Resolve Pend and Submit Claims

This integration point allows a user to resolve pend reasons and submit one or more claims for processing in a single request.

The operation is a long-running operation and is asynchronous in nature.

For details about claims processing, see the Claims Flow chapter in the Operations Guide.

API Endpoint

POST /[api-context-root]/resolvependandsubmit?action={accept|deny}&messageCode={code}

Payload

{
  "claimList": [
    { "code": "" }
  ]
}

claimList : An array of claim references. At least one claim is required.

claimList[].code : The unique identifier of the claim.

Parameters

For parameter details, see Accept and Deny.

Eligible Claim Statuses

Table 1. Eligible Claim Statuses per Action

Status of the Claim	Eligible for Accept	Eligible for Deny
Adjudication done	No	No
Benefits done	No	No
Change	Yes	No
Entry	Yes	No
Finalized	No	No
Initial	No	No
Manual adjudication	Yes	Yes
Manual benefits	Yes	No
Manual pricing	Yes	No
Manual pricing adjudication	Yes	Yes
Pricing adjudication done	No	No
Pricing done	No	No
Pricing finalized	No	No
Sent out for preprocessing	No	No
Sent out for pricing	No	No

Details

• The claim must be in an applicable status.

• The payload should contain at least one claim.

• If the action value is provided, it must be accept or deny. For more information, see Accept and Deny.

• Every claim in the request should exist.

• Every claim in the request is a regular claim. Claims with process category large claim or sub-claim are not allowed.

• The user must have access to resolve all pends on the claim.

Processing

The long-running operation is not initiated if the request returns any of the following errors: CLA-IP-RSMT-002, CLA-IP-RSMT-003, CLA-IP-SBMT-001, CLA-IP-SBMT-002, or CLA-IP-SBMT-003.

• The system starts a long-running operation when a POST request is performed on the endpoint.

  • The progress of the long-running operation can be tracked through the location header.

    • For more information, see Long-Running Operations Through REST.

• For more information, see Accept and Deny Processing.

• Additionally, all unresolved pend reasons at claim header and claim line level are resolved under the name of the calling user and written to pend reason history for both claim and line pends. The claim is then submitted for further processing, and the submit history is updated.

Response Handling

The response data file set holds the result with the following structure. Each claim is identified by the elementId provided in the request message with claim code.

<claims>
  <claim elementId="">
    <resultMessage code="">
      message text
    </resultMessage>
  </claim>
  ...
</claims>

Authorization

This operation is protected by the access restriction resolvependandsubmit IP. A grant to this access restriction is required to make a request.

For more information, see Authorization.

• Pend reasons can be protected by access restrictions. HTTP API operations always enforce these. The user must have resolve access to every unresolved pend reason on the claim, at both claim header and claim line level.

Response Messages

Success

• HTTP 201 Created

Failure

Code	Severity	Description
CLA-IP-RSMT-001	Fatal	Claim {code} is unknown
CLA-IP-RSMT-002	Fatal	At least one claim is needed to proceed with submission
CLA-IP-RMST-003	Fatal	Unknown message {code}
CLA-IP-CLAI-024	Fatal	Claims in {status} cannot be submitted
CLA-IP-SBMT-001	Fatal	Message code of severity FATAL is required when "action" is deny
CLA-IP-SBMT-002	Fatal	The provided fatal message code does not exist in the system
CLA-IP-SBMT-003	Fatal	Only "INFO" severity messages can be used with the "accept" action
CLA-IP-SUBC-001	Fatal	This integration point is not supported for a claim with a process category large claim or sub-claim
CLA-IP-RSMT-004	Fatal	A maximum of 500 claim codes is supported per request