Participant APIs | REST

A unique identifier key for the claim, generated by WCA when the claim was created

Unique identifier key for the Transaction

Date the Transaction was finalized in WCA- Settlement Date

Sequence Number of the FX, TC or “save expense for later” Expense

Amount of the claim line that was eligible for reimbursement but offset or reduced the balance due on one or more claims

For TC and FX claims, this is the amount that was applied to Deductible Manager or the amount applied to the DTR.

Status for the FX or TC Claim line.

On an FX or TC claim, a unique identifier for the Carrier, as submitted on the FX or TC claim

On an FX claim, a unique identifier for the claim, as submitted on the FX record

The claim line number submitted with the claim by the insurance carrier.

Unique identifier for type of Claims : None = 0, Pharmacy = 1, Medical = 2,Dental = 4, Vision = 8, OTC = 16

On an FX or TC, this is the amount that is being denied by the insurance company due to the benefit being maxed out in number of visits or limit (such as a limit of 20 Physical Therapy visits per year). WCA can be configured to reimburse this amount since it would otherwise be covered by insurance were it not for the limit.

The amount the insurance carrier deemed as “Excess Amount” by insurance. It can be used in adjudication as a participant reimbursable liability amount.

The amount the insurance carrier deemed as “not covered” by insurance. It can be used in adjudication as a participant reimbursable liability amount.

On an FX or TC claim or a participant “save expense” for later, this is the amount above the usual and customary rate – for an out of network claim, it’s the amount the provider billed minus the insurance allowed amount. WCA can be configured to reimburse this amount by service category tier.

The provider who provided the service to the participant (this may be different than the billing provider name). It is recommended to use this field as the Provider Name to display.

On a TC claim, a unique identifier for the Billing Provider, as submitted on the TC claim

The Service Categoriy Tier associated with the claim line.

When the activity is for a dependent, this will be populated with an identifier for the dependent, as submitted on the TC or FX claim

The Serive Category Code associated with the claim line

Total of all the participant liability amount fields for the claim line Deductible, Coinsurance, Copay, Not Covered Amount, Benefit Max Met, Amount RBB Excess Amount

Provider ID for the provider who performed the service for the participant.

First Name of participant associated with the expense

Last Name of participant associated with the transaction

Unique identifier key for the Provider, generated by WCA when the provider was first created in the system

Address line 1 associated with the provider’s mailing address

Address line 2 associated with the provider’s mailing address

City associated with the provider’s mailing address

State associated with the provider’s mailing address

Country Code associated with the provider’s mailing address

Zip Code associated with the provider’s mailing address

Phone associated with the provider’s mailing address

Identifier for the Provider, as entered into WCA when the provider was created

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

Unique WCA generated identifier key for the FX, TC or “save expense for later” Expense

Unique identifier key for Employee, generated by WCA when the employee was created in the system

When the activity is for a dependent, this will be populated with a unique identifier for the dependent generated by WCA when the dependent was first entered into the system. This will be null if the activity was not linked to a dependent.

Beginning date of service for the claim line received by the participant.

Ending date of the service for the claim line provided to the participant

Name of the Provider

For a TC claim, this will be the description of service as submitted on the TC claim.

See prior definition in the Employee Activity section. This is the billed amount specific to the claim line.

The amount the insurance carrier deemed eligible for the claim line service. It is not used in adjudication; only the participant’s responsibility fields are used in adjudication (Deductible, Coinsurance, Copay, etc.)

The amount the insurance carrier paid for the claim line service. It is not used in adjudication as this amount has already been paid to the provider; only the participant’s responsibility fields are used in adjudication (Deductible, Coinsurance, Copay, etc.)

Employee Out-of-Pocket Paid Amount. The amount the participant has indicated as paid by other means and they are not seeking reimbursement for the amount. This amount reduces the remaining participant responsibility.

Notes entered by user related to the transaction

Unique identifier key for document attached to this claim line, generated by WCA when the document was first submitted

Indicates whether this claim is a save expense for later submitted by the participant or a TC claim. 1 = participant submitted expense for later 0 = TC claim

The deductible amount as adjudicated by the insurance carrier on the FX or TC claim submitted to WCA. Note: WCA can be configured to reimburse this amount by service category code or not.

The coinsurance amount as adjudicated by the insurance carrier on the FX or TC claim submitted to WCA. Note: WCA can be configured to reimburse this amount by service category code or not.

The copay amount as adjudicated by the insurance carrier on the FX or TC claim submitted to WCA. Note: WCA can be configured to reimburse this amount by service category code or not.

Total Amount of transaction which got reimbursed

Origin Code indicates which way claims initiated : None = 0,POSCardSwipe = 1,POSKeyedIn = 2,POSPhonedIn = 3,POSMbiSubmitted = 4,ManualScreen = 50,ManualEFT = 51, ManualAgent = 52, ParticipantManualScreen = 53,ParticipantMobileScreen = 54, HZDirect = 55, eClaimManagerManual = 56, eClaimManagerTPS = 57, WebServiceClaim = 58

Current status of the eClaim : None = 0, New = 1, (New claim posted to portal but not yet submitted for reimbursement) Matched = 2 (Matched to card transaction) Reimbursed = 3, (Claim was approved but not in full) Not Allow Participant Claim Entry = 4 (Participant claim entry is not allowed. Note: in WCA, WCP, and WCM, an eclaim with this status will display as “not eligible for reimbursement”). Miss Participant Claim Entry UI Template = 5 (Claim can not be submitted as there is no claim entry template in WCA) In_Process = 6 (Claim has been submitted for adjudication, but has not yet been adjudicated) Fully_Paid = 7 (claim is fully approved)

Description related to the claim