Participant APIs | REST

For an FX claim, this will be a number 1 through 9 representing the status of the claim. The FXClaimStatusDesc field will include the corresponding description.   1 = Paid  2 = Approved  3 = Applied to Deductible  4 = Denied  5 = Eligible for Reimbursement  6 = Reversed  8 = Overpaid 9 = Partially Approved

For an FX claim, this will be a human friendly description of the claim status, correpsonding to the FXClaimStatus field.  1 = Paid  2 = Approved  3 = Applied to Deductible  4 = Denied  5 = Eligible for Reimbursement  6 = Reversed  8 = Overpaid  9 = Partially Approved

This indicates, for this specific TransactionDetailEx object, if the information is for the entire FX claim (1), for a single line of the FX claim (2), or for a reimbursement (3). Your response will include a TransactionDetailEx object for each claim line and then a TransactionDetailEx for the entire claim; a TransactionDetailEx object for a reimbursement will only be included if it is applicable to this particular FX claim. 0 = None 1 = Total 2 = Line 3 = Reimbursement

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.

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

Amount the participant designated as paid Out Of Pocket for the claim and therefore the participant is not seeking reimbursements for this portion.

The family member for whom the claim applies

The provider’s patient account number.

The name of the patient associated with the claim.

Represents a system generated identifier for the reimbursement which can be used to retrieve the reimbursement details in a separate request.

Represents the draft # issued by our Integrated Payment vendor.

Represents the payment method used by the participant or our Integrated Payment vendor. Valid methods include Pending, Check, Direct Deposit, External Check, External Direct Deposit, Card, Payroll, ePay-ACH, ePay-Virtual Card, and ePay-eCheck.

Tracking Number assigned by the system importing the transaction to WCA

For an FX claim, this is the external identifier for the claim

The Service Categoriy Tier associated with the claim line.

Refers to claim when multiple claim submitted

CPT, HCPCS or other service procedure type. This information is stored in the system for display to the administrator and participant It is not used by the system to determine whether a claim is eligible

On an FX or TC claim or a participant added expense, this is the amount the provided billed to insurance. It is for information purposes only and is not used for adjudication. It is intended to help a participant match-up to the full billed amount for a service. For TC/FX Claims this is the summation of all claim lines.

On an FX or TC claim or a participant “save expense” for later, this is the amount allowed by insurance. It is for information purposes only and is not used for adjudication. For TC/FX Claims this is the summation of all claim lines.

The participant's deductible responsibility that was requested

The participant's deductible responsibility that was reimbursed

Amount requested by participant's coinsurance

Amount reimbursed to participant's coinsurance

Requested amount will be used as participant's copay responsibility

Reimbursed amount will be used as participant's copay responsibility

On an FX or TC, this is the requested 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.

On an FX or TC, this is the reimbursed 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 participant's Excess Amount responsibility that was requested

The participant's Excess Amount responsibility that was reimbursed

The amount the insurance carrier deemed as "not covered" by insurance but was still requested. It can be used in adjudication as a participant reimbursable liability amount.

The amount the insurance carrier deemed as "not covered" by insurance but was still reimbursed. 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 requested 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.

On an FX or TC claim or a participant “save expense” for later, this is the reimbursed 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.

This is the amount that the insurance provide paid of the billed amount for the service and is only used for display; no system business rules are performed using this amount.

Unique ID of the benefit plan

The Account Type Code for the transaction, such as FSA, FS2, etc.

Date when the plan starts

Date when the plan ends

Merchant Name of merchant associated with provider

Unique identification ID for a provider or vendor

Merchant category code used to create transaction

MCC attached while initiating claim

The purpose of this field varies, depending on the Type Code. TC Claim (5) or Member Expense (4): Total Patient Responsibility Amount. Manual Claim (3): Original claim amount. If Denied or (pended and has pended comment): EligibleAmt + TxnAmtPended + TxnAmtDenied HSA Bill Pay (10): Txn Amount. FX Claims (1): Total Reimbursed Amount

Code to identify the type of transaction.  11 = Purchase  12 = PreAuth  13 = ForcePost  14 = Refund  20 = EmployerDeposit  21 = PrefundedDeposit  22= AutoDeposit   23 = Adjustment  24 = Void  25 = PrefundedDepositReset  26 = BalanceSyncAdjustment  27 = IndividualAmt  28 = IndividualAmtReset  29 = HsaImported  30 = OtherDeposit 31 = RolloverDeposit 32 = FamilyRolloverDeposit 33 = FamilyOther Deposit

Current status of the transaction. Valid values are   2 -Approved  4- Ineligible  8- Pending  16 - Resolved Employee Pay  32 - Resolved Payroll Deduction   64 - New   128 - Denied   256 - Unkown   512 - Resolved No Refund   1024 - Ineligible Partially Offset  2048 - Resolved Offset by Manual Claim  4096 - Unauthorized Refund  8192 - Insufficient Documentation  16384 - Entered but not reviewed 32768 - Reversed 65536 – Claim Reversal 131072 - Overpayment 262144 -Overpayment Partially Resolved 524288 – Overpayment Resolved 1048576 – Non-post 2097153 - Returned 4194304 - Resubmitted

Date when the transaction is made

Convenience Fee Payer Code. This indicates who paid a convenience fee. None = 1 (indicates no fee is set up) Tpa = 2 Employer = 3 Employee = 4

Disbursable Balance: The remaining balance in the account. For account types other than HSA, this is the “Disbursable Balance.” For HSAs, this is the “Available Balance”

Indicates if a dependent is associated ` 1= Yes, 0 = No

If the transaction is for the employee, this will be the Employee ID. If the transaction is for the dependent, this will be the Dependent ID.

Date when the original transaction occurred

Unique number assigned to transactions in WCA

Date when the transaction settlement occurred

A unique identifier for the transaction generated by WCA during the settlement process.

Unique identifier applied to the Transaction in WCA.

If WCA has this information, this will be the check number for the reimbursement.

Date when the reimbursement occurred

Method used for reimbursement Undefined = -1, None = 0, Check = 1, DirectDeposit = 2, ExternalCheck = 3, ExternalDirectDeposit = 4,Card = 5, Payroll = 6

`The amount of the transaction that was eligible to be applied to a participant’s account but was used to offset a participant’s balance due for that account.

Indicates if the transaction is partially authorized. ` 1= Yes, 0 = No

Notes entered by user related to the transaction

Indicates if the Check is reissued. 1 = Yes, 0 = No

Service category code used to create transaction

Description to Service category code used to create transaction

The sub-type code for an Other Deposit Sub-Type

For claims, the SCC description + the Merchant name (Note: a
tag is included to separate the two fields). For Card transactions, the Merchant Name. For other transactions, the type of transaction

The amount of the claim that was denied by the claims processor.

The amount that was either paid from other accounts (or applied to DTR account) or the amount eligible to be reimburse was reduced by a business rule such as a Service Category %, Max Transaction amount or max total amount.

The reason for the excluded amount on a claim.  An excluded amount is due to a system business rule that reduces what is eligible for reimbursement such as an amount paid by a higher priority account or a max transaction amount.

The amount that exceeded the participants balance at the time the transaction was processed.

The amount of the total claim minus the excluded, pending and denied amounts equals the Eligible Amount. Formula: Total Claim – Excluded Amount – Pended Amount – Denied Amount = Eligible Amount

The amount that was applied to the Deductible for Deductible manager enabled plans.

Amount of the claim that the claims processor needs additional information form the participant in order to approve or deny the claim Pended.

Indicates if the transaction is associated with a pay provider. ` 1= Yes, 0 = No

Proxy number of the card

Start date of the service provided to the participant that the transaction is for

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

For a recurring claim, indicates the start date for the recurrence

For a recurring claim, indicates the end date for the recurrence

For a recurring claim, indicates the frequency of recurrence

For a recurring claim, this is the date when the next recurring transaction will be made

For a recurring claim, indicates the date when the last transaction of the series was made

For a recurring claim, this would be the total number of payments that are to be made

For a recurring claim, this would be the number of payments remaining in the series

Refers to the IRS reporting category associated with the HSA account transaction, derived from the transaction type or the product partner HSA Status Code

When a participant’s debit card transaction is marked as ineligible, or if a reimbursement is issued which is later reversed, the ineligible or reversed amount is tracked as a ‘balance due’ and the participant must pay it back. This field returns the amount the participant still owes.

The Ineligible Amount of the transaction

The reason the Ineligible Amount provided is ineligible.

Origin Code indicates which way claims initiated - Mobile/Web Portal/eClaim

A human friendly description that corresponds to OriginCode

Reason provided for pended claims

Text of any comments added to the claim when an amount was marked pended

Reason provided for denied claims

Comment added to claim by claims processor explaining why it was denied

Name of the pay provider

First line of the provider’s mailing address

Second line of the provider’s mailing address

City associated with the provider’s mailing address

State associated with the provider’s mailing address

Zip Code associated with the provider’s mailing address

A unique identifier key generated by WCA when a hold is created, used to identify the hold information

For a recurring claim, this is a unique identifier for task scheduling for a recurring payment

On hold amount balance of the HSA account

Date when the transaction is posted

Card proxy number of the Participant

Origin Txn Amount is total of approved amt,pended amt and denied amt

Date when the claim was put on hold

Returns the status of a check reimbursemement. If transaction is an HSA Import, Auto Deposit, or Other deposit, this field will be empty. If the check trace number exists and has been reissued, this field return the check trace number + a superscript “r” (i.e., 1234r) If the check trace number exists and this was an external check, this field will return the check trace number + a superscript “e” (i.e., 1234e) If the transaction was submitted manually, and was not denied, this will return “Pending Reimbursement" If the transaction was submitted manually, was not denied, and the reimbursement method is card, this will return “Card” If the transaction was submitted manually, was not denied, and the reimbursement method is external check, this will return “Pending External Reimbursement” If the transaction was submitted manually, is fully offset, and fully deductible, this will return “Offset / Deductible” If the transaction was submitted manually and is fully offset and overpayment is resolved, this will return “Offset” If the transaction was submitted manually and is fully deductible, this will return “Deductible” If the transaction was submitted manually, is partially offset and the reimbursement method is external check or external direct deposit, this will return the check trace number with a superscript “e” + “ / Offset” (i.e., “1234e / Offset”) If the transaction was submitted manually, is partially offset, the reimbursement method is check or direct deposit, and the check has been reissued, this will return the check trace number with a superscript “r” + “ / Offset” (i.e., “1234r / Offset”) If the transaction was submitted manually, is partially offset, and a check trace number exists, this will return the check number + “ / Offset” (i.e., “1234 / Offset”) If the transaction was submitted manually, is partially offset, the reimbursement method is external check or external direct deposit, and a check trace number doesnot exist, this will return “Pending External Reimbursement / Offset” If the transaction was submitted manually, reimbursememt method is check, direct deposit, or payroll, the transaction is partially offset, the overpayment is partially resolved, and there is no check trace number, this will return “Pending Reimbursement / Offset” If the transaction was submitted manually, reimbursement is set to “None,” the transaction is partially offset, and the overpayment is partially resolved, this will return “None / Offset” If the transaction does not meet any of the above criteria but a check trace number exists, this will return the check trace number. Otherwise, this field will be empty.

Total Amount of transaction which got reimbursed

Transaction amount entered when the claim or transaction was first entered. The actual transaction amount may be different after adjustments.

The Approved amount is the amount that was debited from (refund: credited to) for this adjudicated claim

Details of attached receipt for claims