingConditions" : {
    "inNetwork" : [...],
    "outOfNetwork" : [...],
    "notApplicableNetwork" : [...],
    "noNetwork" : [...]
}

The benefits array contains detailed information about coverage of various benefits. It is organized by service type with each entry containing benefit information about a particular service type. The name and type properties identify the service type this benefit pertains to.

The benefit has an overall status indicated by the status and statusCode properties. Additional status information is broken down in the statusDetails object. This object is organized by network with each network array containing detailed benefit information (see benefit detail object below).

Financial information about the benefit is contained in the amounts object. You can find information about the co-pay, out-of-pocket expenses, deductibles, and co-insurance here. Each of these financial sections is organized by network with each network array containing detailed benefit information (see benefit detail object below).

Limitations on this benefit are described in the limitations object. It is also organized by network with each network array containing detailed benefit information (see benefit detail object below).

Non-covered information is located in the nonCovered property. This object is organized by network with each network array containing detailed benefit information (see benefit detail object below).

Coverage basis information is located in the coverageBasis property. This object is organized by network with each network array containing detailed benefit information (see benefit detail object below).

Information about pre-existing conditions is located in the preexistingConditions property. This object is organized by network with each network array containing detailed benefit information (see benefit detail object below).

Additional health plans that cover this particular benefit are specified in the additionalPayers array. This array contains the same type of object with the same possible properties as the plan-level additionalPayers array.

Contacts related to this particular benefit are specified in the contacts array. This array contains the same type of object with the same possible properties as the plan level contacts array.

The payerNotes array contains any notes from the health plan that pertain to this particular benefit.

"benefits" : [{
    "name" : "Medical Care",
    "type" : "1",
    "status" : "Active",
    "statusCode" : "1",
    "statusDetails" : {
        "inNetwork" : [...],
        "outOfNetwork" : [...],
        "notApplicableNetwork" : [...],
        "noNetwork" : [...]
    },
    "amounts" : {
        "coPayment" : {
            "inNetwork" : [...],
            "outOfNetwork" : [...],
            "notApplicableNetwork" : [...],
            "noNetwork" : [...]
        },
        "outOfPocket" : {
            "inNetwork" : [...],
            "outOfNetwork" : [...],
            "notApplicableNetwork" : [...],
            "noNetwork" : [...]
        },
        "deductibles" : {
            "inNetwork" : [...],
            "outOfNetwork" : [...],
            "notApplicableNetwork" : [...],
            "noNetwork" : [...]
        },
        "coInsurance" : {
            "inNetwork" : [...],
            "outOfNetwork" : [...],
            "notApplicableNetwork" : [...],
            "noNetwork" : [...]
        }
    },
    "limitations" : {
        "inNetwork" : [...],
        "outOfNetwork" : [...],
        "notApplicableNetwork" : [...],
        "noNetwork" : [...]
    },
    "nonCovered" : {
        "inNetwork" : [...],
        "outOfNetwork" : [...],
        "notApplicableNetwork" : [...],
        "noNetwork" : [...]
    },
    "coverageBasis" : {
        "inNetwork" : [...],
        "outOfNetwork" : [...],
        "notApplicableNetwork" : [...],
        "noNetwork" : [...]
    },
    "preexistingConditions" : {
        "inNetwork" : [...],
        "outOfNetwork" : [...],
        "notApplicableNetwork" : [...],
        "noNetwork" : [...]
    },
    "additionalPayers : [...],
    "contacts : [...],
    "payerNotes : [{
        "type" : "Disclaimer",
        "typeCode" : "D",
        "message" : "This is a disclaimer!"
    }]
}]

Information about benefits is conveyed in the benefit-detail format. This can include specific status information about an aspect of a benefit (status and statusCode), financial information (amount, total remaining), where service should be performed (placeOfService and placeOfServiceCode), dates pertaining to this detail, contacts related to this detail (the same contact object as the plan and benefit-level contacts), and even information about how a service should be delivered deliveryInformation.

{
    "status" : "Active",
    "statusCode" : "1",
    "insuranceType" : "Point of Service (POS)",
    "insuranceTypeCode" : "PS",
    "amount" : "50.00",
    "units" : "USD",
    "amountTimePeriod" : "Visit",
    "amountTimePeriodCode" : "27",
    "remaining" : "25.00",
    "remainingTimePeriod" : "Visit",
    "remainingTimePeriodCode" : "27",
    "total" : "25.00",
    "totalTimePeriod" : "Visit",
    "totalTimePeriodCode" : "27",
    "level" : "Family",
    "levelCode" : "FAM",
    "quantity" : "1",
    "quantityQualifier" : "Days",
    "quantityQualifierCode" : "DY",
    "authorizationRequired" : false,
    "placeOfService" : "Office",
    "placeOfServiceCode" : "11",
    "description" : "BASIC COVERAGE",
    "dischargeDate" : "2017-01-01T00:00:00.000+0000",
    "periodStartDate" : "2017-01-01T00:00:00.000+0000",
    "periodEndDate" : "2017-01-01T00:00:00.000+0000",
    "completionDate" : "2017-01-01T00:00:00.000+0000",
    "coordinationOfBenefitsDate" : "2017-01-01T00:00:00.000+0000",
    "coordinationOfBenefitsBeginDate" : "2017-01-01T00:00:00.000+0000",
    "coordinationOfBenefitsEndDate" : "2017-01-01T00:00:00.000+0000",
    "coverageStartDate" : "2017-01-01T00:00:00.000+0000",
    "coverageEndDate" : "2017-01-01T00:00:00.000+0000",
    "addedDate" : "2017-01-01T00:00:00.000+0000",
    "planStartDate" : "2017-01-01T00:00:00.000+0000",
    "primaryCareProviderDate" : "2017-01-01T00:00:00.000+0000",
    "lastVisitDate" : "2017-01-01T00:00:00.000+0000",
    "eligibilityStartDate" : "2017-01-01T00:00:00.000+0000",
    "eligibilityEndDate" : "2017-01-01T00:00:00.000+0000",
    "benefitBeginDate" : "2017-01-01T00:00:00.000+0000",
    "benefitEndDate" : "2017-01-01T00:00:00.000+0000",
    "admissionDate" : "2017-01-01T00:00:00.000+0000",
    "serviceDate" : "2017-01-01T00:00:00.000+0000",
    "lastUpdateDate" : "2017-01-01T00:00:00.000+0000",
    "statusDate" : "2017-01-01T00:00:00.000+0000",
    "contacts" : [...],
    "payerNotes" : ["A note from the payer."],
    "deliveryInformation" : [{
        "quantityQualifier" : "Visits",
        "quantityQualifierCode" : "VS",
        "quantity" : "12",
        "amount" : "3",
        "per" : "Week",
        "perCode" : "WK",
        "timePeriod" : "Month",
        "timePeriodCode" : "34"
        "timePeriods" : "2",
        "pattern" : "Monday, Wednesday and Thursday",
        "patternCode" : "SY",
        "time" : "A.M.",
        "timeCode" : "D"
    }]
}

Coverage Response Field Mapping Tables

Below you will find tables that provide mapping to various fields in the resource response.

The following are possible values for insuranceTypeCode and insuranceType fields:

Insurance Type Code Insurance Type
12 Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan
13 Medicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination Period with an Employer's Group Health Plan
14 Medicare Secondary, No-fault Insurance Including Auto is Primary
15 Medicare Secondary Worker's Compensation
16 Medicare Secondary Public Health Service (PHS) or Other Federal Agency
41 Medicare Secondary Black Lung
42 Medicare Secondary Veteran's Adminstration
43 Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP)
47 Medicare Secondary, Other Liability Insurance is Primary
AP Auto Insurance Policy
C1 Commercial
CO Consolidated Omnibus Budget Reconciliation Act (COBRA)
CP Medicare Conditionally Primary
D Disability
DB Disability Benefits
EP Exclusive Provider Organization
FF Family or Friends
GP Group Policy
HM Health Maintenance Organization (HMO)
HN Health Maintenance Organization (HMO) - Medicare Risk
HS Special Low Income Medicare Beneficiary
IN Indemnity
IP Individual Policy
LC Long Term Care
LD Long Term Policy
LI Life Insurance
LT Litigation
MA Medicare Part A
MB Medicare Part B
MC Medicaid
MH Medigap Part A
MI Medigap Part B
MP Medicare Primary
OT Other
PE Property Insurance - Personal
PL Personal
PP Personal Payment (Cash - No Insurance)
PR Preferred Provider Organization (PPO)
PS Point of Service (POS)
QM Qualified Medicare Beneficiary
RP Property Insurance - Real
SP Supplemental Policy
TF Tax Equity Fiscal Responsibility Act (TEFRA)
WC Workers Compensation
WU Wrap Up Policy

The following are possible values for subscriberRelationshipCode and subscriberRelationship fields:

Subscriber Relationship Code Subscriber Relationship
18 Self
01 Spouse
19 Child
20 Employee
21 Unknown
39 Organ Donor
40 Cadaver Donor
53 Life Partner
G8 Other Relationship
34 Other Adult

The following are possible values for levelCode and level fields:

Level Code Level
CHD Children Only
DEP Dependents Only
ECH Employee and Children
EMP Employee Only
ESP Employee and Spouse
FAM Family
IND Individual
SPC Spouse and Children
SPO Spouse Only

The following are possible values for timePeriodCode and timePeriod fields:

Time Period Code Time Period
6 Hour
7 Day
13 24 Hours
21 Years
22 Service Year
23 Calendar Year
24 Year to Date
25 Contract
26 Episode
27 Visit
28 Outlier
29 Remaining
30 Exceeded
31 Not Exceeded
32 Lifetime
33 Lifetime Remaining
34 Month
35 Week
36 Admission

The following are possible values for statusCode and status fields for plans and benefits:

Status Code Status
0 Coverage Unknown
1 Active Coverage
2 Active - Full Risk Capitation
3 Active - Services Capitated
4 Active - Services Capitated to Primary Care Physician
5 Active - Pending Investigation
6 Inactive
7 Inactive - Pending Eligibility Update
8 Inactive - Pending Investigation

The following are possible values for quantityQualifierCode and quantityQualifier fields:

Quantity Qualifier Code Quantity Qualifier
8H Minimum
99 Quantity Used
CA Covered - Actual
CE Covered - Estimated
D3 Number of Co-insurance Days
DB Deductible Blood Units
DY Days
HS Hours
LA Life-time Reserve - Actual
LE Life-time Reserve - Estimated
M2 Maximum
MN Month
P6 Number of Services or Procedures
QA Quantity Approved
S7 Maximum Age
S8 Minimum Age
VS Visits
YY Years

The following are possible values for categoryCode and category fields for various contacts and Coverages.requestingProvider and Coverages.plans.primaryCareProvider:

Category Code Category
1 Active Coverage
2 Active - Full Risk Capitation
3 Active - Services Capitated
4 Active - Services Capitated to Primary Care Physician
5 Active - Pending Investigation
6 Inactive
7 Inactive - Pending Eligibility Update
8 Inactive - Pending Investigation
A Co-Insurance
B Co-Payment
C Deductible
CB Coverage Basis
D Benefit Description
E Exclusions
F Limitations
G Out of Pocket (Stop Loss)
H Unlimited
I Non-Covered
J Cost Containment
K Reserve
L Primary Care Provider
M Pre-existing Condition
MC Managed Care Coordinator
N Services Restricted to Following Provider
O Not Deemed a Medical Necessity
P Benefit Disclaimer
Q Second Surgical Opinion Required
R Other or Additional Payor
S Prior Year(s) History
T Card(s) Reported Lost/Stolen
U Contact Following Entity for Eligibility or Benefit Information
V Cannot Process
W Other Source of Data
X Health Care Facility
Y Spend Down

The following are possible values for placeOfServiceCode and placeOfService fields:

Place of Service Code Place of Service
01 Pharmacy
03 School
04 Homeless Shelter
05 Indian Health Service Free-standing Facility
06 Indian Health Service Provider-based Facility
07 Tribal 638 Free-standing Facility
08 Tribal 638 Provider-based Facility
11 Office
12 Home
13 Assisted Living Facility
14 Group Home
15 Mobile Unit
19 Off Campus-Outpatient Hospital
20 Urgent Care Facility
21 Inpatient Hospital
22 On Campus-Outpatient Hospital
23 Emergency Room - Hospital
24 Ambulatory Surgical Center
25 Birthing Center
26 Military Treatment Facility
31 Skilled Nursing Facility
32 Nursing Facility
33 Custodial Care Facility
34 Hospice
41 Ambulance - Land
42 Ambulance - Air or Water
49 Independent Clinic
50 Federally Qualified Health Center
51 Inpatient Psychiatric Facility
52 Psychiatric Facility - Partial Hospitalization
53 Community Mental Health Center
54 Intermediate Care Facility/Mentally Retarded
55 Residential Substance Abuse Treatment Facility
56 Psychiatric Residential Treatment Center
57 Non-residential Substance Abuse Treatment Facility
60 Mass Immunization Center
61 Comprehensive Inpatient Rehabilitation Facility
62 Comprehensive Outpatient Rehabilitation Facility
65 End-State Renal Disease Treatment Facility
71 Public Health Clinic
72 Rural Health Clinic
81 Independent Laboratory
99 Other Place of Service

The following are possible values for typeCode and code fields:

Note: In addition to the following list, type could also be a procedureCode.

Type Code Code
85 AIDS
84 Abortion
64 Acupuncture
28 Adjunctive Dental Services
57 Air Transportation
AJ Alcoholism
GY Allergy
79 Allergy Testing
15 Alternate Method Dialysis
13 Ambulatory Service Center Facility
7 Anesthesia
97 Anesthesiologist
71 Audiology Exam
10 Blood Charges
91 Brand Name Prescription Drug
B2 Brand Name Prescription Drug - Formulary
B3 Brand Name Prescription Drug - Non-Formulary
B1 Burn Care
58 Cabulance
87 Cancer
BL Cardiac
BG Cardiac Rehabilitation
CQ Case Management
78 Chemotherapy
33 Chiropractic
34 Chiropractic Office Visits
16 Chronic Renal Disease (CRD) Equipment
BD Cognitive Therapy
3 Consultation
C1 Coronary Care
BC Day Care (Psychiatric)
37 Dental Accident
35 Dental Care
36 Dental Crowns
DG Dermatology
DS Diabetic Supplies
23 Diagnostic Dental
5 Diagnostic Lab
73 Diagnostic Medical
4 Diagnostic X-Ray
76 Dialysis
63 Donor Procedures
AK Drug Addiction
DM Durable Medical Equipment
12 Durable Medical Equipment Purchase
18 Durable Medical Equipment Rental
86 Emergency Services
BP Endocrine
26 Endodontics
AR Experimental Drug Therapy
BR Eye
CP Eyewear and Eyewear Accessories
82 Family Planning
CO Flu Vaccination
AM Frames
89 Free Standing Prescription Drug
BN Gastrointestinal
60 General Benefits
92 Generic Prescription Drug
GF Generic Prescription Drug - Formulary
GN Generic Prescription Drug - Non-Formulary
BT Gynecological
30 Health Benefit Plan Coverage
42 Home Health Care
43 Home Health Prescriptions
44 Home Health Visits
45 Hospice
47 Hospital
53 Hospital - Ambulatory Surgical
51 Hospital - Emergency Accident
52 Hospital - Emergency Medical
48 Hospital - Inpatient
50 Hospital - Outpatient
49 Hospital - Room and Board
80 Immunizations
61 In-vitro Fertilization
BA Independent Medical Evaluation
83 Infertility
72 Inhalation Therapy
IC Intensive Care
BS Invasive Procedures
AO Lenses
59 Licensed Ambulance
54 Long Term Care
BM Lymphatic
62 MRI/CAT Scan
90 Mail Order Prescription Drug
BW Mail Order Prescription Drug: Brand Name
BX Mail Order Prescription Drug: Generic
55 Major Medical
CM Mammogram, High Risk Patient
CN Mammogram, Low Risk Patient
BE Massage Therapy
69 Maternity
27 Maxillofacial Prosthetics
1 Medical Care
56 Medically Related Transportation
MH Mental Health
CG Mental Health Facility - Inpatient
CH Mental Health Facility - Outpatient
CE Mental Health Provider - Inpatient
CF Mental Health Provider - Outpatient
NI Neonatal Intensive Care
BQ Neurology
65 Newborn Care
AQ Nonmedically Necessary Physical
BI Nursery
BU Obstetrical
BV Obstetrical/Gynecological
AD Occupational Therapy
ON Oncology
40 Oral Surgery
38 Orthodontics
BK Orthopedic
9 Other Medical
77 Otological Exam
BB Partial Hospitalization (Psychiatric)
66 Pathology
BH Pediatric
24 Periodontics
88 Pharmacy
AE Physical Medicine
PT Physical Therapy
BY Physician Visit - Office: Sick
BZ Physician Visit - Office: Well
32 Plan Waiting Period
19 Pneumonia Vaccine
93 Podiatry
95 Podiatry - Nursing Home Visits
94 Podiatry - Office Visits
17 Pre-Admission Testing
74 Private Duty Nursing
CB Private Duty Nursing - Home
CA Private Duty Nursing - Inpatient
96 Professional (Physician)
A3 Professional (Physician) Visit - Home
99 Professional (Physician) Visit - Inpatient
A1 Professional (Physician) Visit - Nursing Home
98 Professional (Physician) Visit - Office
A0 Professional (Physician) Visit - Outpatient
A2 Professional (Physician) Visit - Skilled Nursing Facility
75 Prosthetic Device
39 Prosthodontics
A4 Psychiatric
A7 Psychiatric - Inpatient
A8 Psychiatric - Outpatient
A5 Psychiatric - Room and Board
A6 Psychotherapy
PU Pulmonary
BF Pulmonary Rehabilitation
6 Radiation Therapy
A9 Rehabilitation
AB Rehabilitation - Inpatient
AC Rehabilitation - Outpatient
AA Rehabilitation - Room and Board
RN Renal
14 Renal Supplies in the Home
RT Residential Psychiatric Treatment
46 Respite Care
25 Restorative
41 Routine (Preventive) Dental
AN Routine Exam (Vision)
81 Routine Physical
CL Screening Laboratory
CK Screening X-ray
20 Second Surgical Opinion
AG Skilled Nursing Care
AH Skilled Nursing Care - Room and Board
BJ Skin
67 Smoking Cessation
22 Social Work
AF Speech Therapy
AI Substance Abuse
CI Substance Abuse Facility - Inpatient
CJ Substance Abuse Facility - Outpatient
2 Surgical
8 Surgical Assistance
CD Surgical Benefits - Facility
CC Surgical Benefits - Professional (Physician)
21 Third Surgical Opinion
TC Transitional Care
TN Transitional Nursery Care
70 Transplants
UC Urgent Care
11 Used Durable Medical Equipment
AL Vision (Optometry)
68 Well Baby Care

DELETE /V1/COVERAGES/:ID

You can delete a particular coverage by issuing a DELETE against it.

When you make a valid request, the resource will return a status code of 204 if the resource was successfully deleted.

$ curl -X DELETE "https://api.availity.com/availity/v1/coverages/0001194499098175762045868562105833796329766732695450956940743265"
->
HTTP/1.1 204 No Content
x-api-id: 54cbda17-e010-44f3-a38c-b038c106e0bf
X-Session-ID: 54cbda17-e010-44f3-a38c-b038c106e0bf
X-Api-Mock-Response: true
Cache-Control: private, no-store, max-age=0, must-revalidate
Content-Type: application/json
Date: Tue, 24 Feb 2015 20:58:03 GMT
X-Global-Transaction-ID: 34319985
Connection: close

Configurations

The Configurations service is an extremely powerful API that will make building custom applications that support multiple health plans very easy.

If you've ever tried to support access to multiple heath plans in your application you know how difficult this can be. Even though there are standards in place, such as ASC X12 transactions and HL7, a lot of health plans will support these standards at different levels. This would traditional leave the burden up to you, the developer, on how to normalize this inforamtion across a range of health plans you need to support.

This is where the Availity Configurations API will help save you many weeks of development time. It provides details for each payer we support and provides details such as what are the required fields for a specific payer, required field combinations, validation patterns that can be used by your front end applications, code/values for populating selection groups, etc.

All of this information is kept up to date with the health plans. By utilizing this service to build your application you can ensure you always have the most current data and validation requirements and make them available to your application.

The Resource

Field Type Description
type String The type of resource that this Configuration describes.
subtypeId String The subtype of the resource that this Configuration describes.
subtypeValue String A description of the subtype of the resources that this Configurations describes.
payerId String The id of the health plan that this Configuration is for.
payerName String The name of the health plan that this Configuration is for.
elements Object The elements object describes the input rules for each component of the resource.
requiredFieldCombinations Object The requiredFieldCombinations object provides groups of minimum required fields that can be entered. At least one of each entry must be satisfied.

Example Use Case

Let's take a look at an example using this service that will allow us to discover what fields and field combinations are required to call the Coverages API. When you look at the Coverages documentation you will notice that for the GET request, all of the parameters are identified as Required: No.

The first thing you'll want to do to begin using the Coverages service is to call the Configurations service and specify the type and payerId that you want to send a request to. The Coverages service type is 270 and you can find a list of supported payerId's on our developer portal here: Supported Health Plans.

Here is an excerpt from the Configurations service response for the payer Florida Blue:

{
  "configurations": [
    {
      "type": "270",
      "payerId": "BCBSF",
      "payerName": "FLORIDA BLUE",
      "elements": {
        "providerLastName": {
          "type": "Text",
          "label": "Provider Last Name",
          "order": 0,
          "allowed": true,
          "required": false,
          "errorMessage": "Please enter a valid Provider Last Name.",
          "defaultValue": "AVAILITY",
          "pattern": "^[a-zA-Z0-9\\s!&,()+'\\-./;?=#\\\\]{1,60}$",
          "maxLength": 60
        },
        "providerFirstName": {
          "type": "Text",
          "label": "Provider First Name",
          "order": 1,
          "allowed": true,
          "required": false,
          "errorMessage": "Please enter a valid Provider First Name.",
          "pattern": "^[a-zA-Z0-9\\s!&,()+'\\-./;?=#\\\\]{1,35}$",
          "maxLength": 35
        },
        "providerType": {
          "type": "Unsupported",
          "label": "Provider Type",
          "order": 2,
          "allowed": false,
          "required": false,
          "errorMessage": "This field is not supported."
        },
        "providerNpi": {
          "type": "Text",
          "label": "Provider NPI",
          "order": 4,
          "allowed": true,
          "required": false,
          "errorMessage": "Enter a valid National Provider Identifier (NPI) containing 10 numeric digits and beginning with a 1, 2, 3, or 4.",
          "pattern": "^[1-4][0-9]{9}$",
          "maxLength": 10
        },
        "providerTaxId": {
          "type": "Text",
          "label": "Provider Tax ID",
          "order": 5,
          "allowed": true,
          "required": false,
          "errorMessage": "Enter a valid Tax ID containing nine numeric digits and no dashes.",
          "pattern": "^[0-9]{9}$",
          "maxLength": 9
        }
      }
    }
  ]
}

The first part of the response shows the transaction type - 270 for Eligibility, the payer Id, and the payer name.

Under the elements object is where we find the list of fields this payer supports and whether they are required or not. If a parameter is not supported the field type is listed as Unsupported.

Let's look at the providerLastName parameter and walk through each of the attributes:

  • type: The data type for this parameter.
  • label: The name that can be used to display in your applications UI.
  • order: An optional ordering index you can use when laying out fields in your applications UI.
  • allowed: Boolean indicator specifying if this parameter is valid to use.
  • required: Boolean indicator specifying if this parameter is required.
  • errorMessage: An error message you can use in your applications UI if this field does not pass validation. This can be used if you perform client side validation or if this field is in error after you've submitted a request and it comes back invalid.
  • defaultValue: A default value that can be used for pre-populating a field in your applications UI.
  • pattern: A regular expression you can use to validate input parameter values.
  • maxLength: The maximum legth allowed for this parameter.

Next let's look at the providerType paramter. The first thing we notice is the type attribute is of type Unsupported. That tells us that for this transaction type Florida Blue does not support the providerType parameter so we should not send it with our request.

GET /V1/CONFIGURATIONS

You can find and retrieve Configurations using this endpoint.

Parameters

Parameter Type Description
type String The type of configuration you are looking for.
subtypeId String The subtype id of the configuration you are looking for.
payerId String The health plan id of the configuration you are looking for.

Examples

$ curl -X GET -i https://api.availity.com/availity/v1/configurations?type=270
->
HTTP/1.1 200 OK
x-api-id: a8380404-0d07-47fa-9e86-44eee35a02bb
X-Session-ID: a8380404-0d07-47fa-9e86-44eee35a02bb
X-Api-Mock-Response: true
Cache-Control: private, no-store, max-age=0, must-revalidate
Content-Type: application/json
Date: Thu, 26 Feb 2015 05:10:26 GMT
X-Global-Transaction-ID: 36774789
Connection: close
{
    "totalCount": 2,
    "count": 2,
    "offset": 0,
    "limit": 50,
    "links": {
        "self": {
            "href": "https://api.availity.com/availity/v1/configurations?type=270"
        }
    },
    "configurations": [
        {
            "type": "270",
            "payerId": "BCBSF",
            "payerName" : "FLORIDA BLUE"
        },
        {
            "type": "270",
            "payerId": "HUMANA",
            "payerName" : "Humana"
        }
    ]
}
$ curl -X GET -i https://api.availity.com/availity/v1/configurations?type=service-reviews&subtypeId=HS&payerId=BCBSF
->
HTTP/1.1 200 OK
x-api-id: a8380404-0d07-47fa-9e86-44eee35a02bb
X-Session-ID: a8380404-0d07-47fa-9e86-44eee35a02bb
X-Api-Mock-Response: true
Cache-Control: private, no-store, max-age=0, must-revalidate
Content-Type: application/json
Date: Thu, 26 Feb 2015 05:10:26 GMT
X-Global-Transaction-ID: 36774789
Connection: close
{
    "totalCount": 1,
    "count": 1,
    "offset": 0,
    "limit": 50,
    "links": {
        "self": {
            "href": "https://api.availity.com/availity/v1/configurations?type=service-reviews&subtypeId=HS&payerId=BCBSF"
        }
    },
    "configurations": [
        {
            "type": "service-reviews",
            "subtypeId" : "HS",
            "subtypeValue" : "Health Service Review",
            "payerId": "BCBSF",
            "payerName" : "FLORIDA BLUE"
            "elements" : {
                "requestingProvider" : {
                    "type": "Object",
                    "order": 0,
                    "allowed" : true,
                    "required" : true,
                    "elements" : {
                        "npi" : {
                            "type": "Text",
                            "label": "Requesting Provider NPI",
                            "order": 0,
                            "allowed": true,
                            "required": false,
                            "errorMessage": "Enter a valid Requesting Provider NPI.",
                            "pattern": "^[1-4][0-9]{9}$",
                            "maxLength": 10
                        },
                        "taxId" : {
                            "type": "Text",
                            "label": "Requesting Provider Tax ID",
                            "order": 1,
                            "allowed": true,
                            "required": false,
                            "errorMessage": "Enter a valid Requesting Provider Tax ID",
                            "pattern": "^[0-9]{9}$",
                            "maxLength": 9
                        }
                    }
                },
                "patient" : {
                    "type": "Object",
                    "order": 1,
                    "allowed" : true,
                    "required" : true,
                    "elements" {
                        "birthDate" : {
                            "type": "Date",
                            "label": "Patient Date of Birth",
                            "order": 0,
                            "allowed": true,
                            "required": true,
                            "errorMessage": "Enter a valid date that is not in the future.",
                            "min": "1870-01-01T05:00:00.000+0000",
                            "max": "2015-05-06T03:59:59.999+0000"
                        },
                        "medicareCoverage" : {
                            "type": "Boolean",
                            "label": "Medicare Coverage",
                            "order": 1,
                            "allowed": false,
                            "required": false,
                            "errorMessage": "Please enter a valid Medicare Coverage.",
                            "allowedWhen": {
                                "serviceTypeCode": {
                                    "equalTo": "42"
                                }
                            },
                            "requiredWhen": {
                                "serviceTypeCode": {
                                    "equalTo": "42"
                                }
                            }
                        }
                    }
                },
                "serviceTypeCode" : {
                    "type": "Enumeration",
                    "label": "Type",
                    "order": 2,
                    "allowed": true,
                    "required": true,
                    "errorMessage": "Please enter a valid Service Type.",
                    "mode": "DropDown",
                    "values": [
                        {
                            "code": "1",
                            "value": "Medical Care"
                        },
                        {
                            "code": "42",
                            "value": "Home Health Care"
                        }
                    ]
                },
                "diagnoses" : {
                    "type": "ObjectArray",
                    "order": 3,
                    "errorMessage": "Please enter between 1 and 12 valid Diagnoses.",
                    "maxRepeats": 12,
                    "allowed": true,
                    "objectTypes": {
                        "diagnosis": {
                            "label": "Diagnosis",
                            "maxInstances": 12,
                            "required": true
                        }
                    },
                    "elements": {
                        "code": {
                            "type": "Collection",
                            "label": "Diagnosis Code",
                            "order": 0,
                            "allowed": true,
                            "required": true,
                            "errorMessage": "Please enter a valid Diagnosis Code.",
                            "valuesWhen": {
                                "qualifierCode" : [
                                    {
                                        "equalTo" : "BF",
                                        "values": {
                                            "href": "https://api.availity.com/availity/v1/codes?list=ICD9CMD"
                                        }
                                    }
                                ]
                            }
                        }
                    }
                }
            },
            "requiredFieldCombinations" : {
                "requestingProvider" : [
                    ["npi"],
                    ["taxId"]
                ]
            }
        }
    ]
}

Available Information

type subtypeId payerId Usage
270 - - Returns the list of health plans that support Coverages.
270 - a payer id Returns the validation rules for Coverages for the specified health plan.
claim-statuses - - Returns the list of payers that support ClaimStatues.
claim-statuses - a payer id Returns the validation rules for ClaimStatuses for the specified payer.
professional-claims - - Returns the list of payers that support ProfessionalClaims.
professional-claims PRE_DETERMINATION a payer id Returns the validation rules for a predetermination ProfessionalClaim for the specified payer.
institutional-claims - - Returns the list of payers that support InstitutionalClaims.
institutional-claims PRE_DETERMINATION a payer id Returns the validation rules for a predetermination InstitutionalClaim for the specified payer.
service-reviews - - Returns the list of health plans that support each type of ServiceReview.
service-reviews - a payer id Returns the list of types of ServiceReviews supported by the specified health plan.
service-reviews AR - Returns the list of health plans that support Admission Review (inpatient) ServiceReviews.
service-reviews HS - Returns the list of health plans that support Health Services Review (outpatient) ServiceReviews.
service-reviews SC - Returns the list of health plans that support Specialty Care Review (referral) ServiceReviews.
service-reviews AR a payer id Returns the validation rules for Admission Review (inpatient) ServiceReviews for the specified health plan.
service-reviews HS a payer id Returns the validation rules for Health Services Review (outpatient) ServiceReviews for the specified health plan.
service-reviews SC a payer id Returns the validation rules for Specialty Care Review (referral) ServiceReviews.
service-reviews-inquiry - - Returns the list of health plans that support ServiceReview inquiries.
service-reviews-inquiry - a payer id Returns the validation rules for ServiceReview inquiries for the specified health plan.

Service Reviews

This resource represents a request to obtain authorization to perform a service or refer a patient to another provider. Your application can use the endpoints defined for it to find, create, and manage these requests.

Working with the DEMO endpoints

Availity allows you to specify the type of response you want when interacting with our Service Review demonstration service by sending a header (X-Api-Mock-Scenario-ID) with the appropriate response scenario id. The supported response scenarios are listed below.

For POST methods send an empty JSON body such as: "{}"

Response Scenario ID Method HTTP Status Description
SR-CreateRequestAccepted-i POST 202 Availity is in the process of sending the member's service review information to the health plan.
SR-DeleteRequestAccepted-i DELETE 202 Availity is processing your delete request.
SR-CreateRequestError-i POST 400 Your request failed Availity's input validation rules.
SR-DeleteRequestError-i DELETE 400 Your request failed Availity's delete validation rules.
SR-GetComplete-i GET - use id 12345678 200 Availity has successfully retrieved the member's service review information from the health plan.
SR-GetInProgress-i GET - use id 12345678 202 Availity is processing your request.
SR-GetPayerDown-i GET - use id 12345678 504 Availity did not receive a response from the health plan within the time allotted. You should try your request again later.
SR-UpdateRequestAccepted-i PUT 202 Availity is currently processing your request.
SR-UpdateRequestError-i PUT 400 Your request failed Availity's input validation rules.
SR-GetPayerError-i GET 400 The health plan indicated that something is wrong with the request. The resource should have a list of validationMessages. Correct and resubmit the request.
SR-GetRetrying-i GET - use id 12345678 202 The health plan did not respond. Availity is retrying the request
SRI-GetAccepted-i GET 202 Availity is currently processing your request.
SRI-GetComplete-i GET 200 Availity has successfully retrieved the member's service review inquiry information from the health plan.
SRI-GetInProgress-i GET 202 Availity is currently processing your request.
SRI-GetPayerError-i GET 400 The health plan indicated that something is wrong with the request. The resource should have a list of validationMessages. Correct and resubmit the request.
SRI-GetPayerDown-i GET 504 Availity did not receive a response from the health plan within the time allotted. You should try your request again later.
SRI-GetRetrying-i GET – use id 12345678 202 The health plan did not respond. Availity is retrying the request
SRI-GetRequestError-i GET 400 The health plan indicated that something is wrong with the request. The resource should have a list of validationMessages. Correct and resubmit the request

You can confirm you've received a mock response by inspecting the response headers. You should see the following header:

X-Api-Mock-Response: true

THE RESOURCE

Field Type Description
id String A unique identifier that Availity has assigned to this ServiceReview.
createdDate Timestamp The date and time when this item was created in Availity's system.
updatedDate Timestamp The date and time when this item was last updated.
expirationDate Timestamp The date and time when this item will be removed from Availity's system.
customerId String The id of the Availity customer that owns this ServiceReview. Availity may ask for this during support calls.
controlNumber String The id of the last transaction associated with this ServiceReview. The health plan may ask for this during support calls.
updatable boolean A flag that indicates whether or not this ServiceReview can be updated.
updatableFields String Array Fields in this service review that can be updated.
deletable boolean A flag that indicates whether or not this ServiceReview can be deleted.
status String A description of the current status of this ServiceReview.
statusCode String A code that represents the current status.
statusReasons Object Array An array of reasons that the health plan has given for the current status.
statusReasons.value String A description of the status reason.
statusReasons.code String A code that represents the status reason.
validationMessages Object Array An array of error messages explaining problems with this ServiceReview. Errors encountered during validation at Availity will have a field and possibly an index. Errors returned by the health plan will have a code.
validationMessages.errorMessage String A description of the problem.
validationMessages.field String The field of the ServiceReview that has the problem.
validationMessages.index Number* The index (if applicable) of the item with the field that has the problem.
validationMessages.code String A code identifying the error.
certificationIssueDate Date The date on which the health plan authorized the service or referral.
certificationEffectiveDate Date The date on which the health plan's authorization will take effect.
certificationExpirationDate Date The date on which the health plan's authorization will expire.
certificationNumber String The authorization number assigned by the health plan to be used on claims.
referenceNumber String A reference number assigned by the health plan to pended or otherwise incomplete ServiceReviews.
traceNumbers String Array An array of trace numbers that the health plan has assigned to this ServiceReview.
requestType String A description type of request (inpatient service, outpatient service, or referral).
requestTypeCode String A code respresenting the type of request.
payer Object An object representing the health plan of the patient.
payer.id String The Availity payer id for the health plan.
payer.name String The name of the health plan.
payer.contactName String The contact name of the health plan.
payer.phone String The phone number of the health plan.
payer.extension String The phone number extension of the health plan.
payer.fax String The fax number of the health plan.
payer.emailAddress String The email address of the health plan.
payer.url String The website address of the health plan.
payerNotes Object Array An array of notes that the health plan has added to this ServiceReview.
payerNotes.message String The text of a note.
requestingProvider Object An object representing the provider that is requesting authorization to perform a service or refer a patient.
requestingProvider.lastName String The last or business name of the requesting provider.
requestingProvider.firstName String The first name of the requesting provider.
requestingProvider.middleName String The middle name of the requesting provider.
requestingProvider.suffix String The suffix of the requesting provider.
requestingProvider.npi String The national provider id of the requesting provider.
requestingProvider.taxId String The tax id of the requesting provider.
requestingProvider.payerAssignedProviderId String The health plan assigned id of the requesting provider.
requestingProvider.submitterId String The submitter id of the requesting provider.
requestingProvider.specialty String A description of the specialty of the requesting provider.
requestingProvider.specialtyCode String A code that represents the specialty of the requesting provider.
requestingProvider.addressLine1 String The first line of the address of the requesting provider.
requestingProvider.addressLine2 String The second line of the address of the requesting provider.
requestingProvider.city String The city of the requesting provider.
requestingProvider.state String The name of the state of the requesting provider.
requestingProvider.stateCode String The code of the state of the requesting provider.
requestingProvider.zipCode String The ZIP code of the requesting provider.
requestingProvider.contactName String A contact name for the requesting provider.
requestingProvider.phone String The phone number of the requesting provider.
requestingProvider.extension String The phone extension of the requesting provider.
requestingProvider.fax String The fax number of the requesting provider.
requestingProvider.emailAddress String The email address of the requesting provider.
requestingProvider.url String The website address of the requesting provider.
subscriber Object An object representing the health plan subscriber.
subscriber.memberId String The member id of the subscriber.
subscriber.lastName String The last name of the subscriber.
subscriber.firstName String The first name of the subscriber.
subscriber.middleName String The middle name of the subscriber.
subscriber.suffix String The suffix of the subscriber.
subscriber.addressLine1 String The first line of the address of the subscriber.
subscriber.addressLine2 String The second line of the address of the subscriber.
subscriber.city String The city of the subscriber.
subscriber.state String The name of the state of the subscriber.
subscriber.stateCode String The code of the state of the subscriber.
subscriber.zipCode String The ZIP code of the subscriber.
patient Object An object representing the patient having the service or being referred.
patient.lastName String The last name of the patient.
patient.firstName String The first name of the patient.
patient.middleName String The middle name of the patient.
patient.suffix String The suffix of the patient.
patient.subscriberRelationship String A description of the patient's relationship to the subscriber.
patient.subscriberRelationshipCode String A code representing the patient's relationship to the subscriber.
patient.birthDate Date The birth date of the patient.
patient.gender String A description of the gender of the patient.
patient.genderCode String A code representing the gender of the patient.
patient.addressLine1 String The first line of the address of the patient.
patient.addressLine2 String The second line of the address of the patient.
patient.city String The city of the patient.
patient.state String The name of the state of the patient.
patient.stateCode String The code of the state that the patient resides.
patient.zipCode String The ZIP code of the patient.
patient.status String A description of the status of the patient.
patient.statusCode String A code representing the status of the patient.
patient.condition String A description of condition of the patient.
patient.conditionCode String A code representing the condition of the patient.
patient.medicareCoverage String An indicator identifying whether or not this patient has Medicare coverage.
patient.prognosis String A description of the prognosis of the patient.
patient.prognosisCode String A code representing the prognosis of the patient.
diagnoses Object Array An array of diagnoses that are related to the service or referral.
diagnoses.qualifier String The description of the qualifier indicating what type of diagnosis code is used.
diagnoses.qualifierCode String A code representing the qualifier indicating what type of diagnosis code is used.
diagnoses.value String A description of the diagnosis.
diagnoses.code String A code representing the diagnosis.
diagnoses.date Date The date that the patient was given this diagnosis.
serviceType String A description of the type of service to be performed.
serviceTypeCode String A code representing the type of service to be performed.
placeOfService String A description of the place of service.
placeOfServiceCode String A code representing the place of service.
serviceLevel String A description of the level of service.
serviceLevelCode String A code representing the level of service.
fromDate Date The service start date or admission date.
toDate Date The service end date or discharge date.
quantity String The number of units associated with the service.
quantityType String A description of the quantity units.
quantityTypeCode String A code representing the quantity units.
admissionType String A description of the type of admission on an inpatient authorization request.
admissionTypeCode String A code representing the type of admission on an inpatient authorization request.
admissionSource String A description of the source of admission on an inpatient authorization request.
admissionSourceCode String A code representing the source of admission on an inpatient authorization request.
nursingHomeResidentialStatus String A description of the nursing home residential status on an inpatient authorization request.
nursingHomeResidentialStatusCode String A code representing the nursing home residential status on an inpatient authorization request.
homeHealthStartDate Date The start of home health services for a home health outpatient authorization request.
homeHealthCertificationPeriodStartDate Date The start of the home health certification period for a home health outpatient authorization request.
homeHealthCertificationPeriodEndDate Date The end of the home health certification period for a home health outpatient authorization request.
transportType String A description of the type of transport being performed on a medically related transport outpatient authorization request.
transportTypeCode String A code representing the type of transport being performed on a medically related transport outpatient authorization request.
transportDistance String The distance the patient will be transported on a medically related transport outpatient authorization request.
transportPurpose String The purpose of transporting the patient.
transportLocations Object Array An array of locations associated with a medically related transport outpatient authorization request.
transportLocations.name String The name of the transport location.
transportLocations.addressLine1 String Line one of the address of the transport location.
transportLocations.addressLine2 String Line two of the address of the transport location.
transportLocations.city String The city of the transport location.
transportLocations.state String The name of the state of the transport location.
transportLocations.stateCode String The code of the state of the transport location.
transportLocations.zipCode String The ZIP code of the transport location.
renderingProviders Object Array An array of providers (that will render the service are being referred to) and facilities (where the service will be performed).
renderingProviders.role String A description of the role of this rendering provider.
renderingProviders.roleCode String A code representing the role of this rendering provider.
renderingProviders.lastName String The last or business name of this rendering provider.
renderingProviders.firstName String The first name of this rendering provider.
renderingProviders.middleName String The middle name of this rendering provider.
renderingProviders.suffix String The suffix of this rendering provider.
renderingProviders.npi String The national provider id of this rendering provider.
renderingProviders.taxId String The tax id of this rendering provider.
renderingProviders.payerAssignedProviderId String The health plan assigned provider id of this rendering provider.
renderingProviders.specialty String A description of the specialty of this rendering provider.
renderingProviders.specialtyCode String A code representing the specialty of this rendering provider.
renderingProviders.addressLine1 String The first line of the address of this rendering provider.
renderingProviders.addressLine2 String The second line of the address of this rendering provider.
renderingProviders.city String The city of this rendering provider.
renderingProviders.state String The name of the state of this rendering provider.
renderingProviders.stateCode String The code of the state of this rendering provider.
renderingProviders.zipCode String The ZIP code of this rendering provider.
renderingProviders.contactName String A contact name for this rendering provider.
renderingProviders.phone String The phone number of this rendering provider.
renderingProviders.extension String The phone extension of this rendering provider.
renderingProviders.fax String The fax number of this rendering provider.
renderingProviders.emailAddress String The email address of this rendering provider.
renderingProviders.url String The website address of this rendering provider.
procedures Object Array An array of procedures to be performed.
procedures.status String A description of the authorization status of this procedure.
procedures.statusCode String A code representing the authorization status of this procedure.
procedures.statusReasons String An array of reasons the health plan has given for the status of authorization on this procedure.
procedures.statusReasons.value String A description of the reason for the status.
procedures.statusReasons.code String A code representing the reason for the status.
procedures.certificationIssueDate Date The date on which the health plan authorized the procedure.
procedures.certificationEffectiveDate Date The date on which the health plan's authorization will take effect.
procedures.certificationExpirationDate Date The date on which the health plan's authorization will expire.
procedures.certificationNumber String The authorization number assigned by the health plan to be used on claims.
procedures.qualifier String A description of the category of procedure code.
procedures.qualifierCode String A code representing the category of procedure code.
procedures.value String A description of the procedure.
procedures.code String A code representing the procedure.
procedures.modifier1 String A description of the first modifier applied to this procedure.
procedures.modifier1Code String A code representing the first modifier applied to this procedure.
procedures.modifier2 String A description of the second modifier applied to this procedure.
procedures.modifier2Code String A code representing the second modifier applied to this procedure.
procedures.modifier3 String A description of the third modifier applied to this procedure.
procedures.modifier3Code String A code representing the third modifier applied to this procedure.
procedures.modifier4 String A description of the fourth modifier applied to this procedure.
procedures.modifier4Code String A code representing the fourth modifier applied to this procedure.
procedures.description String A free form description written by the provider describing this procedure.
procedures.quantity String The quantity of this procedure to be rendered.
procedures.quantityType String A description of the type of quantity.
procedures.quantityTypeCode String A code representing the type of quantity.
procedures.fromDate Date The start date of the procedure.
procedures.toDate Date The end date of procedure.
procedures.payerNotes Object Array An array of notes that the health plan has added to this procedure.
procedures.payerNotes.message String The text of a note.
procedures.traceNumbers String Array An array of trace numbers that the health plan has assigned to this procedure.

SERVICE REVIEW STATUSES

ServiceReview.statusCode ServiceReview.status Description
A1 Certified in Total The health plan has fully authorized the request. The resource will have a certificationNumber that you can use on a claim.
A2 Certified - Partial The health plan has partially authorized the request. Check the procedures for more details.
A3 Not Certified The health plan has denied the request. Check the statusReasons for more details.
A6 Modified The health plan has indicated that the request has been modified. Check back later.
C Cancelled The health plan has indicated that the request has been cancelled.
CT Contact Payer The health plan has indicated that the requesting provider should contact them. See the health plan object in the resource for contact information.
NA No Action Required The health plan has indicated that an authorization is not required for the request.
51 Complete The health plan has indicated that the request is complete.
71 Term Expired The health plan has indicated that the term has expired.

POST /V2/SERVICE-REVIEWS

This endpoint creates service reviews asynchronously. To submit a transaction, make a valid request and we will respond with a location header containing a URL you can query for your result.

RESPONSE STATUSES

HTTP Status Code Description
202 We are currently processing your request.
400 Your request has been rejected. It either failed our validation rules or was rejected by the health plan. The errors property will contain detailed information. Errors that specify a field are Availity validation rule failures. Errors that specify a code are from the health plan.
500 We were unable to parse your request.

VALIDATION RULES

The validation rules for the ServiceReview resource can vary by health plan, the type of authorization being requested, and the type of service to be performed. Availity organizes these rules and makes them available through the Configuration resource. The Configuration resource documents the fields you need to send to create a ServiceReview and explains what values are valid for those fields. See Configurations.

EXAMPLES

If your request is invalid, we will respond with a status code of 400 and a list of errors for you to correct.

$ curl -i -H "Content-Type: application/json" -X POST -d '{
  "payer" : {
    "id" : "BCBSF",
  },
  "requestingProvider" : {
    "lastName" : "Slice n Dice Discount Surgery"
  },
  "subscriber" : {
    "memberId" : "XBH1823812"
  },
  "patient" : {
    "lastName" : "Smith",
    "firstName" : "Bob",
    "birthDate" : "1956-01-29",
  },
  "diagnoses" : [{
    "qualifierCode" : "ABF",
    "code" : "W5602XA"
  }],
  "requestTypeCode" : "AR",
  "serviceTypeCode" : "1",
  "placeOfServiceCode" : "11",
  "fromDate" : "2014-05-01",
  "toDate" : "2014-05-03",
  "quantity" : "3",
  "quantityTypeCode" : "DA",
  "admissionTypeCode" : "1",
  "renderingProviders" : [{
    "roleCode" : "71",
    "lastName" : "Jones",
    "firstName" : "Jane",
    "npi" : "1231231238"
  },{
    "roleCode" : "FA",
    "lastName" : "Slice and Dice Surgery Center",
    "npi" : "1234912380"
  }],
  "procedures" : [{
    "qualifierCode" : "HC",
    "code" : "S8948",
    "quantity" : "1",
    "quantityTypeCode" : "UN"
  }]
}' https://api.availity.com/availity/v2/service-reviews
HTTP/1.1 400 Bad Request
x-api-id: a8380404-0d07-47fa-9e86-44eee35a02bb
X-Session-ID: a8380404-0d07-47fa-9e86-44eee35a02bb
X-Api-Mock-Response: true
Cache-Control: private, no-store, max-age=0, must-revalidate
Content-Type: application/json
Date: Thu, 26 Feb 2015 05:10:26 GMT
X-Global-Transaction-ID: 36774789
Connection: close
{
  "userMessage": "The request was invalid. See the 'errors' property for details.",
    "developerMessage": "The request was invalid. See the 'errors' property for details.",
    "documentation": "https://developer.availity.com/documentation",
    "reasonCode": 0,
    "statusCode": 400,
    "errors": [
        {
            "field": "requestingProvider.npi",
            "errorMessage": "Please enter a valid Requesting Provider NPI.",
            "index": 0
        }
    }
}

If your request is valid, we will respond with a status code of 202 and a location header where you can check back for your response. We will continue to respond in this way until we have heard back from the health plan.

$ curl -i -H "Content-Type: application/json" -X POST -d '{
  "payer" : {
    "id" : "BCBSF",
  },
  "requestingProvider" : {
    "lastName" : "Slice n Dice Discount Surgery",
    "npi" : "1234567893"
  },
  "subscriber" : {
    "memberId" : "XBH1823812"
  },
  "patient" : {
    "lastName" : "Smith",
    "firstName" : "Bob",
    "birthDate" : "1956-01-29",
  },
  "diagnoses" : [{
    "qualifierCode" : "ABF",
    "code" : "W5602XA"
  }],
  "requestTypeCode" : "AR",
  "serviceTypeCode" : "1",
  "placeOfServiceCode" : "11",
  "fromDate" : "2014-05-01",
  "toDate" : "2014-05-03",
  "quantity" : "3",
  "quantityTypeCode" : "DA",
  "admissionTypeCode" : "1",
  "renderingProviders" : [{
    "roleCode" : "71",
    "lastName" : "Jones",
    "firstName" : "Jane",
    "npi" : "1231231238"
  },{
    "roleCode" : "FA",
    "lastName" : "Slice and Dice Surgery Center",
    "npi" : "1234912380"
  }],
  "procedures" : [{
    "qualifierCode" : "HC",
    "code" : "S8948",
    "quantity" : "1",
    "quantityTypeCode" : "UN"
  }]
}' https://api.availity.com/availity/v2/service-reviews
->
HTTP/1.1 202 Accepted
x-api-id: a8380404-0d07-47fa-9e86-44eee35a02bb
X-Session-ID: a8380404-0d07-47fa-9e86-44eee35a02bb
X-Api-Mock-Response: true
Cache-Control: private, no-store, max-age=0, must-revalidate
Content-Type: application/json
Date: Thu, 26 Feb 2015 05:10:26 GMT
Location: https://api.availity.com/availity/v2/service-reviews/-11923818311
X-Status-Message: We are processing your request.

GET /V2/SERVICE-REVIEWS/:ID

You can retrieve a service review using this endpoint.

RESPONSE STATUSES

HTTP Status Code Description
200 We are done processing your request and the response body contains the result.
202 We are currently processing your request. We may be retrying it. The X-Status-Message header will contain additional detail.
404 We did not find a ServiceReview with the id that you sent.
504 We were unable to process your request. The health plan did not respond after several retry attempts. Please try your request again later.

EXAMPLES

$ curl -i -X GET -i https://api.availity.com/availity/v2/service-reviews/-11923818311
->
HTTP/1.1 200 OK
x-api-id: a8380404-0d07-47fa-9e86-44eee35a02bb
X-Session-ID: a8380404-0d07-47fa-9e86-44eee35a02bb
X-Api-Mock-Response: true
Cache-Control: private, no-store, max-age=0, must-revalidate
Content-Type: application/json
Date: Thu, 26 Feb 2015 05:10:26 GMT
X-Global-Transaction-ID: 36774789
Connection: close
{
    "id" : "-11923818311",
    "createdDate" : "2014-04-28T21:59:29.000+0000",
    "updatedDate" : "2014-04-29T08:28:01.000+0000",
    "expirationDate" : "2014-05-14T21:59:29.000+0000",
    "customerId" : "11314",
    "updatable" : false,
    "status" : "Certified in Total",
    "statusCode" : "A1",
    "certificationIssueDate" : "2014-04-29",
    "certificationEffectiveDate" : "2014-05-01",
    "certificationExpirationDate" : "2014-05-03",
    "certificationNumber" : "129738127",
    "payer" : {
        "id" : "BCBSF",
        "name" : "Florida Blue",
        "contactName" : "Billing Dept",
        "phone" : "1-800-555-4444"
    },
    "requestingProvider" : {
        "lastName" : "Slice n Dice Discount Surgery",
        "npi" : "1234567893"
    },
    "subscriber" : {
        "memberId" : "XBH1823812"
    },
    "patient" : {
        "lastName" : "Smith",
        "firstName" : "Bob",
        "birthDate" : "1956-01-29",
        "subscriberRelationship" : "Self",
        "subscriberRelationshipCode" : "18"
    },
    "diagnoses" : [{
        "qualifier" : "ICD-10",
        "qualifierCode" : "ABF",
        "value" : "Struck by dolphin, initial encounter",
        "code" : "W5602XA"
    }],
    "requestType" : "Admission Review",
    "requestTypeCode" : "AR",
    "serviceType" : "Medical Care",
    "serviceTypeCode" : "1",
    "placeOfService" : "Office",
    "placeOfServiceCode" : "11",
    "fromDate" : "2014-05-01",
    "toDate" : "2014-05-03",
    "quantity" : "3",
    "quantityType" : "Days",
    "quantityTypeCode" : "DA",
    "admissionType" : "Emergency",
    "admissionTypeCode" : "1",
    "renderingProviders" : [{
        "role" : "Attending Provider",
        "roleCode" : "71",
        "lastName" : "Jones",
        "firstName" : "Jane",
        "npi" : "1231231238"
    },{
        "role" : "Facility",
        "roleCode" : "FA",
        "lastName" : "Slice and Dice Surgery Center",
        "npi" : "1234912380"
    }],
    "procedures" : [{
        "qualifier" : "HCPCS",
        "qualifierCode" : "HC",
        "value" : "Low-level laser treatment, 15 minutes",
        "code" : "S8948",
        "quantity" : "1",
        "quantityType" : "Units",
        "quantityTypeCode" : "UN"
    }]
}

GET /V2/SERVICE-REVIEWS

You can search the for service reviews in the health plan's system using this endpoint.

This endpoint queries the health plan's system asynchronously. To submit a transaction, make a valid request and we will respond with a location header containing a URL you can query for your result.

Parameter Type Description
payer.id String The Availity payer id of the health plan.
requestingProvider.specialtyCode String The specialty code of the requesting provider.
requestingProvider.lastName String The last or business name of the requesting provider.
requestingProvider.firstName String The first name of the requesting provider.
requestingProvider.middleName String The middle name of the requesting provider.
requestingProvider.suffix String The suffix of the requesting provider.
requestingProvider.npi String The NPI of the requesting provider.
requestingProvider.taxId String The tax id of the requesting provider.
requestingProvider.payerAssignedProviderId String The payer assigned provider id of the requesting provider.
requestingProvider.submitterId String The submitter id of the requesting provider.
requestingProvider.addressLine1 String Line one of the address of the requesting provider.
requestingProvider.addressLine2 String Line two of the address of the requesting provider.
requestingProvider.city String The city of the requesting provider.
requestingProvider.stateCode String The state code of the requesting provider.
requestingProvider.zipCode String The ZIP code of the requesting provider.
requestingProvider.contactName String The contact name of the requesting provider.
requestingProvider.phone String The phone number of the requesting provider.
requestingProvider.extension String The phone extension of the requesting provider.
requestingProvider.fax String The fax number of the requesting provider.
subscriber.memberId String The member id of the subscriber.
subscriber.firstName String The first name of the subscriber.
subscriber.lastName String The last name of the subscriber.
subscriber.middleName String The middle name of the subscriber.
subscriber.suffix String The suffix of the subscriber.
patient.lastName String The last name of the patient.
patient.firstName String The first name of the patient.
patient.middleName String The middle name of the patient.
patient.suffix String The suffix of the patient.
patient.birthDate Date The birth date of the patient.
patient.subscriberRelationshipCode String The code of the patient's relationship to the subscriber.
requestTypeCode String The type code of service reviews you would like to query for.
fromDate Date The service from date.
toDate Date The service to date.
certificationIssueDate Date The date the service review certification was issued.
certificationNumber String The number assigned to certified service reviews.
referenceNumber String The number assigned to uncertified service reviews.
statusCode String The status code of the service reviews.
sessionId String Used for polling for a result.

RESPONSE STATUSES

HTTP Status Code Description
200 We are done processing your request and the response body contains the result.
202 We are currently processing your request. We may be retrying it. The X-Status-Message header will contain additional detail.
400 Your request has been rejected. It either failed our validation rules or was rejected by the health plan. The errors property will contain detailed information. Errors that specify a field are Availity validation rule failures. Errors that specify a code are from the health plan.
504 We were unable to process your request. The health plan did not respond after several retry attempts. Please try your request again later.

VALIDATION RULES

The validation rules for the ServiceReview resource can vary by health plan, the type of authorization being requested, and the type of service to be performed. Availity organizes these rules and makes them available through the Configuration resource. The Configuration resource documents the fields you need to send to create a ServiceReview and explains what values are valid for those fields. See Configurations.

EXAMPLES

If your request is invalid, we will respond with a status code of 400 and a list of errors for you to correct.

$ curl -i -X GET -i https://api.availity.com/availity/v2/service-reviews?requestTypeCode=AR&requestingProviderLastName=SLICE N DICE DISCOUNT SURGERY&requestingProviderAddressLine1=123Street&requestingProviderCity=Jacksonville&requestingProviderState=FL&requestingProviderZipCode=123451234&requestingProviderContactName=John&requestingProviderPhone=1112223333&memberId=TEST1&patientLastName=Doe&patientFirstName=John&patientBirthDate=1990-01-01&fromDate=2015-01-01
->
HTTP/1.1 400 Bad Request
x-api-id: a8380404-0d07-47fa-9e86-44eee35a02bb
X-Session-ID: a8380404-0d07-47fa-9e86-44eee35a02bb
X-Api-Mock-Response: true
Cache-Control: private, no-store, max-age=0, must-revalidate
Content-Type: application/json
Date: Thu, 26 Feb 2015 05:10:26 GMT
X-Global-Transaction-ID: 36774789
Connection: close
{
    "userMessage": "The request was invalid. See the 'errors' property for details.",
    "developerMessage": "The request was invalid. See the 'errors' property for details.",
    "documentation": "https://developer.availity.com/documentation",
    "reasonCode": 0,
    "statusCode": 400,
    "errors": [
        {
            "field": "requestingProvider.npi",
            "errorMessage": "Please enter a valid Requesting Provider NPI.",
            "index": 0
        }
    }
}

If your request is valid, we will respond with a status code of 202 and a location header where you can check back for your response. We will continue to respond in this way until we have heard back from the health plan.

$ curl -i -X GET -i https://api.availity.com/availity/v2/service-reviews?requestTypeCode=AR&requestingProviderLastName=SLICE N DICE DISCOUNT SURGERY&requestingProviderAddressLine1=123Street&requestingProviderCity=Jacksonville&requestingProviderState=FL&requestingProviderZipCode=123451234&requestingProviderContactName=John&requestingProviderPhone=1112223333&memberId=TEST1&patientLastName=Doe&patientFirstName=John&patientBirthDate=1990-01-01&fromDate=2015-01-01&requestingProviderNpi=1234567893
->
HTTP/1.1 202 Accepted
x-api-id: a8380404-0d07-47fa-9e86-44eee35a02bb
X-Session-ID: a8380404-0d07-47fa-9e86-44eee35a02bb
X-Api-Mock-Response: true
Cache-Control: private, no-store, max-age=0, must-revalidate
Content-Type: application/json
Date: Thu, 26 Feb 2015 05:10:26 GMT
X-Global-Transaction-ID: 36774789
Connection: close
Location: https://api.availity.com/availity/v2/service-reviews?sessionId=-1283121411
X-Status-Message: We are processing your request.

If the health plan responds with validation messages indicating that they were unable to fulfill your request, we will respond with a status code of 400 and a list of errors from the health plan.

$ curl -i -X GET -i https://api.availity.com/availity/v2/service-reviews?sessionId=-1283121411
->
HTTP/1.1 400 Bad Request
x-api-id: a8380404-0d07-47fa-9e86-44eee35a02bb
X-Session-ID: a8380404-0d07-47fa-9e86-44eee35a02bb
X-Api-Mock-Response: true
Cache-Control: private, no-store, max-age=0, must-revalidate
Content-Type: application/json
Date: Thu, 26 Feb 2015 05:10:26 GMT
X-Global-Transaction-ID: 36774789
Connection: close
{
    "userMessage": "The request was invalid. See the 'errors' property for details.",
    "developerMessage": "The request was invalid. See the 'errors' property for details.",
    "documentation": "https://developer.availity.com/documentation",
    "reasonCode": 0,
    "statusCode": 400,
    "errors": [
        {
            "code": "67",
            "errorMessage": "Patient Not Found - Please Correct and Resubmit"
        }
    }
}

If we are unable to communicate with the health plan (due to maintenance), we will respond with a status code of 504 and a message indicating that the health plan is down for maintenance.

$ curl -i -X GET -i https://api.availity.com/availity/v2/service-reviews?sessionId=-1283121411
->
HTTP/1.1 504 Gateway Timeout
x-api-id: a8380404-0d07-47fa-9e86-44eee35a02bb
X-Session-ID: a8380404-0d07-47fa-9e86-44eee35a02bb
X-Api-Mock-Response: true
Cache-Control: private, no-store, max-age=0, must-revalidate
Content-Type: application/json
Date: Thu, 26 Feb 2015 05:10:26 GMT
X-Global-Transaction-ID: 36774789
Connection: close
{
    "userMessage":"The health plan is down for maintenance.",
    "developerMessage":"We were unable to complete a transaction with the payer.",
    "documentation": "https://developer.availity.com/documentation",
    "reasonCode":7,
    "statusCode":504
}

Once the health plan has successfully fulfilled your inquiry request, we will respond with a status code of 200 and summaries of each service review we found.

$ curl -i -X GET -i https://api.availity.com/availity/v2/service-reviews?sessionId=-1283121411
->
HTTP/1.1 200 OK
x-api-id: a8380404-0d07-47fa-9e86-44eee35a02bb
X-Session-ID: a8380404-0d07-47fa-9e86-44eee35a02bb
X-Api-Mock-Response: true
Cache-Control: private, no-store, max-age=0, must-revalidate
Content-Type: application/json
Date: Thu, 26 Feb 2015 05:10:26 GMT
X-Global-Transaction-ID: 36774789
Connection: close
{
    "totalCount" : 2,
    "count" : 2,
    "offset" : 0,
    "limit" : 50,
    "links" : {
        "self" : {
            "href" : "https://api.availity.com/availity/v2/service-reviews?requestTypeCode=AR&requestingProviderLastName=SLICE N DICE DISCOUNT SURGERY&requestingProviderAddressLine1=123Street&requestingProviderCity=Jacksonville&requestingProviderState=FL&requestingProviderZipCode=123451234&requestingProviderContactName=John&requestingProviderPhone=1112223333&memberId=TEST1&patientLastName=Doe&patientFirstName=John&patientBirthDate=1990-01-01&fromDate=2015-01-01&requestingProviderNpi=1234567893"
        }
    },
    "serviceReviews" : [{
      "links" : {
        "self" : {
          "href" : "https://api.availity.com/availity/v2/service-reviews/111231"
        }
      },
      "id" : "111231",
      "status" : "Pended",
      "statusCode" : "A4",
      "createdDate" : "2015-01-21T17:44:46.000+0000",
      "updatedDate" : "2015-01-22T17:44:52.000+0000",
      "expirationDate" : "2015-02-15T17:44:46.000+0000",
      "updatable" : false,
      "referenceNumber" : "REF12345",
      "payer" : {
          "name" : "FLORIDA BLUE",
          "id" : "BCBSF"
      },
      "requestingProvider" : {
          "lastName" : "SLICE AND DICE DISCOUNT SURGERY",
          "npi" : "1234567893",
      },
      "subscriber" : {
          "firstName" : "BRUCE",
          "lastName" : "WAYNE",
          "memberId" : "ASDF123124",
      },
      "patient" : {
          "firstName" : "BRUCE",
          "lastName" : "WAYNE",
          "subscriberRelationship" : "Self",
          "subscriberRelationshipCode" : "18",
          "birthDate" : "1962-08-10",
      },
      "requestType" : "Admission Review",
      "requestTypeCode" : "AR",
      "serviceType" : "Medical Care",
      "serviceTypeCode" : "1",
      "fromDate" : "2015-01-22",
      "toDate" : "2015-01-25"
    },{
      "links" : {
        "self" : {
          "href" : "https://api.availity.com/availity/v2/service-reviews/111221"
        }
      },
      "id" : "111221",
      "status" : "Certified in Total",
      "statusCode" : "A1",
      "createdDate" : "2015-01-25T17:44:46.000+0000",
      "updatedDate" : "2015-01-25T17:44:52.000+0000",
      "expirationDate" : "2015-02-17T17:44:46.000+0000",
      "updatable" : false,
      "certificationNumber" : "1231723",
      "payer" : {
          "name" : "FLORIDA BLUE",
          "id" : "BCBSF"
      },
      "requestingProvider" : {
          "lastName" : "SLICE AND DICE DISCOUNT SURGERY",
          "npi" : "1234567893",
      },
      "subscriber" : {
          "firstName" : "FRED",
          "lastName" : "FLINTSTONE",
          "memberId" : "ASDF23123123"
      },
      "patient" : {
          "firstName" : "WILMA",
          "lastName" : "FLINTSTONE",
          "subscriberRelationship" : "Spouse",
          "subscriberRelationshipCode" : "01",
          "birthDate" : "1961-01-15"
      },
      "requestType" : "Admission Review",
      "requestTypeCode" : "AR",
      "serviceType" : "Medical Care",
      "serviceTypeCode" : "1",
      "fromDate" : "2015-01-26",
      "toDate" : "2015-01-27"
    }]
}

PUT /V2/SERVICE-REVIEWS

This endpoint updates service reviews asynchronously. Only a service review with updatable=true can be updated. Once you make a valid request, we will respond with a location header containing a URL you can query for your result while we asynchronously send an updated copy of the service review to the health plan.

RESPONSE STATUSES

HTTP Status Code Description
202 We are currently processing your request.
400 Your request has been rejected. It either failed our validation rules (a 400 in res) See the errors property for details.
404 We did not find a ServiceReview with the id that you sent.
500 We were unable to parse your request.

EXAMPLES

$ curl -i -H "Content-Type: application/json" -X PUT -d '{
  "links" : {
    "self" : {
      "href" : "https://api.availity.com/availity/v2/service-reviews/-11923818311"
    }
  },
  "id" : "-11923818311",
  "payer" : {
    "id" : "BCBSF",
    "name" : "Florida Blue"
  },
  "requestingProvider" : {
    "lastName" : "Slice n Dice Discount Surgery",
    "npi" : "1234567893"
  },
  "subscriber" : {
    "memberId" : "XBH1823812"
  },
  "patient" : {
    "lastName" : "Smith",
    "firstName" : "Bob",
    "birthDate" : "1956-01-29",
    "subscriberRelationshipCode" : "18"
  },
  "diagnoses" : [{
    "qualifierCode" : "ABF",
    "code" : "W5602XA"
  }],
  "requestTypeCode" : "AR",
  "serviceTypeCode" : "1",
  "placeOfServiceCode" : "11",
  "fromDate" : "2014-05-01",
  "toDate" : "2014-05-03",
  "quantity" : "3",
  "quantityTypeCode" : "DA",
  "admissionTypeCode" : "1",
  "renderingProviders" : [{
    "roleCode" : "71",
    "lastName" : "Jones",
    "firstName" : "Jane",
    "npi" : "1231231238"
  },{
    "roleCode" : "FA",
    "lastName" : "Slice and Dice Surgery Center",
    "npi" : "1234912380"
  }],
  "procedures" : [{
    "qualifierCode" : "HC",
    "code" : "S8948",
    "quantity" : "1",
    "quantityTypeCode" : "UN"
  }]
}' https://api.availity.com/availity/v2/service-reviews
->
HTTP/1.1 202 Accepted
x-api-id: a8380404-0d07-47fa-9e86-44eee35a02bb
X-Session-ID: a8380404-0d07-47fa-9e86-44eee35a02bb
X-Api-Mock-Response: true
Cache-Control: private, no-store, max-age=0, must-revalidate
Content-Type: application/json
Date: Thu, 26 Feb 2015 05:10:26 GMT
Location: https://api.availity.com/availity/v2/service-reviews/-11923818311
X-Status-Message: We are processing your request.

UPDATABILITY

The ServiceReview resource contains a flag called updatable that indicates whether or not it can be updated. Availity does not allow you to update ServiceReviews that are currently in progress (being processed in our system). Furthermore, health plans can indicate whether or not a ServiceReview is updatable and, if so, which fields can be changed. This can differ from one ServiceReview to another and can change over the life span of a ServiceReview.

In all ServiceReviews that have an updatable property of true, you will find an updatableFields collection (ServiceReview.updatableFields). The health plan determines which fields are updatable for each service review. You will find the fields they have marked as updatable in this collection.

DELETE /V2/SERVICE-REVIEWS/:ID

This endpoint voids an existing service review asynchronously. Only a service review with deleteable=true can be voided. Once you make a valid request, we will respond with a location header containing a URL you can query for your result while we asynchronously send a void request to the health plan.

RESPONSE STATUSES

HTTP Status Code Description
202 We are currently processing your request.
400 Your request has been rejected.
404 We did not find a ServiceReview with the id that you sent.
500 We were unable to parse your request.

EXAMPLES

$ curl -i -H "Content-Type: application/json" -X DELETE https://api.availity.com/availity/v2/service-reviews/-11923818311
->
HTTP/1.1 202 Accepted
x-api-id: a8380404-0d07-47fa-9e86-44eee35a02bb
X-Session-ID: a8380404-0d07-47fa-9e86-44eee35a02bb
X-Api-Mock-Response: true
Cache-Control: private, no-store, max-age=0, must-revalidate
Content-Type: application/json
Date: Thu, 26 Feb 2015 05:10:26 GMT
X-Global-Transaction-ID: 36774789
Connection: close
Location: https://api.availity.com/availity/v2/service-reviews/-11923818311
X-Status-Message: We are processing your request.

DELETABILITY

The ServiceReview resource contains a flag called deletable that indicates whether or not it can be deleted. Availity does not allow you to dlete ServiceReviews that are currently in progress (being processed in our system). Furthermore, health plans can indicate whether or not a ServiceReview is deletable. This can differ from one ServiceReview to another and can change over the life span of a ServiceReview.

Claim Statuses

This resource represents a request and response for claim status information from a health plan. Your application can use the endpoints defined for it to find, create, and manage these requests.

The Resource

Field Type Description
id String A unique identifier that Availity has assigned to this ClaimStatus.
createdDate TimeStamp The date and time when this item was created in Availity's system.
updatedDate TimeStamp The date and time when this item was last updated.
expirationDate TimeStamp The date and time when this item will be removed from Availity's system.
customerId String The id of the Availity customer that owns this ClaimStatus. Availity may ask for this during support calls.
controlNumber String The id of the last transaction associated with this ClaimStatus. The health plan may ask for this during support calls.
status String A description of the current status of this ClaimStatus.
statusCode String A code that represents the current status.
fromDate Date The from date specified in the initial claim status inquiry request.
toDate Date The to date specified in the initial claim status inquiry request.
claimNumber String The health plan's claim tracking number assigned when the original claim was received and processed.
claimAmount String The total claim charge amount of the original claim processed by the health plan.
facilityTypeCode String The code identifying where services were, or may have been, performed for institutional claims.
facilityType String A description of the facility type.
frequencyTypeCode String The code identifying the frequency of an institutional claim.
frequencyType String A description of the frequency type.
payer Object An object representing the health plan of the patient.
payer.id String The Availity id of the health plan.
payer.name String The name of the health plan.
payer.contactName String The contact name of the health plan.
payer.phone String The phone number of the health plan.
payer.extension String The phone number extension of the health plan.
payer.fax String The fax number of the health plan.
payer.emailAddress String The email address of the health plan.
payer.ediAccessNumber String The electronic data interchange access Number or the health plan.
submitter Object An object representing the organization or person that is requesting/submitting the claim status.
submitter.lastName String The last or business name of the submitter.
submitter.firstName String The first name of the submitter.
submitter.middleName String The middle name of the submitter.
submitter.suffix String The suffix of the submitter.
submitter.id String The identifier of the submitter.
submitter.traceId String A reference id assigned by the health plan to uniquely identify the transaction.
submitter.statusDetails Object Array An array of status information reported for the submitter.
submitter.statusDetails.category String A description of the logical groupings of claim status codes.
submitter.statusDetails.categoryCode String An identifier used to specify the logical groupings of claim status codes.
submitter.statusDetails.status String A description of the status associated with a claim or service line.
submitter.statusDetails.statusCode String An identifier of the status associated with a claim or service line.
submitter.statusDetails.entity String A description of the entity associated with the claim status code.
submitter.statusDetails.entityCode String An identifier of the entity associated with the claim status code.
submitter.statusDetails.effectiveDate Date The effective date of the status information.
providers Object Array An array containing information regarding the provider of services from the original claim.
providers.lastName String The last or business name of the service provider.
providers.firstName String The first name of the service provider.
providers.middleName String The middle name of the service provider.
providers.suffix String The suffix of the service provider.
providers.npi String The national provider id of the service provider.
providers.taxId String The tax id of the service provider.
providers.payerAssignedProviderId String The health plan assigned id for the service provider.
providers.traceId String A reference id assigned by the health plan to uniquely identify the transaction.
providers.statusDetails Object Array An array of status information reported for the provider associated with the original claim.
providers.statusDetails.category String A description of the logical groupings of claim status codes.
providers.statusDetails.categoryCode String An identifier used to specify the logical groupings of claim status codes.
providers.statusDetails.status String A description of the status associated with a claim or service line.
providers.statusDetails.statusCode String An identifier of the status associated with a claim or service line.
providers.statusDetails.entity String A description of the entity associated with the claim status code.
providers.statusDetails.entityCode String An identifier of the entity associated with the claim status code.
providers.statusDetails.effectiveDate Date The effective date of the status information.
subscriber Object An object representing the health plan subscriber.
subscriber.lastName String The last name of the subscriber.
subscriber.firstName String The first name of the subscriber.
subscriber.middleName String The middle name of the subscriber.
subscriber.suffix String The suffix of the subscriber.
subscriber.memberId String The member id of the subscriber.
subscriber.taxId String The tax id of the subscriber.
patient Object An object representing the patient for which the original claim was filed.
patient.lastName String The last name of the patient.
patient.firstName String The first name of the patient.
patient.middleName String The middle name of the patient.
patient.suffix String The suffix of the patient.
patient.birthDate Date The birth date of the patient.
patient.gender String A description of the gender of the patient.
patient.genderCode String A code representing the gender of the patient.
patient.accountNumber String A reference identifier for the patient assigned by the service provider.
patient.subscriberRelationship String A description of the patient's relationship to the subscriber.
patient.subscriberRelationshipCode String A code representing the patient's relationship to the subscriber.
claimStatuses Object Array An array of claim status information returned from the health plan.
claimStatuses.traceId String A reference id assigned by the health plan to uniquely identify this claim status.
claimStatuses.claimControlNumber String A unique identifier of the originally submitted/processed claim assigned by the health plan.
claimStatuses.facilityTypeCode String The code identifying where services were, or may have been, performed for institutional claims.
claimStatuses.facilityType String A description of the facility type.
claimStatuses.frequencyTypeCode String The code identifying the frequency of an institutional claim.
claimStatuses.frequencyType String A description of the frequency type.
claimStatuses.patientControlNumber String A reference identifier for the patient assigned by the service provider that was included on the original claim.
claimStatuses.pharmacyPrescriptionNumber String The pharmacy prescription number from the original claim.
claimStatuses.voucherNumber String The voucher number returned from the health plan.
claimStatuses.claimIdentificationNumber String An identifier of the originally submitted claim assigned by a clearinghouse or intermediary.
claimStatuses.fromDate Date The date on which the service began.
claimStatuses.toDate Date The date on which the service ended.
claimStatuses.statusDetails Object Array An array of status information reported for the original claim.
claimStatuses.statusDetails.category String A description of the logical groupings of claim status codes.
claimStatuses.statusDetails.categoryCode String An identifier used to specify the logical groupings of claim status codes.
claimStatuses.statusDetails.status String A description of the status associated with a claim or service line.
claimStatuses.statusDetails.statusCode String An identifier of the status associated with a claim or service line.
claimStatuses.statusDetails.entity String A description of the entity associated with the claim status code.
claimStatuses.statusDetails.entityCode String An identifier of the entity associated with the claim status code.
claimStatuses.statusDetails.effectiveDate Date The effective date of the status information.
claimStatuses.statusDetails.claimAmount String The amount of the originally submitted claim charges.
claimStatuses.statusDetails.claimAmountUnits String The units of the claim amount. (USD)
claimStatuses.statusDetails.paymentAmount String The amount payed by the health plan on the originally submitted claim.
claimStatuses.statusDetails.paymentAmountUnits String The units of claim payment amount. (USD)
claimStatuses.statusDetails.finalizedDate Date The date the original claim was paid.
claimStatuses.statusDetails.remittanceDate Date The date the payment check was issued.
claimStatuses.statusDetails.checkNumber String The number of the check that paid the claim paid amount.
claimStatuses.serviceLines Object Array An array of service line information from the originally submitted/processed claim.
claimStatuses.serviceLines.procedureQualifier String A description of the type or source of the procedure code.
claimStatuses.serviceLines.procedureQualifierCode String A code that identifies the type or source of the procedure code.
claimStatuses.serviceLines.procedure String A description of the procedure performed from the originally submitted claim.
claimStatuses.serviceLines.procedureCode String A code respresenting the procedure performed from the originally submitted claim.
claimStatuses.serviceLines.modifier1 String A description of the first modifier applied to this procedure.
claimStatuses.serviceLines.modifier1Code String A code representing the first modifier applied to this procedure.
claimStatuses.serviceLines.modifier2 String A description of the second modifier applied to this procedure.
claimStatuses.serviceLines.modifier2Code String A code representing the second modifier applied to this procedure.
claimStatuses.serviceLines.modifier3 String A description of the third modifier applied to this procedure.
claimStatuses.serviceLines.modifier3Code String A code representing the third modifier applied to this procedure.
claimStatuses.serviceLines.modifier4 String A description of the fourth modifier applied to this procedure.
claimStatuses.serviceLines.modifier4Code String A code representing the fourth modifier applied to this procedure.
claimStatuses.serviceLines.chargeAmount String The amount of the originally submitted charges for the service.
claimStatuses.serviceLines.chargeAmountUnits String The units of the service line charge amount. (USD)
claimStatuses.serviceLines.paymentAmount String The amount payed by the health plan for the servcie.
claimStatuses.serviceLines.paymentAmountUnits String The units of the service payment amount. (USD)
claimStatuses.serviceLines.service String A description of the product or service performed reported in this service line.
claimStatuses.serviceLines.serviceCode String An identifier of the product or service performed reported in this service line.
claimStatuses.serviceLines.quantity String The originally submitted units of service.
claimStatuses.serviceLines.controlNumber String A reference identifier for the service assigned by the health plan.
claimStatuses.serviceLines.fromDate Date The date on which the service began.
claimStatuses.serviceLines.toDate Date The date on which the service ended.
claimStatuses.serviceLines.statusDetails Object Array An array of status information reported for the service line of the original claim.
claimStatuses.serviceLines.statusDetails.category String A description of the logical groupings of claim status codes.
claimStatuses.serviceLines.statusDetails.categoryCode String An identifier used to specify the logical groupings of claim status codes.
claimStatuses.serviceLines.statusDetails.status String A description of the status associated with a claim or service line.
claimStatuses.serviceLines.statusDetails.statusCode String An identifier of the status associated with a claim or service line.
claimStatuses.serviceLines.statusDetails.entity String A description of the entity associated with the claim status code.
claimStatuses.serviceLines.statusDetails.entityCode String An identifier of the entity associated with the claim status code.
claimStatuses.serviceLines.statusDetails.effectiveDate Date The effective date of the status information.
claimCount String The total number of unique claims reported by this claim status inquiry.

Statuses

ClaimStatus.statusCode ClaimStatus.status Description
0 In Progress Availity is communicating with the health plan. Check back in a few seconds.
19 Request Error The health plan indicated that something is wrong with the request. The resource will have a list of validationMessages. Correct and update the resource.
R1 Communication Error, Retrying The health plan did not respond. Availity will retry the request over the next 30 minutes.
7 Communication Error, Retries Exhausted The health plan did not respond after multiple retries. Please resubmit the request later.
3 Complete Availity has received a response from the health plan and it is now available for viewing.
4 Complete (Invalid Response) Availity has received a response from the health plan but it contained errors that may or may not affect the data returned in the asset.

GET /V1/CLAIM-STATUSES

You can search the collection of claim statuses using this endpoint.

Parameter Type Description
payer.id String The Availity id for the health plan.
submitter.lastName String The last or business name of the submitter.
submitter.firstName String The first name of the submitter.
submitter.middleName String The middle name of the submitter.
submitter.suffix String The suffix of the submitter.
submitter.id String The identifier of the submitter.
providers.lastName String The last or business name of the service provider.
providers.firstName String The first name of the service provider.
providers.middleName String The middle name of the service provider.
providers.suffix String The suffix of the service provider.
providers.npi String The national provider id of the service provider.
providers.taxId String The tax id of the service provider.
providers.payerAssignedProviderId String The health plan assigned id for the service provider.
subscriber.memberId String The member id of the subscriber.
subscriber.lastName String The last name of the subscriber.
subscriber.firstName String The first name of the subscriber.
subscriber.middleName String The middle name of the subscriber.
subscriber.suffix String The suffix of the subscriber.
patient.lastName String The last name of the patient.
patient.firstName String The first name of the patient.
patient.middleName String The middle name of the patient.
patient.suffix String The suffix of the patient.
patient.birthDate Date The birth date of the patient.
patient.genderCode String A code representing the gender of the patient.
patient.accountNumber String A reference identifier for the patient assigned by the service provider.
patient.subscriberRelationshipCode String A code representing the patient's relationship to the subscriber.
fromDate Date The service from date.
toDate Date The service to date.
claimNumber String The health plan's claim tracking number assigned when the original claim was received and processed.
claimAmount String The total claim charge amount of the original claim processed by the health plan.
facilityTypeCode String The code identifying where services were, or may have been, performed for institutional claims.
frequencyTypeCode String The code identifying the frequency of an institutional claim.
q String Fuzzy search parameter - triggers us to search our database instead of reaching out to the health plan.
sortBy String Field we will sort by when returning results from our database. Currently only supports - updatedDate.
sortDirection String The direction we will sort results from our database. Supports asc and desc. Defaults to desc.
id String Allows you to retrive summaries of multiple claim statuses by specifying the id of each.

The endpoint returns summary versions of the claim status resource. Here is an example with all possible fields shown:

{
    "links": {
        "self": {
            "href": "https://api.availity.com/availity/v1/claim-statuses/-1437397854912689422"
        }       
    },      
    "id": "-1437397854912689422",
    "customerId": "1194",
    "userId": "aka71627884343",
    "status": "Complete",
    "statusCode": "0",
    "createdDate": "2015-06-05T17:47:23.000+0000",
    "updatedDate": "2015-06-05T17:47:23.000+0000",
    "expirationDate": "2015-06-06T17:47:23.000+0000",
    "fromDate": "2015-05-15T04:00:00.000+0000",
    "toDate": "2015-05-19T04:00:00.000+0000",
    "claimNumber": "CL4IM2TATUSNUM8ER",
    "claimAmount": "12345678.90",
    "facilityTypeCode": "12",
    "facilityType": "Hospital Inpatient, Part B only",
    "frequencyTypeCode": "1",
    "frequencyType": "Admit thru Discharge Claim",
    "claimCount": "1"
    "payer": {
        "id": "BCBSF",
        "name" : "FLORIDA BLUE"
    },      
    "submitter": {
        "lastName": "SUBMITTERLASTNAME",
        "firstName": "SUBMITTERFIRSTNAME",
        "middleName": "SUBMITTERMIDDLENAME",
        "suffix": "SUBMITTERSUFFIX",
        "id": "SUBMITTERID"
    },      
    "providers": [
        {
            "lastName": "PROVIDERLASTNAME",
            "firstName": "PROVIDERFIRSTNAME",
            "middleName": "PROVIDERMIDDLENAME",
            "suffix": "PROVIDERSUFFIX",
            "npi": "1234567893"
            "taxId": "1234567893"
            "payerAssignedProviderId": "1234567893"
        }       
    ],      
    "subscriber": {
        "firstName": "SUBSCRIBERFIRSTNAME",
        "lastName": "SUBSCRIBERLASTNAME",
        "middleName": "SUBSCRIBERMIDDLENAME",
        "suffix": "SUBSCRIBERSUFFIX",
        "memberId": "ABC123456789"
    },
    "patient": {
        "firstName": "PATIENTFIRSTNAME",
        "lastName": "PATIENTLASTNAME",
        "middleName": "PATIENTMIDDLENAME",
        "suffix": "PATIENTSUFFIX",
        "birthDate": "1999-09-09",
        "gender": "Male",
        "genderCode": "M",
        "accountNumber": "PAT1ENTACC0UNTNUMB3R",
        "subscriberRelationship": "Spouse",
        "subscriberRelationshipCode": "01"
    }
}

Multi-summary Mode

The first way to interact with the endpoint is called multi-summary mode. It allows you to retrieve summary versions and check the status of multiple claim statuses at once. You can initiate it by specifying one or more id parameters where each id is the id of a claim status you are interested in. Any other parameters will be ignored. You can get up to 50 claim status summaries at a time using this feature. Here is an example of getting two summaries by id:

$ curl -i -X GET -i https://api.availity.com/availity/v1/claim-statuses?id=-6444806312330895858&id=-1437397854912689422
->
HTTP/1.1 200 OK
Cache-Control: private,no-store,max-age=0,must-revalidate
Connection: close
Content-Type: application/json
Date: Tue, 09 Jun 2015 19:54:52 GMT
X-Global-Transaction-ID: 113993145
X-Session-ID: 84f311c9-7aca-45fe-b256-d6049c499d66
x-api-id: 84f311c9-7aca-45fe-b256-d6049c499d66
X-Api-Mock-Response: true
{
    "totalCount": 2,
    "count": 2,
    "offset": 0,
    "limit": 50,
    "links": {
        "self": {
            "href": "https://api.availity.com/availity/v1/claim-statuses?id=-6444806312330895858&id=-1437397854912689422"
        }
    },
    "claimStatuses": [
        {
            "links": {
                "self": {
                    "href": "https://api.availity.com/availity/v1/claim-statuses/-6444806312330895858"
                }
            },
            "id": "-6444806312330895858",
            "customerId": "1194",
            "controlNumber": "36374",
            "userId": "aka71627884343",
            "status": "Complete",
            "statusCode": "4",
            "createdDate": "2015-06-05T17:50:30.000+0000",
            "updatedDate": "2015-06-05T17:50:30.000+0000",
            "expirationDate": "2015-06-06T17:50:30.000+0000",
            "fromDate": "2015-05-15T04:00:00.000+0000",
            "toDate": "2015-05-19T04:00:00.000+0000",
            "claimNumber": "CL4IM2TATUSNUM8ER",
            "claimAmount": "12345678.90",
            "facilityTypeCode": "12",
            "facilityType": "Hospital Inpatient, Part B only",
            "frequencyTypeCode": "1",
            "frequencyType": "Admit thru Discharge Claim",
            "payer": {
                "id": "BCBSF"
            },
            "submitter": {
                "lastName": "SUBMITTERLASTNAME",
                "firstName": "SUBMITTERFIRSTNAME",
                "id": "SUBMITTERID"
            },
            "providers": [
                {
                    "lastName": "PROVIDERLASTNAME",
                    "firstName": "PROVIDERFIRSTNAME",
                    "npi": "1234567893"
                }
            ],
            "subscriber": {
                "firstName": "TEST",
                "middleName": "B",
                "lastName": "PATIENT",
                "suffix": "III",
                "memberId": "BEAH276TESTGEN"
            },
            "patient": {
                "firstName": "TEST",
                "middleName": "B",
                "lastName": "PATIENT",
                "suffix": "III",
                "birthDate": "1999-09-09",
                "gender": "Male",
                "genderCode": "M",
                "accountNumber": "UNKNOWN",
                "subscriberRelationship": "Self",
                "subscriberRelationshipCode": "18"
            },
            "claimCount": "1"
        },
        {
            "links": {
                "self": {
                    "href": "https://api.availity.com/availity/v1/claim-statuses/-1437397854912689422"
                }
            },
            "id": "-1437397854912689422",
            "customerId": "1194",
            "controlNumber": "36373",
            "userId": "aka71627884343",
            "status": "Complete (Invalid Response)",
            "statusCode": "3",
            "createdDate": "2015-06-05T17:47:23.000+0000",
            "updatedDate": "2015-06-05T17:47:23.000+0000",
            "expirationDate": "2015-06-06T17:47:23.000+0000",
            "fromDate": "2015-05-15T04:00:00.000+0000",
            "toDate": "2015-05-19T04:00:00.000+0000",
            "claimNumber": "CL4IM2TATUSNUM8ER",
            "claimAmount": "12345678.90",
            "facilityTypeCode": "12",
            "facilityType": "Hospital Inpatient, Part B only",
            "frequencyTypeCode": "1",
            "frequencyType": "Admit thru Discharge Claim",
            "payer": {
                "id": "BCBSF"
            },
            "submitter": {
                "lastName": "SUBMITTERLASTNAME",
                "firstName": "SUBMITTERFIRSTNAME",
                "id": "SUBMITTERID"
            },
            "providers": [
                {
                    "lastName": "PROVIDERLASTNAME",
                    "firstName": "PROVIDERFIRSTNAME",
                    "npi": "1234567893"
                }
            ],
            "subscriber": {
                "firstName": "SUBSCRIBERFIRSTNAME",
                "lastName": "SUBSCRIBERLASTNAME",
                "memberId": "ABC123456789"
            },
            "patient": {
                "firstName": "PATIENTFIRSTNAME",
                "lastName": "PATIENTLASTNAME",
                "birthDate": "1999-09-09",
                "gender": "Male",
                "genderCode": "M",
                "accountNumber": "PAT1ENTACC0UNTNUMB3R",
                "subscriberRelationship": "Unknown",
                "subscriberRelationshipCode": "21"
            },
            "claimCount": "1"
        }
    }]
}

Search Mode

The second way to interact with the endpoint is called search mode. It allows you to search the claim statuses that are in Availity's database. This mode is useful for building searchable list views of claim statuses. You initiate it by sending a q parameter (even a blank one). We will use this parameter to perform a fuzzy search in our database. In addition, you can perform case insensitive filtering by sending any of the other parameters (except id). Furthermore, this mode supports sorting and paging. Here is an example:

$ curl -i -X GET https://api.availity.com/availity/v1/claim-statuses?q=&providers.npi=1234567893
->
HTTP/1.1 200 OK
Cache-Control: private,no-store,max-age=0,must-revalidate
Connection: close
Content-Type: application/json
Date: Tue, 09 Jun 2015 19:54:52 GMT
X-Global-Transaction-ID: 113993145
X-Session-ID: 84f311c9-7aca-45fe-b256-d6049c499d66
x-api-id: 84f311c9-7aca-45fe-b256-d6049c499d66
X-Api-Mock-Response: true
{
    "totalCount": 5,
    "count": 5,
    "offset": 0,
    "limit": 50,
    "links": {
        "self": {
            "href": "https://api.availity.com/availity/v1/claim-statuses?q=&providers.npi=1234567893"
        }
    },
    "claimStatuses": [
        {
            "links": {
                "self": {
                    "href": "https://api.availity.com/availity/v1/claim-statuses/-6444806312330895858"
                }
            },
            "id": "-6444806312330895858",
            "customerId": "1194",
            "controlNumber": "36374",
            "userId": "aka71627884343",
            "status": "Complete",
            "statusCode": "4",
            "createdDate": "2015-06-05T17:50:30.000+0000",
            "updatedDate": "2015-06-05T17:50:30.000+0000",
            "expirationDate": "2015-06-06T17:50:30.000+0000",
            "fromDate": "2015-05-15T04:00:00.000+0000",
            "toDate": "2015-05-19T04:00:00.000+0000",
            "claimNumber": "CL4IM2TATUSNUM8ER",
            "claimAmount": "12345678.90",
            "facilityTypeCode": "12",
            "facilityType": "Hospital Inpatient, Part B only",
            "frequencyTypeCode": "1",
            "frequencyType": "Admit thru Discharge Claim",
            "payer": {
                "id": "BCBSF"
            },
            "submitter": {
                "lastName": "SUBMITTERLASTNAME",
                "firstName": "SUBMITTERFIRSTNAME",
                "id": "SUBMITTERID"
            },
            "providers": [
                {
                    "lastName": "PROVIDERLASTNAME",
                    "firstName": "PROVIDERFIRSTNAME",
                    "npi": "1234567893"
                }
            ],
            "subscriber": {
                "firstName": "SUBSCRIBERFIRSTNAME",
                "middleName": "SUBSCRIBERMIDDLENAME",
                "lastName": "SUBSCRIBERLASTNAME",
                "suffix": "III",
                "memberId": "BEAH276TESTGEN"
            },
            "patient": {
                "firstName": "PATIENTFIRSTNAME",
                "middleName": "PATIENTMIDDLENAME",
                "lastName": "PATIENTLASTNAME",
                "suffix": "III",
                "birthDate": "1999-09-09",
                "gender": "Male",
                "genderCode": "M",
                "accountNumber": "UNKNOWN",
                "subscriberRelationship": "Self",
                "subscriberRelationshipCode": "18"
            },
            "claimCount": "1"
        },
        {
            "links": {
                "self": {
                    "href": "https://api.availity.com/availity/v1/claim-statuses/-1437397854912689422"
                }
            },
            "id": "-1437397854912689422",
            "customerId": "1194",
            "controlNumber": "36373",
            "userId": "aka71627884343",
            "status": "Complete (Invalid Response)",
            "statusCode": "3",
            "createdDate": "2015-06-05T17:47:23.000+0000",
            "updatedDate": "2015-06-05T17:47:23.000+0000",
            "expirationDate": "2015-06-06T17:47:23.000+0000",
            "fromDate": "2015-05-15T04:00:00.000+0000",
            "toDate": "2015-05-19T04:00:00.000+0000",
            "claimNumber": "CL4IM2TATUSNUM8ER",
            "claimAmount": "12345678.90",
            "facilityTypeCode": "12",
            "facilityType": "Hospital Inpatient, Part B only",
            "frequencyTypeCode": "1",
            "frequencyType": "Admit thru Discharge Claim",
            "payer": {
                "id": "BCBSF"
            },
            "submitter": {
                "lastName": "SUBMITTERLASTNAME",
                "firstName": "SUBMITTERFIRSTNAME",
                "id": "SUBMITTERID"
            },
            "providers": [
                {
                    "lastName": "PROVIDERLASTNAME",
                    "firstName": "PROVIDERFIRSTNAME",
                    "npi": "1234567893"
                }
            ],
            "subscriber": {
                "firstName": "SUBSCRIBERFIRSTNAME",
                "lastName": "SUBSCRIBERLASTNAME",
                "memberId": "ABC123456789"
            },
            "patient": {
                "firstName": "PATIENTFIRSTNAME",
                "lastName": "PATIENTLASTNAME",
                "birthDate": "1999-09-09",
                "gender": "Male",
                "genderCode": "M",
                "accountNumber": "PAT1ENTACC0UNTNUMB3R",
                "subscriberRelationship": "Unknown",
                "subscriberRelationshipCode": "21"
            },
            "claimCount": "1"
        },
        {
            "links": {
                "self": {
                    "href": "https://api.availity.com/availity/v1/claim-statuses/8093209937431557081"
                }
            },
            "id": "8093209937431557081",
            "customerId": "1194",
            "controlNumber": "36358",
            "userId": "aka71627884343",
            "status": "Complete",
            "statusCode": "4",
            "createdDate": "2015-06-05T15:52:42.000+0000",
            "updatedDate": "2015-06-05T15:52:42.000+0000",
            "expirationDate": "2015-06-06T15:52:42.000+0000",
            "fromDate": "2015-05-16T04:00:00.000+0000",
            "toDate": "2015-06-01T04:00:00.000+0000",
            "claimNumber": "CL4IM2TATUSNUM8ER",
            "claimAmount": "12345678.90",
            "facilityTypeCode": "12",
            "facilityType": "Hospital Inpatient, Part B only",
            "frequencyTypeCode": "1",
            "frequencyType": "Admit thru Discharge Claim",
            "payer": {
                "id": "BCBSF"
            },
            "submitter": {
                "lastName": "SUBMITTERLASTNAME",
                "firstName": "SUBMITTERFIRSTNAME",
                "id": "SUBMITTERID"
            },
            "providers": [
                {
                    "lastName": "PROVIDERLASTNAME",
                    "firstName": "PROVIDERFIRSTNAME",
                    "npi": "1234567893"
                }
            ],
            "subscriber": {
                "firstName": "SUBSCRIBERFIRSTNAME",
                "middleName": "SUBSCRIBERMIDDLENAME",
                "lastName": "SUBSCRIBERLASTNAME",
                "suffix": "SR",
                "memberId": "CSI276MAXSUBPAT"
            },
            "patient": {
                "firstName": "PATIENTFIRSTNAME",
                "middleName": "PATIENTMIDDLENAME",
                "lastName": "PATIENTLASTNAME",
                "suffix": "SR",
                "birthDate": "1988-08-08",
                "gender": "Female",
                "genderCode": "F",
                "accountNumber": "277PATIENTACCTNUM-NOCLAIMNUM123",
                "subscriberRelationship": "Unknown",
                "subscriberRelationshipCode": "21"
            },
            "claimCount": "2"
        },
        {
            "links": {
                "self": {
                    "href": "https://api.availity.com/availity/v1/claim-statuses/3537415793032824843"
                }
            },
            "id": "3537415793032824843",
            "customerId": "1194",
            "controlNumber": "36371",
            "userId": "aka71627884343",
            "status": "Complete",
            "statusCode": "4",
            "createdDate": "2015-06-04T21:00:50.000+0000",
            "updatedDate": "2015-06-04T21:00:50.000+0000",
            "expirationDate": "2015-06-05T21:00:50.000+0000",
            "fromDate": "2015-05-15T04:00:00.000+0000",
            "toDate": "2015-05-19T04:00:00.000+0000",
            "claimNumber": "CL4IM2TATUSNUM8ER",
            "claimAmount": "8879999.99",
            "payer": {
                "id": "BCBSF"
            },
            "submitter": {
                "lastName": "SUBMITTERLASTNAME",
                "firstName": "SUBMITTERFIRSTNAME",
                "id": "SUBMITTER1D"
            },
            "providers": [
                {
                    "lastName": "PROVIDERLASTNAME",
                    "firstName": "PROVIDERFIRSTNAME",
                    "npi": "1234567893"
                }
            ],
            "subscriber": {
                "firstName": "SUBSCRIBERFIRSTNAME",
                "middleName": "SUBSCRIBERMIDDLENAME",
                "lastName": "SUBSCRIBERLASTNAME",
                "suffix": "SR",
                "memberId": "CSI276MAXSUBPAT"
            },
            "patient": {
                "firstName": "PATIENTFIRSTNAME",
                "middleName": "PATIENTMIDDLENAME",
                "lastName": "PATIENT LASTNAME",
                "suffix": "SR",
                "birthDate": "1912-11-10",
                "gender": "Female",
                "genderCode": "F",
                "accountNumber": "277PATIENTACCTNUM-NOCLAIMNUM123",
                "subscriberRelationship": "Unknown",
                "subscriberRelationshipCode": "21"
            },
            "claimCount": "2"
        },
        {
            "links": {
                "self": {
                    "href": "https://api.availity.com/availity/v1/claim-statuses/-9022098185210411357"
                }
            },
            "id": "-9022098185210411357",
            "customerId": "1194",
            "controlNumber": "36370",
            "userId": "aka71627884343",
            "status": "Complete",
            "statusCode": "4",
            "createdDate": "2015-06-04T20:47:41.000+0000",
            "updatedDate": "2015-06-04T20:47:41.000+0000",
            "expirationDate": "2015-06-05T20:47:41.000+0000",
            "fromDate": "2015-05-15T04:00:00.000+0000",
            "toDate": "2015-05-19T04:00:00.000+0000",
            "claimNumber": "CL4IM2TATUSNUM8ER",
            "claimAmount": "8879999.99",
            "payer": {
                "id": "BCBSF"
            },
            "submitter": {
                "lastName": "SUBMITTERLASTNAME",
                "firstName": "SUBMITTERFIRSTNAME",
                "id": "SUBMITTER1D"
            },
            "providers": [
                {
                    "lastName": "PROVIDERLASTNAME",
                    "firstName": "PROVIDERFIRSTNAME",
                    "npi": "1234567893"
                }
            ],
            "subscriber": {
                "firstName": "SUBSCRIBERFIRSTNAME",
                "lastName": "SUBSCRIBERLASTNAME",
                "memberId": "CSI276SUBPATTEST"
            },
            "patient": {
                "lastName": "PATIENTLASTNAME",
                "birthDate": "1911-09-11",
                "gender": "Male",
                "genderCode": "M",
                "accountNumber": "277PATIENTACCTNUM-NOCLAIMNUM123",
                "subscriberRelationship": "Unknown",
                "subscriberRelationshipCode": "21"
            },
            "claimCount": "2"
        }
    ]
}

Inquiry Mode

The third way to interact with the endpoint is called inquiry mode. It allows you to search the health plan's system for claim status information. It functions in an asynchronous manner. We will return a 202 status code and location header while we process the request. Once we hear back from the health plan, we will insert any new claim statuses into our database. This mode enforces request validation that can vary by health plan. You can find detailed information about the rules by querying our configurations endpoint with a type of claim-statuses-inquiry. In general, you can send as many parameters as you want; Availity will ignore ones that are not supported by the specified health plan.

If your request is invalid, we will respond with a status code of 400 and a list of errors for you to correct.

$ curl -i -X GET https://api.availity.com/availity/v1/claim-statuses?payer.id=BCBSF&submitter.lastName=SUBMITTERLASTNAME&submitter.firstName=SUBMITTERFIRSTNAME&submitter.id=SUBMITTERID&providers.lastName=PROVIDERLASTNAME&providers.firstName=PROVIDERFIRSTNAME&providers.npi=7654321&subscriber.memberId=ABC123456789&subscriber.lastName=SUBSCRIBERLASTNAME&subscriber.firstName=SUBSCRIBERFIRSTNAME&patient.lastName=PATIENTLASTNAME&patient.firstName=PATIENTFIRSTNAME&patient.birthDate=1999-09-09&patient.genderCode=M&patient.accountNumber=PAT1ENTACC0UNTNUMB3R&patient.subscriberRelationshipCode=01&fromDate=2015-05-15&toDate=2015-05-19&claimNumber=CL4IM2TATUSNUM8ER&claimAmount=12345678.90&facilityTypeCode=12&frequencyTypeCode=1
->
HTTP/1.1 400 Bad Request
Cache-Control: private,no-store,max-age=0,must-revalidate
Connection: close
Content-Type: application/json
Date: Tue, 09 Jun 2015 19:54:52 GMT
X-Global-Transaction-ID: 113993145
X-Session-ID: 84f311c9-7aca-45fe-b256-d6049c499d66
x-api-id: 84f311c9-7aca-45fe-b256-d6049c499d66
X-Api-Mock-Response: true
{
    "userMessage": "The request was invalid. See the 'errors' property for details.",
    "developerMessage": "The request was invalid. See the 'errors' property for details.",
    "documentation": "https://developer.availity.com/documentation",
    "reasonCode": 0,
    "statusCode": 400,
    "errors": [
        {
            "field": "providers.npi",
            "errorMessage": "Enter a valid Requesting Provider National Provider Identifier (NPI) containing 10 numeric digits and beginning with a 1, 2, 3, or 4.",
            "index": 0
        }
    }
}

If your request is valid, we will respond with a status code of 202 and a location header where you can check back for your response. We will continue to respond in this way until we have heard back from the health plan.

$ curl -i -X GET https://api.availity.com/availity/v1/claim-statuses?payer.id=BCBSF&submitter.lastName=SUBMITTERLASTNAME&submitter.firstName=SUBMITTERFIRSTNAME&submitter.id=SUBMITTERID&providers.lastName=PROVIDERLASTNAME&providers.firstName=PROVIDERFIRSTNAME&providers.npi=1234567893&subscriber.memberId=ABC123456789&subscriber.lastName=SUBSCRIBERLASTNAME&subscriber.firstName=SUBSCRIBERFIRSTNAME&patient.lastName=PATIENTLASTNAME&patient.firstName=PATIENTFIRSTNAME&patient.birthDate=1999-09-09&patient.genderCode=M&patient.accountNumber=PAT1ENTACC0UNTNUMB3R&patient.subscriberRelationshipCode=01&fromDate=2015-05-15&toDate=2015-05-19&claimNumber=CL4IM2TATUSNUM8ER&claimAmount=12345678.90&facilityTypeCode=12&frequencyTypeCode=1
->
HTTP/1.1 202 Accepted
Cache-Control: private,no-store,max-age=0,must-revalidate
Connection: close
Content-Type: application/json
Date: Tue, 09 Jun 2015 19:54:52 GMT
X-Global-Transaction-ID: 113993145
X-Session-ID: 84f311c9-7aca-45fe-b256-d6049c499d66
x-api-id: 84f311c9-7aca-45fe-b256-d6049c499d66
X-Api-Mock-Response: true
Location: https://api.availity.com/availity/v1/claim-statuses?
X-Status-Message: We are processing your request.
{
    "totalCount": 0,
    "count": 0,
    "offset": 0,
    "limit": 50,
    "links": {
        "self": {
            "href": "https://api.availity.com/availity/v1/claim-statuses?
        }
    },
    "claimStatuses": []
}

If the health plan responds with validation messages indicating that they were unable to fulfill your request, we will respond with a status code of 400 and a list of errors from the health plan.

$ curl -i -X GET https://api.availity.com/availity/v1/claim-statuses?payer.id=BCBSF&submitter.lastName=SUBMITTERLASTNAME&submitter.firstName=SUBMITTERFIRSTNAME&submitter.id=SUBMITTERID&providers.lastName=PROVIDERLASTNAME&providers.firstName=PROVIDERFIRSTNAME&providers.npi=1234567893&subscriber.memberId=ABC123456789&subscriber.lastName=SUBSCRIBERLASTNAME&subscriber.firstName=SUBSCRIBERFIRSTNAME&patient.lastName=PATIENTLASTNAME&patient.firstName=PATIENTFIRSTNAME&patient.birthDate=1999-09-09&patient.genderCode=M&patient.accountNumber=PAT1ENTACC0UNTNUMB3R&patient.subscriberRelationshipCode=01&fromDate=2012-12-01&toDate=2012-12-01&claimNumber=CL4IM2TATUSNUM8ER&claimAmount=12345678.90&facilityTypeCode=12&frequencyTypeCode=1
->
HTTP/1.1 400 Bad Request
Cache-Control: private,no-store,max-age=0,must-revalidate
Connection: close
Content-Type: application/json
Date: Tue, 09 Jun 2015 19:54:52 GMT
X-Global-Transaction-ID: 113993145
X-Session-ID: 84f311c9-7aca-45fe-b256-d6049c499d66
x-api-id: 84f311c9-7aca-45fe-b256-d6049c499d66
X-Api-Mock-Response: true
{
    "userMessage": "The request was invalid. See the 'errors' property for details.",
    "developerMessage": "The request was invalid. See the 'errors' property for details.",
    "documentation": "https://developer.availity.com/documentation",
    "reasonCode": 0,
    "statusCode": 400,
    "errors": [
        {
            "code": "E1:90",
            "errorMessage": "Response not possible  System Status - Entity not eligible for medical benefits for submitted dates of service"
        },
        {
            "code": "A4:35",
            "errorMessage": "Acknowledgement/Not Found  The Claim/Encounter cannot be found in the adjudication system - Claim/Encounter not found"
        },
        {
            "code": "A4:187",
            "errorMessage": "Acknowledgement/Not Found  The Claim/Encounter cannot be found in the adjudication system - Date(s) of service"
        }]
}

If we are unable to communicate with the health plan (due to maintenance), we will respond with a status code of 504 and a message indicating that the health plan is down for maintenance.

$ curl -i -X GET https://api.availity.com/availity/v1/claim-statuses?payer.id=BCBSF&submitter.lastName=SUBMITTERLASTNAME&submitter.firstName=SUBMITTERFIRSTNAME&submitter.id=SUBMITTERID&providers.lastName=PROVIDERLASTNAME&providers.firstName=PROVIDERFIRSTNAME&providers.npi=1234567893&subscriber.memberId=ABC123456789&subscriber.lastName=SUBSCRIBERLASTNAME&subscriber.firstName=SUBSCRIBERFIRSTNAME&patient.lastName=PATIENTLASTNAME&patient.firstName=PATIENTFIRSTNAME&patient.birthDate=1999-09-09&patient.genderCode=M&patient.accountNumber=PAT1ENTACC0UNTNUMB3R&patient.subscriberRelationshipCode=01&fromDate=2015-05-15&toDate=2015-05-19&claimNumber=CL4IM2TATUSNUM8ER&claimAmount=12345678.90&facilityTypeCode=12&frequencyTypeCode=1
->
HTTP/1.1 504 Gateway Timeout
Cache-Control: private,no-store,max-age=0,must-revalidate
Connection: close
Content-Type: application/json
Date: Tue, 09 Jun 2015 19:54:52 GMT
X-Global-Transaction-ID: 113993145
X-Session-ID: 84f311c9-7aca-45fe-b256-d6049c499d66
x-api-id: 84f311c9-7aca-45fe-b256-d6049c499d66
X-Api-Mock-Response: true
{
    "userMessage":"The health plan is down for maintenance.",
    "developerMessage":"We were unable to complete a transaction with the payer.",
    "documentation": "https://developer.availity.com/documentation",
    "reasonCode":7,
    "statusCode":504
}

Once the health plan has successfully fulfilled your request, we will respond with a status code of 200 and summaries of each claim status we found.

$ curl -i -X GET https://api.availity.com/availity/v1/claim-statuses?payer.id=BCBSF&submitter.lastName=SUBMITTERLASTNAME&submitter.firstName=SUBMITTERFIRSTNAME&submitter.id=SUBMITTERID&providers.lastName=PROVIDERLASTNAME&providers.firstName=PROVIDERFIRSTNAME&providers.npi=1234567893&subscriber.memberId=ABC123456789&subscriber.lastName=SUBSCRIBERLASTNAME&subscriber.firstName=SUBSCRIBERFIRSTNAME&patient.lastName=PATIENTLASTNAME&patient.firstName=PATIENTFIRSTNAME&patient.birthDate=1999-09-09&patient.genderCode=M&patient.accountNumber=PAT1ENTACC0UNTNUMB3R&patient.subscriberRelationshipCode=01&fromDate=2015-05-15&toDate=2015-05-19&claimNumber=CL4IM2TATUSNUM8ER&claimAmount=12345678.90&facilityTypeCode=12&frequencyTypeCode=1
->
HTTP/1.1 200 OK
Cache-Control: private,no-store,max-age=0,must-revalidate
Connection: close
Content-Type: application/json
Date: Tue, 09 Jun 2015 19:54:52 GMT
X-Global-Transaction-ID: 113993145
X-Session-ID: 84f311c9-7aca-45fe-b256-d6049c499d66
x-api-id: 84f311c9-7aca-45fe-b256-d6049c499d66
X-Api-Mock-Response: true
{
    "totalCount": 1,
    "count": 1,
    "offset": 0,
    "limit": 1,
    "links": {
        "self": {
            "href": "https://api.availity.com/availity/v1/claim-statuses?id=-1437397854912689422
        }
    },
    "claimStatuses": [
        {
            "links": {
                "self": {
                    "href": "https://api.availity.com/availity/v1/claim-statuses/-1437397854912689422"
                }
            },
            "id": "-1437397854912689422",
            "customerId": "1194",
            "userId": "aka71627884343",
            "status": "In Progress",
            "statusCode": "0",
            "createdDate": "2015-06-05T17:47:23.000+0000",
            "updatedDate": "2015-06-05T17:47:23.000+0000",
            "expirationDate": "2015-06-06T17:47:23.000+0000",
            "fromDate": "2015-05-15T04:00:00.000+0000",
            "toDate": "2015-05-19T04:00:00.000+0000",
            "claimNumber": "CL4IM2TATUSNUM8ER",
            "claimAmount": "12345678.90",
            "facilityTypeCode": "12",
            "facilityType": "Hospital Inpatient, Part B only",
            "frequencyTypeCode": "1",
            "frequencyType": "Admit thru Discharge Claim",
            "payer": {
                "id": "BCBSF"
            },
            "submitter": {
                "lastName": "SUBMITTERLASTNAME",
                "firstName": "SUBMITTERFIRSTNAME",
                "id": "SUBMITTERID"
            },
            "providers": [
                {
                    "lastName": "PROVIDERLASTNAME",
                    "firstName": "PROVIDERFIRSTNAME",
                    "npi": "1234567893"
                }
            ],
            "subscriber": {
                "firstName": "SUBSCRIBERFIRSTNAME",
                "lastName": "SUBSCRIBERLASTNAME",
                "memberId": "ABC123456789"
            },
            "patient": {
                "firstName": "PATIENTFIRSTNAME",
                "lastName": "PATIENTLASTNAME",
                "birthDate": "1999-09-09",
                "gender": "Male",
                "genderCode": "M",
                "accountNumber": "PAT1ENTACC0UNTNUMB3R",
                "subscriberRelationship": "Spouse",
                "subscriberRelationshipCode": "01"
            }
        }
    ]
}

GET /V1/CLAIM-STATUSES/:ID

You can retrieve a claim status using this endpoint.

Example

$ curl -i -X GET https://api.availity.com/availity/v1/claim-statuses/5334032768852043884
->
HTTP/1.1 200 OK
x-api-id: 98b6e65a-4d97-47f7-b9dc-2addb6544895
X-Session-ID: 98b6e65a-4d97-47f7-b9dc-2addb6544895
X-Api-Mock-Response: true
Cache-Control: private, no-store, max-age=0, must-revalidate
Content-Type: application/json
Date: Tue, 9 Jun 2015 09:30:37 GMT 
X-Global-Transaction-ID: 37112879
Connection: close
{
    "links": {
        "self": {
            "href": "https://api.availity.com/availity/v1/claim-statuses/5334032768852043884"
        }
    },
    "id": "5334032768852043884",
    "customerId": "1194",
    "controlNumber": "36392",
    "userId": "userid",
    "status": "Complete",
    "statusCode": "4",
    "createdDate": "2015-06-08T15:41:42.000+0000",
    "updatedDate": "2015-06-08T15:41:42.000+0000",
    "expirationDate": "2015-06-12T17:20:25.000+0000",
    "payer": {
        "id": "BCBSF",
        "name": "BCBSF"
    },
    "submitter": {
        "lastName": "DOCTORS OFFICE",
        "id": "G8486"
    },
    "providers": [
        {
            "lastName": "DOCTORS OFFICE"
            "npi": "1003847047"
        }
    ],
    "subscriber": {
        "firstName": "JAMES",
        "middleName": "E",
        "lastName": "JONES",
        "memberId": "ABCD1234567"
    },
    "patient": {
        "firstName": "JAMES",
        "middleName": "E",
        "lastName": "JONES",
        "birthDate": "1991-11-28",
        "gender": "Male",
        "genderCode": "M",
        "accountNumber": "UNKNOWN",
        "subscriberRelationship": "Self",
        "subscriberRelationshipCode": "18"
    },
    "claimStatuses": [
        {
            "traceId": "534180414",
            "claimControlNumber": "Q100000471322718",
            "facilityTypeCode": "13",
            "facilityType": "Hospital Outpatient",
            "frequencyTypeCode": "1",
            "frequencyType": "Admit thru Discharge Claim",
            "patientControlNumber": "UNKNOWN",
            "fromDate": "2015-05-15",
            "toDate": "2015-05-15",
            "statusDetails": [
                {
                    "category": "Finalized  The Claim/Encounter has completed the adjudication cycle and no more action will be taken",
                    "categoryCode": "F0",
                    "status": "Awaiting next periodic adjudication cycle",
                    "statusCode": "38",
                    "effectiveDate": "2015-06-01",
                    "claimAmount": "1568.34",
                    "claimAmountUnits": "USD",
                    "paymentAmount": "0",
                    "paymentAmountUnits": "USD",
                    "finalizedDate": "2015-05-27",
                    "remittanceDate": "2015-06-01",
                    "checkNumber": "203881588"
                }
            ],
            "serviceLines": [
                {
                    "procedureQualifier": "National Uniform Billing Committee (NUBC) UB92 Codes",
                    "procedureQualifierCode": "NU",
                    "chargeAmount": "195.87",
                    "chargeAmountUnits": "USD",
                    "paymentAmount": "0",
                    "paymentAmountUnits": "USD",
                    "quantity": "1",
                    "controlNumber": "1",
                    "fromDate": "2015-05-15",
                    "toDate": "2015-05-15",
                    "statusDetails": [
                        {
                            "category": "Finalized/Payment  The Claim/Line has been paid",
                            "categoryCode": "F1",
                            "status": "Processed according to contract provisions (Contract refers to provisions that exist between the Health Plan and a Provider of Health Care Services)",
                            "statusCode": "107",
                            "effectiveDate": "2015-06-01"
                        }
                    ]
                },
                {
                    "procedureQualifier": "National Uniform Billing Committee (NUBC) UB92 Codes",
                    "procedureQualifierCode": "NU",
                    "chargeAmount": "195.79",
                    "chargeAmountUnits": "USD",
                    "paymentAmount": "0",
                    "paymentAmountUnits": "USD",
                    "quantity": "1",
                    "controlNumber": "2",
                    "fromDate": "2015-05-15",
                    "toDate": "2015-05-15",
                    "statusDetails": [
                        {
                            "category": "Finalized/Payment  The Claim/Line has been paid",
                            "categoryCode": "F1",
                            "status": "Processed according to contract provisions (Contract refers to provisions that exist between the Health Plan and a Provider of Health Care Services)",
                            "statusCode": "107",
                            "effectiveDate": "2015-06-01"
                        }
                    ]
                },
                {
                    "procedureQualifier": "National Uniform Billing Committee (NUBC) UB92 Codes",
                    "procedureQualifierCode": "NU",
                    "chargeAmount": "7.52",
                    "chargeAmountUnits": "USD",
                    "paymentAmount": "0",
                    "paymentAmountUnits": "USD",
                    "quantity": "1",
                    "controlNumber": "3",
                    "fromDate": "2015-05-15",
                    "toDate": "2015-05-15",
                    "statusDetails": [
                        {
                            "category": "Finalized/Payment  The Claim/Line has been paid",
                            "categoryCode": "F1",
                            "status": "Processed according to contract provisions (Contract refers to provisions that exist between the Health Plan and a Provider of Health Care Services)",
                            "statusCode": "107",
                            "effectiveDate": "2015-06-01"
                        }
                    ]
                },
                {
                    "procedureQualifier": "National Uniform Billing Committee (NUBC) UB92 Codes",
                    "procedureQualifierCode": "NU",
                    "chargeAmount": "412.54",
                    "chargeAmountUnits": "USD",
                    "paymentAmount": "0",
                    "paymentAmountUnits": "USD",
                    "quantity": "1",
                    "controlNumber": "4",
                    "fromDate": "2015-05-15",
                    "toDate": "2015-05-15",
                    "statusDetails": [
                        {
                            "category": "Finalized/Payment  The Claim/Line has been paid",
                            "categoryCode": "F1",
                            "status": "Processed according to contract provisions (Contract refers to provisions that exist between the Health Plan and a Provider of Health Care Services)",
                            "statusCode": "107",
                            "effectiveDate": "2015-06-01"
                        }
                    ]
                },
                {
                    "procedureQualifier": "National Uniform Billing Committee (NUBC) UB92 Codes",
                    "procedureQualifierCode": "NU",
                    "chargeAmount": "385.41",
                    "chargeAmountUnits": "USD",
                    "paymentAmount": "0",
                    "paymentAmountUnits": "USD",
                    "quantity": "1",
                    "controlNumber": "5",
                    "fromDate": "2015-05-15",
                    "toDate": "2015-05-15",
                    "statusDetails": [
                        {
                            "category": "Finalized/Payment  The Claim/Line has been paid",
                            "categoryCode": "F1",
                            "status": "Processed according to contract provisions (Contract refers to provisions that exist between the Health Plan and a Provider of Health Care Services)",
                            "statusCode": "107",
                            "effectiveDate": "2015-06-01"
                        }
                    ]
                },
                {
                    "procedureQualifier": "National Uniform Billing Committee (NUBC) UB92 Codes",
                    "procedureQualifierCode": "NU",
                    "chargeAmount": "371.21",
                    "chargeAmountUnits": "USD",
                    "paymentAmount": "0",
                    "paymentAmountUnits": "USD",
                    "quantity": "1",
                    "controlNumber": "6",
                    "fromDate": "2015-05-15",
                    "toDate": "2015-05-15",
                    "statusDetails": [
                        {
                            "category": "Finalized/Payment  The Claim/Line has been paid",
                            "categoryCode": "F1",
                            "status": "Processed according to contract provisions (Contract refers to provisions that exist between the Health Plan and a Provider of Health Care Services)",
                            "statusCode": "107",
                            "effectiveDate": "2015-06-01"
                        }
                    ]
                }
            ]
        }
    ],
    "claimCount": "1"
}

Responses

HTTP Status Code Description
200 We have returned an up to date copy of the resource.
202 We have not yet received a response from the health plan, but are still trying. You should try again later.
400 The health plan indicated that something is wrong with the request. The resource should have a list of validationMessages. Correct and resubmit the request.
404 We did not find a ClaimStatus with the id that you specified.
504 We did not receive a respsone from the health plan within the time allotted. You should try your request again later.

DELETE /V1/CLAIM-STATUSES/:ID

You can delete a claim status using this endpoint.

Example

$ curl -i -X DELETE https://api.availity.com/availity/v1/claim-statuses/-3067319688589945459
->
HTTP/1.1 204 No Content
x-api-id: 98b6e65a-4d97-47f7-b9dc-2addb6544895
X-Session-ID: 98b6e65a-4d97-47f7-b9dc-2addb6544895
X-Api-Mock-Response: true
Cache-Control: private, no-store, max-age=0, must-revalidate
Content-Type: application/json
Date: Tue, 9 Jun 2015 09:30:37 GMT 
X-Global-Transaction-ID: 37112879
Connection: close

Responses

HTTP Status Code Description
204 We have deleted the resource from our system.
404 We did not find a ClaimStatus with the id that you specified.

Care Cost Estimator - Professional

A Care Cost Estimator (CCE), also known as Predetermination, is a claim request for payment that a health care provider submits to a health plan before they've provided a service or items to a member. Your application can use this endpoint to submit an professional claim predetermination for an professional claim, additionally you can use the endpoint to find and manage previous claim predetermination requests.

Working with the DEMO endpoints

Availity allows you to specify the type of response you want when interacting with our Professional Care Cost Estimator demonstration service by sending a header (X-Api-Mock-Scenario-ID) with the appropriate response scenario id. The supported response scenarios are listed below.

For POST methods send an empty JSON body such as: "{}"

Response Scenario ID Method HTTP Status Description
CCEP-Success-i GET - use id 123 200 Availity has successfully retrieved the member's claim predetermination information from the health plan.
CCEP-Accepted-i POST 202 Availity is in the process of retrieving the member's claim predetermination information from the health plan.
CCEP-RequestErrors1-i POST 400 Your request failed Availity's input validation rules.
CCEP-RequestErrors2-i POST 400 Your request failed Availity's input validation rules.
CCEP-RequestParseError-i POST 500 We were unable to parse your request.
CCEP-MultiServiceLines-i GET - use id 54321 200 Availity has successfully retrieved the member's claim predetermination information that contains multiple service lines from the health plan.

You can confirm you've received a mock response by inspecting the response headers. You should see the following header:

X-Api-Mock-Response: true

Overview

A predetermination of benefits is a review by a health plans automated claim processing system or a their medical staff to decide if they agree that the treatment is right for the patient's health needs. A predetermination is done before a patient receives healthcare. This allows the patient to know early if it is covered by their health plan.

Each health plan has different required information they need to process a CCE. Because of this, you'll want to ensure you utilize the Configurations service to determine the required fields for a specific health plan before submitting it. See the Configurations service for details on it's use.

Configuration Service Subtype

The type name for the professional-claims service is: professional-claims Use the subtypeId name of: PRE_DETERMINATION

Example usage:

$ curl -i -X GET https://api.availity.com/availity/v1/configurations?type=professional-claims&payerId=BCBSF&subtypeId=PRE_DETERMINATION

Submitting a Predetermination Claim

The PRE_DETERMINATION request type submits a claim request to a health plan to determine a patient's out of pocket estimate based on their plans coverage. Note that this does not produce an adjudicated claim.

The Resource

Field Type Description
id String A unique identifier that Availity has assigned to this ProfessionalClaim.
createdDate TimeStamp The date and time when this item was created in Availity's system.
updatedDate TimeStamp The date and time when this item was last updated.
expirationDate TimeStamp The date and time when this item will be removed from Availity's system.
customerId String The id of the Availity customer that owns this ProfessionalClaim. Availity may ask for this during support calls.
requestTypeCode String The type of request to perform for professional claims. Use PRE_DETERMINATION for Predetermination.
submitter Object An object representing the submitter of a claim.
submitter.lastName String The last or business name of the submitter.
submitter.firstName String The first name of the submitter.
submitter.middleName String The middle name of the submitter.
submitter.suffix String The suffix of the submitter.
submitter.id String The identifier of the submitter.
submitter.contactName String The contact name of the submitter.
submitter.phone String The phone number of the submitter.
submitter.extension String The phone extension of the submitter.
submitter.fax String The fax number of the submitter.
submitter.email String The email of the submitter.
payer Object An object representing the health plan of the patient.
payer.id String The Availity id of the health plan.
payer.name String The name of the health plan.
payer.claimFilingIndicatorCode String The claim filing indicator code for the type of insurance.
billingProvider Object An object representing the billing provider of the claim.
billingProvider.specialtyCode String The claim filing indicator code for the type of insurance.
billingProvider.lastName String The last name of individual (Person) or business name (Non-Person Entity) of the billing provider. – REQUIRED
billingProvider.firstName String The first name of the billing provider. Situational: REQUIRED if submitting Individual (Person) billingProvider.ein or billingProvider.ssn
billingProvider.middleName String The middle name of the billing provider.
billingProvider.suffix String The suffix of the billing provider.
billingProvider.npi String The national provider id of the billing provider.
billingProvider.addressLine1 String The first line of the address of the billing provider.
billingProvider.addressLine2 String The second line of the address of the billing provider.
billingProvider.city String The city of the billing provider.
billingProvider.stateCode String The code of the state of the billing provider.
billingProvider.zipCode String The ZIP code of the billing provider.
billingProvider.ein String The employer identification number of the billing provider.
billingProvider.ssn String The social security number of the billing provider.
billingProvider.stateLicenseNumber String The state license number of the billing provider.
billingProvider.payerAssignedProviderId String The payer assigned provider id of the billing provider.
billingProvider.contactName String The contact name of the billing provider.
billingProvider.phone String The phone number of the billing provider.
billingProvider.extension String The phone extension of the billing provider.
billingProvider.fax String The fax number of the billing provider.
billingProvider.email String The email of the billing provider.
billingProvider.payTo.addressLine1 String The first line of the address for the pay to of the billing provider.
billingProvider.payTo.addressLine2 String The second line of the address for the pay to of the billing provider.
billingProvider.payTo.city String The city of the pay to of the billing provider.
billingProvider.payTo.stateCode String The code of the state for the pay to of the billing provider.
billingProvider.payTo.zipCode String The ZIP code for the pay to of the billing provider.
subscriber Object An object representing the subscriber of the claim.
subscriber.lastName String The last or business name of the subscriber.
subscriber.firstName String The first name of the subscriber.
subscriber.middleName String The middle name of the subscriber.
subscriber.suffix String The suffix of the subscriber.
subscriber.memberId String The member id of the subscriber.
subscriber.groupNumber String The group number of the subscriber.
subscriber.groupName String The group name of the subscriber.
subscriber.addressLine1 String The first line of the address of the subscriber.
subscriber.addressLine2 String The second line of the address of the subscriber.
subscriber.city String The city of the subscriber.
subscriber.stateCode String The code of the state of the subscriber.
subscriber.zipCode String The ZIP code of the subscriber.
subscriber.totalDeductible String The total individual deductible dollar amount for this health care plan.
subscriber.accumulatedDeductible String The accumulated individual deductible dollar amount for this health care plan.
subscriber.remainingDeductible String The remaining individual deductible dollar amount for this health care plan.
subscriber.onHold Boolean Indicates where the subscriber is on hold.
subscriber.holdReasons Object Array An array of hold reasons for the claim.
subscriber.holdReasons.code String A code indicating the hold reason.
subscriber.holdReasons.description String A description for why the hold is in place.
patient Object An object representing the patient of the claim.
patient.lastName String The last or business name of the patient.
patient.firstName String The first name of the patient.
patient.middleName String The middle name of the patient.
patient.suffix String The suffix of the patient.
patient.addressLine1 String The first line of the address of the patient.
patient.addressLine2 String The second line of the address of the patient.
patient.city String The city of the patient.
patient.stateCode String The code of the state of the patient.
patient.zipCode String The ZIP code of the patient.
patient.birthDate Date The birth date of the patient.
patient.gender String A description of the gender of the patient.
patient.genderCode String A code representing the gender of the patient.
patient.subscriberRelationship String A description of the patient's relationship to the subscriber.
patient.subscriberRelationshipCode String A code representing the patient's relationship to the subscriber.
claimInformation Object An object representing the claim information of the claim.
claimInformation.bundled Boolean Indicating whether the payer believes that the actual services performed and reported must be paid under only one procedure code.
claimInformation.controlNumber String A unique reference identifier provided by the submitter.
claimInformation.placeOfServiceCode String A code representing the place of service.
claimInformation.frequencyTypeCode String A code specifying the frequency of the claim.
claimInformation.providerSignatureOnFile Boolean Indicates whether a provider's signature is on file with the healthcare plan.
claimInformation.providerAcceptAssignmentCode String A code indicating whether the provider accepts assignment.
claimInformation.benefitsAssignmentCertification String A code indicating assignment of benefits for a claim.
claimInformation.informationReleaseCode String A code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations.
claimInformation.displayMessage String The display message a payer may return.
claimInformation.messages Object Array An array of messages.
claimInformation.messages.code String The message code.
claimInformation.messages.description String The message description.
claimInformation.messages.procedure String The procedure for the message.
claimInformation.diagnoses Object Array An array of diagnosis codes for the claim.
claimInformation.diagnoses.qualifier String The description of the qualifier indicating what type of diagnosis code is used.
claimInformation.diagnoses.qualifierCode String A code representing the qualifier indicating what type of diagnosis code is used.
claimInformation.diagnoses.code String A code representing the diagnosis.
claimInformation.serviceLines Object Array An array of service lines for the claim.
claimInformation.serviceLines.fromDate String The start date of the service.
claimInformation.serviceLines.toDate String The end date of the service.
claimInformation.serviceLines.controlNumber String A unique reference identifier provided by the submitter.
claimInformation.serviceLines.placeOfServiceCode String A code representing the place of service. This overrides the placeOfServiceCode at the Claim Information level.
claimInformation.serviceLines.procedureCode String A code representing the procedure performed.
claimInformation.serviceLines.modifierCode1 String A description of the first modifier applied to this procedure.
claimInformation.serviceLines.modifierCode2 String A description of the second modifier applied to this procedure.
claimInformation.serviceLines.modifierCode3 String A description of the third modifier applied to this procedure.
claimInformation.serviceLines.modifierCode4 String A description of the forth modifier applied to this procedure.
claimInformation.serviceLines.diagnosisCodePointer1 String A pointer to the first diagnosis code in this service.
claimInformation.serviceLines.diagnosisCodePointer2 String A pointer to the second diagnosis code in this service.
claimInformation.serviceLines.diagnosisCodePointer3 String A pointer to the third diagnosis code in this service.
claimInformation.serviceLines.diagnosisCodePointer4 String A pointer to the forth diagnosis code in this service.
claimInformation.serviceLines.amount String This total charge amount for this service line. The amount is inclusive of the provider’s base charge and any applicable tax and/or postage claimed amounts.
claimInformation.serviceLines.quantity String The units of service.
claimInformation.serviceLines.quantityTypeCode String A code representing the quantity units.
claimInformation.serviceLines.estimatedPatientResponsibility String The estimated amount of the patient's responsibility.
claimInformation.serviceLines.bundlingDescription String The service bundling description.
claimInformation.serviceLines.denyReason String The reason why the procedure is denied.
claimInformation.serviceLines.holdReasons Object Array An array of hold reasons for the procedure.
claimInformation.serviceLines.holdReasons.code String The hold reason code.
claimInformation.serviceLines.holdReasons.description String The hold reason description.
claimInformation.serviceLines.messages Object Array An array of messages for the procedure.
claimInformation.serviceLines.messages.code String The message code.
claimInformation.serviceLines.messages.description String The message description.
claimInformation.serviceLines.messages.procedure String The procedure for the message.
claimInformation.serviceLines.displayMessage String The display message a payer may return.
claimInformation.serviceLines.allowed Object An object representing the allowed portion of the procedure performed.
claimInformation.serviceLines.allowed.amount String The amount allowed for the procedure performed.
claimInformation.serviceLines.allowed.code String The code for the procedure performed.
claimInformation.serviceLines.allowed.codeType String A code type for the procedure performed.
claimInformation.serviceLines.allowed.description String The description of the allowed amount the procedure performed.
claimInformation.serviceLines.allowed.procedure String The procedure code of the procedure performed.
claimInformation.serviceLines.allowed.patientLiable Boolean Indicates whether the patient is liable.
claimInformation.serviceLines.notCovered Object An object representing the not covered portion of the procedure performed.
claimInformation.serviceLines.notCovered.amount String The amount not covered for the procedure performed.
claimInformation.serviceLines.notCovered.code String The code for the procedure performed.
claimInformation.serviceLines.notCovered.codeType String A code type for the procedure performed.
claimInformation.serviceLines.notCovered.description String The description of the not covered amount the procedure performed.
claimInformation.serviceLines.notCovered.procedure String The procedure code of the procedure performed.
claimInformation.serviceLines.notCovered.patientLiable Boolean Indicates whether the patient is liable.
claimInformation.serviceLines.coPay Object An object representing the copay portion of the procedure performed.
claimInformation.serviceLines.coPay.amount String The amount of copay for the procedure performed.
claimInformation.serviceLines.coPay.code String The code for the procedure performed.
claimInformation.serviceLines.coPay.codeType String A code type for the procedure performed.
claimInformation.serviceLines.coPay.description String The description of the copay amount the procedure performed.
claimInformation.serviceLines.coPay.procedure String The procedure code of the procedure performed.
claimInformation.serviceLines.coPay.patientLiable Boolean Indicates whether the patient is liable.
claimInformation.serviceLines.coInsurance Object An object representing the co-insurance portion of the procedure performed.
claimInformation.serviceLines.coInsurance.amount String The amount of co-insurance for the procedure performed.
claimInformation.serviceLines.coInsurance.code String The code for the procedure performed.
claimInformation.serviceLines.coInsurance.codeType String A code type for the procedure performed.
claimInformation.serviceLines.coInsurance.description String The description of the co-insurance amount the procedure performed.
claimInformation.serviceLines.coInsurance.procedure String The procedure code of the procedure performed.
claimInformation.serviceLines.coInsurance.patientLiable Boolean Indicates whether the patient is liable.
claimInformation.serviceLines.deductible Object An object representing the deductible portion of the procedure performed.
claimInformation.serviceLines.deductible.amount String The amount of deductible for the procedure performed.
claimInformation.serviceLines.deductible.code String The code for the procedure performed.
claimInformation.serviceLines.deductible.codeType String A code type for the procedure performed.
claimInformation.serviceLines.deductible.description String The description of the deductible amount the procedure performed.
claimInformation.serviceLines.deductible.procedure String The procedure code of the procedure performed.
claimInformation.serviceLines.deductible.patientLiable Boolean Indicates whether the patient is liable.

POST /V1/PROFESSIONAL-CLAIMS

This endpoint creates a CCE asynchronously. To submit a CCE, make a valid request and a response will be returned with a location header containing a URL you can query for your result.

RESPONSES

HTTP Status Code Description
202 The CCE was accepted for processing. Poll the URL in the Location header. The X-Status-Message header will contain additional detail.
400 The CCE request failed validation. It either failed our validation rules or was rejected by the health plan. The errors property will contain detailed information. Errors that specify a field are Availity validation rule failures. Errors that specify a code are from the health plan. Correct the errors and resubmit the request.
500 We were unable to parse your request. Correct the errors and resubmit the request.

VALIDATION RULES

The validation rules for the ProfessionalClaim resource can vary by health plan, the type of claim being requested, and the type of service to be performed. Availity organizes these rules and makes them available through the Configuration service. The Configuration resource documents the fields you need to send to create a ProfessionalClaim and explains what values are valid for those fields. See the Configurations service for details.

EXAMPLES

If your request is invalid, we will respond with a status code of 400 and a list of errors for you to correct.

$ curl -i -H "Content-Type: application/json" -X POST -d '{
  "requestTypeCode": "PRE_DETERMINATION",
  "billingProvider": {
    "npi": "123456789"
  },
  "patient": {
    "relationshipCode": "01",
    "lastName": "Smith",
    "firstName": "Bob",
    "stateCode": "FL",
    "birthDate": "1980-02-12",
    "genderCode": "M"
  },
  "payer": {
    "id": "BCBSF"
  },
  "submitter": {
    "id": "123456789",
    "lastName": "SUBMITTER"
  },
  "subscriber": {
    "memberId": "JDH001",
    "groupName": "ASDF 1-2",
    "groupNumber": "12312412"
  },
  "claimInformation": {
    "placeOfServiceCode": "11",
    "diagnoses": [
      {
        "qualifierCode": "ABK",
        "code": "J3089"
      }
    ],
    "serviceLines": [
      {
        "procedureCode": "92523",
        "quantity": "100",
        "amount": "250",
        "fromDate": "2016-05-10"
      }
    ]
  }
}' https://api.availity.com/availity/v1/professional-claims

HTTP/1.1 400 Bad Request
Cache-Control: private,no-store,max-age=0,must-revalidate
Content-Type: application/json
Date: Fri, 03 Jun 2016 18:19:16 GMT
x-api-id: 7407a7ee-1940-4c8b-b9ec-57e9b0059214
X-Session-ID: 7407a7ee-1940-4c8b-b9ec-57e9b0059214
Connection: close

{
  "userMessage" : "Your request was invalid.",
  "developerMessage" : "The request was invalid. See the 'errors' property for details.",
  "reasonCode" : 0,
  "statusCode" : 400,
  "errors" : [ {
    "field" : "billingProvider.ein",
    "errorMessage" : "Enter a valid Billing Provider EIN.",
    "index" : 0,
    "nestedEntityErrors" : [ ]
  }, {
    "field" : "billingProvider.npi",
    "errorMessage" : "Enter a valid Billing Provider National Provider Identifier (NPI) containing 10 numeric digits and beginning with a 1, 2, 3, or 4.",
    "index" : 0,
    "nestedEntityErrors" : [ ]
  }, {
    "field" : "billingProvider.payerAssignedProviderId",
    "errorMessage" : "Enter a valid Billing Provider Payer Assigned Provider ID",
    "index" : 0,
    "nestedEntityErrors" : [ ]
  } ]
}

If your request is valid, we will respond with a status code of 202 and a location header where you can check back for your response. We will continue to respond in this way until we have heard back from the health plan.

$ curl -i -H "Content-Type: application/json" -X POST -d '{
  "requestTypeCode": "PRE_DETERMINATION",
  "billingProvider": {
    "npi": "1234567893",
    "ein": "111222333",
    "payerAssignedProviderId": "XYZ321"
  },
  "patient": {
    "relationshipCode": "01",
    "lastName": "Smith",
    "firstName": "Bob",
    "stateCode": "FL",
    "birthDate": "1980-02-12",
    "genderCode": "M"
  },
  "payer": {
    "id": "BCBSF"
  },
  "submitter": {
    "id": "123456789",
    "lastName": "SUBMITTER"
  },
  "subscriber": {
    "memberId": "JDH001",
    "groupName": "ASDF 1-2",
    "groupNumber": "12312412"
  },
  "claimInformation": {
    "placeOfServiceCode": "11",
    "diagnoses": [
      {
        "qualifierCode": "ABK",
        "code": "J3089"
      }
    ],
    "serviceLines": [
      {
        "procedureCode": "92523",
        "quantity": "100",
        "amount": "250",
        "fromDate": "2016-05-10"
      }
    ]
  }
}' https://api.availity.com/availity/v1/professional-claims

->
HTTP/1.1 202 Accepted
Cache-Control: private,no-store,max-age=0,must-revalidate
Content-Type: application/json;charset=utf-8
Date: Fri, 03 Jun 2016 20:00:40 GMT
Location: https://api.availity.com/availity/v1/professional-claims/1684335841477061460
x-api-id: 78a4490e-8437-49c1-a5b5-0eab3ba1d996
X-Session-ID: 78a4490e-8437-49c1-a5b5-0eab3ba1d996
X-Status-Message: We are processing your request.
Connection: close

GET /V1/PROFESSIONAL-CLAIMS/:ID

You can retrieve a CCE using this endpoint.

RESPONSES

HTTP Status Code Description
200 We are done processing your request and the response body contains the result.
202 We are currently processing your request. We may be retrying it.
400 Your CCE request failed validation. You can correct the errors and resubmit.
404 We did not find a ProfessionalClaim with the id that you sent.
504 We were unable to process your request. The health plan did not respond after several retry attempts. Please try your request again later.

EXAMPLES

You can request the URI that was returned in the Location response header during from your POST request. If the resource is found but we have not received a response from the health plan, we will respond with a status code of 202 and a Location header where you can check back for your response. We will continue to respond in this way until we have heard back from the health plan.

$ curl -i -X GET https://api.availity.com/availity/v1/professional-claims/1684335841477061460
->
HTTP/1.1 202 Accepted
Cache-Control: private,no-store,max-age=0,must-revalidate
Content-Type: application/json;charset=utf-8
Date: Mon, 06 Jun 2016 18:11:34 GMT
Location: https://api.availity.com/availity/v1/professional-claims/1684335841477061460
x-api-id: 25a71361-7f75-4dc9-918b-021e163b0df8
X-Session-ID: 25a71361-7f75-4dc9-918b-021e163b0df8
X-Status-Message: The health plan did not respond. We are retrying the request.
Connection: close

Once we have a response from the health plan, we will respond with a status code of 200 and a ProfessionalClaim resource.

$ curl -i -X GET https://api.availity.com/availity/v1/professional-claims/1684335841477061460
->
HTTP/1.1 200 OK
Cache-Control: private,no-store,max-age=0,must-revalidate
Content-Type: application/json;charset=utf-8
Date: Mon, 06 Jun 2016 18:35:19 GMT
x-api-id: 22d78708-6094-4e95-a8fe-3bb762975fd3
X-Availity-Transaction-ID: 1613032
X-Session-ID: 22d78708-6094-4e95-a8fe-3bb762975fd3

{
  "id" : "1684335841477061460",
  "createdDate" : "2016-06-06T18:34:46.000+0000",
  "updatedDate" : "2016-06-06T18:34:52.000+0000",
  "expirationDate" : "2016-06-07T18:34:46.000+0000",
  "requestTypeCode" : "PRE_DETERMINATION",
  "submitter" : {
    "lastName" : "Island Ear Nose and Throat",
    "id" : "263749002"
  },
  "payer" : {
    "id" : "BCBSF"
  },
  "billingProvider" : {
    "npi" : "1255569224",
    "payerAssignedProviderId" : "G4402"
  },
  "subscriber" : {
    "memberId" : "H23183209",
    "totalDeductible" : "6100.00",
    "accumulatedDeductible" : "0.00",
    "remainingDeductible" : "6100.00",
    "onHold" : false
  },
  "patient" : {
    "lastName" : "CARIDAD",
    "firstName" : "ANISLEIDY",
    "birthDate" : "1992-11-22",
    "gender" : "Female",
    "genderCode" : "F",
    "subscriberRelationship" : "Self",
    "subscriberRelationshipCode" : "18"
  },
  "claimInformation" : {
    "bundled" : false,
    "diagnoses" : [ {
      "qualifier" : "International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis",
      "qualifierCode" : "ABK",
      "code" : "J3089"
    } ],
    "serviceLines" : [ {
      "procedure" : "PROFESSIONAL SVCS FOR THE SUPERVISION OF PREP & PROVISION OF ANTIGENS FOR ALLERGEN IMMUNOTHERAPY; SINGLE OR MULTIPLE ANTIGENS (SPE",
      "procedureCode" : "95165",
      "amount" : "2500.00",
      "estimatedPatientResponsibility" : "10.00",
      "allowed" : {
        "amount" : "1807.50",
        "code" : "PPSCH",
        "codeType" : "AL",
        "description" : "Allowed amount based on fee schedule",
        "patientLiable" : false
      },
      "coPay" : {
        "amount" : "10.00",
        "code" : "BCPI",
        "codeType" : "CP",
        "patientLiable" : true
      }
    } ]
  }
}

Care Cost Estimator - Institutional

A Care Cost Estimator (CCE), also known as Predetermination, is a claim request for payment that a health care provider submits to a health plan before they've provided a service or items to a member. Your application can use this endpoint to submit an institutional claim predetermination for an institutional claim, additionally you can use the endpoint to find and manage previous claim predetermination requests.

Working with the DEMO endpoints

Availity allows you to specify the type of response you want when interacting with our Institutional Care Cost Estimator demonstration service by sending a header (X-Api-Mock-Scenario-ID) with the appropriate response scenario id. The supported response scenarios are listed below.

For POST methods send an empty JSON body such as: "{}"

Response Scenario ID Method HTTP Status Description
CCEI-Success-i GET - use id 123 200 Availity has successfully retrieved the member's CCE predetermination information from the health plan.
CCEI-Accepted-i POST 202 Availity is in the process of retrieving the member's CCE predetermination information from the health plan.
CCEI-RequestErrors1-i POST 400 Your request failed Availity's input validation rules.
CCEI-RequestErrors2-i POST 400 Your request failed Availity's input validation rules.
CCEI-RequestParseError-i POST 500 We were unable to parse your request.

You can confirm you've received a mock response by inspecting the response headers. You should see the following header:

X-Api-Mock-Response: true

Overview

A predetermination of benefits is a review by a health plans automated claim processing system or a their medical staff to decide if they agree that the treatment is right for the patient's health needs. A predetermination is done before a patient receives healthcare. This allows the patient to know early if it is covered by their health plan.

Each health plan has different required information they need to process a CCE. Because of this, you'll want to ensure you utilize the Configurations service to determine the required fields for a specific health plan before submitting it. See the Configurations service for details on it's use.

Configuration Service Subtype

The type name for the institutional-claims service is: institutional-claims Use the subtypeId name of: PRE_DETERMINATION

Example usage:

$ curl -i -X GET https://api.availity.com/availity/v1/configurations?type=institutional-claims&payerId=BCBSF&subtypeId=PRE_DETERMINATION

Submitting a Predetermination Institutional Claim

The PRE_DETERMINATION request subtype submits a claim request to a health plan to determine a patient's out of pocket estimate based on their plans coverage. Note that this does not produce an adjudicated claim.

The Resource

Field Type Description
id String A unique identifier that Availity has assigned to this InstitutionalClaim.
createdDate TimeStamp The date and time when this item was created in Availity's system.
updatedDate TimeStamp The date and time when this item was last updated.
expirationDate TimeStamp The date and time when this item will be removed from Availity's system.
customerId String The id of the Availity customer that owns this InstitutionalClaim. Availity may ask for this during support calls.
requestTypeCode String The type of request to perform for institutional claims. Use PRE_DETERMINATION for Predetermination.
submitter Object An object representing the submitter of a claim.
submitter.lastName String The last or business name of the submitter.
submitter.firstName String The first name of the submitter.
submitter.middleName String The middle name of the submitter.
submitter.suffix String The suffix of the submitter.
submitter.id String The identifier of the submitter.
submitter.contactName String The contact name of the submitter.
submitter.phone String The phone number of the submitter.
submitter.extension String The phone extension of the submitter.
submitter.fax String The fax number of the submitter.
submitter.email String The email of the submitter.
payer Object An object representing the health plan of the patient.
payer.id String The Availity id of the health plan.
payer.name String The name of the health plan.
payer.claimFilingIndicatorCode String The claim filing indicator code for the type of insurance.
billingProvider Object An object representing the billing provider of the claim.
billingProvider.specialtyCode String The claim filing indicator code for the type of insurance.
billingProvider.name String The business name of the billing provider.
billingProvider.npi String The national provider id of the billing provider.
billingProvider.addressLine1 String The first line of the address of the billing provider.
billingProvider.addressLine2 String The second line of the address of the billing provider.
billingProvider.city String The city of the billing provider.
billingProvider.stateCode String The code of the state of the billing provider.
billingProvider.zipCode String The ZIP code of the billing provider.
billingProvider.ein String The employer identification number of the billing provider.
billingProvider.payerAssignedProviderId String The payer assigned provider id of the billing provider.
billingProvider.contactName String The contact name of the billing provider.
billingProvider.phone String The phone number of the billing provider.
billingProvider.extension String The phone extension of the billing provider.
billingProvider.fax String The fax number of the billing provider.
billingProvider.email String The email of the billing provider.
billingProvider.payTo.addressLine1 String The first line of the address for the pay to of the billing provider.
billingProvider.payTo.addressLine2 String The second line of the address for the pay to of the billing provider.
billingProvider.payTo.city String The city of the pay to of the billing provider.
billingProvider.payTo.stateCode String The code of the state for the pay to of the billing provider.
billingProvider.payTo.zipCode String The ZIP code for the pay to of the billing provider.
subscriber Object An object representing the subscriber of the claim.
subscriber.lastName String The last or business name of the subscriber.
subscriber.firstName String The first name of the subscriber.
subscriber.middleName String The middle name of the subscriber.
subscriber.suffix String The suffix of the subscriber.
subscriber.memberId String The member id of the subscriber.
subscriber.groupNumber String The group number of the subscriber.
subscriber.groupName String The group name of the subscriber.
subscriber.addressLine1 String The first line of the address of the subscriber.
subscriber.addressLine2 String The second line of the address of the subscriber.
subscriber.city String The city of the subscriber.
subscriber.stateCode String The code of the state of the subscriber.
subscriber.zipCode String The ZIP code of the subscriber.
subscriber.totalFamilyDeductible String The total family deductible dollar amount for the health care plan.
subscriber.accumulatedFamilyDeductible String The accumulated family deductible dollar amount for the health care plan.
subscriber.remainingFamilyDeductible String The remaining family deductible dollar amount for the health care plan.
subscriber.totalDeductible String The total individual deductible dollar amount for this health care plan.
subscriber.accumulatedDeductible String The accumulated individual deductible dollar amount for this health care plan.
subscriber.remainingDeductible String The remaining individual deductible dollar amount for this health care plan.
subscriber.onHold Boolean Indicates whether a subscriber is on hold.
subscriber.holdReasons Object Array An array of hold reasons for the claim.
subscriber.holdReasons.code String A code indicating the hold reason.
subscriber.holdReasons.description String A description for why the hold is in place.
patient Object An object representing the patient of the claim.
patient.lastName String The last or business name of the patient.
patient.firstName String The first name of the patient.
patient.middleName String The middle name of the patient.
patient.suffix String The suffix of the patient.
patient.addressLine1 String The first line of the address of the patient.
patient.addressLine2 String The second line of the address of the patient.
patient.city String The city of the patient.
patient.stateCode String The code of the state of the patient.
patient.zipCode String The ZIP code of the patient.
patient.birthDate Date The birth date of the patient.
patient.gender String A description of the gender of the patient.
patient.genderCode String A code representing the gender of the patient.
patient.subscriberRelationship String A description of the patient's relationship to the subscriber.
patient.subscriberRelationshipCode String A code representing the patient's relationship to the subscriber.
claimInformation Object An object representing the claim information of the claim.
claimInformation.controlNumber String A unique reference identifier provided by the submitter that was provided in the original claim status request.
claimInformation.facilityTypeCode String A code representing where services may be performed.
claimInformation.frequencyTypeCode String A code specifying the frequency of the claim.
claimInformation.providerAcceptAssignmentCode String A code indicating whether the provider accepts assignment.
claimInformation.benefitsAssignmentCertification String A code indicating assignment of benefits for a claim.
claimInformation.informationReleaseCode String A code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations.
claimInformation.admissionTypeCode String A code indicating the priority of this admission.
claimInformation.admissionSourceCode String A code indicating the source of this admission.
claimInformation.patientStatusCode String A code indicating patient status as of the "statement covers through date".
claimInformation.bundled Boolean Indicating whether the payer believes that the actual services performed and reported must be paid under only one procedure code.
claimInformation.displayMessage String The display message a payer may return.
claimInformation.principalDiagnosis Object An object representing the principal diagnosis code for the claim.
claimInformation.principalDiagnosis.qualifier String The description of the qualifier indicating what type of diagnosis code is used.
claimInformation.principalDiagnosis.qualifierCode String A code representing the qualifier indicating what type of diagnosis code is used.
claimInformation.principalDiagnosis.presentOnAdmissionIndicatorCode String Identifies the diagnosis onset as it relates to the diagnosis code.
claimInformation.otherDiagnoses Object Array An array representing the other diagnosis codes for the claim.
claimInformation.otherDiagnoses.qualifier String The description of the qualifier indicating what type of diagnosis code is used.
claimInformation.otherDiagnoses.qualifierCode String A code representing the qualifier indicating what type of diagnosis code is used.
claimInformation.otherDiagnoses.presentOnAdmissionIndicatorCode String Identifies the diagnosis onset as it relates to the diagnosis code.
claimInformation.principalProcedure Object An object representing the principal procedure code for the claim.
claimInformation.principalProcedure.qualifier String The description of the qualifier indicating what type of procedure code is used.
claimInformation.principalProcedure.qualifierCode String A code representing the qualifier indicating what type of procedure code is used.
claimInformation.principalProcedure.code String A code respresenting the procedure performed.
claimInformation.otherProcedures Object Array An array representing the other procedure codes for the claim.
claimInformation.otherProcedures.qualifier String The description of the qualifier indicating what type of procedure code is used.
claimInformation.otherProcedures.qualifierCode String A code representing the qualifier indicating what type of procedure code is used.
claimInformation.otherProcedures.code String A code representing the procedure performed.
claimInformation.serviceLines Object Array An array of service lines for the claim.
claimInformation.controlNumber String A unique reference identifier provided by the submitter that was provided in the original claim status request.
claimInformation.serviceLines.fromDate String The start date of the service.
claimInformation.serviceLines.toDate String The end date of the service.
claimInformation.serviceLines.revenueCode String The identifying number for a product or service.
claimInformation.serviceLines.procedure Stirng The description of the procedure performed.
claimInformation.serviceLines.procedureCode String A code respresenting the procedure performed.
claimInformation.serviceLines.modifierCode1 String A description of the first modifier applied to this procedure.
claimInformation.serviceLines.modifierCode2 String A description of the second modifier applied to this procedure.
claimInformation.serviceLines.modifierCode3 String A description of the third modifier applied to this procedure.
claimInformation.serviceLines.modifierCode4 String A description of the forth modifier applied to this procedure.
claimInformation.serviceLines.amount String This total charge amount for this service line. The amount is inclusive of the provider’s base charge and any applicable tax and/or postage claimed amounts.
claimInformation.serviceLines.quantity String The units of service.
claimInformation.serviceLines.quantityTypeCode String A code representing the quantity units.
claimInformation.serviceLines.estimatedPatientResponsibility String The estimated amount of the patient's responsibility.
claimInformation.serviceLines.bundlingDescription String The description from the payer if bundling was performed.
claimInformation.serviceLines.denyReason String The reason why the procedure is denied.
claimInformation.serviceLines.holdReasons Object Array An array of hold reasons for the procedure.
claimInformation.serviceLines.holdReasons.code String The hold reason code.
claimInformation.serviceLines.holdReasons.description String The hold reason description.
claimInformation.serviceLines.messages Object Array An array of messages for the procedure.
claimInformation.serviceLines.messages.code String The message code.
claimInformation.serviceLines.messages.description String The message description.
claimInformation.serviceLines.messages.procedure String The procedure for the message.
claimInformation.serviceLines.displayMessage String The display message a payer may return.
claimInformation.serviceLines.allowed Object An object representing the allowed portion of the procedure performed.
claimInformation.serviceLines.allowed.amount String The amount allowed for the procedure performed.
claimInformation.serviceLines.allowed.code String The code for the procedure performed.
claimInformation.serviceLines.allowed.codeType String A code type for the procedure performed.
claimInformation.serviceLines.allowed.description String The description of the allowed amount the procedure performed.
claimInformation.serviceLines.allowed.procedure String The procedure code of the procedure performed.
claimInformation.serviceLines.allowed.patientLiable Boolean Indicates whether the patient is liable.
claimInformation.serviceLines.notCovered Object An object representing the not covered portion of the procedure performed.
claimInformation.serviceLines.notCovered.amount String The amount not covered for the procedure performed.
claimInformation.serviceLines.notCovered.code String The code for the procedure performed.
claimInformation.serviceLines.notCovered.codeType String A code type for the procedure performed.
claimInformation.serviceLines.notCovered.description String The description of the not covered amount the procedure performed.
claimInformation.serviceLines.notCovered.procedure String The procedure code of the procedure performed.
claimInformation.serviceLines.notCovered.patientLiable Boolean Indicates whether the patient is liable.
claimInformation.serviceLines.coPay Object An object representing the copay portion of the procedure performed.
claimInformation.serviceLines.coPay.amount String The amount of copay for the procedure performed.
claimInformation.serviceLines.coPay.code String The code for the procedure performed.
claimInformation.serviceLines.coPay.codeType String A code type for the procedure performed.
claimInformation.serviceLines.coPay.description String The description of the copay amount the procedure performed.
claimInformation.serviceLines.coPay.procedure String The procedure code of the procedure performed.
claimInformation.serviceLines.coPay.patientLiable Boolean Indicates whether the patient is liable.
claimInformation.serviceLines.coInsurance Object An object representing the co-insurance portion of the procedure performed.
claimInformation.serviceLines.coInsurance.amount String The amount of co-insurance for the procedure performed.
claimInformation.serviceLines.coInsurance.code String The code for the procedure performed.
claimInformation.serviceLines.coInsurance.codeType String A code type for the procedure performed.
claimInformation.serviceLines.coInsurance.description String The description of the co-insurance amount the procedure performed.
claimInformation.serviceLines.coInsurance.procedure String The procedure code of the procedure performed.
claimInformation.serviceLines.coInsurance.patientLiable Boolean Indicates whether the patient is liable.
claimInformation.serviceLines.deductible Object An object representing the deductible portion of the procedure performed.
claimInformation.serviceLines.deductible.amount String The amount of deductible for the procedure performed.
claimInformation.serviceLines.deductible.code String The code for the procedure performed.
claimInformation.serviceLines.deductible.codeType String A code type for the procedure performed.
claimInformation.serviceLines.deductible.description String The description of the deductible amount the procedure performed.
claimInformation.serviceLines.deductible.procedure String The procedure code of the procedure performed.
claimInformation.serviceLines.deductible.patientLiable Boolean Indicates whether the patient is liable.

POST /V1/INSTITUTIONAL-CLAIMS

This endpoint creates a CCE asynchronously. To submit a CCE, make a valid request and a response will be returned with a location header containing a URL you can query for your result.

RESPONSES

HTTP Status Code Description
202 The CCE was accepted for processing. Poll the URL in the Location header. The X-Status-Message header will contain additional detail.
400 The CCE request failed validation. It either failed our validation rules or was rejected by the health plan. The errors property will contain detailed information. Errors that specify a field are Availity validation rule failures. Errors that specify a code are from the health plan. Correct the errors and resubmit the request.
500 We were unable to parse your request. Correct the errors and resubmit the request.

VALIDATION RULES

The validation rules for the InstitutionalClaim resource can vary by health plan, the type of claim being requested, and the type of service to be performed. Availity organizes these rules and makes them available through the Configuration service. The Configuration resource documents the fields you need to send to create a InstitutionalClaim and explains what values are valid for those fields. See the Configurations service for details.

EXAMPLES

If your request is invalid, we will respond with a status code of 400 and a list of errors for you to correct.

$ curl -i -H "Content-Type: application/json" -X POST -d '{
  "requestTypeCode": "PRE_DETERMINATION",
  "billingProvider": {
    "npi": "1234567893",
    "ein": "111222333",
    "payerAssignedProviderId": "XYZ321"
  },
  "patient": {
    "relationshipCode": "01",
    "lastName": "Smith",
    "firstName": "Bob",
    "stateCode": "FL",
    "birthDate": "1980-02-12",
    "genderCode": "M"
  },
  "payer": {
    "id": "BCBSF"
  },
  "submitter": {
    "id": "123456789",
    "lastName": "SUBMITTER"
  },
  "subscriber": {
    "memberId": "JDH001",
    "groupName": "ASDF 1-2",
    "groupNumber": "12312412"
  },
  "claimInformation": {
    "principalDiagnosis": {
      "code": "S52512A",
      "qualifierCode": "ABK"
    },
    "serviceLines": [
      {
        "procedureCode": "A4719",
        "quantity": "1.0",
        "amount": "10.00"
      }
    ]
  }
}' https://api.availity.com/availity/v1/institutional-claims

HTTP/1.1 400 Bad Request
Cache-Control: private,no-store,max-age=0,must-revalidate
Content-Type: application/json
Date: Fri, 03 Jun 2016 18:19:16 GMT
x-api-id: ad4dff7e-7d54-4388-8a80-ce4227cd702a
X-Session-ID: ad4dff7e-7d54-4388-8a80-ce4227cd702a
Connection: close

{
  "userMessage" : "Your request was invalid.",
  "developerMessage" : "The request was invalid. See the 'errors' property for details.",
  "reasonCode" : 0,
  "statusCode" : 400,
  "errors" : [ {
    "field" : "claimInformation.facilityTypeCode",
    "errorMessage" : "Enter a valid Bill Type.",
    "index" : 0,
    "nestedEntityErrors" : [ ]
  }, {
    "field" : "claimInformation.serviceLines.fromDate",
    "errorMessage" : "Enter an as of date up to 24 months in the past and up to 12 months in the future.",
    "index" : 0,
    "nestedEntityErrors" : [ ]
  }, {
    "field" : "claimInformation.serviceLines.revenueCode",
    "errorMessage" : "Enter a valid Revenue Code.",
    "index" : 0,
    "nestedEntityErrors" : [ ]
  } ]
}

If your request is valid, we will respond with a status code of 202 and a location header where you can check back for your response. We will continue to respond in this way until we have heard back from the health plan.

$ curl -i -H "Content-Type: application/json" -X POST -d '{
  "requestTypeCode": "PRE_DETERMINATION",
  "billingProvider": {
    "npi": "1234567893",
    "ein": "111222333",
    "payerAssignedProviderId": "XYZ321"
  },
  "patient": {
    "relationshipCode": "01",
    "lastName": "Smith",
    "firstName": "Bob",
    "stateCode": "FL",
    "birthDate": "1980-02-12",
    "genderCode": "M"
  },
  "payer": {
    "id": "BCBSF"
  },
  "submitter": {
    "id": "123456789",
    "lastName": "JOHNSON"
  },
  "subscriber": {
    "memberId": "JDH001",
    "groupName": "ASDF 1-2",
    "groupNumber": "12312412"
  },
  "claimInformation": {
    "facilityTypeCode": "13",
    "principalDiagnosis": {
      "code": "S52512A",
      "qualifierCode": "ABK"
    },
    "serviceLines": [
      {
        "revenueCode": "0360",
        "procedureCode": "A4719",
        "quantity": "1.0",
        "amount": "10.00",
        "fromDate": "2016-05-10"
      }
    ]
  }

}' https://api.availity.com/availity/v1/institutional-claims

->
HTTP/1.1 202 Accepted
Cache-Control: private,no-store,max-age=0,must-revalidate
Content-Type: application/json;charset=utf-8
Date: Fri, 03 Jun 2016 20:00:40 GMT
Location: https://api.availity.com/availity/v1/institutional-claims/-465960752822731184
x-api-id: 893ef842-5ec0-4223-8338-ab31bdd25c90
X-Session-ID: 893ef842-5ec0-4223-8338-ab31bdd25c90
X-Status-Message: We are processing your request.
Connection: close

GET /V1/INSTITUTIONAL-CLAIMS/:ID

You can retrieve a CCE using this endpoint.

RESPONSES

HTTP Status Code Description
200 We are done processing your request and the response body contains the result.
202 We are currently processing your request. We may be retrying it.
400 Your CCE request failed validation. You can correct the errors and resubmit.
404 We did not find a InstitutionalClaim with the id that you sent.
504 We were unable to process your request. The health plan did not respond after several retry attempts. Please try your request again later.

EXAMPLES

You can request the URI that was returned in the Location response header during from your POST request. If the resource is found but we have not received a response from the health plan, we will respond with a status code of 202 and a Location header where you can check back for your response. We will continue to respond in this way until we have heard back from the health plan.

$ curl -i -X GET https://api.availity.com/availity/v1/institutional-claims/-465960752822731184
->
HTTP/1.1 202 Accepted
Cache-Control: private,no-store,max-age=0,must-revalidate
Content-Type: application/json;charset=utf-8
Date: Mon, 06 Jun 2016 18:11:34 GMT
Location: https://api.availity.com/availity/v1/institutional-claims/-465960752822731184
x-api-id: 25a71361-7f75-4dc9-918b-021e163b0df8
X-Session-ID: 25a71361-7f75-4dc9-918b-021e163b0df8
X-Status-Message: The health plan did not respond. We are retrying the request.
Connection: close

Once we have a response from the health plan, we will respond with a status code of 200 and a InstitutionalClaim resource. This example shows what a response looks like when the health plan is unable to determine a patients liability.

$ curl -i -X GET https://api.availity.com/availity/v1/institutional-claims/-465960752822731184
->
HTTP/1.1 200 OK
Cache-Control: private,no-store,max-age=0,must-revalidate
Content-Type: application/json;charset=utf-8
Date: Mon, 06 Jun 2016 18:35:19 GMT
x-api-id: 22d78708-6094-4e95-a8fe-3bb762975fd3
X-Availity-Transaction-ID: 1613032
X-Session-ID: 22d78708-6094-4e95-a8fe-3bb762975fd3

{
  "id" : "-5375712665050195544",
  "createdDate" : "2016-07-06T14:35:07.000+0000",
  "updatedDate" : "2016-07-06T14:35:08.000+0000",
  "expirationDate" : "2016-07-07T14:35:07.000+0000",
  "requestTypeCode" : "PRE_DETERMINATION",
  "submitter" : {
    "lastName" : "JOHNSON",
    "id" : "123456789"
  },
  "payer" : {
    "id" : "BCBSF"
  },
  "billingProvider" : {
    "ein" : "111222333",
    "payerAssignedProviderId" : "G1234"
  },
  "subscriber" : {
    "memberId" : "JBTEST1",
    "onHold" : false
  },
  "patient" : {
    "lastName" : "SMITH",
    "firstName" : "JOE",
    "birthDate" : "1870-01-01",
    "gender" : "Male",
    "genderCode" : "M",
    "subscriberRelationship" : "Spouse",
    "subscriberRelationshipCode" : "01"
  },
  "claimInformation" : {
    "facilityTypeCode" : "13",
    "frequencyTypeCode" : "1",
    "messages" : [ {
      "code" : "EAPI-90386",
      "description" : " Plan profile information not found"
    } ],
    "displayMessage" : "Unable to determine patient liability; additional information is required. For assistance, contact BCBSF",
    "principalDiagnosis" : {
      "qualifier" : "International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis",
      "qualifierCode" : "ABK",
      "code" : "G912"
    }
  }
}

Dental Claims

This resource allows you to submit dental claims for payment.

Working with the DEMO endpoints

Availity allows you to specify the type of response you want when interacting with our Dental Claims demonstration service by sending a header (X-Api-Mock-Scenario-ID) with the appropriate response scenario id. The supported response scenarios are listed below.

For POST methods send an empty JSON body such as: "{}"

Response Scenario ID Method HTTP Status Description
DC-Create-Success-i POST 202 Availity has successfully received the member's claim information to submit the health plan.
DC-Create-Rejected-i POST 400 Your request failed Availity's input validation rules.
DC-InProgress-i GET - use id 12345 202 Availity is still processing the request.
DC-Complete-i GET - use id 12345 200 Availity has successfully processed your claim and its being sent to the health plan.

You can confirm you've received a mock response by inspecting the response headers. You should see the following header:

X-Api-Mock-Response: true

Configuration Service Subtype

The type name for the dental-claims service is: dental-claims Use the subtypeId name of CLAIM for settings to submit a claim, ENCOUNTER for settings to submit an encounter, or PRE_DETERMINATION to submit a pre-determination claim.

Example usage:

$ curl -i -X GET https://api.availity.com/availity/v1/configurations?type=dental-claims&payerId=BCBSF&subtypeId=CLAIM

The Resource

Field Type Description
id String A unique identifier that Availity has assigned to this DentalClaim.
createdDate TimeStamp The date and time when this item was created in Availity's system.
updatedDate TimeStamp The date and time when this item was last updated.
expirationDate TimeStamp The date and time when this item will be removed from Availity's system.
customerId String The id of the Availity customer that owns this DentalClaim. Availity may ask for this during support calls.
requestTypeCode String The type of request to perform for dental claims. Use CLAIM for Claim, ENCOUNTER for an Encounter, or PRE_DETERMINATION for a pre-determination claim.
submitter Object An object representing the submitter of a claim.
submitter.lastName String The last or business name of the submitter.
submitter.firstName String The first name of the submitter.
submitter.middleName String The middle name of the submitter.
submitter.id String The identifier of the submitter.
submitter.contactName String The contact name of the submitter.
submitter.phone String The phone number of the submitter.
submitter.extension String The phone extension of the submitter.
submitter.fax String The fax number of the submitter.
submitter.email String The email of the submitter.
payer Object An object representing the health plan of the patient.
payer.id String The Availity id of the health plan.
payer.name String The name of the payer.
payer.addressLine1 String The first line of the address of the payer.
payer.addressLine2 String The second line of the address of the payer.
payer.city String The city of the payer.
payer.stateCode String The code of the state of the payer.
payer.zipCode String The ZIP code of the payer.
payer.countryCode String The country code of the payer (US or CA).
payer.ein String The employer identification number of the payer.
payer.claimOfficeNumber String The claim office number of the payer.
payer.naicCode String The NAIC of the payer.
payer.responsibilitySequenceCode String The responsibility sequence code of the payer (P, S, or T).
payer.insurnaceTypeCode String The insurance type code of the payer.
payer.claimFilingIndicatorCode String The claim filing indicator code of the payer.
billingProvider Object An object representing the billing provider of the claim.
billingProvider.specialtyCode String The claim filing indicator code for the type of insurance.
billingProvider.lastName String The last or business name of the billing provider.
billingProvider.firstName String The first name of the billing provider.
billingProvider.middleName String The middle name of the billing provider.
billingProvider.suffix String The suffix of the billing provider.
billingProvider.npi String The national provider id of the billing provider.
billingProvider.addressLine1 String The first line of the address of the billing provider.
billingProvider.addressLine2 String The second line of the address of the billing provider.
billingProvider.city String The city of the billing provider.
billingProvider.stateCode String The code of the state of the billing provider.
billingProvider.zipCode String The ZIP code of the billing provider.
billingProvider.countryCode String The country code of the billing provider (US or CA).
billingProvider.ein String The employer identification number of the billing provider.
billingProvider.ssn String The social security number of the billing provider.
billingProvider.stateLicenseNumber String The state license number of the billing provider.
billingProvider.upin String The UPIN of the billing provider.
billingProvider.payerAssignedProviderId String The payer assigned provider id of the billing provider.
billingProvider.locationNumber String The location number of the billing provider.
billingProvider.contactName String The contact name of the billing provider.
billingProvider.phone String The phone number of the billing provider.
billingProvider.extension String The phone extension of the billing provider.
billingProvider.fax String The fax number of the billing provider.
billingProvider.email String The email of the billing provider.
billingProvider.payTo.addressLine1 String The first line of the address for the pay to of the billing provider.
billingProvider.payTo.addressLine2 String The second line of the address for the pay to of the billing provider.
billingProvider.payTo.city String The city of the pay to of the billing provider.
billingProvider.payTo.stateCode String The code of the state for the pay to of the billing provider.
billingProvider.payTo.zipCode String The ZIP code for the pay to of the billing provider.
billingProvider.payTo.countryCode String The country code of the pay to of the billing provider (US or CA).
subscriber Object An object representing the subscriber of the claim.
subscriber.groupNumber String The group number of the subscriber.
subscriber.groupName String The group name of the subscriber.
subscriber.lastName String The last or business name of the subscriber.
subscriber.firstName String The first name of the subscriber.
subscriber.middleName String The middle name of the subscriber.
subscriber.suffix String The suffix of the subscriber.
subscriber.memberId String The member id of the subscriber.
subscriber.addressLine1 String The first line of the address of the subscriber.
subscriber.addressLine2 String The second line of the address of the subscriber.
subscriber.city String The city of the subscriber.
subscriber.stateCode String The code of the state of the subscriber.
subscriber.zipCode String The ZIP code of the subscriber.
subscriber.countryCode String The country code of the subscriber (US or CA).
subscriber.ssn String The social security number of the subscriber.
patient Object An object representing the patient of the claim.
patient.lastName String The last or business name of the patient.
patient.firstName String The first name of the patient.
patient.middleName String The middle name of the patient.
patient.suffix String The suffix of the patient.
patient.addressLine1 String The first line of the address of the patient.
patient.addressLine2 String The second line of the address of the patient.
patient.city String The city of the patient.
patient.stateCode String The code of the state of the patient.
patient.zipCode String The ZIP code of the patient.
patient.countryCode String The country code of the patient (US or CA).
patient.birthDate Date The birth date of the patient.
patient.genderCode String A code representing the gender of the patient.
patient.subscriberRelationshipCode String A code representing the patient's relationship to the subscriber.
patient.agencyClaimNumber String The agency claim number of the patient.

The following fields are under the claimInformation object - shortened for breveity

Field Type Description
claimInformation Object An object representing the claim information of the claim.
.controlNumber String A unique reference identifier provided by the submitter that was provided in the original claim status request.
.placeOfServiceCode String A code representing the place of service.
.frequencyTypeCode String A code specifying the frequency of the claim.
.providerSignatureOnFile Boolean Indicates whether a provider's signature is on file with the heathcare plan.
.providerAcceptAssignmentCode String A code indicating whether the provider accepts assignment.
.benefitsAssignmentCertification String A code indicating assignment of benefits for a claim.
.informationReleaseCode String A code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations.
.specialProgramCode String A code indicating a special dental program.
.delayReasonCode String A code indicating the delay reason.
.appliancePlacementDate Date The date the appliance was placed.
.serviceFromDate Date The service begin date.
.servicetoDate Date The service end date.
.orthodonticClaim Boolean Indicates whether or not a this was an orthodontic claim.
.orthodonticTreatmentMonths String The estimated number of orthodontic treatment months.
.orthodonticTreatmentRemainingMonths String The number of orthodontic treatment months remaining.
.patientPaidAmount String The amount the patient has paid.
.serviceAuthorizationExceptionCode String The service authorization exception code for this claim.
.payerClaimControlNumber String The payer claim control number for this claim.
.priorAuthorizationNumber String The prior authorization number for this claim.
.claimIdentifier String The trace number for this claim.
.accidentCauseCode1 String The related/accident cause code.
.accidentCauseCode2 String The related/accident cause code.
.accidentStateCode String The state the accident happened in.
.accidentDate Date The date the accident occurred on.
.toothStatuses Object Array An array of tooth statuses.
.toothStatuses.toothCode String A tooth.
.toothStatuses.toothStatusCode String A tooth status.
.supplementalInformation Object Array An array of supplemental information (additonal paperwork).
.supplementalInformation.reportTypeCode String The report type.
.supplementalInformation.reportTransmissionCode String The report transmission method.
.supplementalInformation.controlNumber String The control number.
.contractAmount String The contracted amount.
.contractPercentage String The contracted percentage.
.contractCode String The contract code.
.contractTermsDiscountPercentage String The contract terms discount percentage.
.contractVersion String The contract version.
.notes Object Array An array of notes about this claim.
.notes.message String The message about this claim.
.diagnoses Object Array An array of diagnoses related to this claim.
.diagnoses.qualifierCode String The qualifier for this diagnosis.
.diagnoses.code String The code for this diagnosis.
.referringProvider Object An object representing information about the referring provider.
.referringProvider.lastName String The last or business name of the referring provider.
.referringProvider.firstName String The first name of the referring provider.
.referringProvider.middleName String The middle name of the referring provider.
.referringProvider.suffix String The suffix of the referring provider.
.referringProvider.npi String The national provider id of the referring provider.
.referringProvider.specialtyCode String The social security number of the referring provider.
.referringProvider.stateLicenseNumber String The state license number of the referring provider.
.referringProvider.upin String The UPIN of the referring provider.
referringProvider.payerAssignedProviderId String The payer assigned provider id of the referring provider.
.referringProvider.locationNumber String The location number of the referring provider.
.referringProvider.addressLine1 String The first line of the address of the referring provider.
.referringProvider.addressLine2 String The second line of the address of the referring provider.
.referringProvider.city String The city of the referring provider.
.referringProvider.stateCode String The code of the state of the referring provider.
.referringProvider.zipCode String The ZIP code of the referring provider.
.referringProvider.countryCode String The country code of the referring provider (US or CA).
.referringProvider.referralNumber String The referral number.
.primaryCareProvider Object An object representing information about the primary care provider.
.primaryCareProvider.lastName String The last or business name of the primary care provider.
.primaryCareProvider.firstName String The first name of the primary care provider.
.primaryCareProvider.middleName String The middle name of the primary care provider.
.primaryCareProvider.suffix String The suffix of the primary care provider.
.primaryCareProvider.npi String The national provider id of the primary care provider.
.primaryCareProvider.specialtyCode String The social security number of the primary care provider.
.primaryCareProvider.stateLicenseNumber String The state license number of the primary care provider.
.primaryCareProvider.upin String The UPIN of the primary care provider.
.primaryCareProvider.payerAssignedProviderId String The payer assigned provider id of the primary care provider.
.primaryCareProvider.locationNumber String The location number of the primary care provider.
.primaryCareProvider.addressLine1 String The first line of the address of the primary care provider.
.primaryCareProvider.addressLine2 String The second line of the address of the primary care provider.
.primaryCareProvider.city String The city of the primary care provider.
.primaryCareProvider.stateCode String The code of the state of the primary care provider.
.primaryCareProvider.zipCode String The ZIP code of the primary care provider.
.primaryCareProvider.countryCode String The country code of the primary care provider (US or CA).
.primaryCareProvider.referralNumber String The referral number.
.renderingProvider Object An object representing information about the rendering provider.
.renderingProvider.lastName String The last or business name of the rendering provider.
.renderingProvider.firstName String The first name of the rendering provider.
.renderingProvider.middleName String The middle name of the rendering provider.
.renderingProvider.suffix String The suffix of the rendering provider.
.renderingProvider.npi String The national provider id of the rendering provider.
.renderingProvider.specialtyCode String The social security number of the rendering provider.
.renderingProvider.stateLicenseNumber String The state license number of the rendering provider.
.renderingProvider.upin String The UPIN of the rendering provider.
.renderingProvider.payerAssignedProviderId String The payer assigned provider id of the rendering provider.
.renderingProvider.locationNumber String The location number of the rendering provider.
.renderingProvider.addressLine1 String The first line of the address of the rendering provider.
.renderingProvider.addressLine2 String The second line of the address of the rendering provider.
.renderingProvider.city String The city of the rendering provider.
.renderingProvider.stateCode String The code of the state of the rendering provider.
.renderingProvider.zipCode String The ZIP code of the rendering provider.
.renderingProvider.countryCode String The country code of the rendering provider (US or CA).
.renderingProvider.referralNumber String The referral number.
.serviceFacility Object An object representing information about the service facility.
.serviceFacility.lastName String The last or business name of the service facility.
.serviceFacility.firstName String The first name of the service facility.
.serviceFacility.middleName String The middle name of the service facility.
.serviceFacility.suffix String The suffix of the service facility.
.serviceFacility.npi String The national provider id of the service facility.
.serviceFacility.specialtyCode String The social security number of the service facility.
.serviceFacility.stateLicenseNumber String The state license number of the service facility.
.serviceFacility.upin String The UPIN of the service facility.
.serviceFacility.payerAssignedProviderId String The payer assigned provider id of the service facility.
.serviceFacility.locationNumber String The location number of the service facility.
.serviceFacility.addressLine1 String The first line of the address of the service facility.
.serviceFacility.addressLine2 String The second line of the address of the service facility.
.serviceFacility.city String The city of the service facility.
.serviceFacility.stateCode String The code of the state of the service facility.
.serviceFacility.zipCode String The ZIP code of the service facility.
.serviceFacility.countryCode String The country code of the service facility (US or CA).
.serviceFacility.referralNumber String The referral number.
.assistantSurgeon Object An object representing information about the assistant surgeon.
.assistantSurgeon.lastName String The last or business name of the assistant surgeon.
.assistantSurgeon.firstName String The first name of the assistant surgeon.
.assistantSurgeon.middleName String The middle name of the assistant surgeon.
.assistantSurgeon.suffix String The suffix of the assistant surgeon.
.assistantSurgeon.npi String The national provider id of the assistant surgeon.
.assistantSurgeon.specialtyCode String The social security number of the assistant surgeon.
.assistantSurgeon.stateLicenseNumber String The state license number of the assistant surgeon.
.assistantSurgeon.upin String The UPIN of the assistant surgeon.
.assistantSurgeon.payerAssignedProviderId String The payer assigned provider id of the assistant surgeon.
.assistantSurgeon.locationNumber String The location number of the assistant surgeon.
.assistantSurgeon.addressLine1 String The first line of the address of the assistant surgeon.
.assistantSurgeon.addressLine2 String The second line of the address of the assistant surgeon.
.assistantSurgeon.city String The city of the assistant surgeon.
.assistantSurgeon.stateCode String The code of the state of the assistant surgeony.
.assistantSurgeon.zipCode String The ZIP code of the assistant surgeon.
.assistantSurgeon.countryCode String The country code of the assistant surgeon (US or CA).
.assistantSurgeon.referralNumber String The referral number.
.supervisingProvider Object An object representing information about the supervising provider.
.supervisingProvider.lastName String The last or business name of the supervising provider.
.supervisingProvider.firstName String The first name of the supervising provider.
.supervisingProvider.middleName String The middle name of the supervising provider.
.supervisingProvider.suffix String The suffix of the supervising provider.
.supervisingProvider.npi String The national provider id of the supervising provider.
.supervisingProvider.specialtyCode String The social security number of the supervising provider.
.supervisingProvider.stateLicenseNumber String The state license number of the supervising provider.
.supervisingProvider.upin String The UPIN of the supervising provider.
.supervisingProvider.payerAssignedProviderId String The payer assigned provider id of the supervising provider.
.supervisingProvider.locationNumber String The location number of the supervising provider.
.supervisingProvider.addressLine1 String The first line of the address of the supervising provider.
.supervisingProvider.addressLine2 String The second line of the address of the supervising provider.
.supervisingProvider.city String The city of the supervising provider.
.supervisingProvider.stateCode String The code of the state of the supervising provider.
.supervisingProvider.zipCode String The ZIP code of the supervising provider.
.supervisingProvider.countryCode String The country code of the supervising provider (US or CA).
.supervisingProvider.referralNumber String The referral number.
.otherPayers Object Array An array of information about other payers.
.otherPayers.responsibilitySequenceCode String The responsibility sequence of this payer (P, S, or T).
.otherPayers.insurnaceTypeCode String The insurance type code of the payer.
.otherPayers.claimFilingIndicatorCode String The claim filing indicator code of the payer.
.otherPayers.name String The name of the payer.
.otherPayers.id String The id of this payer.
.otherPayers.addressLine1 String The first line of the address of the payer.
.otherPayers.addressLine2 String The second line of the address of the payer.
.otherPayers.city String The city of the payer.
.otherPayers.stateCode String The code of the state of the payer.
.otherPayers.zipCode String The ZIP code of the payer.
.otherPayers.countryCode String The country code of the payer (US or CA).
.otherPayers.claimPaidDate Date The date this payer paid the claim.
.otherPayers.ein String The employer identification number of the payer.
.otherPayers.claimOfficeNumber String The claim office number of the payer.
.otherPayers.naicCode String The NAIC of the payer.
.otherPayers.responsibilitySequenceCode String The responsibility sequence code of the payer (P, S, or T).
.otherPayers.priorAuthorizationNumber String The prior authorization number assigned by this payer.
.otherPayers.referralNumber String The referral number assigned by this payer.
.otherPayers.claimControlNumber String This payer's claim control number.
.otherPayers.paidAmount String The amount paid by this payer.
.otherPayers.remainingPatientLiabilityAmount String The remaining patient liability.
.otherPayers.notCoveredAmount String The amount that this payer did not cover.
.otherPayers.benefitsAssignmentCertification Boolean The benefits assignment certification indicator for this payer."
.otherPayers.informationReleaseCode String The information release code for this payer.
.otherPayers.subscriberRelationshipCode String The patient's relationship to this payer's subscriber.
.otherPayers.subscriber Object An object representing information about the payer's subscriber.
.otherPayers.subscriber.groupNumber String The group number of the subscriber.
.otherPayers.subscriber.groupName String The group name of the subscriber.
.otherPayers.subscriber.lastName String The last or business name of the subscriber.
.otherPayers.subscriber.firstName String The first name of the subscriber.
.otherPayers.subscriber.middleName String The middle name of the subscriber.
.otherPayers.subscriber.suffix String The suffix of the subscriber.
.otherPayers.subscriber.memberId String The member id of the subscriber.
.otherPayers.subscriber.addressLine1 String The first line of the address of the subscriber.
.otherPayers.subscriber.addressLine2 String The second line of the address of the subscriber.
.otherPayers.subscriber.city String The city of the subscriber.
.otherPayers.subscriber.stateCode String The code of the state of the subscriber.
.otherPayers.subscriber.zipCode String The ZIP code of the subscriber.
.otherPayers.subscriber.countryCode String The country code of the subscriber (US or CA).
.otherPayers.subscriber.ssn String The social security number of the subscriber.

The following fields are under the claimInformation.otherPayers.medicareOutpatientAdjudicationInformation object - shortened for breveity

Field Type Description
.medicareOutpatientAdjudicationInformation Object An object representing information about medicare outpatient adjudication.
.reimburseRate String The medicare outpatient adjudication reimburse rate.
.payableAmount String The medicare outpatient adjudication payable amount.
.claimPaymentRemarkCode1 String A medicare outpatient adjudication claim remark code.
.claimPaymentRemarkCode2 String A medicare outpatient adjudication claim remark code.
.claimPaymentRemarkCode3 String A medicare outpatient adjudication claim remark code.
.claimPaymentRemarkCode4 String A medicare outpatient adjudication claim remark code.
.claimPaymentRemarkCode5 String A medicare outpatient adjudication claim remark code.
.nonPayableProfessionalComponentBilledAmount String The medicare outpatient adjudication non-payable professional component billed amount.

The following fields are under the claimInformation object - shortened for breveity

Field Type Description
.otherPayers.claimAdjustmentGroups Object Array An array of claim level adjustments for this payer.
.otherPayers.claimAdjustmentGroups.groupCode String The adjustment group.
.otherPayers.claimAdjustmentGroups.adjustments Object Array An array of adjustments to this claim.
.otherPayers.claimAdjustmentGroups.adjustments.reasonCode String The adjustment reason code.
.otherPayers.claimAdjustmentGroups.adjustments.amount String The adjustment amount.
.otherPayers.claimAdjustmentGroups.adjustments.quantity String The adjustment quantity.
.serviceLines Object Array An array of service lines for the claim.
.serviceLines.controlNumber String The control number for this service line.
.serviceLines.procedureCode String A code respresenting the procedure performed.
.serviceLines.modifierCode1 String A description of the first modifier applied to this procedure.
.serviceLines.modifierCode2 String A description of the second modifier applied to this procedure.
.serviceLines.modifierCode3 String A description of the third modifier applied to this procedure.
.serviceLines.modifierCode4 String A description of the forth modifier applied to this procedure.
.serviceLines.procedureDescription String A procedure description.
.serviceLines.amount String This charge amount for this service line.
.serviceLines.placeOfServiceCode String The place where this service was performed.
.serviceLines.cavityDesignationCode1 String A cavity designation code.
.serviceLines.cavityDesignationCode2 String A cavity designation code.
.serviceLines.cavityDesignationCode3 String A cavity designation code.
.serviceLines.cavityDesignationCode4 String A cavity designation code.
.serviceLines.cavityDesignationCode5 String A cavity designation code.
.serviceLines.prostheticCode String The presthetic code.
.serviceLines.quantity String The quantity.
.serviceLines.diagnosisCodePointer1 String A pointer to the first diagnosis code in this service.
.serviceLines.diagnosisCodePointer2 String A pointer to the second diagnosis code in this service.
.serviceLines.diagnosisCodePointer3 String A pointer to the third diagnosis code in this service.
.serviceLines.diagnosisCodePointer4 String A pointer to the forth diagnosis code in this service.
.serviceLines.serviceDate Date The date that this service was performed.
.serviceLines.priorPlacementDate Date The prior placement date.
.serviceLines.appliancePlacementDate Date The appliance placement date.
.serviceLines.replacementDate Date The replacement date.
.serviceLines.treatmentStartDate Date The date treatment started.
.serviceLines.treatmentEndDate Date The date treatment ended.
.serviceLines.toothInformation Object Array An array of information about the teeth involved in this service.
.serviceLines.toothInformation.toothCode String The tooth.
.serviceLines.toothInformation.toothSurfaceCode1 String A tooth surface.
.serviceLines.toothInformation.toothSurfaceCode2 String A tooth surface.
.serviceLines.toothInformation.toothSurfaceCode3 String A tooth surface.
.serviceLines.toothInformation.toothSurfaceCode4 String A tooth surface.
.serviceLines.toothInformation.toothSurfaceCode5 String A tooth surface.
.serviceLines.contractTypeCode String The contract type.
.serviceLines.contractAmount String The contract amount.
.serviceLines.contractPercentage String The contract percentage.
.serviceLines.contractCode String The contract code.
.serviceLines.contractTermsDiscountPercentage String The contract terms discount percentage.
.serviceLines.contractVersion String The contract version.
.serviceLines.priorAuthorizationNumber String The prior authorization number for this service.
.serviceLines.referralNumber String The referral number for this service.
.serviceLines.salesTax String The sales tax for this service.
.serviceLines.renderingProvider Object An object representing information about the rendering provider.
.serviceLines.renderingProvider.lastName String The last or business name of the rendering provider.
.serviceLines.renderingProvider.firstName String The first name of the rendering provider.
.serviceLines.renderingProvider.middleName String The middle name of the rendering provider.
.serviceLines.renderingProvider.suffix String The suffix of the rendering provider.
.serviceLines.renderingProvider.npi String The national provider id of the rendering provider.
.serviceLines.renderingProvider.specialtyCode String The social security number of the rendering provider.
.serviceLines.renderingProvider.stateLicenseNumber String The state license number of the rendering provider.
.serviceLines.renderingProvider.upin String The UPIN of the rendering provider.
.serviceLines.renderingProvider.payerAssignedProviderId String The payer assigned provider id of the rendering provider.
.serviceLines.renderingProvider.locationNumber String The location number of the rendering provider.
.serviceLines.renderingProvider.addressLine1 String The first line of the address of the rendering provider.
.serviceLines.renderingProvider.addressLine2 String The second line of the address of the rendering provider.
.serviceLines.renderingProvider.city String The city of the rendering provider.
.serviceLines.renderingProvider.stateCode String The code of the state of the rendering provider.
.serviceLines.renderingProvider.zipCode String The ZIP code of the rendering provider.
.serviceLines.renderingProvider.countryCode String The country code of the rendering provider (US or CA).
.serviceLines.renderingProvider.referralNumber String The referral number.
.serviceLines.assistantSurgeon Object An object representing information about the assistant surgeon.
.serviceLines.assistantSurgeon.lastName String The last or business name of the assistant surgeon.
.serviceLines.assistantSurgeon.firstName String The first name of the assistant surgeon.
.serviceLines.assistantSurgeon.middleName String The middle name of the assistant surgeon.
.serviceLines.assistantSurgeon.suffix String The suffix of the assistant surgeon.
.serviceLines.assistantSurgeon.npi String The national provider id of the assistant surgeon.
.serviceLines.assistantSurgeon.specialtyCode String The social security number of the assistant surgeon.
.serviceLines.assistantSurgeon.stateLicenseNumber String The state license number of the assistant surgeon.
.serviceLines.assistantSurgeon.upin String The UPIN of the assistant surgeon.
.serviceLines.assistantSurgeon.payerAssignedProviderId String The payer assigned provider id of the assistant surgeon.
.serviceLines.assistantSurgeon.locationNumber String The location number of the assistant surgeon.
.serviceLines.assistantSurgeon.addressLine1 String The first line of the address of the assistant surgeon.
.serviceLines.assistantSurgeon.addressLine2 String The second line of the address of the assistant surgeon.
.serviceLines.assistantSurgeon.city String The city of the assistant surgeon.
.serviceLines.assistantSurgeon.stateCode String The code of the state of the assistant surgeony.
.serviceLines.assistantSurgeon.zipCode String The ZIP code of the assistant surgeon.
.serviceLines.assistantSurgeon.countryCode String The country code of the assistant surgeon (US or CA).
.serviceLines.assistantSurgeon.referralNumber String The referral number.
.serviceLines.supervisingProvider Object An object representing information about the supervising provider.
.serviceLines.supervisingProvider.lastName String The last or business name of the supervising provider.
.serviceLines.supervisingProvider.firstName String The first name of the supervising provider.
.serviceLines.supervisingProvider.middleName String The middle name of the supervising provider.
.serviceLines.supervisingProvider.suffix String The suffix of the supervising provider.
.serviceLines.supervisingProvider.npi String The national provider id of the supervising provider.
.serviceLines.supervisingProvider.specialtyCode String The social security number of the supervising provider.
.serviceLines.supervisingProvider.stateLicenseNumber String The state license number of the supervising provider.
.serviceLines.supervisingProvider.upin String The UPIN of the supervising provider.
.serviceLines.supervisingProvider.payerAssignedProviderId String The payer assigned provider id of the supervising provider.
.serviceLines.supervisingProvider.locationNumber String The location number of the supervising provider.
.serviceLines.supervisingProvider.addressLine1 String The first line of the address of the supervising provider.
.serviceLines.supervisingProvider.addressLine2 String The second line of the address of the supervising provider.
.serviceLines.supervisingProvider.city String The city of the supervising provider.
.serviceLines.supervisingProvider.stateCode String The code of the state of the supervising provider.
.serviceLines.supervisingProvider.zipCode String The ZIP code of the supervising provider.
.serviceLines.supervisingProvider.countryCode String The country code of the supervising provider (US or CA).
.serviceLines.supervisingProvider.referralNumber String The referral number.
.serviceLines.serviceFacility Object An object representing information about the service facility.
.serviceLines.serviceFacility.lastName String The last or business name of the service facility.
.serviceLines.serviceFacility.firstName String The first name of the service facility.
.serviceLines.serviceFacility.middleName String The middle name of the service facility.
.serviceLines.serviceFacility.suffix String The suffix of the service facility.
.serviceLines.serviceFacility.npi String The national provider id of the service facility.
.serviceLines.serviceFacility.specialtyCode String The social security number of the service facility.
.serviceLines.serviceFacility.stateLicenseNumber String The state license number of the service facility.
.serviceLines.serviceFacility.upin String The UPIN of the service facility.
.serviceLines.serviceFacility.payerAssignedProviderId String The payer assigned provider id of the service facility.
.serviceLines.serviceFacility.locationNumber String The location number of the service facility.
.serviceLines.serviceFacility.addressLine1 String The first line of the address of the service facility.
.serviceLines.serviceFacility.addressLine2 String The second line of the address of the service facility.
.serviceLines.serviceFacility.city String The city of the service facility.
.serviceLines.serviceFacility.stateCode String The code of the state of the service facility.
.serviceLines.serviceFacility.zipCode String The ZIP code of the service facility.
.serviceLines.serviceFacility.countryCode String The country code of the service facility (US or CA).
.serviceLines.serviceFacility.referralNumber String The referral number.
.serviceLines.adjudicationInformation Object Array An array of adjudication information for this service line.
.serviceLines.adjudicationInformation.payerId String The payer id for this adjudication information.
.serviceLines.adjudicationInformation.paidAmount String The amount this payer paid.
.serviceLines.adjudicationInformation.procedureCode String The procedure performed.
.serviceLines.adjudicationInformation.modifierCode1 String A procedure modifier.
.serviceLines.adjudicationInformation.modifierCode2 String A procedure modifier.
.serviceLines.adjudicationInformation.modifierCode3 String A procedure modifier.
.serviceLines.adjudicationInformation.modifierCode4 String A procedure modifier.
.serviceLines.adjudicationInformation.procedureDescription String A procedure description.
.serviceLines.adjudicationInformation.quantity String A quantity.
.serviceLines.adjudicationInformation.lineNumber String The line number.
.serviceLines.adjudicationInformation.claimPaidDate Date The claim paid date.
.serviceLines.adjudicationInformation.remainingPatientLiabilityAmount String The remaining patient liability amount.

The following fields are under the claimInformation.serviceLines.adjudicationInformation.claimAdjustmentGroups object - shortened for breveity

Field Type Description
.claimAdjustmentGroups Object Array An array of claim line adjustments.
.groupCode String The adjustment group.
.adjustments Object Array An array of adjustments to this claim.
.adjustments.reasonCode String The adjustment reason code.
.adjustments.amount String The adjustment amount.
.adjustments.quantity String The adjustment quantity.

POST /V1/DENTAL-CLAIMS

This endpoint creates a dental claim asynchronously. To submit a dental claim, make a valid request and a response will be returned with a location header containing a URL you can query for your result.

RESPONSES

HTTP Status Code Description
202 The claim was accepted for processing. Poll the URL in the Location header. The X-Status-Message header will contain additional detail.
200 The claim has completed processing and will be submitted to the health plan.
400 The claim request failed validation. It either failed our validation rules or was rejected by the health plan. The errors property will contain detailed information. Errors that specify a field are Availity validation rule failures. Errors that specify a code are from the health plan. Correct the errors and resubmit the request.
500 We were unable to parse your request. Correct the errors and resubmit the request.

VALIDATION RULES

The validation rules for the DentalClaim resource can vary by health plan, the type of claim being requested, and the type of service to be performed. Availity organizes these rules and makes them available through the Configuration service. The Configuration resource documents the fields you need to send to create a DentalClaim and explains what values are valid for those fields. See the Configurations service for details.

EXAMPLES

If your request is invalid, we will respond with a status code of 400 and a list of errors for you to correct.

$ curl -i -H "Content-Type: application/json" -X POST -d ' {
    "requestTypeCode": "CLAIM",
    "submitter": {
        "lastName": "AVAILITY",
        "id": "111222333",
        "phone": "9045556666"
    },
    "payer": {
        "id": "00611",
        "claimFilingIndicatorCode": "BL"
    },
    "billingProvider": {
        "ein": "111222333",
        "lastName": "ASDF",
        "npi": "1234567893",
        "addressLine1": "123 main st",
        "city": "Jacksonville",
        "stateCode": "FL",
        "zipCode": "322231234",
        "countryCode": "US",
        "specialtyCode": "282N00000X"
    },
    "patient": {
        "lastName": "smith",
        "firstName": "bob",
        "addressLine1": "123 main st",
        "city": "Jacksonville",
        "stateCode": "FL",
        "zipCode": "322231234",
        "genderCode": "M",
        "birthDate": "2001-01-01"
    },
    "claimInformation": {
        "diagnoses": [{
            "qualifierCode": "ABK",
            "code": "J3089"
        }],
        "providerSignatureOnFile": true,
        "frequencyTypeCode": "1",
        "informationReleaseCode": "I",
        "placeOfServiceCode": "11",
        "providerAcceptAssignmentCode": "A",
        "serviceFromDate": "2016-07-22",
        "serviceLines": [{
            "amount": "0.01",
            "diagnosisCodePointer1": "1",
            "procedureCode": "D0120",
            "treatmentStartDate": "2016-07-22"
        }]
    }
}' https://api.availity.com/availity/v1/dental-claims

HTTP/1.1 400 Bad Request
Cache-Control: private,no-store,max-age=0,must-revalidate
Content-Type: application/json
Date: Fri, 14 Oct 2016 18:19:16 GMT
x-api-id: c1585584-5d6f-472e-9e8e-f4300b6f237c
X-Session-ID: c1585584-5d6f-472e-9e8e-f4300b6f237c
Connection: close

{
  "userMessage": "Your request was invalid.",
  "developerMessage": "The request was invalid. See the 'errors' property for details.",
  "reasonCode": 0,
  "statusCode": 400,
  "errors": [
    {
      "field": "subscriber.memberId",
      "errorMessage": "Enter a valid alphanumeric Member ID. Punctuation and special characters are not allowed.",
      "index": 0
    }
  ]
}

If your request is valid, we will respond with a status code of 202 and a location header where you can check back for your response. We will continue to respond in this way until we have completed processing the request.

$ curl -i -H "Content-Type: application/json" -X POST -d ' {
    "requestTypeCode": "CLAIM",
    "submitter": {
        "lastName": "AVAILITY",
        "id": "111222333",
        "phone": "9045556666"
    },
    "payer": {
        "id": "00611",
        "claimFilingIndicatorCode": "BL"
    },
    "billingProvider": {
        "ein": "111222333",
        "lastName": "ASDF",
        "npi": "1234567893",
        "addressLine1": "123 main st",
        "city": "Jacksonville",
        "stateCode": "FL",
        "zipCode": "322231234",
        "countryCode": "US",
        "specialtyCode": "282N00000X"
    },
    "subscriber": {
        "memberId": "ABC1234"
    },
    "patient": {
        "lastName": "smith",
        "firstName": "bob",
        "addressLine1": "123 main st",
        "city": "Jacksonville",
        "stateCode": "FL",
        "zipCode": "322231234",
        "genderCode": "M",
        "birthDate": "2001-01-01"
    },
    "claimInformation": {
        "diagnoses": [{
            "qualifierCode": "ABK",
            "code": "J3089"
        }],
        "providerSignatureOnFile": true,
        "frequencyTypeCode": "1",
        "informationReleaseCode": "I",
        "placeOfServiceCode": "11",
        "providerAcceptAssignmentCode": "A",
        "serviceFromDate": "2016-07-22",
        "serviceLines": [{
            "amount": "0.01",
            "diagnosisCodePointer1": "1",
            "procedureCode": "D0120",
            "treatmentStartDate": "2016-07-22"
        }]
    }
}' https://api.availity.com/availity/v1/dental-claims

->
HTTP/1.1 202 Accepted
Cache-Control: private,no-store,max-age=0,must-revalidate
Content-Type: application/json;charset=utf-8
Date: Fri, 14 Oct 2016 18:20:32 GMT
Location: https://api.availity.com/availity/v1/dental-claims/12345
x-api-id: d9cf9b22-a0f6-4179-89f3-14a3909b40f7
X-Session-ID: d9cf9b22-a0f6-4179-89f3-14a3909b40f7
X-Status-Message: We are processing your request.
Connection: close

GET /V1/DENTAL-CLAIMS/:ID

You can retrieve a dental claim using this endpoint.

RESPONSES

HTTP Status Code Description
200 We are done processing your request and the response body contains the result.
202 We are currently processing your request. We may be retrying it.
404 We did not find a ProfessionalClaim with the id that you sent.

EXAMPLES

You can request the URI that was returned in the Location response header during from your POST request. If the resource is found but we have not received a response from the health plan, we will respond with a status code of 202 and a Location header where you can check back for your response. We will continue to respond in this way until we have heard back from the health plan.

$ curl -i -X GET https://api.availity.com/availity/v1/dental-claims/12345
->
HTTP/1.1 202 Accepted
Cache-Control: private,no-store,max-age=0,must-revalidate
Content-Type: application/json;charset=utf-8
Date: Mon, 06 Jun 2016 18:11:34 GMT
Location: https://api.availity.com/availity/v1/dental-claims/12345
x-api-id: 1cea8eb0-35fa-4c32-bfa5-5aade9d46ef6
X-Session-ID: 1cea8eb0-35fa-4c32-bfa5-5aade9d46ef6
X-Status-Message: We are processing your request.
Connection: close

Once we have completed processing the dental claim we'll sumbit it to the health plan, we will respond with a status code of 200 and a resource letting you know the claim was accepted.

$ curl -i -X GET https://api.availity.com/availity/v1/professional-claims/12345
->
HTTP/1.1 200 OK
Cache-Control: private,no-store,max-age=0,must-revalidate
Content-Type: application/json;charset=utf-8
Date: Mon, 06 Jun 2016 18:35:19 GMT
x-api-id: ae25a482-1954-4725-b72b-7a686f03f27c
X-Availity-Transaction-ID: 1613032
X-Session-ID: ae25a482-1954-4725-b72b-7a686f03f27c
Connection: close

{
  "links": {
    "self": {
      "href": "https://api.availity.com/availity/v1/dental-claims/12345"
    }
  },
  "id": "12345",
  "createdDate": "2016-10-10T12:29:19.000+0000",
  "updatedDate": "2016-10-10T12:29:19.000+0000",
  "expirationDate": "2016-10-11T12:29:19.000+0000",
  "message": "Your claim has been accepted for processing. Check your EDI files."
}