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API reference
Redox Data Models
Claim
SubmissionBatch

Claim

This data model facilitates transactions between providers and payers. We support submitting claims and sending payment notifications in batches.

Typically, the claims workflow kicks off with providers grouping (i.e., batching) and sending claims to payers with details about services rendered to a patient and a request for payment. After processing the claims, payers send batched payment notifications to the provider with a status of whether the payment request was accepted or denied. In some cases, the status may indicate that a third party transferred funds to the provider.

This data model has event types that allow you to:

  • submit a batch of claims; or
  • sent a batch of payment notifications.

SubmissionBatch

Send a batch of claims to a payer.

A batch message contains multiple claims with payment requests for multiple patient services.

Dev preview

Request Body Schema

  • Meta
    required, object
    • DataModel
      required, string
      Reliable

      Claim

    • EventType
      required, string
      Reliable

      SubmissionBatch

    • EventDateTime
      string, null
      Reliable

      Displays the UTC date and time that an outgoing request is delivered or an incoming request is received.
      ISO 8601 Format

    • Test
      boolean, null
      Reliable

      Indicates whether the request is a test or not.

    • Source
      object

      Contains the information for the system initiating the message, including the source ID and name.
      Included in messages from Redox

      • ID
        string, null
        Reliable

        Identifies the system initiating the message. If you have multiple OAuth API keys per environment type, this value is required. If you have only one OAuth API key per environment type, or you're using legacy API keys, this value is optional.
        UUID

      • Name
        string, null
        Reliable

        Displays the name of the system initiating the message.

    • Destinations
      Array of object

      Contains the information for the endpoint(s) receiving the request. A request must contain at least one destination, but asynchronous requests can have more than one destination. Synchronous requests like queries can only support one destination.
      Required when sending data to Redox.

      • ID
        string, null
        Reliable

        Identifies the endpoint that the request is directed to.
        UUID

      • Name
        string, null
        Reliable

        Displays the name of the endpoint that the request is directed to.

    • Logs
      Array of object

      Contains the log identifier(s) for the request.

      • ID
        string, null
        Reliable

        Identifies the request log(s) that correspond to this request. You can use this value to locate the relevant log in the Redox dashboard for support and reference.
        UUID

      • AttemptID
        string, null
        Reliable

        Identifies the request log attempt value, which is useful when retries are possible.
        UUID

    • FacilityCode
      string, null
      Possible

      Code for the facility related to the message.
      Only use this field if a health system indicates you should. The code is specific to the health system's EHR and might not be unique across health systems. In general, the facility fields within the data models (e.g. OrderingFacility) are more reliable and informative.

  • Transactions
    Array of object
    • ID
      string, null
      Reliable

      ID used by submitter to reference this Claim Submission

    • IDType
      string, null
      Reliable

      Type of ID

    • Type
      string, null
      Reliable
      Value Set

      The type of Claim Submission, Institutional or Professional

    • Submitter
      object

      Submitter of a Claim Submission

      • Identifiers
        Array of object

        List of IDs and ID Types that identify the concept

        • ID
          string, null
          Reliable

          ID for the submitter

        • IDType
          string, null
          Reliable

          The type of ID

      • Name
        string, null
        Reliable
      • Address
        object

        Address of the Submitter

        • StreetAddress
          string, null
          Probable

          Street address

        • City
          string, null
          Probable

          City

        • State
          string, null
          Probable

          State

        • ZIP
          string, null
          Probable

          ZIP

        • County
          string, null
          Possible

          County

        • Country
          string, null
          Possible
          Value Set

          Country

      • EmailAddress
        string, null
        Probable
      • PhoneNumber
        object
        • Office
          string, null
          Probable

          In E. 164 Format. (e.g. +16085551234)

        • Fax
          string, null
          Probable

          In E. 164 Format. (e.g. +16085551234)

    • Receiver
      object

      Receiver of a Claim Submission

      • Identifiers
        Array of object

        List of IDs and ID Types that identify the concept

        • ID
          string, null
          Reliable

          ID for the receiver

        • IDType
          string, null
          Reliable

          The type of ID

      • Name
        string, null
        Reliable
      • Address
        object

        Address of the Receiver

        • StreetAddress
          string, null
          Probable

          Street address

        • City
          string, null
          Probable

          City

        • State
          string, null
          Probable

          State

        • ZIP
          string, null
          Probable

          ZIP

        • County
          string, null
          Possible

          County

        • Country
          string, null
          Possible
          Value Set

          Country

      • EmailAddress
        string, null
        Probable
      • PhoneNumber
        object
        • Office
          string, null
          Probable

          In E. 164 Format. (e.g. +16085551234)

        • Fax
          string, null
          Probable

          In E. 164 Format. (e.g. +16085551234)

    • Submissions
      Array of object

      A collection of claims submissions from a provider for services provided to patients.

      • BillingProvider
        object

        Billing Provider

        • Identifiers
          Array of object

          List of IDs and ID Types that identify the concept

          • ID
            string, null
            Reliable

            ID for the business

          • IDType
            string, null
            Reliable

            The type of ID

        • Name
          string, null
          Reliable
        • Address
          object

          Address of the business

          • StreetAddress
            string, null
            Probable

            Street address

          • City
            string, null
            Probable

            City

          • State
            string, null
            Probable

            State

          • ZIP
            string, null
            Probable

            ZIP

          • County
            string, null
            Possible

            County

          • Country
            string, null
            Possible
            Value Set

            Country

        • EmailAddress
          string, null
          Probable
        • PhoneNumber
          object
          • Office
            string, null
            Probable

            In E. 164 Format. (e.g. +16085551234)

          • Fax
            string, null
            Probable

            In E. 164 Format. (e.g. +16085551234)

        • Specialty
          object
          • ID
            string, null
            Reliable

            Billing provider's specialty.
            Commonly the taxonomy ID

          • Description
            string, null
            Reliable

            Billing provider's specialty description

      • Subscribers
        Array of object

        The subscriber is the individual who is contracted with the insurance plan

        • Identifiers
          Array of object

          List of IDs and ID Types that identify the concept

          • ID
            string, null
            Reliable

            ID for the subscriber

          • IDType
            string, null
            Reliable

            The type of ID

        • Demographics
          object
          • FirstName
            string, null
            Possible

            First name of the Subscriber

          • MiddleName
            string, null
            Possible

            Middle name of the Subscriber

          • LastName
            string, null
            Possible

            Last name of the Subscriber

          • Address
            object

            Address of the Subscriber

            • StreetAddress
              string, null
              Possible

              Street address

            • City
              string, null
              Possible

              City

            • State
              string, null
              Possible

              State

            • ZIP
              string, null
              Possible

              ZIP

            • County
              string, null
              Possible

              County

            • Country
              string, null
              Possible
              Value Set

              Country

          • PhoneNumber
            object
            • Home
              string, null
              Possible

              Home phone number.
              In E. 164 Format. (e.g. +16085551234)

            • Office
              string, null
              Possible

              Office phone number.
              In E. 164 Format. (e.g. +16085551234)

            • Mobile
              string, null
              Probable

              Mobile phone number.
              In E. 164 Format. (e.g. +16085551234)

          • DOB
            string, null
            Reliable

            Subscriber's date of birth.
            In YYYY-MM-DD format

          • Sex
            string, null
            Reliable
            Value Set

            Subscriber's sex.
            One of the following: Female, Male, Unknown, Other

        • OrganizationName
          string, null
          Reliable

          If the subscriber is not a person, this will contain the organization name

        • ResponsibilityLevel
          string, null
          Reliable
          Value Set

          Payor responsibility level

        • Insurance
          object
          • Plan
            object
            • ID
              string, null
              Probable

              Identifier of insurance plan

            • IDType
              string, null
              Probable

              ID type of insurance plan

            • Name
              string, null
              Probable

              Name of insurance plan

            • Type
              string, null
              Possible

              Type of insurance plan

          • MemberNumber
            string, null
            Possible

            Patient member number

          • Company
            object
            • ID
              string, null
              Probable

              ID of insurance company (payor)

            • IDType
              string, null
              Probable

              ID type of insurance company (payor)

            • Name
              string, null
              Probable

              Name of insurance company (payor)

            • Address
              object

              Insurance company's address

              • StreetAddress
                string, null
                Probable

                Street address

              • City
                string, null
                Probable

                City

              • State
                string, null
                Probable

                State

              • ZIP
                string, null
                Probable

                ZIP

              • County
                string, null
                Possible

                County

              • Country
                string, null
                Possible
                Value Set

                Country

            • PhoneNumber
              string, null
              Probable

              Insurance companys phone number.
              In E. 164 Format (i.e. +16085551234)

          • GroupNumber
            string, null
            Probable

            Insurance policy group number

          • GroupName
            string, null
            Probable

            Insurance policy group name

          • EffectiveDate
            string, null
            Probable

            Effect date of this insurance policy.
            In YYYY-MM-DD format

          • ExpirationDate
            string, null
            Probable

            Expiration date of this insurance policy.
            In YYYY-MM-DD format

          • PolicyNumber
            string, null
            Probable

            Insurance policy number

          • Priority
            string, null
            Possible
            Value Set

            The insurance priority sequence.
            If the insurance works in conjunction with other insurance plans, this field contains priority sequence.

          • AgreementType
            string, null
            Probable
            Value Set

            Type of insurance agreement.

          • CoverageType
            string, null
            Probable
            Value Set

            Type of insurance agreement.
            Indicates who will be receiving the bill for the service.

        • Patients
          Array of object
          • Identifiers
            Array of object

            List of IDs and ID types that identify the patient

            • ID
              string, null
              Reliable

              ID for the patient

            • IDType
              string, null
              Reliable

              Type of ID.
              E.g. MRN, EPI

          • Demographics
            object
            • FirstName
              string, null
              Reliable

              Patient's first name

            • MiddleName
              string, null
              Possible

              Patient's middle name or middle initial. For patients with multiple middle names, all their middle names are included in this field.

            • LastName
              string, null
              Reliable

              Patient's last name

            • DOB
              string, null
              Reliable

              Patient's date of birth.
              In ISO 8601 format

            • SSN
              string, null
              Probable

              Patient's social security number

            • Sex
              string, null
              Reliable
              Value Set

              Patient's sex

            • Race
              string, null
              Possible
              Value Set

              Patient's race

            • IsHispanic
              boolean, null
              Possible
              Value Set

              Indicates if the patient is of hispanic origin.

            • Religion
              string, null
              Possible
              Value Set

              Patient's religious affiliation

            • MaritalStatus
              string, null
              Possible
              Value Set

              Patient's marital status

            • IsDeceased
              boolean, null
              Possible

              Indicates if the patient is deceased

            • DeathDateTime
              string, null
              Possible

              Date and Time the patient was proclaimed deceased.
              ISO 8601 Format

            • PhoneNumber
              object
              • Home
                string, null
                Probable

                Patient's home phone number.
                In E. 164 Format. (e.g. +16085551234)

              • Office
                string, null
                Probable

                Patient's office phone number.
                In E. 164 Format. (e.g. +16085551234)

              • Mobile
                string, null
                Probable

                Patient's mobile phone number.
                In E. 164 Format. (e.g. +16085551234)

            • EmailAddresses
              Array of string

              Patient's email address(es)

            • Language
              string, null
              Possible
              Value Set

              Patient's primary spoken language.
              In ISO 639-1 alpha values (e.g. 'en'). Supported Values

            • Citizenship
              Array of string

              Patient's nation(s) of citizenship.
              In ISO 3166 alpha 2 format (e.g. 'US').

            • Address
              object

              Patient's home address

              • StreetAddress
                string, null
                Probable

                Street address

              • City
                string, null
                Probable

                City

              • State
                string, null
                Probable

                State

              • ZIP
                string, null
                Probable

                ZIP

              • County
                string, null
                Possible

                County

              • Country
                string, null
                Possible
                Value Set

                Country

          • Notes
            Array of string

            Patient-level notes

          • RelationToSubscriber
            string, null
            Reliable
            Value Set

            Relation to the subscriber

          • Claims
            Array of object

            Array of claims for the given subscriber/patient.

            • SubmissionNumber
              string, null
              Reliable

              This will generally be the claim number sent on the initial claim submission.

            • Type
              string, null
              Probable
              Value Set

              Type of Claim (Institutional only).
              May be referred to as the Bill Type Frequency, Claim Frequency Code, or Bill Type

            • TotalAmount
              string, null
              Probable

              Total amount of all lines on the claim.

            • CopayAmount
              string, null
              Probable

              Amount the patient has paid or still owes.

            • IsProviderSignatureOnFile
              boolean, null
              Probable

              Whether or not the provider signature is on file for the claim.

            • IsReleaseOfInformationOnFile
              boolean, null
              Probable

              Whether or not the submitter has a signed ROI form for the patient.

            • ProviderAcceptanceCode
              string, null
              Possible

              Code indicating whether the provider accepts assignment.

            • BenefitsAssignmentCode
              boolean, null
              Probable
              Value Set

              Code indicates whether the patient has or has not assigned benefits to the provider.

            • AdditionalDates
              Array of object

              Collection of additional dates related to the claim

            • ReferenceNumbers
              Array of object

              Reference numbers associated to the claim like Prior Auth Number, Member ID, and Provider IDs

              • ID
                string, null
                Probable

                ID for the claim

              • IDType
                string, null
                Probable

                The type of ID

            • Diagnoses
              Array of object
              • Code
                string, null
                Probable

                Diagnosis code.
                First index in array indicates primary diagnosis

              • Codeset
                string, null
                Probable

                Code set used to identify the diagnosis code.
                e.x. ICD-10, ICD-9

              • Description
                string, null
                Probable

                Diagnosis name

              • Type
                string, null
                Probable

                Type of diagnosis.
                One of the following: Admitting, Working, or Final

            • CMS Diagnosis Related Group for an inpatient admission

            • Providers
              Array of object
              • ID
                string, null
                Possible

                ID of the provider.
                This ID is often required for Inpatient Visits.

              • IDType
                string, null
                Possible

                ID type of the ID for the provider

              • FirstName
                string, null
                Possible

                First name of the undefined

              • LastName
                string, null
                Possible

                Last name of the undefined

              • Credentials
                Array of string

                List of credentials for the undefined.
                e.g. MD, PhD

              • Address
                object

                Provider's address

                • StreetAddress
                  string, null
                  Possible

                  Street address

                • City
                  string, null
                  Possible

                  City

                • State
                  string, null
                  Possible

                  State

                • ZIP
                  string, null
                  Possible

                  ZIP

                • County
                  string, null
                  Possible

                  County

                • Country
                  string, null
                  Possible
                  Value Set

                  Country

              • EmailAddresses
                Array of string

                Provider's email address(es)

              • PhoneNumber
                object
                • Office
                  string, null
                  Possible

                  Provider's office phone number.
                  In E. 164 Format. (e.g. +16085551234)

              • Location
                object

                Provider's location

                • Type
                  string, null
                  Possible

                  Type of location.
                  Examples: Clinic, Department, Home, Nursing Unit, Provider's Office, Phone

                • Facility
                  string, null
                  Possible

                  Facility.
                  Example: Community Hospital

                • FacilityIdentifiers
                  Array of object

                  List of IDs specific to this facility

                  • ID
                    string, null
                    Possible

                    An ID specific to this facility

                  • IDType
                    string, null
                    Possible

                    The source or system to which this ID pertains.
                    Could be an OID or a human-readable name

                • Department
                  string, null
                  Possible

                  Department

                • DepartmentIdentifiers
                  Array of object

                  List of IDs specific to this department

                  • ID
                    string, null
                    Possible

                    An ID specific to this department

                  • IDType
                    string, null
                    Possible

                    The source or system to which this ID pertains.
                    Could be an OID or a human-readable name

                • Room
                  string, null
                  Possible

                  Room.
                  Example: 136

              • Role
                string, null
                Probable

                The role this provider has in patient care.
                E.x. Attending, Referring, Operating

              • Specialty
                object
                • ID
                  string, null
                  Probable

                  ID of specialty.
                  Commonly the taxonomy ID

                • Description
                  string, null
                  Probable

                  Description/name of specialty

            • Services
              Array of object

              Services associated with this claim

              • Code
                string, null
                Probable

                Code for the service line

              • Codeset
                string, null
                Probable

                Code set used to identify the service line

              • Description
                string, null
                Probable

                Description of the service line

              • Modifiers
                Array of string

                Array of service modifiers

              • Amount
                string, null
                Probable

                Total dollar amount for this line item

              • StartDateTime
                string, null
                Probable

                When the service conveyed began

              • EndDateTime
                string, null
                Probable

                When the service conveyed ended

              • RevenueCode
                string, null
                Probable

                Institutional only.

              • Quantity
                object
                • Value
                  string, null
                  Probable

                  Service line quantity.

                • Units
                  string, null
                  Probable

                  Associated units to the quantity

              • IsEmergency
                boolean, null
                Probable

                Whether or not this service was performed in an emergency setting.

              • ReferenceNumbers
                Array of object

                Reference numbers associated to the claim service line

                • ID
                  string, null
                  Probable

                  ID for the service line

                • IDType
                  string, null
                  Probable

                  The type of ID

              • Diagnoses
                Array of object
                • Code
                  string, null
                  Probable

                  Diagnosis code.
                  First index in array indicates primary diagnosis associated with this service line item.

                • Codeset
                  string, null
                  Probable

                  Code set used to identify the diagnosis code.
                  e.x. ICD-10, ICD-9

                • Description
                  string, null
                  Probable

                  Diagnosis name

                • Type
                  string, null
                  Probable

                  Type of diagnosis.
                  One of the following: Admitting, Working, or Final

              • Drug
                object

                Drug information related to the service of an institutional claim

                • PrescriptionID
                  string, null
                  Probable

                  Pharmacy Prescription ID associated to the the drug

                • NDC
                  string, null
                  Probable

                  NDC ID

                • Quantity
                  object
                  • Value
                    string, null
                    Probable

                    Drug Quantity

                  • Units
                    string, null
                    Probable

                    Associated Units to the quantity

              • Notes
                string, null
                Probable

                Additional notes for this line

            • Visit
              object
              • DateTime
                string, null
                Probable

                DateTime of admission.
                ISO 8601 Format

              • DischargeDateTime
                string, null
                Probable

                DateTime of discharge.
                ISO 8601 Format

              • Location
                object
                • Type
                  string, null
                  Probable

                  Type of location.
                  Examples: Clinic, Department, Home, Nursing Unit, Provider's Office, Phone

                • Facility
                  string, null
                  Probable

                  Facility.
                  Example: Community Hospital

                • FacilityIdentifiers
                  Array of object

                  List of IDs specific to this facility

                  • ID
                    string, null
                    Probable

                    An ID specific to this facility

                  • IDType
                    string, null
                    Probable

                    The source or system to which this ID pertains.
                    Could be an OID or a human-readable name

                • Department
                  string, null
                  Probable

                  Department

                • DepartmentIdentifiers
                  Array of object

                  List of IDs specific to this department

                  • ID
                    string, null
                    Probable

                    An ID specific to this department

                  • IDType
                    string, null
                    Probable

                    The source or system to which this ID pertains.
                    Could be an OID or a human-readable name

                • Room
                  string, null
                  Probable

                  Room.
                  Example: 136

              • PreviousLocation
                object
                • Type
                  string, null
                  Probable

                  Type of location.
                  Examples: Clinic, Department, Home, Nursing Unit, Provider's Office, Phone

                • Facility
                  string, null
                  Probable

                  Facility.
                  Example: Community Hospital

                • FacilityIdentifiers
                  Array of object

                  List of IDs specific to this facility

                  • ID
                    string, null
                    Probable

                    An ID specific to this facility

                  • IDType
                    string, null
                    Probable

                    The source or system to which this ID pertains.
                    Could be an OID or a human-readable name

                • Department
                  string, null
                  Probable

                  Department

                • DepartmentIdentifiers
                  Array of object

                  List of IDs specific to this department

                  • ID
                    string, null
                    Probable

                    An ID specific to this department

                  • IDType
                    string, null
                    Probable

                    The source or system to which this ID pertains.
                    Could be an OID or a human-readable name

                • Room
                  string, null
                  Probable

                  Room.
                  Example: 136

              • Type
                string, null
                Probable

                Type of inpatient admission.
                Only populated for inpatient admissions. E.x. Elective, Emergency

              • VisitNumber
                string, null
                Possible

                Visit Number.
                Unique ID of a single visit

Example
json
1
{
2
  "Meta": {
3
    "DataModel": "Claim",
4
    "EventType": "SubmissionBatch",
5
    "EventDateTime": "2024-11-20T14:08:29.777Z",
6
    "Test": true,
7
    "Source": {
8
      "ID": "7ce6f387-c33c-417d-8682-81e83628cbd9",
9
      "Name": "Redox Dev Tools"
10
    },
11
    "Destinations": [
12
      {
13
        "ID": "af394f14-b34a-464f-8d24-895f370af4c9",
14
        "Name": "Redox EMR"
15
      }
16
    ],
17
    "Logs": [
18
      {
19
        "ID": "d9f5d293-7110-461e-a875-3beb089e79f3",
20
        "AttemptID": "925d1617-2fe0-468c-a14c-f8c04b572c54"
21
      }
22
    ],
23
    "FacilityCode": null
24
  },
25
  "Transactions": [
26
    {
27
      "ID": "000000001",
28
      "IDType": null,
29
      "Type": "Institutional",
30
      "Submitter": {
31
        "Identifiers": [
32
          {
33
            "ID": "8675309",
34
            "IDType": "TIN"
35
          }
36
        ],
37
        "Name": "Redox Health System",
38
        "Address": {
39
          "StreetAddress": null,
40
          "City": null,
41
          "State": null,
42
          "ZIP": null,
43
          "County": null,
44
          "Country": null
45
        },
46
        "EmailAddress": null,
47
        "PhoneNumber": {
48
          "Office": null,
49
          "Fax": null
50
        }
51
      },
52
      "Receiver": {
53
        "Identifiers": [
54
          {
55
            "ID": "123456",
56
            "IDType": "TIN"
57
          }
58
        ],
59
        "Name": "National Insurance Company of Redox",
60
        "Address": {
61
          "StreetAddress": null,
62
          "City": null,
63
          "State": null,
64
          "ZIP": null,
65
          "County": null,
66
          "Country": null
67
        },
68
        "EmailAddress": null,
69
        "PhoneNumber": {
70
          "Office": null,
71
          "Fax": null
72
        }
73
      },
74
      "Submissions": [
75
        {
76
          "BillingProvider": {
77
            "Identifiers": [],
78
            "Name": null,
79
            "Address": {
80
              "StreetAddress": null,
81
              "City": null,
82
              "State": null,
83
              "ZIP": null,
84
              "County": null,
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