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Claims start from delivered Care, an eligible Benefit and approved service evidence. Amounts use the currency’s minor unit.

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Submit a Claim

If the eligibility response requires authorization, include its approved preauthorization_id. The authorization, covered Booking and delivered Session must refer to the same service.

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Request evidence

An adjudicator can move a submitted Claim to queried:
Information requests use coded reasons and bounded evidence types. Evidence submissions contain references, not Clinical Notes:
Resubmission increments submission_version. Earlier events remain in the audit history.

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Adjudicate

Every submitted line receives one decision. For each line:
  • allowed = payer + patient_responsibility
  • billed = allowed + adjustment
The API derives approved, partially_approved or denied from the balanced line decisions. The payer’s authorized reviewer remains the decision authority.

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Reconcile remittance

A remittance may allocate to several Claims. Each allocation posts a balanced ledger transaction. A Claim reaches settled only when cumulative remittance equals its approved amount.
Eligibility is an observation for a service date, not a guarantee of Claim payment.
Last modified on July 30, 2026