OptumDeveloper

Professional Claims

commercialv3

The Professional Claims API takes the standard X12 EDI 837P transaction and translates it to JSON so it is more accessible to developers and easily integrated into users’ applications.

All endpoints
POST/medicalnetwork/professionalclaims/v3/submission

processClaim

Claim Submission

Header Parameters

NameTypeDescription
x-chng-trace-idstring—
Authorization*stringBearer Your-Access-Token<br/>Example: <b>Bearer eyJraWQiOiIxIiwid…</b>

Request Body*

application/json

object
controlNumber*string

Header, Segment: ST02 (no loop), Notes: Transaction Set Control Number

tradingPartnerServiceIdstring

Loop: 2010BB Segment: NM1, Element: NM109, Notes: we send this as MN108 as PI = Payer Identification

submitter*object

Loop: 1000A

organizationNamestring

Loop: 1000A, Segment: NM1, Element: NM103

lastNamestring

Loop: 1000A, Segment: NM1, Element: NM103

firstNamestring

Loop: 1000A, Segment: NM1, Element: NM104

middleNamestring

Loop: 1000A, Segment: NM1, Element: NM105

contactInformation*object

PER

name*string

Segment: PER, Element: PER02 and PER01=IC

phoneNumberstring

Segment: PER, Element: PER04 (Provider, Submitter, Subscriber, Dependent) or PER06 (Provider, Submitter) or PER08 (Provider, Submitter), Note: Used when PER03=TE (Provider, Submitter, Subscriber, Dependent) or PER05=TE (Provider, Submitter) or PER07=TE (Provider, Submitter)

faxNumberstring

Segment: PER, Element: PER04 or PER06 or PER08, Note: This is used in (Provider, Submitter) when PER03=FX or PER05=FX or PER07=FX

emailstring

Segment: PER, Element: PER04 or PER06 or PER08, Note: This used in (Provider, Submitter) when PER03=EM or PER05=EM or PER07=EM

phoneExtensionstring

Segment: PER, Element: PER06 (Provider, Submitter, Subscriber, Dependent) or PER08 (Provider, Submitter),Note: Used when PER05=EX (Provider, Submitter, Subscriber, Dependent) or PER07=EX (Provider, Submitter)

receiver*object

Loop: 1000B

organizationName*string

Loop: 1000B, Segment: NM1, Element: NM103

subscriber*object

Loop: 2000B

memberIdstring

Loop: 2010BA, Segment: NM1, Element: NM109

ssnstring

Loop: 2010BA, Segment: REF, Element: REF02 when REF01=SY

paymentResponsibilityLevelCode*string

Loop: 2000B, Segment: SBR, Element: SBR01, Allowed Values:'A' Payer Responsibility Four 'B' Payer Responsibility Five 'C' Payer Responsibility Six 'D' Payer Responsibility Seven 'E' Payer Responsibility Eight 'F' Payer Responsibility Nine 'G' Payer Responsibility Ten 'H' Payer Responsibility Eleven 'P' Primary 'S' Secondary 'T' Tertiary 'U' Unknown

Enum: ABCDEFGHPSTU

organizationNamestring

Loop: 2010BA, Segment: NM1, Element: NM103 when NM102=2, Notes: when subscriber is organization pass patient as dependent

insuranceTypeCodestring

Loop: 2000B, Segment: SBR, Element:SBR05 Notes: Allowed values: '12' Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan, '13' Medicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination Period with an Employer's Group Health Plan, '14' Medicare Secondary, No-fault Insurance including Auto is Primary, '15' Medicare Secondary Worker's Compensation, '16' Medicare Secondary Public Health Service (PHS)or Other Federal Agency, '41' Medicare Secondary Black Lung, '42' Medicare Secondary Veteran's Administration, '43' Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP), '47' Medicare Secondary, Other Liability Insurance is Primary

Enum: 121314151641424347

subscriberGroupNamestring

Loop: 2000B, Segment: SBR, Element: SBR04 Notes: Freeform text

firstNamestring

Loop: 2010BA, Segment: NM1, Element: NM104

lastNamestring

Loop: 2010BA, Segment: NM1, Element: NM103

middleNamestring

Loop: 2010BA, Segment: NM, Element: NM105

suffixstring

Loop: 2010BA, Segment: NM, Element: NM107

genderstring

Loop: 2010BA, Segment: DMG, Element: DMG03 Subscriber Gender, Notes: 'M' Male, 'F' Female'U' Unknown

Enum: MFU

dateOfBirthstring

Loop: 2010BA, Segment: DMG, Element: DMG02

policyNumberstring

Loop: 2000B, Segment: SBR, Element: SBR03

groupNumberstring

Loop: 2010BA, Segment: SBR, Element: SBR04

contactInformationobject

PER

name*string

Segment: PER, Element: PER02 and PER01=IC

phoneNumberstring

Segment: PER, Element: PER04 (Provider, Submitter, Subscriber, Dependent) or PER06 (Provider, Submitter) or PER08 (Provider, Submitter), Note: Used when PER03=TE (Provider, Submitter, Subscriber, Dependent) or PER05=TE (Provider, Submitter) or PER07=TE (Provider, Submitter)

faxNumberstring

Segment: PER, Element: PER04 or PER06 or PER08, Note: This is used in (Provider, Submitter) when PER03=FX or PER05=FX or PER07=FX

emailstring

Segment: PER, Element: PER04 or PER06 or PER08, Note: This used in (Provider, Submitter) when PER03=EM or PER05=EM or PER07=EM

phoneExtensionstring

Segment: PER, Element: PER06 (Provider, Submitter, Subscriber, Dependent) or PER08 (Provider, Submitter),Note: Used when PER05=EX (Provider, Submitter, Subscriber, Dependent) or PER07=EX (Provider, Submitter)

addressobject

N3 and N4

address1*string

Segment: N3, Element: N301

address2string

Segment: N3, Element: N302

city*string

Segment: N4, Element: N401

statestring

Segment: N4, Element: N402

postalCodestring

Segment: N4, Element: N403

countryCodestring

Segment: N4, Element: N404

countrySubDivisionCodestring

Segment: N4, Element: N407

dependentobject

LOOP 2000C

firstName*string

Loop: 2010CA, Segment: NM1, Element: NM104

lastName*string

Loop: 2010CA, Segment: NM1, Element: NM103

middleNamestring

Loop: 2010CA, Segment: NM1, Element: NM105

suffixstring

Loop: 2010CA, Segment: NM, Element: NM107

gender*string

Loop: 2010CA, Segment: DMG, Element: DMG03, Note: Allowed Values are: 'M' Male, 'F' Female, 'U' Unknown

Enum: MFU

dateOfBirth*string

Loop: 2010CA, Segment: DMG, Element: DMG02 when DMG01=D8

ssnstring

Loop: 2010CA, Segment: REF, Element: REF02 when REF01=SY

memberIdstring

Loop: 2010CA, Segment: REF, Element: REF02 when REF01=1W

relationshipToSubscriberCode*string

Loop: 2000C, Segment: PAT, Element: PAT01, Note: Allowed Values are: '01' Spouse, '19' Child, '20' Employee, '21' Unknown, '39' Organ Donor, '40' Cadaver Donor, '53' Life Partner, 'G8' Other Relationship

Enum: 011920394053G8

contactInformationobject

PER

name*string

Segment: PER, Element: PER02 and PER01=IC

phoneNumberstring

Segment: PER, Element: PER04 (Provider, Submitter, Subscriber, Dependent) or PER06 (Provider, Submitter) or PER08 (Provider, Submitter), Note: Used when PER03=TE (Provider, Submitter, Subscriber, Dependent) or PER05=TE (Provider, Submitter) or PER07=TE (Provider, Submitter)

faxNumberstring

Segment: PER, Element: PER04 or PER06 or PER08, Note: This is used in (Provider, Submitter) when PER03=FX or PER05=FX or PER07=FX

emailstring

Segment: PER, Element: PER04 or PER06 or PER08, Note: This used in (Provider, Submitter) when PER03=EM or PER05=EM or PER07=EM

phoneExtensionstring

Segment: PER, Element: PER06 (Provider, Submitter, Subscriber, Dependent) or PER08 (Provider, Submitter),Note: Used when PER05=EX (Provider, Submitter, Subscriber, Dependent) or PER07=EX (Provider, Submitter)

addressobject

N3 and N4

address1*string

Segment: N3, Element: N301

address2string

Segment: N3, Element: N302

city*string

Segment: N4, Element: N401

statestring

Segment: N4, Element: N402

postalCodestring

Segment: N4, Element: N403

countryCodestring

Segment: N4, Element: N404

countrySubDivisionCodestring

Segment: N4, Element: N407

providersarray

setting providers deprecated, please set all providers individually by it's type.

claimInformation*object

Loop2300

claimFilingCode*string

Loop 2000B, Segment: SBR, Element: SBR09, Note: Allowed Values are: '11' Other Non-Federal Programs, '12' Preferred Provider Organization (PPO), '13' Point of Service (POS), '14' Exclusive Provider Organization (EPO), '15' Indemnity Insurance, '16' Health Maintenance Organization (HMO) Medicare Risk, '17' Dental Maintenance Organization, 'AM' Automobile Medical, 'BL' Blue Cross/Blue Shield, 'CH' Champus, 'CI' Commercial Insurance Co., 'DS' Disability, 'FI' Federal Employees Program, 'HM' Health Maintenance Organization, 'LM' Liability Medical, 'MA' Medicare Part A, 'MB' Medicare Part B, 'MC' Medicaid, 'OF' Other Federal Program, 'TV' Title V, 'VA' Veterans Affairs Plan, 'WC' Workers' Compensation Health Claim, 'ZZ' Mutually Defined

Enum: 11121314151617AMBLCHCIDSFIHMLMMAMBMCOFTVVAWCZZ

propertyCasualtyClaimNumberstring

Loop 2010BA, Segment: REF, Element: REF02

deathDatestring

Loop 2000B and 2000C, Segment: PAT, Element: PAT06 and PAT05=D8

patientWeightstring

Loop 2000B and 2000C, Segment: PAT, Element: PAT08 and PAT07=01

pregnancyIndicatorstring

Loop 2000B and 2000C, Segment: PAT, Element: PAT09

Enum: Y

patientControlNumber*string

Loop 2300, Segment: CLM, Element: CLM01

claimChargeAmount*string

Loop 2300, Segment: CLM, Element: CLM02

placeOfServiceCode*string

Loop 2300, Segment: CLM, Element: CLM05-01

claimFrequencyCode*string

Loop 2300, Segment: CLM, Element: CLM05-03

signatureIndicator*string

Loop 2300, Segment: CLM, Element: CLM06, Note: Allowed Values are: 'N' NO, 'Y' Yes

Enum: NY

planParticipationCode*string

Loop 2300, Segment: CLM, Element: CLM07, Note: Allowed Values are: 'A' Assigned, 'B' Assignment Accepted on Clinical Lab Services Only, 'C' Not Assigned

Enum: ABC

benefitsAssignmentCertificationIndicator*string

Loop 2300, Segment: CLM, Element: CLM08, Note: Allowed Values are: 'N' No, 'W' Not Applicable - Use code 'W' when the patient refuses to assign benefits, 'Y' Yes

Enum: NWY

releaseInformationCode*string

Loop 2300, Segment: CLM, Element: CLM09, Note: Allowed Values are: 'I' Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes, 'Y' Yes

Enum: IY

patientSignatureSourceCodeboolean

Loop 2300, Segment: CLM, Element: CLM10, Note: Allowed Values are: 'P' Signature generated by provider because the patient was not physically present for services

Enum: false

relatedCausesCodearray

Loop 2300, Segment: CLM, Element: CLM11-01, CLM11-02, Note: Allowed Values are: 'AA' Auto Accident, 'EM' Employment, 'OA' Other Accident

autoAccidentStateCodestring

Loop 2300, Segment: CLM, Element: CLM11-04, Note: When CLM11-1 or CLM11-2 has a value of 'AA' to identify the state, province or sub-country code in which the automobile accident occurred.

Enum: AAEMOA

autoAccidentCountryCodestring

Loop 2300, Segment: CLM, Element: CLM11-05, Note: When CLM11-1 or CLM11-2 = AA and the accident occurred in a country other than US or Canada.

specialProgramCodestring

Loop 2300, Segment: CLM, Element: CLM12, Note: Allowed Values are: '02' Physically Handicapped Children's Program, '03' Special Federal Funding, '05' Disabolity, '09' Second Opinion or Surgery

Enum: 02030509

delayReasonCodestring

Loop 2300, Segment: CLM, Element: CLM20, Note: Allowed Values are: '1' Proof of Eligibility Unknown or Unavailable, '2' Litigation, '3' Authorization Delays, '4' Delay in Certifying Provider, '5' Delay in Supplying Billing Forms, '6' Delay in Delivery of Custom-made Appliances, '7' Third Party Processing Delay, '8' Delay in Eligibility Determination, '9' Original Claim Rejected or Denied Due to a Reason Unrelated to the Billing Limitation Rules, '10' Administration Delay in the Prior Approval Process, '11' Other, '15' Natural Disaster

Enum: 123456789101115

patientAmountPaidstring

Loop 2300, Segment: AMT, Element: AMT02

fileInformationstring

Loop 2300, Segment: K3, Element: K301

fileInformationListarray

Loop 2300, Segment: K3, Element: K301

claimDateInformationobject

DTP

symptomDatestring

Loop: 2300, Segment: DTP, Element: DTP03

initialTreatmentDatestring

Loop: 2300, Segment: DTP, Element: DTP03

lastSeenDatestring

Loop: 2300, Segment: DTP, Element: DTP03

acuteManifestationDatestring

Loop: 2300, Segment: DTP, Element: DTP03

accidentDatestring

Loop: 2300, Segment: DTP, Element: DTP03

lastMenstrualPeriodDatestring

Loop: 2300, Segment: DTP, Element: DTP03

lastXRayDatestring

Loop: 2300, Segment: DTP, Element: DTP03

hearingAndVisionPrescriptionDatestring

Loop: 2300, Segment: DTP, Element: DTP03

disabilityBeginDatestring

Loop: 2300, Segment: DTP, Element: DTP03

disabilityEndDatestring

Loop: 2300, Segment: DTP, Element: DTP03

lastWorkedDatestring

Loop: 2300, Segment: DTP, Element: DTP03

authorizedReturnToWorkDatestring

Loop: 2300, Segment: DTP, Element: DTP03

admissionDatestring

Loop: 2300, Segment: DTP, Element: DTP03

dischargeDatestring

Loop: 2300, Segment: DTP, Element: DTP03

assumedAndRelinquishedCareBeginDatestring

Loop: 2300, Segment: DTP, Element: DTP03

assumedAndRelinquishedCareEndDatestring

Loop: 2300, Segment: DTP, Element: DTP03

repricerReceivedDatestring

Loop: 2300, Segment: DTP, Element: DTP03

firstContactDatestring

Loop: 2300, Segment: DTP, Element: DTP03

claimContractInformationobject

Loop 2300, Segment: CN1

contractTypeCode*string

Loop: 2300,Segment: CN1, Element: CN101, Note: Allowed Values are: '01' Diagnosis Related Group (DRG), '02' Per Diem, '03' Variable Per Diem, '04' Flat, '05' Capitated, '06' Percent, '09' Other

Enum: 01020304050609

contractAmountstring

Loop: 2300, Segment: CN1, Element: CN102

contractPercentagestring

Loop: 2300, Segment: CN1, Element: CN103

contractCodestring

Loop: 2300, Segment: CN1, Element: CN104

termsDiscountPercentagestring

Loop: 2300, Segment: CN1, Element: CN105

contractVersionIdentifierstring

Loop: 2300, Segment: CN1, Element: CN106

claimSupplementalInformationobject

PWK and REF

reportInformationobject
attachmentReportTypeCode*string

Loop: 2400, Segment: PWK, Element: PWK01, Notes: Allowed Values are: '03' Report Justifying Treatment Beyond Utilization Guidelines, '04' Drugs Administered, '05' Treatment Diagnosis, '06' Initial Assessment, '07' Functional Goals, '08' Plan of Treatment, '09' Progress Report, '10' Continued Treatment, '11' Chemical Analysis, '13' Certified Test Report, '15' Justification for Admission, '21' Recovery Plan, 'A3' Allergies/Sensitivities Document, 'A4' Autopsy Report, 'AM' Ambulance Certification, 'AS' Admission Summary, 'B2' Prescription, 'B3' Physician Order, 'B4' Referral Form, 'BR' Benchmark Testing Results, 'BS' Baseline, 'BT' Blanket Test Results, 'CB' Chiropractic Justification, 'CK' Consent Form(s), 'CT' Certification, 'D2' Drug Profile Document, 'DA' Dental Models, 'DB' Durable Medical Equipment Prescription, 'DG' Diagnostic Report, 'DJ' Discharge Monitoring Report, 'DS' Discharge Summary, 'EB' Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor), 'HC' Health Certificate, 'HR' Health Clinic Records, 'I5' Immunization Record,'IR' State School Immunization Records, 'LA' Laboratory Results, 'M1' Medical Record Attachment, 'MT' Models, 'NM Nursing Notes', 'OB' Operative Note, 'OC' Oxygen Content Averaging Report, 'OD' Orders and Treatments Document, 'OE' Objective Physical Examination (including vital signs) Document, 'OX' Oxygen Therapy Certification, 'OZ' Support Data for Claim, 'P4' Pathology Report, 'P5' Patient Medical History Document, 'PE' Parenteral or Enteral Certification, 'PN' Physical Therapy Notes, 'PO' Prosthetics or Orthotic Certification, 'PQ' Paramedical Results, 'PY' Physician's Report, 'PZ' Physical Therapy Certification, 'RB' Radiology Films, 'RR' Radiology Reports, 'RT' Report of Tests and Analysis Report, 'RX' Renewable Oxygen Content Averaging Report, 'SG' Symptoms Document, 'V5' Death Notification, 'XP' Photographs

Enum: 030405060708091011131521A3A4AMASB2B3B4BRBSBTCBCKCTD2DADBDGDJDSEBHCHRI5IRLAM1MTNMOBOCODOEOXOZP4P5PEPNPOPQPYPZRBRRRTRXSGV5XP

attachmentTransmissionCode*string

Loop: 2400, Segment: PWK, Element: PWK02 Allowed Values are: 'AA' Available on Request at Provider Site, 'BM' By Mail,'EL' Electronically Only, 'EM' E-Mail, 'FT' File Transfer, 'FX' By Fax

Enum: AABMELEMFTFX

attachmentControlNumberstring

Loop 2400, Segment: PWK, Element: PWK05

priorAuthorizationNumberstring

Loop: 2300, Segment: REF, Element: REF02 and REF01=G1

referralNumberstring

Loop: 2300, Segment: REF, Element: REF02 and REF01=9F

claimControlNumberstring

Loop: 2300, Segment: REF, Element: REF02 and REF01=F8

cliaNumberstring

Loop: 2300, Segment: REF, Element: REF02 and REF01=X4

repricedClaimNumberstring

Loop: 2300, Segment: REF, Element: REF02 and REF01=9A

adjustedRepricedClaimNumberstring

Loop: 2300, Segment: REF, Element: REF02 and REF01=9C

investigationalDeviceExemptionNumberstring

Loop: 2300, Segment: REF, Element: REF02 and REF01=LX

claimNumberstring

Loop: 2300, Segment: REF, Element: REF02 and REF01=D9

mammographyCertificationNumberstring

Loop: 2300, Segment: REF, Element: REF02 and REF01=EW

medicalRecordNumberstring

Loop: 2300, Segment: REF, Element: REF02 and REF01=EA

demoProjectIdentifierstring

Loop: 2300, Segment: REF, Element: REF02 and REF01=P4

carePlanOversightNumberstring

Loop: 2300, Segment: REF, Element: REF02 and REF01=1J

medicareCrossoverReferenceIdstring

Loop: 2300, Segment: REF, Element: REF02 and REF01=F5

serviceAuthorizationExceptionCodestring

Loop: 2300, Segment: REF, Element: REF02 and REF01=4N, Note: '1' Immediate/Urgent Care, '2' Services Rendered in a Retroactive Period, '3' Emergency Care, '4' Client has Temporary Medicaid, '5' Request from County for Second Opinion to Determine if Recipient Can Work, '6' Request for Override Pending, '7' Special Handling, Null

Enum: 1234567

claimNoteobject

NTE

additionalInformationstring

Loop 2300, Segment: NTE, Element: NTE02, Note: NTE01=ADD

certificationNarrativestring

Loop 2300, Segment: NTE, Element: NTE02, Note: NTE01=CER

goalRehabOrDischargePlansstring

Loop 2300, Segment: NTE, Element: NTE02, Note: NTE01=DCP

diagnosisDescriptionstring

Loop 2300, Segment: NTE, Element: NTE02, Note: NTE01=DGN

thirdPartOrgNotesstring

Loop 2300, Segment: NTE, Element: NTE02, Note: NTE01=TPO

ambulanceTransportInformationobject

CR1

patientWeightInPoundsstring

Segment: CR1, Element: CR102

ambulanceTransportReasonCode*string

CR104, Note: Allowed Values are: 'A' Patient was transported to nearest facility for care of symptoms, complaints, or both, 'B' Patient was transported for the benefit of a preferred physician, 'C' Patient was transported for the nearness of family members, 'D' Patient was transported for the care of a specialist or for availability of specialized equipment, 'E' Patient Transferred to Rehabilitation Facility

Enum: ABCDE

transportDistanceInMiles*string

Segment: CR1, Element: CR106

roundTripPurposeDescriptionstring

Segment: CR1, Element: CR109

stretcherPurposeDescriptionstring

Segment: CR1, Element: CR110

spinalManipulationServiceInformationobject

Loop 2300, Segment: CR2

patientConditionCode*string

Loop: 2300, Segment: CR, Element: CR208

patientConditionDescription1string

Loop: 2300, Segment: CR, Element: CR210 Note: Allowed Values are: 'A' Acute Condition, 'C' Chronic Condition, 'D' Chronic Condition, 'E' Non-Life Threatening, 'F' Routine, 'G' Symptomatic, 'M' Acute Manifestation of a Chronic Condition

Enum: ACDEFGM

patientConditionDescription2string

Loop: 2300, Segment: CR, Element: CR211

ambulanceCertificationarray

Loop 2300, Segment: CRC

patientConditionInformationVisionarray

Loop 2300, Segment: CRC

homeboundIndicatorboolean

Loop 2300, Segment: CRC

epsdtReferralobject

CRC

certificationConditionCodeAppliesIndicator*string

Loop: 2300, Segment: CRC, Element: CRC02 When CRC01=ZZ, Note: 'N' No, 'Y' Yes

Enum: NY

conditionCodes*array

Loop: 2300, Segment: CRC, Elements: CRC03, CRC04, CRC05 Note: Allowed Values are: 'AV' Available- Not Used, 'NU' Not Used, 'S2' Under Treatment, 'ST' New Services Requested

healthCareCodeInformation*array

Loop 2300, Segment: HI

anesthesiaRelatedSurgicalProcedurearray

Loop 2300, Segment: HI

conditionInformationarray

Loop 2300, Segment: HI

claimPricingRepricingInformationobject

HCP

pricingMethodologyCode*string

Loop: 2300, Segment: HCP, Element: HCP01, Note: Allowed Values are: '00' Zero Pricing (Not Covered Under Contract), '01' Priced as Billed at 100%, '02' Priced at the Standard Fee Schedule, '03' Priced at a Contractual Percentage, '04' Bundled Pricing, '05' Peer Review Pricing, '06' Bundled Pricing, '07' Flat Rate Pricing, '08' Combination Pricing, '09' Maternity Pricing, '10' Other Pricing, '11' Lower of Cost, '12' Ratio of Cost, '13' Cost Reimbursed, '14' Adjustment Pricing

Enum: 000102030405060708091011121314

repricedAllowedAmount*string

Loop: 2300, Segment: HCP, Element: HCP02

repricedSavingAmountstring

Loop: 2300, Segment: HCP, Element: HCP03

repricingOrganizationIdentifierstring

Loop: 2300, Segment: HCP, Element: HCP04

repricingPerDiemOrFlatRateAmountstring

Loop: 2300, Segment: HCP, Element: HCP05

repricedApprovedAmbulatoryPatientGroupCodestring

Loop: 2300, Segment: HCP, Element: HCP06

repricedApprovedAmbulatoryPatientGroupAmountstring

Loop: 2300, Segment: HCP, Element: HCP07

rejectReasonCodestring

Loop: 2300, Segment: HCP, Element: HCP13, Note: Allowed Values are: 'T1' Cannot Identify Provider as TPO (Third Party Organization) Participant, 'T2' Cannot Identify Payer as TPO (Third Party Organization) Participant, 'T3' Cannot Identify Insured as TPO (Third Party Organization) Participant, 'T4' Payer Name or Identifier Missing, 'T5' Certification Information Missing, '16' Claim does not contain enough information for repricing

Enum: T1T2T3T4T5T6

policyComplianceCodestring

Loop: 2300, Segment: HCP, Element: HCP14, Note: Allowed Values are: '1' Procedure Followed (Compliance), '2' Not Followed - Call Not Made (Non-Compliance Call Not Made), '3' Not Medically Necessary (Non-Compliance Non-Medically Necessary), '4' Not Followed Other (Non-Compliance Other), '5' Emergency Admit to Non-Network Hospital

Enum: 12345

exceptionCodestring

Loop: 2300, Segment: HCP, Element: HCP15, Note: Allowed Values are: '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, '6' Other

Enum: 123456

serviceFacilityLocationobject
organizationName*string

Loop: 2420C, Segment: NM1, Element: NM103

address*object

N3 and N4

address1*string

Segment: N3, Element: N301

address2string

Segment: N3, Element: N302

city*string

Segment: N4, Element: N401

statestring

Segment: N4, Element: N402

postalCodestring

Segment: N4, Element: N403

countryCodestring

Segment: N4, Element: N404

countrySubDivisionCodestring

Segment: N4, Element: N407

npistring

Loop: 2420C, Segment: NM1, Element: NM109, Note: National Provider Identifier

secondaryIdentifierarray

Loop: 2420C: Segment: REF, Notes: A list containing qualifier (REF01), identifier (REF02), and otherIdentifier(REF04)

phoneNamestring

Loop: 2310C, Segment: PER, Element: PER02

phoneNumberstring

Loop: 2310C, Segment: PER, Element: PER04

phoneExtensionstring

Loop: 2310C, Segment: PER, Element: PER06

ambulancePickUpLocationobject

N3 and N4

address1*string

Segment: N3, Element: N301

address2string

Segment: N3, Element: N302

city*string

Segment: N4, Element: N401

statestring

Segment: N4, Element: N402

postalCodestring

Segment: N4, Element: N403

countryCodestring

Segment: N4, Element: N404

countrySubDivisionCodestring

Segment: N4, Element: N407

ambulanceDropOffLocationobject

N3 and N4

address1*string

Segment: N3, Element: N301

address2string

Segment: N3, Element: N302

city*string

Segment: N4, Element: N401

statestring

Segment: N4, Element: N402

postalCodestring

Segment: N4, Element: N403

countryCodestring

Segment: N4, Element: N404

countrySubDivisionCodestring

Segment: N4, Element: N407

otherSubscriberInformationarray

Loop 2320

serviceLines*array

Loop 2400

payToAddressobject

N3 and N4

address1*string

Segment: N3, Element: N301

address2string

Segment: N3, Element: N302

city*string

Segment: N4, Element: N401

statestring

Segment: N4, Element: N402

postalCodestring

Segment: N4, Element: N403

countryCodestring

Segment: N4, Element: N404

countrySubDivisionCodestring

Segment: N4, Element: N407

payToPlanobject

2010AC

organizationName*string

Loop: 2010AC, Segment: NM1, Element: NM103

primaryIdentifierTypeCode*string

Loop: 2010AC, Segment: NM1, Element: NM108, Notes: 'PI' Payor Identification and 'XV' Centers for Medicare/Medicaid Services PlanID

Enum: PIXV

primaryIdentifier*string

Loop: 2010AC, Segment: NM1, Element: NM109

address*object

N3 and N4

address1*string

Segment: N3, Element: N301

address2string

Segment: N3, Element: N302

city*string

Segment: N4, Element: N401

statestring

Segment: N4, Element: N402

postalCodestring

Segment: N4, Element: N403

countryCodestring

Segment: N4, Element: N404

countrySubDivisionCodestring

Segment: N4, Element: N407

secondaryIdentifierTypeCodestring

Loop: 2010AC, Segment: REF, Element: REF01, Notes: '2U Payer Identification Number, 'FY' Claim Office Number, 'NF National Association of Insurance Commissioners'

Enum: 2UFYNF

secondaryIdentifierstring

Loop: 2010AC, Segment: REF, Element: REF02

taxIdentificationNumber*string

Loop: 2010AC, Segment: REF, Element: REF02 when REF01=EI

payerAddressobject

N3 and N4

address1*string

Segment: N3, Element: N301

address2string

Segment: N3, Element: N302

city*string

Segment: N4, Element: N401

statestring

Segment: N4, Element: N402

postalCodestring

Segment: N4, Element: N403

countryCodestring

Segment: N4, Element: N404

countrySubDivisionCodestring

Segment: N4, Element: N407

usageIndicatorstring

Interchange Usage Indicator ISA15; T-Test Data, P-Production Data

billing*object

Loop: 2000A

providerType*string
npistring

NM109, Notes: National Provider Identifier

ssnstring

REF02 when REF01=SY, Notes: The Social Security Number must be a string of nine numbers with no separators

employerIdstring

REF02 when REF01=EI, Notes: The Employer Identification Number must be a string of exactly nine numbers with no separators

commercialNumberstring

REF02 when REF01=G2

locationNumberstring

REF02 when REF01=LU

payerIdentificationNumberstring

LOOP: 2010AC, Segment: REF, Element: REF02 when REF01=2U

employerIdentificationNumberstring

LOOP: 2010AC, Segment: REF, Element: REF02 when REF01=EI

claimOfficeNumberstring

Loop: 2010AC, Segment: REF, Element: REF02 when REF01=FY

naicstring

Loop: 2010AC, Segment: REF, Element: REF02 when REF01=NF, Notes: National Association of Insurance Commissioners (NAIC) Code

stateLicenseNumberstring

REF02 when REF01=0B

providerUpinNumberstring

REF02 when REF01=1G, Notes: UPINs must be formatted as either X99999 or XXX999

taxonomyCodestring

PRV03

firstNamestring

NM104

lastNamestring

NM103

middleNamestring

NM105

suffixstring

NM107

organizationNamestring

NM103

addressobject

N3 and N4

address1*string

Segment: N3, Element: N301

address2string

Segment: N3, Element: N302

city*string

Segment: N4, Element: N401

statestring

Segment: N4, Element: N402

postalCodestring

Segment: N4, Element: N403

countryCodestring

Segment: N4, Element: N404

countrySubDivisionCodestring

Segment: N4, Element: N407

contactInformationobject

PER

name*string

Segment: PER, Element: PER02 and PER01=IC

phoneNumberstring

Segment: PER, Element: PER04 (Provider, Submitter, Subscriber, Dependent) or PER06 (Provider, Submitter) or PER08 (Provider, Submitter), Note: Used when PER03=TE (Provider, Submitter, Subscriber, Dependent) or PER05=TE (Provider, Submitter) or PER07=TE (Provider, Submitter)

faxNumberstring

Segment: PER, Element: PER04 or PER06 or PER08, Note: This is used in (Provider, Submitter) when PER03=FX or PER05=FX or PER07=FX

emailstring

Segment: PER, Element: PER04 or PER06 or PER08, Note: This used in (Provider, Submitter) when PER03=EM or PER05=EM or PER07=EM

phoneExtensionstring

Segment: PER, Element: PER06 (Provider, Submitter, Subscriber, Dependent) or PER08 (Provider, Submitter),Note: Used when PER05=EX (Provider, Submitter, Subscriber, Dependent) or PER07=EX (Provider, Submitter)

referringobject

Loop: 2420F

providerType*string
npistring

NM109, Notes: National Provider Identifier

ssnstring

REF02 when REF01=SY, Notes: The Social Security Number must be a string of nine numbers with no separators

employerIdstring

REF02 when REF01=EI, Notes: The Employer Identification Number must be a string of exactly nine numbers with no separators

commercialNumberstring

REF02 when REF01=G2

locationNumberstring

REF02 when REF01=LU

payerIdentificationNumberstring

LOOP: 2010AC, Segment: REF, Element: REF02 when REF01=2U

employerIdentificationNumberstring

LOOP: 2010AC, Segment: REF, Element: REF02 when REF01=EI

claimOfficeNumberstring

Loop: 2010AC, Segment: REF, Element: REF02 when REF01=FY

naicstring

Loop: 2010AC, Segment: REF, Element: REF02 when REF01=NF, Notes: National Association of Insurance Commissioners (NAIC) Code

stateLicenseNumberstring

REF02 when REF01=0B

providerUpinNumberstring

REF02 when REF01=1G, Notes: UPINs must be formatted as either X99999 or XXX999

taxonomyCodestring

PRV03

firstNamestring

NM104

lastNamestring

NM103

middleNamestring

NM105

suffixstring

NM107

organizationNamestring

NM103

addressobject

N3 and N4

address1*string

Segment: N3, Element: N301

address2string

Segment: N3, Element: N302

city*string

Segment: N4, Element: N401

statestring

Segment: N4, Element: N402

postalCodestring

Segment: N4, Element: N403

countryCodestring

Segment: N4, Element: N404

countrySubDivisionCodestring

Segment: N4, Element: N407

contactInformationobject

PER

name*string

Segment: PER, Element: PER02 and PER01=IC

phoneNumberstring

Segment: PER, Element: PER04 (Provider, Submitter, Subscriber, Dependent) or PER06 (Provider, Submitter) or PER08 (Provider, Submitter), Note: Used when PER03=TE (Provider, Submitter, Subscriber, Dependent) or PER05=TE (Provider, Submitter) or PER07=TE (Provider, Submitter)

faxNumberstring

Segment: PER, Element: PER04 or PER06 or PER08, Note: This is used in (Provider, Submitter) when PER03=FX or PER05=FX or PER07=FX

emailstring

Segment: PER, Element: PER04 or PER06 or PER08, Note: This used in (Provider, Submitter) when PER03=EM or PER05=EM or PER07=EM

phoneExtensionstring

Segment: PER, Element: PER06 (Provider, Submitter, Subscriber, Dependent) or PER08 (Provider, Submitter),Note: Used when PER05=EX (Provider, Submitter, Subscriber, Dependent) or PER07=EX (Provider, Submitter)

renderingobject

Loop: 2420A

providerType*string
npistring

NM109, Notes: National Provider Identifier

ssnstring

REF02 when REF01=SY, Notes: The Social Security Number must be a string of nine numbers with no separators

employerIdstring

REF02 when REF01=EI, Notes: The Employer Identification Number must be a string of exactly nine numbers with no separators

commercialNumberstring

REF02 when REF01=G2

locationNumberstring

REF02 when REF01=LU

payerIdentificationNumberstring

LOOP: 2010AC, Segment: REF, Element: REF02 when REF01=2U

employerIdentificationNumberstring

LOOP: 2010AC, Segment: REF, Element: REF02 when REF01=EI

claimOfficeNumberstring

Loop: 2010AC, Segment: REF, Element: REF02 when REF01=FY

naicstring

Loop: 2010AC, Segment: REF, Element: REF02 when REF01=NF, Notes: National Association of Insurance Commissioners (NAIC) Code

stateLicenseNumberstring

REF02 when REF01=0B

providerUpinNumberstring

REF02 when REF01=1G, Notes: UPINs must be formatted as either X99999 or XXX999

taxonomyCodestring

PRV03

firstNamestring

NM104

lastNamestring

NM103

middleNamestring

NM105

suffixstring

NM107

organizationNamestring

NM103

addressobject

N3 and N4

address1*string

Segment: N3, Element: N301

address2string

Segment: N3, Element: N302

city*string

Segment: N4, Element: N401

statestring

Segment: N4, Element: N402

postalCodestring

Segment: N4, Element: N403

countryCodestring

Segment: N4, Element: N404

countrySubDivisionCodestring

Segment: N4, Element: N407

contactInformationobject

PER

name*string

Segment: PER, Element: PER02 and PER01=IC

phoneNumberstring

Segment: PER, Element: PER04 (Provider, Submitter, Subscriber, Dependent) or PER06 (Provider, Submitter) or PER08 (Provider, Submitter), Note: Used when PER03=TE (Provider, Submitter, Subscriber, Dependent) or PER05=TE (Provider, Submitter) or PER07=TE (Provider, Submitter)

faxNumberstring

Segment: PER, Element: PER04 or PER06 or PER08, Note: This is used in (Provider, Submitter) when PER03=FX or PER05=FX or PER07=FX

emailstring

Segment: PER, Element: PER04 or PER06 or PER08, Note: This used in (Provider, Submitter) when PER03=EM or PER05=EM or PER07=EM

phoneExtensionstring

Segment: PER, Element: PER06 (Provider, Submitter, Subscriber, Dependent) or PER08 (Provider, Submitter),Note: Used when PER05=EX (Provider, Submitter, Subscriber, Dependent) or PER07=EX (Provider, Submitter)

orderingobject

Loop: 2420E, Setting ProviderType equal to OrderingProvider is deprecated, please use ClaimInformation.serviceLines.orderingProvider

providerType*string
npistring

NM109, Notes: National Provider Identifier

ssnstring

REF02 when REF01=SY, Notes: The Social Security Number must be a string of nine numbers with no separators

employerIdstring

REF02 when REF01=EI, Notes: The Employer Identification Number must be a string of exactly nine numbers with no separators

commercialNumberstring

REF02 when REF01=G2

locationNumberstring

REF02 when REF01=LU

payerIdentificationNumberstring

LOOP: 2010AC, Segment: REF, Element: REF02 when REF01=2U

employerIdentificationNumberstring

LOOP: 2010AC, Segment: REF, Element: REF02 when REF01=EI

claimOfficeNumberstring

Loop: 2010AC, Segment: REF, Element: REF02 when REF01=FY

naicstring

Loop: 2010AC, Segment: REF, Element: REF02 when REF01=NF, Notes: National Association of Insurance Commissioners (NAIC) Code

stateLicenseNumberstring

REF02 when REF01=0B

providerUpinNumberstring

REF02 when REF01=1G, Notes: UPINs must be formatted as either X99999 or XXX999

taxonomyCodestring

PRV03

firstNamestring

NM104

lastNamestring

NM103

middleNamestring

NM105

suffixstring

NM107

organizationNamestring

NM103

addressobject

N3 and N4

address1*string

Segment: N3, Element: N301

address2string

Segment: N3, Element: N302

city*string

Segment: N4, Element: N401

statestring

Segment: N4, Element: N402

postalCodestring

Segment: N4, Element: N403

countryCodestring

Segment: N4, Element: N404

countrySubDivisionCodestring

Segment: N4, Element: N407

contactInformationobject

PER

name*string

Segment: PER, Element: PER02 and PER01=IC

phoneNumberstring

Segment: PER, Element: PER04 (Provider, Submitter, Subscriber, Dependent) or PER06 (Provider, Submitter) or PER08 (Provider, Submitter), Note: Used when PER03=TE (Provider, Submitter, Subscriber, Dependent) or PER05=TE (Provider, Submitter) or PER07=TE (Provider, Submitter)

faxNumberstring

Segment: PER, Element: PER04 or PER06 or PER08, Note: This is used in (Provider, Submitter) when PER03=FX or PER05=FX or PER07=FX

emailstring

Segment: PER, Element: PER04 or PER06 or PER08, Note: This used in (Provider, Submitter) when PER03=EM or PER05=EM or PER07=EM

phoneExtensionstring

Segment: PER, Element: PER06 (Provider, Submitter, Subscriber, Dependent) or PER08 (Provider, Submitter),Note: Used when PER05=EX (Provider, Submitter, Subscriber, Dependent) or PER07=EX (Provider, Submitter)

supervisingobject

Loop: 2420D

providerType*string
npistring

NM109, Notes: National Provider Identifier

ssnstring

REF02 when REF01=SY, Notes: The Social Security Number must be a string of nine numbers with no separators

employerIdstring

REF02 when REF01=EI, Notes: The Employer Identification Number must be a string of exactly nine numbers with no separators

commercialNumberstring

REF02 when REF01=G2

locationNumberstring

REF02 when REF01=LU

payerIdentificationNumberstring

LOOP: 2010AC, Segment: REF, Element: REF02 when REF01=2U

employerIdentificationNumberstring

LOOP: 2010AC, Segment: REF, Element: REF02 when REF01=EI

claimOfficeNumberstring

Loop: 2010AC, Segment: REF, Element: REF02 when REF01=FY

naicstring

Loop: 2010AC, Segment: REF, Element: REF02 when REF01=NF, Notes: National Association of Insurance Commissioners (NAIC) Code

stateLicenseNumberstring

REF02 when REF01=0B

providerUpinNumberstring

REF02 when REF01=1G, Notes: UPINs must be formatted as either X99999 or XXX999

taxonomyCodestring

PRV03

firstNamestring

NM104

lastNamestring

NM103

middleNamestring

NM105

suffixstring

NM107

organizationNamestring

NM103

addressobject

N3 and N4

address1*string

Segment: N3, Element: N301

address2string

Segment: N3, Element: N302

city*string

Segment: N4, Element: N401

statestring

Segment: N4, Element: N402

postalCodestring

Segment: N4, Element: N403

countryCodestring

Segment: N4, Element: N404

countrySubDivisionCodestring

Segment: N4, Element: N407

contactInformationobject

PER

name*string

Segment: PER, Element: PER02 and PER01=IC

phoneNumberstring

Segment: PER, Element: PER04 (Provider, Submitter, Subscriber, Dependent) or PER06 (Provider, Submitter) or PER08 (Provider, Submitter), Note: Used when PER03=TE (Provider, Submitter, Subscriber, Dependent) or PER05=TE (Provider, Submitter) or PER07=TE (Provider, Submitter)

faxNumberstring

Segment: PER, Element: PER04 or PER06 or PER08, Note: This is used in (Provider, Submitter) when PER03=FX or PER05=FX or PER07=FX

emailstring

Segment: PER, Element: PER04 or PER06 or PER08, Note: This used in (Provider, Submitter) when PER03=EM or PER05=EM or PER07=EM

phoneExtensionstring

Segment: PER, Element: PER06 (Provider, Submitter, Subscriber, Dependent) or PER08 (Provider, Submitter),Note: Used when PER05=EX (Provider, Submitter, Subscriber, Dependent) or PER07=EX (Provider, Submitter)

tradingPartnerNamestring

Loop 2010BB NM103

Responses

200OK
object
statusstring

Status of claim

controlNumberstring

Transaction Set Control Number

tradingPartnerServiceIdstring

Payer ID

claimReferenceobject

Collection of info specific to a given claim

correlationIdstring

Claim correlation ID

submitterIdstring

Submitter ID for transaction

customerClaimNumberstring

Claim number

patientControlNumberstring

Control number for claim

timeOfResponsestring

Time of response for claim

claimTypestring

Claim Type

payerIDstring

Payer ID

formatVersionstring

Format version

rhclaimNumberstring
errorsarray

List of errors

httpStatusCodestring

Enum: 100 CONTINUE101 SWITCHING_PROTOCOLS102 PROCESSING103 EARLY_HINTS103 CHECKPOINT200 OK201 CREATED202 ACCEPTED203 NON_AUTHORITATIVE_INFORMATION204 NO_CONTENT205 RESET_CONTENT206 PARTIAL_CONTENT207 MULTI_STATUS208 ALREADY_REPORTED226 IM_USED300 MULTIPLE_CHOICES301 MOVED_PERMANENTLY302 FOUND302 MOVED_TEMPORARILY303 SEE_OTHER304 NOT_MODIFIED305 USE_PROXY307 TEMPORARY_REDIRECT308 PERMANENT_REDIRECT400 BAD_REQUEST401 UNAUTHORIZED402 PAYMENT_REQUIRED403 FORBIDDEN404 NOT_FOUND405 METHOD_NOT_ALLOWED406 NOT_ACCEPTABLE407 PROXY_AUTHENTICATION_REQUIRED408 REQUEST_TIMEOUT409 CONFLICT410 GONE411 LENGTH_REQUIRED412 PRECONDITION_FAILED413 PAYLOAD_TOO_LARGE413 REQUEST_ENTITY_TOO_LARGE414 URI_TOO_LONG414 REQUEST_URI_TOO_LONG415 UNSUPPORTED_MEDIA_TYPE416 REQUESTED_RANGE_NOT_SATISFIABLE417 EXPECTATION_FAILED418 I_AM_A_TEAPOT419 INSUFFICIENT_SPACE_ON_RESOURCE420 METHOD_FAILURE421 DESTINATION_LOCKED422 UNPROCESSABLE_ENTITY423 LOCKED424 FAILED_DEPENDENCY425 TOO_EARLY426 UPGRADE_REQUIRED428 PRECONDITION_REQUIRED429 TOO_MANY_REQUESTS431 REQUEST_HEADER_FIELDS_TOO_LARGE451 UNAVAILABLE_FOR_LEGAL_REASONS500 INTERNAL_SERVER_ERROR501 NOT_IMPLEMENTED502 BAD_GATEWAY503 SERVICE_UNAVAILABLE504 GATEWAY_TIMEOUT505 HTTP_VERSION_NOT_SUPPORTED506 VARIANT_ALSO_NEGOTIATES507 INSUFFICIENT_STORAGE508 LOOP_DETECTED509 BANDWIDTH_LIMIT_EXCEEDED510 NOT_EXTENDED511 NETWORK_AUTHENTICATION_REQUIRED

metaobject

meta data about the request

submitterIdstring

submitterId assigned to this request

senderIdstring

senderId assigned to this request

billerIdstring

billerId assigned to this request

traceIdstring

Unique Id assigned to each request by Optum

applicationModestring

Used by Optum to identify where this request can be found for support

editStatusstring
payerobject
payerNamestring
payerIDstring
editResponsesarray
failureobject
codestring
descriptionstring

Example Request

cURL
curl -X POST \
  'https://sandbox-apigw.optum.com/medicalnetwork/professionalclaims/v3/submission'