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 `payerId`parameters 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).

Please note that Availity no longer supports the GET/v1/coverages endpoint and has replaced it with the POST/v1/coverages endpoint. Be sure to refer only to documentation that uses the POST endpoint.

Endpoints

Attention: If you navigated to this section because you are affected by the endpoint migration from GET to POST, please follow the instructions below to update your endpoint. For further clarification, refer to the sample requests and responses.

Update the request type from GET to POST and send as URL encoded. Example:
Ensure that your request does not append the data to the URL. Example:

Important: The response for the CREATE utilizing POST uses the coverages object directly. The array of coverages concept was removed for the echo request response. You no longer need to dig for the coverages object, as it is directly returned in the POST response.


	Path	Function
1	POST/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

POST/v1/coverages


Parameter/Request body	Definition
Request body	Represents the details of the coverage information you are requesting. Refer to the request body for fields and definitions.
Content-Type	Set this header to `x-www-form-urlencoded`.
Accept	Allows you to specify `application/json` or `application/xml`


POST/v1/coverages request body
Parameter	Description
payerId	The Availity-specific identifier for the patient's health plan.
providerLastName	The requesting provider's last name.
providerFirstName	The requesting provider's first name.
providerType	Specify whether the health plan is professional or institutional, as required by some health plans.
providerNpi	The requesting provider's National Provider Identifier (NPI). Most health plans require the provider NPI for coverage requests.
providerTaxId	The requesting provider's tax ID, as required by some health plans.
payerAssignedProviderId	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	The requesting provider's Social Security Number (SSN), if required.
providerPIN	The requesting provider's personal identification number.
providerCity	Specify the requesting provider’s city, as required by some health plans.
providerState	Specify the requesting provider’s two-character state code, as required by some health plans.
providerZipCode	Specify the requesting provider’s ZIP code, as required by some health plans.
providerSpecialty	Specifies the requesting provider's specialty using a taxonomy code. Refer to X12 External Code Source 682: Provider Taxonomy Codes.
placeOfService	Identifies the place of service, as required by some health plans.
submitterId	Identifies the submitter using a payer-assigned submitter identifier, as required by some health plans.
asOfDate	Indicates the date of service for which you want to check coverage information.
toDate	Provides an end date for your coverage information search period, as required by some health plans.
serviceType	The type or types of service your request involves.
cardIssueDate	The issue date of the member's health plan card.
procedureCode	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	The patient’s health plan member ID number.
medicaidId	The patient’s Medicaid ID number.
patientSSN	The patient’s Social Security Number.
patientLastName	The patient’s last name.
patientFirstName	The patient’s first name.
patientMiddleName	The patient’s middle name.
patientSuffix	The patient’s suffix.
patientGender	The patient’s gender.
patientBirthDate	The patient’s date of birth.
patientState	Two-character abbreviation for the patient’s state of residence.
groupNumber	The patient’s health plan group number.
subscriberRelationship	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	Definition
status	Search for coverages with a status of `In Progress`, `Request Error`, `Communication Error`, or `Complete`.
planStatus	Search for coverages with a plan status of `Active` or `Inactive`.
q	Search for coverages that match free-form search terms.
sortBy	Sort the results by `lastUpdateDate`, `asOfdate`, or `patientLastName`. The default is `lastUpdateDate`.
sortDirection	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=99999"
->
{
    "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 POST/v1/coverages
Code	Status	Definition
0	In Progress	Availity is in the process of retrieving the coverage from the health plan.
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.
4	Complete	The refresh was completed successfully.
6	Rejection Error
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.
18	Availity Processing Error
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.

2. GET/v1/coverages/{id}


GET/v1/coverages/{id} parameters
Parameter	Definition
id	Retrieve full coverage information using the unique response ID from your initial request.

3. DELETE/v1/coverages/{id}


DELETE/v1/coverages/{id} parameters
Parameter	Definition
id	Delete coverage information using the unique response ID from your initial request.

Sample requests and responses

POST/v1/coverages

Request:

curl --request POST \
  --url https://api.availity.com/availity/v1/coverages/ \
  --header 'Authorization: Bearer ' \
  --header 'Content-Type: application/x-www-form-urlencoded' \
  --data payerId=123 \
  --data providerUserId=123 \
  --data providerNpi=123 \
  --data 'providerLastName=ABC' \
  --data asOfDate=1990-01-01 \
  --data 'serviceType[]=30' \
  --data memberId=ABC123 \
  --data patientBirthDate=1900-01-01 \
  --data patientLastName=LAST \
  --data patientFirstName=FIRST \
  --data patientGender=M \
  --data patientState=FL \
  --data subscriberRelationship=18 \
  --data 'requestedPatientSearchOption=memberId,patientBirthDate,patientState'

Response:

{    
  "links": {        
    "self": {            
      "href": "https://api.availity.com/availity/v1/coverages/1234567890"        
    }    
  },    
  "id": "1234567890",    
  "customerId": "1234",    
  "statusCode": "4",    
  "submitterStatecode": "FL", 
  "asOfDate": "2024-02-01T05:00:00.000+0000",
  "subscriber": {        
    "memberId": "ABC123456789"    
  },    
  "patient": {        
    "firstName": "FIRST",        
    "lastName": "LAST",        
    },    
  "payer": {
    "name": "HealthPlanOne",        
    "payerId": "123",        
  },
}

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 of the Availity API Guide.

Request:

  curl -X GET \ 
 --url https://api.availity.com/availity/v1/coverages \ 
 --header 'Authorization: Bearer ' \ 
 --data-raw 'q={searchQuery}'

Response:

{
  "totalCount": 10,
  "count": 10,
  "offset": 0,
  "limit": 50,
  "links": {
    "self": {
      "href": https://apps.availity.com/api/v1/coverages
    }
  },
  "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": "1234567890"
      },
      "patient": {
        "subscriberRelationship": "Self",
        "subscriberRelationshipCode": "18",
        "birthDate": "1990-01-01T05:00:00.000+0000"
      },
      "payer": {
        "name": "HEALTHPLANONE",
        "payerId": "HEALTHPLANONE"
      },
      "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 (truncated):

{
    "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 (for example: 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: attachments (Refer to the Attachments table for field definitions) diagnoses (Refer to the Diagnoses table for field definitions) procedures (Refer to the Procedures table for field definitions) 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:

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	Array containing information on remarks about this service line, including fields for the remark code (source: Remittance Advice Remark Codes) and description.