Institutional Claims JSON
Submit an 837I institutional claim in JSON format
/change/medicalnetwork/institutionalclaims/v1/submissionThis endpoint sends 837I institutional claims to payers.
- Call this endpoint with a JSON payload.
- Stedi translates your request to the X12 837 EDI format and sends it to the payer.
- The endpoint returns a response from Stedi in JSON format containing information about the claim you submitted and whether the submission was successful.
Visit Submit institutional claims for a full how-to guide.
A Stedi API Key for authentication.
Body
Information about the individual who has overall responsibility for the patient's medical care and treatment reported in the claim. This information is required when the claim contains any services other than non-scheduled transportation claims.
This provider should be an individual, not an organization, and you should supply at least the provider's lastName and an identifier, which is typically the npi.
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The first line of the street address. This typically contains the building number and street name.
The second line of the street address. This typically contains the apartment or suite number.
The city name.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
The postal zone or zip code. Exclude punctuation and spaces.
The state or province code. Only required when the city is in the Unites States and Canada.
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The email address.
The fax number.
The full name of the person or office.
The phone number, formatted as AAABBBCCCC, where AAA represents the area code, BBB is the telephone number prefix, and CCCC is the telephone number. The phone number should only include the digits 0 to 9. Don't include separators, such as dashes, and don't include long distance access numbers, such as 1. For example, you would format the phone number 123-456-7890 as 1234567890.
The provider's first name.
The provider's last name. This is required.
The provider's middle name or initial.
The individual National Provider Identifier (NPI) assigned to the provider.
The provider's business name.
This field is now automatically populated and it only remains for backwards compatibility.
The type of identifier used in secondaryIdentifier. Can be set to 0B - State License Number, 1G - Provider UPIN Number, G2 - Provider Commercial Number, or LU - Location Number. Note that UPIN is deprecated and should not be used.
0B1GG2LUThe identifier referenced by secondaryIdentificationQualifierCode. For example, if secondaryIdentificationQualifierCode is set to 0B, this property should be the provider's state license number.
You can only include one secondary identifier for the provider.
The provider's name suffix, such as Jr. or III.
The provider's taxnonomy code, a unique 10-character code that designates their classification and specialization. Only applies to the attending provider.
Information about the billing provider.
- You must include either the provider's Social Security Number (SSN) or their Employer Identification Number (EIN), but not both.
- The provider's National Provider Identifier (NPI) is required, if one is assigned.
- You must also supply the provider's
organizationName.
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The provider's address. This must be a physical practice location where care is delivered. If the billing provider receives mail at a PO Box, lockbox, or other non-physical address, you can provide that address in the billingPayToAddressName object.
For United States addresses, you must include the full nine-digit zip code with no separators, such as 100031502. If you don't know the full zip code, you can find it using the USPS ZIP Code Lookup tool.
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The first line of the street address. This typically contains the building number and street name.
The second line of the street address. This typically contains the apartment or suite number.
The city name.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
The postal zone or zip code. Exclude punctuation and spaces.
The state or province code. Only required when the city is in the Unites States and Canada.
The provider's contact information.You must include at least one communication method (phone, fax, or email) in this object.
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The email address.
The fax number.
The full name of the person or office.
The phone number, formatted as AAABBBCCCC, where AAA represents the area code, BBB is the telephone number prefix, and CCCC is the telephone number. The phone number should only include the digits 0 to 9. Don't include separators, such as dashes, and don't include long distance access numbers, such as 1. For example, you would format the phone number 123-456-7890 as 1234567890.
The provider's employer ID, also known as an EIN or TIN. Must be a string of exactly nine numbers with no separators.
The provider's first name.
The provider's last name.
The provider's middle name or initial.
The organization National Provider Identifier (NPI).
The provider's business name.
This field is now automatically populated and it only remains for backwards compatibility.
BillingProviderThe type of identifier used in secondaryIdentifier. Can be set to 0B - State License Number, 1G - Provider UPIN Number, G2 - Provider Commercial Number, or LU - Location Number. Note that UPIN is deprecated and should not be used.
0B1GG2LUThe identifier specified in secondaryIdentifierQualifierCode.
You can only include one secondary identifier for the provider.
The provider's suffix, such as Jr. or Sr.
The provider's taxnonomy code, a unique 10-character code that designates their classification and specialization.
Use when the address for payment is different than that of the billing provider for this claim.
This is also where you can provide the billing provider's mailing address when it's a PO Box, lockbox, or other non-physical address. The billing.address object must always contain a physical practice location where care is delivered.
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The address information.
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The first line of the street address. This typically contains the building number and street name.
The second line of the street address. This typically contains the apartment or suite number.
The city name.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
The postal zone or zip code. Exclude punctuation and spaces.
The state or province code. Only required when the city is in the Unites States and Canada.
Code identifying the type of entity. Can be set to 2 - Non-Person Entity.
2Use for subrogation payment requests. If you include this information, you must also set the claimInformation.otherSubscriberInformation.payerPaidAmount to the amount the payer (for example, Medicaid) actually paid.
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Specify the location of the named party.
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The first line of the street address. This typically contains the building number and street name.
The second line of the street address. This typically contains the apartment or suite number.
The city name.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
The postal zone or zip code. Exclude punctuation and spaces.
The state or province code. Only required when the city is in the Unites States and Canada.
The Claim Office Number.
The identification code specified by the identificationCodeQualifier.
The type of identification code used to identify the organization. Can be set to PI - Payer Identification or XV - Centers for Medicare and Medicaid Services PlanID. Use XV when reporting the Health Plan ID (HPID) or Other Entity Identifier (OEID).
PIXVThe National Association of Insurance Commisioners (NAIC) code. This is the five-digit identifier assigned to each insurance company.
The business name of the organization to which the payment should be made.
The payer identification number. Only include this information when the identificationCodeQualifier is set to XV - Centers for Medicare and Medicaid Services PlanID.
The payer tax identification number (TIN). This is a unique number assigned to the payer by the IRS.
A code specifying the type of transaction. Defaults to CH if not provided.
31: Only for use by state Medicaid agencies performing post payment recovery.CH: Use when the transaction contains only fee for service claims or claims with at least one chargeable line item. Also use when it's not clear whether a transaction contains claims or capitated encounters, or if the transaction contains a mix of claims and capitated encounters.RP: Use for capitated encounters. Also use when the transaction is being sent to an entity for purposes other than adjudication of a claim. For example, when you're sending the claim to a state health agency that is using the claim for health data reporting purposes.
31CHRPInformation about the healthcare claim. Note that the objects and properties marked as required are required for all claims, while others are conditionally required, depending on type of claim and claim circumstances. For example, you must always provide the claimChargeAmount, but you only need to provide the otherSubscriberInformation object in coordination of benefits scenarios. When you include a conditionally required object, you must provide all of its required properties.
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The diagnosis for which the patient sought medical care. This may be different from the principal diagnosis.
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The admitting diagnosis code for the patient.
- You must submit a valid, billable code at the highest level of specificity. Include the 4th - 7th characters as applicable.
- Don't submit the decimal point for ICD codes. The decimal point is implied.
- Don't submit ICD-10 header codes. Header codes exist to group related codes and aren't valid for billing. These header codes can change with each new version of ICD-10, so we recommend reviewing your diagnosis codes every year to ensure that they aren't classified as header codes in the most recent version. To determine whether a code is a header code, you can also search the Value Set Authority Center. If the 'Header' property is set, the code is a header code and you shouldn't use it in claim submissions.
Code identifying the type of admitting diagnosis code used. Can be set to ABJ - International Classification of Diseases Clinical Modification (ICD-10-CM) Admitting Diagnosis or BJ - International Classification of Diseases Clinical Modification (ICD-9-CM) Admitting Diagnosis. Note that ICD-9 is deprecated and cannot be used in new claims.
ABJBJA code indicating whether the patient or an authorized person has authorized the plan to remit payment directly to the provider. Use W when the patient refuses to assign benefits. Can be set to N - No (Payment should go to the patient), Y - Yes (Payment should go directly to the provider), or W - Not Applicable.
NWYTo communicate special instructions regarding claim billing. Required when the provider judges the information is needed to substantiate the medical treatment and cannot be provided elsewhere in the request.
The total dollar amount charged for the services on this claim, expressed as a decimal. For example, 100.50. This is the total amount before any adjustments or payments. The amount must balance to the sum of the service line charges.
Supply information specific to hospital claims, such as the priority of the admission.
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Code indicating the source of the admission.
The code indicating the priority of the admission.
Code indicating patient status as of the 'statement covers through date'.
Required when the submitter is contractually obligated to supply this information on post-adjudicated claims.
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^\d+(\.\d{1,2})?$The total dollar amount of the contract, expressed as a decimal. For example, 100.50.
The contract code. This is a unique identifier for the contract.
The allowance or charge percent, expressed as a decimal. For example, 0.80.
A code identifying the type of contract. Can be set to 01 - Diagnosis Related Group (DRG), 02 - Per Diem, 03 - Variable Per Diem, 04 - Flat, 05 - Capitated, 06 - Percent, or 09 - Other.
0102030405An additional identifer for the contract. Identifies the revision level of a particular format, program, technique or algorithm.
Terms discount percentage, expressed as a percent, available to the purchaser if an invoice is paid on or before the Terms Discount Due Date.
Dates and times related to the claim. For example, when the patient was discharged from the hospital.
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^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])([01]\d|2[0-3])[0-5]\d$|^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$When the patient was admitted to the hospital or facility. This property is required on inpatient claims. Can be expressed as a date and time (YYYYMMDDHHMM) or a single date (YYYYMMDD).
^([01]\d|2[0-3])[0-5]\d$The time the patient was discharged from the hospital or facility. This property is required on final inpatient claims. Can be expressed as a time in format HHMM.
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$The date the repricer received the claim. Required when a repricer is passing the claim onto the payer.
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$The beginning date of the statement.
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$The ending date of the statement.
A code identifying the type of claim. For example DS - Disability.
- Use
OFwhen submitting Medicare Part D claims. - Use
ZZwhen you don't know the type of insurance. - Some payers reject claims with invalid codes. If you're not sure which code to use, we recommend running a real-time eligibility check and using the value returned in the most relevant
benefitsInformation.insuranceTypeCodeproperty. Note that the eligibility response uses a different code list than claims, so you may need to map that code value to the appropriate claim filing code.
Visit Claims code lists for a complete list.
1112131415Code specifying the frequency of the claim. Not all payers allow all codes. Can be set to 1 - Original claim submission, 2 - Interim – First Claim, 3 - Interim – Continuing Claim, 4 - Interim – Last Claim, 7 - Replacement, 8 - Void, and 9 - Final Claim for a Home Health PPS Episode.
- Set this to
1when you're submitting a new claim and when you're resubmitting a claim that was rejected before it entered the payer's processing system. You must also set this property to1for every resubmission to Original Medicare because Original Medicare doesn't accept code7. - Set this to
7when you need to resubmit a corrected claim that the payer has already processed. These are claims that the payer has already adjudicated or claims that the payer has rejected with a 277CA containing the Payer Claim Control Number (PCCN), indicating it has entered the payer's system. - When resubmitting with code
7or voiding with code8, you must also include the Payer Claim Control Number (sometimes called the ICN) in theclaimInformation.claimSupplementalInformation.claimControlNumberproperty. An exception is Original Medicare, which requires that you omit the Payer Claim Control Number from resubmissions. - For resubmissions and cancellations, we strongly recommend including a unique Patient Control Number in the
claimInformation.patientControlNumberfor tracking purposes.
Visit Resubmit or cancel claims for complete details.
Free-form information to substantiate the medical treatment that isn't provided elsewhere in the claim submission. Also used to provide narrative information from the forms Home Health Certification and Plan of Treatment or Medical Update and Patient Information, as needed to substantiate home health services. You can provide up to 10 strings in this array.
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Allergies
Diagnosis Description
Durable Medical Equipment (DME) and Supplies
Functional Limitations, Reason Homebound, or Both
Goals, Rehabilitation Potential, or Discharge Plans
Medications
Nutritional Requirements
Orders for Disciplines and Treatments
Reasons Patient Leaves Home
Safety Measures
Supplementary Plan of Treatment
Times and Reasons Patient Not at Home
Unusual Home, Social Environment, or Both
Updated Information
Specifies pricing or repricing information about a claim. Required when this information is deemed necessary by the repricer. For capitated encounters, pricing or repricing information is usually not applicable and is provided to qualify other information within the claim.
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Code specifying the exception reason for consideration of out-of-network health care services. Can be set to 1 - Non-Network Professional Provider in Network Hospital, 2 - Emergency Care, 3 - Services or Specialist not in Network, 4 - Out-of-Service Area, 5 - State Mandates, or 6 - Other.
12345Code indicating the policy compliance. Visit Claims code lists for a complete list.
12345The pricing methodology code. Visit Claims code lists for a complete list.
0001020304Code identifying the type of product or service ID used. Can be set to ER - Jurisdiction Specific Procedure and Supply Codes, HC - Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes, HP - Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code, IV - Home Infusion EDI Coalition (HIEC) Product/Service Code, or WK - Advanced Billing Concepts (ABC) Codes. Note that ABC codes are deprecated and should not be used in new claims. If you provide this property, you must also provide repricedApprovedHCPCSCode Visit Claims code lists for a complete list and additional usage notes.
ERHCHPIVWKCode indicating the rejection message returned from the third party organization. Visit Claims code lists for a complete list.
T1T2T3T4T5The allowed amount, expressed as a decimal.
The approved DRG amount, expressed as a decimal.
The approved DRG code.
The approved procedure code. If you provide this property, you must also include productOrServiceIDQualifier.
The approved revenue code.
The approved service units or inpatient days. Can be set to DA - Days or UN - Unit.
DAUNThe approved service units or inpatient days. The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three.
The organization identification number.
The pricing rate associated with per diem or flat rate pricing, expressed as a decimal.
The savings amount, expressed as a decimal.
Additional information or documentation required for the claim. This is where you can include information about attachments, if applicable.
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The adjusted repriced claim reference number. Required when the repricer believes this information is necessary. Providers should not complete this property.
Required when the services reported on this claim are related to an auto accident and the accident occurred in a country or location that has a state, province, or sub-country code.
This is the Payer Claim Control Number (PCCN) for an existing claim that this claim is meant to replace or cancel. This property is generally required when the claimInformation.claimFrequencyCode is set to 7 or 8. One exception to this guidance is Original Medicare, which specifies that you omit the PCCN from resubmissions.
Visit Resubmit or cancel claims for complete details and information about where to find the PCCN for an existing claim.
The identifier assigned by clearinghouse, van, etc. when they need to assign their own unique claim number.
Stedi overwrites this value when it sends the claim to the payer, so you shouldn't include this property in your request. We strongly recommend using the claimInformation.patientControlNumber property as your claim tracking ID.
Required when it is necessary to identify claims that are atypical in ways such as content, purpose, and/or payment. For example, claims made as the result of a demonstration or a clinical trial.
Required when claim involves a Food and Drug Administration (FDA) assigned investigational device exemption (IDE) number. When more than one IDE applies, you must split into separate claims.
Required when the provider needs to identify the actual medical record of the patient for this episode of care.
Required when an external Peer Review Organization assigns an Approval Number to services deemed medically necessary by that organization.
Required when an authorization number is assigned by the payer or UMO and the services on this claim were preauthorized. The UMO (Utilization Management Organization) is generally the entity empowered to decide the outcome of a health services review or the owner of the information. This value applies to the entire claim unless overridden within a specific service line.
Required when a referral number is assigned by the payer or Utilization Management Organization (UMO) and a referral is involved. This value applies to the entire claim unless overridden within a specific service line.
Required when you plan to submit an attachment for the claim electronically through Stedi APIs or SFTP, when there is a paper attachment following this claim, or when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request.
Use this object when there is a single attachment for the claim. If there are multiple attachments, use the reportInformations array instead.
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The control number assigned to the attachment. The payer uses this identifier to match the attachment to the claim. We recommend using a ULID or UUID of up to 50 characters.
Code indicating the title or contents of a document, report or supporting item. For example, 08 - Plan of Treatment or CT - Certification. Visit Claims code lists for a complete list.
0304050607Code identifying the method by which the provider's report is attached. Can be set to AA - Available on Request at Provider Site, BM - By Mail, EL - Electronically Only, EM - E-Mail, FT - File Transfer, or FX - By Fax.
Set this to EL when you plan to submit attachments electronically through Stedi APIs.
AABMELEMFTAn array of report information for the claim. Use this when you need to submit multiple report information records. You can submit up to 10 objects in this array.
Required when you plan to submit attachments for the claim electronically through Stedi APIs or SFTP, when there is a paper attachment following this claim, or when the provider deems it necessary to identify that they have additional information at their office that is available upon request.
Array item
The control number assigned to the attachment. The payer uses this identifier to match the attachment to the claim. We recommend using a ULID or UUID of up to 50 characters.
Code indicating the title or contents of a document, report or supporting item. For example, 08 - Plan of Treatment or CT - Certification. Visit Claims code lists for a complete list.
0304050607Code identifying the method by which the provider's report is attached. Can be set to AA - Available on Request at Provider Site, BM - By Mail, EL - Electronically Only, EM - E-Mail, FT - File Transfer, or FX - By Fax.
Set this to EL when you plan to submit attachments electronically through Stedi APIs.
AABMELEMFTRequired when the repricer believes this information is necessary. Providers should not complete this property.
Code indicating the type of service authorization exception. Visit Claims code lists for a complete list.
12345Indicates the condition of the patient for EPSDT referral situations. Can be set to AV - Available-Not Used, NU - Not Used, S2 - Under Treatment, ST - New Services Requested.
- Use
AVwhen the patient refused a referral. - Use
S2when the patient is currently under treatment for the referred diagnostic or corrective health problem. - Use
STwhen the patient is referred to another provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals) OR the patient is scheduled for another appointment with the screening provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals).
AVNUS2STRequired when there is a Condition Code that applies to this claim.
This is an array of arrays of objects. You can provide up to two object arrays, and each array can contain up to 12 objects.
Array item
Array item
The condition code.
Code indicating the reason for the delay in claim submission. Visit Claims code lists for a complete list.
12345Diagnosis related group (DRG) code. Required when an inpatient hospital is under DRG contract with a payer and the contract requires the provider to identify the DRG to the payer.
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The diagnosis related group code.
Required on Early & Periodic Screening, Diagnosis, and Treatment (EPSDT) claims when the screening service is being billed in this claim.
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Code indicating whether an EPSDT referral was given to the patient. Can be set to N - No or Y - Yes.
NYCode indicating the patient's status. Set to AV when the patient refused the referral. Set to NU when you set certificationConditionCodeAppliesIndicator to N. Set to S2 when the patient is currently under treatment for the referred diagnostic or corrective health problem. Set to ST when either the patient is referred to another provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals) or the patient is scheduled for another appointment with the screening provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals).
AVNUS2STDiagnosis codes to describe the patient's condition. Required when an external Cause of Injury is needed to describe an injury, poisoning, or adverse effect.
Note that to fully describe an injury using ICD-10-CM, it will be necessary to report a series of 3 external cause of injury codes. Refer to the ICD-10-CM Official Guidelines for Coding and Reporting.
You can provide up to 12 objects in this array.
Array item
The external cause of injury code(s) for the patient.
- You must submit a valid, billable code at the highest level of specificity. Include the 4th - 7th characters as applicable.
- Don't submit the decimal point for ICD codes. The decimal point is implied.
- Don't submit ICD-10 header codes. Header codes exist to group related codes and aren't valid for billing. These header codes can change with each new version of ICD-10, so we recommend reviewing your diagnosis codes every year to ensure that they aren't classified as header codes in the most recent version. To determine whether a code is a header code, you can also search the Value Set Authority Center. If the 'Header' property is set, the code is a header code and you shouldn't use it in claim submissions.
Indicates whether the external cause of injury was present on admission. Can be set to N - No (onset did NOT occur prior to admission to the hospital), Y - Yes (onset occurred prior to admission to the hospital), U - Unknown, or W - Not Applicable.
NUYWCode identifying the type of external cause of injury code used. Can be set to ABN - International Classification of Diseases Clinical Modification External Cause of Injury Code or BN - International Classification of Diseases Clinical Modification External Cause of Injury Code. Note that ICD-9 is deprecated and cannot be used in new claims.
ABNBNUsed to send additional data specifically requested by the payer. Not commonly used.
Required when there is a Occurrence Code that applies to this claim. This is an array of arrays of objects. You can provide up to two object arrays, and each array can contain up to 12 objects.
Array item
Array item
The occurrence span code.
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$The date or date range for the occurrence span.
Required when there is an Occurrence Span Code that applies to this claim. This is an array or arrays of objects. You can provide up to two object arrays and each array can contain up to 12 objects.
Array item
Array item
The occurrence span code.
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$The end date for the occurrence span.
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$The start date for the occurrence span.
Additional diagnosis codes relevant to the claim. Required when other condition(s) coexist or develop(s) subsequently during the patient's treatment. This is an array of arrays of objects. You can provide up to two object arrays, and each object array can contain up to 12 objects.
Array item
Array item
A diagnosis code for the patient.
- You must submit a valid, billable code at the highest level of specificity. Include the 4th - 7th characters as applicable.
- Don't submit the decimal point for ICD codes. The decimal point is implied.
- Don't submit ICD-10 header codes. Header codes exist to group related codes and aren't valid for billing. These header codes can change with each new version of ICD-10, so we recommend reviewing your diagnosis codes every year to ensure that they aren't classified as header codes in the most recent version. To determine whether a code is a header code, you can also search the Value Set Authority Center. If the 'Header' property is set, the code is a header code and you shouldn't use it in claim submissions.
Indicates whether the other diagnosis was present on admission. Can be set to N - No (onset did NOT occur prior to admission to the hospital), Y - Yes (onset occurred prior to admission to the hospital), U - Unknown, or W - Not Applicable.
NYUWCode identifying the type of diagnosis code used. Can be set to ABF - International Classification of Diseases Clinical Modification (ICD-10-CM) or BF - International Classification of Diseases Clinical Modification (ICD-9-CM). Note that ICD-9 is deprecated and cannot be used in new claims.
ABFBFRequired on inpatient claims when additional procedures must be reported. This is an array of arrays of objects. You can provide up to two object arrays, and each array can contain up to 12 objects.
Array item
Array item
The code from the code set specified in qualifierCode. Don't submit the decimal for ICD codes; the decimal is implied.
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$The date when the procedure was performed.
Identifies an industry code list. This can be set to BBQ: International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes or BQ: International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes. Note that ICD-9-CM codes are deprecated and shouldn't be used in new claim submissions.
BBQBQRequired when other payers are known to potentially be involved in paying on this claim. This object contains information about other health plans under which the patient has coverage. It's used for coordination of benefits scenarios.
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Code indicating whether or not the insured has authorized the plan to remit payment directly to the provider. Can be set to N - No (Payment should go to the patient), Y - Yes (Payment should go directly to the provider), or W - Not Applicable. Use W when the patient refuses to assign benefits.
NYWA code identifying the type of claim. For example DS - Disability. Use OF when submitting Medicare Part D claims. Use ZZ when you don't know the type of insurance. Visit Claims code lists for a complete list.
1112131415Supply adjustment reason codes and amounts as needed. Required when the claim has been adjudicated by the payer identified in this loop, and the claim has claim level adjustment information. Submitters must use this object to report prior payers' claim level adjustments that cause the amount paid to differ from the amount originally charged. Codes and associated amounts must come from either paper remittance advice or 835s (Electronic Remittance Advice) received on the claim. When the information originates from a paper remittance advice that does not use the standard Claim Adjustment Reason Codes, the paper values must be converted to standard Claim Adjustment Reason Codes. You can include up to five claimLevelAdjustments objects in this array.
Array item
Code identifying the general category of payment adjustment. Can be set to CO - Contractual Obligations, CR - Correction and Reversals, OA - Other adjustments, PI - Payor Initiated Reductions, or PR - Patient Responsibility.
COCROAPIPRThe adjustment reason, amount, and quantity. You can include up to six of these objects to describe a single adjustmentGroupCode.
Array item
The dollar amount of the adjustment, expressed as a decimal.
The units of service being adjusted, expressed as a decimal.
Code identifying the detailed reason the adjustment was made. Visit the X12 Claim Adjustment Reason Codes for a complete list.
The group number for the subscriber's health plan.
Provide this property OR the otherInsuredGroupName, not both. If this property is set, Stedi ignores the otherInsuredGroupName property.
Code identifying the relationship to the person insured. Visit Claims code lists for a complete list.
0118192021Claim-level data related to the adjudication of Medicare inpatient claims. Required when inpatient adjudication information is reported in the remittance advice or when you need to report remark codes.
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The capital exception amount, expressed as a decimal.
The Prospective Payment System (PPS) capital, hospital specific portion, Diagnosis Related Group (DRG) amount. Expressed as a decimal.
The Diagnosis Related Group (DRG) amount, expressed as a decimal.
The disproportionate share amount, expressed as a decimal.
The indirect teaching amount, expressed as a decimal.
The Medicare Secondary Payer (MSP) pass-through amount, expressed as a decimal.
The claim payment remark code. Refer to the X12 Remittance Advice Remark Codes for a complete list. You can include up to four codes in this array.
The Prospective Payment System (PPS) capital amount, expressed as a decimal.
The Prospective Payment System (PPS) capital outlier amount, expressed as a decimal.
The number of cost report days, expressed as a decimal.
The number of covered days, expressed as a decimal.
The number of lifetime psychiatric days, expressed as a decimal.
The professional component amount billed but not payable, expressed as a decimal.
The old capital amount, expressed as a decimal.
The prospective Payment System (PPS) capital, disproportionate share, hospital Diagnosis Related Group (DRG) amount. Expressed as a decimal.
The Prospective Payment System (PPS) capital, disproportionate share, hospital Diagnosis Related Group (DRG) amount. Expressed as a decimal.
The Prospective Payment System (PPS) capital Indirect Medical Education (IME) claim amount, expressed as a decimal.
The federal specific Diagnosis Related Group (DRG) amount, expressed as a decimal.
The hospital specific Diagnosis Related Group (DRG) amount, expressed as a decimal.
Claim-level data related to the adjudication of Medicare claims not related to an inpatient setting. Required when outpatient adjudication information is reported in the remittance advice or when you need to report remark codes.
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The remark code. Visit the X12 Remittance Advice Remark Codes for a complete list. You can include up to five codes in this array.
^\d+(\.\d{1,2})?$The End-Stage Renal Disease (ESRD) payment amount, expressed as a decimal.
^\d+(\.\d{1,2})?$The claim Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount, expressed as a decimal.
^\d+(\.\d{1,2})?$The professional component amount billed but not payable, expressed as a decimal.
The reimbursement percentage, expressed as a decimal.
Required when the destination payer's cost avoidance policy allows providers to bypass claim submission to the otherwise prior payer identified in otherPayerName. The amount must equal the total claim charge amount you reported in claimInformation.claimChargeAmount.
The name of the subscriber's health plan.
Provide either this property OR the groupNumber, not both. If groupNumber is set, Stedi ignores this value and uses the value in groupNumber.
Information regarding the other payer's attending provider. The attending provider is the provider who is primarily responsible for the care of the patient.
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The provider's identifier. The qualifier can be set to OB - State License Number, 1G - Provider UPIN Number, G2 - Provider Commercial Number, or LU - Location Number. Note that UPIN numbers are deprecated and should not be used in new claims.
Array item
The identifier specified in qualifier.
The code qualifying the type of identifier.
Information regarding the other payer's billing provider.
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The provider's identifier. The qualifier can be set to G2 - Provider Commercial Number or LU - Location Number. Note that UPIN numbers are deprecated and should not be used in new claims.
Array item
The identifier specified in qualifier.
The code qualifying the type of identifier.
Details about the other payer.
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The address of the other payer. You must include at least the address1 and city properties in this object.
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The first line of the street address. This typically contains the building number and street name.
The second line of the street address. This typically contains the apartment or suite number.
The city name.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
The postal zone or zip code. Exclude punctuation and spaces.
The state or province code. Only required when the city is in the Unites States and Canada.
Required when the claim is being sent in the payer-to-payer COB model, AND the destination payer is secondary to the payer identified in this object, AND the payer identified in this object re-adjudicated the claim. Can be set to Y - Yes.
The other payer's claim control number for this claim.
The identifier specified in otherPayerIdentifierTypeCode.
Code specifying the type of identifier used for the other payer. Can be set to PI - Payor Identification or XV - Centers for Medicare and Medicaid Services PlanID. Use XV when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).
PIXVThe business name of the other payer.
The other payer's prior authorization number. Required when this payer has assigned a prior authorization number to this claim.
The other payer's referral number. Required when this payer has assigned a referral number to this claim.
Additional identification number for the other payer. The qualifier property can be set to 2U - Payer Identification Number, EI - Employer's Identification Number, FY - Claim Office Number, or NF - National Association of Insurance Commissioners (NAIC) Code.
Array item
The identifier specified in qualifier.
The code qualifying the type of identifier.
Information regarding the other payer's operating physician. The operating physician is the provider who performed the procedure.
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The qualifier can be set to OB - State License Number, 1G - Provider UPIN Number, G2 - Provider Commercial Number, or LU - Location Number. Note that UPIN numbers are deprecated and should not be used in new claims.
Array item
The identifier specified in qualifier.
The code qualifying the type of identifier.
Information regarding the other payer's other operating physician. The other operating physician is the provider who performed a secondary surgical procedure or assisted the otherPayerOperatingPhysician.
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The physician's identifier. The qualifier can be set to OB - State License Number, 1G - Provider UPIN Number, G2 - Provider Commercial Number, or LU - Location Number. Note that UPIN numbers are deprecated and should not be used in new claims.
Array item
The identifier specified in qualifier.
The code qualifying the type of identifier.
Information regarding the other payer's referring provider. This is the provider who sent the patient to another provider for services.
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The provider's identifier. The qualifier can be set to OB - State License Number, 1G - Provider UPIN Number, or G2 - Provider Commercial Number. Note that UPIN numbers are deprecated and should not be used in new claims.
Array item
The identifier specified in qualifier.
The code qualifying the type of identifier.
Information regarding the other payer's rendering provider. The rendering provider is the provider who performed the service or non-surgical procedure.
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The provider's identifier. The qualifier can be set to OB - State License Number, 1G - Provider UPIN Number, G2 - Provider Commercial Number, or LU - Location Number. Note that UPIN numbers are deprecated and should not be used in new claims.
Array item
The identifier specified in qualifier.
The code qualifying the type of identifier.
Information regarding the other payer's service facility location. This is where the service was performed.
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The facility's identifier. The qualifier can be set to OB - State License Number, G2 - Provider Commercial Number, or LU - Location Number.
Array item
The identifier specified in qualifier.
The code qualifying the type of identifier.
The person or entity who is the primary policyholder for the other payer's health plan.
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The subscriber's address. You must include at least the address1 and city properties in this object.
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The first line of the street address. This typically contains the building number and street name.
The second line of the street address. This typically contains the apartment or suite number.
The city name.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
The postal zone or zip code. Exclude punctuation and spaces.
The state or province code. Only required when the city is in the Unites States and Canada.
The subscriber's social security number (SSN). This must be a string of exactly nine numbers with no separators.
The subscriber's first name.
The identifier specified in otherInsuredIdentifierTypeCode.
Code identifying the type of identifier used for the other insured. Can be set to II - Standard Unique Health Identifier for each Individual in the United States or MI - Member Identification Number. Note that II is deprecated and should not be used in new claims.
IIMIThe last name (when the subscriber is an individual) or the name of the organization (when the subscriber is an organization). Don't include the subscriber's name suffix, such as Jr. or III. Use the designated otherInsuredSuffix property instead.
The subscriber's middle name or initial.
Code identifying the type of entity. Can be set to 1 - Person or 2 - Non-Person Entity.
12The subscriber's name suffix, such as Jr or III. Only include the subscriber's personal name suffix - don't include professional or academic titles, such as M.D. or MBA.
The total amount in dollars the payer has paid on this claim. It is acceptable to set this to 0 (Zero). This is required when you include the payToPlan object, and you should set it to the amount the Medicaid agency actually paid.
Code identifying the payer's level of responsibility for paying this claim. Visit Claims code lists for a complete list.
- This will almost always be
P- Primary. However, you may need to use other codes if the patient has multiple insurance policies. For example, if a patient is covered by both Medicare and an employer-sponsored commercial plan, you could bill Medicare first asPand then bill the commercial payer second asS. - Either this property or
subscriber.paymentResponsibilityLevelCodemust be set toPto indicate the primary insurance payer. Stedi rejects claims - including secondary and tertiary claims - that don't include information for the primary payer.
ABCDEThe policy number for the subscriber's health plan.
Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations. Can be set to I - Informed Consent to Release Medical Information or Y - Yes. Code I is required when the provider has not collected a signature AND state or federal laws do not require a signature be collected. Code Y is required when the provider has collected a signature OR when state or federal laws require a signature be collected.
IYThis is the remaining amount (as determined by the provider) to be paid after the other payer identified in the otherPayerName object has adjudicated the claim. Required when the other payer adjudicated the claim and provided claim level information only or when the other payer adjudicated the claim, and the provider received a paper remittance advice, and the provider does not have the ability to report line item information. Don't include this property if you're specifying remaining patient liability at the service line level.
An identifier you assign to the claim. We strongly recommend submitting a unique value for this property so that you can use it to correlate this claim with responses from the payer, such as the 835 ERA.
We recommend using only alphanumeric characters and generating unique values that are the shortest possible length. Stedi accepts any valid value, but some payers replace non-alphanumeric characters and truncate shorter than the official 20-character limit. When this happens, the payer returns a different identifier in responses than the one you originally sent, making it more difficult to correlate the claim and perform real-time claim status checks.
^\d+(\.\d{1,2})?$The total estimated amount the patient must pay for the services listed in this claim. Expressed as a decimal, such as 20.50. This includes any co-payments, co-insurance, or other costs.
The diagnosis for which the patient visited an outpatient provider. Required when the claim involves outpatient visits. This may be different from the principal diagnosis. This is an array of objects and you can provide up to three objects.
Array item
The patient's reason for visit code.
- You must submit a valid, billable code at the highest level of specificity. Include the 4th - 7th characters as applicable.
- Don't submit the decimal point for ICD codes. The decimal point is implied.
- Don't submit ICD-10 header codes. Header codes exist to group related codes and aren't valid for billing. These header codes can change with each new version of ICD-10, so we recommend reviewing your diagnosis codes every year to ensure that they aren't classified as header codes in the most recent version. To determine whether a code is a header code, you can also search the Value Set Authority Center. If the 'Header' property is set, the code is a header code and you shouldn't use it in claim submissions.
Code identifying the type of reason for visit code used. Can be set to APR - International Classification of Diseases Clinical Modification Patient's Reason for Visit or PR - International Classification of Diseases Clinical Modification Patient's Reason for Visit. Note that ICD-9 is deprecated and cannot be used in new claims.
APRPRCode identifying the type of facility where the services were or may be performed. This must be the two-digit facility type code from the National Uniform Billing Committee Official UB-04 Data File (FL 04 - Type of Bill Facility Codes).
Code indicating whether the provider accepts assignment. This refers to whether the provider accepts assignment and/or has a participation agreement with the destination payer. It does not indicate whether the patient has assigned benefits to the provider. Can be set to A - Assigned, B - Assignment Accepted on Clinical Lab Services Only, or C - Not Assigned. Choose A when the provider accepts assignment and/or has a participation agreement with the destination payer, OR the provider does not accept assignment and/or have a participation agreement, but is advising the payer to adjudicate this specific claim under the participating provider benefits allowed under certain plans.
ABCThis is the diagnosis for the condition determined to be primarily responsible for admission of the patient into the health facility for care.
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Indicates whether the principal diagnosis was present on admission. Can be set to N - No (onset did NOT occur prior to admission to the hospital), Y - Yes (onset occurred prior to admission to the hospital), U - Unknown, or W - Not Applicable.
NYUWThe principal diagnosis code for the patient.
- You must submit a valid, billable code at the highest level of specificity. Include the 4th - 7th characters as applicable.
- Don't submit the decimal point for ICD codes. The decimal point is implied.
- Don't submit ICD-10 header codes. Header codes exist to group related codes and aren't valid for billing. These header codes can change with each new version of ICD-10, so we recommend reviewing your diagnosis codes every year to ensure that they aren't classified as header codes in the most recent version. To determine whether a code is a header code, you can also search the Value Set Authority Center. If the 'Header' property is set, the code is a header code and you shouldn't use it in claim submissions.
Code identifying the type of diagnosis code used. Can be set to ABK - International Classification of Diseases Clinical Modification Principal Diagnosis or BK - International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis. Note that ICD-9 is deprecated and cannot be used in new claims.
ABKBKThe procedure code for the primary procedure performed on the patient. Required on inpatient claims when a procedure was performed.
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The principal procedure code for the patient. It must be a valid code from the appropriate coding system. Don't submit the decimal for ICD codes; the decimal is implied.
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$The date when the procedure was performed.
Code identifying the type of procedure code used. Can be set to BBR - International Classification of Diseases Clinical Modification (ICD-10-PCS) Principal Procedure Codes, BR - International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Procedure Codes, or CAH - Advanced Billing Concepts (ABC) Codes. Note that ICD-9 and ABC codes are deprecated and cannot be used in new claims.
BBRBRCAHThe agency claim number for this transaction. Used when services included in this claim are part of a property and casualty claim. This property is typically not used by Stedi customers.
Indicates whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations. Can be set to Y - Yes, or I - Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statues. Use I when the provider has not collected a signature AND state or federal laws do not require a signature be collected.
IYThe service facility location. Required when the location of healthcare services is different from the billing provider's address.
- When an organization's healthcare provider's NPI is provided to identify the service location, the organization healthcare provider must be external to the entity identified as the billing provider (for example, a reference lab).
- The service location can't be a component or subpart of the billing provider entity. Only include this object when the service location is different from the billing provider's address. If you include this object when the address is the same, Stedi omits all of the service facility location information from the claim submission, including the name and any identifiers.
- Sometimes the billing provider is an actual physician group that is located at the same address as a hospital, but is in fact a separate entity. In this case, you can differentiate the service facility location by including the specific suite or building number of the physician group. This ensures that the service facility location is different from the billing provider's address and is reported accurately.
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The location where services were rendered.
If this was in an an area where there are no street addresses, enter a description of where the service was rendered. For example, 'crossroad of State Road 34 and 45' or 'Exit near Mile marker 265 on Interstate 80'.
For United States addresses, you must include the full nine-digit zip code with no separators, such as 100031502. If you don't know the full zip code, you can find it using the USPS ZIP Code Lookup tool.
Show attributes
The first line of the street address. This typically contains the building number and street name.
The second line of the street address. This typically contains the apartment or suite number.
The city name.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
The postal zone or zip code. Exclude punctuation and spaces.
The state or province code. Only required when the city is in the Unites States and Canada.
The organization National Provider Identifier (NPI) assigned to the service facility location. Required when the service location to be identified has an NPI and is not a component or subpart of the billing provider.
The business name of the laboratory or facility.
Code identifying the type of secondary identification. Can be set to 0B - State License Number, G2 - Provider Commercial Number, or LU - Location Number.
0BG2LUThe identifier specified in secondaryIdentifierQualifierCode.
You can only include one secondary identifier for the service facility.
Information about one or more services rendered to the patient. - Each service line must be a unique service event as defined by the payer's billing policies. This means that you can use the same procedure code on multiple service lines as long as they are distinct events. - Some procedure codes are date-specific. In these cases, you may need to create a separate service line with that code for each applicable date of service, even if the episode of care extended over multiple days. - Service lines can share the same dates of service if the patient received multiple services on the same day.
Array item
Required when a repricing (pricing) organization needs to have an identifying number on an adjusted service line in their submission to their payer organization. Providers shouldn't complete this property.
^\d+$Max length: 6Stedi assigns this value automatically. It's a unique number identifying the service line within the claim.
A free-form description to clarify information about the service line. You can use this to further describe the service/product/supply reported in the service line or for non-specific procedure codes. Non-specific procedure codes may include descriptors such as 'Not Otherwise Classified (NOC)', 'Unlisted', 'Unspecified', 'Other', 'Prescription Drug: Generic', 'Prescription Drug, Brand Name', or 'Miscellaneous'.
Report drugs and biologics related to the service line. Required when government regulation mandates that prescribed drugs and biologics are reported with NDC numbers or when when the provider or submitter chooses to report NDC numbers to enhance the claim reporting or adjudication processes.
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The sequence number assigned to the drug or biologic. Required when the provided medication involves the compounding of two or more drugs being reported and there is no prescription number. The link sequence number is a provider-assigned number unique to this claim. Its purpose is to enable the receiver to piece together the components of the compound. Note that you can set either this property or pharmacyPrescriptionNumber, but not both.
Code identifying the unit of measure for the drug or biologic. Can be set to F2 - International Unit, GR - Gram, ME - Milligram, ML - Milliliter, or UN - Unit.
F2GRMEMLUNThe National Drug Code (NDC) number for the drug or biologic. This is a unique number that identifies the drug or biologic, including the labeler code, product code, and package code. The NDC number must be formatted as 5-4-2, with hyphens separating the three parts. For example, 12345-6789-01.
^\d{1,15}$The number of units of the drug or biologic, formtted as a decimal.
The prescription number assigned by the pharmacy. Required when dispensing of the drug has been done with an assigned prescription number. In cases where a compound drug is being billed, the components of the compound will all have the same prescription number. Payers receiving the claim can relate all the components by matching the prescription number. Note that you can set either this property or linkSequenceNumber, but not both.
^\d+(\.\d{1,2})?$The amount of the facility tax or surcharge, formatted as a decimal. Required when a facility tax applies to the service being reported. The claimInformation.serviceLines.institutionalService.lineItemChargeAmount must include the amount you report here.
Details about the service line, including the procedure code and the line item charge amount.
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The description of the procedure identified in procedureCode.
^\d+(\.\d{1,2})?$The amount charged for the service line, expressed as a decimal. This should include the provider's base charge and any applicable tax amounts reported within the service line.
The unit of measurement for the service. Can be set to DA - Days or UN - Unit.
DAUN^\d+(\.\d{1,2})?$The non-covered service amount, expressed as a decimal. This property isn't intended for sending claims to secondary insurance after receiving a remittance from the original payer. It's used when a provider wants to report that they performed an uncovered service for a patient, but they aren't asking for payment. For example, a cosmetic procedure that isn't covered by the patient's health plan.
The procedure code. If you set this property, you must also set the procedureIdentifier.
Code identifying the type of procedureCode. If you set this property, you must also set procedureCode.
Can be set to ER - Jurisdiction Specific Procedure and Supply Codes, HC - Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes, HP - Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code, IV - Home Infusion EDI Coalition (HIEC) Product/Service Code, or WK - Advanced Billing Concepts (ABC) Codes. Note that ABC codes are deprecated and shouldn't be used in new claims.
Visit Claims code lists for more information and usage instructions.
ERHCHPIVWKA modifier that conveys special circumstances related to the performance of the service.
The identifying number for the product or service. Visit the National Uniform Billing Committee (NUBC) Codes documentation for a complete list.
The number of units of service provided. The maximum length for this property is 8 digits, excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is 3.
The units depend on the procedure code being billed and the nature of the service. For example, they may correspond to days (1 unit = 1 inpatient day), individual treatments or encounters (3 units = 3 dialysis sessions), or medication doses (2 units = 2 doses or vials).
Includes service line adjudication information for coordination of benefits between the initial payers of a health care claim and all subsequent payers.
Array item
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$The date the claim was paid.
^\d{1,6}$The LX assigned number of the service line into which this service line is bundled. It's only used to bundle service lines.
Adjustment reason codes and amounts as needed for the service line. You can include up to five of these objects within claimInformation.serviceLines.lineAdjudicationInformation.claimAdjustmentInformation.
Array item
Code identifying the general category of payment adjustment. Can be set to CO - Contractual Obligations, CR - Correction and Reversals, OA - Other adjustments, PI - Payor Initiated Reductions, or PR - Patient Responsibility.
COCROAPIPRThe adjustment reason, amount, and quantity. You can include up to six of these objects to describe a single adjustmentGroupCode.
Array item
The dollar amount of the adjustment, expressed as a decimal.
The units of service being adjusted, expressed as a decimal.
Code identifying the detailed reason the adjustment was made. Visit the X12 Claim Adjustment Reason Codes for a complete list.
The payer ID for the payer responsible for reimbursement.
^\d{1,8}(\.\d{1,3})?$The number of paid units from the remittance advice. When paid units are not present on the remittance advice, use the original billed units. The maximum length for this property is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three.
The procedure code.
A description of the procedure identified in procedureCode.
A modifier that conveys special circumstances related to the performance of the service.
Code identifying the type of procedureCode. Can be set to ER - Jurisdiction Specific Procedure and Supply Codes, HC - Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes, HP - Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code, IV - Home Infusion EDI Coalition (HIEC) Product/Service Code, or WK - Advanced Billing Concepts (ABC) Codes. Note that ABC codes are deprecated and shouldn't be used in new claims. Visit Claims code lists for a complete list and usage guidelines.
ERHCHPIVWK^\d+(\.\d{1,2})?$The remaining amount (as determined by the provider) to be paid after the other payer identified in the otherPayerPrimaryIdentifier property has adjudicated the claim. Expressed as a decimal. Only used in claims submitted by providers - not in payer-to-payer coordination of benefits (COB). Don't include this if you already provided claimInformation.otherSubscriberInformation.remainingPatientLiability for the claim.
^\d+(\.\d{1,2})?$The amount paid for this service line, expressed as a decimal. Zero (0) is an acceptable value.
The revenue code for the service line.
Show attributes
^\d{1,6}$Show attributes
Code identifying the general category of payment adjustment. Can be set to CO - Contractual Obligations, CR - Correction and Reversals, OA - Other adjustments, PI - Payor Initiated Reductions, or PR - Patient Responsibility.
COCROAPIPRThe adjustment reason, amount, and quantity. You can include up to six of these objects to describe a single adjustmentGroupCode.
Array item
The dollar amount of the adjustment, expressed as a decimal.
The units of service being adjusted, expressed as a decimal.
Code identifying the detailed reason the adjustment was made. Visit the X12 Claim Adjustment Reason Codes for a complete list.
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$^\d{1,8}(\.\d{1,3})?$^\d+(\.\d{1,2})?$Code identifying the type of procedureCode. Can be set to ER - Jurisdiction Specific Procedure and Supply Codes, HC - Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes, HP - Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code, IV - Home Infusion EDI Coalition (HIEC) Product/Service Code, or WK - Advanced Billing Concepts (ABC) Codes. Note that ABC codes are deprecated and shouldn't be used in new claims. Visit Claims code lists for a complete list and usage guidelines.
ERHCHPIVWK^\d+(\.\d{1,2})?$A unique identifier for this service line within the claim. It appears in the 835 (ERA) response as lineItemControlNumber, allowing you to correlate ERAs to the specific service lines from the original claim. If you don't set this property, Stedi uses a random ULID. Stedi returns service line identifiers in the claimReference.serviceLines.lineItemControlNumber object of the synchronous API response.
Another way to provide additional information for comment or special instruction - same as thirdPartyOrganizationNotes. Required when the TPO/repricer needs to forward additional information to the payer.
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^\d+(\.\d{1,2})?$Code specifying the exception reason for consideration of out-of-network health care services. Can be set to 1 - Non-Network Professional Provider in Network Hospital, 2 - Emergency Care, 3 - Services or Specialist not in Network, 4 - Out-of-Service Area, 5 - State Mandates, or 6 - Other.
12345^\d+(\.\d{1,2})?$The unit of measurement for the service. Can be set to DA - Days or UN - Unit.
DAUN12345Code indicating the pricing or repricing methodology. Visit Claims code lists for a complete list.
0001020304T1T2T3T4T5^\d+(\.\d{1,2})?$^\d{1,8}(\.\d{1,3})?$^\d+(\.\d{1,2})?$Code identifying the type of procedureCode. If you set this property, you must also set procedureCode.
Can be set to ER - Jurisdiction Specific Procedure and Supply Codes, HC - Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes, HP - Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code, IV - Home Infusion EDI Coalition (HIEC) Product/Service Code, or WK - Advanced Billing Concepts (ABC) Codes. Note that ABC codes are deprecated and shouldn't be used in new claims.
Visit Claims code lists for more information and usage instructions.
ERHCHPIVWKInformation about the pricing or repricing of the service line. This information should only be completed by repricers.
Show attributes
Code specifying the exception reason for consideration of out-of-network health care services. Can be set to 1 - Non-Network Professional Provider in Network Hospital, 2 - Emergency Care, 3 - Services or Specialist not in Network, 4 - Out-of-Service Area, 5 - State Mandates, or 6 - Other.
12345Code indicating the policy compliance. Visit Claims code lists for a complete list.
12345The pricing methodology code. Visit Claims code lists for a complete list.
0001020304Code identifying the type of product or service ID used. Can be set to ER - Jurisdiction Specific Procedure and Supply Codes, HC - Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes, HP - Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code, IV - Home Infusion EDI Coalition (HIEC) Product/Service Code, or WK - Advanced Billing Concepts (ABC) Codes. Note that ABC codes are deprecated and should not be used in new claims. If you provide this property, you must also provide repricedApprovedHCPCSCode Visit Claims code lists for a complete list and additional usage notes.
ERHCHPIVWKCode indicating the rejection message returned from the third party organization. Visit Claims code lists for a complete list.
T1T2T3T4T5The allowed amount, expressed as a decimal.
The approved DRG amount, expressed as a decimal.
The approved DRG code.
The approved procedure code. If you provide this property, you must also include productOrServiceIDQualifier.
The approved revenue code.
The approved service units or inpatient days. Can be set to DA - Days or UN - Unit.
DAUNThe approved service units or inpatient days. The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three.
The organization identification number.
The pricing rate associated with per diem or flat rate pricing, expressed as a decimal.
The savings amount, expressed as a decimal.
Additional information or documentation required for the claim. This is where you can include information about attachments, if applicable.
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Required when you plan to submit an attachment for the claim electronically through Stedi APIs or SFTP, when there is a paper attachment following this claim, or when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request.
Use this object when there is a single attachment for the claim. If there are multiple attachments, use the reportInformations array instead.
Show attributes
The control number assigned to the attachment. The payer uses this identifier to match the attachment to the claim. We recommend using a ULID or UUID of up to 50 characters.
Code indicating the title or contents of a document, report or supporting item. For example, 08 - Plan of Treatment or CT - Certification. Visit Claims code lists for a complete list.
0304050607Code identifying the method by which the provider's report is attached. Can be set to AA - Available on Request at Provider Site, BM - By Mail, EL - Electronically Only, EM - E-Mail, FT - File Transfer, or FX - By Fax.
Set this to EL when you plan to submit attachments electronically through Stedi APIs.
AABMELEMFTAn array of report information for the claim. Use this when you need to submit multiple report information records. You can submit up to 10 objects in this array.
Required when you plan to submit attachments for the claim electronically through Stedi APIs or SFTP, when there is a paper attachment following this claim, or when the provider deems it necessary to identify that they have additional information at their office that is available upon request.
Array item
The control number assigned to the attachment. The payer uses this identifier to match the attachment to the claim. We recommend using a ULID or UUID of up to 50 characters.
Code indicating the title or contents of a document, report or supporting item. For example, 08 - Plan of Treatment or CT - Certification. Visit Claims code lists for a complete list.
0304050607Code identifying the method by which the provider's report is attached. Can be set to AA - Available on Request at Provider Site, BM - By Mail, EL - Electronically Only, EM - E-Mail, FT - File Transfer, or FX - By Fax.
Set this to EL when you plan to submit attachments electronically through Stedi APIs.
AABMELEMFTCode indicating the type of service authorization exception. Visit Claims code lists for a complete list.
12345Information about the individual with primary responsibility for performing the surgical procedure(s) listed in the service line. Required when a surgical procedure code is listed.
This should be an individual, not an organization, and you should supply at least the provider's lastName and an identifier, which is typically the npi.
Show attributes
The physician's first name.
The type of identifier used in secondaryIdentifier. Can be set to 0B - State License Number, 1G - Provider UPIN Number, G2 - Provider Commercial Number, or LU - Location Number. Note that UPIN is deprecated and should not be used.
0B1GG2LUThe physician's last name.
The physician's middle name or initial.
The individual National Provider Identifier (NPI) assigned to the physician.
The physician's business name.
The identifier specified in identificationQualifierCode.
You can only include one secondary identifier for the provider.
The physician's name suffix, such as Jr. or III.
Information about the individual who performed a secondary surgical procedure or assisted the operatingPhysician. Required when another operating physician is involved in the surgical procedures listed in the service line.
This should be an individual, not an organization, and you should supply at least the provider's lastName and an identifier, which is typically the npi.
Show attributes
The physician's first name.
The type of identifier used in secondaryIdentifier. Can be set to 0B - State License Number, 1G - Provider UPIN Number, G2 - Provider Commercial Number, or LU - Location Number. Note that UPIN is deprecated and should not be used.
0B1GG2LUThe physician's last name.
The physician's middle name or initial.
The individual National Provider Identifier (NPI) assigned to the physician.
The physician's business name.
The identifier specified in identificationQualifierCode.
You can only include one secondary identifier for the provider.
The physician's name suffix, such as Jr. or III.
Information about the provider who referred the patient for care.
- Include this object only when the referring provider is different than the provider listed in the
attendingobject. - This should be an individual, not an organization, and you should supply at least the provider's
lastNameand an identifier, which is typically thenpi.
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Show attributes
The first line of the street address. This typically contains the building number and street name.
The second line of the street address. This typically contains the apartment or suite number.
The city name.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
The postal zone or zip code. Exclude punctuation and spaces.
The state or province code. Only required when the city is in the Unites States and Canada.
Show attributes
The email address.
The fax number.
The full name of the person or office.
The phone number, formatted as AAABBBCCCC, where AAA represents the area code, BBB is the telephone number prefix, and CCCC is the telephone number. The phone number should only include the digits 0 to 9. Don't include separators, such as dashes, and don't include long distance access numbers, such as 1. For example, you would format the phone number 123-456-7890 as 1234567890.
The provider's first name.
The provider's last name.
The provider's middle name or initial.
The individual National Provider Identifier (NPI) assigned to the provider.
The provider's business name.
This field is now automatically populated and it only remains for backwards compatibility.
ReferringProviderAdditional identifiers for the provider. You can set qualifier to 2U - Payer Identification Number.
Array item
The identifier specified in qualifier.
The code qualifying the type of identifier.
The type of identifier used in secondaryIdentifier. Can be set to 0B - State License Number, 1G - Provider UPIN Number, or G2 - Provider Commercial Number. Note that UPIN is deprecated and should not be used.
0B1GG2The identifier specified in secondaryIdentifierQualifierCode.
You can only include one secondary identifier for the provider.
The provider's suffix, such as Jr. or Sr.
^[A-Za-z0-9]{10}$Information about the provider who delivered the medical services or non-surgical procedures in this service line. This must be an individual, not an organization, and you must include the provider's lastName and an identifier, which is typically the npi. The provider's firstName is also required, if applicable.
Include this object when the following are both true:
- The rendering provider for this service line is different than the provider listed in the attending and rendering objects for the entire claim.
- State or federal regulatory requirements call for a combined claim. A combined claim includes both facility and professional components, such as a Medicaid clinic bill or a critical access hospital claim.
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Show attributes
The first line of the street address. This typically contains the building number and street name.
The second line of the street address. This typically contains the apartment or suite number.
The city name.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
The postal zone or zip code. Exclude punctuation and spaces.
The state or province code. Only required when the city is in the Unites States and Canada.
Show attributes
The email address.
The fax number.
The full name of the person or office.
The phone number, formatted as AAABBBCCCC, where AAA represents the area code, BBB is the telephone number prefix, and CCCC is the telephone number. The phone number should only include the digits 0 to 9. Don't include separators, such as dashes, and don't include long distance access numbers, such as 1. For example, you would format the phone number 123-456-7890 as 1234567890.
The provider's first name.
The provider's last name.
The provider's middle name or initial.
The individual National Provider Identifier (NPI) assigned to the provider.
The provider's business name.
This field is now automatically populated and it only remains for backwards compatibility.
RenderingProviderAdditional identifiers for the provider. You can set qualifier to 2U - Payer Identification Number.
Array item
The identifier specified in qualifier.
The code qualifying the type of identifier.
The type of identifier used in secondaryIdentifier. Can be set to 0B - State License Number, 1G - Provider UPIN Number, G2 - Provider Commercial Number, or LU - Location Number. Note that UPIN is deprecated and should not be used.
0B1GG2LUThe identifier specified in secondaryIdentifierQualifierCode.
You can only include one secondary identifier for the provider.
The provider's suffix, such as Jr. or Sr.
^[A-Za-z0-9]{10}$Required when a repricing (pricing) organization needs to have an identifying number on the service line in their submission to their payer organization.
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$Either a single date of service or the beginning of a range of service dates. If a range is provided, the end date should be provided in serviceDateEnd.
This property is required on outpatient service lines where a drug is not being billed and the Statement Covers Period is greater than one day.
It's also required when a drug is being billed and the payer's adjudication is known to be impacted by the drug duration or the date the prescription was written. In cases where a drug is being billed on a service line, this property may be used to indicate the date the prescription was written (or otherwise communicated by the prescriber if not written).
This property may also be used to indicate the beginning of the duration for which the drug supply will be used by the patient. The difference in dates, including both the begin and end dates, are the days supply of the drug. Example: 20000101-20000107 (1/1/00 to 1/7/00) is used for a 7 day supply where the first day of the drug used by the patient is 1/1/00. In the event a drug is administered on less than a daily basis (for example, every other day) the date range would include the entire period during which the drug was supplied, including the last day the drug was used. Example: 20000101-20000108 (1/1/00 to 1/8/00) is used for an 8 days supply where the prescription is written for Q48 (every 48 hours), four doses of the drug are dispensed and the first dose is used on 1/1/00.
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$The end of a range of service dates. If you include this property, you must also include serviceDate to indicate the beginning of the range.
Show attributes
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$Additional identifiers for the service line. We strongly recommend setting the providerControlNumber property for each service line within the claim.
A unique identifier for this service line within the claim. It appears in the 835 (ERA) response as lineItemControlNumber, allowing you to correlate ERAs to the specific service lines from the original claim. We strongly recommend setting this property for every service line within the claim. We also recommend using a ULID instead of a UUID because payers are only required to store up to 30 characters for this value.
Required when a repricing (pricing) organization needs to have an identifying number on the service line in their submission to their payer organization. Providers shouldn't complete this property.
Required when a repricing (pricing) organization needs to have an identifying number on an adjusted service line in their submission to their payer organization. Providers shouldn't complete this property.
Supporting documentation for the service line. Required when you plan to submit an attachment for the service line electronically through Stedi APIs or SFTP, when there is a paper attachment following this claim, or when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request.
Use this object when there is a single attachment. If there are multiple attachments, use the serviceLineSupplementalInformations array instead.
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The control number assigned to the attachment. Required when the attachmentTransmissionCode = BM, EL, EM, FX, or FT.
The payer uses this identifier to match the attachment to the claim. We recommend using a ULID or UUID of up to 50 characters.
Code indicating the title or contents of a document, report or supporting item. For example, 08 - Plan of Treatment or CT - Certification. Visit Claims code lists for a complete list.
0304050607Code identifying the method by which the provider's report is attached. Can be set to AA - Available on Request at Provider Site, BM - By Mail, EL - Electronically Only, EM - E-Mail, FT - File Transfer, or FX - By Fax.
Set this to EL when you plan to submit attachments electronically through Stedi APIs.
AABMELEMFTAn array of supplemental information for the service line. This is the array version of the serviceLineSupplementalInformation property.
This array is required when you plan to submit multiple attachments for the service line electronically through Stedi APIs or SFTP, when there is a paper attachment following this claim, or when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request.
You can submit up to 10 objects in this array.
Array item
The control number assigned to the attachment. Required when the attachmentTransmissionCode = BM, EL, EM, FX, or FT.
The payer uses this identifier to match the attachment to the claim. We recommend using a ULID or UUID of up to 50 characters.
Code indicating the title or contents of a document, report or supporting item. For example, 08 - Plan of Treatment or CT - Certification. Visit Claims code lists for a complete list.
0304050607Code identifying the method by which the provider's report is attached. Can be set to AA - Available on Request at Provider Site, BM - By Mail, EL - Electronically Only, EM - E-Mail, FT - File Transfer, or FX - By Fax.
Set this to EL when you plan to submit attachments electronically through Stedi APIs.
AABMELEMFT^\d+(\.\d{1,2})?$The amount of the service tax or surcharge, formatted as a decimal. Required when a service tax or surcharge applies to the service being reported. The claimInformation.serviceLines.institutionalService.lineItemChargeAmount must include the amount you report here.
To provide additional information for comment or special instruction. Required when the TPO/repricer needs to forward additional information to the payer.
Required when Home Health Agencies need to report Plan of Treatment information under various payer contracts. This is an array of arrays of strings. You can provide up to two string arrays, and each array can contain up to 12 strings. Each string represents one treatment code.
Required when there is a Value Code that applies to this claim. This is an array of arrays of objects. You can provide up to two object arrays, and each array can contain up to 12 objects.
Array item
Array item
The value code.
^\d+(\.\d{1,2})?$The monetary amount associated with the value code, expressed as a decimal.
^\d+$Length: 9Not currently used.
Dependent who received the medical care associated with the claim. When the dependent has their own member ID for the health plan, you should include the dependent's information in the subscriber object instead. To check whether a dependent has a member ID, submit an Eligibility Check to the payer. The payer returns the dependent's member ID in the dependents.memberId property in the response, if present.
Show attributes
The patient's address. Every claim must include this information in either the subscriber (when the patient is the subscriber) or dependent (when the patient is a dependent) object. You must include at least the address1 and city properties in this object. The state and postalCode properties are also required for all United States and Canadian addresses.
- The address must be the patient's correct address at the time of service. Don't use placeholder values to complete unknown address information. Use of outdated or placeholder values could cause the payer to reject, deny, or delay the claim due to suspected fraud.
- If you don't know the patient's address, you should first submit a Real-Time Eligibility Check for the patient and then copy the patient's address from either the subscriber or dependent object in the response.
- If the patient doesn't have a current address, you can populate the address1 property with UNKNOWN and populate the city, state, and zip code with appropriate values based on your discretion. However, some payers may have explicit rules for how to handle this situation, so you should check the payer's specific requirements before using this approach.
Show attributes
The first line of the street address. This typically contains the building number and street name.
The second line of the street address. This typically contains the apartment or suite number.
The city name.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
The postal zone or zip code. Exclude punctuation and spaces.
The state or province code. Only required when the city is in the Unites States and Canada.
^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$The patient's date of birth.
The patient's first name.
Code identifying the gender. Can be set to F - Female, M - Male, or U - Unknown.
Some payers may reject the claim if the patient's gender doesn't match the gender they have recorded in their member records. If the gender isn't known or the patient declines to answer, use U or perform an eligibility check to determine the gender according to the payer's records.
MFUThe patient's last name. Don't include the patient's name suffix, such as Jr. or III. Use the designated suffix property instead.
The patient's middle name or initial.
Identifies the relationship of the patient to the subscriber. Can be set to 01 - Spouse, 19 - Child, 20 - Employee, 21 - Unknown, 39 - Organ Donor, 40 - Cadaver Donor, 53 - Life Partner, or G8 - Other Relationship.
0119202139The patient's Social Security Number. Only used for Property and Casualty claims.
The patient's name suffix, such as Jr. or III. Only include the patient's personal name suffix - don't include professional or academic titles, such as M.D. or MBA.
Information about the individual with primary responsibility for performing the surgical procedure(s) listed in the claim. Required when a surgical procedure code is listed on the claim. Use this object for operating physicians that apply to the entire claim.
This should be an individual, not an organization, and you should supply at least the physician's lastName and an identifier, which is typically the npi.
Show attributes
The physician's first name.
The type of identifier used in secondaryIdentifier. Can be set to 0B - State License Number, 1G - Provider UPIN Number, G2 - Provider Commercial Number, or LU - Location Number. Note that UPIN is deprecated and should not be used.
0B1GG2LUThe physician's last name.
The physician's middle name or initial.
The individual National Provider Identifier (NPI) assigned to the physician.
The physician's business name.
The identifier specified in identificationQualifierCode.
You can only include one secondary identifier for the provider.
The physician's name suffix, such as Jr. or III.
Information about any other operating physician involved in the surgical procedures listed in the claim. Required when another operating physician is involved in the surgical procedures listed in the claim. Use this object for physicians that apply to the entire claim.
This should be an individual, not an organization, and you should supply at least the physician's lastName and an identifier, which is typically the npi.
Show attributes
The physician's first name.
The type of identifier used in secondaryIdentifier. Can be set to 0B - State License Number, 1G - Provider UPIN Number, G2 - Provider Commercial Number, or LU - Location Number. Note that UPIN is deprecated and should not be used.
0B1GG2LUThe physician's last name.
The physician's middle name or initial.
The individual National Provider Identifier (NPI) assigned to the physician.
The physician's business name.
The identifier specified in identificationQualifierCode.
You can only include one secondary identifier for the provider.
The physician's name suffix, such as Jr. or III.
Address information for the entity responsible for payment of the claim, listed in the receiver object.
Show attributes
The first line of the street address. This typically contains the building number and street name.
The second line of the street address. This typically contains the apartment or suite number.
The city name.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
The postal zone or zip code. Exclude punctuation and spaces.
The state or province code. Only required when the city is in the Unites States and Canada.
Another way to send information for each provider relevant to the claim. This object overwrites the information you send in the billing, referring, rendering, and attending objects. Note that your request must include information about the billing provider either here or within the billing object.
Array item
The provider's business address. Only applies to the billing provider.
Show attributes
The first line of the street address. This typically contains the building number and street name.
The second line of the street address. This typically contains the apartment or suite number.
The city name.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
The postal zone or zip code. Exclude punctuation and spaces.
The state or province code. Only required when the city is in the Unites States and Canada.
The provider's contact information. Only applies to the billing provider. You must include at least one communication method (phone, fax, or email) in this object.
Show attributes
The email address.
The fax number.
The full name of the person or office.
The phone number, formatted as AAABBBCCCC, where AAA represents the area code, BBB is the telephone number prefix, and CCCC is the telephone number. The phone number should only include the digits 0 to 9. Don't include separators, such as dashes, and don't include long distance access numbers, such as 1. For example, you would format the phone number 123-456-7890 as 1234567890.
The provider's employer ID, also known as an EIN or TIN. Must be a string of exactly nine numbers with no separators. Only applies to the billing provider.
The provider's first name.
The provider's last name.
The provider's middle name or initial.
The National Provider Identifier (NPI) of the provider. Note that this is required for billing providers that have an NPI assigned.
The provider's business name, when the provider is not an individual.
The type of provider. Set to the type that matches the provider's role in the claim. For example, if the provider is the referring provider, set this to ReferringProvider.
BillingProviderAttendingProviderReferringProviderRenderingProviderThe type of identifier used in secondaryIdentifier. Can be set to 0B - State License Number, 1G - Provider UPIN Number, G2 - Provider Commercial Number, or LU - Location Number. Note that UPIN is deprecated and should not be used.
0B1GG2LUThe identifier referenced by secondaryIdentificationQualifierCode. For example, if secondaryIdentificationQualifierCode is set to 0B, this property should be the provider's state license number.
You can only include one secondary identifier for the provider.
The provider's name suffix, such as Jr. or III.
The provider's taxnonomy code, a unique 10-character code that designates their classification and specialization. Only applies to the attending provider.
The entity responsible for the payment of the claim, such as an insurance company or government agency.
Show attributes
The business name of the payer receiving the claim, such as Aetna or Cigna.
The receiver's Electronic Transmitter Identification Number (ETIN), as assigned by the payer. This may be the same as the payer's TIN, but it can also be another unique identifier. We strongly recommend including this property in your request.
Information about the provider who referred the patient for care.
- Include this object only when the referring provider is different than the provider listed in the
attendingobject. - Use this object for providers that apply to the entire claim.
- This should be an individual, not an organization, and you should supply at least the provider's
lastNameand an identifier, which is typically thenpi.
Show attributes
Show attributes
The first line of the street address. This typically contains the building number and street name.
The second line of the street address. This typically contains the apartment or suite number.
The city name.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
The postal zone or zip code. Exclude punctuation and spaces.
The state or province code. Only required when the city is in the Unites States and Canada.
Show attributes
The email address.
The fax number.
The full name of the person or office.
The phone number, formatted as AAABBBCCCC, where AAA represents the area code, BBB is the telephone number prefix, and CCCC is the telephone number. The phone number should only include the digits 0 to 9. Don't include separators, such as dashes, and don't include long distance access numbers, such as 1. For example, you would format the phone number 123-456-7890 as 1234567890.
The provider's first name.
The provider's last name.
The provider's middle name or initial.
The individual National Provider Identifier (NPI) assigned to the provider.
The provider's business name.
This field is now automatically populated and it only remains for backwards compatibility.
ReferringProviderThe type of identifier used in secondaryIdentifier. Can be set to 0B - State License Number, 1G - Provider UPIN Number, or G2 - Provider Commercial Number. Note that UPIN is deprecated and should not be used.
0B1GG2The identifier specified in secondaryIdentifierQualifierCode.
You can only include one secondary identifier for the provider.
The provider's name suffix, such as Jr. or III.
Information about the provider who delivered the medical services or non-surgical procedures listed in the claim. This must be an individual, not an organization, and you must supply at least the provider's lastName and an identifier, which is typically the npi. The provider's firstName is also required, if applicable.
Include this object when all of the following are true:
- The rendering provider is different than the provider listed in the
attendingobject. - The provider applies to the entire claim or to at least one service line. For example, if a claim had two service lines with two different rendering providers, you would include the provider for the first service line here and leave the
claimInformation.serviceLines.renderingProviderobject for that service line blank. Then, you would specify the second provider in the appropriate service line'sclaimInformation.serviceLines.renderingProviderobject. - State or federal regulatory requirements call for a combined claim. A combined claim includes both facility and professional components, such as a Medicaid clinic bill or a critical access hospital claim.
Show attributes
Show attributes
The first line of the street address. This typically contains the building number and street name.
The second line of the street address. This typically contains the apartment or suite number.
The city name.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
The postal zone or zip code. Exclude punctuation and spaces.
The state or province code. Only required when the city is in the Unites States and Canada.
The provider's commercial number.
Show attributes
The email address.
The fax number.
The full name of the person or office.
The phone number, formatted as AAABBBCCCC, where AAA represents the area code, BBB is the telephone number prefix, and CCCC is the telephone number. The phone number should only include the digits 0 to 9. Don't include separators, such as dashes, and don't include long distance access numbers, such as 1. For example, you would format the phone number 123-456-7890 as 1234567890.
The provider's first name.
The provider's last name.
The provider's location number.
The provider's middle name or initial.
The individual National Provider Identifier (NPI) assigned to the provider.
The provider's business name.
This field is now automatically populated and it only remains for backwards compatibility.
The type of identifier used in secondaryIdentifier. Can be set to 0B - State License Number, 1G - Provider UPIN Number, G2 - Provider Commercial Number, or LU - Location Number. Note that UPIN is deprecated and should not be used.
0B1GG2LUThe identifier specified in the secondaryIdentificationQualifierCode.
You can only include one secondary identifier for the provider.
The provider's state license number. This is assigned directly by a payer in order to identify the provider in their system. This is not commonly used.
The provider's name suffix, such as Jr. or III.
The entity submitting the healthcare claim. This is an organization, such as a hospital or other treatment center.
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Contact information for the institution submitting the claim. This should be the person or department that deals with data submission and claim processing issues. You must include at least one communication method (phone, fax, or email) in this object.
Show attributes
The email address.
The fax number.
The full name of the person or office.
The phone number, formatted as AAABBBCCCC, where AAA represents the area code, BBB is the telephone number prefix, and CCCC is the telephone number. The phone number should only include the digits 0 to 9. Don't include separators, such as dashes, and don't include long distance access numbers, such as 1. For example, you would format the phone number 123-456-7890 as 1234567890.
The business name of the institution submitting the claim.
The submitter's Electronic Transmitter Identification Number (ETIN), as assigned by the payer. For some payers, this may be the same as the submitter's NPI, EIN/TIN, but it can also be another unique identifier. Payers can refer to this identifier as the Provider Number, Submitter ID, Submitter Identifier, Submitter Primary Number, Sender Code, Certified Contracted Provider ID, and other names.
The person or entity who is the primary policyholder for the health plan or a dependent with their own member ID.
- When a dependent has a unique, payer-assigned member ID, treat them as the subscriber for the claim submission - include their information here and omit the
dependentobject from the request. - You must set the
dateOfBirthandgenderproperties when the subscriber is the patient. Stedi determines that the subscriber is the patient when thedependentobject is not included in the request. - If either
dateOfBirthorgenderis set, you must include both properties. You can either include both properties or neither within a single request.
Show attributes
The subscriber's address. Every claim must include address information in either the subscriber (when the patient is the subscriber) or dependent (when the patient is a dependent) object. You must include at least the address1 and city properties in this object. The state and postalCode properties are also required for all United States and Canadian addresses.
- The address must be the patient's correct address at the time of service. Don't use placeholder values to complete unknown address information. Use of outdated or placeholder values could cause the payer to reject, deny, or delay the claim due to suspected fraud.
- If you don't know the patient's address, you should first submit a Real-Time Eligibility Check for the patient and then copy the patient's address from either the subscriber or dependents object in the response.
- If the patient doesn't have a current address, you can populate the address1 property with UNKNOWN and populate the city, state, and zip code with appropriate values based on your discretion. However, some payers may have explicit rules for how to handle this situation, so you should check the payer's specific requirements before using this approach.
Show attributes
The first line of the street address. This typically contains the building number and street name.
The second line of the street address. This typically contains the apartment or suite number.
The city name.
Use the alpha-2 country codes from Part 1 of ISO 3166.
Use the country subdivision codes from Part 2 of ISO 3166.
The postal zone or zip code. Exclude punctuation and spaces.
The state or province code. Only required when the city is in the Unites States and Canada.
The subscriber's date of birth, formatted as YYYYMMDD.
The subscriber's first name.
Code identifying the gender. Can be set to F - Female, M - Male, or U - Unknown.
Some payers may reject the claim if the patient's gender doesn't match the gender they have recorded in their member records. If the gender isn't known or the patient declines to answer, use U or perform an eligibility check to determine the gender according to the payer's records.
MFUThe subscriber's health plan group number.
The subscriber's last name. Don't include the subscriber's name suffix, such as Jr. or III. Use the designated suffix property instead.
The member ID for the subscriber's insurance policy.
The subscriber's middle name or initial.
Code identifying the payer's level of responsibility for paying this claim. Visit Claims code lists for a complete list of possible codes.
- Stedi sets this property to
P- Primary by default. You only need to include it when you need to submit codes other thanP. This can happen when the patient has multiple insurance policies. For example, if a patient is covered by both Medicare and an employer-sponsored commercial plan, you could bill the commercial plan first asPand then bill the Medicare payer second asS. - Either this property or
otherSubscriberInformation.paymentResponsibilityLevelCodemust be set toP. Stedi rejects claims - including secondary and tertiary claims - that don't include information for the primary payer.
ABCDEDeprecated.
The subscriber's Social Security Number. This must be a string of exactly nine numbers with no separators. For example, 123456789.
Deprecated. Use the memberId property instead.
The subscriber's name suffix, such as Jr. or III. Only include the subscriber's personal name suffix - don't include professional or academic titles, such as M.D. or MBA.
This is the payer's business name, like Cigna or Aetna.
This is the Payer ID. Visit the Payer Network for a complete list. You can send requests using the Primary Payer ID, the Stedi Payer ID, or any alias listed in the payer record.
Whether you want to send a test or production claim. This property also allows you to filter claims in the Stedi portal by production or test data. By default, this property is set to P for production data. Use T to designate a claim as test data.
Response
InstitutionalClaimsSubmission 200 response
Information about the claim.
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The type of claim, always INST.
An identifier Stedi assigns to the claim.
A tracking number that Stedi assigns to the claim.
The X12 EDI version Stedi used to generate the claim for the payer. This is always 5010.
The patientControlNumber from the original request, if supplied. This is a unique identifier that you assign to the claim so you can track the claim and correlate it with responses from the payer.
The payer's ID. This is the same as the tradingPartnerServiceId.
A tracking number Stedi assigns to the claim. This is the same as the correlationId.
Contains a unique identifier for each service line, listed in the order the service lines were included in the claim. You can use these identifiers to correlate payer responses to specific service lines.
Array item
A unique identifier for the service line, matching the value provided for the claimInformation.serviceLines.providerControlNumber property in the claim submission. If you didn't provide a value for providerControlNumber, this property contains a randomly generated a ULID for the service line.
Stedi's ID for the entity that submitted the claim.
A timestamp for Stedi's response to the claim submission.
An identifier for the transaction.
Currently not used.
Array item
This shape is deprecated: Currently not used.
Errors resulting from claim edits. You must review and fix these errors before resubmitting.
Array item
The error code.
The description of the error code.
The field related to the error.
Recommended followup actions to correct the error.
Where the error is located in the original request.
The value for the data causing the error.
Currently not used.
Show attributes
A 200 response indicates that Stedi successfully generated the X12 EDI claim format required by the payer. It does not indicate whether the payer has accepted the claim - the payer will respond later with a 277CA containing this information. Learn more about 277CAs. A 400 response indicates one or more problems with the claim data in the request. Examples include missing required fields, invalid values, or incorrect data types. The response includes a message describing the problem.
200 OK400 BAD_REQUESTMetadata from Stedi about the request.
Show attributes
Indicates where this request can be found for support.
The biller ID assigned to this request.
The sender ID assigned to this request.
The submitter ID assigned to this request.
The file execution ID, a unique identifier assigned to the processed file within the Stedi platform.
The status of the claim submission.
An ID for the payer you identified in the original claim. This value may differ from the tradingPartnerServiceId you submitted in the original request because it reflects the payer's internal concept of their ID, not necessarily the ID Stedi uses to route requests to this payer.
A list of warnings. Currently not used.
Array item
A machine-readable code indicating the type of problem.
A human-readable description of the problem.
curl --request POST \ --url "https://healthcare.us.stedi.com/2024-04-01/change/medicalnetwork/institutionalclaims/v1/submission" \ --header "Authorization: <api_key>" \ --header "Content-Type: application/json" \ --data '{ "claimInformation": { "benefitsAssignmentCertificationIndicator": "Y", "claimChargeAmount": "500.00", "claimCodeInformation": { "admissionSourceCode": "9", "admissionTypeCode": "3", "patientStatusCode": "30" }, "claimDateInformation": { "admissionDateAndHour": "202409091000", "statementBeginDate": "20241015", "statementEndDate": "20241015" }, "claimFilingCode": "ZZ", "claimFrequencyCode": "0", "patientControlNumber": "<YOUR-CLAIM-ID>", "placeOfServiceCode": "11", "planParticipationCode": "C", "principalDiagnosis": { "principalDiagnosisCode": "R45851", "qualifierCode": "ABK" }, "releaseInformationCode": "Y", "serviceLines": [ { "assignedNumber": "0", "institutionalService": { "lineItemChargeAmount": "500.00", "measurementUnit": "UN", "procedureCode": "H0001", "procedureIdentifier": "HC", "serviceLineRevenueCode": "0800", "serviceUnitCount": "1" }, "lineItemControlNumber": "111222333", "serviceDate": "20241015", "serviceDateEnd": "20241015" } ] }, "controlNumber": "123456789", "providers": [ { "address": { "address1": "123 Mulberry Street", "city": "Seattle", "postalCode": "111135272", "state": "WA" }, "contactInformation": { "name": "Test Facility", "phoneNumber": "2065551234" }, "employerId": "123456789", "npi": "0123456789", "organizationName": "Test Facility", "providerType": "BillingProvider" }, { "contactInformation": { "name": "name" }, "firstName": "Doctor", "lastName": "Provider", "npi": "1234567890", "providerType": "AttendingProvider" } ], "receiver": { "organizationName": "UnitedHealthcare" }, "submitter": { "contactInformation": { "name": "Test Facility", "phoneNumber": "2225551234" }, "organizationName": "Test Facility", "taxId": "123456789" }, "subscriber": { "dateOfBirth": "19000101", "firstName": "JANE", "gender": "F", "lastName": "DOE", "memberId": "98765", "paymentResponsibilityLevelCode": "P" }, "tradingPartnerName": "UnitedHealthcare", "tradingPartnerServiceId": "87726", "usageIndicator": "T" }'const body = JSON.stringify({ "claimInformation": { "benefitsAssignmentCertificationIndicator": "Y", "claimChargeAmount": "500.00", "claimCodeInformation": { "admissionSourceCode": "9", "admissionTypeCode": "3", "patientStatusCode": "30" }, "claimDateInformation": { "admissionDateAndHour": "202409091000", "statementBeginDate": "20241015", "statementEndDate": "20241015" }, "claimFilingCode": "ZZ", "claimFrequencyCode": "0", "patientControlNumber": "<YOUR-CLAIM-ID>", "placeOfServiceCode": "11", "planParticipationCode": "C", "principalDiagnosis": { "principalDiagnosisCode": "R45851", "qualifierCode": "ABK" }, "releaseInformationCode": "Y", "serviceLines": [ { "assignedNumber": "0", "institutionalService": { "lineItemChargeAmount": "500.00", "measurementUnit": "UN", "procedureCode": "H0001", "procedureIdentifier": "HC", "serviceLineRevenueCode": "0800", "serviceUnitCount": "1" }, "lineItemControlNumber": "111222333", "serviceDate": "20241015", "serviceDateEnd": "20241015" } ] }, "controlNumber": "123456789", "providers": [ { "address": { "address1": "123 Mulberry Street", "city": "Seattle", "postalCode": "111135272", "state": "WA" }, "contactInformation": { "name": "Test Facility", "phoneNumber": "2065551234" }, "employerId": "123456789", "npi": "0123456789", "organizationName": "Test Facility", "providerType": "BillingProvider" }, { "contactInformation": { "name": "name" }, "firstName": "Doctor", "lastName": "Provider", "npi": "1234567890", "providerType": "AttendingProvider" } ], "receiver": { "organizationName": "UnitedHealthcare" }, "submitter": { "contactInformation": { "name": "Test Facility", "phoneNumber": "2225551234" }, "organizationName": "Test Facility", "taxId": "123456789" }, "subscriber": { "dateOfBirth": "19000101", "firstName": "JANE", "gender": "F", "lastName": "DOE", "memberId": "98765", "paymentResponsibilityLevelCode": "P" }, "tradingPartnerName": "UnitedHealthcare", "tradingPartnerServiceId": "87726", "usageIndicator": "T"})fetch("https://healthcare.us.stedi.com/2024-04-01/change/medicalnetwork/institutionalclaims/v1/submission", { headers: { "Authorization": "<api_key>" }, body})package mainimport ( "fmt" "net/http" "io/ioutil" "strings")func main() { url := "https://healthcare.us.stedi.com/2024-04-01/change/medicalnetwork/institutionalclaims/v1/submission" body := strings.NewReader(`{ "claimInformation": { "benefitsAssignmentCertificationIndicator": "Y", "claimChargeAmount": "500.00", "claimCodeInformation": { "admissionSourceCode": "9", "admissionTypeCode": "3", "patientStatusCode": "30" }, "claimDateInformation": { "admissionDateAndHour": "202409091000", "statementBeginDate": "20241015", "statementEndDate": "20241015" }, "claimFilingCode": "ZZ", "claimFrequencyCode": "0", "patientControlNumber": "<YOUR-CLAIM-ID>", "placeOfServiceCode": "11", "planParticipationCode": "C", "principalDiagnosis": { "principalDiagnosisCode": "R45851", "qualifierCode": "ABK" }, "releaseInformationCode": "Y", "serviceLines": [ { "assignedNumber": "0", "institutionalService": { "lineItemChargeAmount": "500.00", "measurementUnit": "UN", "procedureCode": "H0001", "procedureIdentifier": "HC", "serviceLineRevenueCode": "0800", "serviceUnitCount": "1" }, "lineItemControlNumber": "111222333", "serviceDate": "20241015", "serviceDateEnd": "20241015" } ] }, "controlNumber": "123456789", "providers": [ { "address": { "address1": "123 Mulberry Street", "city": "Seattle", "postalCode": "111135272", "state": "WA" }, "contactInformation": { "name": "Test Facility", "phoneNumber": "2065551234" }, "employerId": "123456789", "npi": "0123456789", "organizationName": "Test Facility", "providerType": "BillingProvider" }, { "contactInformation": { "name": "name" }, "firstName": "Doctor", "lastName": "Provider", "npi": "1234567890", "providerType": "AttendingProvider" } ], "receiver": { "organizationName": "UnitedHealthcare" }, "submitter": { "contactInformation": { "name": "Test Facility", "phoneNumber": "2225551234" }, "organizationName": "Test Facility", "taxId": "123456789" }, "subscriber": { "dateOfBirth": "19000101", "firstName": "JANE", "gender": "F", "lastName": "DOE", "memberId": "98765", "paymentResponsibilityLevelCode": "P" }, "tradingPartnerName": "UnitedHealthcare", "tradingPartnerServiceId": "87726", "usageIndicator": "T" }`) req, _ := http.NewRequest("POST", url, body) req.Header.Add("Authorization", "<api_key>") req.Header.Add("Content-Type", "application/json") res, _ := http.DefaultClient.Do(req) defer res.Body.Close() body, _ := ioutil.ReadAll(res.Body) fmt.Println(res) fmt.Println(string(body))}import requestsurl = "https://healthcare.us.stedi.com/2024-04-01/change/medicalnetwork/institutionalclaims/v1/submission"body = { "claimInformation": { "benefitsAssignmentCertificationIndicator": "Y", "claimChargeAmount": "500.00", "claimCodeInformation": { "admissionSourceCode": "9", "admissionTypeCode": "3", "patientStatusCode": "30" }, "claimDateInformation": { "admissionDateAndHour": "202409091000", "statementBeginDate": "20241015", "statementEndDate": "20241015" }, "claimFilingCode": "ZZ", "claimFrequencyCode": "0", "patientControlNumber": "<YOUR-CLAIM-ID>", "placeOfServiceCode": "11", "planParticipationCode": "C", "principalDiagnosis": { "principalDiagnosisCode": "R45851", "qualifierCode": "ABK" }, "releaseInformationCode": "Y", "serviceLines": [ { "assignedNumber": "0", "institutionalService": { "lineItemChargeAmount": "500.00", "measurementUnit": "UN", "procedureCode": "H0001", "procedureIdentifier": "HC", "serviceLineRevenueCode": "0800", "serviceUnitCount": "1" }, "lineItemControlNumber": "111222333", "serviceDate": "20241015", "serviceDateEnd": "20241015" } ] }, "controlNumber": "123456789", "providers": [ { "address": { "address1": "123 Mulberry Street", "city": "Seattle", "postalCode": "111135272", "state": "WA" }, "contactInformation": { "name": "Test Facility", "phoneNumber": "2065551234" }, "employerId": "123456789", "npi": "0123456789", "organizationName": "Test Facility", "providerType": "BillingProvider" }, { "contactInformation": { "name": "name" }, "firstName": "Doctor", "lastName": "Provider", "npi": "1234567890", "providerType": "AttendingProvider" } ], "receiver": { "organizationName": "UnitedHealthcare" }, "submitter": { "contactInformation": { "name": "Test Facility", "phoneNumber": "2225551234" }, "organizationName": "Test Facility", "taxId": "123456789" }, "subscriber": { "dateOfBirth": "19000101", "firstName": "JANE", "gender": "F", "lastName": "DOE", "memberId": "98765", "paymentResponsibilityLevelCode": "P" }, "tradingPartnerName": "UnitedHealthcare", "tradingPartnerServiceId": "87726", "usageIndicator": "T"}response = requests.request("POST", url, json = body, headers = { "Authorization": "<api_key>", "Content-Type": "application/json"})print(response.text)import java.net.URI;import java.net.http.HttpClient;import java.net.http.HttpRequest;import java.net.http.HttpResponse;import java.net.http.HttpResponse.BodyHandlers;import java.time.Duration;import java.net.http.HttpRequest.BodyPublishers;var body = BodyPublishers.ofString("""{ "claimInformation": { "benefitsAssignmentCertificationIndicator": "Y", "claimChargeAmount": "500.00", "claimCodeInformation": { "admissionSourceCode": "9", "admissionTypeCode": "3", "patientStatusCode": "30" }, "claimDateInformation": { "admissionDateAndHour": "202409091000", "statementBeginDate": "20241015", "statementEndDate": "20241015" }, "claimFilingCode": "ZZ", "claimFrequencyCode": "0", "patientControlNumber": "<YOUR-CLAIM-ID>", "placeOfServiceCode": "11", "planParticipationCode": "C", "principalDiagnosis": { "principalDiagnosisCode": "R45851", "qualifierCode": "ABK" }, "releaseInformationCode": "Y", "serviceLines": [ { "assignedNumber": "0", "institutionalService": { "lineItemChargeAmount": "500.00", "measurementUnit": "UN", "procedureCode": "H0001", "procedureIdentifier": "HC", "serviceLineRevenueCode": "0800", "serviceUnitCount": "1" }, "lineItemControlNumber": "111222333", "serviceDate": "20241015", "serviceDateEnd": "20241015" } ] }, "controlNumber": "123456789", "providers": [ { "address": { "address1": "123 Mulberry Street", "city": "Seattle", "postalCode": "111135272", "state": "WA" }, "contactInformation": { "name": "Test Facility", "phoneNumber": "2065551234" }, "employerId": "123456789", "npi": "0123456789", "organizationName": "Test Facility", "providerType": "BillingProvider" }, { "contactInformation": { "name": "name" }, "firstName": "Doctor", "lastName": "Provider", "npi": "1234567890", "providerType": "AttendingProvider" } ], "receiver": { "organizationName": "UnitedHealthcare" }, "submitter": { "contactInformation": { "name": "Test Facility", "phoneNumber": "2225551234" }, "organizationName": "Test Facility", "taxId": "123456789" }, "subscriber": { "dateOfBirth": "19000101", "firstName": "JANE", "gender": "F", "lastName": "DOE", "memberId": "98765", "paymentResponsibilityLevelCode": "P" }, "tradingPartnerName": "UnitedHealthcare", "tradingPartnerServiceId": "87726", "usageIndicator": "T"}""");HttpClient client = HttpClient.newBuilder() .connectTimeout(Duration.ofSeconds(10)) .build();HttpRequest.Builder requestBuilder = HttpRequest.newBuilder() .uri(URI.create("https://healthcare.us.stedi.com/2024-04-01/change/medicalnetwork/institutionalclaims/v1/submission")) .header("Content-Type", "application/json") .header("Authorization", "<api_key>") .POST(body) .build();try { HttpResponse<String> response = client.send(requestBuilder.build(), BodyHandlers.ofString()); System.out.println("Status code: " + response.statusCode()); System.out.println("Response body: " + response.body());} catch (Exception e) { e.printStackTrace();}{
"claimReference": {
"claimType": "INST",
"correlationId": "01JABEX6DPF4FCT2J0Y0SGFCY8",
"formatVersion": "5010",
"patientControlNumber": "00001111222233334444",
"payerId": "87726",
"rhClaimNumber": "01JABEX6DPF4FCT2J0Y0SGFCY8",
"serviceLines": [
{
"lineItemControlNumber": "111222333"
}
],
"timeOfResponse": "2024-10-16T20:04:32.962Z"
},
"controlNumber": "123456789",
"httpStatusCode": "200 OK",
"meta": {
"traceId": "a742ab42-a6f3-4232-a88c-197d341afdbe"
},
"payer": {
"payerID": "87726",
"payerName": "UnitedHealthcare"
},
"status": "SUCCESS",
"tradingPartnerServiceId": "87726"
}{
"code": "string",
"message": "string"
}{
"code": "string",
"message": "string"
}{
"code": "string",
"message": "string"
}{
"code": "string",
"message": "string"
}{
"code": "string",
"message": "string"
}{
"code": "string",
"message": "string"
}{
"code": "string",
"message": "string"
}