The Claim submission API from Stedi — 8 operation(s) for claim submission.
components:
schemas:
AccessDeniedException:
description: The server response for authorization failure.
properties:
code:
description: Error classification code
type: string
message:
description: Human-readable error message
type: string
required:
- message
type: object
AccessDeniedExceptionResponseContent:
description: The server response for authorization failure.
properties:
code:
description: Error classification code
type: string
message:
description: Human-readable error message
type: string
required:
- message
type: object
AdjustmentGroupCode:
description: Code identifying the general category of payment adjustment. Can be set to `CO` - Contractual
Obligations, `CR` - Correction and Reversals, `OA` - Other Adjustments, `PI` - Payor Initiated Reductions,
or `PR - Patient Responsibility.
enum:
- CO
- CR
- OA
- PI
- PR
type: string
AdmittingDiagnosis:
properties:
admittingDiagnosisCode:
description: "The admitting diagnosis code for the patient.\n - You must submit a valid, billable code\
\ at the highest level of specificity. Include the 4th - 7th characters as applicable.\n - **Don't**\
\ submit the decimal point for ICD codes. The decimal point is implied.\n - **Don't** submit ICD-10\
\ header codes. Header codes exist to group related codes and aren't valid for billing. These header\
\ codes can change with each new version of ICD-10, so we recommend reviewing your diagnosis codes every\
\ year to ensure that they aren't classified as header codes in the most recent version. To determine\
\ whether a code is a header code, you can also search the [Value Set Authority Center](https://vsac.nlm.nih.gov/context/cs).\
\ If the 'Header' property is set, the code is a header code and you shouldn't use it in claim submissions."
maxLength: 30
type: string
qualifierCode:
$ref: '#/components/schemas/AdmittingDiagnosisQualifierCode'
required:
- admittingDiagnosisCode
- qualifierCode
type: object
AdmittingDiagnosisQualifierCode:
description: Code identifying the type of admitting diagnosis code used. Can be set to `ABJ` - International
Classification of Diseases Clinical Modification (ICD-10-CM) Admitting Diagnosis or `BJ` - International
Classification of Diseases Clinical Modification (ICD-9-CM) Admitting Diagnosis. Note that ICD-9 is deprecated
and cannot be used in new claims.
enum:
- ABJ
- BJ
type: string
AmbulanceCertification:
description: Required when the claim involves ambulance transport services.
properties:
certificationConditionIndicator:
$ref: '#/components/schemas/AmbulanceCertificationCertificationConditionIndicator'
conditionCodes:
items:
$ref: '#/components/schemas/AmbulanceCertificationConditionCodesItem'
maxItems: 5
minItems: 1
type: array
required:
- certificationConditionIndicator
- conditionCodes
type: object
AmbulanceCertificationCertificationConditionIndicator:
description: Code indicating whether there is an ambulance certification.
enum:
- N
- Y
type: string
AmbulanceCertificationConditionCodesItem:
description: Code indicating the condition of the patient at the time of transport. You can provide up to
five codes. Visit [Claims code lists](https://www.stedi.com/docs/healthcare/claims-code-lists#ambulance-certification-condition-codes)
for a complete list.
enum:
- '01'
- '04'
- '05'
- '06'
- '07'
- 08
- 09
- '12'
type: string
AmbulanceTransportInformation:
description: Information about the ambulance service provided to the patient.
properties:
ambulanceTransportReasonCode:
$ref: '#/components/schemas/AmbulanceTransportReasonCode'
patientWeightInPounds:
description: The weight of the patient, in pounds, at the time of transport. Provide this value as a decimal,
such as `150.5`
type: string
roundTripPurposeDescription:
description: The reason for the round trip ambulance service.
type: string
stretcherPurposeDescription:
description: The reason for usage of a stretcher during ambulance service.
type: string
transportDistanceInMiles:
description: The number of miles the ambulance traveled to transport the patient. Provide this value as
a decimal, such as `20.5`. Note that `0` (zero) is a valid value when ambulance services do not include
a charge for mileage.
type: string
required:
- ambulanceTransportReasonCode
- transportDistanceInMiles
type: object
AmbulanceTransportReasonCode:
description: Code indicating the reason for ambulance transport. For example, `A` - Patient was transported
to nearest facility for care of symptoms, complaints, or both. Visit [Claims code lists](https://www.stedi.com/docs/healthcare/claims-code-lists#ambulance-transport-reason-codes)
for a complete list.
enum:
- A
- B
- C
- D
- E
type: string
AssistantSurgeon:
description: 'Information about the assistant surgeon who rendered the care. Use this object when the rendering
providers provided these services in the role of the assistant surgeon.
This should be an individual, not an organization, and you should supply at least the surgeon''s `lastName`,
`taxonomyCode`, and an identifier, which is typically the `npi`.'
properties:
address:
$ref: '#/components/schemas/ClaimsAddress'
commercialNumber:
description: The provider's commercial number.
type: string
contactInformation:
$ref: '#/components/schemas/ClaimsContactInformation'
firstName:
description: The assistant surgeon's first name.
maxLength: 35
minLength: 1
type: string
lastName:
description: The assistant surgeon's last name. You must include either the `lastName` or `organizationName`
property in this object.
maxLength: 60
minLength: 1
type: string
locationNumber:
description: The provider's location number.
type: string
middleName:
description: The assistant surgeon's middle name or initial.
maxLength: 25
minLength: 1
type: string
npi:
description: The individual National Provider Identifier (NPI) assigned to the surgeon.
pattern: ^\d{10}$
type: string
providerUpinNumber:
deprecated: true
description: Deprecated; do not use.
type: string
stateLicenseNumber:
description: The provider's state license number. This is assigned directly by a payer in order to identify
the provider in their system. This is not commonly used.
type: string
suffix:
description: The assistant surgeon's name suffix, such as Jr. or III.
maxLength: 10
minLength: 1
type: string
taxonomyCode:
description: "Code from the National Uniform Claims Committee [Health Care Provider Taxonomy Code Set](https://taxonomy.nucc.org/).\
\ This identifies the provider's type and/or area of specialty. For example, code `\t1223S0112X` is\
\ for Oral and Maxillofacial Surgery."
maxLength: 10
minLength: 10
pattern: ^[A-Za-z0-9]{10}$
type: string
required:
- lastName
- taxonomyCode
type: object
AttachmentReportTypeCode:
description: Code indicating the title or contents of a document, report or supporting item. For example,
`08` - Plan of Treatment or `CT` - Certification. Visit [Claims code lists](https://www.stedi.com/docs/healthcare/claims-code-lists#attachment-report-type-codes)
for a complete list.
enum:
- '03'
- '04'
- '05'
- '06'
- '07'
- 08
- 09
- '10'
- '11'
- '13'
- '15'
- '21'
- A3
- A4
- AM
- AS
- B2
- B3
- B4
- BR
- BS
- BT
- CB
- CK
- CT
- D2
- DA
- DB
- DG
- DJ
- DS
- EB
- HC
- HR
- I5
- IR
- LA
- M1
- MT
- NN
- OB
- OC
- OD
- OE
- OX
- OZ
- P4
- P5
- PE
- PN
- PO
- PQ
- PY
- PZ
- RB
- RR
- RT
- RX
- SG
- V5
- XP
type: string
Attending:
description: 'Information about the individual who has overall responsibility for the patient''s medical care
and treatment reported in the claim. This information is required when the claim contains any services other
than non-scheduled transportation claims.
This provider should be an individual, not an organization, and you should supply at least the provider''s
`lastName` and an identifier, which is typically the `npi`.'
properties:
address:
$ref: '#/components/schemas/InstitutionalAddress'
deprecated: true
contactInformation:
$ref: '#/components/schemas/InstitutionalContactInformation'
deprecated: true
employerId:
deprecated: true
type: string
firstName:
description: The provider's first name.
maxLength: 35
minLength: 1
type: string
lastName:
description: The provider's last name. This is **required**.
maxLength: 60
minLength: 1
type: string
middleName:
description: The provider's middle name or initial.
maxLength: 25
minLength: 1
type: string
npi:
description: The individual [National Provider Identifier (NPI)](https://www.stedi.com/docs/healthcare/national-provider-identifier)
assigned to the provider.
pattern: ^\d{10}$
type: string
organizationName:
description: The provider's business name.
maxLength: 60
minLength: 1
type: string
providerType:
deprecated: true
description: This field is now automatically populated and it only remains for backwards compatibility.
type: string
secondaryIdentificationQualifierCode:
$ref: '#/components/schemas/OperatingPhysicianIdentificationQualifierCode'
secondaryIdentifier:
description: 'The identifier referenced by `secondaryIdentificationQualifierCode`. For example, if `secondaryIdentificationQualifierCode`
is set to `0B`, this property should be the provider''s state license number.
You can only include one secondary identifier for the provider.'
type: string
suffix:
description: The provider's name suffix, such as Jr. or III.
maxLength: 10
minLength: 1
type: string
taxonomyCode:
description: The provider's [taxnonomy code](https://www.cms.gov/medicare/enrollment-renewal/providers-suppliers/health-care-taxonomy),
a unique 10-character code that designates their classification and specialization. Only applies to
the attending provider.
maxLength: 10
minLength: 10
pattern: ^[A-Za-z0-9]{10}$
type: string
type: object
Billing:
description: 'Information about the billing provider.
- You must provide an `address` that is a physical location such as the office where care is delivered or
an administrative facility.
- For tax identification, you must include either the provider''s Social Security Number (SSN) in the `ssn`
property _or_ their Employer Identification Number (EIN) in the `employerId` property, but not both.
- If the billing provider has an NPI, you must include it in the `npi` property. If the billing provider
does not have an NPI, you must include either the `commercialNumber` or the `locationNumber` for identification.
Some payers may require the `npi` **and** either the `commercialNumber` or the `locationNumber` as a secondary
identifier.
- Some solo providers may use their SSN as their EIN. In this case, submit the SSN in the `ssn` property
and leave the `employerId` property blank.'
properties:
address:
$ref: '#/components/schemas/ClaimsAddress'
description: 'The billing provider''s address. This is **required** and must be a physical location such
as the office where care is delivered or an administrative facility. If the billing provider expects
to receive paper checks at a PO Box, lockbox, or other non-physical address, provide that in `payToAddress`.
For United States addresses, you **must** include the full nine-digit zip code with no separators, such
as `100031502`. If you don''t know the full zip code, you can find it using the [USPS ZIP Code Lookup](https://tools.usps.com/zip-code-lookup.htm)
tool.'
claimOfficeNumber:
deprecated: true
description: Claim Office Number.
maxLength: 50
type: string
commercialNumber:
description: The billing provider's commercial number, as assigned by this payer. The commercial number
is a unique identifier that the payer assigns to the provider. For providers without an NPI, you must
provide either the `commercialNumber` or the `locationNumber` for identification.
type: string
contactInformation:
$ref: '#/components/schemas/ClaimsContactInformation'
description: Contact information for the billing provider. You can include a maximum of two objects in
this array.
employerId:
description: The billing provider's Employer Identification Number (EIN). Typically a string of exactly
nine numbers with no separators, unless otherwise instructed by the payer. If you include this value,
you cannot include the `ssn`.
type: string
firstName:
description: The billing provider's first name, if the provider is an individual.
maxLength: 35
minLength: 1
type: string
lastName:
description: The provider's last name, if the provider is an individual.
maxLength: 60
minLength: 1
type: string
locationNumber:
description: The billing provider's location number. For providers without an NPI, you must provide either
the `commercialNumber` or the `locationNumber` for identification.
type: string
middleName:
description: The provider's middle name or initial, if the provider is an individual.
maxLength: 25
minLength: 1
type: string
naic:
deprecated: true
description: National Association of Insurance Commissioners (NAIC) Code.
maxLength: 50
type: string
npi:
description: The billing provider's [National Provider Identifier (NPI)](https://www.stedi.com/docs/healthcare/national-provider-identifier).
Optional. When the billing provider is not assigned an NPI, supply `commercialNumber` or `locationNumber`
instead.
pattern: ^\d{10}$
type: string
organizationName:
description: The provider's business name.
maxLength: 60
minLength: 1
type: string
payerIdentificationNumber:
deprecated: true
description: Payer Identification Number.
maxLength: 50
type: string
providerType:
deprecated: true
description: This field is now automatically populated and it only remains for backwards compatibility.
type: string
providerUpinNumber:
deprecated: true
description: Deprecated; do not use.
type: string
ssn:
description: The billing provider's Social Security Number. Must be a string of exactly nine numbers with
no separators. If you include this value, you cannot include the `employerId`.
pattern: ^\d{9}$
type: string
stateLicenseNumber:
description: The billing provider's state license number. This is assigned directly by a payer in order
to identify the provider in their system. This is not commonly used.
type: string
suffix:
description: The provider's name suffix, such as Jr. or III.
maxLength: 10
minLength: 1
type: string
taxonomyCode:
description: Code from the National Uniform Claims Committee [Health Care Provider Taxonomy Code Set](https://taxonomy.nucc.org/).
This identifies the billing provider's type and/or area of specialty.
maxLength: 10
minLength: 10
pattern: ^[A-Za-z0-9]{10}$
type: string
type: object
BillingProviderType:
description: Defines the billing provider type.
enum:
- BillingProvider
type: string
CertificationConditionCodeAppliesIndicator:
description: Code indicating whether an EPSDT referral was given to the patient. Can be set to `N` - No or
`Y` - Yes.
enum:
- N
- Y
type: string
CertificationTypeCode:
description: Code indicating the type of certification. Can be set to `I` - Initial, `R` - Renewal, or `S`
- Revised.
enum:
- I
- R
- S
type: string
ClaimAdjustment:
properties:
adjustmentDetails:
items:
$ref: '#/components/schemas/ClaimAdjustmentDetails'
maxItems: 6
minItems: 1
type: array
adjustmentGroupCode:
$ref: '#/components/schemas/AdjustmentGroupCode'
required:
- adjustmentDetails
- adjustmentGroupCode
type: object
ClaimAdjustmentDetails:
description: The adjustment reason codes and amounts. You can include up to six objects in this array to describe
a single adjustment group code.
properties:
adjustmentAmount:
description: The dollar amount of the adjustment, expressed as a decimal. For example, `100.50`.
pattern: ^\d+(\.\d{1,2})?$
type: string
adjustmentQuantity:
description: The units of service being adjusted.
type: string
adjustmentReasonCode:
description: Code identifying the detailed reason the adjustment was made. Visit the X12 [Claim Adjustment
Reason Codes](https://x12.org/codes/claim-adjustment-reason-codes) for a complete list.
type: string
required:
- adjustmentAmount
- adjustmentReasonCode
type: object
ClaimCodeInformation:
description: Supply information specific to hospital claims, such as the priority of the admission.
properties:
admissionSourceCode:
description: 'Code indicating the source of the admission, such as the emergency room (ER), a doctor’s
referral, or another facility.
This code is **required** for all institutional claims except when the `claimInformation.placeOfServiceCode`
is set to `14` (Non-Patient Laboratory). Stedi rejects claims that don''t meet this requirement [Full
code list](https://med.noridianmedicare.com/web/jea/topics/claim-submission/point-of-origin-codes).'
type: string
admissionTypeCode:
description: The code indicating the priority of the admission.
maxLength: 1
minLength: 1
type: string
patientStatusCode:
description: 'Code indicating patient status as of the end of the claim''s billed period. It tells the
payer whether the patient was discharged, transferred, or still admitted.
This code must be compatible with the `claimInformation.claimFrequencyCode`. For example, claim frequency
code `1` (Admit thru Discharge Claim) means the patient''s stay is finished. In this case, the patient
status code shouldn''t be `30` (Still a Patient), which indicates the patient is still in the facility.
[Full code list](https://med.noridianmedicare.com/web/jea/topics/claim-submission/patient-discharge-status-codes)'
maxLength: 2
minLength: 1
type: string
required:
- admissionTypeCode
- patientStatusCode
type: object
ClaimContractInformation:
description: Required when the submitter is contractually obligated to supply this information on post-adjudicated
claims.
properties:
contractAmount:
description: The total dollar amount of the contract, expressed as a decimal. For example, `100.50`.
pattern: ^\d+(\.\d{1,2})?$
type: string
contractCode:
description: The contract code. This is a unique identifier for the contract.
type: string
contractPercentage:
description: The allowance or charge percent, expressed as a decimal. For example, `0.80`.
type: string
contractTypeCode:
$ref: '#/components/schemas/ClaimContractInformationContractTypeCode'
contractVersionIdentifier:
description: An additional identifer for the contract. Identifies the revision level of a particular format,
program, technique or algorithm.
type: string
termsDiscountPercentage:
description: Terms discount percentage, expressed as a percent, available to the purchaser if an invoice
is paid on or before the Terms Discount Due Date.
type: string
required:
- contractTypeCode
type: object
ClaimContractInformationContractTypeCode:
description: A code identifying the type of contract. Can be set to `01` - Diagnosis Related Group (DRG),
`02` - Per Diem, `03` - Variable Per Diem, `04` - Flat, `05` - Capitated, `06` - Percent, or `09` - Other.
enum:
- '01'
- '02'
- '03'
- '04'
- '05'
- '06'
- 09
type: string
ClaimDateInformation:
description: You must provide at least one date related to the claim. For example, the date on which the patient
was admitted to the hospital.
properties:
accidentDate:
description: The date of the accident related to this claim. Required when `relatedCausesCode` is set
to `AA` - Auto Accident or `OA` - Other Accident. Also required when `relatedCausesCode` is set to `EM`
- Employment and this claim is the result of an accident.
type: string
acuteManifestationDate:
description: The date the patient first experienced acute symptoms for a chronic condition. Required when
the `patientConditionCode` = `A` (Acute Condition) or `M` (Acute Manifestation of a Chronic Condition),
the claim involves spinal manipulation, and the payer is Medicare.
type: string
admissionDate:
description: The date the patient was admitted to the hospital. Required on ambulance claims when the
patient was known to be admitted to the hospital. Also required on inpatient claims.
type: string
assumedAndRelinquishedCareBeginDate:
description: The date the provider filing this claim assumed care from another provider during post-operative
care. Required when providers share post-operative care (global surgery claims).
type: string
assumedAndRelinquishedCareEndDate:
description: The date the provider filing this claim relinquished post-operative care to another provider.
Required when providers share post-operative care (global surgery claims).
type: string
authorizedReturnToWorkDate:
description: The date the provider has authorized the patient to return to work. Required on claims where
this information is necessary for adjudication, such as workers compensation claims.
type: string
disabilityBeginDate:
description: The start date of the patient's disability period. You can include this date without providing
a `disabilityEndDate` if the patient is currently disabled and the end date is unknown. Used for claims
involving disability where the provider judges that the patient was or will be unable to perform the
duties normally associated with their work.
type: string
disabilityEndDate:
description: The end date of the patient's disability period. You can include this date without including
a `disabilityStartDate` if the patient is no longer disabled and the start date is unknown. Used for
claims involving disability where the provider judges that the patient was or will be unable to perform
the duties normally associated with their work.
type: string
dischargeDate:
description: The date the patient was discharged from the hospital. Required for inpatient claims when
the patient was discharged from the facility and the discharge date is known
type: string
firstContactDate:
description: Date the patient first consulted the provider for their condition by any means. This is not
necessarily the same as the initial treatment date. Required for Property and Casualty claims when state
mandated.
type: string
hearingAndVisionPrescriptionDate:
description: The date of the patient's hearing and vision prescription. Required on claims where a prescription
has been written for hearing devices or vision frames and lenses and it is being billed on this claim.
type: string
initialTreatmentDate:
description: The date the patient first received treatment for the current illness or condition. Required
when the Initial Treatment Date is known to impact adjudication for claims involving spinal manipulation,
physical therapy, occupational therapy, speech language pathology, dialysis, optical refractions, or
pregnancy.
type: string
lastMenstrualPeriodDate:
description: The date of the patient's last menstrual period. Required when the provider believes the
services on this claim are related to the patient's pregnancy.
type: string
lastSeenDate:
description: The date that the patient was seen by the attending or supervising physician for the qualifying
medical condition related to the services performed. Required when claims involve services for routine
foot care and this date is known to impact the payer's adjudication process.
type: string
lastWorkedDate:
description: The date the patient last worked, related to disability claims. Required on claims where
this information is necessary for adjudication, such as workers compensation claims.
type: string
lastXRayDate:
description: The date of the patient's last x-ray. Required when claim involves spinal manipulation and
an x-ray was taken.
type: string
repricerReceivedDate:
description: The date the repricing entity received the initial claim. Required when a repricer is passing
the claim onto the payer.
type: string
symptomDate:
description: The date the patient began experiencing acute symptoms for the current illness or condition.
Required for the initial medical service or visit performed in response to a medical emergency when
the date is available and is different than the date of service.
type: string
type: object
ClaimFilingCode:
description: 'A code identifying the type of claim. For example `DS` - Disability.
- Use `OF` when submitting Medicare Part D claims.
- Use `ZZ` when you don''t know the type of insurance.
- Some payers reject claims with invalid codes. If you''re not sure which code to use, we recommend running
a [real-time eligibility check](https://www.stedi.com/docs/healthcare/api-reference/post-healthcare-eligibility)
and using the value returned in the most relevant `benefitsInformation.insuranceTypeCode` property. Note
that the eligibility response uses a different code list than claims, so you may need to map that code value
to the appropriate claim filing code.
Visit [Claims code lists](https://www.stedi.com/docs/healthcare/claims-code-lists#claim-filing-indicator-codes)
for a complete list.'
enum:
- '11'
- '12'
- '13'
- '14'
- '15'
- '16'
- '17'
- AM
- BL
- CH
- CI
- DS
- FI
- HM
- LM
- MA
- MB
- MC
- OF
- TV
- VA
- WC
- ZZ
type: string
ClaimFilingIndicatorCode:
description: A code identifying the type of claim. For example `DS` - Disability. Use `OF` when submitting
Medicare Part D claims. Use `ZZ` when you don't know the type of insurance. Visit [Claims code lists](https://www.stedi.com/docs/healthcare/claims-code-lists#claim-filing-indicator-codes)
for a complete list.
enum:
- '11'
- '12'
- '13'
- '14'
- '15'
- '16'
- '17'
- AM
- BL
- CH
- CI
- DS
- FI
- HM
- LM
- MA
- MB
- MC
- OF
- TV
- VA
- WC
- ZZ
type: string
ClaimFrequencyCode:
description: 'Identify the type of claim. Can be set to: `1` - indicates an original claim, `7` - Indicates
the new claim is a replacement or correction, `8` - Indicates the claim is void or canceled'
enum:
- '1'
- '7'
- '8'
type: string
ClaimIdentifier:
description: "A code specifying the type of transaction. Defaults to `CH` if not provided.\n - `31`: Only\
\ for use by state Medicaid agencies performing post payment recovery.\n - `CH`: Use when the transaction\
\ contains only fee for service claims or claims with at least one chargeable line item. Also use when it's\
\ not clear whether a transaction contains claims or capitated encounters, or if the transaction contains\
\ a mix of claims and capitated encounters.\n - `RP`: Use for capitated encounters. Also use when the transaction\
\ is being sent to an entity for purposes other than adjudication of a claim. For example, when you're sending\
\ the claim to a state health agency that is using the claim for health data reporting purposes."
enum:
- '31'
- CH
- RP
type: string
ClaimInformation:
description: "Information about the healthcare claim. \n\nNote that the objects and properties marked as **required**\
\ are required for all claims, while others are conditionally required, depending on type of claim and claim\
\ circumstances. For example, you must always provide the patient's diagnosis codes in the `healthCareCodeInformation`\
\ object, but you only need to provide the `otherSubscriberInformation` object in coordination of benefits\
\ scenarios. When you include a conditionally required object, you must provide all of its required properties."
properties:
ambulanceCertification:
descrip
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# Full source: https://raw.githubusercontent.com/api-evangelist/stedi/refs/heads/main/openapi/stedi-claim-submission-api-openapi.yml