User Get Claim Detail

The User Get Claim Detail web service retrieves detail information about a claim.

 

USER GET CLAIM DETAIL- INPUT FILE CONTENT

 

Field

Format

Description

Optional/Mandatory

Notes

Submitted User Id

String

The ID of the user of the Client GUI application

Optional

Max Length = 16

Logical User Id

String

The iSeries user ID

Optional

Max Length = 10

Logical Password

String

The iSeries Password

Mandatory if Logical User Id provided

Max Length = 18

Unique Claim ID

String

The Unique ID of the Trial Claim

Mandatory

Max Length = 15

Claim Sequence Number

Int

A claim sequence number

Mandatory

Max 999

 

 

USER GET CLAIM DETAIL - OUTPUT FILE CONTENT

 

Only one record will be returned in the result set and the image will be a SOAP attachment.

 

Field

Format

Description

Notes

Unique Claim ID

Decimal

The Unique ID of the Trial Claim

Total Digits = 15

Fraction Digits = 0

Claim Sequence Number

Decimal

A claim sequence number

Total Digits = 3

Fraction Digits = 0

Claim Status

String

The status of the claim:

 

P - Paid

R - Rejected

C - Captured

X - Reversed

Max Length = 1

Claim Type

String

Used to identify DMR Claims

Max Length = 1

Copay Amount Paid

Decimal

Copay Amount Paid

Total Digits = 9

Fraction Digits = 2

Copay Flat Amt

Decimal

Copay Flat $ Amount

Total Digits = 9

Fraction Digits = 2

Copay Percent Amount

Decimal

Copay Percent $ Amt

Total Digits = 9

Fraction Digits = 2

Amount Applied Per Deductible

Decimal

Amount Applied Per Deductible

Total Digits = 9

Fraction Digits = 2

Over Cap

Decimal

Exceed Per Benefit

Total Digits = 9

Fraction Digits = 2

Product Select Amt

Decimal

Amount Attributed to Product Selection

Total Digits = 9

Fraction Digits = 2

Sales Tax

Decimal

Sales Tax Amount

Total Digits = 9

Fraction Digits = 2

Patient Pay Amt

Decimal

Total amount to be collected from patient.  

Total Digits = 9

Fraction Digits = 2

Other Payer Amt

Decimal

 

Total Digits = 9

Fraction Digits = 2

Part D Benefit Amt

Decimal

 

Total Digits = 9

Fraction Digits = 2

Total Drug Cost

Decimal

 

Total Digits = 9

Fraction Digits = 2

Rx Number

String

Prescription or service reference number

Max Length = 7

Fill Number

Int

 

 

Fill Date

String

The date that the service was performed

YYYYMMDD

Plan ID

Plan Data Type

The effective date of the plan used to process the claim

Max Length = 10

Plan From Date

Plan Data Type

The effective date of the plan used to process the claim

YYYYMMDD

Reject Code

String

Code(s) indicating error encountered

Max Length = 3

Repeatable up to 10 times

Reject Message

String

Free form message

Max Length = 40 Repeatable up to 5 times

Carrier ID

String

The Carrier ID of the member

Max Length = 9

Account ID

String

The Account ID of the member

Max Length = 15

Group ID

String

The Group ID of the member

Max Length = 15

Member ID

String

The full member ID

Max Length = 18

Last Name

String

The member’s last name

Max Length = 25

First Name

String

The member’s first name

Max Length = 15

Date of Birth

String

Member’s date of birth

YYYYMMDD

Gender

String

The member’s gender

Optional

F=Female

M=Male

Max Length = 1

Person Code

String

The Person Code of the member

Max Length = 3

Relationship Code

String

The member’s relationship code:

0=Not Specified

1=Cardholder

2=Spouse

3=Child

4=Other

Max Length = 1

Member Address

Address Data Type

The member's primary address

 

Prescriber ID

String

The Identification number of the individual who prescribed the medication

Max Length = 15

Prescriber Qualifier

String

The type of Identification that was used by the prescriber

Max Length = 2

Prescriber Name

String

The name of the prescriber

Max Length = 51

Pharmacy ID

String

The ID of the Pharmacy providing the drugs

Max Length = 15

Pharmacy Qualifier

String

The Type of ID used to identify the Pharmacy

Max Length = 2

Pharmacy Name

String

The Name of the Pharmacy

Max Length =

Pharmacy Address

Address Data Type

The address of the Pharmacy

 

Pharmacy Phone

String

The phone number of the pharmacy

Max Length = 10

Product Qualifier

String

The identification system used to describe the product supplied

Max Length = 2

Product ID

String

The identification number of the product supplied. May not exist if it is a compound

Max Length = 20

Drug Name

String

The full name extension of the drug

Max Length = 70

Days Supply

Int

The duration that this prescription is intended to last

Max Length = 3

Quantity Dispensed

Decimal

The quantity of product dispensed

Total Digits = 11

Fraction Digits = 3

DAW Code

String

The DAW code

Max Length = 1

GPI

String

The product GPI

Max Length = 14

AHFS Code

String

The AHFS code

Max Length = 8

GCN Sequence Number

Int

The product GCN Sequence Number

Max Length = 6

Usual Customary Cost

Decimal

The U&C of the product

Total Digits = 9

Fraction Digits = 2

Prior Auth Type

String

GPI/NDC

Max Length = 1

PA Reason Code

String

A code that represents the reason for granting the prior authorization

Max Length = 2

Prior Auth Number

String

The Unique number of the member’s Prior Authorization

Max Length = 11

PA From Date

String

The date at which the prior authorization became active

YYYYMMDD

PA Thru Date

String

The last date that a claim could be processed against this prior authorization

YYYYMMDD

Check Amt

Decimal

The amount of the check used to pay a DMR claim

Total Digits = 9

Fraction Digits = 2

Check Number

String

The check number on which this claim was paid

Total Digits = 9

Fraction Digits = 0

Check Sent Date

String

The date the check was created

YYYYMMDD

Tracking Number

String

 

 

Received Date

String

 

YYYYMMDD

 

File Links

 

User Claim Detail WSDL

User Common XSD

Exception WSDL

SXC Common XSD