openapi: 3.0.0 info: version: 1.0.0 description: The GraphQL Claims Inquiry API allows users to retrieve claim information and status using GraphQL queries. It supports various operations such as getting claim summary, claim detail, claim Acknowledgement and downloading a document as well. title: Claim Inquiry API servers: - url: https://sandbox-apigw.optum.com paths: /oihub/claim/inquiry/v1: post: security: - oAuth: - read_healthcheck operationId: claimInquiry tags: - Claim Inquiry parameters: - name: providerTaxId in: header description: Provider Tax ID required: true schema: type: string example: '123456789' - name: x-optum-consumer-correlation-id in: header description: Unique UUID to track the transaction required: false schema: type: string example: 4d4a8964-e5fa-42dc-a37d-12345789 - name: environment in: header description: Environment required: false schema: type: string example: sandbox - name: nextPageToken in: header description: Paging Identifier to access the next set of records required: false schema: type: string example: trwmem123451416167 requestBody: content: application/json: schema: description: GraphQL queries to fetch Claims information properties: operationName: type: string description: Name of the GraphQL operation to execute (optional) query: type: string description: GraphQL query or mutation variables: description: Variables for the GraphQL query type: object properties: searchClaimInput: type: object properties: claimNumber: description: Required to retrieve claim summary and detail by unique claim number example: '1234567890' type: string patientAccountNumber: description: Required to retrieve claim summary/detail by Patient account number. example: '1234567890' type: string memberId: description: 'Required (one-of) with memberFirstName/memberLastName/memberDateOfBirth. Use for member data search. Supported combinations: Id+DoB / Id+Name / Name+DoB.' example: '1234567890' type: string memberFirstName: description: Required (one-of) with memberId/memberLastName/memberDateOfBirth. Use for member data search. example: John type: string memberLastName: description: Required (one-of) with memberId/memberFirstName/memberDateOfBirth. Use for member data search. example: Cena type: string memberDateOfBirth: description: Required (one-of) with memberId/memberFirstName/memberLastName. Use for member data search. example: 10/01/1975 type: string memberPolicy: description: Optional. The member's policy number. example: 002781 type: string serviceStartDate: description: Conditional. Required for search by member data or provider TIN. Maximum 90 day range. example: 01/01/2025 type: string serviceEndDate: description: Conditional. Required for search by member data or provider TIN. Maximum 90 day range. example: 10/01/2025 type: string payerId: description: Required. Unique identifier assigned to a health insurance payer. example: '87726' type: string required: - payerId searchClaimTicketInput: type: object properties: ticketNumber: description: Required (one-of). Provide to search by existing Ticket number. example: '840868613' type: string ticketType: description: 'Required. Type of rework ticket: Pend, Recon, or Appeal.' example: RECON type: string ticketFromDate: description: Required (one-of) with ticketToDate. Provide both to search by date range. Maximum 30 day range. example: '2020-07-27' type: string ticketToDate: description: Required (one-of) with ticketFromDate. Provide both to search by date range. Maximum 30 day range. example: '2020-08-27' type: string payerId: description: Required. Unique identifier assigned to a health insurance payer. example: '87726' type: string required: - ticketType - payerId search277CAInput: type: object properties: transactionId: description: Required. To retrieve 277 claim acknowledgement by transactionId (returned from claim submission API). example: '123456789' type: string payerId: description: Required. Unique identifier assigned to a health insurance payer. example: '87726' type: string required: - transactionId - payerId claimLineActionInput: type: object properties: claimActionIdentifier: description: Required. Identifier returned in SearchClaim operation. example: '840868613' type: string lineKeys: description: Required. Service line identifier(s) returned in SearchClaim operation. example: - '1' - '2' - '5' items: type: string type: array payerId: description: Required. Unique identifier assigned to a health insurance payer. example: '87726' type: string required: - payerId - lineKeys - claimActionIdentifier documentInput: type: object properties: documentId: description: Required. Unique document identifier returned in SearchClaim or SearchClaimTicket operation. example: 5e63205d-9517-4043-9231-ea1a47fb6c07~repoid~fdsid~cloudspaceid type: string payerId: description: Required. Unique identifier assigned to a health insurance payer. example: '87726' type: string required: - documentId - payerId type: object required: - query - variables examples: SearchClaim: summary: Search Claim value: operationName: SearchClaim query: 'query SearchClaim($searchClaimInput: SearchClaimInput!) { searchClaim(searchClaimInput: $searchClaimInput) { claims { claimNumber claimReceiptLocatorNumber claimInventoryControlNumber claimStatus isMedicarePendProcess hasClaimDetails member { subscriberId policyNumber firstName lastName middleInitial dateOfBirth relationshipCode dependentSequenceNumber memberId } provider { submitted { billingTin billingProviderName billingNpi renderingProviderName } adjudicated { billingTinPrefix billingTin billingTinSuffix billingProviderName billingNpi billingProviderMpin renderingProviderName renderingProviderMpin } } claimEvents { receivedDate processedDate processedTime serviceStartDate serviceEndDate statusEffectiveDate } claimLevelInfo { patientAccountNumber claimType providerNetworkStatus claimFlagTag surpriseMedicalBillingIndicator surpriseMedicalBillingState } claimLevelTotalAmount { totalBilledChargeAmount totalProviderWriteOffAmount totalPatientNotCoveredAmount totalProviderNotCoveredAmount totalAllowedAmount totaldeductibleAmount totalCopayAmount totalCoinsAmount totalPaidAmount totalPatientResponsibilityAmount } payments { paymentNumber adjudicatedClaimPaymentNumber adjudicatedClaimPaymentAmount checkSeriesDesignator paymentModeCode paymentAmount paymentIssueDate claimPayeeAssignmentCode payeeName payeeAddress { addressLine cityName state zip } } claimStatusCrosswalkData { claim507Code claim507CodeDesc claim508Code claim508CodeDesc adjudicatedClaimSuffixCode adjudicatedClaimPaymentNumber } claimAdjudicationCodes { claimCodeType code description } documents { documentType documentCreatedDate documentReceivedDate documentName documentId } claimDetailedInformation { claimNumber adjudicatedClaimSummaryStatus claimActionIdentifier allowedActions payerId coordinationOfBenefits { cobPayerId claimOIPaidAmount otherInsuredName submittedCobIndicator cobPayerType cobDesc cobPolicyDesc cobPaymentType adjudicatedCobIndicator cobMedicalCalcType cobCommercialCalcType } diagnosisCodes { diagnosisSequenceNumber diagnosisCode diagnosisCodeType } claimDetailEvents { receivedDate initialDecisionDate lastDenialDate } claimLevelIndicators { claimReprocessedIndicator paymentToEnrolleeCode isCapitationIndicator electronicPayerID placeOfService payerType } patientInfo { patientName patientGroupNumber patientSubscriberNumber patientRelationship } claimLineActions { ticketType allowedAction actionMessage allowedReconReasons allowedReconsiderationReasons { isAttachmentRequired requestReason requestReasonDesc requestReasonMsg } requiredConsentForm note documentLink ticketDetails { ticketNumber ticketSubmitDate ticketStatus ticketOutcome ticketReason isClosed lastUpdatedDate lastComment ticketType } } lines { lineKey lineNumber unitCount serviceCode revenueCode linePaymentServiceCode procedureCode procedureTypeCode modifiers diagnosisPointers lineEvents { processedDate processedTime serviceStartDate serviceEndDate } lineLevelTotalAmounts { billedChargeAmount notCoveredAmount providerNotCoveredAmount patientNotCoveredAmount providerWriteOffAmount allowedAmount deductibleAmount copayAmount coinsuranceAmount paidAmount memberResponsiblityAmount medicarePaidAmount reserveAmount qualifiedPaymentAmount } lineIndicators { inventoryControlNumberSuffix inventoryControlNumberSuffixVersion providerNetworkStatus transactionCode causeCode overrideCode planCoveragePercent capitationIndicator capFundType lineLevelPlaceOfService surpriseMedicalBillingIndicator surpriseMedicalBillingState providerGroupOfferPercentage } lineAdjudicationCodes { type code description } } } } pagination { hasMoreRecords nextPageToken } } }' variables: searchClaimInput: claimNumber: '1234567890' patientAccountNumber: '1234567890' memberId: '1234567890' memberFirstName: John memberLastName: Cena memberDateOfBirth: 10/1/1975 memberPolicy: 002781 serviceStartDate: 01/01/2025 serviceEndDate: 10/01/2025 payerId: '87726' SearchClaimTicket: summary: Search Claim Ticket value: operationName: SearchClaimTicket query: 'query SearchClaimTicket($searchClaimTicketInput: SearchClaimTicketInput!) { searchClaimTicket(searchClaimTicketInput: $searchClaimTicketInput) { ticketDetails { ticketNumber ticketSubmitDate ticketStatus ticketOutcome ticketReason isClosed lastUpdatedDate lastComment ticketType } comments { addedBy addedOn comment } claimInfo { claimNumber isOwedAmountUnknown claimAmountOwed totalBilledChargedAmount claimStatus serviceStartDate patientAccountNumber claimType inventoryControlNumber } member { subscriberId policyNumber firstName lastName middleInitial dateOfBirth relationshipCode dependentSequenceNumber memberId } provider { submitted { billingTin billingProviderName billingNpi renderingProviderName } adjudicated { billingTinPrefix billingTin billingTinSuffix billingProviderName billingNpi billingProviderMpin renderingProviderName renderingProviderMpin } } operatorInfo { name emailId phoneNumber } payerInfo { payerId payerName } attachmentList { ticketNumber ticketType fileName reportTypeCode reportTypeDesc documentId } } }' variables: searchClaimTicketInput: ticketNumber: TICK123456 ticketType: RECON ticketFromDate: '2023-01-01' ticketToDate: '2023-12-31' payerId: '87726' Search277CA: summary: Search Claim 277CA value: operationName: Search277CA query: 'query Search277CA($search277CAInput: Search277CAInput!) { search277CA(search277CAInput: $search277CAInput) { responseType x12ResponseData statuscode message } }' variables: search277CAInput: transactionId: '123456789' payerId: '87726' GetClaimLineAction: summary: Get Claim Line Action value: operationName: GetClaimLineAction query: 'query GetClaimLineAction($claimLineActionInput: ClaimLineActionInput!) { getClaimLineAction(claimLineActionInput: $claimLineActionInput) { claimLineActions { ticketType allowedAction actionMessage allowedReconReasons allowedReconsiderationReasons { isAttachmentRequired requestReason requestReasonDesc requestReasonMsg } requiredConsentForm note documentLink ticketDetails { ticketNumber ticketSubmitDate ticketStatus ticketOutcome ticketReason isClosed lastUpdatedDate lastComment ticketType } } } }' variables: claimLineActionInput: claimActionIdentifier: '840868613' lineKeys: - '1' - '2' - '5' payerId: '87726' GetDocument: summary: Get Document value: operationName: GetDocument query: 'query GetDocument($documentInput: DocumentInput!) { getDocument(documentInput: $documentInput) { base64Document } }' variables: documentInput: documentId: 5e63205d-9517-4043-9231-ea1a47fb6c07~repoid~fdsid~cloudspaceid payerId: '87726' required: true responses: '200': content: application/json: examples: SearchClaim: summary: Search Claim Response value: data: searchClaim: claims: - claimNumber: AB123456789 claimReceiptLocatorNumber: '9322320112345' claimInventoryControlNumber: FE12345678 claimStatus: Finalized isMedicarePendProcess: false hasClaimDetails: true member: subscriberId: 0536219151 policyNumber: '911302' firstName: John lastName: Cena middleInitial: null dateOfBirth: 09/16/1965 relationshipCode: null dependentSequenceNumber: null memberId: null provider: submitted: billingTin: '12345678' billingProviderName: Test SPECIALTY billingNpi: '1043382302' renderingProviderName: Test SPECIALTY adjudicated: billingTinPrefix: '2' billingTin: '12345678' billingTinSuffix: '00003' billingProviderName: ;Test SPECIALTY billingNpi: billingNpi billingProviderMpin: null renderingProviderName: Test SPECIALTY renderingProviderMpin: null claimEvents: receivedDate: 06/10/2025 processedDate: 06/25/2025 processedTime: 07.42.49 serviceStartDate: 06/01/2025 serviceEndDate: 06/01/2025 statusEffectiveDate: 06/27/2019 claimLevelInfo: patientAccountNumber: I-57258454 claimType: P providerNetworkStatus: I claimFlagTag: Y surpriseMedicalBillingIndicator: S surpriseMedicalBillingState: TX claimLevelTotalAmount: totalBilledChargeAmount: '1144.21' totalProviderWriteOffAmount: '137.31' totalPatientNotCoveredAmount: '0.00' totalProviderNotCoveredAmount: '0.00' totalAllowedAmount: '1006.90' totaldeductibleAmount: '0.00' totalCopayAmount: '0.00' totalCoinsAmount: '0.00' totalPaidAmount: '1006.90' totalPatientResponsibilityAmount: '0.00' payments: - paymentNumber: S5sadsadsa adjudicatedClaimPaymentNumber: null adjudicatedClaimPaymentAmount: '671.13' checkSeriesDesignator: '806' paymentModeCode: E paymentAmount: 10XXX.89 paymentIssueDate: 02/18/2025 claimPayeeAssignmentCode: P payeeName: XYZ HOSPITAL INC payeeAddress: addressLine: PO BOX 406152 cityName: ATLANTA state: GA zip: '303846152' claimStatusCrosswalkData: - claim507Code: F1 claim507CodeDesc: Finalized/Payment-The claim/line has been paid. claim508Code: '65' claim508CodeDesc: Claim/line has been paid. adjudicatedClaimSuffixCode: '01' adjudicatedClaimPaymentNumber: 0087637641 claimAdjudicationCodes: - claimCodeType: REMARK code: YL description: Benefits for this claim are based on the provider's contracted rate. documents: - documentType: Commercial/Detailed PRAs documentCreatedDate: 06/18/2025 documentReceivedDate: 06/18/2025 documentName: ABCD documentId: 5e63205d-9517-4043-9231-ea1a47fb6c07~repoid~fdsid~cloudspaceid claimDetailedInformation: claimNumber: AB123456789 adjudicatedClaimSummaryStatus: null claimActionIdentifier: 12345-123391-129910-1192010 allowedActions: 'true' payerId: '87726' coordinationOfBenefits: cobPayerId: '' claimOIPaidAmount: '' otherInsuredName: '' submittedCobIndicator: P cobPayerType: '' cobDesc: '' cobPolicyDesc: '' cobPaymentType: P adjudicatedCobIndicator: S cobMedicalCalcType: '612' cobCommercialCalcType: '612' diagnosisCodes: - diagnosisSequenceNumber: '1' diagnosisCode: R509 diagnosisCodeType: '0' claimDetailEvents: receivedDate: 06/04/2021 initialDecisionDate: 06/06/2021 lastDenialDate: 06/06/2021 claimLevelIndicators: claimReprocessedIndicator: N paymentToEnrolleeCode: N isCapitationIndicator: false electronicPayerID: UHNDCT placeOfService: '12' payerType: COM patientInfo: patientName: TestUser patientGroupNumber: ' patientGroupNumber -123' patientSubscriberNumber: ' patientSubscriberNumber-123' patientRelationship: EE claimLineActions: - ticketType: RECON allowedAction: Create actionMessage: disallowed action message allowedReconReasons: - RECON_REASON_1 - RECON_REASON_2 allowedReconsiderationReasons: null requiredConsentForm: AOR note: Consent form is required only when the appeal is submitted on behalf of member. documentLink: https://maelstrom-dmz-nonprod.uhcprovider.com/cdn/uhcp/documents/claims/appeal-messaging/WOL.pdf ticketDetails: - ticketNumber: '1234567890' ticketSubmitDate: 06/06/2021 ticketStatus: '' ticketOutcome: '' ticketReason: '' isClosed: false lastUpdatedDate: 07/27/2020 lastComment: '' ticketType: null lines: - lineKey: '1' lineNumber: '1' unitCount: '1' serviceCode: J0638 revenueCode: '' linePaymentServiceCode: J0638 procedureCode: J0638 procedureTypeCode: HC modifiers: - RT - '25' diagnosisPointers: - '1' - '0' - '0' - '0' lineEvents: processedDate: 06/06/2021 processedTime: 04.40.07 serviceStartDate: 06/01/2021 serviceEndDate: 06/01/2021 lineLevelTotalAmounts: billedChargeAmount: '20044.36' notCoveredAmount: '0.00' providerNotCoveredAmount: '0.00' patientNotCoveredAmount: '0.00' providerWriteOffAmount: '3758.32' allowedAmount: '16286.04' deductibleAmount: '0.00' copayAmount: '0.00' coinsuranceAmount: '0.00' paidAmount: '16286.04' memberResponsiblityAmount: '0.00' medicarePaidAmount: '0.00' reserveAmount: '0.00' qualifiedPaymentAmount: '0.00' lineIndicators: inventoryControlNumberSuffix: '01' inventoryControlNumberSuffixVersion: '1' providerNetworkStatus: I transactionCode: '00' causeCode: '0' overrideCode: '23' planCoveragePercent: '1.00' capitationIndicator: '' capFundType: '' lineLevelPlaceOfService: '12' surpriseMedicalBillingIndicator: S surpriseMedicalBillingState: TX providerGroupOfferPercentage: '1.00' lineAdjudicationCodes: - type: REMARK code: YL description: Benefits for this claim are based on the provider's contracted rate. pagination: hasMoreRecords: true nextPageToken: trwmem123451416167 SearchClaimTicket: summary: Search Claim Ticket Response value: data: searchClaimTicket: - ticketDetails: ticketNumber: AT-12345678 ticketSubmitDate: 03/01/2025 ticketStatus: Create ticketOutcome: The final outcome of the ticket ticketReason: The reason why the ticket was submitted. isClosed: false lastUpdatedDate: 09/01/2025 lastComment: The latest comments on the ticket. ticketType: RECON comments: - addedBy: '12344455' addedOn: 03/04/2025 comment: '' claimInfo: claimNumber: '12344455' isOwedAmountUnknown: false claimAmountOwed: '123.45' totalBilledChargedAmount: '46.00' claimStatus: F serviceStartDate: 06/01/2025 patientAccountNumber: I-57258454 claimType: P inventoryControlNumber: AB123456789 member: subscriberId: 0536219151 policyNumber: '911302' firstName: John lastName: Cena middleInitial: Doe dateOfBirth: 09/16/1965 relationshipCode: EE dependentSequenceNumber: '01' memberId: '483865773' provider: submitted: billingTin: '12345678' billingProviderName: Test SPECIALTY billingNpi: '1043382302' renderingProviderName: Test SPECIALTY adjudicated: billingTinPrefix: '2' billingTin: '12345678' billingTinSuffix: '00003' billingProviderName: Test SPECIALTY billingNpi: billingNpi billingProviderMpin: '73123456' renderingProviderName: Joe Cole renderingProviderMpin: '12345678' operatorInfo: name: Joe C Davis emailId: abcd@test.com phoneNumber: 999-999-9999 payerInfo: payerId: '87726' payerName: UnitedHealthcare attachmentList: - ticketNumber: AT-12345678 ticketType: RECON fileName: attachment.pdf reportTypeCode: M1 reportTypeDesc: Medical Record Attachment documentId: abcd-efgh-ijkl-mnop Search277CA: summary: Search 277CA Response value: data: search277CA: responseType: ACK x12ResponseData: ISA*00* *00* *ZZ*ABCDEFGHIJKLMNO*12*123456789012345*210101*1253*^*00501*000000905*0*T*:~GS*HN*123456789*987654321*20210101*1253*1*X*005010X279A1~ST*277*0001~BHT*0019*00*0123*20210101*1253*RP~HL*1**20*1~NM1*PR*2*PAYER NAME*****PI*12345~HL*2*1*21*1~NM1*41*2*SENDER NAME*****46*54321~HL*3*2*22*0~TRN*1*1234567890~STC*A1:19:PR~SE*10*0001~GE*1*1~IEA*1*000000905~ statuscode: '200' message: Transaction processed successfully GetClaimLineAction: summary: Get Claim Line Action Response value: data: getClaimLineAction: claimLineActions: - ticketType: RECON allowedAction: Create actionMessage: This insured member is covered under an AARP Supplemental Health Plan. For claim appeals or reconsiderations, use the claim address on the back of the insured member ID card. allowedReconReasons: - RECON_REASON_1 - RECON_REASON_2 allowedReconsiderationReasons: - isAttachmentRequired: 'Yes' requestReason: Medical Records Provided requestReasonDesc: Select this option to submit additional medical records requestReasonMsg: Attachments should include all requested documents - isAttachmentRequired: 'Yes' requestReason: Coordination of Benefits requestReasonDesc: Select this option for payment responsibility requestReasonMsg: Attachments should include the primary carriers EOB requiredConsentForm: null note: null documentLink: null ticketDetails: [] - ticketType: Appeal allowedAction: create actionMessage: disallowed action message allowedReconReasons: [] allowedReconsiderationReasons: [] requiredConsentForm: AOR note: Consent form is required only when the appeal is submitted on behalf of member. documentLink: https://maelstrom-dmz-nonprod.uhcprovider.com/cdn/uhcp/documents/claims/appeal-messaging/WOL.pdf ticketDetails: - ticketNumber: AT-12345678 ticketSubmitDate: 03/01/2025 ticketStatus: Create ticketOutcome: The final outcome of the ticket ticketReason: The reason why the ticket was submitted. isClosed: false lastUpdatedDate: 09/01/2025 lastComment: The latest comments on the ticket. ticketType: RECON GetDocument: summary: Get Document Response value: data: getDocument: base64Document: JVBERi0xLjQKJcfs... schema: type: object properties: data: type: object properties: searchClaimTicket: type: array items: $ref: '#/components/schemas/ClaimTicketSearchResponse' searchClaim: $ref: '#/components/schemas/ClaimSearchResponse' getDocument: $ref: '#/components/schemas/DocumentDownloadResponse' getClaimLineAction: $ref: '#/components/schemas/ClaimLineActionValidationResponse' search277CA: $ref: '#/components/schemas/ClaimAck277SearchResponse' errors: items: type: object properties: code: type: string description: Error code identifying the specific error description: type: string description: Detailed error message description: List of errors if occurred during Claim Inquiry type: array description: Successful operation '400': content: application/json: example: errors: - code: GRAPHQL_VALIDATION_FAILED description: Cannot query field... schema: type: object properties: errors: type: array items: type: object properties: code: type: string description: type: string description: Bad request '401': content: application/json: example: errors: - code: AUTH_FAILURE description: Invalid or expired token schema: type: object properties: errors: type: array items: type: object properties: code: type: string description: type: string description: Unauthorized '500': content: application/json: example: errors: - code: INTERNAL_SERVER_ERROR description: An unexpected error occurred. schema: type: object properties: errors: type: array items: type: object properties: code: type: string description: type: string description: Internal server error components: schemas: ClaimSearchResponse: type: object properties: claims: description: Full claim information including summary and details items: $ref: '#/components/schemas/Claims' type: array pagination: description: Pagination details $ref: '#/components/schemas/Pagination' description: Search claim response. SearchClaimInputDTO: type: object properties: claimNumber: description: The payer assigned Original Document Control NumberInternal Control Number (DCNICN) assigned to this claim by the payer identified in the 2010BB loop of this claim (Payer to payer claim). This number would be received from a payer in a case where the payer had received the original claim and, for whatever reason, had asked the provider to resubmit the claim and had given the provider the payers claim identification number. In this case the payer is expecting the provider to give them back their (the payers) claim number so that the payer can match it in their adjudication system. By matching this number in the adjudication system, the payer knows this is not a duplicate claim. In simple terms this is the number that is assigned by the Claim Adjudication engine of the payer. example: '1234567890' type: string patientAccountNumber: description: This is the providers claim account number. Identifier used to track a claim from creation by the health care provider through payment. example: '1234567890' type: string memberId: description: This Identifier of the Member which is on the identity card. example: '1234567890' type: string memberFirstName: description: Member's first name example: John type: string memberLastName: description: Member's last name example: Cena type: string memberDateOfBirth: description: Member's date of birth example: 10/1/1975 type: string memberPolicy: description: The policyNumber is a unique identifier assigned to an insurance policy. It is used by insurance companies, healthcare providers, and billing systems to track and manage a specific policyholder’s coverage. example: 002781 type: string serviceStartDate: description: Identifies the starting (earliest) service date based on all of the claim service lines. Most commonly used on an inpatient facility claim where a patient stays multiple days. example: 01/01/2025 type: string serviceEndDate: description: Identifies the ending service date based on all of the claim service lines. Most commonly used on an inpatient facility claim where a patient stays multiple days. example: 10/01/2025 type: string payerId: description: payerId for the claim-unique identifier assigned to a health insurance payer. example: '87726' type: string description: SearchClaimInputDTO ClaimTicketSearchResponse: type: object properties: ticketDetails: description: Ticket details $ref: '#/components/schemas/TicketDetails' comments: description: List of comments associated with the ticket items: $ref: '#/components/schemas/ClaimTicketComment' type: array claimInfo: description: Claim information associated with the ticket $ref: '#/components/schemas/ClaimInfo' member: description: Member information associated with the ticket $ref: '#/components/schemas/Member' provider: description: Provider information associated with the ticket $ref: '#/components/schemas/Provider' operatorInfo: description: Operator information who created/updated the ticket $ref: '#/components/schemas/OperatorInfo' payerInfo: description: Payer information associated with the ticket $ref: '#/components/schemas/PayerInfo' attachmentList: description: List of attachments associated with the ticket items: $ref: '#/components/schemas/AttachmentList' type: array description: Search claim ticket response. SearchClaimTicketInputDTO: type: object properties: ticketNumber: description: The unique identifier for the ticket. example: TICK123456 type: string ticketType: description: The type of ticket. example: RECON type: string ticketFromDate: description: The start date for the ticket search range (YYYY-MM-DD). example: '2023-01-01' type: string ticketToDate: description: The end date for the ticket search range (YYYY-MM-DD). example: '2023-12-31' type: string payerId: description: payerId for the claim-unique identifier assigned to a health insurance payer. example: '87726' type: string description: SearchClaimTicketInputDTO ClaimAck277SearchResponse: type: object properties: responseType: description: Response type example: ACK type: string x12ResponseData: description: X12 response data example: ISA*00* *00* *ZZ*ABCDEFGHIJKLMNO*12*123456789012345*210101*1253*^*00501*000000905*0*T*:~GS*HN*123456789*987654321*20210101*1253*1*X*005010X279A1~ST*277*0001~BHT*0019*00*0123*20210101*1253*RP~HL*1**20*1~NM1*PR*2*PAYER NAME*****PI*12345~HL*2*1*21*1~NM1*41*2*SENDER NAME*****46*54321~HL*3*2*22*0~TRN*1*1234567890~STC*A1:19:PR~SE*10*0001~GE*1*1~IEA*1*000000905~ type: string statuscode: description: Status code example: '200' type: string message: description: Message example: Transaction processed successfully type: string description: Search 277CA response. Search277CAInputDTO: type: object properties: transactionId: description: The unique identifier for the transaction. example: '123456789' type: string payerId: description: payerId for the claim-unique identifier assigned to a health insurance payer. example: '87726' type: string description: Search277CAInputDTO ClaimLineActionValidationResponse: type: object properties: claimLineActions: description: Claim line actions items: $ref: '#/components/schemas/ClaimLineActions' type: array description: Claim line action response. ClaimLineActionInputDTO: type: object properties: claimActionIdentifier: description: The unique identifier for the claim action. example: '840868613' type: string lineKeys: description: The list of line keys. example: - '1' - '2' - '5' items: type: string type: array payerId: description: payerId for the claim-unique identifier assigned to a health insurance payer. example: '87726' type: string description: ClaimLineActionInputDTO DocumentDownloadResponse: type: object properties: base64Document: description: Base64 encoded document content. example: JVBERi0xLjQKJcfs... type: string description: DocumentDownloadResponse DocumentInputDTO: type: object properties: documentId: description: The unique identifier for the document. example: 5e63205d-9517-4043-9231-ea1a47fb6c07~repoid~fdsid~cloudspaceid type: string payerId: description: payerId for the claim-unique identifier assigned to a health insurance payer. example: '87726' type: string description: DocumentInputDTO ClaimLevelTotalAmount: type: object properties: totalBilledChargeAmount: description: Total Amount of all services submitted on the claim by the provider for services rendered. example: '1144.21' type: string totalProviderWriteOffAmount: description: Amount discounted from the claim requested amount due to contract agreements, Prompt Pay discounts, etc. example: '137.31' type: string totalPatientNotCoveredAmount: description: Breaks out the the total amount not covered for all services on the claim to the patient. example: '0.00' type: string totalProviderNotCoveredAmount: description: Breaks out the The total amount not covered for all services on the claim to the provider. example: '0.00' type: string totalAllowedAmount: description: The maximum amount determined by the payer as being allowable under the provisions of the contract prior to the determination of actual payment. example: '1006.90' type: string totaldeductibleAmount: description: The set amount a member pays for services until they reach a specified limit (usually defined on an annual basis). After the limit is reached, the members payment for services changes to a percentage of covered amount. This dollar amount is derived using the members benefit rules. The Members Benefits are determined based on their eligibility using the claim service date spans. This is the sum of the Deductible Line Amount for all service lines. example: '0.00' type: string totalCopayAmount: description: The sum of all service level copay amounts example: '0.00' type: string totalCoinsAmount: description: The total of the Benefit Coinsurance amount for all service lines. The Coinsurance amount (usually calculated as a percent of the providers submitted charges) the member pays for a specific service as defined in their benefit plan. For example, 80 of the cost of an outpatient physical therapy visit. This dollar amount is derived using the members benefit rules. The Members Benefits are determined based on their eligibility using the claim service date spans. example: '0.00' type: string totalPaidAmount: description: The actual amount paid to the provider or member for all the services performed after all deductions and calculations are performed. This does not include the amount calculated as fee for service on a capitated service. example: '1006.90' type: string totalPatientResponsibilityAmount: description: Required when the Patient Responsibility Amount is applicable to the claim. The amount applies to all service lines. example: '0.00' type: string description: ClaimLevelTotalAmount ClaimDetailEvent: type: object properties: receivedDate: description: The receivedDate refers to the date when the claim was officially received by the payer or claims system. It is a critical timestamp used to initiate the claim lifecycle. This date helps determine whether the claim was submitted within the allowable filing period and is used to calculate processing timelines and compliance metrics. It may differ from the service date or submission date, depending on when the claim was transmitted and logged. Accurate tracking of receivedDate ensures timely adjudication, supports audit trails, and helps in meeting regulatory and contractual obligations for claim handling. example: 06/04/2025 type: string initialDecisionDate: description: The initialDecisionDate refers to the date on which the first adjudication decision was made for a submitted claim. example: 06/06/2025 type: string lastDenialDate: description: The lastDenialDate refers to the most recent date on which the claim—or a specific line item within the claim—was denied by the payer. This date is crucial for tracking the claim’s adjudication history and managing follow-up actions such as appeals or reconsiderations. example: 06/06/2025 type: string description: ClaimDetailEvent ClaimLevelInformation: type: object properties: patientAccountNumber: description: This is the providers claim account number. Identifier used to track a claim from creation by the health care provider through payment. example: I-57258454 type: string claimType: description: Identifies the type of claim. e.g (I))Institutional (P)Professional example: P type: string providerNetworkStatus: description: A code that identifies if the Provider is in network, out of network. example: I type: string claimFlagTag: description: if Y indicates that flag tag code was applied for attachments example: Y type: string surpriseMedicalBillingIndicator: description: A code that will identify the level of authority that surprise medical billing will be applied whether at Federal (F) or State (S) Level. example: S type: string surpriseMedicalBillingState: description: A state code that will identify the level of authority that surprise medical billing will be applied. e.g. NJ, NY, SC, MN etc example: NY type: string description: ClaimLevelInformation Pagination: type: object properties: hasMoreRecords: description: Indicates if more results are available example: false type: boolean nextPageToken: description: Page identifier for pagination example: trwmem123451416167 type: string description: Pagination LineEvents: type: object properties: processedDate: description: The lineProcessedDate refers to the date on which a specific service line within a claim was adjudicated by the insurance company example: 06/06/2025 type: string processedTime: description: The lineProcessedTime refers to the time on which a specific service line within a claim was adjudicated by the insurance company example: 04.40.07 type: string serviceStartDate: description: 'The serviceStartDate refers to the first date on which a healthcare service was provided to the patient for a particular service line. It marks the beginning of the treatment or service period ' example: 06/01/2025 type: string serviceEndDate: description: The serviceEndDate refers to the last date on which a healthcare service was provided to the patient for a particular claim or service line. It marks the end of the treatment or service period, especially for services that span multiple days, such as inpatient stays, therapy sessions, or ongoing treatments example: 06/01/2025 type: string description: LineEvents PatientInfo: type: object properties: patientName: description: patientName refers to the full legal name of the individual who received the medical service or treatment. It typically includes the first name, last name, and sometimes middle name or initial. This field is essential for identifying the claim's beneficiary and ensuring accurate matching with patient records. example: John type: string patientGroupNumber: description: The patientGroupNumber refers to the unique identifier assigned to the group health insurance plan under which the patient is covered. This number is typically issued by the insurance provider to an employer or organization offering the group policy. It helps link the patient’s claim to the correct group benefits, coverage rules, and billing arrangements. The patientGroupNumber is essential for verifying eligibility, processing claims accurately, and ensuring the correct application of deductibles, copays, and coverage limits. It is usually found on the patient’s insurance card and is required for both electronic and paper claim submissions. example: TNEONX type: string patientSubscriberNumber: description: The patientSubscriberNumber is a unique identifier assigned to the primary policyholder—the person who holds the insurance plan. Even if the patient is a dependent (like a spouse or child), the claim is often linked to the subscriber’s number. This number is crucial for verifying coverage, processing claims, and coordinating benefits. It is typically found on the insurance card and used alongside the patientName and groupNumber to ensure accurate claim routing. In electronic data interchange (EDI), this field is often required to match the claim to the correct member record in the payer’s system. example: '992111233' type: string patientRelationship: description: The patientRelationship field indicates the relationship between the patient and the subscriber (the primary policyholder). This information is essential for determining eligibility, coordinating benefits, and processing claims correctly. example: EE type: string description: PatientInfo TicketDetails: type: object properties: ticketNumber: description: A ticket number is a unique identifier assigned to an Appeal, Reconsideration or Pending ticket. example: AT-12345678 type: string ticketSubmitDate: description: The date the ticket number was submitted. example: 03/01/2025 type: string ticketStatus: description: The status of the ticket. example: Create type: string ticketOutcome: description: The outcome of the ticket. example: The final outcome of the ticket type: string ticketReason: description: The reason why the ticket was submitted. example: The reason why the ticket was submitted. type: string isClosed: description: A flag which indicates if the ticket was closed or not. example: false type: boolean lastUpdatedDate: description: The latest date on which an update was made on the ticket. example: 09/01/2025 type: string lastComment: description: The latest comments on the ticket. example: The latest comments on the ticket. type: string ticketType: description: The type of ticket. example: RECON type: string description: TicketDetails Claims: type: object properties: claimNumber: description: The payer assigned Original Document Control NumberInternal Control Number (DCNICN) assigned to this claim by the payer identified in the 2010BB loop of this claim (Payer to payer claim). This number would be received from a payer in a case where the payer had received the original claim and, for whatever reason, had (1) asked the provider to resubmit the claim and (2) had given the provider the payers claim identification number. In this case the payer is expecting the provider to give them back their (the payers) claim number so that the payer can match it in their adjudication system. By matching this number in the adjudication system, the payer knows this is not a duplicate claim. In simple terms this is the number that is assigned by the Claim Adjudication engine of the payer. example: AB123456789 type: string claimReceiptLocatorNumber: description: A unique number that is assigned by the claim intake process for the purpose of identifying that the claim has been successfully received by UHG. This number is communicated back to the sender of the claim (Via HIPAA 277ACK) as well as passed down to the adjudication engine responsible to adjudicate the claim. For Paper claims this will be the DCC Number (document control center - where document was scanned). It is also known as Film Locator Number (FLN). example: '9322320112345' type: string claimInventoryControlNumber: description: An Inventory Control Number (ICN) is a unique identifier assigned to each claim as it enters the payer's system. It is used to track, manage, and audit the claim throughout its lifecycle — from submission to adjudication and payment. example: FE12345678 type: string claimStatus: description: The claimStatus indicates the current stage of a healthcare claim in the processing workflow. Common statuses include Acknowledged, In Review, Pending, Denied, Finalized, Misdirected, Multiple Status or Rejected. Each status provides insight into whether the claim is being reviewed, requires additional information, has been approved for payment, or has been denied. Accurate tracking of claimStatus helps providers follow up appropriately, ensures timely reimbursement, and supports transparency for patients. example: Finalized type: string isMedicarePendProcess: description: Indicates whether the claim is currently in a Medicare pend process. example: false type: boolean hasClaimDetails: description: Indicates if claim detailed information is available or not example: true type: boolean member: description: Member information $ref: '#/components/schemas/Member' provider: description: Provider $ref: '#/components/schemas/Provider' claimEvents: description: Claim events $ref: '#/components/schemas/ClaimEvents' claimLevelInfo: description: Claim level information $ref: '#/components/schemas/ClaimLevelInformation' claimLevelTotalAmount: description: Claim level total amount $ref: '#/components/schemas/ClaimLevelTotalAmount' payments: description: Claim payment information items: $ref: '#/components/schemas/ClaimPaymentInfo' type: array claimStatusCrosswalkData: description: Claim status cross walk data items: $ref: '#/components/schemas/ClaimStatusCrosswalkData' type: array claimAdjudicationCodes: description: Adjudication code type items: $ref: '#/components/schemas/AdjudicationCodeType' type: array documents: description: Documents items: $ref: '#/components/schemas/Documents' type: array claimDetailedInformation: description: Claim detailed information $ref: '#/components/schemas/ClaimDetailedInformation' description: Claims ClaimEvents: type: object properties: receivedDate: description: The receivedDate refers to the date when the claim was officially received by the payer or claims system. It is a critical timestamp used to initiate the claim lifecycle. This date helps determine whether the claim was submitted within the allowable filing period and is used to calculate processing timelines and compliance metrics. It may differ from the service date or submission date, depending on when the claim was transmitted and logged. Accurate tracking of receivedDate ensures timely adjudication, supports audit trails, and helps in meeting regulatory and contractual obligations for claim handling. example: 06/10/2025 type: string processedDate: description: Date of final adjudication or denial determination by Claim Payer. Sometimes used as a Paid ready. example: 06/25/2025 type: string processedTime: description: Time of final adjudication or denial determination by Claim Payer. Sometimes used as a Paid ready. example: 07.42.49 type: string serviceStartDate: description: Identifies the starting (earliest) service date based on all of the claim service lines. Most commonly used on an inpatient facility claim where a patient stays multiple days. example: 06/01/2025 type: string serviceEndDate: description: Identifies the ending service date based on all of the claim service lines. Most commonly used on an inpatient facility claim where a patient stays multiple days. example: 06/01/2025 type: string statusEffectiveDate: description: Effective date of the status of the Claim example: 06/27/2025 type: string description: ClaimEvents Documents: type: object properties: documentType: description: A type of document example: Commercial/Detailed PRAs type: string documentCreatedDate: description: The date when the document was created. example: 06/18/2025 type: string documentReceivedDate: description: The date when the document was received. example: 06/18/2025 type: string documentName: description: The name of the document. example: ABCD type: string documentId: description: A unique identifier for the document, typically a UUID or composite key. example: abcdef-aaaa-aaaa-aa-aaaa%ee-08_v4~repoid~fdsid~cloudspaceid type: string description: Documents ClaimLineActions: type: object properties: ticketType: description: Ticket Type example: RECON type: string allowedAction: description: Allowed actions example: Create type: string actionMessage: description: msg when allowedAction='Stop Process' example: This insured member is covered under an AARP Supplemental Health Plan. For claim appeals or reconsiderations, use the claim address on the back of the insured member ID card. type: string allowedReconReasons: description: List of allowed reasons for recon example: - RECON_REASON_1 - RECON_REASON_2 items: type: string type: array allowedReconsiderationReasons: description: List of allowed reconsideration reasons with attachment requirements items: $ref: '#/components/schemas/AllowedReconsiderationReason' type: array requiredConsentForm: description: Required Consent Form example: AOR type: string note: description: Notes example: Consent form is required only when the appeal is submitted on behalf of member. type: string documentLink: description: Document Link example: https://maelstrom-dmz-nonprod.uhcprovider.com/cdn/uhcp/documents/claims/appeal-messaging/WOL.pdf type: string ticketDetails: description: Ticket details items: $ref: '#/components/schemas/TicketDetails' type: array description: ClaimLineActions AllowedReconsiderationReason: type: object properties: isAttachmentRequired: description: Indicates if an attachment is required for this reconsideration reason example: 'Yes' type: string requestReason: description: The reconsideration request reason code example: Medical Records Provided type: string requestReasonDesc: description: Description of the reconsideration request reason example: Select this option to submit additional medical records type: string requestReasonMsg: description: Message providing additional guidance for the reconsideration reason example: Attachments should include all requested documents type: string description: AllowedReconsiderationReason SubmittedProviderInfo: type: object properties: billingTin: description: Identifies a Tax Identification number issued by the Internal Revenue Service. Payer uses this identifier in claims processing to identify who is accountable for tax reporting back to the Internal Revenue Service. This identification can be defined as a social security number or an algorithmic number assigned by the Internal Revenue Service (IRS). example: '12345678' type: string billingProviderName: description: Name of the billing provider example: Test SPECIALTY type: string billingNpi: description: Identifies the standard 10 digit identifier mandated by the HIPAA (Health Insurance Portability and Accountability Act). Healthcare Professional s can only have one while Healthcare Organizations can have multiple. example: '1043382302' type: string renderingProviderName: description: Name of the servicing provider example: Test SPECIALTY type: string description: SubmittedProviderInfo PayerInfo: type: object properties: payerId: description: The payer id of the health insurance company. example: '87726' type: string payerName: description: The name of the health insurance company. example: UnitedHealthcare type: string description: Payer information associated with the ticket ClaimLineType: type: object properties: lineKey: description: The lineKey typically refers to a unique identifier for a specific claim line within a claim. example: lrizy7ahqahdbt1752584225159 type: string lineNumber: description: The lineNumber is a sequential identifier used to distinguish individual claim lines within a single claim. example: '1' type: string unitCount: description: The term unitCount (or simply 'units') refers to the quantity of a service, procedure, or item provided to a patient on a specific date. example: '1' type: string serviceCode: description: The serviceCode is a standardized code used to identify the specific medical service, procedure, or item provided to a patient. example: J0638 type: string revenueCode: description: A revenueCode is a 4-digit code used primarily in institutional (facility) claims to indicate the type of service or department that provided the care. It helps categorize charges on a claim and links them to specific cost centers within a hospital or facility. example: '0121' type: string linePaymentServiceCode: description: The linePaymentServiceCode refers to the specific service code used to represent the adjudicated (finalized) payment decision for a particular service line within a claim. This code may differ from the originally submitted procedure code, especially if the payer adjusts or reclassifies the service during processing. example: '99214' type: string procedureCode: description: This entity stores the ICD procedure codes for the claim. Procedure codes are numbers or alphanumeric codes used to identify specific health interventions such as products, services or procedures taken by medical professional. example: J0638 type: string procedureTypeCode: description: procedureTypeCode identifies the coding system used for the procedure or service being billed. It helps payers interpret the procedure code correctly by specifying its source or classification. E.g. HCPCS (Healthcare Common Procedure Coding System) example: HC type: string modifiers: description: A modifierCode is used in claim adjudication to provide additional details about a healthcare service or procedure that was performed. It helps clarify how, why, or where the service was delivered, especially when it deviates from the standard definition of the procedure code. Modifier codes ensure accurate billing and reimbursement by indicating special circumstances such as bilateral procedures, reduced services, or separate components. For example, RT indicates the procedure was performed on the right side of the body, LT for the left side, and TC denotes the technical component of a diagnostic service. These codes enhance claim specificity and accuracy. example: RT items: type: string type: array diagnosisPointers: description: A diagnosis pointer is used in medical billing to link a diagnosis code to a specific procedure or service on a claim form. It helps insurance companies understand the medical reason for the service provided. example: - '1' - '2' - '' - '' items: type: string type: array lineEvents: description: Line events $ref: '#/components/schemas/LineEvents' lineLevelTotalAmounts: description: Line level total amounts $ref: '#/components/schemas/LineLevelTotalAmounts' lineIndicators: description: Line indicators $ref: '#/components/schemas/LineIndicators' lineAdjudicationCodes: description: Line Adjudication code types items: $ref: '#/components/schemas/LineAdjudicationCodeTypes' type: array description: ClaimLineType ClaimTicketComment: type: object properties: addedBy: description: The user who added the comments. example: '12344455' type: string addedOn: description: The date the comments were added. example: 03/04/2025 type: string comment: description: Field comment type: string description: ClaimTicketComment AttachmentList: type: object properties: ticketNumber: description: The type of ticket. example: AT-12345678 type: string ticketType: description: The type of ticket. example: RECON type: string fileName: description: The name of the file uploaded. example: attachment.pdf type: string reportTypeCode: description: The type of attachment that was uploaded. example: M1 type: string reportTypeDesc: description: The description of attachment that was uploaded. example: Medical Record Attachment type: string documentId: description: The document identifier which was was uploaded. example: abcd-efgh-ijkl-mnop type: string description: AttachmentList AdjudicationCodeType: type: object properties: claimCodeType: description: The type of code example: REMARK type: string code: description: Code value example: YL type: string description: description: Description of the code example: Benefits for this claim are based on the provider's contracted rate. type: string description: AdjudicationCodeType LineLevelTotalAmounts: type: object properties: billedChargeAmount: description: The dollar amount the provider requested to be reimbursed for the service they provided. Also known as the Submitted Service Charge Amount. Can be submitted on 1500 Paper claim form in field 24F UB04 Pare claim form in field 47 837P Loop 2400SV1 837I Loop 2400SV2 example: '20044.36' type: string notCoveredAmount: description: The notCoveredAmount refers to the portion of the billed charges that is not covered by the health plan and is therefore not eligible for reimbursement. This amount is typically the responsibility of the patient or may be written off by the provider, depending on contractual agreements. example: '10.00' type: string providerNotCoveredAmount: description: Breaks out the The service amount not covered to the provider. example: '10.00' type: string patientNotCoveredAmount: description: Breaks out the service amount not covered to the patient. example: '20.00' type: string providerWriteOffAmount: description: Amount discounted from the claimed amount due to contract agreement. This includes Prompt Pay discounts. example: '3758.32' type: string allowedAmount: description: The portion of submitted charges covered under plan benefits. This amount is after discounts and not coveredexcluded expenses, and before employee and member responsibility (e.g., benefit limitations, copay amounts, etc.). example: '16286.04' type: string deductibleAmount: description: The set amount a member pays for services until they reach a specified limit (usually defined on an annual basis). After the limit is reached, the members payment for services changes to a percentage of covered amount. This dollar amount is derived using the members benefit rules. The Members Benefits are determined based on their eligibility using the claim service date spans. example: '500.00' type: string copayAmount: description: The fixed amount the member pays for a specific service as defined in their benefit plan. For example, 10 for an office visit. This dollar amount is derived using the members benefit rules. The Members Benefits are determined based on their eligibility using the claim service date spans. example: '10.00' type: string coinsuranceAmount: description: The amount (usually calculated as a percent of the providers submitted charges) the member pays for a specific service as defined in their benefit plan. For example. 80% per of the cost of an outpatient physical therapy visit. This dollar amount is derived using the members benefit rules. The Members Benefits are determined based on their eligibility using the claim service date spans. example: '0.00' type: string paidAmount: description: The actual amount paid to the provider for the service performed after all deductions and calculations are performed. This does not include the amount calculated as fee for service on a capitated service. example: '16286.04' type: string memberResponsiblityAmount: description: Member Responsibility amount is the sum of the various types of detail amounts that are coded as member responsible. Some of the detail amount types are Benefit amounts (deductible, copay, etc.) - Non-allowed amounts that the member is responsible for - Non-covered amounts that the member is responsible for - Etc. example: '0.00' type: string medicarePaidAmount: description: The amount that Medicare has agreed to pay for the service. example: '0.00' type: string reserveAmount: description: The reserveAmount refers to the estimated amount of money set aside by a payer (such as an insurance company) to cover the expected payment for a claim or group of claims. It acts as a financial placeholder until the claim is fully processed and finalized. This amount ensures that funds are available for future disbursement and may be adjusted as more information becomes available. In some cases, reserveAmount may also represent a withhold amount—a portion of the payment temporarily held back for administrative or contractual reasons, such as risk-sharing arrangements or performance-based incentives. example: '0.00' type: string qualifiedPaymentAmount: description: Qualified payment amount is a calulated amount to support surprise billing. It is term specific to UHG and will be published to the providers remittance advice. e.g. (Submitted amount - Pricing Amount) = Basis for Deductible - Provider Payout Amount = Qualified Payment Amount (100.00 - 75.00) = 25.00 - 70.00 = 45.00 example: '0.00' type: string description: LineLevelTotalAmounts ClaimInfo: type: object properties: claimNumber: description: Field claimNumber example: '12344455' type: string isOwedAmountUnknown: description: A boolean field and is set to true or false if the Owed Amount is not known to the user. example: false type: boolean claimAmountOwed: description: The total amount owed. example: '123.45' type: string totalBilledChargedAmount: description: The total amount a healthcare provider charges for all services or items listed on a claim. example: '46.00' type: string claimStatus: description: The status of the claim. example: F type: string serviceStartDate: description: The earliest date on which a claimed service was delivered, based on all the claim service lines. example: 06/01/2025 type: string patientAccountNumber: description: Patient's account number example: I-57258454 type: string claimType: description: Indicates Facility or professional code example: P type: string inventoryControlNumber: description: An Inventory Control Number (ICN) is a unique identifier assigned to each claim as it enters the payer’s system. It is used to track, manage, and audit the claim throughout its lifecycle — from submission to adjudication and payment. example: AB123456789 type: string description: ClaimInfo AdjudicatedProviderInfo: type: object properties: billingTinPrefix: description: Prefix for the tax identification number example: '2' type: string billingTin: description: Identifies a Tax Identification number issued by the Internal Revenue Service. Payer uses this identifier in claims processing to identify who is accountable for tax reporting back to the Internal Revenue Service. This identification can be defined as a social security number or an algorithmic number assigned by the Internal Revenue Service (IRS). example: '12345678' type: string billingTinSuffix: description: Suffix for the tax identification number example: '00003' type: string billingProviderName: description: Name of the billing provider example: Test SPECIALTY type: string billingNpi: description: Identifies the standard 10 digit identifier mandated by the HIPAA (Health Insurance Portability and Accountability Act). Healthcare Professional s can only have one while Healthcare Organizations can have multiple. example: billingNpi type: string billingProviderMpin: description: The UHC internal identifier for the billing provider. example: '73123456' type: string renderingProviderName: description: The rendering provider name. example: Joe Cole type: string renderingProviderMpin: description: The UHC internal identifier for the rendering provider. example: '12345678' type: string description: AdjudicatedProviderInfo PayeeAddressType: type: object properties: addressLine: description: Address line example: PO BOX 406152 type: string cityName: description: City name example: ATLANTA type: string state: description: State code example: GA type: string zip: description: ZIP code example: '303846152' type: string description: PayeeAddressType LineAdjudicationCodeTypes: type: object properties: type: description: Type of code example: REMARK type: string code: description: Code value example: YL type: string description: description: Description of the code example: Benefits for this claim are based on the provider's contracted rate. type: string description: LineAdjudicationCodeTypes ClaimLevelIndicators: type: object properties: claimReprocessedIndicator: description: 'The claimReprocessedIndicator is a flag that indicates whether a claim has been reprocessed after its initial adjudication. ' example: N type: string paymentToEnrolleeCode: description: The paymentToEnrolleeCode is a code that indicates whether a payment was made directly to the enrollee (the insured individual) rather than to the healthcare provider example: N type: string isCapitationIndicator: description: The isCapitationIndicator is a Boolean flag that indicates whether the claim is associated with a capitated payment arrangement. example: false type: boolean electronicPayerID: description: The electronicPayerID is a unique identifier assigned to a health insurance payer (such as an insurance company or third-party administrator) for the purpose of electronic data interchange (EDI). example: '87726' type: string placeOfService: description: The placeOfService (POS) refers to a code that identifies the location where the medical service was provided. example: '12' type: string payerType: description: the payerType field identifies the category of the insurance provider responsible for processing the claim. It helps determine the applicable rules, coverage policies, and reimbursement methods. Common values include COM for commercial insurance (typically employer-sponsored or private plans), MDR for Medicare (a federal program for seniors and certain disabled individuals), and MCD for Medicaid (a state-administered program for low-income individuals and families). This classification is essential for routing claims correctly, applying the right adjudication logic, and coordinating benefits when multiple payers are involved. example: COM type: string description: ClaimLevelIndicators DiagnosisCodeType: type: object properties: diagnosisSequenceNumber: description: The diagnosisSequenceNumber refers to the order in which a diagnosis is listed or prioritized in a medical record or claim. In healthcare data, multiple diagnoses may be associated with a patient encounter, and this field helps identify the primary diagnosis (usually sequence 1) and any secondary or supporting diagnoses (sequence 2, 3, etc.). This sequencing is important for billing, clinical documentation, and analytics, as it indicates the relative importance or relevance of each diagnosis to the treatment provided. A lower sequence number typically means higher clinical or financial significance in the context of the patient’s care. example: '1' type: string diagnosisCode: description: The diagnosisCode is a standardized alphanumeric code used in healthcare to identify a specific medical condition, disease, or diagnosis. These codes are typically based on classification systems like ICD-10-CM (International Classification of Diseases, 10th Revision, Clinical Modification). Each diagnosis code corresponds to a particular health issue and is used in clinical documentation, billing, insurance claims, and data analysis. For example, the code E11.9 represents Type 2 diabetes mellitus without complications. Accurate use of diagnosis codes ensures proper treatment tracking, reimbursement, and reporting. They are essential for maintaining consistency and clarity across healthcare systems and provider. example: R509 type: string diagnosisCodeType: description: The diagnosisCodeType refers to the classification system used to assign a diagnosis code in healthcare data. It identifies the coding standard applied, such as value 0 indicates ICD-10-CM (International Classification of Diseases, 10th Revision, Clinical Modification) vs 9 as ICD-9-CM (9th Revision). example: '0' type: string description: DiagnosisCodeType ClaimDetailedInformation: type: object properties: claimNumber: description: The payer assigned Original Document Control NumberInternal Control Number (DCNICN) assigned to this claim by the payer identified in the 2010BB loop of this claim (Payer to payer claim). This number would be received from a payer in a case where the payer had received the original claim and, for whatever reason, had (1) asked the provider to resubmit the claim and (2) had given the provider the payers claim identification number. In this case the payer is expecting the provider to give them back their (the payers) claim number so that the payer can match it in their adjudication system. By matching this number in the adjudication system, the payer knows this is not a duplicate claim. In simple terms this is the number that is assigned by the Claim Adjudication engine of the payer. example: AB123456789 type: string adjudicatedClaimSummaryStatus: description: ' AI generated claim sumamry message detailing denial reasons and suggested next steps.' example: 'Denial Reason: Filing Time Limit Has Expired We are unable to process payment because the deadline to file this claim has elapsed.' type: string claimActionIdentifier: description: The claimActionIdentifier is typically a unique reference or token associated with a specific claim that enables authorized users or systems to perform actions on that claim, such as Pend – Temporarily hold the claim for further review or missing information. Recon (Reconsideration) – Request a re-evaluation of the claim decision. Appeal – Formally dispute a denied or partially paid claim. example: 12345-123391-129910-1192010 type: string allowedActions: description: The allowedActions flag is typically a Boolean indicator (true or false) that tells whether any user-initiated actions are currently permitted on a given claim. example: 'true' type: string payerId: description: payerId (derived) for the claim-unique identifier assigned to a health insurance payer. example: '87726' type: string coordinationOfBenefits: description: Cob information type $ref: '#/components/schemas/CobInfoType' diagnosisCodes: description: Diagnosis codes type items: $ref: '#/components/schemas/DiagnosisCodeType' type: array claimDetailEvents: description: Claim detail event $ref: '#/components/schemas/ClaimDetailEvent' claimLevelIndicators: description: Claim level indicators $ref: '#/components/schemas/ClaimLevelIndicators' patientInfo: description: Patient information $ref: '#/components/schemas/PatientInfo' claimLineActions: description: Claim line actions items: $ref: '#/components/schemas/ClaimLineActions' type: array lines: description: Claim line type items: $ref: '#/components/schemas/ClaimLineType' type: array description: ClaimDetailedInformation Member: type: object properties: subscriberId: description: Identifies the source specific identifier of the Subscriber. The person responsible for payment of premiums, or whose employment is the basis for eligibility for membership in a Health insurance plan. example: 0536219151 type: string policyNumber: description: The policyNumber is a unique identifier assigned to an insurance policy. It is used by insurance companies, healthcare providers, and billing systems to track and manage a specific policyholder’s coverage. example: '911302' type: string firstName: description: Member's first name example: John type: string lastName: description: Member's last name example: Cena type: string middleInitial: description: Member's middle initial example: Doe type: string dateOfBirth: description: Member's date of birth example: 09/16/1965 type: string relationshipCode: description: Relationship Code example: EE type: string dependentSequenceNumber: description: The dependent sequence number example: '01' type: string memberId: description: The member identifier example: '483865773' type: string description: Member ClaimPaymentInfo: type: object properties: paymentNumber: description: paymentNumber is a unique identifier assigned to a specific payment issued for a healthcare claim. It can represent various payment types, including a check, Electronic Funds Transfer (EFT), Virtual Card Payment (VCP), or even a zero-dollar check (used for explanation of benefits without actual funds). This number is crucial for tracking and reconciling payments across systems. It links the adjudicated claim to the financial transaction, enabling providers and payers to audit, verify, and resolve payment issues. Even when no money is transferred, a paymentNumber ensures transparency and traceability in the claim settlement process. example: TZ12341212 type: string adjudicatedClaimPaymentNumber: description: adjudicatedClaimPaymentNumber is an internal identifier assigned by the claim adjudication engine to uniquely track a specific payment instance for a claim. This number is especially important when a claim is split into multiple parts or processed in multiple cycles (e.g., adjustments, reprocessing, or partial payments). Each adjudicated portion receives a distinct payment number, allowing systems to trace the exact adjudication event and its associated payment. Also known as a draft Number. example: '32112121221' type: string adjudicatedClaimPaymentAmount: description: The adjudicatedClaimPaymentAmount refers to the final dollar amount paid by the payer after a healthcare claim has been fully processed (adjudicated). This amount reflects the outcome of the claim review, including adjustments for allowed charges, deductibles, co-pays, coinsurance, and any denials. It represents what the payer has agreed to pay the provider or member, and may differ from the billed amount. example: '671.13' type: string checkSeriesDesignator: description: The payment system designator code, could be same or different than the check series designator. example: '806' type: string paymentModeCode: description: The mode of payment like Electronic Fund Transfer or Virtual Card Payment or Paper Check. example: E type: string paymentAmount: description: The paymentAmount refers to the total dollar value of a payment issued to a provider or member, covering one or more adjudicated claims. This amount may be disbursed through various methods such as check, Electronic Funds Transfer (EFT), Virtual Card Payment (VCP), or even a zero-dollar payment (used for explanation of benefits without funds). It represents the aggregate reimbursement tied to a specific paymentNumber, which helps in tracking and reconciling payments across multiple claims. This field is essential for financial reporting, auditing, and ensuring that all claims included in the payment batch are properly accounted for. example: '109999.89' type: string paymentIssueDate: description: paymentIssueDate is the date on which a payment—via check, Electronic Funds Transfer (EFT), or Virtual Card Payment (VCP)—was officially issued by the payer. This date marks when the funds were released or made available to the provider or member. It is critical for tracking payment timelines, reconciling accounts, and determining interest or late payment penalties. Even for zero-dollar payments (used for explanation of benefits without actual funds), the paymentIssueDate provides a reference point for when the adjudication was finalized and communicated. example: 02/18/2025 type: string claimPayeeAssignmentCode: description: The claimPayeeAssignmentCode is a code used in healthcare claims processing to indicate who the payment is assigned to—typically either the provider or the member (patient) or a special payee as well like the state. example: P type: string payeeName: description: payeeName refers to the individual or entity receiving the payment for a healthcare claim. This could be a provider (such as a hospital, clinic, or physician), a billing agency, or the insured member (patient), depending on the claim’s assignment of benefits. example: XYZ HOSPITAL INC type: string payeeAddress: description: Payee address type $ref: '#/components/schemas/PayeeAddressType' description: ClaimPaymentInfo Provider: type: object properties: submitted: description: Submitted provider information $ref: '#/components/schemas/SubmittedProviderInfo' adjudicated: description: Adjudicated provider info $ref: '#/components/schemas/AdjudicatedProviderInfo' description: Provider ClaimStatusCrosswalkData: type: object properties: claim507Code: description: laim507Code is part of the X12 EDI standard and represents a Claim Status Category Code used to group related claim status codes (from code set 508). These codes help categorize the status of a healthcare claim during electronic inquiries and responses (like the 276/277 transactions). For example, they indicate whether a claim is acknowledged, in process, paid, denied, or requires more information. Code 507 itself is not a specific status but a category identifier used to organize and interpret claim status messages efficiently in automated systems. example: F1 type: string claim507CodeDesc: description: Description of claim 507 code example: Finalized/Payment-The claim/line has been paid. type: string claim508Code: description: claim508Code is a standardized code used to communicate the specific status of a healthcare claim in electronic transactions. It falls under the X12 EDI standard and works in conjunction with claim507Code, which provides a broader status category. While claim507Code might indicate a general status like “Acknowledged” or “Denied,” the claim508Code gives a more detailed explanation—such as “Missing Information,” “Invalid Procedure Code,” or “Duplicate Claim.” These codes are essential for providers and payers to track, troubleshoot, and resolve claims efficiently. example: '65' type: string claim508CodeDesc: description: Description of claim 508 code example: Claim/line has been paid. type: string adjudicatedClaimSuffixCode: description: adjudicatedClaimSuffixCode is a field used in healthcare claims processing to differentiate between multiple adjudicated instances of the same claim in case the claim has been split by the claim adjudication engine. example: '01' type: string adjudicatedClaimPaymentNumber: description: adjudicatedClaimPaymentNumber is an internal identifier assigned by the claim adjudication engine to uniquely track a specific payment instance for a claim. This number is especially important when a claim is split into multiple parts or processed in multiple cycles (e.g., adjustments, reprocessing, or partial payments). Each adjudicated portion receives a distinct payment number, allowing systems to trace the exact adjudication event and its associated payment. Also known as a draft Number. example: 0087637641 type: string description: ClaimStatusCrosswalkData CobInfoType: type: object properties: cobPayerId: description: COB Payer ID refers to the Coordination of Benefits (COB) Payer Identifier or the payer id of the other Insurance Company the member is covered. example: LIFE1 type: string claimOIPaidAmount: description: The claimOIPaidAmount refers to the amount paid by another insurance provider (Other Insurance) in a Coordination of Benefits (COB) scenario. When a patient has multiple insurance plans, the primary insurer pays first, and the secondary (or tertiary) insurer may cover remaining costs. The claimOIPaidAmount captures how much the secondary insurer has paid toward the claim. This value is essential for accurate claims processing, ensuring providers are reimbursed correctly and patients are not overcharged. It helps prevent duplicate payments and supports proper financial reconciliation between insurers involved in the claim. example: '25.00' type: string otherInsuredName: description: The otherInsuredName refers to the name of an individual who holds another insurance policy that may provide coverage for the patient. This is commonly used in Coordination of Benefits (COB) scenarios, where a patient is covered by more than one insurance plan. The otherInsuredName field helps identify the policyholder of the secondary or tertiary insurance—often a spouse, parent, or guardian. Accurate entry of this information ensures proper routing and processing of claims between insurers. It is essential for determining the order of benefit payments and avoiding duplicate or incorrect reimbursements. example: XYZ Health Insurance type: string submittedCobIndicator: description: The submittedCobIndicator is a flag or field used in healthcare claims processing to indicate whether a Coordination of Benefits (COB) claim has been submitted. It helps payers understand if the claim involves multiple insurance coverages and whether the primary, secondary, or tertiary payer has already processed the claim. example: P type: string cobPayerType: description: cobPayerType refers to the classification of the payer's role in a Coordination of Benefits (COB) scenario—essentially identifying whether the payer is commercial, medicare or medicaid. example: COM type: string cobDesc: description: cobDesc typically stands for Coordination of Benefits Description in healthcare or insurance claims. It provides a textual explanation or label for the type of COB arrangement or payer involved in a claim. type: string cobPolicyDesc: description: cobPolicyDesc stands for Coordination of Benefits Policy Description. It provides a textual explanation or label describing the type or nature of the other insurance policy involved in a COB scenario. type: string cobPaymentType: description: cobPaymentType refers to the method or classification of payment made by another insurance provider in a Coordination of Benefits (COB) scenario. It helps define how the secondary or tertiary payer contributed to the claim. type: string adjudicatedCobIndicator: description: Identifies the level of payment responsibility determined by the payer that adjudicated the specific instance of the claim. e.g Primary Secondary example: S type: string cobMedicalCalcType: description: The term cobMedicalCalcType is not widely standardized across all healthcare systems, but based on naming conventions and usage in claims processing, it likely refers to the method or formula used to calculate the Coordination of Benefits (COB) payment for medical claims. example: '612' type: string cobCommercialCalcType: description: The cobCommercialCalcType describes the method a commercial insurance company uses to calculate its share of payment in a Coordination of Benefits (COB) scenario. This field helps determine how much the commercial payer owes after the primary insurer has paid. Calculation types may include methods like “standard COB,” “non-duplication,” or “maintenance of benefits,” each with different rules for how payments are coordinated. This ensures accurate reimbursement, prevents overpayments, and aligns with payer-specific policies. Understanding this field is essential for claims processors to apply the correct logic when multiple insurers are involved. example: '612' type: string description: CobInfoType LineIndicators: type: object properties: inventoryControlNumberSuffix: description: An Inventory Control Number (ICN) is a unique identifier assigned to each claim as it enters the payer’s system. It is used to track, manage, and audit the claim throughout its lifecycle — from submission to adjudication and payment. A ICN suffix refers to part of the claim if the claim is split for any reason. example: '01' type: string inventoryControlNumberSuffixVersion: description: An Inventory Control Number (ICN) is a unique identifier assigned to each claim as it enters the payer’s system. It is used to track, manage, and audit the claim throughout its lifecycle — from submission to adjudication and payment. A ICN suffix version refers to claim instance in case the claim is adjudicated multiple times during a given point of date and time. example: '1' type: string providerNetworkStatus: description: The providerNetworkStatus refers to the contractual relationship between the healthcare provider and the insurance payer at the time of service. It indicates whether the provider is in-network or out-of-network, which directly affects how the claim is processed and reimbursed. example: I type: string transactionCode: description: In claim adjudication, the transactionCode identifies the type of claim transaction being processed. It indicates whether the claim is an original submission, an adjustment to a previously processed claim, a void or cancellation, or a reversal. example: '00' type: string causeCode: description: A Benefit Cause Code in claim adjudication identifies the reason a healthcare claim is submitted. It explains the underlying cause for seeking benefits, such as illness, injury, accident, maternity, or preventive care. This code helps payers apply the correct adjudication rules, determine eligibility, and coordinate benefits. For example, if the cause is an auto accident, the claim may be routed differently than one for preventive care. example: '0' type: string overrideCode: description: An override code is a special code used to bypass or override standard claim processing rules under specific, justified circumstances. These codes are typically used when a claim would otherwise be denied or flagged due to standard edits, but there is a valid reason to allow it. example: '23' type: string planCoveragePercent: description: The calculated percentage of the members responsibility twards the coinsurance example: '1.00' type: string capitationIndicator: description: If the service is capitated, this is the capitation indicator example: Y type: string capFundType: description: If the service is capitated, this is the capitation fund type code example: B type: string lineLevelPlaceOfService: description: The unique coder which identifies a clinical setting where a medical service is performed. example: '12' type: string surpriseMedicalBillingIndicator: description: A code that will identify if the surprise medical billing is applied. The surprise medical billing could be applied to the state (S) or federal(F) level. example: S type: string surpriseMedicalBillingState: description: A state code that will identify the level of authority that surprise medical billing will be applied. e.g. NJ, NY, SC, MN etc example: CA type: string providerGroupOfferPercentage: description: The percentage of the Qualifying Payment Amount (QPA) that a provider group is requesting or offering during the Independent Dispute Resolution (IDR) process. Also the percentage discount or negotiated reduction offered by a provider group (e.g., hospital system, physician network) off the total billed charges during the resolution of a surprise medical bill. example: '1.00' type: string description: LineIndicators OperatorInfo: type: object properties: name: description: The Name of the Operator. example: Joe C Davis type: string emailId: description: The email id of the Operator. example: abcd@test.com type: string phoneNumber: description: The phone number of the Operator. example: 999-999-9999 type: string description: Operator information who created/updated the ticket SearchClaimRequest: type: object properties: claimNumber: description: Required to retrieve claim summary and detail by unique claim number example: '1234567890' type: string patientAccountNumber: description: Required to retrieve claim summary/detail by Patient account number. example: '1234567890' type: string memberId: description: 'Required (one-of) with memberFirstName/memberLastName/memberDateOfBirth. Use for member data search. Supported combinations: Id+DoB / Id+Name / Name+DoB.' example: '1234567890' type: string memberFirstName: description: Required (one-of) with memberId/memberLastName/memberDateOfBirth. Use for member data search. example: John type: string memberLastName: description: Required (one-of) with memberId/memberFirstName/memberDateOfBirth. Use for member data search. example: Cena type: string memberDateOfBirth: description: Required (one-of) with memberId/memberFirstName/memberLastName. Use for member data search. example: 10/01/1975 type: string memberPolicy: description: Optional. The member's policy number. example: 002781 type: string serviceStartDate: description: Conditional. Required for search by member data or provider TIN. Maximum 90 day range. example: 01/01/2025 type: string serviceEndDate: description: Conditional. Required for search by member data or provider TIN. Maximum 90 day range. example: 10/01/2025 type: string payerId: description: Required. Unique identifier assigned to a health insurance payer. example: '87726' type: string required: - payerId description: SearchClaimInput SearchClaimTicketRequest: type: object properties: ticketNumber: description: Required (one-of). Provide to search by existing Ticket number. example: '840868613' type: string ticketType: description: 'Required. Type of rework ticket: Pend, Recon, or Appeal.' example: RECON type: string ticketFromDate: description: Required (one-of) with ticketToDate. Provide both to search by date range. Maximum 30 day range. example: '2020-07-27' type: string ticketToDate: description: Required (one-of) with ticketFromDate. Provide both to search by date range. Maximum 30 day range. example: '2020-08-27' type: string payerId: description: Required. Unique identifier assigned to a health insurance payer. example: '87726' type: string required: - ticketType - payerId description: SearchClaimTicketInput Search277CARequest: type: object properties: transactionId: description: Required. To retrieve 277 claim acknowledgement by transactionId (returned from claim submission API). example: '123456789' type: string payerId: description: Required. Unique identifier assigned to a health insurance payer. example: '87726' type: string required: - transactionId - payerId description: Search277CAInput GetClaimLineActionRequest: type: object properties: claimActionIdentifier: description: Required. Identifier returned in SearchClaim operation. example: '840868613' type: string lineKeys: description: Required. Service line identifier(s) returned in SearchClaim operation. example: - '1' - '2' - '5' items: type: string type: array payerId: description: Required. Unique identifier assigned to a health insurance payer. example: '87726' type: string required: - claimActionIdentifier - lineKeys - payerId description: ClaimLineActionInput GetDocumentRequest: type: object properties: documentId: description: Required. Unique document identifier returned in SearchClaim or SearchClaimTicket operation. example: 5e63205d-9517-4043-9231-ea1a47fb6c07~repoid~fdsid~cloudspaceid type: string payerId: description: Required. Unique identifier assigned to a health insurance payer. example: '87726' type: string required: - documentId - payerId description: DocumentInput securitySchemes: oAuth: type: oauth2 description: This API uses OAuth 2 with the client_credentials grant flow. flows: clientCredentials: tokenUrl: /apip/auth/sntl/v1/token scopes: read_txn: read transactions create_txn: submit a new transaction request read_coveragediscovery: read coverage discovery tasks create_coveragediscovery: submit a new coverage discovery task read_healthcheck: check the status of the system x-readme: explorer-enabled: true proxy-enabled: true