Optum Institutional Claims API

openapi: 3.2.0
info:
  title: Medical Network V1 Institutional Claims API
  description: 837 Institutional Claim
  version: V1
servers:
- url: https://sandbox-apigw.optum.com
  description: Optum
tags:
- name: Institutional Claims
  description: Institutional Claims
paths:
  /medicalnetwork/institutionalclaims/v1/validation:
    post:
      tags:
      - Institutional Claims
      summary: Claim Validation
      operationId: validateClaim
      parameters:
      - name: x-chng-trace-id
        in: header
        required: false
        schema:
          type: string
      - name: USERNAME
        in: query
        required: true
        schema:
          type: string
      - name: Authorization
        in: header
        description: 'Bearer Your-Access-Token<br/>Example: <b>Bearer eyJraWQiOiIxIiwid…</b>'
        required: true
        schema:
          type: string
      requestBody:
        content:
          application/json:
            schema:
              $ref: '#/components/schemas/InstitutionalClaimsRequest'
        required: true
      responses:
        '200':
          description: OK
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Response'
  /medicalnetwork/institutionalclaims/v1/submission:
    post:
      tags:
      - Institutional Claims
      summary: Claim Submission
      operationId: processClaim
      parameters:
      - name: x-chng-trace-id
        in: header
        required: false
        schema:
          type: string
      - name: Authorization
        in: header
        description: 'Bearer Your-Access-Token<br/>Example: <b>Bearer eyJraWQiOiIxIiwid…</b>'
        required: true
        schema:
          type: string
      requestBody:
        content:
          application/json:
            schema:
              $ref: '#/components/schemas/InstitutionalClaimsRequest'
        required: true
      responses:
        '200':
          description: OK
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Response'
  /medicalnetwork/institutionalclaims/v1/raw-x12-submission:
    post:
      tags:
      - Institutional Claims
      summary: Claim Submission x12
      operationId: processClaim_1
      parameters:
      - name: x-chng-trace-id
        in: header
        required: false
        schema:
          type: string
      - name: Authorization
        in: header
        description: 'Bearer Your-Access-Token<br/>Example: <b>Bearer eyJraWQiOiIxIiwid…</b>'
        required: true
        schema:
          type: string
      requestBody:
        content:
          application/json:
            schema:
              $ref: '#/components/schemas/RawX12Request'
        required: true
      responses:
        '200':
          description: OK
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Response'
  /medicalnetwork/institutionalclaims/v1/raw-x12-validation:
    post:
      tags:
      - Institutional Claims
      summary: Claim Validation x12
      operationId: validateRawX12
      parameters:
      - name: x-chng-trace-id
        in: header
        required: false
        schema:
          type: string
      - name: Authorization
        in: header
        description: 'Bearer Your-Access-Token<br/>Example: <b>Bearer eyJraWQiOiIxIiwid…</b>'
        required: true
        schema:
          type: string
      requestBody:
        content:
          application/json:
            schema:
              $ref: '#/components/schemas/RawX12Request'
        required: true
      responses:
        '200':
          description: OK
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/Response'
components:
  schemas:
    ServiceLine:
      required:
      - assignedNumber
      - institutionalService
      type: object
      properties:
        assignedNumber:
          type: string
          description: 'Loop: 2400, Segment: LX, Element: LX01'
          example: '1'
        serviceDate:
          type: string
          description: 'Loop: 2400, Segment: DTP, DTP03, Notes: If no end date is passed, this will be DTP03, if end date is passed along with this then serviceDate will be used as the begin date for format ''CCYYMMDD-CCYYMMDD'' in DTP03, where DTP01=472'
        serviceDateEnd:
          type: string
          description: 'Loop: 2400, Segment: DTP, DTP03, Notes: Must send this with serviceDate (which will be used as the beginning service date) and they will be expressed as ''CCYYMMDD-CCYYMMDD'' in DTP03'
        serviceTaxAmount:
          type: string
          description: 'Loop 2400, Segment: AMT, Element: AMT02, Notes: Where AMT01 = GT'
        facilityTaxAmount:
          type: string
          description: 'Loop 2400, Segment: AMT, Element: AMT02, Notes: Where AMT01 = N8'
        thirdPartyOrganizationNotes:
          type: string
          description: 'Loop 2400, Segment: NTE, Element: NTE02'
          deprecated: true
        lineItemControlNumber:
          type: string
          description: 'Loop 2400, Segment: REF, Element: REF02, Notes: Where REF01 = 6R'
        repricedLineItemReferenceNumber:
          type: string
          description: 'Loop 2400, Segment: REF, Element: REF02, Notes: Where REF01 = 9B'
        description:
          type: string
          description: 'Loop 2400, Segment: REF, Element: REF03'
        adjustedRepricedLineItemReferenceNumber:
          type: string
          description: 'Loop 2400, Segment: REF, Element: REF02, Notes: Where REF01 = 9D'
        lineNoteText:
          type: string
          description: 'Loop 2400, Segment: NTE, Element: NTE02, Notes: Where NTE01 = TPO'
        lineAdjudicationInformation:
          maxItems: 15
          minItems: 0
          type: array
          description: 'Loop 2430, Segment: SVD'
          items:
            $ref: '#/components/schemas/LineAdjudicationInformation'
        renderingProvider:
          $ref: '#/components/schemas/ServiceLineProvider'
        referringProvider:
          $ref: '#/components/schemas/ServiceLineProvider'
        lineSupplementInformation:
          $ref: '#/components/schemas/ClaimSupplementalInformation'
        institutionalService:
          $ref: '#/components/schemas/InstitutionalService'
        serviceLineSupplementalInformation:
          $ref: '#/components/schemas/ServiceLineSupplementalInformation'
        serviceLineDateInformation:
          $ref: '#/components/schemas/ServiceLineDateInformation'
        serviceLineReferenceInformation:
          $ref: '#/components/schemas/ServiceLineReferenceInformation'
        linePricingInformation:
          $ref: '#/components/schemas/LinePricingInformation'
        drugIdentification:
          $ref: '#/components/schemas/DrugIdentification'
        lineAdjustmentInformation:
          $ref: '#/components/schemas/LineAdjustmentInformation'
        operatingPhysician:
          $ref: '#/components/schemas/OperatingPhysician'
        otherOperatingPhysician:
          $ref: '#/components/schemas/OperatingPhysician'
        lineRepricingInformation:
          $ref: '#/components/schemas/ClaimPricingInformation'
      description: 'Loop: 2400, 2410, 2420A, 2420C, 2420D and 2430'
    MedicareInpatientAdjudication:
      required:
      - coveredDaysOrVisitsCount
      type: object
      properties:
        coveredDaysOrVisitsCount:
          type: string
          description: 'Loop: 2320, Segment: MIA, Element: MIA01, Notes: Number of days covered'
        lifetimePsychiatricDaysCount:
          type: string
          description: 'Loop: 2320, Segment: MIA, Element: MIA03, Notes: Lifetime of psychiatric days '
        claimDRGAmount:
          type: string
          description: 'Loop: 2320, Segment: MIA, Element: MIA04, Notes: Diagnosis Related Group (DRG) amount'
        claimPaymentRemarkCode:
          maxItems: 5
          minItems: 0
          type: array
          description: 'Loop: 2320, Segment: MIA, Element: MIA05, Notes: Claim payment remark code'
          items:
            type: string
        claimDisproportionateShareAmount:
          type: string
          description: 'Loop: 2320, Segment: MIA, Element: MIA06, Notes: Disproportionate share amount'
        claimMspPassThroughAmount:
          type: string
          description: 'Loop: 2320, Segment: MIA, Element: MIA07, Notes: Medicare Secondary Payer (MSP) pass-through amount'
        claimPpsCapitalAmount:
          type: string
          description: 'Loop: 2320, Segment: MIA, Element: MIA08, Notes: Prospective Payment System (PPS) capital amount.'
        ppsCapitalHspDrgAmount:
          type: string
          description: 'Loop: 2320, Segment: MIA, Element: MIA09, Notes: Prospective Payment System (PPS) capital, federal specific portion, Diagnosis Related Group (DRG) amount.'
        capitalHSPDRGAmount:
          type: string
          description: 'Loop: 2320, Segment: MIA, Element: MIA10, Notes: Prospective Payment System (PPS) capital, hospital specific portion, Diagnosis Related Group (DRG) amount.'
        ppsCapitalDshDrgAmount:
          type: string
          description: 'Loop: 2320, Segment: MIA, Element: MIA11, Notes: Prospective Payment System (PPS) capital, disproportionate share, hospital Diagnosis Related Group (DRG) amount.'
        oldCapitalAmount:
          type: string
          description: 'Loop: 2320, Segment: MIA, Element: MIA12, Notes: The old capital amount'
        ppsCapitalImeAmount:
          type: string
          description: 'Loop: 2320, Segment: MIA, Element: MIA13, Notes: Prospective Payment System (PPS) capital Indirect Medical Education (IME) claim amount'
        ppsOperatingHospitalSpecificDrgAmount:
          type: string
          description: 'Loop: 2320, Segment: MIA, Element: MIA14, Notes: Hospital specific Diagnosis Related Group (DRG) amount'
        costReportDayCount:
          type: string
          description: 'Loop: 2320, Segment: MIA, Element: MIA15, Notes: Cost report days'
        ppsOperatingFederalSpecificDrgAmount:
          type: string
          description: 'Loop: 2320, Segment: MIA, Element: MIA16, Notes: Federal specific Diagnosis Related Group (DRG) amount'
        claimPpsCapitalOutlierAmmount:
          type: string
          description: 'Loop: 2320, Segment: MIA, Element: MIA17, Notes: Prospective Payment System (PPS) capital outlier amount'
        claimIndirectTeachingAmount:
          type: string
          description: 'Loop: 2320, Segment: MIA, Element: MIA18, Notes: Indirect teaching amount'
        nonPayableProfessionalComponentBilledAmount:
          type: string
          description: 'Loop: 2320, Segment: MIA, Element: MIA19, Notes: The professional component amount billed but not payable'
        capitalExceptionAmount:
          type: string
          description: 'Loop: 2320, Segment: MIA, Element: MIA24, Notes: The capital exception amount'
      description: 'Loop: 2320, Segment: MIA, Notes: Medical inpatient claim information'
    ServiceFacilityLocation:
      required:
      - address
      - organizationName
      type: object
      properties:
        organizationName:
          type: string
          description: 'Loop: 2310E, Segment: NM1, Element: NM103'
          example: ABC clinic
        address:
          $ref: '#/components/schemas/Address'
        secondaryIdentificationQualifierCode:
          type: string
          description: 'Loop: 2310E, Segment: REF, Element: REF01, Notes: Allowed Values are: ''0B'' State License Number, ''G2'' Provider Commercial Number, ''LU'' Location Number'
          enum:
          - 0B
          - G2
          - LU
        secondaryIdentifier:
          type: string
          description: 'Loop: 2310E, Segment: REF, Element: REF02'
        identificationCode:
          type: string
          description: 'Loop: 2310E, Segment: NM1, Element: NM109, Notes: Required when the service location to be identified has an NPI and is not a component or subpart of the Billing Provider entity. If not required by this implementation guide, do not send.'
      description: 'Loop: 2310E'
    Receiver:
      required:
      - organizationName
      type: object
      properties:
        organizationName:
          type: string
          description: 'Segment: NM1, Element:NM103 where NM102=2'
          example: EXTRA HEALTHY INSURANCE
        taxId:
          type: string
          description: 'Segment: NM1, Element: NM109 where NM108=46'
          example: '67890'
      description: 'Loop: 1000B'
    ClaimDateInformation:
      required:
      - statementBeginDate
      - statementEndDate
      type: object
      properties:
        admissionDateAndHour:
          type: string
          description: 'Loop: 2300, Segment: DTP, Element: DTP03, Notes: Code D8 or DT in DTP03. Can express range of dates or single date.'
        statementBeginDate:
          type: string
          description: 'Loop: 2300, Segment: DTP, Element: DTP03, Notes: DTP03=434, Can express range of dates or single date.'
        statementEndDate:
          type: string
          description: 'Loop: 2300, Segment: DTP, Element: DTP03, Notes: DTP03=434, Can express range of dates or single date.'
        dischargeHour:
          type: string
          description: 'Loop: 2300, Segment: DTP, Element: DTP03, Notes: Date, time, or range of dates'
        repricerReceivedDate:
          type: string
          description: 'Loop: 2300, Segment: DTP, Element: DTP03, Notes: DTP01=505 DTP02=D8'
    PatientReasonForVisit:
      required:
      - patientReasonForVisitCode
      - qualifierCode
      type: object
      properties:
        qualifierCode:
          type: string
          description: 'Loop: 2300, Segment: HI, Element: HI01-01, Notes: Code identifying a specific industry code list Allowed Values: ''APR'' International Classification of Diseases Clinical Modification Patient''s Reason for Visit,''PR'' International Classification of Diseases Clinical Modification Patient''s Reason for Visit'
          enum:
          - APR
          - PR
        patientReasonForVisitCode:
          type: string
          description: 'Loop: 2300, Segment:HI, Element: HI01-02, Notes: Code indicating a code from a specific industry code list'
    LineAdjudicationInformation:
      required:
      - adjudicationOrPaymentDate
      - otherPayerPrimaryIdentifier
      - paidServiceUnitCount
      - serviceLinePaidAmount
      - serviceLineRevenueCode
      type: object
      properties:
        otherPayerPrimaryIdentifier:
          type: string
          description: 'Loop: 2430 , Segment: SVD, Element:SVD01 , Notes: Payer Identification Code'
        serviceLinePaidAmount:
          type: string
          description: 'Loop: 2430, Segment: SVD, Element: SVD02, Notes: Amount paid for this service line'
        productOrServiceIDQualifier:
          type: string
          description: 'Loop: 2430: Segment: SVD, Element: SVD03-01, Notes: Allowed Values are: ''ER'' Jurisdiction Specific Procedure and Supply Codes, ''HC'' Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes, ''HP'' Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code, ''IV'' Home Infusion EDI Coalition (HIEC) Product/Service Code, ''WK'' Advanced Billing Concepts (ABC) Codes'
          enum:
          - ER
          - HC
          - HP
          - IV
          - WK
        procedureCode:
          type: string
          description: 'Loop: 2430, Segment: SVD, Element: SDV03-02, Notes: Identifying Number for product or service'
        procedureModifier:
          maxItems: 4
          minItems: 0
          type: array
          items:
            type: string
            description: 'Loop: 2430, Segment: SVD, Element: SVD03-03 to SVD03-06, Notes: Identifies special circumstance related to the performance of the service'
        serviceLineRevenueCode:
          type: string
          description: 'Loop: 2430, Segment: SVD, Element: SVD04, Notes: Revenue Code'
        procedureCodeDescription:
          type: string
          description: 'Loop: 2430, Segment: SVD, Element: SVD03-07, Notes: Freeform Description'
        paidServiceUnitCount:
          type: string
          description: 'Loop: 2430, Segment: SVD, Element: SVD05, Notes: Paid units of service'
        bundledLineNumber:
          type: string
          description: 'Loop: 2430, Segment: SVD, Element: SVD06, Notes: Number assigned for differentiation within a transaction set'
        adjudicationOrPaymentDate:
          type: string
          description: 'Loop: 2430, Segment: DTP, Element: DTP03, Notes: Date'
        remainingPatientLiability:
          type: string
          description: 'Loop:2430 , Segment: AMT, Element: AMT02, Notes: Monetary amount'
        lineAdjustment:
          type: array
          items:
            $ref: '#/components/schemas/ClaimAdjustment'
    InstitutionalService:
      required:
      - lineItemChargeAmount
      - measurementUnit
      - serviceLineRevenueCode
      - serviceUnitCount
      type: object
      properties:
        serviceLineRevenueCode:
          type: string
          description: 'Loop: 2400, Segment: SV2, Element: SV201, Notes: Product or service revenue code'
        procedureIdentifier:
          type: string
          description: 'Loop: 2400, Segment: SV2, Element: SV202-01, Note: Allowed Values are: ''ER'' Jurisdiction Specific Procedure and Supply Codes, ''HC'' Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes, ''HP'' Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code, ''IV'' Home Infusion EDI Coalition (HIEC) Product/Service Code, ''WK'' Advanced Billing Concepts (ABC) Codes'
          enum:
          - ER
          - HC
          - HP
          - IV
          - WK
        procedureCode:
          type: string
          description: 'Loop: 2400, Segment: SV2, Element: SV202-02, Notes: Product or Service ID'
          example: '80199'
        procedureModifiers:
          maxItems: 4
          minItems: 0
          type: array
          items:
            type: string
            description: 'Loop: 2400, Segment: SV2, Element: SV202-03 through SV202-06, Notes: Procedure Modifier Codes'
            example: '1234'
        description:
          type: string
          description: 'Loop: 2400, Segment: SV2, Element: SV202-07, Notes: Freeform description'
          example: Some description text about the procedure
        lineItemChargeAmount:
          type: string
          description: 'Loop: 2400, Segment: SV2, Element: SV203, Notes: Submitted service line item amount'
        measurementUnit:
          type: string
          description: 'Loop: 2400, Segment: SV2, Element: SV204, Notes: Allowed Values are: ''DA'' Days, ''UN'' Unit'
          enum:
          - DA, UN
        serviceUnitCount:
          type: string
          description: 'Loop: 2400, Segment: SV2, Element: SV205, Notes: Numeric value of the quantity'
        nonCoveredChargeAmount:
          type: string
          description: 'Loop: 2400, Segment: SV2, Element: SV207, Notes: Non-covered service amount'
      description: 'Loop: 2400, Segment: SV2'
    LineAdjustmentInformation:
      required:
      - claimPaidDate
      - otherPayerPrimaryIdentifier
      - paidServiceUnitCount
      - procedureCode
      - remainingPatientLiability
      - serviceIdQualifier
      - serviceLinePaidAmount
      type: object
      properties:
        otherPayerPrimaryIdentifier:
          type: string
        serviceLinePaidAmount:
          type: string
        serviceIdQualifier:
          type: string
        procedureCode:
          type: string
        procedureModifiers:
          maxItems: 4
          minItems: 0
          type: array
          items:
            type: string
        procedureCodeDescription:
          type: string
        paidServiceUnitCount:
          type: string
        bundledOrUnbundledLineNumber:
          type: string
        remainingPatientLiability:
          type: string
        claimPaidDate:
          type: string
        claimAdjustment:
          $ref: '#/components/schemas/ClaimAdjustment'
      description: 'Loop 2430, Segment: CAS'
      deprecated: true
    ClaimPricingInformation:
      required:
      - pricingMethodologyCode
      - repricedAllowedAmount
      type: object
      properties:
        pricingMethodologyCode:
          type: string
          description: 'Loop: 2300 and 2400, Segment: HCP, Element: HCP01, Notes: Allowed Values are: ''00'' Zero Pricing (Not Covered Under Contract), ''01'' Priced as Billed at 100%, ''02'' Priced at the Standard Fee Schedule, ''03'' Not Priced at a Contractual Percentage, ''04'' Bundled Pricing, ''05'' Peer Review Pricing, ''06'' Per Diem Pricing, ''07'' Flat Rate Pricing, ''08'' Combination Pricing, ''09'' Maternity Pricing, ''10'' Other Pricing, ''11'' Lower of Cost, ''12'' Ratio of Cost, ''13'' Cost Reimbursed, ''14'' Adjustment Pricing.'
          enum:
          - '00'
          - '01'
          - '02'
          - '03'
          - '04'
          - '05'
          - '06'
          - '07'
          - 08
          - 09
          - '10'
          - '11'
          - '12'
          - '13'
          - '14'
        repricedAllowedAmount:
          type: string
          description: 'Loop: 2300 and 2400, Segment: HCP, Element: HCP02'
        repricedSavingAmount:
          type: string
          description: 'Loop: 2300 and 2400, Segment: HCP, Element: HCP03'
        repricedOrgIdentifier:
          type: string
          description: 'Loop: 2300 and 2400, Segment: HCP, Element: HCP04'
        repricedPerDiem:
          type: string
          description: 'Loop: 2300 and 2400, Segment: HCP, Element: HCP05'
        repricedApprovedDRGCode:
          type: string
          description: 'Loop: 2300 and 2400, Segment: HCP, Element: HCP06'
        repricedApprovedAmount:
          type: string
          description: 'Loop: 2300 and 2400, Segment: HCP, Element: HCP07'
        repricedApprovedRevenueCode:
          type: string
          description: 'Loop: 2300 and 2400, Segment: HCP, Element: HCP08'
        repricedApprovedServiceUnitCode:
          type: string
          description: 'Loop: 2300 and 2400, Segment: HCP, Element: HCP11, Notes: Allowed Values are: ''DA'' Days, ''UN'' Unit.'
          enum:
          - DA
          - UN
        repricedApprovedServiceUnitCount:
          type: string
          description: 'Loop: 2300 and 2400, Segment: HCP, Element: HCP12'
        rejectReasonCode:
          type: string
          description: 'Loop: 2300 and 2400, Segment: HCP, Element: HCP13, Notes: Allowed Values are: ''T1'' Cannot Identify Provider as TPO (Third Party Organization) Participant, ''T2'' Cannot Identify Payer as TPO (Third Party Organization) Participant, ''T3'' Cannot Identify Insured as TPO (Third Party Organization) Participant, ''T4'' Payer Name or Identifier Missing, ''T5'' Certification Information Missing, ''T6'' Claim does not contain enough information for re-pricing.'
          enum:
          - T1
          - T2
          - T3
          - T4
          - T5
          - T6
        policyComplianceCode:
          type: string
          description: 'Loop: 2300 and 2400, Segment: HCP, Element: HCP14, Notes: Allowed Values are: ''1'' Procedure Followed (Compliance), ''2'' Not Followed - Call Not Made (Non-Compliance Call Not Made), ''3'' Not Medically Necessary (Non-Compliance Non-Medically Necessary), ''4'' Not Followed Other (Non-Compliance Other), ''5'' Emergency Admit to Non-Network Hospital.'
          enum:
          - '1'
          - '2'
          - '3'
          - '4'
          - '5'
        exceptionCode:
          type: string
          description: 'Loop: 2300 and 2400, Segment: HCP, Element: HCP15, Notes: Allowed Values are: ''1'' Non-Network Professional Provider in Network Hospital, ''2'' Emergency Care, ''3'' Services or Specialist not in Network, ''4'' Out-of-Service Area, ''5'' State Mandates, ''6'' Other.'
          enum:
          - '1'
          - '2'
          - '3'
          - '4'
          - '5'
          - '6'
        productOrServiceIDQualifier:
          type: string
          description: 'Loop: 2400, Segment: HCP, Element: HCP09, Notes: Allowed Values are: ''ER'' Jurisdiction Specific Procedure and Supply Codes, ''HC'' Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes, ''HP'' Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code,  ''IV'' Home Infusion EDI Coalition (HIEC) Product/Service Code, ''WK'' Advanced Billing Concepts (ABC) Codes'
          enum:
          - ER
          - HC
          - HP
          - IV
          - WK
        repricedApprovedHCPCSCode:
          type: string
          description: 'Loop: 2400, Segment: HCP, Element: HCP10'
      description: 'Loop 2400, Segment: HCP'
    ExternalCauseOfInjury:
      required:
      - externalCauseOfInjury
      - qualifierCode
      type: object
      properties:
        qualifierCode:
          type: string
          description: 'Loop: 2300, Segment: HI, Element: HI01-01, Notes:Allowed Values are: ''ABN'' International Classification of Diseases Clinical Modification External Cause of Injury Code, ''BN'' International Classification of Diseases Clinical Modification External Cause of Injury Code'
          enum:
          - ABN
          - BN
        externalCauseOfInjury:
          type: string
          description: 'Loop: 2300, Segment: HI, Element: HI01-02'
        presentOnAdmissionIndicator:
          type: string
          description: 'Loop: 2300, Segment: HI, Element: HI01-09, Notes: Allowed Values are: ''N'' NO, ''Y'' Yes, ''U'' Unknown, ''W'' Not Applicable.'
          enum:
          - N
          - U
          - Y
          - W
    ClaimInformation:
      required:
      - benefitsAssignmentCertificationIndicator
      - claimChargeAmount
      - claimCodeInformation
      - claimFilingCode
      - claimFrequencyCode
      - patientControlNumber
      - placeOfServiceCode
      - planParticipationCode
      - principalDiagnosis
      - releaseInformationCode
      - serviceLines
      type: object
      properties:
        claimFilingCode:
          type: string
          description: 'Loop 2000B, Segment: SBR, Element: SBR09, Notes: Claim filing indicator code, Allowed Values are: ''11'' Other Non-Federal Programs, ''12'' Preferred Provider Organization (PPO), ''13'' Point of Service (POS), ''14'' Exclusive Provider Organization (EPO), ''15'' Indemnity Insurance, ''16'' Health Maintenance Organization (HMO) Medicare Risk, ''17'' Dental Maintenance Organization, ''AM'' Automobile Medical, ''BL'' Blue Cross/Blue Shield, ''CH'' Champus, ''CI'' Commercial Insurance Co., ''DS'' Disability, ''FI'' Federal Employees Program, ''HM'' Health Maintenance Organization, ''LM'' Liability Medical, ''MA'' Medicare Part A, ''MB'' Medicare Part B, ''MC'' Medicaid, ''OF'' Other Federal Program, ''TV'' Title V, ''VA'' Veterans Affairs Plan, ''WC'' Workers'' Compensation Health Claim, ''ZZ'' Mutually Defined.'
          example: '11'
          enum:
          - '11'
          - '12'
          - '13'
          - '14'
          - '15'
          - '16'
          - '17'
          - AM
          - BL
          - CH
          - CI
          - DS
          - FI
          - HM
          - LM
          - MA
          - MB
          - MC
          - OF
          - TV
          - VA
          - WC
          - ZZ
        propertyCasualtyClaimNumber:
          type: string
          description: 'Loop: 2000C Segment: REF, Element: REF02 where REF01=Y4'
        patientWeight:
          type: string
          description: Deprecated PAT08
          deprecated: true
        patientControlNumber:
          type: string
          description: 'Loop: 2300, Segment: CLM, Element: CLM01, Notes: Used to track claim by the healthcare provider through payment. Also known as Claim Submitter''s Identifier'
          example: '12345'
        claimChargeAmount:
          type: string
          description: 'Loop: 2300, Segment: CLM, Element: CLM02, Notes: Total amount of all submitted charges of service segments. Must balance to the sum of all service line charge amounts (line SV2)'
          example: '375'
        placeOfServiceCode:
          type: string
          description: 'Loop: 2300, Segment: CLM, Element: CLM05-01, Notes: Code identifying where services were, or may be, performed.'
          example: '11'
        claimFrequencyCode:
          type: string
          description: 'Loop: 2300, Segment: CLM, Element: CLM05-03, Notes: Specifies the frequency of the claim.'
          example: '1'
        signatureIndicator:
          type: string
          deprecated: true
        planParticipationCode:
          type: string
          description: 'Loop: 2300, Segment: CLM, Element: CLM07, Notes: Code indicating whether the provider accepts assignment.Allowed Values are: ''A'' Assigned, ''B'' Assignment Accepted on Clinical Lab Services Only, ''C'' Not Assigned.'
          example: A
          enum:
          - A
          - B
          - C
        benefitsAssignmentCertificationIndicator:
          type: string
          description: 'Loop: 2300, Segment: CLM, Element: CLM08, Notes: Code indicating a Yes/No Response, Allowed Values are: ''N'' No, ''W'' Assignment Not Applicable, ''Y'' Yes.'
          example: N
          enum:
          - N
          - W
          - Y
        releaseInformationCode:
          type: string
          description: 'Loop: 2300, Segment: CLM, Element: CLM09, Notes: Indicates whether the provider has on file a signed statement by patient authorizing the release of medical data to other organizations. Allowable Values are: ''I'' Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes, ''Y'' Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim.'
          example: I
          enum:
          - I, Y
        delayReasonCode:
          type: string
          description: 'Loop: 2300, Segment: CLM, Element: CLM20, Notes: Required when the claim is submitted late. If not required by this guide, do not send. Allowable Values are: ''1'' Proof of Eligibility Unknown or Unavailable, ''2'' Litigation, ''3'' Authorization Delays, ''4'' Delay in Certifying Provider, ''5'' Delay in Supplying Billing Forms, ''6'' Delay in Delivery of Custom-made Appliances, ''7'' Third Party Processing Delay, ''8'' Delay in Eligibility Determination, ''9'' Original Claim Rejected or Denied Due to a Reason Unrelated to the Billing Limitation Rules, ''10'' Administration Delay in the Prior Approval Process, ''11'' Other, ''15 Natural Disaster'
          enum:
          - '1'
          - '2'
          - '3'
          - '4'
          - '5'
          - '6'
          - '7'
          - '8'
          - '9'
          - '10'
          - '11'
          - '15'
        patientAmountPaid:
          type: string
          description: Deprecated AMT02
          deprecated: true
        patientEstimatedAmountDue:
          type: string
          description: 'Loop 2300, Segment: AMT, Element: AMT02 where AMT01=F3, Notes: Estimated patient responsibility amount due.'
        fileInformation:
          maxItems: 10
          minItems: 0
          type: array
          items:
            type: string
            description: 'Loop 2300, Segment: K3, Element: K301'
        billingNote:
          type: string
          description: 'Loop 2300, Segment: NTE, Element: NTE02 where NTE01=ADD'
        claimNotes:
          $ref: '#/components/schemas/ClaimNotes'
        claimDateInformation:
          $ref: '#/components/schemas/ClaimDateInformation'
        claimContractInformation:
          $ref: '#/components/schemas/ClaimContractInformation'
        claimSupplementalInformation:
          $ref: '#/components/schemas/ClaimSupplementalInformation'
        conditionCodes:
          maxItems: 12
          minItems: 1
          type: array
          description: 'Loop 2300, Segment: CRC, Element: CRC03, CRC04, CRC05, Notes: Allowed Values are: ''AV'' Available-Not Used, ''NU'' Not Used, ''S2'' Under Treatment, ''ST'' New Services Requested.'
          example: 1
          items:
            type: string
            enum:
            - AV
            - NU
            - S2
            - ST
        principalDiagnosis:
          $ref: '#/components/schemas/PrincipalDiagnosis'
        admittin

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# Full source: https://raw.githubusercontent.com/api-evangelist/optum/refs/heads/main/openapi/optum-institutional-claims-api-openapi.yml