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Claims Inquiry API Flow

Suggest edit Updated on April 26, 2021

The Claims Inquiry API Flow is as follows:

Step 1: Smart Claims Engine begins by accepting the Incoming Inquiry Request. The system checks for the format of the request. If the format of the request is not valid, then the system send a response indicating an Invalid Request has been be submitted.

Step 2: Smart Claims Engine then checks for the mandatory fields which need to be present on the request. These fields would be used to search for Claims and creating an Inquiry. The Mandatory Fields are as follows:

  1. Patient ID OR Subscriber ID OR
  2. Provider ID OR
  3. Claim ID
If the Mandatory fields are missing then the system sends a response indicating an Invalid request has been submitted where the mandatory fields are missing.

Step 3: Smart Claim Engine proceeds to create a Unique case for the given request submitted.

Note:

  1. Smart Claims Engine would search for existing ICN’s within the system based on the request submitted and attach them to the created case. For e.g. if a Patient ID and Date of service is submitted on the request, a case for the given Patient ID w(ith all the claims within the submitted date of service range) would be created.
  2. In Smart Claims Engine, the max number of claims limits in a case can be configured (SearchResultsLimitForClaimsInquiry). The number of claims identified by the system should be less than the configured limit.

If no ICN’s are found, a Claims Inquiry case is still created. (This is configurable using DSS CreateEmptyCICase settings) CreateEmptyCICase. With the setting as true, claimsInquiry cases will be created even when no claims are found for the corresponding incoming request. With the help of DSS CreateEmptyCICase setting as true, inquiry case can be created even when no claims are found as part of the POST claimsInquiry request API as well.

Step 4: Once the Inquiry case is created, Smart Claims Engine Routes the case to the appropriate configured workbasket. The Workbasket can be configured under Declare_Config.ClaimsInquiryWB.

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