Create Professional Claim

POST

api

claim

professional

cURL

curl --request POST \
  --url https://forecaster.cairhealth.com/api/claim/professional/v1 \
  --header 'Authorization: Bearer <token>' \
  --header 'Content-Type: application/json' \
  --data '
{
  "accept_assignment": true,
  "id": "12345",
  "date_of_service": "2025-03-15",
  "total_charge": "250.00",
  "patient": {
    "id": "P98765",
    "first_name": "John",
    "last_name": "Doe",
    "name": "John Doe",
    "gender": "male",
    "dob": "1980-05-15",
    "location": {
      "city": "San Francisco",
      "country": "USA",
      "line1": "123 Main St",
      "line2": "Apt 4B",
      "state": "CA",
      "zip": "94105"
    },
    "policies": [
      {
        "id": "POL123",
        "group_num": "GRP456",
        "name": "Premium Health Plan",
        "holder_first": "John",
        "holder_last": "Doe",
        "holder_relationship": "self",
        "claim_filing_indicator": "CI",
        "priority_type": "primary",
        "insurance_plan": {
          "payer_name": "Blue Cross",
          "payer_id": "BCBS123",
          "name_and_id": "Blue Cross (BCBS123)"
        }
      }
    ]
  },
  "billing_provider": {
    "name": "Medical Group Inc",
    "npi": "1234567890",
    "tax_id": "12-3456789",
    "taxonomy_code": "207Q00000X",
    "location": {
      "city": "San Francisco",
      "country": "USA",
      "line1": "456 Health Ave",
      "state": "CA",
      "zip": "94107"
    }
  },
  "rendering_provider": {
    "id": "DR12345",
    "first_name": "Jane",
    "last_name": "Smith",
    "npi": "5432167890",
    "taxonomy_code": "207Q00000X",
    "name": "Jane Smith, MD"
  },
  "service_location": {
    "city": "San Francisco",
    "state": "CA",
    "zip": "94107",
    "name": "Medical Group Inc",
    "place_of_service": {
      "code": "11",
      "name": "Office",
      "code_name": "11 - Office"
    }
  },
  "cpt_codes_cms1500s": [
    {
      "cpt_code": {
        "code": "99213"
      },
      "fee": "150.00",
      "units": "1"
    },
    {
      "cpt_code": {
        "code": "85025"
      },
      "fee": "100.00",
      "units": "1"
    }
  ],
  "icd_codes_cms1500s": [
    {
      "icd_code": {
        "code": "J20.9"
      }
    },
    {
      "icd_code": {
        "code": "R50.9"
      }
    }
  ],
  "claim_condition_codes": [
    {
      "code": "01"
    }
  ],
  "claim_additional_information": [
    {
      "code": "A1",
      "text": "Additional information"
    }
  ],
  "injury_cause_reasons": {
    "employment_related": false,
    "auto_accident": false,
    "other": false
  },
  "patient_paid_amount": 50
}
'

{
  "resourceType": "OperationOutcome",
  "issue": [
    {
      "severity": "information",
      "code": "informational",
      "details": {
        "text": "All OK"
      }
    }
  ]
}

Authorizations

Authorization

string

header

required

Bearer authentication header of the form Bearer <token>, where <token> is your auth token.

Query Parameters

attachmentId

string

Optional ID of document references to associate with the claim. Can be specified multiple times. This id will be returned from the Create Claim Attachment endpoint.

Body

application/json

CMS 1500 professional claim data

accept_assignment

boolean

required

Whether the provider agrees to accept assignment

string

required

Unique identifier for the CMS 1500 form

date_of_service

string

required

Date when the service was provided

total_charge

string

required

Total charge amount for the claim

patient

object

required

Information about the patient

Show child attributes

patient.id

string

Patient identifier

patient.first_name

string

Patient's first name

patient.last_name

string

Patient's last name

patient.name

string

Patient's full name

patient.gender

string

Patient's gender

patient.dob

string

Patient's date of birth

patient.location

object

Patient's address information

Show child attributes

patient.location.city

string

City

patient.location.country

string

Country

patient.location.line1

string

Address line 1

patient.location.line2

string

Address line 2

patient.location.name

string

Location name

patient.location.state

string

State

patient.location.to_oneline

string

Single line address representation

patient.location.zip

string

ZIP/Postal code

patient.location.place_of_service

object

Place of service details

Show child attributes

patient.location.place_of_service.code

string

Code of the place of service

patient.location.place_of_service.name

string

Name of the place of service

patient.location.place_of_service.code_name

string

Code name of the place of service

patient.policies

object[]

Patient's insurance policies

Show child attributes

patient.policies.id

string

Policy identifier

patient.policies.num

string

Policy number

patient.policies.group_num

string

Insurance group number

patient.policies.name

string

Policy name

patient.policies.holder_first

string

Policy holder's first name

patient.policies.holder_last

string

Policy holder's last name

patient.policies.holder_relationship

string

Relationship between patient and policy holder

patient.policies.claim_filing_indicator

string

Claim filing indicator code

patient.policies.priority_type

string

Priority type of the insurance policy

patient.policies.insurance_plan

object

Insurance plan details

Show child attributes

patient.policies.insurance_plan.payer_name

string

required

Name of the insurance payer

patient.policies.insurance_plan.payer_id

string

required

Identifier for the insurance payer

patient.policies.insurance_plan.name_and_id

string

Combined name and ID of the insurance plan

billing_provider

object

required

Information about the billing provider

Show child attributes

billing_provider.name

string

required

Provider name

billing_provider.npi

string

required

National Provider Identifier

billing_provider.tax_id

string

required

Provider tax ID

billing_provider.location

object

required

Provider's address information

Show child attributes

billing_provider.location.city

string

City

billing_provider.location.country

string

Country

billing_provider.location.line1

string

Address line 1

billing_provider.location.line2

string

Address line 2

billing_provider.location.name

string

Location name

billing_provider.location.state

string

State

billing_provider.location.to_oneline

string

Single line address representation

billing_provider.location.zip

string

ZIP/Postal code

billing_provider.location.place_of_service

object

Place of service details

Show child attributes

billing_provider.location.place_of_service.code

string

Code of the place of service

billing_provider.location.place_of_service.name

string

Name of the place of service

billing_provider.location.place_of_service.code_name

string

Code name of the place of service

billing_provider.taxonomy_code

string

Provider taxonomy code

rendering_provider

object

required

Information about the rendering provider

Show child attributes

rendering_provider.npi

string

required

Provider's NPI

rendering_provider.id

string

Provider identifier

rendering_provider.first_name

string

Provider's first name

rendering_provider.last_name

string

Provider's last name

rendering_provider.name

string

Provider's full name

rendering_provider.taxonomy_code

string

Provider's taxonomy code

rendering_provider.gender

string

Provider's gender

rendering_provider.dob

string

Provider's date of birth

rendering_provider.location

object

Provider's address information

Show child attributes

rendering_provider.location.city

string

City

rendering_provider.location.country

string

Country

rendering_provider.location.line1

string

Address line 1

rendering_provider.location.line2

string

Address line 2

rendering_provider.location.name

string

Location name

rendering_provider.location.state

string

State

rendering_provider.location.to_oneline

string

Single line address representation

rendering_provider.location.zip

string

ZIP/Postal code

rendering_provider.location.place_of_service

object

Place of service details

Show child attributes

rendering_provider.location.place_of_service.code

string

Code of the place of service

rendering_provider.location.place_of_service.name

string

Name of the place of service

rendering_provider.location.place_of_service.code_name

string

Code name of the place of service

cpt_codes_cms1500s

object[]

required

CPT codes associated with the claim

Show child attributes

cpt_codes_cms1500s.cpt_code

object

required

Show child attributes

cpt_codes_cms1500s.cpt_code.code

string

required

CPT code value

cpt_codes_cms1500s.fee

string

Billed amount for this service

cpt_codes_cms1500s.units

string

Number of units for this service

cpt_codes_cms1500s.mod1

string

Modifier 1

cpt_codes_cms1500s.mod2

string

Modifier 2

cpt_codes_cms1500s.mod3

string

Modifier 3

cpt_codes_cms1500s.mod4

string

Modifier 4

icd_codes_cms1500s

object[]

required

ICD diagnosis codes associated with the claim

Show child attributes

icd_codes_cms1500s.icd_code

object

required

Show child attributes

icd_codes_cms1500s.icd_code.code

string

required

ICD code value

service_location

object

Location of the service

Show child attributes

service_location.city

string

City

service_location.country

string

Country

service_location.line1

string

Address line 1

service_location.line2

string

Address line 2

service_location.name

string

Location name

service_location.state

string

State

service_location.to_oneline

string

Single line address representation

service_location.zip

string

ZIP/Postal code

service_location.place_of_service

object

Place of service details

Show child attributes

service_location.place_of_service.code

string

Code of the place of service

service_location.place_of_service.name

string

Name of the place of service

service_location.place_of_service.code_name

string

Code name of the place of service

claim_condition_codes

object[]

Claim condition codes

Show child attributes

claim_condition_codes.code

string

required

Condition code value

claim_additional_information

object[]

Additional information codes for the claim

Show child attributes

claim_additional_information.code

string

required

Additional information code

claim_additional_information.text

string

Additional information text

injury_cause_reasons

object

Information about injury cause and reasons. If all are false, omit this field.

Show child attributes

Whether the injury is employment related

injury_cause_reasons.auto_accident

boolean

required

Whether the injury is from an auto accident

injury_cause_reasons.other

boolean

required

Whether the injury is from another cause

injury_cause_reasons.state

string

State where the accident occurred

patient_paid_amount

number

Amount paid by the patient

Response

Claim created successfully

A FHIR standard response format for operations

resourceType

enum<string>

required

Type of resource

Available options:

OperationOutcome

issue

object[]

required

A list of issues with the operation

Show child attributes

issue.severity

enum<string>

required

Severity of the issue

Available options:

fatal,

error,

warning,

information

issue.code

enum<string>

required

Error or warning code

Available options:

invalid,

structure,

required,

value,

invariant,

security,

login,

unknown,

expired,

forbidden,

suppressed,

processing,

not-supported,

duplicate,

multiple-matches,

not-found,

deleted,

too-long,

code-invalid,

extension,

too-costly,

business-rule,

conflict,

transient,

lock-error,

no-store,

exception,

timeout,

incomplete,

throttled,

informational

issue.diagnostics

string

Additional diagnostic information about the issue

issue.details

object

Show child attributes

issue.details.text

string

Text description of the issue

issue.details.coding

object[]

Coding of the issue

issue.location

string[]

Locations in the resource where the issue occurred

issue.expression

string[]

FHIRPath of element(s) causing the issue

string

Logical id of this artifact

Optimize X12 Claim DenialsProcesses X12 denials and returns associated claim IDs.

⌘I

cURL

curl --request POST \
  --url https://forecaster.cairhealth.com/api/claim/professional/v1 \
  --header 'Authorization: Bearer <token>' \
  --header 'Content-Type: application/json' \
  --data '
{
  "accept_assignment": true,
  "id": "12345",
  "date_of_service": "2025-03-15",
  "total_charge": "250.00",
  "patient": {
    "id": "P98765",
    "first_name": "John",
    "last_name": "Doe",
    "name": "John Doe",
    "gender": "male",
    "dob": "1980-05-15",
    "location": {
      "city": "San Francisco",
      "country": "USA",
      "line1": "123 Main St",
      "line2": "Apt 4B",
      "state": "CA",
      "zip": "94105"
    },
    "policies": [
      {
        "id": "POL123",
        "group_num": "GRP456",
        "name": "Premium Health Plan",
        "holder_first": "John",
        "holder_last": "Doe",
        "holder_relationship": "self",
        "claim_filing_indicator": "CI",
        "priority_type": "primary",
        "insurance_plan": {
          "payer_name": "Blue Cross",
          "payer_id": "BCBS123",
          "name_and_id": "Blue Cross (BCBS123)"
        }
      }
    ]
  },
  "billing_provider": {
    "name": "Medical Group Inc",
    "npi": "1234567890",
    "tax_id": "12-3456789",
    "taxonomy_code": "207Q00000X",
    "location": {
      "city": "San Francisco",
      "country": "USA",
      "line1": "456 Health Ave",
      "state": "CA",
      "zip": "94107"
    }
  },
  "rendering_provider": {
    "id": "DR12345",
    "first_name": "Jane",
    "last_name": "Smith",
    "npi": "5432167890",
    "taxonomy_code": "207Q00000X",
    "name": "Jane Smith, MD"
  },
  "service_location": {
    "city": "San Francisco",
    "state": "CA",
    "zip": "94107",
    "name": "Medical Group Inc",
    "place_of_service": {
      "code": "11",
      "name": "Office",
      "code_name": "11 - Office"
    }
  },
  "cpt_codes_cms1500s": [
    {
      "cpt_code": {
        "code": "99213"
      },
      "fee": "150.00",
      "units": "1"
    },
    {
      "cpt_code": {
        "code": "85025"
      },
      "fee": "100.00",
      "units": "1"
    }
  ],
  "icd_codes_cms1500s": [
    {
      "icd_code": {
        "code": "J20.9"
      }
    },
    {
      "icd_code": {
        "code": "R50.9"
      }
    }
  ],
  "claim_condition_codes": [
    {
      "code": "01"
    }
  ],
  "claim_additional_information": [
    {
      "code": "A1",
      "text": "Additional information"
    }
  ],
  "injury_cause_reasons": {
    "employment_related": false,
    "auto_accident": false,
    "other": false
  },
  "patient_paid_amount": 50
}
'

{
  "resourceType": "OperationOutcome",
  "issue": [
    {
      "severity": "information",
      "code": "informational",
      "details": {
        "text": "All OK"
      }
    }
  ]
}

Overview

API Authentication

Eligibility

Enrollments

Claims

Webhooks

AI Phone Calls

Authorizations

Query Parameters

Body

Response