Overview

This section aims to provide you with practical examples of how to combine several API calls to accomplish specific tasks. Whether you are a seasoned developer or just getting started with our API, the use cases presented here will help you understand how to interact with our system to achieve your desired results. In this section, we will cover some essential use cases, such as adding a claim, adding an authorization, and adjudicating a claim. By following these examples, you will be able to leverage our API to streamline your workflow and enhance your productivity. Let's dive in and explore the possibilities of our API!

Adding a Claim

In this section, we will guide you through the process of creating a claim and show you how to use our API to achieve this task. To add a claim, you will need to perform the following steps:

Step 1: Create Claim Batches (Optional)

  1. Use our API endpoint Create Claim Batches to create a "container" for the claims. This step groups the claims that need to be processed. Note that this step is optional, and if you already have a claim batch container, you can use that instead.

Step 2: Create Claim Batch

  1. Make a POST request to the Create Claim Batch API endpoint to create a header record for the claim.
  2. Specify the batch_number , which is the number of the batch created in the previous step (if applicable).
  3. Provide a unique number within the batch known as the batch_claim number.

Step 3: Create Claim Batch Detail

  1. Use the Create Claim Batch Detail API endpoint to create detail records for each service line and assign them to the claim header.
  2. Specify a unique claim sequence ( claim_Seq ) number for each service line within the claim header (e.g., 01 , 02 , 12 ).
  3. Set the adjustment sequence number ( adjustment_Seq ) to 00 for a new claim.

The relationship of the claim entities is represented in the image below: Claim Entities

By following these steps, you will be able to add a claim to our system and leverage our API to streamline your workflow. Please note that the creation of claim batches is optional, and you can proceed directly to creating a claim batch if you already have a suitable container. Let's get started!

Adjudicating or Processing a ClaimQueue

Follow these steps to adjudicate or process a claim using the VBASoftware APIs.

Step 1: Create a Claim Queue

To start the adjudication process, you need to create a claim queue.

  1. Make a POST request to the Create Claim Queue endpoint.
  2. Include the necessary headers, such as the target database name.
  3. Provide the required data for creating a claim queue.
  4. The API will respond with a success message, and the claim queue will be created.

Step 2: Create ClaimQueueDetail Records

Once you have a claim queue, you can add one or more ClaimQueueDetail records to it. These records represent individual claims to be processed or adjudicated.

  1. Make a POST request to the Claim Queue Details endpoint.
  2. Include the target database name and the claim queue key in the request.
  3. Provide the data for creating ClaimQueueDetail records.
  4. The API will respond with a success message, and the records will be added to the claim queue.

Step 3: Adjudicate or Process the Claim Queue

Now that you have created the claim queue and added claim details, you can proceed to adjudicate or process the claims in the queue. Depending on your requirements, you can choose one of the following options:

Adjudicate Claim Queue

To adjudicate the entire claim queue, use the AdjudicateClaimQueue API. This is a fire-and-forget operation, and the results will become visible shortly after the call.

  1. Make a POST request to the Adjudicate Claim Queue endpoint.
  2. Include the target database name and the claim queue key in the request.
  3. The API will accept the request and initiate the adjudication process.

Process Claim Queue

To process the entire claim queue, use the ProcessClaimQueue API. Similar to adjudication, this is a fire-and-forget operation, and the results will become visible shortly after the call.

  1. Make a POST request to the Process Claim Queue endpoint.
  2. Include the target database name and the claim queue key in the request.
  3. The API will accept the request and initiate the claim processing.

That's it! You've successfully adjudicated or processed a claim queue using the VBASoftware APIs.

Adjudicating or Processing a Single Claim

Follow these steps to adjudicate or process a single claim using the VBASoftware APIs.

Adjudicate Single Claim

Step 1: Adjudicate and Wait for Response

To adjudicate a single claim and wait for the response, use the AdjudicateClaimNow API.

  1. Make a POST request to the Adjudicate Claim Now endpoint.
  2. Include the target database name, batch number, and batch claim in the request.
  3. Optionally, provide the requesting user as an optional parameter.
  4. The API will process the claim and provide a response with claim details.

Step 2: Adjudicate without Response (Fire and Forget)

To adjudicate a single claim without waiting for a response (fire and forget), use the AdjudicateClaimNoResponse API.

  1. Make a POST request to the Adjudicate Claim No Response endpoint.
  2. Include the target database name, batch number, and batch claim in the request.
  3. Optionally, provide the requesting user as an optional parameter.
  4. The API will accept the request and process the claim without returning a response.

Process Single Claim

Step 1: Process and Wait for Response

To process a single claim and wait for the response, use the ProcessClaimNow API.

  1. Make a POST request to the Process Claim Now endpoint.
  2. Include the target database name, batch number, and batch claim in the request.
  3. Optionally, provide the requesting user as an optional parameter.
  4. The API will process the claim and provide a response with claim details.

Step 2: Process without Response (Fire and Forget)

To process a single claim without waiting for a response (fire and forget), use the ProcessClaimNoResponse API.

  1. Make a POST request to the Process Claim No Response endpoint.
  2. Include the target database name, batch number, and batch claim in the request.
  3. Optionally, provide the requesting user as an optional parameter.
  4. The API will accept the request and process the claim without returning a response.

That's it! You've successfully adjudicated or processed a single claim using the VBASoftware APIs.

Load an Authorization

To load an authorization for use in the adjudication process, follow these steps:

Step 1: Create Authorization

  1. Make a POST request to the Create Authorization endpoint using our API.
  2. Fill in the core fields and requested fields. The approved fields will be used later in the process.
    • Core Fields: [List of Core Fields]
    • Requested Fields: [List of Requested Fields]

Step 2: Create Authorization Diagnosis and Procedure Codes

Create the necessary diagnosis and procedure codes for the authorization using our API. This step is critical for accurate processing of the authorization and ensures that the required procedures are carried out.

By following these steps, you can load an authorization into our system for use in the adjudication process. Please note that approval is still required, and additional steps will be necessary to obtain authorization for the relevant procedures. Let's get started!

Adding an Enrollment Using Advanced API

To add an enrollment using the advanced API for add-enrollment, several pre-requisites need to be set up. These pre-requisites include:

Pre-requisites:

  1. Create a BillingCyce
  2. Create a Group
    • Depends on BillingCycle ( Billing_Cycle_ID )
  3. Create a GroupDivision
    • Depends on Groups ( Group_ID )
  4. Create GroupContract
    • Depends on GroupDivision ( Group_ID , GroupDivision.Division_ID )

Enrollment Process:

Once the pre-requisites are in place, follow these steps for the enrollment process:

  1. Create Subscriber
  2. Create Member
    • Depends on Subscriber ( Subscriber_ID )
  3. Call Advanced API Subscriber Add Enrollment
    • Your SubEnrollment record passed in should include:
    • Subscriber.Subscriber_ID
    • GroupDivision.Group_ID
    • GroupDivision.Division_ID
    • This API call will create the underlying SubEnrollment records, update the subscriber, and update the members associated with the subscriber.

After completing the enrollment, you can proceed with creating a SubEnrollmentPlan:

  1. Create PlanType
  2. Create Plan
    • Depends on PlanType ( Plan_Type )
  3. Create SubEnrollmentPlan
    • Depends on:
    • subEnrollment.Subscriber_ID
    • subEnrollment.Group_ID
    • subEnrollment.Division_ID
    • subEnrollment.Group_Coverage_Start
    • subEnrollment.Start_Date

These steps will guide you through the process of adding an enrollment using the advanced API and setting up related records as required.