API Use Cases

Overview

This section provides practical examples demonstrating how to combine multiple API calls to achieve specific objectives. Whether you are an experienced developer or new to our API, these use cases will guide you in effectively leveraging our system.

Covered use cases include:

• Adding a Claim
• Adjudicating or Processing Claims
• Loading an Authorization
• Adding an Enrollment

Each use case is broken into sequential steps with example requests to ensure clarity and ease of implementation.

Adding a Claim

Step 1: (Optional) Create Claim Batches

Use the Create Claim Batches endpoint to create a container for claims.

Step 2: Create Claim Batch

Make a POST request to Create Claim Batch to create the claim header.

Step 3: Add Claim Details

Use Create Claim Batch Detail to specify claim service lines.

Adjudicating or Processing a Claim Queue

Step 1: Create a Claim Queue

Use Create Claim Queue to start the adjudication process.

Step 2: Add Claims to Queue

Add claims using Claim Queue Details.

Step 3: Adjudicate or Process the Claim Queue

• Adjudicate : Use Adjudicate Claim Queue
• Process : Use Process Claim Queue

Adjudicating or Processing a Single Claim

Option 1: Adjudicate a Single Claim

• With Response : Use Adjudicate Claim Now
• Fire and Forget : Use Adjudicate Claim No Response

Option 2: Process a Single Claim

• With Response : Use Process Claim Now
• Fire and Forget : Use Process Claim No Response

Loading an Authorization

Step 1: Create an Authorization

Make a POST request to Create Authorization.

Step 2: Add Diagnosis & Procedure Codes

• Create Authorization Procedure Code
• Create Authorization Diagnostic Code

Adding an Enrollment

Pre-requisites:

1. Create a BillingCycle
2. Create a Group
3. Create a GroupDivision
4. Create GroupContract

Enrollment Process

1. Create a Subscriber
2. Create a Member
3. Call Subscriber Add Enrollment

Adding a Plan

1. Create PlanType
2. Create Plan
3. Create SubEnrollmentPlan

By following these use cases, you can efficiently integrate VBAPI into your workflow, ensuring smooth processing and automation of claims, authorizations, and enrollments.