Using our Knowledge Packs, our representatives can tailor your Professional Claims error checks and validations to the needs of your medical team.
If you need a powerful General Billing capability, or you specialize in Medicare, Ambulance Place of Service, Dialysis, you can order a Knowledge Pack that matches specific Claims requirements.
Frequently Asked Questions
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):
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:
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 Professional 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 approvals or disapprovals. Claims Edits can change at any time, and notifications of these changes may or may not reach you before you submit a professional claim, much less be integrated into your claims submission software.
Because of this likelihood, you may encounter unexpected errors and incur unexpected delays when filing claims, even when you think your software is up to date and hence your claims are accurate.
These issues can occur at any time. Some medical practices may subscribe to continuous payer updates and submission edits, and receive their notifications from the payer. Others may not do so, finding the costs prohibitive. The Integrated Rules Professional Services team monitors regulatory requirements from Medicare and from industry organizations of many different types, and builds the Integrated Rules Knowledge Packs based upon the medical disciplines and the Rules/Edits that apply to them. Using the Knowledge Packs that you order as a match for your business, we tailor your Integrated Rules API to your specific needs.
A: The standard Professional Claims API uses a separate set of rules and logic for scrubbing a professional claim, and is applicable across a range of professional specialties. The Integrated Rules Professional API provides greater specialization through the selection of Knowledge Packs to support your provider's medical specialties.
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