Claims File

Claims data file containing claim information for processing.

File Information

Property	Value
File Type	CSV
Delimiter	comma (,)
Includes Headers	Yes

Fields

Position	Header Name	Description	Required	Type	Format	Valid Values	Example
1	Client ID	Employer-specific unique identifier in partner's system	Yes	String			CLIENT-12345
2	Employee ID	Employee-specific unique identifier in payroll system	Yes	String			EMPLOYEE-12345
3	Plan ID	Plan-specific unique identifier in partner's system that must match the Plan ID in the eligibility file (for validation)	Yes	String			PLAN-12345
4	Plan Year Start	Plan year-specific start date	Yes	Date	YYYY-MM-DD		2020-01-01
5	Plan Year End	Plan year-specific end date	Yes	Date	YYYY-MM-DD		2020-01-01
6	Transaction ID	Transaction-specific unique identifier in partner's system (for duplicate checking)	Yes	UUID			550e8400-e29b-41d4-a716-446655440000
7	Claim ID	Claim-specific unique identifier in partner's system (for matching with original claim id if adjustment or reversal)	Yes	String			CLAIM-12345
8	Claim Type	Original, Adjustment, Reversal	Yes	String		Original, Adjustment, Reversal	Original
9	Date of Service	Date when employee receives care (could be in the past)	Yes	Date	YYYY-MM-DD		1900-01-01
10	Processing Date	Date when claim is adjudicated	Yes	Date	YYYY-MM-DD		1900-01-01
10	Employee Responsibility	Amount employee is responsible for (could be positive or negative)	Yes	Decimal			100.00
12	Billed Amount	Amount provider billed insurance for	Yes	Decimal			100.00
13	Service Description	Procedure or medication name (open text)	Yes	String			Office Visit
14	Service Category	Medical, Pharmacy	Yes	String			Medical
15	Provider Name	Provider or pharmacy name (open text)	Yes	String			Dr. John Smith
16	Plan Network	InNetwork, OutOfNetwork	No	String		InNetwork, OutOfNetwork	InNetwork

Example

Client ID,Employee ID,Plan ID,Plan Year Start,Plan Year End,Transaction ID,Claim ID,Claim Type,Date of Service,Processing Date,Employee Responsibility,Billed Amount,Service Description,Service Category,Provider Name,Plan Network
CLIENT-12345,EMPLOYEE-12345,PLAN-12345,2020-01-01,2020-01-01,550e8400-e29b-41d4-a716-446655440000,CLAIM-12345,Original,1900-01-01,1900-01-01,100.00,100.00,Office Visit,Medical,Dr. John Smith,InNetwork