Claim.MD API (1.17)

Download OpenAPI specification:Download

Claim.MD API Service calls. Locate your AccountKey under the Settings->Account Settings menu in the web portal. Contact support if no key is available.

API calls should not exceed 100 requests per-minute.

[Additional Code Samples Available]

Upload Batch Files

Batch file upload. Submit claims, eligibility, ERA or attachment files. Acceptable claim file formats include 837P, 837I, CSV, XML, XLS, XLSX.

Request
header Parameters
Accept
string
Default: application/xml
Enum: "application/xml" "application/json"
Request Body schema: multipart/form-data
AccountKey
required
string

Claim.MD API Key. Locate this value in the portal under Settings - Account Settings.

File
required
string <binary>

Claim file data.

Responses
200

OK

post/services/upload/
Request samples
curl -i -X POST \
  https://www.claim.md/services/upload/ \
  -H 'Accept: application/xml' \
  -H 'Content-Type: multipart/form-data' \
  -F AccountKey=string \
  -F File=@filepath
Response samples
<result messages="Received 2 claims in file: sample837.txt">
  <claim batchid="13388918" bill_npi="1234567893" bill_taxid="741111111" claimid="396723060" claimmd_id="396891541" fdos="2022-08-22" fileid="662053345" filename="sample837.txt" ins_number="ZGQ23333352902" payerid="22099" pcn="151068-1" remote_claimid="396723060" sender_icn="" sender_name="CLAIM.MD" senderid="CLMMD" status="A" total_charge="165.00">
    <messages fields="" mesgid="ACK" message="Acknowledged" status="A" />
  </claim>
  <claim batchid="13388919" bill_npi="1234567893" bill_taxid="741111111" claimid="396723069" claimmd_id="396891542" fdos="2022-08-22" fileid="662053345" filename="sample837.txt" ins_number="BXYZ99PA" payerid="60054" pcn="107026-1" remote_claimid="396723069" sender_icn="" sender_name="CLAIM.MD" senderid="CLMMD" status="A" total_charge="75.00">
    <messages fields="" mesgid="ACK" message="Acknowledged" status="A" />
  </claim>
</result>

List Uploaded Files

List of files uploaded into Claim.MD

Request
header Parameters
Accept
string
Default: application/xml
Enum: "application/xml" "application/json"
Request Body schema: application/x-www-form-urlencoded
AccountKey
required
string

Claim.MD API Key. Locate this value in the portal under Settings - Account Settings.

Page
string

Up to 500 results returned at a time. Use Page to request additional pages. (i.e. Page=2, for the second page of results)

UploadDate
string

Return files uploaded on a specific date. Format yyyy-mm-dd.

Responses
200

OK

post/services/uploadlist/
Request samples
application/x-www-form-urlencoded
AccountKey=string
Response samples
<result>
  <file file_amount="1297271.00" file_count="294" file_type="claim" filename="myfile.txt" inboundid="12345" uploadtime="1542326648" />
  <file file_amount="3990.00" file_count="1" file_type="claim" filename="medicare_claims.txt" inboundid="12346" uploadtime="1542326648" />
  <file file_amount="2000070.00" file_count="62" file_type="claim" filename="bcbs_claims.txt" inboundid="12347" uploadtime="1542241184" />
</result>

Response Request

Receive delayed claim status updates. Periodically call this service to download the most recent updates on all claims submitted from this account. Max 20,000 results per request.

Request
header Parameters
Accept
string
Default: application/xml
Enum: "application/xml" "application/json"
Request Body schema: application/x-www-form-urlencoded
AccountKey
required
string

Claim.MD API Key. Locate this value in the portal under Settings - Account Settings.

ResponseID
required
string

Download all responses greater than a specific ResponseID. First request should contain ResponseID=0, save the last_responseid to use on follow up requests.

ClaimID
string

Download all responses received for a particular Claim.MD claim ID. Do not use this option for periodic status updates.[optional]

Responses
200

OK

post/services/response/
Request samples
application/x-www-form-urlencoded
AccountKey=string&ResponseID=string
Response samples
<result last_responseid="755595618">
  <claim batchid="13388918" bill_npi="1234567893" bill_taxid="741111111" claimid="396723060" claimmd_id="396891541" fdos="2022-08-22" fileid="662053345" filename="sample837.txt" ins_number="ZGQ23333352902" payerid="22099" pcn="151068-1" remote_claimid="396723060" response_time="2022-09-01 11:34:59am" sender_icn="" sender_name="CLAIM.MD" senderid="CLMMD" status="A" total_charge="165.00">
    <messages fields="" mesgid="ACK" message="Acknowledged" responseid="755534642" status="A" />
  </claim>
  <claim batchid="13388919" bill_npi="1234567893" bill_taxid="741111111" claimid="396723069" claimmd_id="396891542" fdos="2022-08-22" fileid="662053345" filename="sample837.txt" ins_number="BXYZ99PA" payerid="60054" pcn="107026-1" remote_claimid="396723069" response_time="2022-09-01 11:34:59am" sender_icn="" sender_name="CLAIM.MD" senderid="CLMMD" status="A" total_charge="75.00">
    <messages fields="" mesgid="ACK" message="Acknowledged" responseid="755534643" status="A" />
  </claim>
  <claim batchid="13388918" bill_npi="1234567893" bill_taxid="741111111" claimid="396723060" claimmd_id="396891541" fdos="2022-08-22" fileid="662053345" filename="sample837.txt" ins_number="ZGQ23333352902" payerid="22099" pcn="151068-1" remote_claimid="396723060" response_time="2022-09-01 12:44:49pm" sender_icn="TST396891541" sender_name="NJ BCBS" senderid="FAKE" status="A" total_charge="165.00">
    <messages fields="" mesgid="ACK" message="CLAIM ACKNOWLEDGED" responseid="755595616" status="A" />
  </claim>
  <claim batchid="13388919" bill_npi="1234567893" bill_taxid="741111111" claimid="396723069" claimmd_id="396891542" fdos="2022-08-22" fileid="662053345" filename="sample837.txt" ins_number="BXYZ99PA" payerid="60054" pcn="107026-1" remote_claimid="396723069" response_time="2022-09-01 12:44:49pm" sender_icn="TST396891542" sender_name="AETNA HMO" senderid="FAKE" status="A" total_charge="75.00">
    <messages fields="" mesgid="ACK" message="CLAIM ACKNOWLEDGED" responseid="755595617" status="A" />
    <messages fields="" mesgid="ACK" message="STATUS - Finalized/Payment-The claim/line has been paid. - Payment reflects usual and customary charges." responseid="755595618" status="A" />
  </claim>
</result>

Eligibility Request 270/271

Realtime eligibility request in the X12 270/271 formats. Send one request per 270 file.

Request
header Parameters
Accept
string
Default: application/xml
Enum: "application/xml" "application/json"
Request Body schema: multipart/form-data
AccountKey
required
string

Claim.MD API Key. Locate this value in the portal under Settings - Account Settings.

File
required
string <binary>

270 file data

Responses
200

OK

post/services/elig/
Request samples
Response samples
<result>
  <eligibility data="ISA... DATA ...IEA" eligid="43830230" />
</result>

Eligibility Request XML/JSON

Realtime eligibility request, send parameters. Results return in XML or JSON formats.
Service formerly /eligxml/, this legacy URL is still supported.

Request
header Parameters
Accept
string
Default: application/xml
Enum: "application/xml" "application/json"
Request Body schema: application/x-www-form-urlencoded
AccountKey
required
string

Claim.MD API Key. Locate this value in the portal under Settings - Account Settings.

ins_name_l
required
string

Insured/Patient last name

ins_name_f
required
string

Insured/Patient first name

ins_name_m
string

Insured/Patient middle name

payerid
required
string

Payer ID to identify which payer to query.

pat_rel
required
any

Patient relationship code.
Valid values:
18 = Self
G8 = Dependent

Enum: "18" "G8"
service_code
string

Eligibility benefit type codes requested. Comma separated values. Corresponds with 'benefit_type_code' listed in reference above. Defaults to '30', Health Benefit Plan Coverage.

Enum: "1" "2" "3" "4" "5" "6" "7" "8" "9" "10" "11" "12" "13" "14" "15" "16" "17" "18" "19" "20" "21" "22" "23" "24" "25" "26" "27" "28" "30" "32" "33" "34" "35" "36" "37" "38" "39" "40" "41" "42" "43" "44" "45" "46" "47" "48" "49" "50" "51" "52" "53" "54" "55" "56" "57" "58" "59" "60" "61" "62" "63" "64" "65" "66" "67" "68" "69" "70" "71" "72" "73" "74" "75" "76" "77" "78" "79" "80" "81" "82" "83" "84" "85" "86" "87" "88" "89" "90" "91" "92" "93" "94" "95" "96" "97" "98" "99" "A0" "A1" "A3" "A4" "A5" "A6" "A7" "A8" "A9" "AA" "AB" "AC" "AD" "AE" "AF" "AG" "AH" "AI" "AJ" "AK" "AL" "AM" "AN" "AO" "AP" "AQ" "AR" "B1" "B2" "B3" "BA" "BB" "BC" "BD" "BE" "BF" "BG" "BH" "BI" "BJ" "BK" "BL" "BM" "BN" "BP" "BQ" "BR" "BS" "BT" "BU" "BV" "BW" "BX" "BY" "BZ" "C1" "CA" "CB" "CC" "CD" "CE" "CF" "CG" "CH" "CI" "CJ" "CK" "CL" "CM" "CN" "CO" "CP" "CQ" "DG" "DM" "DS" "GF" "GN" "GY" "IC" "MH" "NI" "ON" "PT" "PU" "RN" "RT" "TC" "TN" "UC" "E0" "E1" "E2" "E3" "E4" "E5" "E6" "E7" "E8" "E9" "E10" "E11" "E12" "E13" "E14" "E15" "E16" "E17" "E18" "E19" "E20" "E21" "E22" "E23" "E24" "E25" "E26" "E27" "E28" "E29" "E30" "E31" "E32" "E33" "E34" "E35" "E36" "EA" "EB" "EC" "ED" "EE" "EF" "GF" "GN" "GY" "IC" "MH" "NI" "ON" "PE" "PT" "PU" "RN" "RT" "SMH" "TC" "TN" "UC"
proc_code
string

CPT Code. Used in place of service_code.

fdos
required
string

Service date. Format yyyymmdd.

prov_npi
required
string

Provider NPI

ins_number
string

Insured policy/MBI

ins_dob
string

Insured date of birth. Format yyyymmdd.

pat_name_l
string

Patient last name (used when pat_rel = G8)

pat_name_f
string

Patient first name (used when pat_rel = G8)

pat_name_m
string

Patient middle name (used when pat_rel = G8)

pat_dob
string

Patient date of birth. Format yyyymmdd. (used when pat_rel = G8)

prov_name_l
string

Provider organization name, or individual provider last name.

prov_name_f
string

Individual provider first name.

prov_taxonomy
string

Provider taxonomy code.

prov_taxid
string

Provider tax ID.

prov_taxid_type
any

Provider tax ID Type
E = EIN
S = SSN

Enum: "E" "S"
prov_addr_1
string

Provider street address.

prov_city
string

Provider city.

prov_state
string

Provider state.

prov_zip
string

Provider zip.

Responses
200

OK

post/services/eligdata/
Request samples
application/x-www-form-urlencoded
AccountKey=string&ins_name_l=string&ins_name_f=string&payerid=string&pat_rel=18&fdos=string&prov_npi=string
Response samples
<result>
  <elig elig_result_date="20220909" elig_result_time="1341" eligid="28277016" group_number="202GROUP" ins_addr_1="21 JUMP ST" ins_city="MEMPHIS" ins_dob="19800101" ins_name_f="JOE" ins_name_l="SMITH" ins_number="12345678" ins_sex="M" ins_state="TN" ins_zip="871019998" plan_begin_date="20220810-20221009" plan_number="PLAN101">
    <benefit benefit_code="30" benefit_coverage_code="1" benefit_coverage_description="Active Coverage" benefit_description="Health Benefit Plan Coverage" benefit_notes="FUNDING TYPE = FULLY INSURED" date_of_last_update="20160702" insurance_plan="UNITED HEALTH CARE CHOICE PLUS" insurance_type_code="C1" insurance_type_description="Commercial">
      <entity_addr_1>P.O. BOX 30555</entity_addr_1>
      <entity_city>SALT LAKE CITY</entity_city>
      <entity_code>PR</entity_code>
      <entity_description>Payer</entity_description>
      <entity_name>UNITED HEALTH CARE</entity_name>
      <entity_state>UT</entity_state>
      <entity_zip>841300555</entity_zip>
    </benefit>
    <benefit benefit_amount="0" benefit_code="30" benefit_coverage_code="C" benefit_coverage_description="Deductible" benefit_description="Health Benefit Plan Coverage" benefit_level_code="FAM" benefit_level_description="Family" benefit_period_code="24" benefit_period_description="Year to Date" inplan_network="W" />
    <benefit benefit_amount="0" benefit_code="30" benefit_coverage_code="C" benefit_coverage_description="Deductible" benefit_description="Health Benefit Plan Coverage" benefit_level_code="IND" benefit_level_description="Individual" benefit_period_code="24" benefit_period_description="Year to Date" inplan_network="W" />
    <benefit benefit_amount="0" benefit_code="30" benefit_coverage_code="G" benefit_coverage_description="Out of Pocket (Stop Loss)" benefit_description="Health Benefit Plan Coverage" benefit_level_code="FAM" benefit_level_description="Family" benefit_period_code="24" benefit_period_description="Year to Date" inplan_network="W" insurance_type_code="C1" insurance_type_description="Commercial" />
    <benefit benefit_amount="0" benefit_code="30" benefit_coverage_code="G" benefit_coverage_description="Out of Pocket (Stop Loss)" benefit_description="Health Benefit Plan Coverage" benefit_level_code="IND" benefit_level_description="Individual" benefit_period_code="24" benefit_period_description="Year to Date" inplan_network="W" insurance_type_code="C1" insurance_type_description="Commercial" />
    <benefit benefit_amount="3000" benefit_code="30" benefit_coverage_code="C" benefit_coverage_description="Deductible" benefit_description="Health Benefit Plan Coverage" benefit_level_code="FAM" benefit_level_description="Family" benefit_period_code="23" benefit_period_description="Calendar Year" inplan_network="N" />
    <benefit benefit_amount="0" benefit_code="30" benefit_coverage_code="C" benefit_coverage_description="Deductible" benefit_description="Health Benefit Plan Coverage" benefit_level_code="IND" benefit_level_description="Individual" benefit_period_code="29" benefit_period_description="Remaining" inplan_network="Y" />
    <benefit benefit_amount="9000" benefit_code="30" benefit_coverage_code="G" benefit_coverage_description="Out of Pocket (Stop Loss)" benefit_description="Health Benefit Plan Coverage" benefit_level_code="FAM" benefit_level_description="Family" benefit_period_code="23" benefit_period_description="Calendar Year" inplan_network="N" insurance_type_code="C1" insurance_type_description="Commercial" />
    <benefit benefit_amount="1500" benefit_code="30" benefit_coverage_code="C" benefit_coverage_description="Deductible" benefit_description="Health Benefit Plan Coverage" benefit_level_code="IND" benefit_level_description="Individual" benefit_period_code="29" benefit_period_description="Remaining" inplan_network="N" />
    <benefit benefit_amount="99999" benefit_code="30" benefit_coverage_code="G" benefit_coverage_description="Out of Pocket (Stop Loss)" benefit_description="Health Benefit Plan Coverage" benefit_level_code="FAM" benefit_level_description="Family" benefit_period_code="29" benefit_period_description="Remaining" inplan_network="Y" insurance_type_code="C1" insurance_type_description="Commercial" />
    <benefit benefit_amount="99999" benefit_code="30" benefit_coverage_code="G" benefit_coverage_description="Out of Pocket (Stop Loss)" benefit_description="Health Benefit Plan Coverage" benefit_level_code="IND" benefit_level_description="Individual" benefit_period_code="29" benefit_period_description="Remaining" inplan_network="Y" insurance_type_code="C1" insurance_type_description="Commercial" />
    <benefit benefit_amount="4500" benefit_code="30" benefit_coverage_code="G" benefit_coverage_description="Out of Pocket (Stop Loss)" benefit_description="Health Benefit Plan Coverage" benefit_level_code="IND" benefit_level_description="Individual" benefit_period_code="23" benefit_period_description="Calendar Year" inplan_network="N" insurance_type_code="C1" insurance_type_description="Commercial" />
    <benefit benefit_amount="99999" benefit_code="30" benefit_coverage_code="G" benefit_coverage_description="Out of Pocket (Stop Loss)" benefit_description="Health Benefit Plan Coverage" benefit_level_code="IND" benefit_level_description="Individual" benefit_period_code="23" benefit_period_description="Calendar Year" inplan_network="Y" insurance_type_code="C1" insurance_type_description="Commercial" />
    <benefit benefit_amount="1500" benefit_code="30" benefit_coverage_code="C" benefit_coverage_description="Deductible" benefit_description="Health Benefit Plan Coverage" benefit_level_code="IND" benefit_level_description="Individual" benefit_period_code="23" benefit_period_description="Calendar Year" inplan_network="N" />
    <benefit benefit_amount="3000" benefit_code="30" benefit_coverage_code="C" benefit_coverage_description="Deductible" benefit_description="Health Benefit Plan Coverage" benefit_level_code="FAM" benefit_level_description="Family" benefit_period_code="29" benefit_period_description="Remaining" inplan_network="N" />
    <benefit benefit_amount="0" benefit_code="30" benefit_coverage_code="C" benefit_coverage_description="Deductible" benefit_description="Health Benefit Plan Coverage" benefit_level_code="FAM" benefit_level_description="Family" benefit_period_code="29" benefit_period_description="Remaining" inplan_network="Y" />
    <benefit benefit_amount="9000" benefit_code="30" benefit_coverage_code="G" benefit_coverage_description="Out of Pocket (Stop Loss)" benefit_description="Health Benefit Plan Coverage" benefit_level_code="FAM" benefit_level_description="Family" benefit_period_code="29" benefit_period_description="Remaining" inplan_network="N" insurance_type_code="C1" insurance_type_description="Commercial" />
    <benefit benefit_amount="99999" benefit_code="30" benefit_coverage_code="G" benefit_coverage_description="Out of Pocket (Stop Loss)" benefit_description="Health Benefit Plan Coverage" benefit_level_code="FAM" benefit_level_description="Family" benefit_period_code="23" benefit_period_description="Calendar Year" inplan_network="Y" insurance_type_code="C1" insurance_type_description="Commercial" />
    <benefit benefit_amount="0" benefit_code="30" benefit_coverage_code="C" benefit_coverage_description="Deductible" benefit_description="Health Benefit Plan Coverage" benefit_level_code="FAM" benefit_level_description="Family" benefit_period_code="23" benefit_period_description="Calendar Year" inplan_network="Y" />
    <benefit benefit_amount="0" benefit_code="30" benefit_coverage_code="C" benefit_coverage_description="Deductible" benefit_description="Health Benefit Plan Coverage" benefit_level_code="IND" benefit_level_description="Individual" benefit_period_code="23" benefit_period_description="Calendar Year" inplan_network="Y" />
    <benefit benefit_amount="4500" benefit_code="30" benefit_coverage_code="G" benefit_coverage_description="Out of Pocket (Stop Loss)" benefit_description="Health Benefit Plan Coverage" benefit_level_code="IND" benefit_level_description="Individual" benefit_period_code="29" benefit_period_description="Remaining" inplan_network="N" insurance_type_code="C1" insurance_type_description="Commercial" />
    <benefit benefit_code="1" benefit_coverage_code="1" benefit_coverage_description="Active Coverage" benefit_description="Medical Care" inplan_network="W" />
    <benefit benefit_code="33" benefit_coverage_code="1" benefit_coverage_description="Active Coverage" benefit_description="Chiropractic" inplan_network="W" />
    <benefit benefit_code="47" benefit_coverage_code="1" benefit_coverage_description="Active Coverage" benefit_description="Hospital" inplan_network="W" />
    <benefit benefit_code="48" benefit_coverage_code="1" benefit_coverage_description="Active Coverage" benefit_description="Hospital - Inpatient" inplan_network="W" />
    <benefit benefit_code="50" benefit_coverage_code="1" benefit_coverage_description="Active Coverage" benefit_description="Hospital - Outpatient" inplan_network="W" />
    <benefit benefit_code="86" benefit_coverage_code="1" benefit_coverage_description="Active Coverage" benefit_description="Emergency Services" inplan_network="W" />
    <benefit benefit_code="98" benefit_coverage_code="1" benefit_coverage_description="Active Coverage" benefit_description="Professional (Physician) Visit - Office" inplan_network="W" />
    <benefit benefit_code="AL" benefit_coverage_code="1" benefit_coverage_description="Active Coverage" benefit_description="Vision (Optometry)" inplan_network="W" />
    <benefit benefit_code="MH" benefit_coverage_code="1" benefit_coverage_description="Active Coverage" benefit_description="Mental Health" inplan_network="W" />
    <benefit benefit_code="PT" benefit_coverage_code="1" benefit_coverage_description="Active Coverage" benefit_description="Physical Therapy" inplan_network="W" />
    <benefit benefit_code="UC" benefit_coverage_code="1" benefit_coverage_description="Active Coverage" benefit_description="Urgent Care" inplan_network="W" />
    <benefit benefit_code="96" benefit_coverage_code="1" benefit_coverage_description="Active Coverage" benefit_description="Professional (Physician)" benefit_notes="SPECIALIST" inplan_network="W" />
    <benefit benefit_code="96" benefit_coverage_code="A" benefit_coverage_description="Co-Insurance" benefit_description="Professional (Physician)" benefit_level_code="IND" benefit_level_description="Individual" benefit_notes="SPECIALIST" benefit_percent="0" benefit_period_code="27" benefit_period_description="Visit" inplan_network="Y" />
    <benefit benefit_code="33" benefit_coverage_code="A" benefit_coverage_description="Co-Insurance" benefit_description="Chiropractic" benefit_level_code="IND" benefit_level_description="Individual" benefit_percent="0" benefit_period_code="27" benefit_period_description="Visit" inplan_network="Y" />
    <benefit benefit_code="98" benefit_coverage_code="A" benefit_coverage_description="Co-Insurance" benefit_description="Professional (Physician) Visit - Office" benefit_level_code="IND" benefit_level_description="Individual" benefit_p rcent="0" benefit_period_code="27" benefit_period_description="Visit" inplan_network="Y" />
    <benefit benefit_code="PT" benefit_coverage_code="A" benefit_coverage_description="Co-Insurance" benefit_description="Physical Therapy" benefit_level_code="IND" benefit_level_description="Individual" benefit_percent="0" benefit_period_code="27" benefit_period_description="Visit" inplan_network="Y" />
    <benefit benefit_code="UC" benefit_coverage_code="A" benefit_coverage_description="Co-Insurance" benefit_description="Urgent Care" benefit_level_code="IND" benefit_level_description="Individual" benefit_percent="0" benefit_period_code="27" benefit_period_description="Visit" inplan_network="Y" />
    <benefit benefit_code="48" benefit_coverage_code="A" benefit_coverage_description="Co-Insurance" benefit_description="Hospital - Inpatient" benefit_level_code="IND" benefit_level_description="Individual" benefit_percent="0" benefit_period_code="27" benefit_period_description="Visit" inplan_network="Y" />
    <benefit benefit_code="50" benefit_coverage_code="A" benefit_coverage_description="Co-Insurance" benefit_description="Hospital - Outpatient" benefit_level_code="IND" benefit_level_description="Individual" benefit_percent="0" benefit_period_code="27" benefit_period_description="Visit" inplan_network="Y" />
    <benefit benefit_code="86" benefit_coverage_code="A" benefit_coverage_description="Co-Insurance" benefit_description="Emergency Services" benefit_level_code="IND" benefit_level_description="Individual" benefit_percent="0" benefit_period_code="27" benefit_period_description="Visit" inplan_network="Y" />
    <benefit benefit_code="33" benefit_coverage_code="A" benefit_coverage_description="Co-Insurance" benefit_description="Chiropractic" benefit_level_code="IND" benefit_level_description="Individual" benefit_percent="50" benefit_period_code="27" benefit_period_description="Visit" inplan_network="N" />
    <benefit benefit_code="50" benefit_coverage_code="A" benefit_coverage_description="Co-Insurance" benefit_description="Hospital - Outpatient" benefit_level_code="IND" benefit_level_description="Individual" benefit_percent="50" benefit_period_code="27" benefit_period_description="Visit" inplan_network="N" />
    <benefit benefit_code="86" benefit_coverage_code="A" benefit_coverage_description="Co-Insurance" benefit_description="Emergency Services" benefit_level_code="IND" benefit_level_description="Individual" benefit_percent="50" benefit_period_code="27" benefit_period_description="Visit" inplan_network="N" />
    <benefit benefit_code="98" benefit_coverage_code="A" benefit_coverage_description="Co-Insurance" benefit_description="Professional (Physician) Visit - Office" benefit_level_code="IND" benefit_level_description="Individual" benefit_percent="50" benefit_period_code="27" benefit_period_description="Visit" inplan_network="N" />
    <benefit benefit_code="UC" benefit_coverage_code="A" benefit_coverage_description="Co-Insurance" benefit_description="Urgent Care" benefit_level_code="IND" benefit_level_description="Individual" benefit_percent="50" benefit_period_code="27" benefit_period_description="Visit" inplan_network="N" />
    <benefit benefit_code="PT" benefit_coverage_code="A" benefit_coverage_description="Co-Insurance" benefit_description="Physical Therapy" benefit_level_code="IND" benefit_level_description="Individual" benefit_percent="50" benefit_period_code="27" benefit_period_description="Visit" inplan_network="N" />
    <benefit benefit_code="48" benefit_coverage_code="A" benefit_coverage_description="Co-Insurance" benefit_description="Hospital - Inpatient" benefit_level_code="IND" benefit_level_description="Individual" benefit_percent="50" benefit_period_code="27" benefit_period_description="Visit" inplan_network="N" />
    <benefit benefit_code="96" benefit_coverage_code="A" benefit_coverage_description="Co-Insurance" benefit_description="Professional (Physician)" benefit_level_code="IND" benefit_level_description="Individual" benefit_notes="SPECIALIST" benefit_percent="50" benefit_period_code="27" benefit_period_description="Visit" inplan_network="N" />
    <benefit benefit_amount="0" benefit_code="96" benefit_coverage_code="B" benefit_coverage_description="Co-Payment" benefit_description="Professional (Physician)" benefit_level_code="IND" benefit_level_description="Individual" benefit_notes="SPECIALIST" benefit_period_code="27" benefit_period_description="Visit" inplan_network="N" />
    <benefit benefit_amount="35" benefit_code="UC" benefit_coverage_code="B" benefit_coverage_description="Co-Payment" benefit_description="Urgent Care" benefit_level_code="IND" benefit_level_description="Individual" benefit_period_code="27" benefit_period_description="Visit" inplan_network="Y" />
    <benefit benefit_amount="0" benefit_code="UC" benefit_coverage_code="B" benefit_coverage_description="Co-Payment" benefit_description="Urgent Care" benefit_level_code="IND" benefit_level_description="Individual" benefit_period_code="27" benefit_period_description="Visit" inplan_network="N" />
    <benefit benefit_amount="0" benefit_code="48" benefit_coverage_code="B" benefit_coverage_description="Co-Payment" benefit_description="Hospital - Inpatient" benefit_level_code="IND" benefit_level_description="Individual" benefit_period_code="27" benefit_period_description="Visit" inplan_network="N" />
    <benefit benefit_amount="0" benefit_code="PT" benefit_coverage_code="B" benefit_coverage_description="Co-Payment" benefit_description="Physical Therapy" benefit_level_code="IND" benefit_level_description="Individual" benefit_period_code="27" benefit_period_description="Visit" inplan_network="N" />
    <benefit benefit_amount="0" benefit_code="98" benefit_coverage_code="B" benefit_coverage_description="Co-Payment" benefit_description="Professional (Physician) Visit - Office" benefit_level_code="IND" benefit_level_description="Individual" benefit_period_code="27" benefit_period_description="Visit" inplan_network="N" />
    <benefit benefit_amount="0" benefit_code="33" benefit_coverage_code="B" benefit_coverage_description="Co-Payment" benefit_description="Chiropractic" benefit_level_code="IND" benefit_level_description="Individual" benefit_period_code="27" benefit_period_description="Visit" inplan_network="N" />
    <benefit benefit_amount="0" benefit_code="86" benefit_coverage_code="B" benefit_coverage_description="Co-Payment" benefit_description="Emergency Services" benefit_level_code="IND" benefit_level_description="Individual" benefit_period_code="27" benefit_period_description="Visit" inplan_network="N" />
    <benefit benefit_amount="0" benefit_code="50" benefit_coverage_code="B" benefit_coverage_description="Co-Payment" benefit_description="Hospital - Outpatient" benefit_level_code="IND" benefit_level_description="Individual" benefit_period_code="27" benefit_period_description="Visit" inplan_network="N" />
    <benefit benefit_amount="125" benefit_code="50" benefit_coverage_code="B" benefit_coverage_description="Co-Payment" benefit_description="Hospital - Outpatient" benefit_level_code="IND" benefit_level_description="Individual" benefit_period_code="27" benefit_period_description="Visit" inplan_network="Y" />
    <benefit benefit_amount="15" benefit_code="96" benefit_coverage_code="B" benefit_coverage_description="Co-Payment" benefit_description="Professional (Physician)" benefit_level_code="IND" benefit_level_description="Individual" benefit_notes="SPECIALIST" benefit_period_code="27" benefit_period_description="Visit" inplan_network="Y" />
    <benefit benefit_amount="15" benefit_code="98" benefit_coverage_code="B" benefit_coverage_description="Co-Payment" benefit_description="Professional (Physician) Visit - Office" benefit_level_code="IND" benefit_level_description="Individual" benefit_period_code="27" benefit_period_description="Visit" inplan_network="Y" />
    <benefit benefit_amount="15" benefit_code="33" benefit_coverage_code="B" benefit_coverage_description="Co-Payment" benefit_description="Chiropractic" benefit_level_code="IND" benefit_level_description="Individual" benefit_period_code="27" benefit_period_description="Visit" inplan_network="Y" />
    <benefit benefit_amount="15" benefit_code="PT" benefit_coverage_code="B" benefit_coverage_description="Co-Payment" benefit_description="Physical Therapy" benefit_level_code="IND" benefit_level_description="Individual" benefit_period_code="27" benefit_period_description="Visit" inplan_network="Y" />
    <benefit benefit_amount="250" benefit_code="48" benefit_coverage_code="B" benefit_coverage_description="Co-Payment" benefit_description="Hospital - Inpatient" benefit_level_code="IND" benefit_level_description="Individual" benefit_period_code="27" benefit_period_description="Visit" inplan_network="Y" />
    <benefit benefit_amount="75" benefit_code="86" benefit_coverage_code="B" benefit_coverage_description="Co-Payment" benefit_description="Emergency Services" benefit_level_code="IND" benefit_level_description="Individual" benefit_period_code="27" benefit_period_description="Visit" inplan_network="Y" />
    <benefit benefit_amount="999999.99" benefit_code="33" benefit_coverage_code="F" benefit_coverage_description="Limitations" benefit_description="Chiropractic" benefit_level_code="IND" benefit_level_description="Individual" benefit_notes="ADDITIONAL VISITS AVAILABLE BASED ON MEDICAL NECESSITY REVIEW REHABILITATIVE" benefit_period_code="23" benefit_period_description="Calendar Year" benefit_qnty="30" inplan_network="W" />
    <benefit benefit_amount="999999.99" benefit_code="33" benefit_coverage_code="F" benefit_coverage_description="Limitations" benefit_description="Chiropractic" benefit_level_code="IND" benefit_level_description="Individual" benefit_notes="ADDITIONAL VISITS AVAILABLE BASED ON MEDICAL NECESSITY REVIEW REHABILITATIVE" benefit_period_code="29" benefit_period_description="Remaining" benefit_qnty="30" inplan_network="W" />
    <benefit benefit_code="PT" benefit_coverage_code="F" benefit_coverage_description="Limitations" benefit_description="Physical Therapy" benefit_level_code="IND" benefit_level_description="Individual" benefit_notes="REHABILITATIVE ADDITIONAL BENEFIT FOR MUSCULOSKELETAL PAIN MANAGEMENT PROGRAM" benefit_period_code="29" benefit_period_description="Remaining" benefit_qnty="3" inplan_network="Y" />
    <benefit benefit_code="33" benefit_coverage_code="F" benefit_coverage_description="Limitations" benefit_description="Chiropractic" benefit_level_code="IND" benefit_level_description="Individual" benefit_notes="REHABILITATIVE ADDITIONAL BENEFIT FOR MUSCULOSKELETAL PAIN MANAGEMENT PROGRAM" benefit_period_code="29" benefit_period_description="Remaining" benefit_qnty="3" inplan_network="Y" />
    <benefit benefit_amount="999999.99" benefit_code="PT" benefit_coverage_code="F" benefit_coverage_description="Limitations" benefit_description="Physical Therapy" benefit_level_code="IND" benefit_level_description="Individual" benefit_notes="REHABILITATIVE" benefit_period_code="23" benefit_period_description="Calendar Year" benefit_qnty="20" inplan_network="W" />
    <benefit benefit_amount="999999.99" benefit_code="PT" benefit_coverage_code="F" benefit_coverage_description="Limitations" benefit_description="Physical Therapy" benefit_level_code="IND" benefit_level_description="Individual" benefit_notes="REHABILITATIVE" benefit_period_code="29" benefit_period_description="Remaining" benefit_qnty="20" inplan_network="W" />
    <benefit benefit_code="88" benefit_coverage_code="U" benefit_coverage_description="Contact Following Entity for Eligibility or Benefit Information" benefit_description="Pharmacy">
      <entity_code>VN</entity_code>
      <entity_description>Vendor</entity_description>
      <entity_name>OPTUMRX</entity_name>
      <entity_website>PROFESSIONALS.OPTUMRX.COM</entity_website>
    </benefit>
  </elig>
</result>

Electronic Remittance Advice (ERA) List

This service will return a list of ERA received. To keep your system updated with all new remittance it is recommended you use the "ERAID" parameter to download the latest updates. After successfully loading all results returned, store the value of "last_eraid", and use it as the parameter in "ERAID" to only receive the latest remits. [For remittance details see the below service options.]Service formerly /era/, this legacy URL is still supported.

Request
header Parameters
Accept
string
Default: application/xml
Enum: "application/xml" "application/json"
Request Body schema: application/x-www-form-urlencoded
AccountKey
required
string

Locate this value under Settings - Account Settings in the web portal.

CheckDate
string

Search for ERA with a specific payment date. Format mm-dd-yyyy.

ReceivedDate
string

Search for ERA using the date Claim.MD received the file.Format mm-dd-yyyy, or ‘today’ or ‘yesterday’

ReceivedAfterData
string

Returns all ERA received after a specific date. Format mm-dd-yyyy, or ‘today’ or ‘yesterday’

CheckNumber
string

Search for ERA with specific Check/EFT

CheckAmount
string

Search for ERA with specific payment amoun

PayerID
string

Search for ERA with specific PayerID

NPI
string

Search for ERA with specific Billing Provider NPI

TaxID
string

Search for ERA with specific Billing Provider Tax ID

NewOnly
string

Only list ERA not yet downloaded, true or false (use ‘1’ or ‘0’). Defaults to ‘1’ if no search options are given.

ERAID
string

Return only remits with an ERAID greater than this

Page
string

If more than 100 results are available use Page to return additional results. Defaults to ‘1’.

Responses
200

OK

post/services/eralist/
Request samples
application/x-www-form-urlencoded
AccountKey=string
Response samples
<result last_eraid="23853671">
  <era check_number="397547097-1662491256" check_type="eft" claimmd_prov_name="MEDICAL CARE CENTER" download_time="" eraid="23853666" paid_amount="182.00" paid_date="2022-09-06" payer_name="NJ BCBS" payerid="22099" prov_name="MEDICAL CARE CENTER" prov_npi="1234567893" prov_taxid="741111111" received_time="09-06-2022 13:07" />
  <era check_number="397547116-1662491256" check_type="eft" claimmd_prov_name="MEDICAL CARE CENTER" download_time="" eraid="23853667" paid_amount="86.00" paid_date="2022-09-06" payer_name="TML HMP" payerid="39026" prov_name="MEDICAL CARE CENTER" prov_npi="1234567893" prov_taxid="741111111" received_time="09-06-2022 13:07" />
  <era check_number="397547086-1662491256" check_type="eft" claimmd_prov_name="MEDICAL CARE CENTER" download_time="" eraid="23853668" paid_amount="45.00" paid_date="2022-09-06" payer_name="AETNA HMO" payerid="60054" prov_name="MEDICAL CARE CENTER" prov_npi="1234567893" prov_taxid="741111111" received_time="09-06-2022 13:07" />
  <era check_number="397547087-1662491256" check_type="eft" claimmd_prov_name="MEDICAL CARE CENTER" download_time="" eraid="23853669" paid_amount="795.00" paid_date="2022-09-06" payer_name="AETNA" payerid="60054" prov_name="MEDICAL CARE CENTER" prov_npi="1234567893" prov_taxid="741111111" received_time="09-06-2022 13:07" />
  <era check_number="397547090-1662491257" check_type="eft" claimmd_prov_name="MEDICAL CARE CENTER" download_time="" eraid="23853670" paid_amount="490.40" paid_date="2022-09-06" payer_name="CIGNA" payerid="62308" prov_name="MEDICAL CARE CENTER" prov_npi="1234567893" prov_taxid="741111111" received_time="09-06-2022 13:07" />
  <era check_number="397547083-1662491258" check_type="eft" claimmd_prov_name="MEDICAL CARE CENTER" download_time="" eraid="23853671" paid_amount="346.00" paid_date="2022-09-06" payer_name="UNITED HEALTHCARE PPO" payerid="87726" prov_name="MEDICAL CARE CENTER" prov_npi="1234567893" prov_taxid="741111111" received_time="09-06-2022 13:07" />
</result>

ERA Details (835 Format)

Download a specific electronic remittance in the 835 file format.

Request
header Parameters
Accept
string
Default: application/xml
Enum: "application/xml" "application/json"
Request Body schema: application/x-www-form-urlencoded
AccountKey
required
string

Locate this value under Settings - Account Settings in the web portal.

eraid
required
string

Claim.MD ERA ID, found using /era/ service

Responses
200

OK

post/services/era835/
Request samples
application/x-www-form-urlencoded
AccountKey=string&eraid=string
Response samples
<result check_number="397547083-1662491258" check_type="eft" eraid="23853671" paid_amount="346.00" paid_date="2022-09-06" payer_name="UNITED HEALTHCARE PPO" payerid="87726" prov_name="MEDICAL CARE CENTER" prov_npi="1234567893">
  <data>ISA... DATA ...IEA</data>
</result>

ERA Details (PDF Format)

Download a specific electronic remittance in the human readable PDF report format. Results are Base64 encoded.

Request
header Parameters
Accept
string
Default: application/xml
Enum: "application/xml" "application/json"
Request Body schema: application/x-www-form-urlencoded
AccountKey
required
string

Locate this value under Settings - Account Settings in the web portal.

eraid
required
string

Claim.MD ERA ID, found using /era/ service

pcn
string

Generate remittance for only the given Acct #. [Optional]

Responses
200

OK

post/services/erapdf/
Request samples
application/x-www-form-urlencoded
AccountKey=string&eraid=string
Response samples
<result check_number="397547083-1662491258" eraid="23853671" paid_amount="346.00" paid_date="2022-09-06" payer_name="UNITED HEALTHCARE PPO" payerid="87726" prov_name="MEDICAL CARE CENTER" prov_npi="1234567893">
  <data>BASE64 ENCODED PDF DATA</data>
</result>

ERA Details (XML/JSON Format)

Download a specific electronic remittance in the XML/JSON formats.
Service formerly /eraxml/, this legacy URL is still supported.

Request
header Parameters
Accept
string
Default: application/xml
Enum: "application/xml" "application/json"
Request Body schema: application/x-www-form-urlencoded
AccountKey
required
string

Account associated

eraid
required
string

Claim.MD ERA ID, found using /era/ service

Responses
200

OK

post/services/eradata/
Request samples
application/x-www-form-urlencoded
AccountKey=string&eraid=string
Response samples
<result check_number="397547083-1662491258" eraid="23853671" paid_amount="346.00" paid_date="2022-09-06" payer_account="700000000" payer_addr_1="" payer_city="ATLANTA" payer_companyid="" payer_name="UNITED HEALTHCARE PPO" payer_routing="111111111" payer_state="GA" payer_zip="303740800" payerid="87726" payment_format="CCP" payment_method="ACH" prov_account="111111111" prov_addr_1="" prov_city="SANTA FE" prov_name="MEDICAL CARE CENTER" prov_npi="1234567893" prov_routing="111111111" prov_state="NM" prov_taxid="741111111" prov_zip="875059998">
  <claim crossover_carrier="" crossover_id="" from_dos="20220827" ins_name_f="NORMAN" ins_name_l="BATES" ins_number="412098745" pat_name_f="ETHYL" pat_name_l="BATES" payer_icn="TST397547083" pcn="124974-1" prov_npi="1111111112" status_code="4" thru_dos="" total_charge="48" total_paid="0">
    <charge allowed="0" charge="48" chgid="221043771" from_dos="20220827" mod1="" mod2="" mod3="" mod4="" paid="0" proc_code="99212" thru_dos="" units="1">
      <adjustment amount="48" code="109" group="OA" />
    </charge>
  </claim>
  <claim crossover_carrier="" crossover_id="" from_dos="20220827" ins_name_f="ROBERT" ins_name_l="DENNIS" ins_number="223444467" pat_name_f="MARYLOU" pat_name_l="DENNIS" payer_icn="TST397547094" pcn="21830-1" prov_npi="1111111112" status_code="1" thru_dos="" total_charge="75" total_paid="45">
    <charge allowed="60" charge="75" chgid="221043716" from_dos="20220827" mod1="" mod2="" mod3="" mod4="" paid="45" proc_code="99213" thru_dos="" units="1">
      <adjustment amount="15" code="45" group="CO" />
      <adjustment amount="10" code="2" group="PR" />
      <adjustment amount="5" code="3" group="PR" />
    </charge>
  </claim>
  <claim crossover_carrier="" crossover_id="" from_dos="20220827" ins_name_f="VIRGINIA" ins_name_l="GUNTHRIE" ins_number="412341611" pat_name_f="BRISTER" pat_name_l="GUNTHRIE" payer_icn="TST397547101" pcn="103756-1" prov_npi="1111111112" status_code="1" thru_dos="" total_charge="75" total_paid="45">
    <charge allowed="60" charge="75" chgid="221043755" from_dos="20220827" mod1="" mod2="" mod3="" mod4="" paid="45" proc_code="99213" thru_dos="" units="1">
      <adjustment amount="15" code="45" group="CO" />
      <adjustment amount="10" code="2" group="PR" />
      <adjustment amount="5" code="3" group="PR" />
    </charge>
  </claim>
  <claim crossover_carrier="" crossover_id="" from_dos="20220827" ins_name_f="OHPELIA" ins_name_l="HAQUE" ins_number="42211616100" pat_name_f="OHPELIA" pat_name_l="HAQUE" payer_icn="TST397547102" pcn="109126-1" prov_npi="1111111112" status_code="1" thru_dos="" total_charge="100" total_paid="65">
    <charge allowed="80" charge="100" chgid="221043774" from_dos="20220827" mod1="" mod2="" mod3="" mod4="" paid="65" proc_code="99214" thru_dos="" units="1">
      <adjustment amount="20" code="45" group="CO" />
      <adjustment amount="10" code="2" group="PR" />
      <adjustment amount="5" code="3" group="PR" />
    </charge>
  </claim>
  <claim crossover_carrier="" crossover_id="" from_dos="20220827" ins_name_f="JANET" ins_name_l="IMHOFF" ins_number="22222933300" pat_name_f="JANET" pat_name_l="IMHOFF" payer_icn="TST397547104" pcn="47147-1" prov_npi="1111111112" status_code="1" thru_dos="" total_charge="100" total_paid="65">
    <charge allowed="80" charge="100" chgid="221043722" from_dos="20220827" mod1="" mod2="" mod3="" mod4="" paid="65" proc_code="99214" thru_dos="" units="1">
      <adjustment amount="20" code="45" group="CO" />
      <adjustment amount="10" code="2" group="PR" />
      <adjustment amount="5" code="3" group="PR" />
    </charge>
  </claim>
  <claim crossover_carrier="" crossover_id="" from_dos="20220827" ins_name_f="JAMES" ins_name_l="NEAL" ins_number="329223333" pat_name_f="BOYCE" pat_name_l="NEAL" payer_icn="TST397547120" pcn="107417-1" prov_npi="1111111112" status_code="1" thru_dos="" total_charge="100" total_paid="65">
    <charge allowed="80" charge="100" chgid="221043779" from_dos="20220827" mod1="" mod2="" mod3="" mod4="" paid="65" proc_code="99214" thru_dos="" units="1">
      <adjustment amount="20" code="45" group="CO" />
      <adjustment amount="10" code="2" group="PR" />
      <adjustment amount="5" code="3" group="PR" />
    </charge>
  </claim>
  <claim crossover_carrier="" crossover_id="" from_dos="20220508" ins_name_f="LYDIA" ins_name_l="WEEKS" ins_number="123461616" pat_name_f="MARISSA" pat_name_l="WEEKS" payer_icn="TST397547134" pcn="11762-1" prov_npi="1111111112" status_code="1" thru_dos="" total_charge="95" total_paid="61">
    <charge allowed="16" charge="20" chgid="221043759" from_dos="20220508" mod1="" mod2="" mod3="" mod4="" paid="16" proc_code="81000" thru_dos="" units="1">
      <adjustment amount="4" code="45" group="CO" />
    </charge>
    <charge allowed="60" charge="75" chgid="221043760" from_dos="20220508" mod1="" mod2="" mod3="" mod4="" paid="45" proc_code="99213" thru_dos="" units="1">
      <adjustment amount="15" code="45" group="CO" />
      <adjustment amount="10" code="2" group="PR" />
      <adjustment amount="5" code="3" group="PR" />
    </charge>
  </claim>
</result>

Archive Claim

Remove a claim from the Manage Claims Menu. delete_status of ‘archived’ will be returned on claims that were removed from the Manage Claims menu that have been transmitted previously. delete_status of ‘deleted’ will be returned on claims that have never been transmitted.

Request
header Parameters
Accept
string
Default: application/xml
Enum: "application/xml" "application/json"
Request Body schema: application/x-www-form-urlencoded
AccountKey
required
string

Locate this value under Settings - Account Settings in the web portal.

claimid
required
string

Claim.MD Claim ID, this argument can be sent multiple times.

Responses
200

OK

post/services/archive/
Request samples
application/x-www-form-urlencoded
AccountKey=string&claimid=string
Response samples
application/xml
{
  "result": [
    {
      "claimid": "160050620",
      "delete_status": "archived",
      "success": "1"
    },
    {
      "claimid": "160050631",
      "delete_status": "deleted",
      "success": "1"
    },
    {
      "claimid": "160050632",
      "delete_status": "archived",
      "success": "1"
    }
  ]
}

Claim Modification Request

List all modifications made to any claims within Claim.MD. This may include changes that occur due to a corrected claim upload. Save the value of "LastModid" and pass as parameter in ModID to always download only new modification updates.

Request
header Parameters
Accept
string
Default: application/xml
Enum: "application/xml" "application/json"
Request Body schema: application/x-www-form-urlencoded
AccountKey
required
string

Locate this value under Settings - Account Settings in the web portal.

ModID
string

Return all modifications that have occurred after ModID [Optional]

ClaimMD_ID
string

Download all responses that have been returned for a particular “claimmd_id”[Optional]

Field
string

Only return changes on a particular field. Note that further requests using ModID will not contain any modifications skipped over in sequence. [Optional]

Responses
200

OK

post/services/modify/
Request samples
application/x-www-form-urlencoded
AccountKey=string
Response samples
{
  "LastModid": "12345678",
  "claim": [
    {
      "claimid": "ABCD1",
      "claimmd_id": "135961467",
      "modification": [
        {
          "modid": "123000001",
          "field": "pcn",
          "was": "A1234",
          "value": "A1111",
          "mod_time": "2015-08-01 10:48:00am",
          "username": "bob"
        },
        {
          "modid": "12300190",
          "field": "ins_number",
          "value": "1000034A",
          "mod_time": "2015-08-01 10:49:00am",
          "username": "bob"
        },
        {
          "modid": "12345677",
          "field": "proc_code_1",
          "value": "90054",
          "mod_time": "2015-08-01 11:60:00am",
          "username": "sara"
        },
        {
          "modid": "12345678",
          "field": "from_date_1",
          "value": "2016-01-12",
          "mod_time": "2015-08-01 11:60:00am",
          "username": "sara"
        }
      ]
    }
  ]
}

Provider Enrollment Request

Initiate provider enrollment. Request will add provider to Claim.MD account and return a link to be displayed to customer. Link will contain one of the following: Online Enrollment Form, Quick Enrollment Option, Enrollment Instructions, Existing Enrollment Status

Request
header Parameters
Accept
string
Default: application/xml
Enum: "application/xml" "application/json"
Request Body schema: application/x-www-form-urlencoded
AccountKey
required
string

Locate this value under Settings - Account Settings in the web portal.

payerid
required
string

Payer ID for the desired payer

enroll_type
required
string

Enrollment Type:
era = Electronic Remittance Advice / 835
1500 = Professional Claims / 837P / CMS-1500
ub = Institutional Claims / 837I / UB-04
elig = Eligibility
attach = Electronic Attachments

Enum: "era" "500" "ub" "elig" "attach"
prov_taxid
required
string

Tax ID for the provider

prov_npi
string

(situational) Provider Group or individual NPI. *Required unless the provider is atypical.

prov_name_l
string

(situational) Provider organization name or individual provider last name. *Required if no NPI given

prov_name_f
string

(situational) Individual provider first name. *Required if no NPI given and the provider is not an organization

prov_name_m
string

Individual provider middle name [optional]

contact
string

Individual who will be completing this enrollment form. (recommended)

contact_title
string

Title for the Individual who will be completing this enrollment form. (recommended)

contact_email
string

(optional) Phone number for the individual completing this form. (recommended)

contact_phone
string

(optional) Phone number for the individual completing this form. (recommended)

contact_fax
string

(optional) Fax number for the individual completing this form.

prov_id
string

(optional) Payer specific provider ID (Medicare/Medicaid provider ID)

prov_addr_1
string

(optional) Provider address line (auto completed when NPI given)

prov_addr_2
string

(optional) Provider address line (auto completed when NPI given)

prov_city
string

(optional) Provider city (auto completed when NPI given)

prov_state
string

(optional) Provider state (auto completed when NPI given)

prov_zip
string

Provider zip code (auto completed when NPI given)

Responses
200

OK

post/services/enroll/
Request samples
application/x-www-form-urlencoded
AccountKey=string&payerid=string&enroll_type=era&prov_taxid=string
Response samples
<result success="1">
  <link url="https://www.claim.md/enroll/11074_DmtGQYjHVZtCscQxrHosXjRzZyWCysWS/" />
</result>

Claim Appeal Request

Initiate an appeal from an existing claim. Request will return a link to be loaded in iframe or popup. Link will contain online form for completing an appeal to be submitted to the payer. Choices include options to fax, mail, download or submit electronic appeals. Service fees may apply for faxed or mailed appeals. Either claimid OR remote_claimid MUST be sent

Request
header Parameters
Accept
string
Default: application/xml
Enum: "application/xml" "application/json"
Request Body schema: application/x-www-form-urlencoded
AccountKey
required
string

Locate this value under Settings - Account Settings in the web portal.

claimid
string

Claim.MD Claim ID - ID assigned by Claim.MD on claim upload.

remote_claimid
string

Unique claim identifier sent on original claim submission. (In 837 this is the REF*D9 segment, in XML/CSV/XLS this is the remote_claimid field).

contact_name
string

Individual who will be completing this appeal. (recommended)

contact_title
string

Title for the Individual who will be completing this appeal. (recommended)

contact_email
string

(optional) Phone number for the individual completing appeal. (recommended)

contact_phone
string

(optional) Phone number for the individual completing appeal. (recommended)

contact_fax
string

(optional) Fax number for the individual completing appeal.

contact_addr_1
string

(optional) Contact address line 1 (Defaults to claim billing provider address)

contact_addr_2
string

(optional) Contact address line 2 (Defaults to claim billing provider address)

contact_city
string

(optional) Contact city (Defaults to claim billing provider address)

contact_state
string

(optional) Contact state (Defaults to claim billing provider address)

contact_zip
string

(optional) Contact zip code (Defaults to claim billing provider address)

Responses
200

OK

post/services/appeal/
Request samples
application/x-www-form-urlencoded
AccountKey=string
Response samples
<result success="1">
  <link url="https://www.claim.md/appeal/11074_DmtGQYjHVZtCscQxrHosXjRzZyWCysWS/" />
</result>

Payer List

Current Payer List and available services.

Request
header Parameters
Accept
string
Default: application/xml
Enum: "application/xml" "application/json"
Request Body schema: application/x-www-form-urlencoded
AccountKey
required
string

Account associated

payerid
string

Request specific payer ID.

payer_name
string

Wildcard search for matching payer name or alt payer name.

Responses
200

OK

post/services/payerlist/
Request samples
application/x-www-form-urlencoded
AccountKey=string
Response samples
<result>
  <payer 1500_claims="yes" attachment="no" auto="no" dent_claims="no" eligibility="yes" era="enrollment" payer_name="Aetna TX Medicaid CHIP" payer_state="" payer_type="medicaid" payerid="38692" secondary_support="yes" ub_claims="yes" workers_comp="no">
    <payer_alt_names alt_payer_name="Aetna Better Health of Texas" />
  </payer>
  <payer 1500_claims="yes" attachment="no" auto="no" dent_claims="no" eligibility="no" era="no" payer_name="Texas Medicaid - Yes Waiver Claims" payer_state="" payer_type="medicaid" payerid="TXYES" secondary_support="" ub_claims="no" workers_comp="no">
    <payer_alt_names alt_payer_name="TX Medicaid - Yes Waiver" />
    <payer_alt_names alt_payerid="TXYWB" />
  </payer>
  <payer 1500_claims="enrollment" attachment="no" auto="no" dent_claims="enrollment" eligibility="no" era="enrollment" payer_name="TMHP Long Term Care" payer_state="" payer_type="medicaid" payerid="TXLTC" secondary_support="yes" ub_claims="enrollment" workers_comp="no">
    <payer_alt_names alt_payer_name="TX Medicaid LTC" />
    <payer_alt_names alt_payer_name="Local intellectual and development disability authorities (LIDDAs)" />
    <payer_alt_names alt_payer_name="Texas Home Living (TxHmL)" />
    <payer_alt_names alt_payer_name="Home and Community-based Services (HCS)" />
    <payer_alt_names alt_payer_name="TDMHMR" />
    <payer_alt_names alt_payerid="SKTX1" />
    <payer_alt_names alt_payer_name="617591011CMSP" />
  </payer>
  <payer 1500_claims="yes" attachment="no" auto="no" dent_claims="no" eligibility="yes" era="enrollment" payer_name="TX Medicaid" payer_state="TX" payer_type="medicaid" payerid="86916" secondary_support="yes" ub_claims="yes" workers_comp="no">
    <payer_alt_names alt_payerid="SKTX0" />
    <payer_alt_names alt_payerid="CKTX1" />
    <payer_alt_names alt_payerid="12K64" />
    <payer_alt_names alt_payer_name="Texas Medicaid" />
    <payer_alt_names alt_payerid="MCDTX" />
    <payer_alt_names alt_payer_name="TMHP" />
    <payer_alt_names alt_payer_name="Texas Medicaid/Healthcare Services" />
    <payer_alt_names alt_payer_name="999999999" />
    <payer_alt_names alt_payer_name="617591011C21P" />
  </payer>
  <payer 1500_claims="yes" attachment="no" auto="no" dent_claims="no" eligibility="no" era="no" payer_name="TX Medicaid - LTSS" payer_state="TX" payer_type="medicaid" payerid="TXLTS" secondary_support="" ub_claims="no" workers_comp="no">
    <payer_alt_names alt_payer_name="Texas Medicaid - Long Term Support Services" />
    <payer_alt_names alt_payer_name="TX EVV - LTSS" />
    <payer_alt_names alt_payer_name="TMHP" />
  </payer>
</result>          

Claim Notes Request

List all notes made to any claims within Claim.MD. This includes any notes made by users from the web portal.

Request
header Parameters
Accept
string
Default: application/xml
Enum: "application/xml" "application/json"
Request Body schema: application/x-www-form-urlencoded
AccountKey
required
string

Locate this value under Settings - Account Settings in the web portal.

NoteID
string

Return all notes that have occurred after NoteID [Optional] [Recommended]

ClaimMD_ID
string

Download all notes that have been returned for a particular “claimmd_id” [Optional]

Responses
200

OK

post/services/notes/
Request samples
application/x-www-form-urlencoded
AccountKey=string
Response samples
{
  "LastNoteID": "111111112",
  "notes": [
    {
      "note": "I updated this claim.",
      "claimmd_id": "135961467",
      "claimid": "123ABC",
      "username": "Joe S.",
      "date_time": "2021-03-19 11:20:48am",
      "noteid": "111111111",
      "pcn": "ACNT456"
    },
    {
      "note": "Following up next week.",
      "claimmd_id": "135934535",
      "claimid": "124BBB",
      "username": "Joe S.",
      "date_time": "2021-03-19 11:20:48am",
      "noteid": "111111112",
      "pcn": "ACNT999"
    }
  ]
}

WebhookWebhook

Request
Request Body schema: application/json

Webhook results. Claim.MD Webhook will return provider enrollment updates and appeal form creation/updates. Open a support ticket to request setup of webhook to your HTTPS server.

UTCTime
string

UTC current time.

acct_number
string

Claim.MD Account Number.

remote_acct_number
string

Customer assigned account number.

Array of objects
Responses
200

Return a 200 status to indicate that the data was received successfully

Request samples
application/json
{
  • "UTCTime": "string",
  • "acct_number": "string",
  • "remote_acct_number": "string",
  • "events": [
    ]
}