HIPAA Transaction APIs

Submitted by katieaugustus on Mon, 01/29/2024 - 12:00

Healthcare HIPAA Transaction APIs

 

For more information about Availity's APIs, refer to the Availity API Guide. The Product Overview section includes descriptions of the seven Healthcare HIPAA Transaction APIs documented in this tab.

Availity Payer List 1.0.4

Endpoints

GET/availity-payer-list

Retrieve a customized list of Availity payers and transactions.

Parameters

 
Parameter Type Definition
payerId Query string (optional) The payer's Availity-specific identifier.
transactionType Query array (optional) The code identifying the EDI/HIPAA transaction(s) supported by a payer. Accepted values include the following (definitions are in parentheses):
  • 270 (Eligibility Benefit Inquiry)
  • 276 (Claim Status Request)
  • 278I (Service Review Inquiry)
  • 835 (Claim Payment/Advice)
  • 837P (Claim: Professional)
  • 837PEncounter (Encounter: Professional)
  • 837PPredetermination (Predetermination: Professional)
  • 837I (Claim: Institutional)
  • 837IEncounter (Encounter: Institutional)
  • 837IPredetermination (Predetermination: Instutional)
  • 837D (Dental Claim)

  • 837DEncounter (Dental Encounter)
  • 837DPredetermination (Dental Predetermination)
  • 277RFAI (Claim Request for Additional Information)
  • 275 (Medical Attachments)
  • 278N (Notice of admission)
  • ClaimStatusSummary (Enhanced Claim Status summarySearch)
  • ClaimStatusDetail (Enhanced Claim Status detailSearch)

  • ClaimStatusValueAdd (Enhanced Claim Status valueAdd277)

submissionMode Query array (optional) The method of submission for the transaction(s) supported by a payer. Accepted values: Portal, Batch, RealTime, and API.
availability Query string (optional) Accepted values: availability=available (returns payers that do not require an Availity contract) and availability=contractrequired (returns payers that require an Availity contract).
enrollmentRequired Query boolean (optional) Allows you to filter whether enrollment is required for any payer transaction.
Accept Header string (optional) Allows you to specify application.json

Sample request

curl --request GET \
  --url 'https://api.availity.com/availity/v1/availity-payer-list?payerId=591209257&transactionType=276&submissionMode=PORTAL
&availability=AVAILABLE&enrollmentRequired=true' \
  --header 'Authorization: Bearer REPLACE_BEARER_TOKEN' \
  --header 'accept: application.json'

Sample response

[
  {
    "name": "Brian Wilkins",
    "payerId": "591209257",
    "displayName": "Addie Hoffman",
    "shortName": "Jay Garza",
    "processingRoutes": {
      "transactionDescription": "Javauh baele caf wug etaaf sa kispa girhamok remowloj tu mu tob iteno ijri sevonler ori anu.",
      "submissionMode": "portal",
      "effectiveDate": "10/11/2030",
      "availability": false,
      "enrollmentRequired": false,
      "enrollmentMode": "paper enrollment",
      "additionalInfo": "rozteddawdes",
      "rebateTier": "ufufenagazaz",
      "passThroughRate": "kipcekvevzelepu",
      "newTierNotice": "jadjuzt",
      "gateway": "gocrifakoriw",
      "recentlyAdded": "vopadcezaenouvc"
    }
  }
]

Response definitions

 
Payer List response definitions: Primary fields and objects
Field Type Definition
name String The common name for the health plan.
payerID String The payer's Availity-specific identifier.
displayName String The payer's name as displayed on Availity Essentials.
shortName String The payer's shortened name used in the file naming convention for batch transactions.
processingRoutes Object Object providing information about the routes available for communication from Availity to the payer. See the processingRoutes table for field definitions.
 
Payer List response definitions: Fields within processingRoutes
Field Type Definition
transactionDescription String Describes the HIPAA transaction type. See the transactionType parameter for possible values.
submissionMode String The method of submission for the transaction(s) supported by a payer. Possible values: Portal, Batch, RealTime, and API.
effectiveDate String The date the transaction became available for this payer.
availability Boolean Indicates whether the transaction is available to the payer under its current Availity contract or requires an additional Availity contract.
enrollmentRequired Boolean Indicates whether enrollment with Availity is required to submit the transaction.
enrollmentMode String Indicates the type of enrollment required with Availity. Possible values:
  • Manual Payer Submission
  • Paperless
  • Payer Portal Enrollment
  • Paper
  • Email Attachment
  • Auto Complete
additionalInfo String Provides additional information about the transaction, if applicable.
rebateTier String The processing route's cost tier.
passThroughRate String The processing route's pass-through rate.
newTierNotice String Provides notice of an upcoming tier change, if applicable.
gateway String The designation if Availity is the gateway for this payer for this route.
recentlyAdded String The date the route was added.

Configurations 1.0.0

Endpoints

GET/v1/configurations

Retrieve payer configurations and validation rules by type, subtype, and payer ID for use in your application. May return abbreviated configuration versions if multiple are found.

Parameters

 
Parameter Type Definition
type Query string (required) Indicate the type of HIPAA transaction for the configuration you're requesting. Refer to the Validation rules subsection in each applicable API's reference section or the table below for accepted values.
subtypeId Query string (optional) The subtype ID for your request. Refer to the Validation rules subsection in each applicable API's reference section or the table below for accepted values.
payerId Query string (optional) A health plan's Availity-specific identifier.
Accept Header string (optional) Allows you to specify application/json or application/xml.

The accepted values for type and subtypeId are listed for each applicable API in the table below. Refer to each API's reference documentation for definitions.

 
Healthcare Transactions API type value subtypeId value
Coverages

Send the type parameter without specifying a payerId for a list of all payers that support the Coverages API. Send type with the payerId to return the validation rules for this API for a specific payer.

270
Service Reviews (Authorization/Referral Request

This type name allows you to search for validation rules and parameter list for the POST/v2/service-reviews request. Sending the type, subtypeId, and payerIdparameters returns the validation rules and parameter list for Service Reviews for a specific payer.

service-reviews
  • HS (outpatient authorization)
  • AR (inpatient authorization/admission review)
  • SC (referral)

Service Reviews (Authorization/Referral Inquiry)

This type name allows you to search for validation rules and parameter list for the GET/v2/service-reviews request.

service-reviews-inquiry
  • HS (outpatient authorization)
  • AR (inpatient authorization/admission review)
  • SC (referral)

Claim Statuses

Send the type parameter without specifying a payerId for a list of all payers that support the Claim Statuses API. Specify type and payerId to return the validation rules for a specific payer.

claim-statuses-inquiry
Care Cost Estimator – Professional

Send the type parameter without specifying a payerId for a list of all payers that support the CCE – Professional API. Specify type and subtypeId with the payerId to return the validation rules for a specific payer.

professional-claims PRE_DETERMINATION
Care Cost Estimator – Institutional

Send the type parameter without specifying a payerId for a list of all payers that support the CCE – Institutional API. Specify type and subtypeId with the payerId to return the validation rules for a specific payer.

institutional-claims PRE_DETERMINATION
Enhanced Claim Status

Send the type parameter without specifying a payerId for a list of all payers that support the Enhanced Claim Status API. Specify type and subTypeId with the payerId to return the validation rules for a specific payer for a particular Enhanced Claim Status search.

enhanced-claim-status
  • HIPAA_276
  • VALUE_ADDS_277
  • SUMMARY
  • DETAIL

Sample request

curl -X GET "https://api.availity.com/availity/v1/configurations?payerId=BCBSF&type=270" 

Sample response

{
  "totalCount": 27734645,
  "count": 38099164,
  "offset": 50559072,
  "limit": 93842940,
  "links": {
    "id": 5689220412735488
  },
  "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
        }
      }
    }
  ]
}

Response definitions

 
Configurations response definitions: Primary result set
Field Type Definition
totalCount Integer Total number of assets.
count Integer Number of assets in the result set.
offset Integer Paging offset.
limit Integer Paging limit.
links Object Object containing a set of resource URIs.
configurations Array Array providing configurations by type, subTypeId, and/or payerId. See the Configurations table for field definitions.
 
Configurations response definitions: Fields within configurations
Field Type Definition
type String The type of HIPAA transaction for which you requested configurations.
categoryId String The configuration category ID.
categoryValue String The configuration category value.
subtypeId String The subtype ID specified in your request.
subtypeValue String The subtype value specified in your request.
payerId String The Availity-specific payer identifier for this configuration.
payerName String The name of the health plan that this configuration request involves.
version String The configuration version. Values include the following for Enhanced Claim Status:
  • HIPAA_276 (searchBy276)
  • VALUE_ADDS_277 (valueAdds277)
  • CLAIM_HISTORY (summarySearch)
  • SERVICE_DATE (summarySearch)
  • CHECK_NUMBER (summarySearch)
  • MEMBER_ID (summarySearch)
  • CLAIM_NUMBER (detailSearch)
sourceId String The configuration source ID.
elements Object Object providing information about each of the elements that make up the health plan's configuration form and indicating whether and under what conditions those elements are supported. See the Elements table for field definitions.
requiredFieldCombinations Array Array providing information about field combinations required by the health plan. Each entry defines a rule where all fields in at least one of the lists of fields must be provided.
settings Object Object providing information about key-value settings.
 
Configurations response definitions: Fields within elements
Field Type Definition
type String The data type for this element that maps to the type of element displayed in your UI. Not to be confused with the type parameter. Accepted values:
  • Unsupported (not shown in UI)
  • Boolean (checkmark)
  • Collection (searchable REST-backed drop-down)
  • Date (date picker)
  • Enumeration (searchable inline drop-down)
  • Information (text)
  • Section (grouper or container with text)
  • Text (standard text box)
  • Number (text box serialized as numeric)
  • Object (grouping as in Section, but with additional metadata)
  • ObjectArray (repeating grouping with additional metadata)
label String The name used for display in your application's UI.
order Integer An optional ordering index you can use to lay out fields in your application's UI.
helpTopicId String  
elements Object Child elements.
errorMessage String An error message you can use in your application's UI if this element does not pass validation. You can use this message if you perform client-side validation or after you've submitted a request and it returns as invalid.
maxRepeats Integer Maximum number of item repetitions.
allowed Boolean Indicates whether the element is valid to use.
required Boolean Indicates whether the element is required.
information Array A list of information.
groups Array A list of groups.
repeats Boolean Indicates whether the item repeats.
hidden Boolean Indicates whether the item is hidden.
minRepeats Integer Minimum number of item repetitions.
defaultValue String A default value you can use for pre-populating a field in your application's UI.
values String A list of values.
valuesWhen Object Conditional values.
min String (date) Minimum date.
max String (date) Maximum date.
pattern String A regular expression you can use to validate input parameter values.
maxLength Integer The maximum character length allowed for this element.
minLength Integer The minimum character length allowed for this element.
maxLengthWhen Object Conditional maximum length. Refer to the elements—Conditional fields table for field definitions.
patternWhen Object Conditional pattern. Refer to the elements—Conditional fields table for field definitions.
mode String Indicates whether the element uses a drop-down list or radio button group.
allowedWhen Object Object indicating the conditions under which the element is allowed. Refer to the elements—Conditional fields table for field definitions.
notAllowedWhen Object Object indicating the conditions under which the element is not allowed. Refer to the elements—Conditional fields table for field definitions.
requiredWhen Object Object indicating the conditions under which the element is required. Refer to the elements—Conditional fields table for field definitions.
notRequiredWhen Object Object indicating the conditions under which the element is not required. Refer to the elements—Conditional fields table for field definitions.
objectTypes Object Object array item type prototype definitions. See the elements.objectTypes table for field definitions.
 
Configurations response definitions: Fields within elements—Conditional fields
Field Type Definition
equalTo String Applies when the element value is equal to this value.
containedIn Array Applies when the field value is in the list.
greaterThan String Applies when the field value is greater than this value.
lessThan String Applies when the field value is less than this value.
greaterEqual String Applies when the field value is greater than or equal to this value.
lessEqual String Applies when the field value is less than or equal to this value.
maxLength Integer Maximum character length.
pattern Integer A regular expression you can use to validate input parameter values.
values ? Possible values or link to possible values.
 
Configurations response definitions: Fields within elements.objectTypes
Field Type Definition
label String A label for this object type.
minInstances Integer The minimum number of instances of this type of object.
maxInstances Integer The maximum number of instances of this type of object.
required Boolean Indicates whether the object is required.
allowedWhen Object Object type is allowed when one condition is true.
notAllowedWhen Object Object type is not allowed when one condition is true.
requiredWhen Object Object type is required when one condition is true.
notRequiredWhen Object Object type is not required when one condition is true.
fieldValues Object Object type discriminators.

Coverages 1.0.0

Find a summary or details about a member's healthcare coverage with this API, which enables the X12 270/271 transaction. Code lists and sources can be found in the ASC X12 Standards for Electronic Data Interchange Technical Report Type 3 (TR3) titled Health Care Eligibility Benefit Inquiry and Response (270/271).

Endpoints

 
  Path Function
1 GET/v1/coverages Retrieve a snapshot of a member's health plan coverage by querying the resource with certain parameters. You can also search your recent coverage requests with this endpoint.
2 GET/v1/coverages/{id} Retrieve details about a specific member's coverage by requesting coverage by ID number. Replace {id} with the response ID from your initial request.
3 DELETE/v1/coverages/{id} Delete a specific coverage by sending a DELETE request by ID number. Replace {id} with the response ID from your initial request.

Demo response scenarios

To test the demo version of this API, send the X-Api-Mock-Scenario-ID header with the appropriate response scenario ID, as listed in the following table.
 
Coverages demo response scenarios
Response scenario ID Status code Definition
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.

Parameters

GET/v1/coverages

Although none of the Coverages request parameters are required by the API, it is a good idea to send as many fields as you can. Requirements vary by health plan, as noted in the table below.
 
GET/v1/coverages parameters
Parameter Type Description
payerId Query string (optional) The Availity-specific identifier for the patient's health plan.
providerLastName Query string (optional) The requesting provider's last name.
providerFirstName Query string (optional) The requesting provider's first name.
providerType Query string (optional) Specify whether the health plan is professional or institutional, as required by some health plans.
providerNpi Query string (optional) The requesting provider's National Provider Identifier (NPI). Most health plans require the provider NPI for coverage requests.
providerTaxId Query string (optional) The requesting provider's tax ID, as required by some health plans.
payerAssignedProviderId Query string (optional) Some health plans allow you to specify a payer-assigned identifier for the requesting provider. If the payer has assigned the requesting provider an ID number, specify it using this parameter.
providerSSN Query string (optional) The requesting provider's Social Security Number (SSN), if required.
providerPIN Query string (optional) The requesting provider's personal identification number.
providerCity Query string (optional) Specify the requesting provider’s city, as required by some health plans.
providerState Query string (optional) Specify the requesting provider’s two-character state code, as required by some health plans.
providerZipCode Query string (optional) Specify the requesting provider’s ZIP code, as required by some health plans.
providerSpecialty Query string (optional) Specifies the requesting provider's specialty using a taxonomy code. Refer to X12 External Code Source 682: Provider Taxonomy Codes.
placeOfService Query string (optional) Identifies the place of service, as required by some health plans.
submitterId Query string (optional) Identifies the submitter using a payer-assigned submitter identifier, as required by some health plans.
asOfDate Query string (optional) Indicates the date of service for which you want to check coverage information.
toDate Query string (optional) Provides an end date for your coverage information search period, as required by some health plans.
serviceType Query string (optional) The type or types of service your request involves.
cardIssueDate Query string (optional) The issue date of the member's health plan card.
procedureCode Query string (optional) The procedure code for the coverage you're requesting. Refer to the ASC X12 270/271 TR3 for the full list of procedure code sources.
memberId Query string (optional) The patient’s health plan member ID number.
medicaidId Query string (optional) The patient’s Medicaid ID number.
patientSSN Query string (optional) The patient’s Social Security Number.
patientLastName Query string (optional) The patient’s last name.
patientFirstName Query string (optional) The patient’s first name.
patientMiddleName Query string (optional) The patient’s middle name.
patientSuffix Query string (optional) The patient’s suffix.
patientGender Query string (optional) The patient’s gender.
patientBirthDate Query string (date) (optional) The patient’s date of birth.
patientState Query string (optional) Two-character abbreviation for the patient’s state of residence.
groupNumber Query string (optional) The patient’s health plan group number.
subscriberRelationship Query string (optional) Specifies the patient’s relationship to the health plan subscriber if the patient is not the subscriber. Values with definitions in parentheses:
  • 18 (Self)
  • 01 (Spouse)
  • 19 (Child)
  • G8 (Other relationship)

Search GET/v1/coverages parameters

Availity stores short-lived, local copies of each coverage request until the time specified by the expirationDate property. If Availity does not have a recent local copy of a particular coverage, it will request one from the health plan. This is an asynchronous process. You can track the current status using the status and statusCode properties. To search your recent coverage requests, you can use the following parameters in addition to the parameters listed above:
 
Search GET/v1/coverages parameters
Parameter Type Definition
status String (optional) Search for coverages with a status of In Progress, Request Error, Communication Error, or Complete.
planStatus String (optional) Search for coverages with a plan status of Active or Inactive.
q String (required) Search for coverages that match free-form search terms.
sortBy String (optional) Sort the results by lastUpdateDate, asOfdate, or patientLastName. The default is lastUpdateDate.
sortDirection String (optional) Sort the results in asc or desc order. The default is desc.
Note: When performing a search query, you must include the q parameter. If you do not require a free-form matching of terms, you can leave the field 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: ,;'-.?!&/\\#+=()"
        }
    ]
}
If a coverage reports its statusCode and status properties as 0 and In Progress, respectively, this means Availity is in the process of retrieving the coverage from the health plan. You can either repeat your request or periodically make a GET by {id} request for the coverage until the statusCode and status properties change. In Progress coverages include an etaDate property that reports the time Availity anticipates the refresh will be complete. The status property will then change to one of several values:
 
Status codes for GET/v1/coverages
Code Status Definition
0 In Progress Availity is in the process of retrieving the coverage from the health plan.
19 Request Error The health plan has returned one or more validationMessages. (Refer to the validationMessages table.)
R1 Communication Error, Retrying The health plan did not respond and Availity is retrying the request.
7 Communication Error The health plan did not respond.
13 Communication Error 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 it is down for maintenance.
4 Complete The refresh was completed successfully.
3 Complete (Invalid Response) The refresh was completed successfully, but the health plan's response was partially invalid. Availity still returns all available information from the response, but some values may be missing.
2. GET/v1/coverages/{id}
 
GET/v1/coverages/{id} parameters
Parameter Type Definition
id Path string (required) Retrieve full coverage information using the unique response ID from your initial request.

3. DELETE/v1/coverages/{id}

 
DELETE/v1/coverages/{id} parameters
Parameter Type Definition
id Path string (required) Delete coverage information using the unique response ID from your initial request.

Sample requests and responses

  1. GET/v1/coverages

Request:

curl -X GET "https://api.availity.com/availity/v1/coverages" 

Response (truncated):

{
  "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"
        }
      ]
    }
  ]
}

Search GET/v1/coverages

When you make a search request, the resource will return a status code of 200 and the first page of matching coverage summaries. 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, refer to the Pagination section.

Request:

$ 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"
 

Response:

{
  "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"
      }
    }
  ]
}

3. GET/v1/coverages/{id}

Note: Replace {id} with the unique response ID from your initial polling request.

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

Request:

$ curl -X GET "https://api.availity.com/availity/v1/coverages?id=00011944990
98175762045868562105833796329766732695450956940743265&id=00011944990981
757620458685621358337963297667326954509569407491523"
    

Response:

{
    "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": [...]
        }
    ]
}

4. DELETE/v1/coverages/{id}

Note: Replace {id} with the unique response ID from your initial polling request.

Request:

$ curl -X DELETE "https://api.availity.com/availity/v1/coverages/0001194499098175
762045868562105833796329766732695450956940743265"

When you make a valid delete request, the resource returns a status code of 204. Response:

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

Response definitions

 
Coverages response definitions: Primary result set
Field Type Definition
totalCount Integer The total number of items available that match the parameters specified.
count Integer The number of items returned.
offset Integer The zero-based starting index in the collection of the first item to return.
limit Integer The maximum number of collection items returned for a single request.
links Object Object containing the URL for the request.
coverages Array Array providing information about the coverage or coverages you requested. Refer to the coverages table for field definitions.
 
Coverages response definitions: Fields within coverages
Field Type Definition
id String The unique response ID from the initial polling request.
customerId String The unique number Availity uses to identify an organization.
createdDate String (date-time) The time and date the coverage was added to Availity's system.
updatedDate String (date-time) The time and date the coverage was last updated in the system.
expirationDate String (date-time) The time and date this coverage will expire.
controlNumber String An Availity-assigned tracking number for this transaction.
submitterStateCode String The submitting customer's configured state code.
status String The current status of the coverage request. Refer to the Status codes table for statuses.
statusCode String The code for the current status of the coverage request. Refer to the Status codes table for codes.
asOfDate String (date-time) The date for which the patient's coverage information is being verified.
toDate String (date-time) The end date for the coverage information search.
cardIssueDate String (date-time) The patient's health plan member card issue date.
payer Object Object providing information about the health plan that returned this coverage information. Refer to the Payer table for field definitions.
requestingProvider Object Object providing identifying information about the provider that requested this coverage information, including information sent within the request and additional information sent from the health plan in the response. Refer to the requestingProvider table for field definitions.
patient Object Object providing demographic information about the patient, who may be the subscriber or a dependent. Refer to the Patient table for field definitions.
subscriber Object Object providing demographic information about the health plan subscriber. Refer to the Subscriber table for field definitions.
plans Array Array listing information about all health plans returned for the member. Refer to the Plans table for field definitions.
requestedServiceType Array Array listing requested service types. Properties include the service type code and value (description). Refer to the ASC X12 270/271 TR3 for the full list of service type codes.
procedureCode Array Array listing requested procedure codes. Refer to the ASC X12 270/271 TR3 for the full list of procedure code sources.
validationMessages Array A list of validation messages from the payer. Refer to the validationMessages table for field definitions.
 
Coverages response definitions: Fields within payer
Field Type Definition
payerId String The requested payer's Availity-specific identifier.
name String The requested payer's name.
responsePayerId String The ID the payer responded with.
responseName String The name the payer responded with.
 
Coverages response definitions: Fields within requestingProvider
Field Type Definition
lastName/firstName String The requesting provider's last or business name/first name.
type String Describes the requesting provider type.
typeCode String Code for the requesting provider type. Refer to the X12 270/271 TR3 for the full list of provider type codes.
specialtyCode String Code for the requesting provider's specialty. Refer to the X12 270/271TR3 for specialty code sources.
npi String The requesting provider's National Provider Identifier (NPI).
taxId String The requesting provider's tax ID number.
payerAssignedProviderId String The requesting provider's ID assigned by the payer.
ssn String The requesting provider's Social Security Number.
submitterId String The requesting provider's submitter ID.
placeOfService String Description of the place of service.
placeOfServiceCode String Code for the place of service. Refer to X12 Code Source 237: Place of Service Codes for Professional Claims.
address Object Object providing information about the requesting provider's address. Fields in this object are omitted for brevity.
pin String The requesting provider's personal identification number.
 
Coverages response definitions: Fields within patient
Field Type Definition
lastName/firstName /middleName/suffix String The patient's last name/first name/middle name/suffix.
birthDate String (date-time) The patient's date of birth.
ssn String The patient's Social Security Number.
gender String The patient's gender.
genderCode String Code for the patient's gender. Values with definitions in parentheses: F (female), M (male), U (unknown).
subscriberRelationship String Describes the patient's relationship to the subscriber.
subscriberRelationshipCode String Code for the patient's relationship to the subscriber. Values with definitions in parentheses:
  • 18 (Self)
  • 01 (Spouse)
  • 19 (Child)
  • G8 (Other relationship)
address Object Object providing information about the patient's address. Fields in this object are omitted for brevity.
 
Coverages response definitions: Fields within subscriber
Field Type Definition
memberId String The subscriber's health plan member ID number.
medicaidId String The subscriber's Medicaid member ID number, if applicable.
lastName/firstName /middleName/suffix String The subscriber's last name/first name/middle name/suffix.
birthDate String (date-time) The subscriber's date of birth.
gender String The subscriber's gender.
genderCode String Code for the patient's gender. Values with definitions in parentheses: F (female), M (male), U (unknown).
caseNumber String The case number assigned to the subscriber by the information source (e.g., payer, employer, HMO).
 
Coverages response definitions: Fields within plans
Field Type Definition
status String The patient's coverage status (e.g., active).
statusCode String The code for the coverage status. See the ASC X12 270/271 TR3 for the full list of eligibility and benefit information codes.
identityCardNumber String Identifying card number used in addition to the member card number; typically prevalent in the Medicaid environment.
groupNumber String The patient's health plan group number.
groupName String The patient's health plan group name.
description String  
coverageSummaryAdditionalPayers Array Array listing objects for additional payers. Refer to the coverageSummaryAdditionalPayers table for definitions of fields within these objects.
eligibilityStartDate String (date-time) Date the patient's eligibility for benefits began/will begin.
eligibilityEndDate String (date-time) Date the patient's eligibility for benefits ended/will end.
coverageStartDate String (date-time) The date coverage began/will begin.
coverageEndDate String (date-time) The date coverage ended/will end.
insuranceType String The patient's type of insurance.
insuranceTypeCode String Code for the insurance type. Refer to the ASC X12 270/271 TR3 for the full list of insurance type codes.
primaryCareProvider Object Object providing information about the patient's primary care provider. Fields (with definitions in parentheses) are as follows:
  • name (primary care provider's name)
  • category (provider's category)
  • categoryCode (code for the provider's category. Refer to the ASC X12 270/271 TR3 for the full list of provider codes.)
 
Coverages response definitions: Fields within coverageSummaryAdditionalPayers
Field Type Definition
name String The additional payer's name.
serviceTypeCode String Code for the additional payer's service type. See the ASC X12 270/271 TR3 for the full list of service type codes.
insuredMemberId String The insured's member ID with the additional payer.
primary Boolean Indicates whether this additional payer is the primary payer.
secondary Boolean Indicates whether this additional payer is the secondary payer.
tertiary Boolean Indicates whether this additional payer is the tertiary payer.
coordinationOfBenefitsBeginDate String (date) Date coordination of benefits began/will begin.
coordinationOfBenefitsEndDate String (date) Date coordination of benefits ended/will end.
coordinationOfBenefitsDate String (date)  
 
Coverages response definitions: Fields within validationMessages
Field Type Definition
field String The field or parameter associated with this error.
code String The error code.
errorMessage String The message associated with this error.
index Integer The array index of the item associated with this error.
 
Coverages response definitions: Fields within coverage
Field Type Definition
id String The unique response ID from the initial polling request.
customerId String The unique number Availity uses to identify an organization.
controlNumber String An Availity-assigned tracking number for this transaction.
status String The current status of the coverage request. Refer to the Status codes table for statuses.
statusCode String The code for the current status of the coverage request. Refer to the Status codes table for codes.
submitterStatecode String The submitting customer's configured state code.
createdDate String (date-time) The time and date the coverage was added to Availity's system.
updatedDate String (date-time) The time and date the coverage was last updated in the system.
expirationDate String (date-time) The time and date this coverage will expire.
asOfDate String (date-time) Indicates the date of service for which you want to check coverage information.
toDate String (date-time) Provides an end date for your coverage information search period, as required by some health plans.
cardIssueDate String (date-time) The issue date of the member's health plan card.
requestedServiceType Object Object including fields for the requested service type code and requested service type description. Refer to the ASC X12 270/271 TR3 for the full list of service type codes.
procedureCode String Code for the product or service. Refer to the ASC X12 270/271 TR3 for the full list of procedure code sources.
validationMessages Array Array listing validation messages from the payer. Refer to the validationMessages table for field definitions.
subscriber Object Object providing information about the health plan subscriber. Refer to the coverage.subscriber table for field definitions.
patient Object Object providing information about the patient. Refer to the coverage.patient table for field definitions.
payer Object Object providing information about the payer. Refer to the coverage.payer table for field definitions.
requestingProvider Object Object providing information about the payer. Refer to the coverage.requestingProvider table for field definitions.
plans Array Array containing objects with policy plan information. Refer to the coverage.plans table for field definitions.
supplementalInformation Object Object containing supplemental information about the coverage. Refer to the supplementalInformation table for field definitions.
reminders Object Object containing care reminders pertaining to the coverage. Refer to thereminders table for field definitions.
 
Coverages response definitions: Fields within coverage.subscriber
Field Type Definition
memberId String The subscriber's health plan member ID number.
medicaidId String The subscriber's Medicaid member ID number, if applicable.
lastName/firstName /middleName/suffix String The subscriber's last name/first name/middle name/suffix.
birthDate String (date-time) The subscriber's date of birth.
gender String The subscriber's gender.
genderCode String Code for the patient's gender. Values with definitions in parentheses: F (female), M (male), U (unknown).
ssn String The subscriber's Social Security Number.
address Object Object providing information about the subscriber's address. Fields in this object are omitted for brevity.
caseNumber String The case number assigned to the subscriber by the information source (e.g., payer, employer, HMO).
 
Coverages response definitions: Fields within coverage.patient
Field Type Definition
lastName/firstName /middleName/suffix String The patient's last name/first name/middle name/suffix.
patientAccountNumber String Number for the patient’s health plan account.
memberId String The patient's health plan member ID.
familyUnitNumber String Number required when the information source is a Pharmacy Benefit Manager and the patient has a suffix on their member ID number required for use in the NCPDP Telecom Standard.
birthDate String (date-time) The patient's date of birth.
deathDate String (date-time) The patient's date of death.
ssn String The patient's Social Security Number.
gender String The patient's gender.
genderCode String Code for the patient's gender. Values with definitions in parentheses: F (female), M (male), U (unknown).
subscriberRelationship String Describes the patient's relationship to the subscriber.
subscriberRelationshipCode String Code for the patient's relationship to the subscriber. Values with definitions in parentheses:
  • 18 (Self)
  • 01 (Spouse)
  • 19 (Child)
  • G8 (Other relationship)
address Object Object providing information about the patient's address. Fields in this object are omitted for brevity.
updateYourRecords Boolean Indicates whether the patient's demographic or address information needs to be updated.
 
Coverages response definitions: Fields within coverage.payer
Field Type Definition
type String The payer's type.
typeCode String The code for the payer's type. Refer to the ASC X12 270/271 TR3 for the full list of insurance type codes.
name String The payer's name.
payerId String The requested payer's Availity-specific identifier.
responsePayerId String The ID the payer responded with.
responseName String The name the payer responded with.
primary Boolean Indicates whether this is the primary payer.
secondary Boolean Indicates whether this is the secondary payer.
tertiary Boolean Indicates whether this is the tertiary payer.
thirdPartyAdministrator String Indicates whether the payer is a third-party administrator.
insuredLastName String The insured person's last name.
insuredFirstName String The insured person's first name.
insuredMiddleName String The insured person's middle name.
insuredMemberId String The insured person's health plan member ID.
insuredAddress Object Object providing information about the insured person's address. Fields in this object are omitted for brevity.
groupNumber String The insured person's group number.
groupName String The insured person's group name.
policyNumber String The insured person's policy number.
planNumber String The insured person's plan number.
planName String The insured person's plan name.
planNetworkId String The insured person's plan network ID.
memberIdentificationNumber String The insured person's member ID number.
familyUnitNumber String Number required when the information source is a Pharmacy Benefit Manager and the patient has a suffix on their member ID number required for use in the NCPDP Telecom Standard.
healthInsuranceClaimNumber String The health insurance claim number (HICN), a Medicare beneficiary's identification number for paying claims and determining eligibility for services.
medicaidRecipient IdentificationNumber String The patient's Medicaid Recipient ID number.
dischargeDate String (date-time) Date the patient was discharged.
periodStartDate String (date-time) The eligibility period start date.
periodEndDate String (date-time) The eligibility period end date.
completionDate String (date-time)  
coordinationOfBenefitsDate String (date-time)  
coordinationOfBenefitsBeginDate String (date-time) Date coordination of benefits began/will begin.
coordinationOfBenefitsEndDate String (date-time) Date coordination of benefits ended/will end.
coverageStartDate String (date-time) Date the patient's coverage started/will start.
coverageEndDate String (date-time) Date the patient's coverage ended/will end.
addedDate String (date-time)  
planStartDate String (date-time)  
primaryCareProviderDate String (date-time)  
lastVisitDate String (date-time)  
eligibilityStartDate String (date-time) Date the patient's eligibility began.
eligibilityEndDate String (date-time) Date the patient's eligibility ended.
benefitBeginDate String (date-time) Date benefits began/will begin.
benefitEndDate String (date-time) Date benefits ended/will end.
admissionDate String (date-time) Date the patient was admitted.
serviceDate String (date-time) The date of service.
lastUpdateDate String (date-time)  
statusDate String (date-time)  
insuredContactInformation Array Contact information for the insured person. Fields in this array are omitted for brevity.
address    
contactInformation Array The payer's contact information. Fields in this array are omitted for brevity.
payerNotes Array Array containing general disclaimers and messages from the health plan. Refer to the payerNotes table for fields and definitions.
serviceTypeCode String Code for the payer's service type. Refer to the ASC X12 270/271 TR3 for the full list of service type codes.
 
Coverages response definitions: Fields within coverage.requestingProvider
Field Type Definition
category String Category for the requesting provider.
categoryCode String Code for the provider's category. Refer to the ASC X12 270/271 TR3 for the full list of provider codes.
type String Describes the requesting provider type.
typeCode String Code for the requesting provider type. Refer to the X12 270/271 TR3 for the full list of provider type codes.
role String Describes the requesting provider's role related to the eligibility/benefit being inquired about.
roleCode String Code for the provider's role. Refer to the ASC X12 270/271 TR3 for the full list of provider codes.
name String Business name of the requesting provider.
lastName/firstName/ middleName String The requesting provider's last name/first name/middle name.
npi String The requesting provider's National Provider Identifier.
taxId String The requesting provider's tax ID number.
stateLicenseNumber String The requesting provider's state license number.
medicareProviderNumber String The requesting provider's Medicare provider number.
medicaidProviderNumber String The requesting provider's Medicaid provider number.
facilityId String The requesting provider's Facility Identification.
pin String The requesting provider's personal identification number.
contractNumber String The requesting provider's contract number.
electronicPin String The requesting provider's electronic device personal identification number.
providerPlanNetworkId String The requesting provider's Provider Plan Network Identification Number.
facilityNetworkId String The requesting provider's Facility Network Identification Number.
ssn String The requesting provider's Social Security Number.
ein String The requesting provider's Employer Identification Number.
etin String The requesting provider's Electronic Transmitter Identification Number.
payerId String The Availity-specific identifier for the patient's health plan.
pharmacyProcessorNumber String The requesting provider's Pharmacy Processor Number.
planId String The requesting provider's Centers for Medicare & Medicaid Services Plan ID.
policyNumber String The health plan policy number.
memberId String The health plan member ID number.
familyUnitNumber String Number required when the information source is a Pharmacy Benefit Manager and the patient has a suffix on their member ID number required for use in the NCPDP Telecom Standard.
groupNumber String The health plan group number.
referralNumber String Number or code that indicates that a referral for services has been approved.
alternateListId String Allows the information source to identify a list of drugs and alternative drugs with the associated formulary status for the patient.
coverageListId String Allows the information source to identify a list of drugs that have coverage limitations for the associated patient.
healthInsuranceClaimNumber String The health insurance claim number (HICN), a Medicare beneficiary's identification number for paying claims and determining eligibility for services.
drugFormularyNumber String The drug formulary number.
priorAuthorizationNumber String Number that indicates the services on this claim have been authorized.
medicalAssistanceCategoryId String The Medical Assistance Category ID number.
planNetworkId String The Plan Network Identification number.
planNetworkName String The Plan Network name.
medicaidRecipientId String The Medicaid recipient ID number.
suhi String  
naicId String The requesting provider's National Association of Insurance Commissioners number.
payerAssignedProviderId String The requesting provider's payer-assigned provider identification number.
submitterId String The requesting provider's submitter ID.
payerAssignedUserId String The requesting provider's payer-assigned user ID.
specialty String The requesting provider's specialty.
specialtyCode String Code for the requesting provider's specialty. Refer to the X12 270/271TR3 for code sources.
placeOfService String Identifies the place of service.
placeOfServiceCode String Code for the place of service. Refer to X12 Code Source 237: Place of Service Codes for Professional Claims.
dischargeDate String (date-time)  
periodStartDate String (date-time)  
periodEndDate String (date-time)  
completionDate String (date-time)  
coordinationOfBenefitsDate String (date-time)  
coordinationOfBenefitsBegin Date String (date-time)  
coordinationOfBenefitsEnd Date String (date-time)  
coverageStartDate String (date-time)  
coverageEndDate String (date-time)  
addedDate String (date-time)  
planStartDate String (date-time)  
primaryCareProviderDate String (date-time)  
primaryCareProviderStart Date String (date-time)  
primaryCareProviderEnd Date String (date-time)  
lastVisitDate String (date-time)  
eligibilityStartDate String (date-time)  
eligibilityEndDate String (date-time)  
benefitBeginDate String (date-time)  
benefitEndDate String (date-time)  
admissionDate String (date-time)  
serviceDate String (date-time)  
lastUpdateDate String (date-time)  
statusDate String (date-time)  
authorizationRequired Boolean Indicates whether the provider is required to obtain authorization to perform this service.
address Object Object providing information about the requesting provider's address. Fields in this object are omitted for brevity.
contactInformation Array Array providing contact information for the requesting provider. Fields in this array are omitted for brevity.
deliveryInformation Array Array listing healthcare service delivery information for the requesting provider. Refer to the requestingprovider.deliveryInformation table for field definitions.
payerNotes Array Array listing payer notes about the requesting provider. Refer to the payerNotes table for fields.
 
Coverages response definitions: Fields within coverage.requestingProvider.deliveryInformation
Field Type Definition
quantityQualifier String Describes the type of units used for the quantity of benefits.
quantityQualifierCode String Code for the type of units used for the quantity of benefits. Refer to the ASC X12 270/271 TR3 for the full list of quantity qualifier codes.
quantity String The quantity of benefits.
amount String  
per String The frequency period over which the service is delivered.
perCode String The code for the frequency period. Refer to the ASC X12 270/271 TR3 for the full list of delivery frequency codes.
timePeriod String The time period measurement for this service delivery.
timePeriodCode String The code for the time period measurement. Refer to the ASC X12 270/271 TR3 for the full list of time period qualifier codes.
timePeriods String The number of periods involved in the service delivery.
pattern String The routine deliveries or calendar pattern for this service delivery.
patternCode String The code for the calendar pattern. Refer to the ASC X12 270/271 TR3 for the full list of delivery frequency codes.
time String The time of day for this service delivery.
timeCode String The code for the time of day. Refer to the ASC X12 270/271 TR3 for the full list of delivery pattern time codes.
 
Coverages response definitions: Fields within coverage.plans
Field Type Definition
status String The patient's coverage status (e.g., active).
statusCode String The code for the coverage status. See the ASC X12 270/271 TR3 for the full list of eligibility and benefit information codes.
identityCardNumber String Identifying card number used in addition to the member card number; typically prevalent in the Medicaid environment.
groupNumber String The patient's health plan group number.
groupName String The patient's health plan group name.
policyNumber String The patient's health plan policy number.
planNumber String The patient's health plan number.
planName String The patient's health plan name.
planNetworkId String The patient's plan network ID.
planNetworkName String The patient's plan network name.
contractClassCode   Class of contract code; used in the X12 835 transaction and may be returned if there is sufficient information in the 270 transaction.
contractNumber String The provider's contract number.
medicalRecordNumber String The medical record identification number.
healthInsuranceClaimNumber String The health insurance claim number (HICN), a Medicare beneficiary's identification number for paying claims and determining eligibility for services.
identificationCardSerialNumber String The patient's ID card serial number.
identityCardNumber String The patient's ID card number.
issueNumber String The patient's issue number.
medicaidRecipient IdentificationNumber String The patient's Medicaid recipient ID number.
priorIdentificationNumber String The patient's prior identifier number.
agencyClaimNumber String Claim number used only when the information source is a Property and Casualty payer.
admissionDate String (date-time) The patient's admission date.
dischargeDate String (date-time) The patient's discharge date.
issueDate String (date-time)  
serviceDate String (date-time)  
coverageStartDate String (date-time)  
coverageEndDate String (date-time)  
planStartDate String (date-time)  
planEndDate String (date-time)  
planEnrollmentDate String (date-time)  
certificationDate String (date-time)  
eligibilityStartDate String (date-time) Date the patient's eligibility for benefits began/will begin.
eligibilityEndDate String (date-time) Date the patient's eligibility for benefits ended/will end.
policyEffectiveDate String (date-time)  
policyExpirationDate String (date-time)  
effectiveChangeDate String (date-time)  
cobraStartDate String (date-time)  
cobraEndDate String (date-time)  
lastUpdateDate String (date-time)  
addedDate String (date-time)  
premiumPaidToBeginDate String (date-time)  
premiumPaidToEndDate String (date-time)  
periodStartDate String (date-time)  
periodEndDate String (date-time)  
statusDate String (date-time)  
additionalPayers Array Array listing information for additional payers. Refer to the coverage.payer table for fields and definitions.
primaryCareProvider Array Array listing information for the primary care provider. Refer to the coverage.requestingProvider table for fields and definitions.
contacts Array Array listing contact information for the patient. Fields in this array are omitted for brevity.
benefits Array Array listing information about benefits. Refer to the coverage.plans.benefits table for fields and definitions.
preexistingConditions Object Object providing eligibility/benefit information for preexisting conditions. Refer to the plans.benefits.benefitDetail table for fields and definitions.
costContainment Object Object providing information about the total amount the patient will have to pay out of pocket before benefits begin. Typically applies to the Medicaid environment. Refer to the plans.benefits.benefitDetail table for fields and definitions.
limitations Object Object providing information about eligibility/ benefit limitations. Refer to the plans.benefits.benefitDetail table for fields and definitions.
benefitDescriptions Object Object providing a description of benefits. Refer to the plans.benefits.benefitDetail table for fields and definitions.
coverageBasis Object Object providing information about the basis for coverage. Refer to the plans.benefits.benefitDetail table for fields and definitions.
insuranceType String The type of insurance.
insuranceTypeCode String Code for the insurance type. Refer to the ASC X12 270/271 TR3 for the full list of insurance type codes.
reserve Object Refer to the plans.benefits.benefitDetail table for fields and definitions.
payerNotes Array List of general payer notes and disclaimers. Refer to the payerNotes table for fields and definitions.
 
Coverages response definitions: Fields within coverage.plans.benefits
Field Type Definition
name String The name of the benefit.
type String Type of benefit.
source String The source of the procedure benefit.
status String The status of coverage for this benefit.
statusCode String The status code of the coverage for this benefit. See the ASC X12 270/271 TR3 for the full list of eligibility and benefit information codes.
statusDetails Object Refer to the plans.benefits.benefitDetail table for fields and definitions.
amounts Object Object providing information about amounts involved in this benefit. Refer to the plans.benefits.amounts table for fields and definitions.
limitations Object Object providing information about eligibility/ benefit limitations. Refer to the plans.benefits.benefitDetail table for fields and definitions.
benefitDescriptions Object Object providing a description of benefits. Refer to the plans.benefits.benefitDetail table for fields and definitions.
nonCovered Object Object providing information about non-covered services. Refer to the plans.benefits.benefitDetail table for fields and definitions.
coverageBasis Object Object providing information about the basis for coverage. Refer to the plans.benefits.benefitDetail table for fields and definitions.
reserve Object Refer to the plans.benefits.benefitDetail table for fields and definitions.
preexistingConditions Object Object providing eligibility/benefit information for preexisting conditions. Refer to the plans.benefits.benefitDetail table for fields and definitions.
costContainment Object Object providing information about the total amount the patient will have to pay out of pocket before benefits begin. Typically applies to the Medicaid environment. Refer to the plans.benefits.benefitDetail table for fields and definitions.
exclusions Object Object providing information about exclusions. Refer to the plans.benefits.benefitDetail table for fields and definitions.
additionalPayers Array Array listing information for additional payers. Refer to the coverage.payer table for fields and definitions.
contacts Array Array listing additional contacts for this benefit. Refer to the coverage.requestingProvider table for fields and definitions.
payerNotes   List of general payer notes and disclaimers. Refer to the payerNotes table for fields and definitions.
 
Coverages response definitions: Fields within plans.benefits.benefitDetail
Field Type Definition
inNetwork Array Array listing information about benefits that apply to in-network providers. Refer to the networkBenefit table for fields and definitions.
outOfNetwork Array Array listing information about benefits that apply to out-of-network providers. Refer to the networkBenefit table for fields and definitions.
notApplicableNetwork Array Array listing information about benefits that apply regardless of network. Refer to the networkBenefit table for fields and definitions.
noNetwork Array Array listing information about benefits that are not specific to a network. Refer to the networkBenefit table for fields and definitions.
 
Coverages response definitions: Fields within plans.benefits.benefitDetail.amounts
Field Type Definition
coPayment Object Object providing information about copayment amounts. Refer to the plans.benefits.benefitDetail table for fields and definitions.
outOfPocket Object Object providing information about out-of-pocket amounts. Refer to the plans.benefits.benefitDetail table for fields and definitions.
deductibles Object Object providing information about deductible amounts. Refer to the plans.benefits.benefitDetail table for fields and definitions.
coInsurance Object Object providing information about coinsurance amounts. Refer to the plans.benefits.benefitDetail table for fields and definitions.
 
Coverages response definitions: Fields within plans.benefits.benefitDetail.networkBenefit
Field Type Definition
status String  
statusCode String The code for the coverage status. See the ASC X12 270/271 TR3 for the full list of eligibility and benefit information codes.
insuranceType String The patient's type of insurance.
insuranceTypeCode String Code for the insurance type. Refer to the ASC X12 270/271 TR3 for the full list of insurance type codes.
amount String  
units String  
amountTimePeriod String The time period this benefit applies to.
amountTimePeriodCode String  
remaining String The remaining amount.
remainingTimePeriod String The time period that the remaining benefit applies to.
remainingTimePeriodCode String  
total String Total amount.
totalTimePeriod String  
totalTimePeriodCode String  
level String  
levelCode String  
quantity String  
quantityQualifier String  
quantityQualifierCode String  
authorizationRequired Boolean Indicates whether the provider is required to obtain authorization to perform this service.
authorizationRequiredUnknown Boolean Indicates if it is unknown whether the provider is required to obtain authorization.
placeOfService String Description of the place of service.
placeOfServiceCode String Code for the place of service. Refer to X12 Code Source 237: Place of Service Codes for Professional Claims.
description String  
planNumber String The plan number.
planName String The plan name.
policyNumber String The plan network ID.
memberIdentificationNumber String The member ID number.
familyUnitNumber String Number required when the information source is a Pharmacy Benefit Manager and the patient has a suffix on their member ID number required for use in the NCPDP Telecom Standard.
groupNumber String The patient's health plan group number.
groupName String The patient's health plan group name.
referralNumber String Number or code that indicates that a referral for services has been approved.
healthInsuranceClaimNumber String The health insurance claim number (HICN), a Medicare beneficiary's identification number for paying claims and determining eligibility for services.
priorAuthorizationNumber String Number that indicates the services on this claim have been authorized.
insurancePolicyNumber String The health insurance policy number.
planNetworkId String The insured person's plan network ID.
planNetworkName String The insured person's member ID number.
medicaidRecipient IdentificationNumber String The patient's Medicaid Recipient ID number.
dischargeDate String  
periodStartDate String  
periodEndDate String  
completionDate String  
coordinationOfBenefitsDate String  
coordinationOfBenefits BeginDate String  
coordinationOfBenefitsEndDate String  
coverageStartDate String  
coverageEndDate String  
addedDate String  
planStartDate String  
primaryCareProviderDate String  
lastVisitDate String  
eligibilityStartDate String  
eligibilityEndDate String  
benefitBeginDate String  
benefitEndDate String  
admissionDate String  
serviceDate String  
lastUpdateDate String  
statusDate String  
contacts Array Array listing contact information for this benefit. Fields in this array are omitted for brevity.
payerNotes Array Array containing general disclaimers and messages from the health plan. Refer to the payerNotes table for fields and definitions.
deliveryInformation Array Array containing service delivery information. Refer to the deliveryInformation table for fields and definitions.
 
Coverages response definitions: Fields within coverage.supplementalInformation
Field Type Definition
professionalPatientCost Estimator Boolean Indicates whether the Professional Patient Cost Estimator is available.
institutionalPatientCost Estimator Boolean Indicates whether the Institutional Patient Cost Estimator is available.
patientCareSummary Boolean Indicates whether the patient care summary is available.
patientCareSummaryReason String Indicates the reason for the patient care summary availability.
patientCareSummaryReasonCode String Code for the reason for the patient care summary availability.
assessmentCarePlan Boolean Indicates whether an assessment and care plan are available.
thirdPartySystemId   Third party system ID for supplemental information.
routingCode   Routing code for supplemental information.
outOfArea Boolean Flag used by certain payers to indicate out of area.
clickToTalkPhoneNumber String  
clickToTalkKey    
localMemberId String Local member ID for third-party clinical exchanges.
pceMemberLocatorKey String Local member key for patient cost estimator for third-party clinical exchanges.
pceHostIndicator Boolean Host plan indicator for patient cost estimator for third-party clinical exchanges.
referralShortFormIndicator Boolean Referral short form indicator.
viewReferralAuthIndicator Boolean View all auths and referrals indicator.
csnpIndicator Boolean Indicates whether a C-SNP form is available.
requestLtssccAmount Boolean Indicates whether to initiate a request to LTSSCC.
pregnant Boolean Indicates whether the Patient Assessment (Maternity) form exists.
pharmacyRestrictions Object Object containing information about pharmacy restrictions. Includes fields for address and contact information, effective date, and termination date.
erReferralCompleted Boolean Indicates whether the ER Referral Questionnaire was completed.
 
Coverages response definitions: Fields within coverage.reminders
Field Type Definition
titles Object Object containing clinical message titles.
messages Array Array listing objects containing clinical message content.
inference String Clinical inference.
 
Coverages response definitions: Fields within payerNotes
Field Type Definition
type String Describes the type of note.
typeCode String Code for the type of note.
message String The content of the note from the payer.

Service Reviews 2.0.0

Create, update, void, and search for service reviews (Admission Reviews, Health Service Reviews, and Specialty Care Reviews) with this API, which enables the ASC X12N 278 transaction. Code lists and sources can be found in the ASC X12 Standards for Electronic Data Interchange Technical Report Type 3 (TR3) titled Health Care Services Review – Inquiry and Response (278) and Health Care Services Review – Request for Review and Response (278).

Endpoints

 
  Path Function
1 POST/v2/service-reviews Create service reviews (i.e., submit authorizations/referrals) asynchronously. To submit a transaction, make a valid request and Availity responds with a location header containing a URL you can query for your result.
2 GET/v2/service-reviews Search for service reviews in the health plan's system. This endpoint queries the health plan's system asynchronously. To submit a transaction, make a valid request and Availity responds with a location header containing a URL you can query for your result. This method can be used to check the status of a service review (i.e., perform an authorization/referral inquiry) and is a prerequisite to performing an update or delete.
3 GET/v2/service-reviews/{id} Retrieve a specific service review (i.e., perform an authorization/referral inquiry). Replace {id} with the response ID from your initial request.
4 PUT/v2/service-reviews Update service reviews asynchronously. Only a service review with updatable=true can be updated. Once you make a valid request, Availity will respond with a location header containing a URL you can query for your result while Availity asynchronously sends an updated copy of the service review to the health plan. Note: The updatableFields array will list which fields the payer allows the client to update.
5 DELETE/v2/service-reviews/{id} Void an existing service review asynchronously. Only a service review with deletable=true can be voided. Once you make a valid request, Availity responds with a location header containing a URL you can query for your result while asynchronously sending a void request to the health plan. Replace {id} with the response ID from your initial request.

Demo response scenarios

To test the demo version of this API, send the (X-Api-Mock-Scenario-ID) header with the appropriate response scenario ID, as listed in the following table. For POST methods, send an empty JSON body: {}.
 
Service Reviews demo response scenarios
Response scenario ID Method Status code Definition
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 can retry your request 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 an error in 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 and Availity is retrying the request.
SRI-GetAccepted-i GET 202 Availity is processing your request.
SRI-GetComplete-i GET 200 Availity has successfully retrieved the member's service review information from the health plan.
SRI-GetInProgress-i GET 202 Availity is processing your request.
SRI-GetPayerError-i GET 400 The health plan indicated an error in 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 can retry your request later.
SRI-GetRetrying-i GET – use {id} 12345678 202 The health plan did not respond and Availity is retrying the request.
SRI-GetRequestError-i GET 400 The health plan indicated an error in the request. The resource should have a list of validationMessages. Correct and resubmit the request.

Validation rules

The validation rules for the Service Reviews resource can vary by health plan, the type of authorization requested, and the type of service performed. Availity organizes and makes these rules available through the Configurations API, which documents the fields required to create a service review and explains which values are valid for those fields.

Service Reviews has two type names in Configurations: service-reviews, which allows you to search for validation rules for the POST/v2/service-reviews request, and service-reviews-inquiry, which allows you to search for validation rules for the GET/v2/service-reviews request. For both types, the subtype ID is HS (Health Services Review/outpatient authorization), AR (Admission Review/inpatient authorization), or SC (Specialty Care Review/referral). Here's an example of a Configurations request for service review information for the payer Florida Blue:

$ curl -i -X GET https://api.availity.com/availity/v1/configurations?
type=service-reviews&subtypeId=HS&payerId=BCBSF

Refer to the Configurations reference section for further details.

Parameters

1. POST /v2/service-reviews
 
Parameter/Request body Type Definition
serviceReview Body object (optional) Represents the details of the service review (authorization/referral) you are submitting. Refer to the request body for possible fields. Refer to Response definitions for field definitions.
Content-Type Header string (optional) Allows you to specify application/json or application/xml
Accept Header string (optional) Allows you to specify application/json or application/xml

serviceReview POST request body:

{
    "type": "object",
    "properties": {
        "id": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "customerId": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "controlNumber": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "userId": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "shortFormIndicator": {
            "type": "boolean",
            "$ref": "#/definitions/Primaryfields"
        },
        "updatable": {
            "type": "boolean",
            "$ref": "#/definitions/Primaryfields"
        },
        "deletable": {
            "type": "boolean",
            "$ref": "#/definitions/Primaryfields"
        },
        "updatableFields": {
            "type": "array",
            "$ref": "#/definitions/Primaryfields"
        },
        "status": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "statusCode": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "statusReasons": {
            "type": "array",
            "$ref": "#/definitions/Primaryfields"
        },
        "createdDate": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "updatedDate": {
            "type": "string",
           "$ref": "#/definitions/Primaryfields"
        },
        "expirationDate": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "validationMessages": {
            "type": "array",
            "$ref": "#/definitions/Primaryfields"
        },
        "providerNotes": {
            "type": "array",
            "$ref": "#/definitions/Primaryfields"
        },
        "payerNotes": {
            "type": "array",
            "$ref": "#/definitions/Primaryfields"
        },
        "payer": {
            "$ref": "#/definitions/Primaryfields"
        },
        "requestingProvider": {
            "$ref": "#/definitions/Primaryfields"
        },
        "subscriber": {
            "$ref": "#/definitions/Primaryfields"
        },
        "patient": {
            "$ref": "#/definitions/Primaryfields"
        },
        "diagnoses": {
            "type": "array",
            "$ref": "#/definitions/Primaryfields"
        },
        "certificationIssueDate": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "certificationEffectiveDate": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "certificationExpirationDate": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "certificationNumber": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "referenceNumber": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "traceNumbers": {
            "type": "array",
            "$ref": "#/definitions/Primaryfields"
        },
        "requestType": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "requestTypeCode": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "serviceType": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "serviceTypeCode": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "additionalServiceTypes": {
            "type": "array",
            "$ref": "#/definitions/Primaryfields"
        },
        "placeOfService": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "placeOfServiceCode": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "serviceLevel": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "serviceLevelCode": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "fromDate": {
            "type": "string",
            "format": "date",
            "$ref": "#/definitions/Primaryfields"
        },
        "toDate": {
            "type": "string",
            "format": "date",
            "$ref": "#/definitions/Primaryfields"
        },
        "quantity": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "quantityType": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "quantityTypeCode": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "admissionType": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "admissionTypeCode": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "admissionSource": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "admissionSourceCode": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "nursingHomeResidentialStatus": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "nursingHomeResidentialStatusCode": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "homeHealthStartDate": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "homeHealthCertificationPeriodStartDate": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "homeHealthCertificationPeriodEndDate": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "transportType": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "transportTypeCode": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "transportDistance": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "transportPurpose": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "chiropracticTreatmentCount": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "beginningSubluxationLevel": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "beginningSubluxationLevelCode": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "endingSubluxationLevel": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "endingSubluxationLevelCode": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "spinalCondition": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "spinalConditionCode": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "spinalConditionDescription": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "oxygenEquipmentType": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "oxygenEquipmentTypeCode": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "oxygenFlowRate": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "oxygenDailyUseCount": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "oxygenUsePeriodHourCount": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "oxygenOrderText": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "oxygenDeliverySystemType": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "oxygenDeliverySystemTypeCode": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "transportLocations": {
            "type": "array",
            "$ref": "#/definitions/Primaryfields"
        },
        "procedures": {
            "type": "array",
            "$ref": "#/definitions/Primaryfields"
        },
        "renderingProviders": {
            "type": "array",
            "$ref": "#/definitions/Primaryfields"
        },
        "supplementalInformation": {
            "$ref": "#/definitions/Primaryfields"
        }
    }
}

2. GET /v2/service-reviews

 
Parameter Type Definition
payer.id Query string (optional) The Availity-specific identifier for the patient's health plan.
requestingProvider.specialtyCode Query string (optional) The requesting provider's specialty code. Refer to X12 External Code Source 682: Provider Taxonomy Codes.
requestingProvider.lastName Query string (optional) The requesting provider's last or business name.
requestingProvider.firstName Query string (optional) The requesting provider's first name.
requestingProvider.middleName Query string (optional) The requesting provider's middle name.
requestingProvider.suffix Query string (optional) The requesting provider's suffix.
requestingProvider.npi Query string (optional) The requesting provider's National Provider Identifier (NPI).
requestingProvider.taxId Query string (optional) The requesting provider's tax ID number.
requestingProvider.payer AssignedProviderId Query string (optional) The requesting provider's payer-assigned provider ID.
requestingProvider.submitterId Query string (optional) The requesting provider's health plan-specific submitter ID.
requestingProvider.addressLine1 Query string (optional) First line of the requesting provider's address.
requestingProvider.addressLine2 Query string (optional) Second line of the requesting provider's address.
requestingProvider.city Query string (optional) The requesting provider's city.
requestingProvider.stateCode Query string (optional) Two-character abbreviation for the requesting provider's state.
requestingProvider.zipCode Query string (optional) The requesting provider's ZIP code.
requestingProvider.contactName Query string (optional) Name for the requesting provider's contact person.
requestingProvider.phone Query string (optional) The requesting provider's phone number/extension/fax number.
requestingProvider.extension Query string (optional) The requesting provider's phone extension.
requestingProvider.fax Query string (optional) The requesting provider's fax number.
subscriber.memberId Query string (optional) The health plan subscriber's member ID number.
subscriber.firstName Query string (optional) The health plan subcriber's first name.
subscriber.lastName Query string (optional) The health plan subcriber's last name.
subscriber.middleName Query string (optional) The health plan subcriber's middle name.
subscriber.suffix Query string (optional) The health plan subcriber's suffix.
patient.lastName Query string (optional) The patient's last name.
patient.firstName Query string (optional) The patient's first name.
patient.middleName Query string (optional) The patient's middle name.
patient.suffix Query string (optional) The patient's suffix.
patient.birthDate Query string (date) (optional) The patient's birth date.
patient.subscriberRelationshipCode Query string (optional) Code representing the patient's relationship to the subscriber. Values with definitions in parentheses:
  • 18 (Self)
  • 01 (Spouse)
  • 19 (Child)
  • G8 (Other relationship)
requestTypeCode Query string (optional) The code for the request type. Possible values: HS (Health Services Review/outpatient), AR (Admission Review/inpatient), and SC (Specialty Care Review/referral).
fromDate Query string (date) (optional) The service beginning date.
toDate Query string (date) (optional) The service end date.
certificationIssueDate Query string (optional) The date the authorization certification was issued.
certificationNumber Query string (optional) Number assigned by the health plan once an authorization is certified.
referenceNumber Query string (optional) Number assigned by the health plan for a submitted authorization while it is being reviewed (prior to certification). Typically, the terms "reference number," "case number," and "authorization number" are synonymous.
statusCode Query string (optional) Code for the status of the authorization or referral. Refer to the status and statusCodes table for values and definitions.
sessionId Query string (optional) Identifier included in a 200, 404, and 504 response. Valid for 24 hours.
3. GET /v2/service-reviews/{id}
 
Parameter Type Definition
id Path string (required) The unique response ID from your initial request.
Accept Header string (optional) Allows you to specify application/json or application/xml
4. PUT /v2/service-reviews
 
Parameter/Request body Type Definition
serviceReview Body object (optional) Represents the service review you are updating. Refer to the request body for fields and definitions.
Content-Type Header string (optional) Allows you to specify application/json or application/xml
Accept Header string (optional) Allows you to specify application/json or application/xml
5. DELETE /v2/service-reviews/{id}
 
Parameter Type Definition
id Path string (required) The unique response ID from your initial request.
Accept Header string (optional) Allows you to specify application/json or application/xml

Sample requests and responses

1. POST /v2/service-reviews

Request:

curl -X POST "https://api.availity.com/availity/v2/service-reviews" -d { "payer": { "name": "FLORIDA BLUE", "id": "BCBSF" }, 
"requestingProvider": { "lastName": "RP Surgery Center", "npi": "1111111112", "submitterId": "G12345", "specialtyCode": "207T00000X"
, "addressLine1": "321 Main St", "city": "JACKSONVILLE", "state": "Florida", "stateCode": "FL", "zipCode": "322231234", "contactName":
 "John Doe", "phone": "9043334444" }, "subscriber": { "firstName": "Jane", "middleName": "J", "lastName": "Smith", "suffix": "JR", 
"memberId": "TEST1", "addressLine1": "123 MAIN ST", "addressLine2": "APT 3", "city": "JACKSONVILLE", "state": "Florida", "stateCode": 
"FL", "zipCode": "123123331" }, "patient": { "firstName": "Jane", "middleName": "J", "lastName": "Smith", "suffix": "JR", 
"subscriberRelationship": "Self", "subscriberRelationshipCode": "18", "birthDate": "2009-09-09T05:00:00.000+0000", "gender": "Female",
 "genderCode": "F", "addressLine1": "123 MAIN ST", "addressLine2": "APT 3", "city": "JACKSONVILLE", "state": "Florida", "stateCode": 
"FL", "zipCode": "123123331" }, "diagnoses": [ { "qualifier": "International Classification of Diseases Clinical Modification (ICD-10-CM)
 Principal Diagnosis", "qualifierCode": "BF", "value": "Medical Diagnosis", "code": "0011", "date": "2015-01-01T05:00:00.000+0000" } ], 
"requestTypeCode": "AR", "serviceTypeCode": "1", "placeOfServiceCode": "21", "fromDate": "2015-01-01T05:00:00.000+0000", 
"admissionTypeCode": "1", "admissionSourceCode": "1", "renderingProviders": [ { "lastName": "smith", "firstName": "bobby", 
"npi": "1111111112", "specialtyCode": "282N00000X", "roleCode": "SJ", "addressLine1": "321 Main St", "city": "Jacksonville", 
"stateCode": "FL", "zipCode": "322561234" } ] } 

Responses:

If your request is invalid, the resource responds with a status code of 400 and a list of errors for you to correct. If your request is valid, the resource responds with a status code of 202 and a location header where you can check back for your response. The resource continues to respond in this way, as shown below, until the health plan responds:

{
  "links": {
    "self": {
      "href": "https://api.availity.com/availity/v2/service-reviews/0001234476904234805
       043040461830325519306571042495809029976148661"
    }
  },
  "id": "0001234476904234805043040461830325519306571042495809029976148661",
  "customerId": "1234",
  "status": "Building Request",
  "statusCode": "BR",
  "createdDate": "2015-02-24T18:51:39.000+0000",
  "updatedDate": "2015-02-24T18:51:39.000+0000",
  "expirationDate": "2015-02-25T18:51:39.000+0000",
  "validationMessages": [
    {
      "field": "renderingProviders",
      "errorMessage": "Please enter at least one Service Provider and one Facility."
    }
  ],
  "payer": {
    "name": "FLORIDA BLUE",
    "id": "BCBSF"
  },
  "requestingProvider": {
    "lastName": "RP Surgery Center",
    "npi": "1111111112",
    "submitterId": "G12345",
    "specialtyCode": "207T00000X",
    "addressLine1": "321 Main St",
    "city": "JACKSONVILLE",
    "state": "Florida",
    "stateCode": "FL",
    "zipCode": "322231234",
    "contactName": "John Doe",
    "phone": "9043334444"
  },
  "subscriber": {
    "firstName": "Jane",
    "middleName": "J",
    "lastName": "Smith",
    "suffix": "JR",
    "memberId": "TEST1",
    "addressLine1": "123 MAIN ST",
    "addressLine2": "APT 3",
    "city": "JACKSONVILLE",
    "state": "Florida",
    "stateCode": "FL",
    "zipCode": "123123331"
  },
  "patient": {
    "firstName": "Jane",
    "middleName": "J",
    "lastName": "Smith",
    "suffix": "JR",
    "subscriberRelationship": "Self",
    "subscriberRelationshipCode": "18",
    "birthDate": "2009-09-09T05:00:00.000+0000",
    "gender": "Female",
    "genderCode": "F",
    "addressLine1": "123 MAIN ST",
    "addressLine2": "APT 3",
    "city": "JACKSONVILLE",
    "state": "Florida",
    "stateCode": "FL",
    "zipCode": "123123331"
  },
  "diagnoses": [
    {
      "qualifier": "International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis",
      "qualifierCode": "BF",
      "value": "Medical Diagnosis",
      "code": "0011",
      "date": "2015-01-01T05:00:00.000+0000"
    }
  ],
  "requestTypeCode": "AR",
  "serviceTypeCode": "1",
  "placeOfServiceCode": "21",
  "fromDate": "2015-01-01T05:00:00.000+0000",
  "admissionTypeCode": "1",
  "admissionSourceCode": "1",
  "renderingProviders": [
    {
      "lastName": "smith",
      "firstName": "bobby",
      "npi": "1111111112",
      "specialtyCode": "282N00000X",
      "roleCode": "SJ",
      "addressLine1": "321 Main St",
      "city": "Jacksonville",
      "stateCode": "FL",
      "zipCode": "322561234"
    }
  ]
}' 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.

Once the health plan successfully fulfills your request, the resource responds with a status code of 202 and a summary of the new service review.

3. GET/v2/service-reviews

Request:

curl -X GET
      "https://api.availity.com/availity/v2/service-reviews?requestTypeCode=AR&
requestingProviderLastName=Procorp&requestingProviderNPI=1234567893&submitterId=G12345
&requestingProviderSpecialtyCode=207X00000X&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"
    

Responses:

If your request is invalid, Availity responds with a status code of 400 and a list of errors for you to correct. If your request is valid, Availity responds with a status code of 202 and a location header where you can check back for your response. Availity continues to respond this way, as shown below, until the health plan responds:

$ curl -i -X GET -i https://api.availity.com/availity/v2/service-reviews?request
TypeCode=AR&requestingProviderLastName=SLICE N DICE DISCOUNT SURGERY&requestingProvider
AddressLine1=123Street&requestingProviderCity=Jacksonville&requestingProviderState=FL&
requestingProviderZipCode=123451234&requestingProviderContactName=John&requestingProvider
Phone=1112223333&memberId=TEST1&patientLastName=Doe&patientFirstName=John&patientBirth
Date=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.

Once the health plan successfully fulfills your service review request, the resource responds with a status code of 200 and a summary of each service review 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&requestingProvider
AddressLine1=123Street&requestingProviderCity=Jacksonville&requestingProviderState=FL&
requestingProviderZipCode=123451234&requestingProviderContactName=John&requestingProvider
Phone=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"
    }]
}

2. GET/v2/service-reviews/{id}

Request:

curl -X GET "https://api.availity.com/availity/v2/service-reviews/0001233411014786160466715575
       7587374114129045756512963141509096868"

Response:

{
  "links": {
    "self": {
      "href": "https://api.availity.com/availity/v2/service-reviews/000123341101478616046
       67155757587374114129045756512963141509096868"
    }
  },
  "id": "00012334110147861604667155757587374114129045756512963141509096868",
  "customerId": "1234",
  "controlNumber": "31722",
  "status": "Certified in Total",
  "statusCode": "A1",
  "createdDate": "2015-02-24T19:28:44.000+0000",
  "updatedDate": "2015-02-24T19:28:48.000+0000",
  "expirationDate": "2015-02-25T19:28:44.000+0000",
  "serviceReviewEffectiveDate": "2014-11-28T05:00:00.000+0000",
  "serviceReviewExpireDate": "2014-11-27T05:00:00.000+0000",
  "serviceReviewNumber": "123306685",
  "payer": {
    "name": "FLORIDA BLUE",
    "id": "BCBSF"
  },
  "requestingProvider": {
    "lastName": "John Doe Hospital",
    "npi": "1233459975",
    "submitterId": "H1123",
    "specialty": "General Hospital",
    "specialtyCode": "282N00000X",
    "addressLine1": "123 MAIN ST",
    "city": "JACKSONVILLE",
    "state": "Florida",
    "stateCode": "FL",
    "zipCode": "322231234",
    "contactName": "John Doe",
    "phone": "7275271234",
    "fax": "7273695123"
  },
  "subscriber": {
    "firstName": "JAMIE",
    "lastName": "SMITH",
    "memberId": "XJBH1234567890",
    "addressLine1": "123 MAIN ST",
    "addressLine2": "APT 3",
    "city": "JACKSONVILLE",
    "state": "Florida",
    "stateCode": "FL",
    "zipCode": "123123331"
  },
  "patient": {
    "firstName": "ARINA",
    "lastName": "JOHNSON",
    "subscriberRelationship": "Spouse",
    "subscriberRelationshipCode": "01",
    "birthDate": "1988-08-08T05:00:00.000+0000",
    "gender": "Female",
    "genderCode": "F",
    "addressLine1": "123 MAIN ST",
    "addressLine2": "APT 3",
    "city": "JACKSONVILLE",
    "state": "Florida",
    "stateCode": "FL",
    "zipCode": "123451112"
  },
  "diagnoses": [
    {
      "qualifier": "International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis",
      "qualifierCode": "BF",
      "value": "Cholera d/t vib el tor",
      "code": "0011",
      "date": "2014-11-17T05:00:00.000+0000"
    }
  ],
  "requestType": "Admission Review",
  "requestTypeCode": "AR",
  "serviceType": "Maternity",
  "serviceTypeCode": "69",
  "placeOfService": "Inpatient Hospital",
  "placeOfServiceCode": "21",
  "fromDate": "2014-11-18T05:00:00.000+0000",
  "quantity": "3",
  "quantityType": "Days",
  "quantityTypeCode": "DY",
  "admissionType": "Emergency",
  "admissionTypeCode": "1",
  "admissionSource": "Transfer from Hospital",
  "admissionSourceCode": "4",
  "nursingHomeResidentialStatus": "Newly Admitted",
  "nursingHomeResidentialStatusCode": "2",
  "procedures": [
    {
      "qualifier": "Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes",
      "qualifierCode": "HC",
      "value": "OBSTETRICAL CARE",
      "code": "59409",
      "description": "PROCEDURE DATES- 20141118",
      "fromDate": "2015-01-02T05:00:00.000+0000",
      "toDate": "2015-01-03T05:00:00.000+0000"
    }
  ],
  "renderingProviders": [
    {
      "lastName": "ABC HOSPITAL",
      "npi": "1477123123",
      "specialty": "General Hospital",
      "specialtyCode": "282N00000X",
      "role": "Service Provider",
      "roleCode": "SJ",
      "addressLine1": "200 MAIN ST",
      "city": "ORLANDO",
      "state": "Florida",
      "stateCode": "FL",
      "zipCode": "33881",
      "phone": "8632931123"
    },
    {
      "role": "Attending Physician",
      "roleCode": "71",
      "lastName": "MUNA",
      "firstName": "TELT",
      "middleName": "D",
      "npi": "1234567893",
      "specialty": "Obstetrics & Gynecology",
      "specialtyCode": "207V00000X",
      "addressLine1": "123 CENTRAL AVE",
      "city": "ORLANDO",
      "state": "Florida",
      "stateCode": "FL",
      "zipCode": "33880",
      "phone": "8632123123",
      "fax": "8632123123"
    }
  ]
}

4. PUT/v2/service-reviews

The Service Reviews resource contains an updatable flag that indicates whether a service review can be updated. Availity does not allow you to update service reviews that are currently being processed. Furthermore, health plans can indicate whether a service review is updatable and, if so, which fields can be changed. This can vary from one service review to another and can change over the life span of a service review.

In all service reviews that have an updatable property of true, you will find an updatableFields array (ServiceReview.updatableFields). The health plan determines which fields are updatable for each service review.

Request:

curl -X PUT "https://api.availity.com/availity/v2/service-reviews" -d { "renderingProviders": [ { "lastName": 
"smith", "firstName": "bobby", "npi": "1111111112", "specialtyCode": "282N00000X", "roleCode": "SJ", "addressLine1": 
"123 Main St", "city": "Jacksonville", "stateCode": "FL", "zipCode": "322561234" }, { "lastName": "Surgery Center", 
"npi": "1234567893", "specialtyCode": "282N00000X", "roleCode": "FA", "addressLine1": "123 Main St", "addressLine2": 
"123 Second St", "city": "Jacksonville", "stateCode": "FL", "zipCode": "322581234" } ] } 

Response:

{
  "links": {
    "self": {
      "href": "https://api.availity.com/availity/v2/service-reviews/00012344769042348050430
       40461830325519306571042495809029976148661"
    }
  },
  "id": "0001234476904234805043040461830325519306571042495809029976148661",
  "customerId": "1234",
  "status": "In Progress",
  "statusCode": "0",
  "createdDate": "2015-02-24T18:24:25.000+0000",
  "updatedDate": "2015-02-24T18:24:25.000+0000",
  "expirationDate": "2015-02-25T18:24:25.000+0000",
  "validationMessages": [],
  "payer": {
    "name": "FLORIDA BLUE",
    "id": "BCBSF"
  },
  "requestingProvider": {
    "lastName": "RP Surgery Center",
    "npi": "1111111112",
    "submitterId": "G12345",
    "specialtyCode": "282N00000X",
    "addressLine1": "123 MAIN ST",
    "city": "JACKSONVILLE",
    "state": "Florida",
    "stateCode": "FL",
    "zipCode": "322231234",
    "contactName": "John Doe",
    "phone": "9043334444"
  },
  "subscriber": {
    "firstName": "Jane",
    "middleName": "J",
    "lastName": "Smith",
    "suffix": "JR",
    "memberId": "TEST1",
    "addressLine1": "123 MAIN ST",
    "addressLine2": "APT 3",
    "city": "JACKSONVILLE",
    "state": "Florida",
    "stateCode": "FL",
    "zipCode": "123123331"
  },
  "patient": {
    "firstName": "Jane",
    "middleName": "J",
    "lastName": "Smith",
    "suffix": "JR",
    "subscriberRelationship": "Self",
    "subscriberRelationshipCode": "18",
    "birthDate": "2009-09-08T05:00:00.000+0000",
    "gender": "Female",
    "genderCode": "F",
    "addressLine1": "123 MAIN ST",
    "addressLine2": "APT 3",
    "city": "JACKSONVILLE",
    "state": "Florida",
    "stateCode": "FL",
    "zipCode": "123123331"
  },
  "diagnoses": [
    {
      "qualifier": "International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis",
      "qualifierCode": "BF",
      "value": "Medical Diagnosis",
      "code": "0011",
      "date": "2015-01-01T05:00:00.000+0000"
    }
  ],
  "requestTypeCode": "AR",
  "serviceTypeCode": "1",
  "placeOfServiceCode": "21",
  "fromDate": "2015-01-01T05:00:00.000+0000",
  "toDate": "2015-02-02T05:00:00.000+0000",
  "quantity": "2",
  "quantityTypeCode": "DY",
  "admissionTypeCode": "1",
  "admissionSourceCode": "1",
  "nursingHomeResidentialStatusCode": "2",
  "renderingProviders": [
    {
      "lastName": "smith",
      "firstName": "bobby",
      "npi": "1111111112",
      "specialtyCode": "282N00000X",
      "roleCode": "SJ",
      "addressLine1": "123 Main St",
      "city": "Jacksonville",
      "stateCode": "FL",
      "zipCode": "322561234"
    },
    {
      "lastName": "Surgery Center",
      "npi": "1234567893",
      "specialtyCode": "282N00000X",
      "roleCode": "FA",
      "addressLine1": "123 Main St",
      "addressLine2": "123 Second St",
      "city": "Jacksonville",
      "stateCode": "FL",
      "zipCode": "322581234"
    }
  ]
}

 

5. DELETE/v2/service-reviews/{id}

The Service Reviews resource contains a deletable flag that indicates whether a service review can be deleted. Availity does not allow you to delete service reviews that are currently being processed. Furthermore, health plans can indicate whether a service review is deletable. This can vary from one service review to another and can change over the life span of a service review.

Request:

curl -X DELETE "https://api.availity.com/availity/v2/service-reviews/
-11923818311"

Response:

Once you make a valid request, Availity responds with a location header containing a URL you can query for your result while Availity asynchronously sends a void request to the health plan.

$ 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.

Response definitions

 
Service Reviews response definitions: Primary result set
Field Type Definition
id String The unique response ID from your initial request.
customerId String The Availity customer ID of the organization that submitted the authorization or referral. Availity may ask for this number during support calls.
userId String The user ID of the organization that submitted this service review.
status String Describes the current status of the service review. Refer to the status and statusCodes table for status and status code definitions.
statusCode String The code for the current status of the authorization or referral. Refer to the status and statusCodes table for status and status code definitions.
statusReasons Object array Provides information about the reason(s) the health plan has given for the current status of the authorization or referral. Refer to the statusReasons table for field definitions.
createdDate Timestamp The date and time Availity created the item in the system.
updatedDate Timestamp The date and time the item was last updated.
expirationDate Timestamp The date and time the item will be removed from Availity's system.
controlNumber String The ID number of the last transaction associated with this service review. The health plan may ask for this number during support calls.
shortFormIndicator Boolean

Used to set the transaction type code. Whether TRUE or FALSE, this indicator sets the transaction type code to 25 for admission reviews and 26 for health service reviews. For specialty care review, the transaction type code is set as follows:

  • TRUE: 429
  • FALSE: 24
updatable Boolean Indicates whether the service review can be updated.
updatableFields String array Indicates the fields the health plan allows to be updated.
deletable Boolean Indicates whether the service review can be deleted.
validationMessages Object array Provides information about problems with the service review. Errors encountered during validation at Availity have a field and possibly an index, while errors returned by the health plan have a code. Refer to the validationMessages table for field definitions.
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 takes place.
certificationExpirationDate Date The date on which the health plan's authorization expires.
certificationNumber String The health plan's authorization number for claims.
referenceNumber String The health plan's reference number assigned to pended or otherwise incomplete service reviews.
traceNumbers String array An array of trace numbers the health plan has assigned to the service review.
requestType String Describes the type of request: inpatient service authorization/referral, outpatient service authorization/referral, or referral.
requestTypeCode String The code for the request type. Values: HS (Health Services Review/outpatient), AR (Admission Review/inpatient), and SC (Specialty Care Review/referral).
payer Object Object providing information about the patient's health plan. Refer to the Payer table for field definitions.
payerNotes Object array Provides information about the array of notes the health plan added to the service review. Text is included in the payerNotes.message field.
providerNotes Array Provides information about the array of notes the provider added to the service review.
requestingProvider Object Object providing information about the provider who requested authorization to perform the service or referral. Refer to the requestingProvider table for field definitions.
subscriber Object Object providing information about the health plan subscriber. Refer to the Subscriber table for field definitions.
patient Object Object providing information about the patient who received/will receive the service or referral. Refer to the Patient table for field definitions.
diagnoses Object array Array providing information about the patient's diagnosis/es related to the service or referral. Refer to the Diagnoses table for field definitions.
serviceType String Describes the type of service to be rendered.
serviceTypeCode String Code indicating the service type. Refer to the ASC X12 278 TR3 for the full list of service type codes.
additionalServiceTypes Array Describes additional types of services to be rendered.
placeOfService String Describes the place the service was rendered. Refer to X12 External Code Source 237: Place of Service Codes for Professional Claims (professional) or External Code Source 236: Uniform Billing Claim Form Bill Type (institutional).
placeOfServiceCode String The code for the place the service was or will be rendered. Refer to X12 External Code Source 237: Place of Service Codes for Professional Claims (professional) or External Code Source 236: Uniform Billing Claim Form Bill Type (institutional).
serviceLevel String Describes the level of service rendered.
serviceLevelCode String The code for the service level.
fromDate Date The service or admission starting date.
toDate Date The service end date or discharge date.
quantity String The number of units associated with the service.
quantityType String Describes the type of units.
quantityTypeCode String The code for the type of units.
admissionType String Describes the type of admission listed in an inpatient authorization request.
admissionTypeCode String The code for the admission type. Refer to X12 External Code Source 231: Admission Type Code.
admissionSource String Describes the source of the admission listed in an inpatient authorization request.
admissionSourceCode String The code for the admission source. Refer to X12 External Code Source 230: Admission Source Code.
nursingHomeResidentialStatus String Indicates whether the patient is a nursing home resident.
nursingHomeResidential StatusCode String The code for the patient's nursing home residential status.
homeHealthStartDate Date The starting date of the patient's home health services.
homeHealthCertificationPeriod StartDate Date The starting date of the period for which home health services were certified.
homeHealthCertificationPeriod EndDate Date The end date of the period for which home health services were authorized.
transportType String The type of transport used in a medically-related transport outpatient authorization request.
transportTypeCode String The code for the transport type.
transportDistance String The distance the patient was transported on a medically related transport outpatient authorization request.
transportPurpose String The purpose of the patient transport.
transportLocations Object array An array providing information on the locations associated with a medically related transport outpatient authorization request. Refer to the transportLocations table for field definitions.
chiropracticTreatmentCount String Number of the chiropractic treatment if it is one in a series.
beginningSubluxationLevel String Level of sublaxation at the beginning of chiropractic treatment.
beginningSubluxationLevelCode String Code for the level of sublaxation at the beginning of chiropractic treatment. Refer to the ASC X12 278 TR3 (Health Care Services Review and Response) for the full list of subluxation level codes.
endingSubluxationLevel String Code for the level of subluxation at the end of chiropractic treatment. Refer to the ASC X12 278 TR3 for the full list of subluxation level codes.
spinalCondition String Description of the spinal condition. Mapped to CR208 in the ASC X12 278 TR3.
spinalConditionCode String Code for the spinal condition. Equivalent to Nature of Condition code (CR208) in the ASC X12 278 TR3.
spinalConditionDescription String Mapped to CR210 in the ASC X12 278 TR3.
oxygenEquipmentType String Describes the type of oxygen equipment authorized.
oxygenEquipmentTypeCode String Code indicating the oxygen equipment type. Refer to the ASC X12 278 TR3 for the full list of oxygen equipment codes.
oxygenFlowRate String Describes the oxygen flow rate in liters per minute.
oxygenDailyUseCount String Describes the number of times per day the patient must use oxygen.
oxygenUsePeriodHourCount String Describes the number of hours per period of oxygen use.
oxygenOrderText String Free-form description of special orders for the respiratory therapist.
oxygenDeliverySystemType String Describes the type of oxygen delivery system, if one was prescribed.
oxygenDeliverySystemTypeCode String Code for the oxygen delivery system. Refer to the ASC X12 278 TR3 (Health Care Services Review and Response) for the full list of oxygen delivery system codes.
renderingProviders Object array Array of objects providing information about the provider(s) who rendered/will render the service. Refer to the renderingProviders table for field definitions.
procedures Object array Array of objects providing information about the medical procedure(s) performed during the service. Refer to the Procedures table for field definitions.
supplementalInformation Object Object providing supplemental information about the authorization or referral. Contains the following arrays:
Also contains the following strings:
  • refAuthNumber (the authorization or referral number)
  • sequence (the sequence number)
  • updateType
 
Service Reviews status and statusCode definitions
statusCode status Definition
A1 Certified in Total The health plan fully authorized the request. The resource has a certificationNumber you can use on an 837 transaction if services were preauthorized.
A2 Certified - Partial The health plan partially authorized the request. Check the procedures object array in the response for more details on the partial certification.
A3 Not Certified The health plan denied the request. Check the statusReasons object array in the response for more details on this status.
A4 Pending The payer is still processing the request. Check back later.
A6 Modified The health plan indicated that the request was modified. Check back later.
C Canceled The health plan indicated that the request was canceled.
CT Contact Payer The requesting provider should contact the health plan. Refer to the payer object in the response for contact information.
NA No Action Required The health plan indicated that authorization is not required for the request.
51 Complete The health plan indicated that the request is complete.
71 Term Expired The term for the authorization has expired.
 
Service Reviews response definitions: Fields within statusReasons
Field Type Definition
value String Description of the reason for the current status of the service review.
code String The code representing the status reason. Refer to X12 External Code Source 886: Service Review Decision Reason Codes.
 
Service Reviews response definitions: Fields within validationMessages
Field Type Definition
errorMessage String Message describing an error.
field String Identifies the field or parameter in the service review with an error.
index Integer The array index, if applicable, of the item associated with an error.
code String The code identifying an error.
 
Service Reviews response definitions: Fields within payer
Field Type Definition
id String The health plan's Availity payer ID.
name String The health plan's name.
contactName String The full name of the health plan's contact person.
phone/extension/fax String The health plan's contact phone number/phone extension/fax number.
emailAddress String The health plan's email address.
url String The health plan's website address.
 
Service Reviews response definitions: Fields within requestingProvider
Field Type Definition
lastName/ firstName/middleName/suffix String The last name or business name/first name/middle name/suffix of the requesting provider.
npi String The requesting provider's NPI.
taxId String The requesting provider's tax ID number.
payerAssigned ProviderId String The requesting provider's payer-assigned provider ID.
submitterId String The requesting provider's health plan-specific submitter ID.
specialty String Describes the requesting provider's specialty.
specialtyCode String The code for the requesting provider's specialty. Refer to X12 External Code Source 682: Provider Taxonomy Codes.
addressLine1/addressLine2 String The first and second lines of the requesting provider's address.
city/state/stateCode/zipCode String The requesting provider's city/state/state code/ZIP code.
contactName String The name for the requesting provider's contact person.
phone/extension/fax String The requesting provider's contact phone number/phone extension/fax number.
emailAddress String The requesting provider's email address.
url String The requesting provider's website address.
 
Service Reviews response definitions: Fields within subscriber
Field Type Definition
memberId String The health plan subscriber's member ID number.
lastName/firstName/ middleName/suffix String The last name/first name/middle name/suffix of the health plan subscriber.
addressLine1/ addressLine2 String The first and second lines of the subscriber's address.
city/state/stateCode/zipCode String The health plan subscriber's city/state/state code/ZIP code.
 
Service Reviews response definitions: Fields within patient
Field Type Definition
lastName/firstName/middleName/suffix String The patient's last name/first name/middle name/suffix.
birthDate String (date) The patient's date of birth.
gender String The patient's gender.
genderCode String The code for the patient's gender. Values: F (female), M (male), U (unknown).
accountNumber String The service provider's patient identifier.
subscriberRelationship String The patient's relationship to the subscriber or policy holder.
subscriberRelationshipCode String The code for the patient's relationship to the subscriber or policy holder. Values with definitions in parentheses:
  • 18 (Self)
  • 01 (Spouse)
  • 19 (Child)
  • G8 (Other relationship)
addressLine1/addressLine2 String The first and second lines of the patient's address.
city/state/stateCode/zipCode String The patient's city/state/state code/ZIP code.
status String Describes the patient's status.
statusCode String The code for the patient's status. Refer to X12 External Code Source 239: Patient Status Code.
condition String Describes the patient's condition.
conditionCode String The code for the patient's condition.
medicareCoverage String Indicates whether the patient has Medicare coverage.
prognosis String Describes the patient's prognosis.
prognosisCode String The code for the patient's prognosis. Values with definitions in parentheses:
  • 2 (Guarded)
  • 3 (Fair)
  • 4 (Good)
  • 5 (Very Good)
  • 6 (Excellent)
  • 7 (Less than six Months to Live)
  • 8 (Terminal)
 
Service Reviews response definitions: Fields within diagnoses
Field Type Definition
qualifier String Indicates the healthcare information code set used for the diagnosis.
qualifierCode String The code for the qualifier. Refer to ASC X12 278 TR3 for the full list of diagnosis qualifier codes.
value String Description of the diagnosis/es.
date Date The date of the patient's diagnosis/es.
 
Service Reviews response definitions: Fields within transportLocations
Field Type Definition
name String The name of the transport location.
address Line1/addressLine2 String The first and second lines of the location address.
city/state/stateCode/zipCode String The transport location's city/state/state code/ZIP code.
 
Service Reviews response definitions: Fields within renderingProviders
Field Type Definition
role String Describes the rendering provider's role.
roleCode String The code for the rendering provider's role. Refer to the ASC X12 278 TR3 (Health Care Services Review and Response) for the full list of provider codes.
lastName/firstName/middleName/suffix String The last name or business name/first name/middle name/suffix of the rendering provider.
npi String The rendering provider's NPI.
taxId String The rendering provider's tax ID number.
payerAssignedProviderId String The rendering provider's payer-assigned provider ID.
specialty String Describes the rendering provider's specialty.
specialtyCode String The code for the rendering provider's specialty. Refer to X12 External Code Source 682: Provider Taxonomy Codes.
addressLine1/addressLine2 String The first and second lines of the rendering provider's address.
city/state/stateCode/zipCode String The rendering provider's city/state/state code/ZIP code.
contactName String The name for the rendering provider's contact person.
phone/extension/fax String The rendering provider's contact phone number/phone extension/fax number.
email Address String The rendering provider's email address.
url String The rendering provider's website address.
 
Service Reviews response definitions: Fields within procedures
Field Type Definition
status String Describes the authorization status of the procedure. Refer to the status and statusCodes table for definitions.
statusCode String The code for the authorization status. Refer to the status and statusCodes table for definitions.
statusReasons Array An array of reasons the health plan has given for the authorization status. Refer to the statusReasons table for definitions.
certificationIssueDate String (date) The date the health plan authorized the procedure.
certificationEffectiveDate String (date) The date the health plan's authorization will take effect.
certificationExpirationDate String (date) The date the health plan's authorization will expire.
certificationNumber String The health plan-assigned authorization number to be used on claims.
qualifier String Identifies the healthcare information code set used for the procedure code.
qualifierCode String The code for the qualifier. Refer to the ASC X12 278 TR3 for the full list of procedure qualifier codes.
value String Describes the procedure.
code String Code identifying the procedure. Refer to the ASC X12 278 TR3 (Health Care Services Review and Response) for code sources.
modifier1/modifier1Code/ modifier2/modifier2Code/ modifier3/modifier3Code/ modifier4/modifier4Code String Descriptions and codes identifying special circumstances related to the procedure.
description String Free-form description of the procedure written by the provider.
quantity String The quantity of procedures rendered.
quantityType String Describes the quantity type.
quantityTypeCode String The code for the quantity type.
fromDate Date The procedure's start date.
toDate Date The procedure's end date.
payerNotes Object array Array of notes the health plan added to the procedure. The text of notes is included in the procedures.payerNotes.message field.
traceNumbers String array An array of trace numbers the health plan assigned to the procedure.
 
Service Reviews response definitions: Fields within supplementalInformation.attachments
Field Type Definition
fileName String The attachment file name.
id String The attachment's ID number.
idType String The attachment's ID number type.
dateReceived String The date the attachment information was received.

Claim Statuses 1.0.0

Endpoints

 
  Path Function
1 GET/v1/claim-statuses Initiate a new claim status inquiry or view an existing request.
2 GET/v1/claim-statuses/{id} Retrieve a full claim status by ID number. Replace {id} with the response ID from your initial request.
3 DELETE/v1/claim-statuses/{id} Delete a claim status. Replace {id} with the response ID from your initial request.

Parameters

1. GET/v1/claim-statuses

 
GET/v1/claim-statuses parameters
Parameter Type Definition
payer.Id Query string (optional) The Availity ID number for the health plan.
submitter.lastName/ submitter.firstName/ submitter.middleName/ submitter.suffix Query string (optional) The submitter's last or business name/first name/middle name/suffix.
submitter.id Query string (optional) The submitter's identifier.
providers.lastName/ providers.firstName/ providers.middleName/ providers.suffix Query string (optional) The service provider's last or business name/first name/middle name/suffix.
providers.npi Query string (optional) The service provider's NPI number.
providers.taxId Query string (optional) The service provider's tax ID number.
providers.payerAssignedProviderId Query string (optional) The health plan-assigned ID for the service provider.
subscriber.memberId Query string (optional) The health plan subscriber's member ID number.
subscriber.lastName/ subscriber.firstName/ subscriber.middleName/ subscriber.suffix Query string (optional) The subscriber's last name/first name/middle name/suffix.
patient.lastName/patient.firstName/ patient.middleName/patient.suffix Query string (optional) The patient's last name/first name/middle name/suffix.
patient.birthDate Query string (optional) The patient's birth date.
patient.genderCode Query string (optional) The code for the patient's gender. Values: F (female), M (male).
patient.accountNumber Query string (optional) The service provider's reference identifier for the patient.
patient.subscriberRelationship

Code

Query string (optional) The code representing the patient's relationship to the subscriber. See the X12 837 (Health Care Claim: Institutional or Professional) TR3 for the full list of individual relationship codes.
fromDate Query string (date) (optional) The service beginning date.
toDate Query string (date) (optional) The service end date.
claimNumber Query string (optional) The health plan's claim tracking number assigned when the original claim was received and processed.
claimAmount Query string (optional) The total claim charge amount processed by the health plan.
facilityTypeCode Query string (optional) The code identifying where services were, or may have been, performed. See X12 External Code Source 237: Place of Service Codes for Professional Claims (professional) or External Code Source 236: Uniform Billing Claim Form Bill Type (institutional).
frequencyTypeCode Query string (optional) The code identifying the frequency of services. See X12 External Code Source 235: Claim Frequency Type Code.
Accept Header string (optional) Allows you to specify application/json or application/xml

2. GET/v1/claim-statuses/{id}

 
GET/v2/claim-statuses/{id} parameters
Parameter Type Definition
id Path string (required) The unique response ID from your initial request.
Accept Header string (optional) Allows you to specify application/json or application/xml

3. DELETE/v1/claim-statuses/{id}

 
DELETE/v1/claim-statuses/{id} parameters
Parameter Type Definition
id Path string (required) The unique response ID from your initial request.
Accept Header string (optional) Allows you to specify application/json or application/xml

Sample requests and responses

1. GET/v1/claim-statuses

Request:

curl --request GET \
  --url 'https://api.availity.com/availity/v1/claim-statuses?payer.id=REPLACE_THIS_VALUE&
submitter.lastName=REPLACE_THIS_VALUE&submitter.firstName=REPLACE_THIS_VALUE&submitter.
middleName=REPLACE_THIS_VALUE&submitter.suffix=REPLACE_THIS_VALUE&submitter.id=REPLACE_THIS
_VALUE&providers.lastName=REPLACE_THIS_VALUE&providers.firstName=REPLACE_THIS_VALUE&providers.
middleName=REPLACE_THIS_VALUE&providers.suffix=REPLACE_THIS_VALUE&providers.npi=REPLACE_THIS_
VALUE&providers.taxId=REPLACE_THIS_VALUE&providers.payerAssignedProviderId=REPLACE_THIS_VALUE&
subscriber.memberId=REPLACE_THIS_VALUE&subscriber.lastName=REPLACE_THIS_VALUE&subscriber.first
Name=REPLACE_THIS_VALUE&subscriber.middleName=REPLACE_THIS_VALUE&subscriber.suffix=REPLACE_THIS
_VALUE&patient.lastName=REPLACE_THIS_VALUE&patient.firstName=REPLACE_THIS_VALUE&patient.middle
Name=REPLACE_THIS_VALUE&patient.suffix=REPLACE_THIS_VALUE&patient.birthDate=REPLACE_THIS_VALUE& 
patient.genderCode=REPLACE_THIS_VALUE&patient.accountNumber=REPLACE_THIS_VALUE&patient.subscriber
RelationshipCode=REPLACE_THIS_VALUE&fromDate=REPLACE_THIS_VALUE&toDate=REPLACE_THIS_VALUE&claim
Number=REPLACE_THIS_VALUE&claimAmount=REPLACE_THIS_VALUE&facilityTypeCode=REPLACE_THIS_VALUE&
frequencyTypeCode=REPLACE_THIS_VALUE' \
  --header 'Authorization: Bearer REPLACE_BEARER_TOKEN' \
  --header 'accept: application/json'

Response:

If your request is invalid, Availity will respond with a status code of 400 and a list of errors for you to correct. If your request is valid, Availity responds with a status code of 202 and a location header where you can check back for your response. The resource responds in this way until the health plan responds:

$ 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=PATIENT
LASTNAME&patient.firstName=PATIENTFIRSTNAME&patient.birthDate=1999-09-09&patient.
genderCode=M&patient.accountNumber=PAT1ENTACC0UNTNUMB3R&patient.subscriberRelationship
Code=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 Availity is unable to communicate with the health plan (e.g., due to maintenance), the resource responds with a status code of 504 and a message indicating the issue.

Once the health plan successfully fulfills your request, the resource responds with a status code of 200 and summaries of each claim status 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"
            }
        }
    ]
}

2. GET/v1/claim-statuses/{id}

Note: Replace {id} with the unique response ID from your initial polling request.
$ 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"
}

3. DELETE/v1/claim-statuses/{id}

Note: Replace {id} with a real ID number.
$ 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

HTTP status codes

 
HTTP status codes for GET/v1/claim-statuses and GET/v1/claim-statuses/{id}
Code Description
200 Your request has been successfully fulfilled.
202 The resource has not yet received a response from the health plan. You should try again later.
400 The health plan indicated that an error with the request. The resource should have a list of validationMessages. Correct and resubmit the request.
404 The resource did not find a claim status with the ID that you specified.
504 The resource did not receive a response from the health plan within the time allotted. You should try again later.
 
HTTP status codes for DELETE/v1/claim-statuses/{id}
Code Description
204 Availity has deleted the claim status from our system.
404 The resource did not find a claim with the ID number specified.

Response definitions

 
Claim Statuses response definitions: Primary result set
Field Type Definition
id String The unique response ID from your initial request.
customerId String The Availity customer ID of the organization that submitted the claim. Availity may ask for this ID during support calls.
createdDate String (date) The date and time this item was created in Availity's system.
updatedDate String (date) The date and time this item was last updated.
expirationDate String (date) The date and time this item will be removed from Availity's system.
controlNumber String An Availity-assigned tracing number assigned to the transaction with the payer.
status String The current status of the claim. See X12 External Code Source 508: Claim Status Codes.
statusCode String A code indicating the current claim status. See X12 External Code Source 508: Claim Status Codes.
payer Object Object providing identifying and contact information about the patient's health plan. Definitions for the fields within this object are omitted for brevity; see the X12 276/277 TR3 (Health Care Claim Status Request and Response) for more information.
submitter Object Object providing information about identifying and contact information the organization or person who requested the claim status. Definitions for the fields within this object are omitted for brevity; see the X12 276/277 TR3 (Health Care Claim Status Request and Response) for more information.
providers Array Array providing information about the service provider(s) from the original claim. Definitions for the fields within this object are omitted for brevity; see the X12 276/277 TR3 (Health Care Claim Status Request and Response) for more information.
patient Object Object providing identifying and contact information about the patient for whom the original claim was filed. Definitions for the fields within this object are omitted for brevity; see the X12 276/277 TR3 (Health Care Claim Status Request and Response) for more information.
subscriber Object Object providing identifying and contact information about the health plan subscriber. Definitions for the fields within this object are omitted for brevity; see the X12 276/277 TR3 (Health Care Claim Status Request and Response) for more information.
fromDate String (date) The beginning date specified in the initial claim status inquiry request.
toDate String (date) The end 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 processed by the health plan.
facilityTypeCode String The code identifying where services were performed for an institutional claim. See X12 External Code Source 237: Place of Service Codes for Professional Claims (professional) or External Code Source 236: Uniform Billing Claim Form Bill Type (institutional).
facilityType String Description of the facility type.
frequencyTypeCode String The code identifying the frequency of services. See X12 External Code Source 235: Claim Frequency Type Code.
frequencyType String Description of the claim frequency type. See X12 External Code Source 235: Claim Frequency Type Code.
claimCount String The total number of unique claims reported in this claim status response.
claimStatuses Object Object providing information on the claim statuses returned. See the claimStatuses table for field definitions.
 
Claim Statuses response definitions: Fields within claimStatuses
Field Type Definition
traceId String The health plan's unique reference ID for this claim.
claimControlNumber String The health plan's unique identifier for the originally submitted/processed claim.
facilityTypeCode String The code identifying where services were or may have been performed. See X12 External Code Source 237: Place of Service Codes for Professional Claims (professional) or External Code Source 236: Uniform Billing Claim Form Bill Type (institutional).
facilityType String Description of the facility type.
frequencyTypeCode String The code identifying the frequency of services. See X12 External Code Source 235: Claim Frequency Type Code.
frequencyType String Description of the claim's frequency. See X12 External Code Source 235: Claim Frequency Type Code.
patientControlNumber String The service provider's reference identifier for the patient included on the original claim.
pharmacyPrescriptionNumber String The pharmacy prescription number from the original claim.
voucherNumber String The voucher number returned from the health plan.
claimIdentificationNumber String An identifier from the original claim that was assigned by a clearinghouse or intermediary.
fromDate String (date) The date the service began.
toDate String (date) The date the service ended.
statusDetails Array Array providing status, required action, and paid information reported for the original claim. See the claimStatuses.statusDetails table for field definitions.
serviceLines Object Object providing information about the service line for the original claim. See the claimStatuses.serviceLines table for field definitions.
 
Claim Statuses response definitions: Fields within claimStatuses.statusDetails
Field Type Definition
category String Describes the logical grouping associated with the claim. See X12 External Code Source 507: Claim Status Category Codes.
categoryCode String Code indicating the category of the associated claim status code. See X12 External Code Source 507: Claim Status Category Codes.
status String Describes the status of the claim. See X12 External Code Source 508: Claim Status Codes.
statusCode String The code for the claim's status. See X12 External Code Source 508: Claim Status Codes.
entity String Describes the organizational entity, physical location, or individual associated with the claim status code.
entityCode String The code identifying the entity associated with the claim status. See the X12 276/277 (Healthcare Claim Status Request and Response) TR3 for the full list of codes.
effectiveDate String (date) The effective date for the status information.
claimAmount String The monetary charge amount for the original claim.
claimAmountUnits String The units used for the claim amount.
paymentAmount String The amount paid by the health plan for the original claim.
paymentAmountUnits String The units used for the paid amount.
finalizedDate String (date) The date the original claim was finalized/adjudicated.
remittanceDate String (date) The date the original claim was paid by the health plan.
checkNumber String The check or EFT trace number that paid the original claim.
 
Claim Statuses response definitions: Fields within claimStatuses.serviceLines
Field Type Definition
procedureQualifier String Describes the type/source of the procedure code for this service line.
procedureQualifierCode String Code identifying the type/source of the procedure or product/service code used for this service line. See the X12 276/277 (Healthcare Claim Status Request and Response) TR3 for the full list of product/service ID qualifier codes.
procedure String Description of the procedure performed for this service line.
procedureCode String Code for the procedure performed. See the X12 276/277 (Healthcare Claim Status Request and Response) TR3 for code sources.
modifier1/modifier1Code/ modifier2/modifier2Code/ modifier3/modifier3Code/ modifier4/modifier4Code String Descriptions and codes for special circumstances related to performing the service.
chargeAmount String The line item total on the current claim service status.
chargeAmount Units String Units used for the charge amount.
paymentAmount String The line item paid amount.
paymentAmount Units String Units used for the paid amount.
service String Describes the product or service reported in this service line.
serviceCode String Identifier of the product or service performed reported in this service line.
quantity String The quantity of the product or service.
controlNumber String The service line control number.
fromDate String (date) The service line beginning date.
toDate String (date) The service line end date.
statusDetails Array Array providing service line-level information on the claim status. See the claimStatuses.serviceLines.statusDetails table for field definitions.
 
Claim Statuses response definitions: Fields within claimStatuses.serviceLines.statusDetails
Field Type Definition

category

String Describes the logical grouping associated with the service line. See X12 External Code Source 507: Claim Status Category Codes.

categoryCode

String The code for the service line's category. See X12 External Code Source 507: Claim Status Category Codes.

status

String Describes the claim status associated with this service line. See X12 External Code Source 508: Claim Status Codes.

statusCode

String The status code for the status inquiry associated with this service line. See X12 External Code Source 508: Claim Status Codes.
entity String Describes the organizational entity, physical location, or individual associated with the claim status code.
entityCode String The code for the entity associated with the claim status. See the X12 276/277 (Healthcare Claim Status Request and Response) TR3 for the full list of codes.
effectiveDate String The effective date for the status information.
claimAmount String The charge amount for the original claim.

claimAmountUnits

String The units used for the claim amount.

finalizedDate

String The amount paid by the health plan for the original claim.

remittanceDate

String The units used for the paid amount.

checkNumber

String The check or EFT number that paid the claim associated with this service line.

Care Cost Estimator – Professional

Endpoints

 
  Path Function
1 POST/v1/professional-claims Create a professional claim predetermination asynchronously. To submit a claim predetermination, make a valid request and receive a response with a location header containing a URL you can query for your result.
2 GET/v1/professional-claims/{id} Retrieve a particular professional claim predetermination. Replace {id} with the response ID from your initial request.

Validation rules

Different health plans may require differing information to process a claim predetermination. Therefore, be sure to use the Configurations resource to determine the required fields for a specific health plan before submitting it. For the CCE Professional resource, the type is professional-claims and the subtype ID is PRE-DETERMINATION. For example:

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

See the Configurations reference section for details.

Demo response scenarios

To test the demo version of this API, send the X-Api-Mock-Scenario-ID header with the appropriate response scenario ID, as listed in the following table. For POST methods, send an empty JSON body: {}.

 
CCE – Professional demo response scenarios
Response scenario ID Method HTTP status Definition
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 Availity was unable to parse your request.
CCEP-MultiServiceLines-i GET (use {id} 54321) 200 Availity has successfully retrieved the member's claim predetermination information, which contains multiple service lines.

Parameters

1. POST/v1/professional-claims

 
POST/v1/professional-claims parameters
Parameter Type Definition
professionalClaim Body object (optional) Represents the details of the new professional claim predetermination you are creating. See the request body for possible fields. See Response definitions for field definitions.
Content-Type Header string (optional) Allows you to specify application/json or application/xml
Accept Header string (optional) Allows you to specify application/json or application/xml

professionalClaim request body (truncated):

{
    "type": "object",
    "properties": {
        "id": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "createdDate": {
            "type": "string",
            "format": "date-time",
            "$ref": "#/definitions/Primaryfields"
        },
        "updatedDate": {
            "type": "string",
            "format": "date-time",
            "$ref": "#/definitions/Primaryfields"
        },
        "expirationDate": {
            "type": "string",
            "format": "date-time",
            "$ref": "#/definitions/Primaryfields"
        },
        "message": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "customerId": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "requestTypeCode": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "submitter": {
            "type": "object",
            "$ref": "#/definitions/Primaryfields"
        },
        "payer": {
            "type": "object",
            "$ref": "#/definitions/payer"
        },
        "billingProvider": {
            "type": "object",
            "$ref": "#/definitions/billingProvider"
        },
        "patient": {
            "type": "object",
            "$ref": "#/definitions/Primaryfields"
        },
        "claimInformation": {
            "type": "object",
            "$ref": "#/definitions/claimInformation"
        },
        "payerSpecificFlags": {
            "type": "array",
            "$ref": "#/definitions/Primaryfields"
        }
    }
}
                

2. GET/v1/professional-claims/{id}

 
GET/v1/professional-claims/{id} parameters
Parameter Type Definition
id Path string (required) The unique response ID from your initial request, which can be used in follow-up requests.
Accept Header string (optional) Allows you to specify application/json or application/xml

Sample requests and responses

1. POST/v1/professional-claims

Request:

curl -i -H "Content-Type: application/json" -X POST https://api.availity.com/
availity/v1/professional-claims -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"
      }
    ]
  }
}

Response:

If your POST request is invalid, Availity responds with a status code of 400 and a list of errors for you to correct. If your request is valid, Availity responds with a status code of 202 and a location header where you can check back for your response. Availity continues to respond this way until the health plan responds:

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

2. GET/v1/professional-claims/{id}

Note: Replace {id} with the unique response ID from your initial POST request.

After you make a POST request, you can request the URI returned in the location header. If the resource is found but the health plan has not yet responded, Availity responds with a status code of 202 and a location header where you can check back for your response:

$ 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 the health plan responds, Availity responds with a status code of 200 and the full response:

$ 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
      }
    } ]
  }
}

HTTP status codes

 
HTTP status codes for CCE – Professional
Code Status Definition
200 OK We have processed your request and the response body contains the result.
202 Accepted We are currently processing or retrying your request.
400 Bad Request Your claim predetermination request failed validation. You can correct the errors and resubmit.
404 Not Found We did not find a claim predetermination with the ID you sent.
500 Internal Server Error The health plan did not respond due to a server error. Please try your request again later.
504 Gateway Timeout The health plan did not respond after several retry attempts. Please try your request again later.

Response definitions

 
CCE – Professional response definitions: Primary objects and fields
Field Type Definition
id String The unique response ID from your initial request, which can be used in follow-up requests.
createdDate String (date-time) The date and time this item was created in Availity's system.
updatedDate String (date-time) The date and time this item was last updated.
expirationDate String (date-time) The date and time this item will be removed from Availity's system.
message String A text message with information about the claim.
customerId String The Availity customer ID of the organization that submitted this claim predetermination. Availity may ask for this ID during support calls.
requestTypeCode String The type of request. Use PRE_DETERMINATION for this transaction.
submitter Object Object providing identifying and contact information about the submitter of the claim predetermination. Definitions for the fields within this object are omitted for brevity; see the X12 837 TR3 (Health Care Claim: Professional) for more information on these fields.
payer Object Object providing information about the payer involved in the claim. See the Payer table for select field definitions.
billingProvider Object Object providing identifying and contact information about the billing provider involved in the claim predetermination. See the billingProvider table for select field definitions.
subscriber Object Object providing identifying and contact information about the health plan subscriber involved in the claim predetermination. See the Subscriber table for select field definitions.
patient Object An object providing identifying and contact information about the patient involved in the claim predetermination (if different from the subscriber). Definitions for the fields within this object are omitted for brevity; see the X12 837 TR3 (Health Care Claim: Professional) for more information on these fields.
claimInformation Object Object providing further information about the claim predetermination. See the claimInformation table for select field definitions.
payerSpecificFlags Array Array including the name and value of payer-specific flags.
 
CCE – Professional response definitions: Select fields within payer
Field Type Definition
naicCode String The payer's North American Industry Classification (NAIC) System code.
responsibilitySequenceCode String The responsibility sequence of the payer. Options: P (primary), S (secondary), or T (tertiary).
insuranceTypeCode String Code identifying the type of insurance policy within a specific insurance program. See the X12 837 TR3 (Health Care Claim: Professional) for the full list of codes.
claimFilingIndicatorCode String The payer's claim filing indicator code. See the X12 837 TR3 (Health Care Claim: Professional) for the full list of codes.
Note: Fields related to the payer's identifying and contact information are omitted for brevity.

 

 
CCE – Professional response definitions: Select fields within billingProvider
Field Type Definition
specialtyCode String Specifies the requesting provider's specialty using a taxonomy code. See X12 External Code Source 682: Provider Taxonomy Codes.
stateLicenseNumber String The billing provider's state medical license number.
upin String The billing provider's Unique Personal Identification Number (UPIN).
payerAssignedProviderId String The billing provider's ID number assigned by the payer.
payToAddress Object Object containing fields for the billing provider's pay-to address, if different from the physical address.
Note: Fields related to the billing provider's identifying and contact information are omitted for brevity.
 
CCE – Professional response definitions: Select fields within subscriber
Field Type Definition
totalDeductible String The total amount of the subscriber's health insurance deductible.
accumulatedDeductible String The subscriber's accumulated deductible.
remainingDeductible String The amount the subscriber has left to pay on the deductible.
onHold Boolean Indicates whether the subscriber is on hold. Options: Y/N.
holdReasons Array Array describing reasons for the hold.
Note: Fields related to the subscriber's identifying and contact information are omitted for brevity.

 

 
CCE – Professional response definitions: Fields within claimInformation
Field Type Definition
controlNumber String A unique reference identifier provided by the submitter and included in the original claim request.
placeOfServiceCode String Code identifying where services were or may be performed. See X12 External Code Source 237: Place of Service Codes for Professional Claims.
frequencyTypeCode String Code specifying the frequency of the claim. See X12 External Code Source 235: Claim Frequency Type Code.
providerSignatureOnFile Boolean Indicates whether the provider signature is on file. Options: Y/N.
providerAcceptAssignmentCode String Code indicating whether the provider accepts assignment from the payer. Options: A (assigned), B (accepted on clinical lab services only), C (not assigned).
benefitsAssignmentCertification String Indicates whether the insured has authorized the plan to remit payment directly to the provider. Options: Y, N, W (not applicable).
informationReleaseCode String Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations. Options: Y, I (the provider has not collected a signature AND state or federal laws do not require it).
patientSignatureSourceCode String Code indicating how the patient or subscriber authorization signatures were obtained and how the provider retains them. Required when a signature was executed on the patient's behalf under state or federal law.
specialProgramCode String A code indicating whether the services were rendered under a special program. Options: 02 (Physically Handicapped Children's Program – Medicaid only), 03 (Special Federal Funding – Medicaid only), 05 (Disability – Medicaid only), 09 (Second Opinion or Surgery – Medicaid only).
delayReasonCode String A code indicating the reason for a delay when a claim is submitted past the contracted date of filing limitations. See the X12 837 TR3 (Health Care Claim: Professional) for the full list of codes.
serviceTypeCode String Code identifying the type of service to be performed. See the ASC X12 270/271 TR3 (Health Care Eligibility Benefit Inquiry and Response) for the full list of service type codes.
accidentCauseCode1/2 String If an accident occurred to cause the claim, these fields indicate the first and second related/accident cause codes. Options: AA (auto accident), EM (employment), OA (other accident).
accidentStateCode String Two-digit code identifying the state in which the accident occurred, if applicable. See X12 External Code Source 22: States and Provinces.
accidentDate String (date) The date on which the accident occurred, if applicable.
onsetOfCurrentIllnessOrSymptomDate String (date) Date of the onset of acute symptoms of the current illness or condition.
initialTreatmentDate String (date) Date when initial treatment for the current illness or condition began. Required when the date is known to impact adjudication for claims involving spinal manipulation, physical therapy, occupational therapy, speech language pathology, dialysis, optical refractions, or pregnancy.
lastSeenDate String (date) Date that the patient was last seen by the attending or supervising physician for the qualifying medical condition related to the services to be performed.
acuteManifestationDate String (date) Date of acute manifestation of a chronic condition. Required only when the condition is acute or an acute manifestation of a chronic condition; the claim involves spinal manipulation; and the payer is Medicare.
lastMenstrualPeriodDate String (date) Date of the patient's last menstrual period. Required when the services on the claim are related to the patient's pregnancy.
lastXrayDate String (date) Date of patient's last x-ray. Required when the claim involves spinal manipulation and an x-ray was taken.
hearingAndVisionPrescriptionDate String (date) Date when a hearing device or vision frames/lenses were prescribed and billed on this claim.
disabilityPeriodStartDate String (date) Date when the patient became unable to perform duties associated with his/her work.
disabilityPeriodEndDate String (date) Date when the patient has returned or will return to work.
lastWorkedDate String (date) Date the patient last worked. Required on claims where this information is necessary for adjudication (e.g., workers compensation claims).
authorizedReturnToWorkDate String (date) The date the provider has authorized the patient to return to work. Required on claims where this information is necessary for adjudication (e.g., workers compensation claims).
admissionDate String (date) Date the patient was/will be admitted to the hospital, if applicable.
dischargeDate String (date) Date the patient was or will be discharged from the hospital, if applicable.
assumedCareDate String (date) Date the patient's care was assumed by another provider during post-operative care.
relinquishedCareDate String (date) Date the provider filing this claim ceased post-operative care.
propertyAndCasualtyFirstContactDate String (date) Date the patient first consulted the service provider for this condition (not necessarily the initial treatment date). Only for property and casualty claims where state-mandated.
repricerReceivedDate String (date) Date required when a repricer is passing the claim onto the payer.
supplementalInformation Array Additional information about a claim predetermination included as a paper attachment, an electronic attachment transmitted in another functional group, or when the provider deems it necessary to identify additional information held at the provider's office but not submitted with the claim. See the claimInformation.supplementalInformation table for select field definitions.
contractTypeCode String Code identifying the contract type. Options: 01 (Diagnosis Related Group [DRG]), 02 (per diem), 03 (variable per diem), 04 (flat), 05 (capitated), 06 (percent), 09 (other).
contractAmount String The contracted monetary amount.
contractPercentage String The contracted allowance or charge percent.
contractCode String Code for the contract.
contractTermsDiscountPercentage String Terms discount percentage, expressed as a percent, available to the purchaser if an invoice is paid on or before the term discount due date.
contractVersionIdentifier String Additional identifying number for the contract.
patientPaidAmount String Amount the patient has paid specifically toward this claim.
serviceAuthorizationException Code String Code identifying an exception to the mandate requiring authorization for specific service(s). See the X12 837 TR3 (Health Care Claim: Professional) for the full list of codes.
medicareCrossoverIndicator Boolean Required when the submitter is Medicare and the claim is a Medigap or coordination of benefits (COB) crossover claim. Options: Y (4801), N (regular crossover).
mammographyCertificationNumber String Certification number for a claim involving mammography services rendered by a certified mammography provider.
referralNumber String Referral number for the claim, if one was assigned by the payer and a referral is involved.
priorAuthorizationNumber String Prior authorization number for the claim, if one was assigned by the payer and the services were preauthorized.
payerClaimControlNumber String Control number required when this claim predetermination is a replacement or void to a previously adjudicated claim.
clinicalLaboratory

ImprovementAmendmentNumber

String Number required for all Clinical Laboratory Improvement Amendment (CLIA)-certified facilities performing CLIA-covered lab services.
repricedClaimReferenceNumber String Reference number required when the information is deemed necessary by the repricer.
adjustedRepricedClaimReferenceNumber String Reference number required when the information is deemed necessary by the repricer.
investigationalDeviceExemptionIdentifier String Identifier required when the claim involves an FDA-assigned investigational device exemption (IDE) number.
claimIdentifier String Identifer assigned by transmission intermediaries (e.g., automated clearinghouses) that must attach their own unique claim number.
medicalRecordNumber String Required when the provider needs to identify the actual medical record of the patient for future inquiries.
demonstrationProjectIdentifier String Identifier used to identify atypical claims (e.g., claims for a demonstration, special project, or clinical trial).
carePlanOversightNumber String Number required when the physician is billing Medicare for Care Plan Oversight (CPO).
claimNoteReferenceCode String Code identifying the functional area or purpose for a note about the claim. Options: ADD (additional information), CER (certification narrative), DCP (goals, rehabilitation potential, or discharge plans), DGN (diagnosis description), or TPO (third-party organization notes).
claimNoteText String Free-form content of the claim note.
ambulanceTransportReasonCode String Code indicating the reason for ambulance transport, if applicable. See the X12 837 TR3 (Health Care Claim: Professional) for the full list of codes.
ambulanceTransportDistance String The distance traveled during the ambulance transport.
ambulanceTransport

RoundTripPurposeDescription

String Free-form description of the purpose for a round-trip ambulance transport, if applicable.
ambulanceTransport

StretcherPurposeDescription

String Free-form description justifying usage of a stretcher duirng ambulance service, if applicable.
spinalManipulation

ServicePatientConditionCode

String Code indicating the patient's condition for chiropractic claims involving spinal manipulation. See the X12 837 TR3 (Health Care Claim: Professional) for the full list of codes.
spinalManipulationService

PatientConditionDescription1/2

String The first and second free-form descriptions of the patient's condition.
ambulanceCertifications Array Array containing information about the ambulance transport and condition codes. See the claimInformation.ambulanceCertifications table for select field definitions.
visionConditions Array Array containing information on the patient's vision condition(s). See the clamInformation.visionConditions table for select field definitions.
homeboundIndicator Boolean Indicates whether the patient is homebound. Required for Medicare claims when an independent laboratory renders an EKG tracing or optains a specimen from a homebound or institutionalized patient. Options: Y/N.
epsdtReferralCertification

ConditionCodeAppliesIndicator

Boolean Indicates whether the patient received an EPSDT referral when EPSDT is being billed in the claim. Options: Y/N.
epsdtReferralCondition

Cide1/2/3

String Codes for the condition of the EPSDT referral. Options: AV (available – not used; patient refused referral); NU (not used), S2 (under treatment), ST (new services requested).
diagnoses Array Array providing information about the patient's principal diagnosis. See the claimInformation.diagnoses table for field definitions.
anesthesiaRelated

SurgicalPrincipalProcedure

String Code for a principal surgical procedure that requires anesthesia. See X12 External Code Source 130: Healthcare Common Procedure Coding System (HCPCS).
anesthesiaRelatedSurgical

OtherProcedure

String Code for a secondary surgical procedure that requires anesthesia. See X12 External Code Source 130: Healthcare Common Procedure Coding System (HCPCS).
conditionInformation Array Array that includes the patient's condition code.
referringProvider Object Object providing identifying and contact information about the provider who referred the patient, if applicable. Definitions for the fields within this object are omitted for brevity.
primaryCareProvider Object Object providing identifying and contact information about the patient's primary care provider. Definitions for the fields within this object are omitted for brevity.
renderingProvider Object Object providing identifying and contact information about the provider who rendered/will render the service. Definitions for the fields within this object are omitted for brevity.
serviceFacility Object Object providing identifying and contact information about the facility where the service will be performed. Definitions for the fields within this object are omitted for brevity.
supervisingProvider Object Object providing identifying and contact information about the supervising provider, if applicable. Definitions for the fields within this object are omitted for brevity.
ambulancePickUpLocation Object Object providing address information about the location where an ambulance picked up the patient, if applicable. Definitions for the fields within this object are omitted for brevity.
ambulanceDropOffLocation Object Object providing address information about the location where an ambulance dropped off the patient, if applicable. Definitions for the fields within this object are omitted for brevity.
otherPayers Array Array including information about other payers involved in the claim predetermination. See the claimInformation.otherPayers table for select field definitions.
serviceLines Array Array providing information about the service lines for the claim. See the claimInformation.serviceLines table for select field definitions.
bundled Boolean Indicates whether the claim is bundled. Options: true/false.
messages Array Array of messages from the payer.
displayMessage String A display message from the payer.
totalCharges String Object providing information about the total charge amount for the claim predetermination. Includes fields for the amount, the description, code, and codeType for the amount, the procedure, and a Boolean field that indicates whether the patient is liable for this item.
totalAllowed Object Object providing information about the total allowed amount for the claim predetermination. Includes fields for the amount, the description, code, and codeType for the amount, the procedure, and a Boolean field that indicates whether the patient is liable for this item.
totalEstimated Object Object providing information about the total estimated amount for the claim predetermination. Includes fields for the amount, the description, code, and codeType for the amount, the procedure, and a Boolean field that indicates whether the patient is liable for this item.
totalNotCovered Object Object providing information about the total amount not covered for the claim predetermination. Includes fields for the amount, the description, code, and codeType for the amount, the procedure, and a Boolean field that indicates whether the patient is liable for this item.
totalCoPay Object Object providing information about the total copay amount. Includes fields for the amount, the description, code, and codeType for the amount, the procedure, and a Boolean field that indicates whether the patient is liable for this item.
totalCoInsurance Object Object providing information about the total co-insurance amount. Includes fields for the amount, the description, code, and codeType for the amount, the procedure, and a Boolean field that indicates whether the patient is liable for this item.
totalDeductible Object Object providing information about the total deductible amount. Includes fields for the amount, the description, code, and codeType for the amount, the procedure, and a Boolean field that indicates whether the patient is liable for this item.
totalContractual Object Object providing information about the total contractual charge amount for the claim predetermination. Includes fields for the amount, the description, code, and codeType for the amount, the procedure, and a Boolean field that indicates whether the patient is liable for this item.
totalProviderInitiated Object Object providing information about the total provider-initiated charge amount for the claim predetermination. Includes fields for the amount, the description, code, and codeType for the amount, the procedure, and a Boolean field that indicates whether the patient is liable for this item.
totalProviderResponsibility Object Object providing information about the provider's total respoinsibility. Includes fields for the amount, the description, code, and codeType for the amount, the procedure, and a Boolean field that indicates whether the patient is liable for this item.
totalPatientLiability Object Object providing information about the patient's total liability for the claim predetermination. Includes fields for the amount, the description, code, and codeType for the amount, the procedure, and a Boolean field that indicates whether the patient is liable for this item.
 
CCE – Professional response definitions: Fields within claimInformation.supplementalInformation
Field Type Definition
reportTypeCode String Code indicating the title or contents of a document, report, or supporting item. See the X12 837 TR3 (Health Care Claim: Professional) for the full list of codes.
reportTransmissionCode String Code defining timing, transmission method, or format by which the report was sent. See the X12 837 TR3 (Health Care Claim: Professional) for the full list of codes.
controlNumber String Control number for the supplemental information.
 
CCE – Professional response definitions: Fields within claimInformation.ambulanceCertifications
Field Type Definition

certificationConditionIndicator

Boolean Indicates whether the condition codes apply to ambulance certification. Options: Y/N.
conditionCode1/2/3/4/5 String Codes indicating the patient's condition when ambulance services were used. See the X12 837 TR3 (Health Care Claim: Professional) for the full list of codes.
 
CCE – Professional response definitions: Fields within claimInformation.visionConditions
Field Type Definition
codeCategory String Specifies the situation or category to which the condition codes apply. Options: E1 (spectacle lenses), E2 (contact lenses), E3 (spectacle frames).
certificationConditionIndicator String Indicates whether the condition codes apply to the vision certification. Options: Y/N.
conditionCode1/2/3/4/5 String Codes indicating the patient's vision condition. See the X12 837 TR3 (Health Care Claim: Professional) for the full list of codes.
 
CCE – Professional response definitions: Fields within claimInformation.diagnoses
Field Type Definition
qualifier String Identifies the healthcare information code set used for the diagnosis.
qualifierCode String Code identifying the code set. Options: ABK (ICD-10-CM Principal Diagnosis), BK (ICD-9-CM Principal Diagnosis).
code String The code for the diagnosis. Code source: Code source: ICD-9-CM.
 
CCE – Professional response definitions: Fields within claimInformation.otherPayers
Field Type Definition
responsibilitySequenceCode String The responsibility sequence of this payer. Options: P (primary), S (secondary), or T (tertiary).
insuranceTypeCode String Code identifying the type of insurance policy within this specific insurance program. See the X12 837 TR3 (Health Care Claim: Professional) for the full list of codes.
claimFileIndicatorCode String This payer's claim filing indicator code. See the X12 837 TR3 (Health Care Claim: Professional) for the full list of codes.
claimPaidDate String (date) Date on which the claim was paid by this payer.
secondaryPayerIdentificationNumber String This payer's ID number.
ein String This payer's Employer Identification Number (EIN).
claimOfficeNumber String This payer's claim office number.
naicCode String This payer's North American Industry Classification (NAIC) System code.
priorAuthorizationNumber String Prior authorization number for the claim, if one was assigned by this payer and the services were preauthorized.
referralNumber String Referral number for the claim, if one was assigned by this payer and a referral is involved.
claimAdjustmentIndicator Boolean Required only if the claim is sent in the payer-to-payer COB model and the payer has readjudicated the claim. The only valid value is Y.
claimControlNumber String Control number required when this claim predetermination is a replacement or void to a previously adjudicated claim.
paidAmount String Amount this payer has paid on the claim.
remainingPatientLiabilityAmount String The patient's remaining liability for the claim.
nonCoveredAmount String The monetary amount not covered by this payer.
benefitsAssignmentCertification Boolean Indicates whether the insured has authorized this plan to remit payment directly to the provider. Options: Y, N, W (not applicable).
patientSignatureSourceCode String Code indicating how the patient or subscriber authorization signatures were obtained and how the provider retains them. Required when a signature was executed on the patient's behalf under state or federal law.
informationReleaseCode String Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations. Options: Y, I (the provider has not collected a signature AND state or federal laws do not require it).
subscriberRelationshipCode String Code representing the patient's relationship to this payer's subscriber. See the X12 837 TR3 (Health Care Claim: Professional) for the full list of codes.
 
CCE – Professional response definitions: Fields within claimInformation.serviceLines
Field Type Definition
controlNumber String The service line control number. Required when the submitter needs a line item control number for subsequent communications to or form the payer.
procedureCode String Code for the procedure performed upon which adjudication of the service line is based. See the ASC X12 TR3 837 (Health Care Claim: Professional) for code sources.
modifierCode1/2/3/4 String Codes indicating special circumstances related to the performance of the service, as defined by trading partners. Required when a modifier clarifies or improves the reporting accuracy of the associated procedure code.
procedureDescription String A free-form description of the procedure performed.
amount String The charge amount for this service line.
quantityTypeCode String Code for the service line unit type.
quantity String Service line unit count.
placeOfServiceCode String Code for the place of service for this service line if different from the overall claim place of service. Code source: Place of Service Codes for Professional Claims.
diagnosisCodePointer1/2/3/4 String Pointers to the diagnosis code in the order of importance to this service. The first pointer designates the primary diagnosis for this service line; remaining diagnosis pointers indicate declining levels of importance. Options: 1 – 12.
emergencyIndicator Boolean Indicates whether the service is known to be an emergency. Options: Y/N.
epsdtIndicator Boolean Indicates whether Medicaid services are the result of an EPSDT screening referral. Options: Y/N.
familyPlanningIndicator Boolean Indicates whether family planning services were involved in the service. Options: Y/N.
copayStatusCode String Code indicating whether copayment requirements were met on a line-by-line basis. Required when the paitent is exempt from copay. Copay exempt value = 0.
dmeProcedureCode String Code for the procedure requiring durable medical equipment (DME). Code source: Healthcare Common Procedure Coding System.
dmeLengthOfMedicalNecessity String Length of DME treatment required.
dmeRentalPrice String The price to rent the DME.
dmePurchasePrice String The price to buy the DME.
dmeFrequencyCode String Code indicating the frequency at which the rental DME is billed. Options: 1 (weekly), 4 (monthly), 6 (daily).
supplementalInformation Array Array providing information on the type or transmission of paperwork or supporting information.
dmeCertificateOfMedicalNecessity AttachmentTransmissionCode String Code defining timing, transmission method, or format by which the certification is to be sent. See the X12 837 TR3 (Health Care Claim: Professional) for the full list of codes.
ambulanceTransportReasonCode String Code indicating the reason for ambulance transport. See the X12 837 TR3 (Health Care Claim: Professional) for the full list of codes.
ambulanceTransportDistance String The distance traveled during ambulance transport.
ambulanceTransportRoundTrip PurposeDescription String Free-form description of the purpose for a round-trip ambulance transport, if applicable.
ambulanceTransportStretcher PurposeDescription String Free-form description justifying usage of a stretcher duirng ambulance service, if applicable.
dmeCertificationTypeCode String Code indicating the type of certification for DME. Options: I (initial), R (renewal), S (revised).
dmeDuration String Length of time DME equipment is needed.
ambulanceCertifications Array Array providing information on ambulance certifications. Includes certification condition indicator and condition codes.
hospiceEmployeeIndicator Boolean Indicates whether the provider is employed by a hospice. Options: Y/N.
dmeCertificationConditionIndicator Boolean Indicates whether a DME Regional Carrier Certificate of Medical Necessity (DMERC CMN) or a DMERC Information Form or Oxygen Therapy Certification is included on this service line and the information is necessary for adjudication. Options: Y/N.
dmeCertificationConditionCode1/2 String Codes indicating the patient's condition when DME was certified.
fromDate String (date) The service beginning date.
toDate String (date) The service end date.
prescriptionDate String (date) Date a prescription was written.
certificationRevisionDate String (date) Date the DME certification was revised.
beginTherapyDate String (date) Date therapy began. Required when a DME Regional Carrier Certificate of Medical Necessity (DMERC CMN) or a DMERC Information Form or Oxygen Therapy Certification is included on this service line.
lastCertificationDate String (date) Date the ordering physician signed the CMN or Oxygen Therapy Certification, or the date the supplier signed the DMER Information Form.
latestVisitOrConsultationDate String (date) Specifies the last visit or consultation date when a claim involves physician services for routine foot care and is different from the date listed at the claim level and known to impact the payer's adjudication process.
mostRecentHemoglobinOrHematocrit TestPerformedDate String (date) Test date required on initial EPO claims service lines for dialysis patients when test results are being billed or reported.
mostRecentSerumCreatine TestPerformedDate String (date) Test date required on initial EPO claims service lines for dialysis patients when test results are being billed or reported.
shippedDate String (date) Date required when billing or reporting shipped products.
lastXrayDate String (date) Date required when the claim involves spinal manipulation and an x-ray was taken, and this is different from information at the claim level.
initialTreatmentDate String (date) Date required when known to impact adjudication for claims involving spinal manipulation, physical therapy, occupational therapy, or speech language pathology, and when different from what is reported at the claim level.
ambulancePatientCount String Number of patients transported in the same ambulance.
obstetricAdditionalUnits String Number of additional units reported by an anesthesia provider to reflect additional service complexity.
testResults Array Required on dialysis-related service lines for end-stage renal disease. Includes test result reference ID code, qualifier, and value.
contractTypeCode String Code identifying a contract type. Options: 01 (Diagnosis Related Group [DRG]), 02 (per diem), 03 (variable per diem), 04 (flat), 05 (capitated), 06 (percent), 09 (other).
contractAmount String Monetary contract amount. Required when information is different from that at the claim level.
contractPercentage String Contract allowance or charge percent. Required when information is different from that at the claim level.
contractCode String Code for the contract. Required when information is different from that at the claim level.
contractTermsDiscount Percentage String Terms discount percentage, expressed as a percent, available to the purchaser if an invoice is paid on or before the term discount due date. Required when information is different from that at the claim level.
contractVersionIdentifier String Additional identifying information for the contract. Required when information is different from that at the claim level.
repricedLineItemReference Number String Required when a repricing organization needs to have an identifying number on the service line in its submission to its payer organization.
adjustedRepricedLineItem ReferenceNumber String Required when a repricing organization needs to have an identifying number on an adjusted service line in its submission to its payer organization.
priorAuthorizationNumber String Required when the service line involved a prior authorization number different from that reported at the claim level.
mammographyCertificationNumber String Required when mammography services are rendered by a certified mammography provider and the certification number is different from that at the claim level.
clinicalLaboratoryImprovement AmendmentNumber String Required for all CLIA-certified facilities performing CLIA-covered services and the number is different from that at the claim level.
referringClinicalLaboratory ImprovementAmendmentNumber String Required for claims for any laboratory that referred tests to another laboratory covered by CLIA that is billed on this line.
immunizationBatchNumber String Required when mandated by state or federal law or regulations.
referralNumber String Required when this service line involved a referral number that is different from the number reported at the claim level.
salesTaxAmount String Required when sales tax applies to this service line and the submitter is require to report it to the receiver.
postageClaimedAmount String Required when the service line charge includes a postage amount claimed in this service line.
additionalInformationLineNote String Additional free-form information that substantiates the medical treatment and is not reported elsewhere within the claim data.
thirdPartyOrganizationNote String Free-form note forwarded from a repricer or third-party organization to the payer.
purchasedServiceProviderIdentifier String Identifier used on non-vision service lines when the charge amount for services purchased from another source will impact adjudication, or on vision service lines when the acquisition cost of lenses will affect adjudication.
purchasedServiceChargeAmount String The charge amount for services purchased from another source.
nationalDrugCode String Code sources: National Drug Code (NDC) or Universal Product Numbers (UPNs). Required when government regulation mandates that prescribed drugs are reported with NDC numbers, or when the numbers will enhance the claim reporting or adjudication processes. Also required when government regulation mandates that medical and surgical supplies are reported with UPNs.
nationalDrugUnitCount String Number of drug units.
nationalDrugUnitCodeQualifer String Code specifying the drug units. Options: F2 (international unit), GR (gram), ME (milligram), ML (milliliter), UN (unit).
linkSequenceNumber String A provider-assigned number unique to this claim that identifies a drug provided without a prescription.
pharmacyPrescriptionNumber String Assigned prescription number for a drug.
renderingProvider Object Object providing identifying and contact information about the provider who will render the service, if different from the information at the claim level. Definitions for the fields within this object are omitted for brevity.
purchasedServiceProvider Object Object providing identifying and contact information about the provider of purchased services. Definitions for the fields within this object are omitted for brevity.
serviceFacility Object Object providing identifying and contact information about the facility where the service will be performed. Definitions for the fields within this object are omitted for brevity.
supervisingProvider Object Object providing identifying and contact information about the supervising provider, if applicable, and the supervisor is different from that listed at the claim level for this service line. Definitions for the fields within this object are omitted for brevity.
orderingProvider Object Object providing identifying and contact information about the ordering provider, if different from the rendering provider for this service line. Definitions for the fields within this object are omitted for brevity.
referringProvider Object Object providing identifying and contact information about the referring provider, if applicable and different from that reported at the claim level. Definitions for the fields within this object are omitted for brevity.
primaryCareProvider Object Object providing identifying and contact information about the referring provider, if applicable and different from that reported at the claim level. Definitions for the fields within this object are omitted for brevity.
ambulancePickUpLocation Object Object providing address information about the ambulance pick-up location. Required when the location for this service line is different from that provided at the claim level.
ambulanceDropOffLocation Object Object providing address information about the ambulance drop-off location. Required when the location for this service line is different from that provided at the claim level.
adjudicationInformation Array Array providing service line adjudication information. See the claimInformation.serviceLines.adjudication Information table for field definitions.
formIdentificationCodes Array Array providing information about a specific form. See the claimInformation.serviceLines. formIdentificationCodes table for field definitions.
estimatedPatientResponsibility String The estimated amount the patient is responsible for in this service line.
bundlingDescription String Description of how the service lines were bundled, if applicable.
denyReason String The reason for a service line denial.
holdReasons Array Array describing reasons for a service line being placed on hold.
messages String List of messages from the payer for this service line.
displayMessage String A display message from the payer for this service line.
allowed String The allowed monetary amount for this service line.
notCovered Object Object providing information about the monetary amount not covered for this service line. Includes fields for the amount, the description, code, and codeType for the amount, the procedure, and a Boolean field that indicates whether the patient is liable for this item.
coPay Object Object providing information about the monetary copay amount for this service line. Includes fields for the amount, the description, code, and codeType for the amount, the procedure, and a Boolean field that indicates whether the patient is liable for this item.
coInsurance Object Object providing information about the monetary co-insurance amount for this service line. Includes fields for the amount, the description, code, and codeType for the amount, the procedure, and a Boolean field that indicates whether the patient is liable for this item.
deductible Object Object providing information about the monetary deductible amount for this service line. Includes fields for the amount, the description, code, and codeType for the amount, the procedure, and a Boolean field that indicates whether the patient is liable for this item.
estimated Object Object providing information about the estimated monetary amount for this service line. Includes fields for the amount, the description, code, and codeType for the amount, the procedure, and a Boolean field that indicates whether the patient is liable for this item.
contractual Object Object providing information about the monetary contractual amount for this service line. Includes fields for the amount, the description, code, and codeType for the amount, the procedure, and a Boolean field that indicates whether the patient is liable for this item.
providerInitiated Object Object providing information about the monetary provider-initiated amount for this service line. Includes fields for the amount, the description, code, and codeType for the amount, the procedure, and a Boolean field that indicates whether the patient is liable for this item.
providerResponsibility Object Object providing information about the provider's monetary responsibility for this service line. Includes fields for the amount, the description, code, and codeType for the amount, the procedure, and a Boolean field that indicates whether the patient is liable for this item.
remarks Array Arraying containing information on remarks about this service line, including fields for the remark code (source: Remittance Advice Remark Codes) and description.
 
CCE – Professional response definitions: Fields within claimInformation.serviceLines.adjudicationInformation
Field Type Definition
payerId String Payer ID that identifies the payer that adjudicated the service line.
paidAmount String The monetary amount paid for this service line.
procedureCode String Procedure code used to pay this service line.
modifierCode1/2/3/4 String Codes identifying special circumstances related to the performance of the service, as defined by trading partners.
procedureDescription String Free-form description to clarify the procedure.
quantity String The number of paid units from the remittance advice.
lineNumber String LX Assigned Number, required only for bundling of service lines.
claimPaidDate String (date) The date the claim was paid.
remainingPatientLiability Amount String The amount of the patient's remaining liability for this service line.
claimAdjustmentGroups Array Array providing information about claim adjustments. See the adjudicationInformation.claim AdjustmentGroups table for field definitions.
 
CCE – Professional response definitions: Fields within claimInformation.serviceLines.formIdentificationCodes
Field Type Definition
codeListQualifierCode String Code identifying a specific industry code list. Options: AS (Form Type Codes), UT (DMERC CMN forms).
formIdentifier String Code identifying the form within one of the code lists. Required when adjudication will be impacted by one of the types of supporting documentation.
supportingDocumentation Array

Array used to identify answers to specific questions on the form. Fields include:

  • questionNumber: the question number on a questionnaire or codified form.
  • yesNoResponse: Indicates whether the question uses a yes or no format. Options: Y, N, W (not applicable).
  • textResponse: Required when the question uses a text or uncodified response format.
  • percentResponse: Required when the question uses a percent response format.
  • dateResponse: Required when the question uses a date response format.
 
CCE – Professional response definitions: Fields within claimInformation.serviceLines.adjudicationInformation.claimAdjustmentGroups
Field Type Definitions
groupCode String Code identifying the general category of payment adjustment. Options: CO (contractual obligations), CR (correction and reversals), OA (other adjustments), PI (payer-initiated reductions), PR (patient responsibility).
adjustments Array Contains a list of adjustments associated with this claim adjustment group. Includes fields for reasonCode, amount, and quantity of adjustments.

Care Cost Estimator – Institutional

Refer to the Availity API Guide for more information about Availity's APIs.

Endpoints

 
  Path Function
1 POST/v1/institutional-claims Create an institutional claim predetermination asynchronously. To submit a claim predetermination, make a valid request and receive a response with a location header containing a URL you can query for your result.
2 GET/v1/institutional-claims/{id} Retrieve a particular institutional claim predetermination. Replace {id} with the response ID from your initial request.

Validation rules

As with the Care Cost Estimator – Professional API, the validation rules for this Institutional resource can vary by health plan, the type of claim requested, and the type of service to be performed. Availity organizes these rules and makes them available through the Configurations API, which documents the fields required to send or create an institutional claim predetermination and explains which values are valid for those fields. See the Configurations section for more details. For the Institutional resource, the type is institutional-claims and the subtype ID is PRE-DETERMINATION. For example:

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

See the Configurations reference section for details.

Parameters

1. POST/v1/institutional-claims

 
POST/v1/institutional-claims parameters
Parameter Type Definition
institutionalClaim Body object (optional) Represents the details of the new institutional claim predetermination you are creating. See the request body for possible fields. See Response definitions for field definitions.
Content-Type Header string (optional) Allows you to specify application/json or application/xml
Accept Header string (optional) Allows you to specify application/json or application/xml

institutionalClaim request body (truncated):

{
    "type": "object",
    "properties": {
        "id": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "createdDate": {
            "type": "string",
            "format": "date-time",
            "$ref": "#/definitions/Primaryfields"
        },
        "updatedDate": {
            "type": "string",
            "format": "date-time",
            "$ref": "#/definitions/Primaryfields"
        },
        "expirationDate": {
            "type": "string",
            "format": "date-time",
            "$ref": "#/definitions/Primaryfields"
        },
        "message": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "customerId": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "requestTypeCode": {
            "type": "string",
            "$ref": "#/definitions/Primaryfields"
        },
        "submitter": {
            "type": "object",
            "$ref": "#/definitions/Primaryfields"
        },
        "payer": {
            "type": "object",
            "$ref": "#/definitions/payer"
        },
        "billingProvider": {
            "type": "object",
            "$ref": "#/definitions/billingProvider"
        },
        "patient": {
            "type": "object",
            "$ref": "#/definitions/Primaryfields"
        },
        "claimInformation": {
            "type": "object",
            "$ref": "#/definitions/claimInformation"
        },
        "payerSpecificFlags": {
            "type": "array",
            "$ref": "#/definitions/Primaryfields"
        }
    }
}

2. GET/v1/institutional-claims/{id}

 
GET/v1/institutional-claims/{id} parameters
Parameter Type Definition
id Path string (required) The unique response ID from your initial request, which can be used in followup requests.
Accept Header string (optional) Allows you to specify application/json or application/xml

Sample requests and responses

1. POST/v1/institutional-claims

Request:

$ 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"
      }
    ]
  }

}

Response:

If your POST request is invalid, Availity responds with a status code of 400 and a list of errors for you to correct. If your request is valid, Availity responds with a status code of 202 and a location header where you can check back for your response:

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

2. GET/v1/institutional-claims/{id}

Note: Replace {id} with the unique response ID from your initial POST request.

After you make a POST request, you can request the URI returned in the location header. If the resource is found but the health plan has not yet responded, Availity responds with a status code of 202 and a location header where you can check back for your response:

$ 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 the health plan responds, Availity responds with a status code of 200 and the full response:

$ 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"
    }
  }
}

HTTP status codes

 
HTTP status codes for CCE – Institutional
Code Status Definition
200 OK We have processed your request and the response body contains the result.
202 Accepted We are currently processing or retrying your request.
400 Bad Request Your claim predetermination request failed validation. You can correct the errors and resubmit.
404 Not Found We did not find a claim predetermination with the ID you sent.
500 Internal Server Error The health plan did not respond due to a server error. Please try your request again later.
504 Gateway Timeout The health plan did not respond after several retry attempts. Please try your request again later.

Response definitions

 
CCE – Institutional response definitions: Primary objects and fields
Field Type Definition
id String The unique response ID from your initial request, which can be used in follow-up requests.
createdDate String (date-time) The date and time this item was created in Availity's system.
updatedDate String (date-time) The date and time this item was last updated.
expirationDate String (date-time) The date and time this item will be removed from Availity's system.
customerId String The Availity customer ID of the organization that submitted this claim predetermination. Availity may ask for this ID during support calls.
requestTypeCode String The type of request. Use PRE_DETERMINATION for this transaction.
submitter Object Object providing identifying and contact information about the submitter of the claim predetermination. Definitions for the fields within this object are omitted for brevity; see the X12 837 TR3 (Health Care Claim: Institutional) for more information on these fields.
payer Object Object providing information about the payer involved in the claim. See the Payer table for select field definitions.
billingProvider Object Object providing identifying and contact information about the billing provider involved in the claim predetermination. See the billingProvider table for select field definitions.
subscriber Object Object providing identifying and contact information about the health plan subscriber involved in the claim predetermination. See the Subscriber table for select field definitions.
patient Object An object providing identifying and contact information about the patient involved in the claim predetermination (if different from the subscriber). Definitions for the fields within this object are omitted for brevity; see the X12 837 TR3 (Health Care Claim: Institutional) for more information on these fields.
claimInformation Object Object providing further information about the claim predetermination. See the claimInformation table for select field definitions.
payerSpecificFlags Array Array including the name and value of payer-specific flags.
 
CCE – Institutional response definitions: Select fields within payer
Field Type Definition
naicCode String The payer's North American Industry Classification (NAIC) System code.
responsibilitySequenceCode String The responsibility sequence of the payer. Options: P (primary), S (secondary), or T (tertiary).
insuranceTypeCode String Code identifying the type of insurance policy within a specific insurance program. See the X12 837 TR3 (Health Care Claim: Institutional) for the full list of codes.
claimFilingIndicatorCode String The payer's claim filing indicator code. See the X12 837 TR3 (Health Care Claim: Institutional) for the full list of codes.
Note: Fields related to the payer's identifying and contact information are omitted for brevity.
 
CCE – Institutional response definitions: Select fields within billingProvider
Field Type Definition
specialtyCode String Specifies the requesting provider's specialty using a taxonomy code. See X12 External Code Source 682: Provider Taxonomy Codes.
stateLicenseNumber String The billing provider's state medical license number.
upin String The billing provider's Unique Personal Identification Number (UPIN).
payerAssignedProviderId String The billing provider's ID number assigned by the payer.
payToAddress Object Object containing fields for the billing provider's pay-to address, if different from the physical address.
Note: Fields related to the billing provider's identifying and contact information are omitted for brevity.
 
CCE – Institutional response definitions: Select fields within subscriber
Field Type Definition
totalFamilyDeductible String The total amount of the subscriber's health insurance deductible for a family policy.
accumulatedFamilyDeductible String The subscriber's accumulated deductible for a family policy.
remainingFamilyDeductible String The amount the subscriber has left to pay on the deductible for a family policy.
totalDeductible String The total amount of the subscriber's health insurance deductible.
accumulatedDeductible String The subscriber's accumulated deductible.
remainingDeductible String The amount the subscriber has left to pay on the deductible.
onHold Boolean Indicates whether the subscriber is on hold. Options: Y/N.
holdReasons Array Array describing reasons for the hold.
 
CCE – Institutional response definitions: Fields within claimInformation
Field Type Definition
controlNumber String A unique reference identifier provided by the submitter and included in the original claim request.
facilityTypeCode String Code identifying the type of facility where services were or may be performed. Code source: First and second positions of Uniform Bill Type Code for Institutional Services.
frequencyTypeCode String Code specifying the frequency of the claim. See X12 External Code Source 235: Claim Frequency Type Code.
providerAcceptAssignmentCode String Code indicating whether the provider accepts assignment from the payer. Options: A (assigned), B (accepted on clinical lab services only), C (not assigned).
benefitsAssignmentCertification String Indicates whether the insured has authorized the plan to remit payment directly to the provider. Options: Y, N, W (not applicable).
informationReleaseCode String Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations. Options: Y, I (the provider has not collected a signature AND state or federal laws do not require it).
admissionTypeCode String Code indicating the priority of this admission. See X12 External Code Source 231: Priority (Type) of Admission or Visit.
admissionSourceCode String Code indicating the source of the admission. See X12 External Code Source 230: Point of Origin for Admission or Visit.
patientStatusCode String Code indicating the patient's status at the date of admission, outpatient service, or start of care. See X12 External Code Source 239: Patient Status Code.
bundled Boolean Indicates whether the claim is bundled. Options: true/false.
messages Array Array listing messages from the payer.
specialMessages Array Array listing special messages from the payer.
displayMessage String A display message from the payer.
serviceTypeCode String Code identifying the type of service to be performed. See the ASC X12 270/271 TR3 (Health Care Eligibility Benefit Inquiry and Response) for the full list of service type codes.
occurrenceCode String Code defining a significant even relating to this bill that may affect payer processing. See X12 External Code Source 132: NUBC.
occurrenceCodeDate String (date) Date associated with the occurrenceCode.
valueCode String Code identifying monetary data that is necessary for processing this claim as required by the payer organization. See X12 External Code Source 132: NUBC Codes.
valueCodeAmount String Amount associated with the valueCode.
conditionCode String Code indicating the patient's condition. See X12 External Code Source 132: NUBC Codes.
claimIdentifier String Identifer assigned by transmission intermediaries (e.g., automated clearinghouses) that must attach their own unique claim number.
principalDiagnosis Object Object providing information about the patient's principal diagnosis, which is considered to be chiefly responsible for the condition that caused the patient's admission. See the claimInformation.principalDiagnosis table for field definitions.
admittingDiagnosis Object Object providing information about the patient's diagnosis at the time of admission. See the claimInformation.admittingDiagnosis table for field definitions.
patientsReasonForVisit Object Object providing information about the patient's reason for an outpatient visit, if applicable. See the claimInformation.patientsReasonForVisit table for field definitions.
principalProcedure Object Object providing information about the patient's principal procedure, product, or service. See the claimInformation.principalProcedure table for field definitions.
diagnosisRelatedGroupCode String The Diagnosis Related Group (DRG) code. See the X12 External Code Source 229: Diagnosis Related Group Number (DRG).
otherDiagnoses Array Array providing information on the patient's additional diagnoses, if applicable. See the claimInformation.otherDiagnoses table for field definitions.
otherProcedures Array Array providing information on the patient's additional procedures, if applicable. See the claimInformation.otherProcedures table for field definitions.
serviceLines Array Array listing service lines used. See the claimInformation.ServiceLines table for field definitions.
totalCharges String Object providing information about the total charge amount for the claim predetermination. Includes fields for the amount, the description, code, and codeType for the amount, the procedure, and a Boolean field that indicates whether the patient is liable for this item.
totalAllowed Object Object providing information about the total allowed amount for the claim predetermination. Includes fields for the amount, the description, code, and codeType for the amount, the procedure, and a Boolean field that indicates whether the patient is liable for this item.
totalEstimated Object Object providing information about the total estimated amount for the claim predetermination. Includes fields for the amount, the description, code, and codeType for the amount, the procedure, and a Boolean field that indicates whether the patient is liable for this item.
totalNotCovered Object Object providing information about the total amount not covered for the claim predetermination. Includes fields for the amount, the description, code, and codeType for the amount, the procedure, and a Boolean field that indicates whether the patient is liable for this item.
totalCoPay Object Object providing information about the total copay amount. Includes fields for the amount, the description, code, and codeType for the amount, the procedure, and a Boolean field that indicates whether the patient is liable for this item.
totalCoInsurance Object Object providing information about the total co-insurance amount. Includes fields for the amount, the description, code, and codeType for the amount, the procedure, and a Boolean field that indicates whether the patient is liable for this item.
totalDeductible Object Object providing information about the total deductible amount. Includes fields for the amount, the description, code, and codeType for the amount, the procedure, and a Boolean field that indicates whether the patient is liable for this item.
totalContractual Object Object providing information about the total contractual charge amount for the claim predetermination. Includes fields for the amount, the description, code, and codeType for the amount, the procedure, and a Boolean field that indicates whether the patient is liable for this item.
totalProviderInitiated Object Object providing information about the total provider-initiated charge amount for the claim predetermination. Includes fields for the amount, the description, code, and codeType for the amount, the procedure, and a Boolean field that indicates whether the patient is liable for this item.
totalProviderResponsibility Object Object providing information about the provider's total respoinsibility. Includes fields for the amount, the description, code, and codeType for the amount, the procedure, and a Boolean field that indicates whether the patient is liable for this item.
totalPatientLiability Object Object providing information about the patient's total liability for the claim predetermination. Includes fields for the amount, the description, code, and codeType for the amount, the procedure, and a Boolean field that indicates whether the patient is liable for this item.
attendingProvider Object Object providing information about the attending provider (last name, first name, NPI number).
 
CCE – Institutional response definitions: Fields within claimInformation.principalDiagnosis
Field Type Definition
qualifier String Identifies the healthcare information code set used for the diagnosis.
qualifierCode String Code identifying the code set. Options: ABK (ICD-10-CM Principal Diagnosis), BK (ICD-9-CM Principal Diagnosis).
code String The code for the principal diagnosis. Code source: ICD-9-CM.
description String A description of the principal diagnosis.
presentOnAdmissionIndicatorCode String Code indicating whether the principal diagnosis was present on admission to the facility. Options: Y, N, U (unknown), W (not applicable).
 
CCE – Institutional response definitions: Fields within claimInformation.admittingDiagnosis
Field Type Definition
qualifier String Identifies the healthcare information code set used for the admitting diagnosis.
qualifierCode String Code identifying the code set. Options: ABJ (ICD-10-CM Admitting Diagnosis), BJ (ICD-9-CM Admitting Diagnosis).
code String The code for the principal diagnosis. Code source: ICD-9-CM.
description String A description of the admitting diagnosis.
presentOnAdmissionIndicatorCode String Code indicating whether the admitting diagnosis was present on admission to the facility. Options: Y, N, U (unknown), W (not applicable).
 
CCE – Institutional response definitions: Fields within claimInformation.patientsReasonForVisit
Field Type Definition
qualifier String Identifies the healthcare information code set used for the patient's reason for visit.
qualifierCode String Code identifying the code set. Options: APR (ICD-10-CM Patient's Reason for Visit), PR (ICD-9-CM Patient's Reason for Visit).
code String The code for the patient's reason for outpatient visit. Code source: ICD-9-CM.
description String A description of the patient's reason for visit at the time of outpatient registration.
presentOnAdmissionIndicatorCode String Code indicating whether the patient's reason for outpatient visit was present on admission to the facility. Options: Y, N, U (unknown), W (not applicable).
 
CCE – Institutional response definitions: Fields within claimInformation.principalProcedure
Field Type Definition
qualifier String Identifies the healthcare information code set used for the principal procedure.
qualifierCode String Code identifying the code set. Options: BBR (ICD-10-CM Principal Procedure Codes), BR (ICD-9-CM Principal Procedure Codes), CAH (Advanced Billing Concepts [ABC] Codes).
code String The code for the patient's principal procedure. Code source: ICD-9-CM.
description String A description of the patient's principal procedure, product, or service.
codeDate String (date) Date on which the principal procedure was performed.
 
CCE – Institutional response definitions: Fields within claimInformation.otherDiagnoses
Field Type Definition
qualifier String Identifies the healthcare information code set used for the additional diagnosis.
qualifierCode String Code identifying the code set. Options: ABF (ICD-10-CM Diagnosis), BF (ICD-9-CM Diagnosis).
code String The code for the patient's additional diagnosis. Code source: ICD-9-CM.
description String A description of the patient's additional diagnosis.
presentOnAdmissionIndicatorCode String Code indicating whether the patient's other diagnosis was present on admission to the facility. Options: Y, N, U (unknown), W (not applicable).
 
CCE – Institutional response definitions: Fields within claimInformation.otherProcedures
Field Type Definition
qualifier String Identifies the healthcare information code set used for the additional procedure.
qualifierCode String Code identifying the code set. Options: BBQ (ICD-10-CM Other Procedure Codes), BQ (ICD-9-CM Other Procedure Codes).
code String The code for the patient's additional procedure. Code source: ICD-9-CM.
description String A description of the patient's additional procedure, product, or service.
codeDate String (date) Date on which the additional procedure was performed.
 
CCE – Institutional response definitions: Fields within claimInformation.serviceLines
Field Type Definition
controlNumber String The service line control number. Required when the submitter needs a line item control number for subsequent communications to or form the payer.
fromDate String (date) The service from (start) date.
toDate String (date) The service to (end) date.
revenue String Description of the service line revenue.
revenueCode String The service line revenue code. See X12 External Code Source 132: NUBC Codes.
procedure String Description of the procedure for this service line.
procedureCode String Code for the procedure performed upon which adjudication of the service line is based. See the ASC X12 TR3 837 (Health Care Claim: Institutional) for code sources.
alternateProcedure String Code for the alternate procedure performed upon which adjudication of the service line is based. See the ASC X12 TR3 837 (Health Care Claim: Institutional) for code sources.
modifierCode1/2/3/4 String Codes indicating special circumstances related to the performance of the service, as defined by trading partners. Required when a modifier clarifies or improves the reporting accuracy of the associated procedure code.
procedureDescription String A free-form description of the procedure performed.
amount String The charge amount for this service line.
quantityTypeCode String Code for the service line unit type. Options: DA (days), UN (unit).
quantity String Service line unit count.
estimatedPatientResponsibility String The estimated amount the patient is responsible for in this service line.
bundlingDescription String Description of how the service lines were bundled, if applicable.
denyReason String The reason for a claim denial.
holdReasons Array Array describing reasons for a service line being placed on hold.
messages String List of messages from the payer for this service line.
displayMessage String A display message from the payer for this service line.
allowed Object Object providing information about the allowed monetary amount for this service line. Includes fields for the amount, the description, code, and codeType for the amount, the procedure, and a Boolean field that indicates whether the patient is liable for this item.
estimated Object Object providing information about the estimated monetary amount for this service line. Includes fields for the amount, the description, code, and codeType for the amount, the procedure, and a Boolean field that indicates whether the patient is liable for this item.
notCovered Object Object providing information about the monetary amount not covered for this service line. Includes fields for the amount, the description, code, and codeType for the amount, the procedure, and a Boolean field that indicates whether the patient is liable for this item.
coPay Object Object providing information about the monetary copay amount for this service line. Includes fields for the amount, the description, code, and codeType for the amount, the procedure, and a Boolean field that indicates whether the patient is liable for this item.
coInsurance Object Object providing information about the monetary co-insurance amount for this service line. Includes fields for the amount, the description, code, and codeType for the amount, the procedure, and a Boolean field that indicates whether the patient is liable for this item.
deductible Object Object providing information about the monetary deductible amount for this service line. Includes fields for the amount, the description, code, and codeType for the amount, the procedure, and a Boolean field that indicates whether the patient is liable for this item.
contractual Object Object providing information about the monetary contractual amount for this service line. Includes fields for the amount, the description, code, and codeType for the amount, the procedure, and a Boolean field that indicates whether the patient is liable for this item.
providerInitiated Object Object providing information about the monetary provider-initiated amount for this service line. Includes fields for the amount, the description, code, and codeType for the amount, the procedure, and a Boolean field that indicates whether the patient is liable for this item.
providerResponsibility Object Object providing information about the provider's monetary responsibility for this service line. Includes fields for the amount, the description, code, and codeType for the amount, the procedure, and a Boolean field that indicates whether the patient is liable for this item.
remarks Array Arraying containing information on remarks about this service line, including fields for the remark code (source: Remittance Advice Remark Codes) and description.