This data model facilitates transactions between providers and payers. We support submitting claims and sending payment notifications in batches.
Typically, the claims workflow kicks off with providers grouping (i.e., batching) and sending claims to payers with details about services rendered to a patient and a request for payment. After processing the claims, payers send batched payment notifications to the provider with a status of whether the payment request was accepted or denied. In some cases, the status may indicate that a third party transferred funds to the provider.
This data model has event types that allow you to:
- submit a batch of claims; or
- sent a batch of payment notifications.
Send a batch of claims to a payer.
A batch message contains multiple claims with payment requests for multiple patient services.
Request Body Schema
- Metarequired, object
- DataModelrequired, stringReliable
Claim
- EventTyperequired, stringReliable
SubmissionBatch
- EventDateTimestring, nullReliable
Displays the UTC date and time that an outgoing request is delivered or an incoming request is received.
ISO 8601 Format - Testboolean, nullReliable
Indicates whether the request is a test or not.
- Sourceobject
Contains the information for the system initiating the message, including the source ID and name.
Included in messages from Redox- IDstring, nullReliable
Identifies the system initiating the message. If you have multiple OAuth API keys per environment type, this value is required. If you have only one OAuth API key per environment type, or you're using legacy API keys, this value is optional.
UUID - Namestring, nullReliable
Displays the name of the system initiating the message.
- DestinationsArray of object
Contains the information for the endpoint(s) receiving the request. A request must contain at least one destination, but asynchronous requests can have more than one destination. Synchronous requests like queries can only support one destination.
Required when sending data to Redox.- IDstring, nullReliable
Identifies the endpoint that the request is directed to.
UUID - Namestring, nullReliable
Displays the name of the endpoint that the request is directed to.
- LogsArray of object
Contains the log identifier(s) for the request.
- IDstring, nullReliable
Identifies the request log(s) that correspond to this request. You can use this value to locate the relevant log in the Redox dashboard for support and reference.
UUID - AttemptIDstring, nullReliable
Identifies the request log attempt value, which is useful when retries are possible.
UUID
- FacilityCodestring, nullPossible
Code for the facility related to the message.
Only use this field if a health system indicates you should. The code is specific to the health system's EHR and might not be unique across health systems. In general, the facility fields within the data models (e.g. OrderingFacility) are more reliable and informative.
- TransactionsArray of object
- IDstring, nullReliable
ID used by submitter to reference this Claim Submission
- IDTypestring, nullReliable
Type of ID
- Typestring, nullReliableValue Set
The type of Claim Submission, Institutional or Professional
- Submitterobject
Submitter of a Claim Submission
- IdentifiersArray of object
List of IDs and ID Types that identify the concept
- IDstring, nullReliable
ID for the submitter
- IDTypestring, nullReliable
The type of ID
- Namestring, nullReliable
- Addressobject
Address of the Submitter
- StreetAddressstring, nullProbable
Street address
- Citystring, nullProbable
City
- Statestring, nullProbable
State
- ZIPstring, nullProbable
ZIP
- Countystring, nullPossible
County
- Countrystring, nullPossibleValue Set
Country
- EmailAddressstring, nullProbable
- PhoneNumberobject
- Officestring, nullProbable
In E. 164 Format. (e.g. +16085551234)
- Faxstring, nullProbable
In E. 164 Format. (e.g. +16085551234)
- Receiverobject
Receiver of a Claim Submission
- IdentifiersArray of object
List of IDs and ID Types that identify the concept
- IDstring, nullReliable
ID for the receiver
- IDTypestring, nullReliable
The type of ID
- Namestring, nullReliable
- Addressobject
Address of the Receiver
- StreetAddressstring, nullProbable
Street address
- Citystring, nullProbable
City
- Statestring, nullProbable
State
- ZIPstring, nullProbable
ZIP
- Countystring, nullPossible
County
- Countrystring, nullPossibleValue Set
Country
- EmailAddressstring, nullProbable
- PhoneNumberobject
- Officestring, nullProbable
In E. 164 Format. (e.g. +16085551234)
- Faxstring, nullProbable
In E. 164 Format. (e.g. +16085551234)
- SubmissionsArray of object
A collection of claims submissions from a provider for services provided to patients.
- BillingProviderobject
Billing Provider
- IdentifiersArray of object
List of IDs and ID Types that identify the concept
- IDstring, nullReliable
ID for the business
- IDTypestring, nullReliable
The type of ID
- Namestring, nullReliable
- Addressobject
Address of the business
- StreetAddressstring, nullProbable
Street address
- Citystring, nullProbable
City
- Statestring, nullProbable
State
- ZIPstring, nullProbable
ZIP
- Countystring, nullPossible
County
- Countrystring, nullPossibleValue Set
Country
- EmailAddressstring, nullProbable
- PhoneNumberobject
- Officestring, nullProbable
In E. 164 Format. (e.g. +16085551234)
- Faxstring, nullProbable
In E. 164 Format. (e.g. +16085551234)
- Specialtyobject
- IDstring, nullReliable
Billing provider's specialty.
Commonly the taxonomy ID - Descriptionstring, nullReliable
Billing provider's specialty description
- SubscribersArray of object
The subscriber is the individual who is contracted with the insurance plan
- IdentifiersArray of object
List of IDs and ID Types that identify the concept
- IDstring, nullReliable
ID for the subscriber
- IDTypestring, nullReliable
The type of ID
- Demographicsobject
- FirstNamestring, nullPossible
First name of the Subscriber
- MiddleNamestring, nullPossible
Middle name of the Subscriber
- LastNamestring, nullPossible
Last name of the Subscriber
- Addressobject
Address of the Subscriber
- StreetAddressstring, nullPossible
Street address
- Citystring, nullPossible
City
- Statestring, nullPossible
State
- ZIPstring, nullPossible
ZIP
- Countystring, nullPossible
County
- Countrystring, nullPossibleValue Set
Country
- PhoneNumberobject
- Homestring, nullPossible
Home phone number.
In E. 164 Format. (e.g. +16085551234) - Officestring, nullPossible
Office phone number.
In E. 164 Format. (e.g. +16085551234) - Mobilestring, nullProbable
Mobile phone number.
In E. 164 Format. (e.g. +16085551234)
- DOBstring, nullReliable
Subscriber's date of birth.
In YYYY-MM-DD format - Sexstring, nullReliableValue Set
Subscriber's sex.
One of the following: Female, Male, Unknown, Other
- OrganizationNamestring, nullReliable
If the subscriber is not a person, this will contain the organization name
- ResponsibilityLevelstring, nullReliableValue Set
Payor responsibility level
- Insuranceobject
- Planobject
- IDstring, nullProbable
Identifier of insurance plan
- IDTypestring, nullProbable
ID type of insurance plan
- Namestring, nullProbable
Name of insurance plan
- Typestring, nullPossible
Type of insurance plan
- MemberNumberstring, nullPossible
Patient member number
- Companyobject
- IDstring, nullProbable
ID of insurance company (payor)
- IDTypestring, nullProbable
ID type of insurance company (payor)
- Namestring, nullProbable
Name of insurance company (payor)
- Addressobject
Insurance company's address
- StreetAddressstring, nullProbable
Street address
- Citystring, nullProbable
City
- Statestring, nullProbable
State
- ZIPstring, nullProbable
ZIP
- Countystring, nullPossible
County
- Countrystring, nullPossibleValue Set
Country
- PhoneNumberstring, nullProbable
Insurance companys phone number.
In E. 164 Format (i.e. +16085551234)
- GroupNumberstring, nullProbable
Insurance policy group number
- GroupNamestring, nullProbable
Insurance policy group name
- EffectiveDatestring, nullProbable
Effect date of this insurance policy.
In YYYY-MM-DD format - ExpirationDatestring, nullProbable
Expiration date of this insurance policy.
In YYYY-MM-DD format - PolicyNumberstring, nullProbable
Insurance policy number
- Prioritystring, nullPossibleValue Set
The insurance priority sequence.
If the insurance works in conjunction with other insurance plans, this field contains priority sequence. - AgreementTypestring, nullProbableValue Set
Type of insurance agreement.
- CoverageTypestring, nullProbableValue Set
Type of insurance agreement.
Indicates who will be receiving the bill for the service.
- PatientsArray of object
- IdentifiersArray of object
List of IDs and ID types that identify the patient
- IDstring, nullReliable
ID for the patient
- IDTypestring, nullReliable
Type of ID.
E.g. MRN, EPI
- Demographicsobject
- FirstNamestring, nullReliable
Patient's first name
- MiddleNamestring, nullPossible
Patient's middle name or middle initial. For patients with multiple middle names, all their middle names are included in this field.
- LastNamestring, nullReliable
Patient's last name
- DOBstring, nullReliable
Patient's date of birth.
In ISO 8601 format - SSNstring, nullProbable
Patient's social security number
- Sexstring, nullReliableValue Set
Patient's sex
- Racestring, nullPossibleValue Set
Patient's race
- IsHispanicboolean, nullPossibleValue Set
Indicates if the patient is of hispanic origin.
- Religionstring, nullPossibleValue Set
Patient's religious affiliation
- MaritalStatusstring, nullPossibleValue Set
Patient's marital status
- IsDeceasedboolean, nullPossible
Indicates if the patient is deceased
- DeathDateTimestring, nullPossible
Date and Time the patient was proclaimed deceased.
ISO 8601 Format - PhoneNumberobject
- Homestring, nullProbable
Patient's home phone number.
In E. 164 Format. (e.g. +16085551234) - Officestring, nullProbable
Patient's office phone number.
In E. 164 Format. (e.g. +16085551234) - Mobilestring, nullProbable
Patient's mobile phone number.
In E. 164 Format. (e.g. +16085551234)
- EmailAddressesArray of string
Patient's email address(es)
- Languagestring, nullPossibleValue Set
Patient's primary spoken language.
In ISO 639-1 alpha values (e.g. 'en'). Supported Values - CitizenshipArray of string
Patient's nation(s) of citizenship.
In ISO 3166 alpha 2 format (e.g. 'US'). - Addressobject
Patient's home address
- StreetAddressstring, nullProbable
Street address
- Citystring, nullProbable
City
- Statestring, nullProbable
State
- ZIPstring, nullProbable
ZIP
- Countystring, nullPossible
County
- Countrystring, nullPossibleValue Set
Country
- NotesArray of string
Patient-level notes
- RelationToSubscriberstring, nullReliableValue Set
Relation to the subscriber
- ClaimsArray of object
Array of claims for the given subscriber/patient.
- SubmissionNumberstring, nullReliable
This will generally be the claim number sent on the initial claim submission.
- Typestring, nullProbableValue Set
Type of Claim (Institutional only).
May be referred to as the Bill Type Frequency, Claim Frequency Code, or Bill Type - TotalAmountstring, nullProbable
Total amount of all lines on the claim.
- CopayAmountstring, nullProbable
Amount the patient has paid or still owes.
- IsProviderSignatureOnFileboolean, nullProbable
Whether or not the provider signature is on file for the claim.
- IsReleaseOfInformationOnFileboolean, nullProbable
Whether or not the submitter has a signed ROI form for the patient.
- ProviderAcceptanceCodestring, nullPossible
Code indicating whether the provider accepts assignment.
- BenefitsAssignmentCodeboolean, nullProbableValue Set
Code indicates whether the patient has or has not assigned benefits to the provider.
- AdditionalDatesArray of object
Collection of additional dates related to the claim
- DateTimestring, nullProbable
- Typestring, nullProbable
Type of date value.
e.x. Service Period Start (https://ushik.ahrq.gov/ViewItemDetails?system=sdo&itemKey=133121000)
- ReferenceNumbersArray of object
Reference numbers associated to the claim like Prior Auth Number, Member ID, and Provider IDs
- IDstring, nullProbable
ID for the claim
- IDTypestring, nullProbable
The type of ID
- DiagnosesArray of object
- Codestring, nullProbable
Diagnosis code.
First index in array indicates primary diagnosis - Codesetstring, nullProbable
Code set used to identify the diagnosis code.
e.x. ICD-10, ICD-9 - Descriptionstring, nullProbable
Diagnosis name
- Typestring, nullProbable
Type of diagnosis.
One of the following: Admitting, Working, or Final
CMS Diagnosis Related Group for an inpatient admission
- ProvidersArray of object
- IDstring, nullPossible
ID of the provider.
This ID is often required for Inpatient Visits. - IDTypestring, nullPossible
ID type of the ID for the provider
- FirstNamestring, nullPossible
First name of the undefined
- LastNamestring, nullPossible
Last name of the undefined
- CredentialsArray of string
List of credentials for the undefined.
e.g. MD, PhD - Addressobject
Provider's address
- StreetAddressstring, nullPossible
Street address
- Citystring, nullPossible
City
- Statestring, nullPossible
State
- ZIPstring, nullPossible
ZIP
- Countystring, nullPossible
County
- Countrystring, nullPossibleValue Set
Country
- EmailAddressesArray of string
Provider's email address(es)
- PhoneNumberobject
- Officestring, nullPossible
Provider's office phone number.
In E. 164 Format. (e.g. +16085551234)
- Locationobject
Provider's location
- Typestring, nullPossible
Type of location.
Examples: Clinic, Department, Home, Nursing Unit, Provider's Office, Phone - Facilitystring, nullPossible
Facility.
Example: Community Hospital - FacilityIdentifiersArray of object
List of IDs specific to this facility
- IDstring, nullPossible
An ID specific to this facility
- IDTypestring, nullPossible
The source or system to which this ID pertains.
Could be an OID or a human-readable name
- Departmentstring, nullPossible
Department
- DepartmentIdentifiersArray of object
List of IDs specific to this department
- IDstring, nullPossible
An ID specific to this department
- IDTypestring, nullPossible
The source or system to which this ID pertains.
Could be an OID or a human-readable name
- Roomstring, nullPossible
Room.
Example: 136
- Rolestring, nullProbable
The role this provider has in patient care.
E.x. Attending, Referring, Operating - Specialtyobject
- IDstring, nullProbable
ID of specialty.
Commonly the taxonomy ID - Descriptionstring, nullProbable
Description/name of specialty
- ServicesArray of object
Services associated with this claim
- Codestring, nullProbable
Code for the service line
- Codesetstring, nullProbable
Code set used to identify the service line
- Descriptionstring, nullProbable
Description of the service line
- ModifiersArray of string
Array of service modifiers
- Amountstring, nullProbable
Total dollar amount for this line item
- StartDateTimestring, nullProbable
When the service conveyed began
- EndDateTimestring, nullProbable
When the service conveyed ended
- RevenueCodestring, nullProbable
Institutional only.
- Quantityobject
- Valuestring, nullProbable
Service line quantity.
- Unitsstring, nullProbable
Associated units to the quantity
- IsEmergencyboolean, nullProbable
Whether or not this service was performed in an emergency setting.
- ReferenceNumbersArray of object
Reference numbers associated to the claim service line
- IDstring, nullProbable
ID for the service line
- IDTypestring, nullProbable
The type of ID
- DiagnosesArray of object
- Codestring, nullProbable
Diagnosis code.
First index in array indicates primary diagnosis associated with this service line item. - Codesetstring, nullProbable
Code set used to identify the diagnosis code.
e.x. ICD-10, ICD-9 - Descriptionstring, nullProbable
Diagnosis name
- Typestring, nullProbable
Type of diagnosis.
One of the following: Admitting, Working, or Final
- Drugobject
Drug information related to the service of an institutional claim
- PrescriptionIDstring, nullProbable
Pharmacy Prescription ID associated to the the drug
- NDCstring, nullProbable
NDC ID
- Quantityobject
- Valuestring, nullProbable
Drug Quantity
- Unitsstring, nullProbable
Associated Units to the quantity
- Notesstring, nullProbable
Additional notes for this line
- Visitobject
- DateTimestring, nullProbable
DateTime of admission.
ISO 8601 Format - DischargeDateTimestring, nullProbable
DateTime of discharge.
ISO 8601 Format - Locationobject
- Typestring, nullProbable
Type of location.
Examples: Clinic, Department, Home, Nursing Unit, Provider's Office, Phone - Facilitystring, nullProbable
Facility.
Example: Community Hospital - FacilityIdentifiersArray of object
List of IDs specific to this facility
- IDstring, nullProbable
An ID specific to this facility
- IDTypestring, nullProbable
The source or system to which this ID pertains.
Could be an OID or a human-readable name
- Departmentstring, nullProbable
Department
- DepartmentIdentifiersArray of object
List of IDs specific to this department
- IDstring, nullProbable
An ID specific to this department
- IDTypestring, nullProbable
The source or system to which this ID pertains.
Could be an OID or a human-readable name
- Roomstring, nullProbable
Room.
Example: 136
- PreviousLocationobject
- Typestring, nullProbable
Type of location.
Examples: Clinic, Department, Home, Nursing Unit, Provider's Office, Phone - Facilitystring, nullProbable
Facility.
Example: Community Hospital - FacilityIdentifiersArray of object
List of IDs specific to this facility
- IDstring, nullProbable
An ID specific to this facility
- IDTypestring, nullProbable
The source or system to which this ID pertains.
Could be an OID or a human-readable name
- Departmentstring, nullProbable
Department
- DepartmentIdentifiersArray of object
List of IDs specific to this department
- IDstring, nullProbable
An ID specific to this department
- IDTypestring, nullProbable
The source or system to which this ID pertains.
Could be an OID or a human-readable name
- Roomstring, nullProbable
Room.
Example: 136
- Typestring, nullProbable
Type of inpatient admission.
Only populated for inpatient admissions. E.x. Elective, Emergency - VisitNumberstring, nullPossible
Visit Number.
Unique ID of a single visit