Availity Institutional Claims API
The Institutional Claims API from Availity — 2 operation(s) for institutional claims.
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OpenAPI Specification
openapi: 3.2.0
info:
title: Availity Institutional Claims API
version: 1.0.0
x-custom-api-description: The Availity Patient Cost Estimator – Institutional 1.0.0 API is designed to help healthcare institutions, such as hospitals, skilled nursing facilities, and outpatient centers estimate the cost of services before they are rendered.
description: 'Operations tagged Institutional Claims across 2 of this provider''s published API definitions: availity-care-cost-estimator-institutional-openapi.json, availity-care-cost-estimator-institutional-openapi.yml. Each path carries the servers of the definition it was published in.'
servers:
- url: https://api.availity.com/v1
security:
- oauth2:
- hipaa
tags:
- name: Institutional Claims
paths:
/institutional-claims:
post:
operationId: createInstitutionalClaim
responses:
'202':
description: Accepted
headers:
Location:
description: Location of the institutional claim.
schema:
type: string
X-Status-Message:
description: Current status of the pending request.
schema:
type: string
'400':
description: Bad Request
content:
application/json:
schema:
$ref: '#/components/schemas/ErrorResponse'
application/xml:
schema:
$ref: '#/components/schemas/ErrorResponse'
'401':
description: Not Authorized
content:
application/json:
schema:
$ref: '#/components/schemas/ErrorResponse'
application/xml:
schema:
$ref: '#/components/schemas/ErrorResponse'
'403':
description: Forbidden
content:
application/json:
schema:
$ref: '#/components/schemas/ErrorResponse'
application/xml:
schema:
$ref: '#/components/schemas/ErrorResponse'
'500':
description: Internal Server Error
content:
application/json:
schema:
$ref: '#/components/schemas/ErrorResponse'
application/xml:
schema:
$ref: '#/components/schemas/ErrorResponse'
summary: Create a new institutional claims
requestBody:
content:
application/json:
schema:
$ref: '#/components/schemas/InstitutionalClaim'
application/xml:
schema:
$ref: '#/components/schemas/InstitutionalClaim'
tags:
- Institutional Claims
servers:
- url: https://api.availity.com/v1
/institutional-claims/{id}:
parameters:
- description: A professional claim id
in: path
name: id
required: true
schema:
type: string
get:
operationId: getInstitutionalClaim
parameters:
- in: path
name: id
required: true
schema:
type: string
responses:
'200':
description: OK
content:
application/json:
schema:
$ref: '#/components/schemas/InstitutionalClaim'
application/xml:
schema:
$ref: '#/components/schemas/InstitutionalClaim'
'202':
description: Accepted
headers:
Location:
description: Location of the institutional claim.
schema:
type: string
X-Status-Message:
description: Current status of the pending request.
schema:
type: string
'400':
description: Bad Request
content:
application/json:
schema:
$ref: '#/components/schemas/ErrorResponse'
application/xml:
schema:
$ref: '#/components/schemas/ErrorResponse'
'401':
description: Not Authorized
content:
application/json:
schema:
$ref: '#/components/schemas/ErrorResponse'
application/xml:
schema:
$ref: '#/components/schemas/ErrorResponse'
'403':
description: Forbidden
content:
application/json:
schema:
$ref: '#/components/schemas/ErrorResponse'
application/xml:
schema:
$ref: '#/components/schemas/ErrorResponse'
'404':
description: Not Found
content:
application/json:
schema:
$ref: '#/components/schemas/ErrorResponse'
application/xml:
schema:
$ref: '#/components/schemas/ErrorResponse'
'500':
description: Internal Server Error
content:
application/json:
schema:
$ref: '#/components/schemas/ErrorResponse'
application/xml:
schema:
$ref: '#/components/schemas/ErrorResponse'
'504':
description: Gateway Timeout
content:
application/json:
schema:
$ref: '#/components/schemas/ErrorResponse'
application/xml:
schema:
$ref: '#/components/schemas/ErrorResponse'
summary: Get a institutional claim by its id
tags:
- Institutional Claims
servers:
- url: https://api.availity.com/v1
components:
schemas:
FieldError:
properties:
code:
description: A code for the error.
type: string
errorMessage:
description: The message associated with this error.
type: string
field:
description: The field or parameter associated with this error.
type: string
index:
description: The array index of the item associated with this error.
type: integer
type: object
ErrorResponse:
properties:
developerMessage:
description: A more technical error message.
type: string
errors:
description: A list of detailed user friendly messages.
items:
$ref: '#/components/schemas/FieldError'
type: array
reasonCode:
description: A reason code.
type: integer
statusCode:
description: The status code.
type: integer
userMessage:
description: A high level error message.
type: string
type: object
Procedure:
properties:
code:
description: The procedure code.
type: string
codeDate:
description: The code date.
format: date
type: string
description:
description: The procedure description.
type: string
qualifier:
description: The qualifier description.
type: string
qualifierCode:
description: The qualifier code.
type: string
type: object
ItemDescription:
properties:
amount:
description: An amount.
type: string
code:
description: A code.
type: string
codeType:
description: A code type.
type: string
description:
description: A description.
type: string
patientLiable:
description: Indicates whether the patient is liable for the item.
type: boolean
procedure:
description: The procedure.
type: string
type: object
Diagnosis:
properties:
code:
description: The diagnosis code.
type: string
description:
description: The diagnosis description.
type: string
presentOnAdmissionIndicatorCode:
description: The present on admission indicator code.
type: string
qualifier:
description: The qualifier description.
type: string
qualifierCode:
description: The qualifier code.
type: string
type: object
InstitutionalClaim:
properties:
billingProvider:
description: The billing provider.
properties:
addressLine1:
description: The address of the billing provider.
type: string
addressLine2:
description: The address of the billing provider.
type: string
city:
description: The city of the billing provider.
type: string
contactName:
description: The contact name of the billing provider.
type: string
countryCode:
description: The country code of the billing provider.
enum:
- US
- CA
type: string
ein:
description: The EIN of the billing provider.
type: string
email:
description: The email address of the billing provider.
type: string
extension:
description: The phone number extension of the billing provider.
type: string
fax:
description: The fax number of the billing provider.
type: string
name:
description: The name of the billing provider.
type: string
npi:
description: The national provider id of the billing provider.
type: string
payToAddress:
description: The pay to address of the billing provider.
properties:
addressLine1:
description: The address of the pay to address.
type: string
addressLine2:
description: The address of the pay to address.
type: string
city:
description: The city of the pay to address.
type: string
stateCode:
description: The state code of the pay to address.
type: string
zipCode:
description: The ZIP code of the pay to address.
type: string
type: object
payerAssignedProviderId:
description: The payer assigned provider id of the billing provider.
type: string
phone:
description: The phone number of the billing provider.
type: string
specialtyCode:
description: The specialty code of the billing provider.
type: string
ssn:
description: The SSN of the billing provider.
type: string
stateCode:
description: The state code of the billing provider.
type: string
stateLicenseNumber:
description: The state license number of the billing provider.
type: string
zipCode:
description: The ZIP code of the billing provider.
type: string
type: object
claimInformation:
description: The claim information.
properties:
admissionSourceCode:
description: The admission source code.
type: string
admissionTypeCode:
description: The admission type code.
type: string
admittingDiagnosis:
$ref: '#/components/schemas/Diagnosis'
attendingProvider:
description: The attending provider.
properties:
firstName:
description: The attending provider's first name.
type: string
lastName:
description: The attending provider's last name.
type: string
npi:
description: The attending provider's national provider id.
type: string
type: object
benefitsAssignmentCertification:
description: The benefits assignment certification indicator.
type: boolean
bundled:
description: The bundled indicator.
type: boolean
claimIdentifier:
description: The claim identifier.
type: string
conditionCode:
description: The condition code.
type: string
controlNumber:
description: The institutional claim's control number.
type: string
diagnosisRelatedGroupCode:
description: The diagnosis related group code.
type: string
displayMessage:
description: A display message from the payer.
type: string
facilityTypeCode:
description: The facility type code.
type: string
frequencyTypeCode:
description: The frequency type code.
type: string
informationReleaseCode:
description: The information release code.
type: string
messages:
description: A list of messages from the payer.
items:
$ref: '#/components/schemas/ItemDescription'
type: array
occurrenceCode:
description: The occurrence code.
type: string
occurrenceCodeDate:
description: The occurrence code date.
format: date
type: string
otherDiagnoses:
description: A list of other diagnoses.
items:
$ref: '#/components/schemas/Diagnosis'
type: array
otherProcedures:
description: A list of other procedures.
items:
$ref: '#/components/schemas/Procedure'
type: array
patientStatusCode:
description: The patient status code.
type: string
patientsReasonForVisit:
$ref: '#/components/schemas/Diagnosis'
principalDiagnosis:
$ref: '#/components/schemas/Diagnosis'
principalProcedure:
$ref: '#/components/schemas/Procedure'
providerAcceptAssignmentCode:
description: The provider accept assignment code.
type: string
serviceLines:
description: A list of service lines.
items:
properties:
allowed:
$ref: '#/components/schemas/ItemDescription'
alternateProcedure:
description: Alternate procedure.
type: string
amount:
description: The service charge amount.
type: string
bundlingDescription:
description: A bundling description.
type: string
coInsurance:
$ref: '#/components/schemas/ItemDescription'
coPay:
$ref: '#/components/schemas/ItemDescription'
contractual:
$ref: '#/components/schemas/ItemDescription'
controlNumber:
description: The service line's control number.
type: string
deductible:
$ref: '#/components/schemas/ItemDescription'
denyReason:
description: The deny reason.
type: string
displayMessage:
description: A display message.
type: string
estimated:
$ref: '#/components/schemas/ItemDescription'
estimatedPatientResponsibility:
description: The estimated patient responsibility.
type: string
fromDate:
description: The service from date.
format: date
type: string
holdReasons:
description: A list of hold reasons for this service line.
items:
$ref: '#/components/schemas/ItemDescription'
type: array
messages:
description: A list of messages for this service line.
items:
$ref: '#/components/schemas/ItemDescription'
type: array
modifierCode1:
description: The first procedure modifier.
type: string
modifierCode2:
description: The second procedure modifier.
type: string
modifierCode3:
description: The third procedure modifier.
type: string
modifierCode4:
description: The fourth procedure modifier.
type: string
notCovered:
$ref: '#/components/schemas/ItemDescription'
procedure:
description: The procedure description.
type: string
procedureCode:
description: The procedure code.
type: string
providerInitiated:
$ref: '#/components/schemas/ItemDescription'
providerResponsibility:
$ref: '#/components/schemas/ItemDescription'
quantity:
description: The service quantity.
type: string
quantityTypeCode:
description: The service quantity type code.
type: string
remarks:
description: Remarks about this service line.
items:
properties:
description:
description: The description.
type: string
remarkCode:
description: The remark code.
type: string
type: object
type: array
revenue:
description: The revenue description.
type: string
revenueCode:
description: The revenue code.
type: string
toDate:
description: The service to date.
format: date
type: string
type: object
type: array
serviceTypeCode:
description: The service type code.
type: string
specialMessages:
description: A list of special messages from the payer.
items:
$ref: '#/components/schemas/ItemDescription'
type: array
totalAllowed:
$ref: '#/components/schemas/ItemDescription'
totalCharges:
$ref: '#/components/schemas/ItemDescription'
totalCoInsurance:
$ref: '#/components/schemas/ItemDescription'
totalCoPay:
$ref: '#/components/schemas/ItemDescription'
totalContractual:
$ref: '#/components/schemas/ItemDescription'
totalDeductible:
$ref: '#/components/schemas/ItemDescription'
totalEstimated:
$ref: '#/components/schemas/ItemDescription'
totalNotCovered:
$ref: '#/components/schemas/ItemDescription'
totalPatientLiability:
$ref: '#/components/schemas/ItemDescription'
totalProviderInitiated:
$ref: '#/components/schemas/ItemDescription'
totalProviderResponsibility:
$ref: '#/components/schemas/ItemDescription'
valueCode:
description: The value code.
type: string
valueCodeAmount:
description: The value code amount.
type: string
type: object
createdDate:
description: The date and time that this institutional claim was created.
format: date-time
type: string
customerId:
description: The id of the customer that owns this institutional claim.
type: string
expirationDate:
description: The date and time that this institutional claim will expire from our system.
format: date-time
type: string
id:
description: The id of the institutional claim.
type: string
patient:
description: The patient.
properties:
addressLine1:
description: The address of the patient.
type: string
addressLine2:
description: The address of the patient.
type: string
birthDate:
description: The birth date of the patient.
format: date
type: string
city:
description: The city of the patient.
type: string
firstName:
description: The first name of the patient.
type: string
gender:
description: The gender of the patient.
enum:
- Female
- Male
- Unknown
type: string
genderCode:
description: The gender code of the patient.
enum:
- F
- M
- U
type: string
lastName:
description: The last name of the patient.
type: string
middleName:
description: The middle name of the patient.
type: string
ssn:
description: The SSN of the patient.
type: string
stateCode:
description: The state code of the patient.
type: string
subscriberRelationship:
description: The relationship of the patient to the subscriber.
enum:
- Self
- Spouse
- Child
- Employee
- Unknown
- Organ Donor
- Cadaver Donor
- Life Partner
- Other Relationship
- Other Adult
type: string
subscriberRelationshipCode:
description: The relationship code of the patient to the subscriber.
enum:
- 18
- 1
- 19
- 20
- 21
- 39
- 40
- 53
- G8
- 34
type: string
suffix:
description: The suffix of the patient.
type: string
zipCode:
description: The ZIP code of the patient.
type: string
type: object
payer:
description: The payer.
properties:
addressLine1:
description: The address of the payer.
type: string
addressLine2:
description: The address of the payer.
type: string
city:
description: The city of the payer.
type: string
claimFilingIndicatorCode:
description: The claim filing indicator code of the payer.
type: string
claimOfficeNumber:
description: The claim office number of the payer.
type: string
countryCode:
description: The country code of the payer.
enum:
- US
- CA
type: string
disclaimer:
description: A disclaimer from the payer.
type: string
ein:
description: The EIN of the payer.
type: string
id:
description: The id of the payer.
type: string
insuranceTypeCode:
description: The insurance type code of the payer.
type: string
naicCode:
description: The NAIC code of the payer.
type: string
name:
description: The name of the payer.
type: string
responsibilitySequenceCode:
description: The responsibility sequence code of the payer.
enum:
- P
- S
- T
type: string
stateCode:
description: The state code of the payer.
type: string
zipCode:
description: The ZIP code of the payer.
type: string
type: object
payerSpecificFlags:
description: A list of payer specific flags on this institutional claim.
items:
properties:
name:
description: A payer specific flag name.
type: string
value:
description: A payer specific flag value.
type: string
type: object
type: array
requestTypeCode:
description: The type of institutional claim.
enum:
- PRE_DETERMINATION
type: string
submitter:
description: The submitter.
properties:
contactName:
description: The contact name of the submitter.
type: string
email:
description: The email address of the submitter.
type: string
extension:
description: The phone number extension of the submitter.
type: string
fax:
description: The fax number of the submitter.
type: string
firstName:
description: The first name of the submitter.
type: string
id:
description: The id of the submitter.
type: string
lastName:
description: The last name of the submitter.
type: string
middleName:
description: The middle name of the submitter.
type: string
phone:
description: The phone number of the submitter.
type: string
type: object
subscriber:
description: The subscriber.
properties:
accumulatedDeductible:
description: The accumulated deductible of the subscriber.
type: string
accumulatedFamilyDeductible:
description: The accumulated family deductible of the subscriber.
type: string
firstName:
description: The first name of the subscriber.
type: string
groupName:
description: The group name of the subscriber.
type: string
groupNumber:
description: The group number of the subscriber.
type: string
holdReasons:
description: A list of hold reasons.
items:
$ref: '#/components/schemas/ItemDescription'
type: array
lastName:
description: The last name of the subscriber.
type: string
memberId:
description: The member id of the subscriber.
type: string
middleName:
description: The middle name of the subscriber.
type: string
onHold:
description: The subscriber's on hold indicator.
type: boolean
remainingDeductible:
description: The remaining deductible of the subscriber.
type: string
remainingFamilyDeductible:
description: The remaining family deductible of the subscriber.
type: string
ssn:
description: The SSN of the subscriber.
type: string
suffix:
description: The suffix of the subscriber.
type: string
totalDeductible:
description: The total deductible of the subscriber.
type: string
totalFamilyDeductible:
description: The total family deductible of the subscriber.
type: string
type: object
updatedDate:
description: The date and time that this institutional claim was last updated.
format: date-time
type: string
type: object
securitySchemes:
oauth2:
type: oauth2
flows:
clientCredentials:
scopes:
healthcare-hipaa-transactions: Healthcare HIPAA Transactions
healthcare-hipaa-transactions-demo: Demo
healthcare-hipaa-transactions-highvolume: Healthcare HIPAA Transactions High Volume
healthcare-hipaa-transactions-highvolume-standard: Standard
healthcare-hipaa-transactions-highvolume-unlimited: Unlimited
healthcare-hipaa-transactions-standard: Standard
tokenUrl: https://api.availity.com/v1/token
x-refined-from:
- availity-care-cost-estimator-institutional-openapi.json
- availity-care-cost-estimator-institutional-openapi.yml