Vet an insurance claim
curl --request POST \
--url https://api.clinikehr.com/v1/clinics/{clinic_id}/insurance/claims/{claim_id}/adjudication \
--header 'Authorization: Bearer <token>' \
--header 'Content-Type: application/json' \
--header 'Idempotency-Key: <idempotency-key>' \
--data '
{
"reason": "<string>",
"pa_code": "<string>",
"items": [
{
"item_id": "3c90c3cc-0d44-4b50-8888-8dd25736052a",
"qty_approved": 1,
"unit_price_approved": 1,
"reason": "<string>",
"comment": "<string>"
}
]
}
'const options = {
method: 'POST',
headers: {
'Idempotency-Key': '<idempotency-key>',
Authorization: 'Bearer <token>',
'Content-Type': 'application/json'
},
body: JSON.stringify({
reason: '<string>',
pa_code: '<string>',
items: [
{
item_id: '3c90c3cc-0d44-4b50-8888-8dd25736052a',
qty_approved: 1,
unit_price_approved: 1,
reason: '<string>',
comment: '<string>'
}
]
})
};
fetch('https://api.clinikehr.com/v1/clinics/{clinic_id}/insurance/claims/{claim_id}/adjudication', options)
.then(res => res.json())
.then(res => console.log(res))
.catch(err => console.error(err));import requests
url = "https://api.clinikehr.com/v1/clinics/{clinic_id}/insurance/claims/{claim_id}/adjudication"
payload = {
"reason": "<string>",
"pa_code": "<string>",
"items": [
{
"item_id": "3c90c3cc-0d44-4b50-8888-8dd25736052a",
"qty_approved": 1,
"unit_price_approved": 1,
"reason": "<string>",
"comment": "<string>"
}
]
}
headers = {
"Idempotency-Key": "<idempotency-key>",
"Authorization": "Bearer <token>",
"Content-Type": "application/json"
}
response = requests.post(url, json=payload, headers=headers)
print(response.text){
"data": {
"id": "3c90c3cc-0d44-4b50-8888-8dd25736052a",
"claim_number": "<string>",
"insurance_company_id": "3c90c3cc-0d44-4b50-8888-8dd25736052a",
"status": "<string>",
"insurance_plan_id": "3c90c3cc-0d44-4b50-8888-8dd25736052a",
"enrollee_id": "3c90c3cc-0d44-4b50-8888-8dd25736052a",
"patient_id": "3c90c3cc-0d44-4b50-8888-8dd25736052a",
"encounter_id": "3c90c3cc-0d44-4b50-8888-8dd25736052a",
"pre_auth_ids": [
"3c90c3cc-0d44-4b50-8888-8dd25736052a"
],
"pa_code": "<string>",
"claim_type": "outpatient",
"hmo_status": "PENDING",
"currency": "<string>",
"amount_billed": 123,
"amount_approved": 123,
"paid_amount": 123,
"written_off_amount": 123,
"patient_responsibility": 123,
"service_date_from": "2023-11-07T05:31:56Z",
"service_date_to": "2023-11-07T05:31:56Z",
"admission_date": "2023-11-07T05:31:56Z",
"discharge_date": "2023-11-07T05:31:56Z",
"is_floating": true,
"submitted_at": "2023-11-07T05:31:56Z",
"vetted_at": "2023-11-07T05:31:56Z",
"approved_at": "2023-11-07T05:31:56Z",
"paid_at": "2023-11-07T05:31:56Z",
"denial_reason": "<string>",
"denial_code": "<string>",
"created_at": "2023-11-07T05:31:56Z",
"updated_at": "2023-11-07T05:31:56Z",
"items": [
{
"id": "3c90c3cc-0d44-4b50-8888-8dd25736052a",
"item_type": "<string>",
"description": "<string>",
"tariff_code": "<string>",
"service_date": "2023-11-07T05:31:56Z",
"qty_billed": 123,
"unit_price_billed": 123,
"sub_total_billed": 123,
"qty_approved": 123,
"unit_price_approved": 123,
"sub_total_approved": 123,
"hmo_item_status": "PENDING",
"denial_reason": "<string>",
"comments": [
"<string>"
],
"benefit_label": "<string>"
}
],
"diagnoses": [
{
"icd_code": "<string>",
"name": "<string>",
"is_primary": true
}
],
"documents": [
{
"id": "3c90c3cc-0d44-4b50-8888-8dd25736052a",
"document_type": "<string>",
"file_name": "<string>",
"mime_type": "<string>",
"file_size": 123,
"document_date": "2023-11-07T05:31:56Z",
"description": "<string>"
}
]
},
"idempotent_replay": true
}{
"type": "<string>",
"title": "<string>",
"status": 123,
"code": "<string>",
"request_id": "<string>",
"detail": "<string>",
"errors": [
{
"pointer": "<string>",
"message": "<string>"
}
]
}{
"type": "<string>",
"title": "<string>",
"status": 123,
"code": "<string>",
"request_id": "<string>",
"detail": "<string>",
"errors": [
{
"pointer": "<string>",
"message": "<string>"
}
]
}{
"type": "<string>",
"title": "<string>",
"status": 123,
"code": "<string>",
"request_id": "<string>",
"detail": "<string>",
"errors": [
{
"pointer": "<string>",
"message": "<string>"
}
]
}{
"type": "<string>",
"title": "<string>",
"status": 123,
"code": "<string>",
"request_id": "<string>",
"detail": "<string>",
"errors": [
{
"pointer": "<string>",
"message": "<string>"
}
]
}{
"type": "<string>",
"title": "<string>",
"status": 123,
"code": "<string>",
"request_id": "<string>",
"detail": "<string>",
"errors": [
{
"pointer": "<string>",
"message": "<string>"
}
]
}{
"type": "<string>",
"title": "<string>",
"status": 123,
"code": "<string>",
"request_id": "<string>",
"detail": "<string>",
"errors": [
{
"pointer": "<string>",
"message": "<string>"
}
]
}HMO insurance
Vet an insurance claim
Permission: insurance.claims:adjudicate
Vet a claim.
Approve, adjust or decline lines of a claim of the insurer the clinic linked to your organization. See the request body for how decision and items combine. Answers 200 with the claim. It never moves money: a claim the clinic has already recorded a payment or write-off against answers 409 invalid_status_transition. A clinic-owned key and an organization with no insurer link are refused (hmo_not_linked). The Idempotency-Key header is REQUIRED.
POST
/
v1
/
clinics
/
{clinic_id}
/
insurance
/
claims
/
{claim_id}
/
adjudication
Vet an insurance claim
curl --request POST \
--url https://api.clinikehr.com/v1/clinics/{clinic_id}/insurance/claims/{claim_id}/adjudication \
--header 'Authorization: Bearer <token>' \
--header 'Content-Type: application/json' \
--header 'Idempotency-Key: <idempotency-key>' \
--data '
{
"reason": "<string>",
"pa_code": "<string>",
"items": [
{
"item_id": "3c90c3cc-0d44-4b50-8888-8dd25736052a",
"qty_approved": 1,
"unit_price_approved": 1,
"reason": "<string>",
"comment": "<string>"
}
]
}
'const options = {
method: 'POST',
headers: {
'Idempotency-Key': '<idempotency-key>',
Authorization: 'Bearer <token>',
'Content-Type': 'application/json'
},
body: JSON.stringify({
reason: '<string>',
pa_code: '<string>',
items: [
{
item_id: '3c90c3cc-0d44-4b50-8888-8dd25736052a',
qty_approved: 1,
unit_price_approved: 1,
reason: '<string>',
comment: '<string>'
}
]
})
};
fetch('https://api.clinikehr.com/v1/clinics/{clinic_id}/insurance/claims/{claim_id}/adjudication', options)
.then(res => res.json())
.then(res => console.log(res))
.catch(err => console.error(err));import requests
url = "https://api.clinikehr.com/v1/clinics/{clinic_id}/insurance/claims/{claim_id}/adjudication"
payload = {
"reason": "<string>",
"pa_code": "<string>",
"items": [
{
"item_id": "3c90c3cc-0d44-4b50-8888-8dd25736052a",
"qty_approved": 1,
"unit_price_approved": 1,
"reason": "<string>",
"comment": "<string>"
}
]
}
headers = {
"Idempotency-Key": "<idempotency-key>",
"Authorization": "Bearer <token>",
"Content-Type": "application/json"
}
response = requests.post(url, json=payload, headers=headers)
print(response.text){
"data": {
"id": "3c90c3cc-0d44-4b50-8888-8dd25736052a",
"claim_number": "<string>",
"insurance_company_id": "3c90c3cc-0d44-4b50-8888-8dd25736052a",
"status": "<string>",
"insurance_plan_id": "3c90c3cc-0d44-4b50-8888-8dd25736052a",
"enrollee_id": "3c90c3cc-0d44-4b50-8888-8dd25736052a",
"patient_id": "3c90c3cc-0d44-4b50-8888-8dd25736052a",
"encounter_id": "3c90c3cc-0d44-4b50-8888-8dd25736052a",
"pre_auth_ids": [
"3c90c3cc-0d44-4b50-8888-8dd25736052a"
],
"pa_code": "<string>",
"claim_type": "outpatient",
"hmo_status": "PENDING",
"currency": "<string>",
"amount_billed": 123,
"amount_approved": 123,
"paid_amount": 123,
"written_off_amount": 123,
"patient_responsibility": 123,
"service_date_from": "2023-11-07T05:31:56Z",
"service_date_to": "2023-11-07T05:31:56Z",
"admission_date": "2023-11-07T05:31:56Z",
"discharge_date": "2023-11-07T05:31:56Z",
"is_floating": true,
"submitted_at": "2023-11-07T05:31:56Z",
"vetted_at": "2023-11-07T05:31:56Z",
"approved_at": "2023-11-07T05:31:56Z",
"paid_at": "2023-11-07T05:31:56Z",
"denial_reason": "<string>",
"denial_code": "<string>",
"created_at": "2023-11-07T05:31:56Z",
"updated_at": "2023-11-07T05:31:56Z",
"items": [
{
"id": "3c90c3cc-0d44-4b50-8888-8dd25736052a",
"item_type": "<string>",
"description": "<string>",
"tariff_code": "<string>",
"service_date": "2023-11-07T05:31:56Z",
"qty_billed": 123,
"unit_price_billed": 123,
"sub_total_billed": 123,
"qty_approved": 123,
"unit_price_approved": 123,
"sub_total_approved": 123,
"hmo_item_status": "PENDING",
"denial_reason": "<string>",
"comments": [
"<string>"
],
"benefit_label": "<string>"
}
],
"diagnoses": [
{
"icd_code": "<string>",
"name": "<string>",
"is_primary": true
}
],
"documents": [
{
"id": "3c90c3cc-0d44-4b50-8888-8dd25736052a",
"document_type": "<string>",
"file_name": "<string>",
"mime_type": "<string>",
"file_size": 123,
"document_date": "2023-11-07T05:31:56Z",
"description": "<string>"
}
]
},
"idempotent_replay": true
}{
"type": "<string>",
"title": "<string>",
"status": 123,
"code": "<string>",
"request_id": "<string>",
"detail": "<string>",
"errors": [
{
"pointer": "<string>",
"message": "<string>"
}
]
}{
"type": "<string>",
"title": "<string>",
"status": 123,
"code": "<string>",
"request_id": "<string>",
"detail": "<string>",
"errors": [
{
"pointer": "<string>",
"message": "<string>"
}
]
}{
"type": "<string>",
"title": "<string>",
"status": 123,
"code": "<string>",
"request_id": "<string>",
"detail": "<string>",
"errors": [
{
"pointer": "<string>",
"message": "<string>"
}
]
}{
"type": "<string>",
"title": "<string>",
"status": 123,
"code": "<string>",
"request_id": "<string>",
"detail": "<string>",
"errors": [
{
"pointer": "<string>",
"message": "<string>"
}
]
}{
"type": "<string>",
"title": "<string>",
"status": 123,
"code": "<string>",
"request_id": "<string>",
"detail": "<string>",
"errors": [
{
"pointer": "<string>",
"message": "<string>"
}
]
}{
"type": "<string>",
"title": "<string>",
"status": 123,
"code": "<string>",
"request_id": "<string>",
"detail": "<string>",
"errors": [
{
"pointer": "<string>",
"message": "<string>"
}
]
}Authorizations
Bearer authentication header of the form Bearer <token>, where <token> is your auth token.
Headers
A unique value you choose for this request, such as a UUID. Sending the same key again returns the first answer instead of doing the work twice, so a timed-out request is safe to retry. Reusing a key for a different request is refused with 409 idempotency_key_conflict, and retrying while the first request is still running with 409 idempotency_key_reused. See Retries and idempotency.
Minimum string length:
1Body
application/json
Vet a claim. decision sets what EVERY line gets (approved at billed figures, or rejected at zero); items overrides individual lines, so "approve everything except this line" is decision: approved plus one declined line. The claim's status follows the lines: all approved as billed - approved; all declined - denied; anything else - partially_approved. A rejection needs a reason. You can never approve more than was billed, and a claim the clinic has already recorded money against can no longer be vetted. Nothing here moves money.
Response
OK.
A claim the clinic submitted to an insurer. status is the clinic-side lifecycle (submitted, approved, partially_approved, denied, partially_paid, paid, ...); hmo_status is the insurer's verdict (PENDING, APPROVED, PARTIALLY_APPROVED, REJECTED). paid_amount and written_off_amount are what the CLINIC has recorded - no API call changes them. items, diagnoses and documents are on the single-claim read only. The clinic's notes and internal analysis are never exposed.
Show child attributes
Show child attributes
Present and true when this Idempotency-Key was already used and the original answer is returned.