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Setup

To enable Optimizer output or EDI delivery through webhooks, you will need to navigate to your admin panel, and setup webhooks with a credentials set. You must have a webhook registered for each event you want to receive. You will receive the following responses for the claim optimization APIs:

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Output

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X12 Claim Denials

The output of the Optimizer X12 Denials API will be a body like so:

{
    "claim_id": "123456789",
    "patient_control_number": "PCN12345",
    "edits": [
                {
                  "difference": "The uploaded claim's total charge amount is $536.53, while the AI-generated claim's total charge amount is $311.00.",
                  "rationale": "The AI removed the denied procedure code T1015 from the claim, resulting in a lower total charge amount. The original claim was denied for several reasons, including the inclusion of procedure code T1015, which was deemed not medically necessary and ineligible for the patient's plan."
                },
                {
                  "difference": "The uploaded claim contains two service lines, while the AI-generated claim contains one.",
                  "rationale": "The AI removed the service line for procedure code T1015, as it was denied in the original claim. The 835 denial reason indicated that the code was not medically necessary and the patient was not eligible for the service."
                },
                {
                  "difference": "The uploaded claim's transaction set trailer segment (SE) count is 38, while the AI-generated claim's count is 30.",
                  "rationale": "The AI-generated claim removed eight segments corresponding to the denied procedure code T1015, resulting in a lower segment count in the SE segment."
                },
                {
                  "difference": "The uploaded claim reports the patient's gender as \"M\" (male) in the DMG segment, while the Cair Health Claims Optimizer AI's Claim reports the patient's gender as \"F\" (female).",
                  "rationale": "The encounter details specify that Amanda Smith is a female patient. The Cair Health Claims Optimizer AI correctly identifies and uses the appropriate gender code based on the provided information."
                }
              ],
    "ai_generated_claim": "**Patient:** Amanda Smith, **Date of Birth**: ...",
    "ai_generated_encounter_summary": Amanda Smith is a 45 year-old female patient of Victoria Green. On November 15, 2024, Ms. Taylor underwent a ..."
}
FieldDescription
claim_idA unique identifier for the claim.
patient_control_numberThe control number assigned to the patient.
editsA list of differences identified by the AI between the uploaded claim and the AI-generated claim. Each difference includes:
- difference: A description of the specific discrepancy found in the claim.
- rationale: The reasoning provided by the Cair AI for the identified discrepancy.
ai_generated_claimThe claim generated by the Cair Health Claims Optimizer AI, including corrected or updated information.
ai_generated_encounter_summaryA natural language summary of the patient’s encounter, providing context and details about the patient’s visit and treatment.

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Draft Claim From Notes PDF

The output for the Draft Claim From Notes API will look similar the above, but slightly different. Notably the inclusion of the ai_generated_x12_837 field with the submission-ready 837.

{
    {
        "claim_id": "987654321",
        "patient_control_number": "PCN67890",
        "ai_generated_x12_837": "ISA*00*..."
        "ai_generated_encounter_summary": "John Doe is a 30 year-old male patient of Dr. Emily Carter. On December 10, 2024, Mr. Doe was diagnosed with acute bronchitis and prescribed antibiotics."
    }
}
FieldDescription
claim_idA unique identifier for the claim.
patient_control_numberThe control number assigned to the patient.
ai_generated_x12_837The X12 837 formatted claim generated by the Cair Health Claims Optimizer AI.
ai_generated_encounter_summaryA natural language summary of the patient’s encounter, providing context and details about the patient’s visit and treatment.