Integrated Rules Institutional

A: The Integrated Rules Institutional API performs advanced rules-based checking and validation of Professional claims based upon the X12 EDI 837i standard. It uses compilations of medical business specialties, called Knowledge Packs, for fine-tuned claim inspection. It does not submit your claim to the payer, and is designed to be complementary to the Professional Claims API.

• You can submit your completed claims to the payer through the standard Institutional Claims Submission API (this will incur an additional charge):

  https://apigw.changehealthcare.com/medicalnetwork/institutionalclaims/v3/submission

• You may use the the standard Professional Claims API validation endpoint to check and validate your upcoming submission. It applies a different and simpler set of rules that don't affect or repeat the functions from the Integrated Rules Professional API. Your transaction will not be sent to the payer:

  https://apigw.changehealthcare.com/medicalnetwork/institutionalclaims/v3/validation

If you use a different claim submission workflow, you can also submit your claim that way. Consult your Change Healthcare representative for more information.

A: We do! You can use our Sandbox environment even before signing a contract. It requires a separate set of secure credentials, which you can obtain from your Change Healthcare representative. After receiving your client_id and client_secret for our Sandbox environment, you can test the API in our interactive documentation, use an application such as Postman, or test APIs using your own development console.

A: For all Integrated Rules Institutional API applications, be familiar with the term Edits, which has a specific meaning in this context.

Payers control their own claims edit specifications. Edit specifications govern how medical practices must submit correct claims information for payer processing and claim adjudication. Claims Edits can change at any time, and these changes may or may not reach you before you submit an institutional claim, much less be integrated into your claims submission software.

Because of this likelihood, you may encounter unexpected errors and incur delays when filing claims, even when you think your software and processes are up to date.

These issues can occur at any time. Some medical practices may subscribe to continuous payer updates and submission edits. They receive their Claim edits notifications from the payer. Others may not do so, finding the costs prohibitive. The Integrated Rules Services team monitors regulatory requirements from Medicare and from industry organizations of many different types, and develops the Integrated Rules Knowledge Packs based upon the Packs' medical disciplines and the Rules/Edits that apply to them.

We continuously track and follow the Rules/Edits changes so you don't have to. Using the Knowledge Packs that you order as a match for your business, we tailor your Institutional Claims Integrated Rules API to your specific needs.

A: The standard Institutional Claims API uses a separate set of rules and logic for scrubbing an institutional claim, and is automatically applicable across a range of institutional specialties. The Integrated Rules Institutional API provides greater specialization through the selection of Knowledge Packs to support your provider's medical specialties. It can be considered complementary to the standard Institutional Claims API.