Submit manual claims

https://api.wealthcare.com/participant/services/participant/claims/{tpaId}/{employerId}/{participantId}

Submit one or more manual claims.

Path parameters

tpaId string Required

A unique identifier used to identify your admin instance. This value was system generated with the admin instance was created.
employerId string Required

Unique identifier for the employer. Note: When the employer was created, WealthCare Admin assigned the 3-character prefix; you assigned the remaining characters.
participantId string Required

Participant Id

Query parameters

decrypt integer <int32>

Indicate if the URI parameters are encrypted or not. 1: encrypted, 0: decrypted, default to 0.
org integer <int32>

Code used to indicate the origin of the claim 0: regular claims from mobile apps, 4: regular claims from member portal

Request body

Claims array <object>

A list of Submit Manual Claim With Receipt
- EventName string
  
  Event's name
- IsESignatureClaim boolean
  
  Is ESignature Claim (1 (true), 0 (false))
- TpaId string
  
  A unique identifier used to identify your admin instance. This value was system generated with the admin instance was created.
- EmployerId string
  
  Unique identifier for the employer. Note: When the employer was created, WealthCare Admin assigned the 3-character prefix; you assigned the remaining characters.
- ServiceStartDate string <date-time>
  
  Service Start Date for the claim
- ServiceEndDate string <date-time>
  
  Service End Date for the claim
- Claimant object
  - TpaId string
    
    A unique identifier used to identify your admin instance. This value was system generated with the admin instance was created.
  - EmprId string
    
    Unique identifier for the employer. Note: When the employer was created, WealthCare Admin assigned the 3-character prefix; you assigned the remaining characters.
  - CardholderKey integer <int32>
    
    A system generated key used to indicate the specific employee or dependent.
  - LastName string
    
    The last name of the claimant.
  - FirstName string
    
    The first name of the claimant.
  - SocSecNum string
    
    Depending on the CardholderTypeCde, this will be the employee ID or the dependent ID (this is not necessarily an actual SSN unless you use SSNs for your employee IDs).
  - NamePrefix string
    
    The prefix for the claimant's name. Valid values are Mr., Mrs., Ms., Dr., and Rev.
  - Initial string
    
    The middle initial of the claimant
  - CardholderTypeCde integer <int32>
    
    Cardholder Type Cde: Employee = 1, Dependent = 2
  - CardNum string
    
    Card Proxy Number
- AcctTypeCde string
  
  The account type code for the benefit account the claim is processed under.
- AccountKey integer <int32>
  
  A system generated ID for the benefit account the claim is processed under (also referred to as flex account key).
- TxnAmt number <double>
  
  The claim's transaction amount
- FlexAcctKey integer <int32>
  
  A system generated ID for the benefit account the claim is processed under. Same value as AccountKey
- ProviderId string
  
  Provider Id on th claim
- ProviderDesc string
  
  Provider Description on the claim
- TrackingNum string
  
  Number you assign to track claims. Note: WCA does not use this number.
- ClaimDesc string
  
  Description of service
- ReimbModeCde integer
  
  The method used to reimburse the employee or dependent for this transaction: 0 - None (default), 1 - Check, 2 - Direct deposit, 3 - External check, 4 - External direct deposit, 5 - Card, 6 - Payroll. Note: If reimbursement method is 2 (direct deposit) and the direct deposit account has not yet been validated, the reimbursement defaults to check as a one-time override (if check reimbursement is available). If check reimbursement is not available, the claim is denied.
- ScCde string
  
  The Service Category Code that the claim should be processed with. The Service Category Code must match to an SCC setup for the Employer Plan in which the employee is enrolled or the claim will be denied. This should not be sent if AccountTypeCde is used.
- Notes string
  
  Claim notes
- FileKey integer <int32>
  
  This is a value to be generated by the system when the file is uploaded into WCA. Send 0 on the Upload Manual Claim Receipt request.
- Receipt object
  - FileKey integer <int32>
    
    This is a value to be generated by the system when the file is uploaded into WCA. Send 0 on the Upload Manual Claim Receipt request.
  - FileFormat integer <int32>
    
    Refers to format of receipt file uploaded: Unknown = 0, Fixed = 1, CSV = 2, XML = 4, PDF = 8, QIF = 16, Excel = 32, JPEG/JPG = 64, GIF = 128, BMP =256, FixedNacha = 512, Delimited = 1024, Word = 2048, PNG = 4096, TIFF = 8192, ExtFileFormat = 16384
  - ContentLength integer <int32>
    
    The file length, in bytes.
  - ContentType string
    
    The MIME content type of the uploaded file.
  - FileName string
    
    The name of the receipt file, including the directory path.
  - InputStream string <byte>
    
    A byte array representing the contents of the file for the reciept.
  - Base64 string
    
    The string representation in Base 64 of the file content. You will need to decode this to display the image.
- PayProviderKey integer <int32>
  
  This is a system generated key used to identify a specific pay provider. If this is a pay provider claim, the pay provider must be added to (or already exist) in the system prior to claim submission. The PayProviderKey is returned on the "Save a provider" and "Return the list of provider based on the search criteria" API requests.
- PatientIdNum string
  
  The provider's patient account number
- ExpenseKey integer <int64>
  
  Expense Key
- ClaimId string
  
  A system generated key used to uniquely identify the claim. This should be empty on the request.
- BenefitMaxMetAmount number <double>
  
  Amount that would otherwise be covered but has been denied by the carrier due to a benefit maximum being met.
- RbbExcessAmount number <double>
  
  If provided, this amount will be used as the participant's Excess Amount responsibility
- NotCoveredAmount number <double>
  
  Amount denied as not covered by the insurance plan; typically, this amount will match the Billed Amount.
- AboveRcAmount number <double>
  
  The amount above the usual and customary rate.
- DeductibleAmount number <double>
  
  If provided, this amount will be used as the participant's deductible responsibility
- CoinsuranceAmount number <double>
  
  If provided, this amount will be used as the participant's Coinsurance responsibility
- CoPayAmount number <double>
  
  If provided, this amount will be used as the participant's Copay responsibility
- ExternalClaimNumber string
  
  The external claim number is used to process claim reversals when using EDI. If a manual claim is received with an external claim number that matches another manual claim with the same external claim number, WCA will process a claim reversal. The reversal will either credit back the benefit account, or add to the balance due, depending upon if the original manual claim has been reimbursed in WCA. Note: Using external claim number to generate claim reversals will only work if the administrator is linked to the “auto claim reversal creation” feature on the admin options page within WCA.
- ClaimReceivedDate string <date-time>
  
  The date the claim was received by the carrier (not the date the claim is adjudicated)
- RecurrenceFrequency integer
  
  Recurrence Frequency: None = 0, Daily = 1, Weekly = 2, BiMonthly = 4, Monthly = 8, Quarterly = 16, Yearly = 32, SemiMonthly = 64, BiWeekly = 128, Once = 256
- RecurrenceStartDte string <date-time>
  
  If this is a recurring claim, this is the start date for the first recurrence of the claim. Required if Recurrence value is not set to 0 = None. Start Date must be greater than or equal to today's date and cannot be more than 18 months in the future
- RecurrenceEndDte string <date-time>
  
  If this is a recurring claim, this is the end date for the recurrence. If specified, no claims will be created after this date. End Date must be greater than or equal to today's date and cannot be more than 18 months after the Start Date.
- TotalNoOfPayments integer <int32>
  
  If this is a recurring claim, this is the number of Payments to be made. For Weekly Recurring Frequency, Total Number of Payments cannot be more than 75. For Monthly Recurring Frequency, Total Number of Payments cannot be more than 18.
- ScTierKey integer <int32>
  
  The Service Category Tier that the claim should be processed with. The Service Category Tier must be setup within the Service Category for this field to successfully process. Must match a Service Category tier setup in the WealthCare Administration system for a claim to be successfully processed. This should not be sent if AccountTypeCde is used.
SingleReceipt boolean

Single receipt allows submitting multiple claims with the same receipt. Set to true to allow a single receipt to be used on multiple claims. To upload multiple claims with individual receipts, set SingleReceipt to false.

Response

array <object>
- EventName string
  
  Event's name
- IsESignatureClaim boolean
  
  Is ESignature Claim (1 (true), 0 (false))
- TpaId string
  
  A unique identifier used to identify your admin instance. This value was system generated with the admin instance was created.
- EmployerId string
  
  Unique identifier for the employer. Note: When the employer was created, WealthCare Admin assigned the 3-character prefix; you assigned the remaining characters.
- TransactionDate string <date-time>
  
  Transaction Date
- ServiceStartDate string <date-time>
  
  Service Start Date
- ServiceEndDate string <date-time>
  
  Service End Date
- Type string
  
  Type
- Claimant object
  - TpaId string
    
    A unique identifier used to identify your admin instance. This value was system generated with the admin instance was created.
  - EmprId string
    
    Unique identifier for the employer. Note: When the employer was created, WealthCare Admin assigned the 3-character prefix; you assigned the remaining characters.
  - CardholderKey integer <int32>
    
    A system generated key used to indicate the specific employee or dependent.
  - LastName string
    
    The last name of the claimant.
  - FirstName string
    
    The first name of the claimant.
  - SocSecNum string
    
    Depending on the CardholderTypeCde, this will be the employee ID or the dependent ID (this is not necessarily an actual SSN unless you use SSNs for your employee IDs).
  - NamePrefix string
    
    The prefix for the claimant's name. Valid values are Mr., Mrs., Ms., Dr., and Rev.
  - Initial string
    
    The middle initial of the claimant
  - CardholderTypeCde integer <int32>
    
    Cardholder Type Cde: Employee = 1, Dependent = 2
  - CardNum string
    
    Card Proxy Number
- AcctTypeCde string
  
  Account Type Code
- AcctTypeDesc string
  
  Account Type Description
- AccountKey integer <int32>
  
  Account Key
- PlanStartDate string <date-time>
  
  Plan Start Date
- PlanEndDate string <date-time>
  
  Plan End Date
- Status string
  
  Status
- TxnAmt number <double>
  
  Transaction Amount
- FlexAcctKey integer <int32>
  
  Flex Account Key
- TxnAmtOrig number <double>
  
  Original Transaction Amount
- TxnAmtDenied number <double>
  
  Transaction Amount Denied
- TxnAmtPending number <double>
  
  Transaction Amount Pending
- TxnCde integer <int32>
  
  Transaction Code
- TxnMsg string
  
  Transaction Message
- TxnAmtRefund number <double>
  
  Transaction Amount Refund
- TxnOriginCde enum<string>
  
  Transaction Origin Code
  
  Possible values: None POSCardSwipe POSKeyedIn POSPhonedIn POSMbiSubmitted ManualScreen ManualEFT ManualAgent ParticipantManualScreen ParticipantMobileScreen HZDirect eClaimManagerManual eClaimManagerTPS WebServiceClaim
- TxnOptions enum<string>
  
  Transaction Options
  
  Possible values: None IncludeNoteInReceiptNotificationLetter ResolveRefund IncludeNoteInDenialLetter GenerateDenialLetter IsDuplicate DenialLetterReportKeyGenerated WasChargedBack IsAChargeback ChargebackWasReversed IsAChargebackReversal EligibleForPOSOffset ManualClaimFullyOffset ManualClaimPartiallyOffset ReimbLetterGenerated ReissueCheckPending PartialAuthInd PartialAuthorized HideOrigOnHoldTxn CheckVoided IiasMerchant CheckReissued TxnReissued OverrideSuspendActivity OnHoldFlg DenialOverride ReduceForBalanceMax BypassDeductibleRule PrimaryRolloverTxn FixedEmprFundingDeposit SplitTxn ByPassPercentCoverage EnforceParticipantEligibility EnforceAccountEligibility ManualClaimFullyDeductible PendingVerify CrossOverClaim SkipDuplicateClaimCheck PayProvider PendingLetter2 Reprocessed PendedWorkflow NachaGenearated CurrentReprocessed EmployerEnteredDeposits PayrollFundingDeposit FutureDeposited PendingDepositProcessed TxnWasReimbursed PendingExternalDepositVoid PriorYearContribution OverpaymentPartiallyResolved OverpaymentResolved CopayFirstApplied HideFromReports AutoDepositAgentDeposit ExcludeFromEmployerFunding PayrollNacha ForceExternalNacha OriginatedFromTPSEntry OriginatedFromEClaims CardProcessed SCTierAmountFeatureEnabled EmailSentForPayrollFunding
- BalanceDue number <double>
  
  Balance Due
- CardHolderDisplay boolean
  
  CardHolder Display (1 (true), 0 (false))
- ProviderId string
  
  Provider Id
- ProviderDesc string
  
  Provider Description
- FileKey integer <int32>
  
  File Key
- HasReceipt boolean
  
  Has Receipt (1 (true), 0 (false))
- ReceiptExpired boolean
  
  Receipt Expired (1 (true), 0 (false))
- ReceiptsInfo array <object>
  
  Receipts Info
  - TpaId string
    
    A unique identifier used to identify your admin instance. This value was system generated with the admin instance was created.
  - FileKey integer <int32>
    
    A system generated ID used to identify the receipt file.
  - DocId string
    
    A system generated ID created when a file is submitted through a document queue instead of by a participant.
  - DocDisplayName string
    
    Document Display Name
  - OriginalFileName string
    
    Original File Name
  - UploadDate string <date-time>
    
    The date the receipt file was uploaded.
- DisplayableFields array <object>
  
  Displayable Fields
  - OriginalFieldName string
    
    Displays Orignal Filed Name.
  - AlternativeFieldName string
    
    Displays Alternative Field Name.
  - DisplayOptions enum<string>
    
    Field Display Options - NoDisplay = 0, Original = 1, Alternative = 2,
    
    Possible values: NoDisplay Original Alternative
  - DisplaySpecifications enum<string>
    
    Field Display Specifications - None = 0, IsVisible = 1, IsRequired = 2, IsOptional = 4, IsReadOnly = 8, MAX_COMMON_VALUE = 4294967296
    
    Possible values: None IsVisible IsRequired IsOptional IsReadOnly MAX_COMMON_VALUE
- InsertDate string <date-time>
  
  Insert Date
- UpdateDte string <date-time>
  
  Update Date
- InsertUserIdKey integer <int32>
  
  Insert User Id Key
- UpdateUserIdKey integer <int32>
  
  Update User Id Key
- ExpenseKey integer <int64>
  
  Expense Key