New member - Need API information

[Shahul Hameed]

Hello Team

I have joined new to this team. My organization is a medical billing company which integrates with EPIC and generates 837 files and sends it to various payors like Blue Cross. I am trying to identify if there are any available APIs that provides 

Financial information relating to the claim like payment accepted, denied, denial reasons, partial payments etc. (similar to 835/277 files)

Please help. Thanks in advance.

[Beneficiary Claims Data API (BCDA) Community]

Hello and welcome!  

Thanks for reaching out regarding access to BCDA. We offer Medicare Parts A, B, and D claims data, which does include information on claim status and payments. Today, access to BCDA is available only to organizations participating in the Medicare Shared Savings Program, ACO REACH, or the Kidney Care Choice model. If you are partnered with a healthcare organization participating in one of those three Alternative Payment Models, please reach out to a representative from the model participant.

If your organization is not participating in one of these Alternative Payment Models or acting on behalf of a model participant, you might find one of the APIs at developer.cms.gov are suitable depending on your use cases.

If none of those APIs looks quite right, please let us know how your organization intends to work with Medicare claims data and we might be able to point you in the right direction.

Thanks,
The BCDA Team

[Shahul Hameed]

Thank you very much for the reply. Yes, my client organizations deals with all of the three Alternative Payment Models. Having that confirmation, is it possible to access those APIs ( ...Medicare Parts A, B, and D claims data, which does include information on claim status and payments...) in sandbox environment for testing purpose which would help integrate it in production eventually.

Please advise.

[Beneficiary Claims Data API (BCDA) Community]

Hello,

You can find instructions on how to connect to the BCDA public sandbox environment here. Once you have completed your testing in the sandbox environment, you will need to create production BCDA credentials for each of the organizations you are working with. Refer to our instructions on managing production credentials here.

Please let us know if you have any other questions as you get started with the sandbox environment.

Thanks,
The BCDA Team

[Shahul Hameed]

Hello BCDA Team

Thank you very much for your response. I started working on the sandbox environment. I have followed the below steps:

1. Get access token using Auth Token API: https://sandbox.bcda.cms.gov/auth/token

2. Using the access token above i triggerred the bulk job API by invoking the "/Group/all/$export" API

3. I retrieved the Job Id from the above API and using the job id i am trying to retrieve the file name using the API "/jobs/{job id}

In this step, it is not returning the type ClaimResponse. Below are the only types it returns. I am more interested in the ClaimResponse type as i believe it has more information about the claims.

{
    "transactionTime": "2024-11-27T07:02:46.387-05:00",
    "request": "https://sandbox.bcda.cms.gov/api/v2/Group/all/$export",
    "requiresAccessToken": true,
    "output": [{
            "type": "Patient",
            "url": "https://sandbox.bcda.cms.gov/data/73888/9436548a-eaac-47e0-812e-72cf7de23e82.ndjson"
        }, {
            "type": "ExplanationOfBenefit",
            "url": "https://sandbox.bcda.cms.gov/data/73888/7ed9a76f-09c9-4bab-835e-4169283b7858.ndjson"
        }, {
            "type": "Coverage",
            "url": "https://sandbox.bcda.cms.gov/data/73888/e07f33ad-c495-4381-8554-40399f7a9c27.ndjson"
        }
    ],
    "error": [],
    "JobID": 73888

Can you please help on this.

Thanks and regards

Shahul Hameed

EMC Soft

[Beneficiary Claims Data API (BCDA) Community]

Hi,

Please review the descriptions of BCDA's FHIR resources provided here for a brief overview of the data you can expect to find within each resource type. You may find that Explanation Of Benefit resources will best meet your needs as those resources contain much of the data about a claim once it has been fully adjudicated and are available to all organizations with BCDA access.

Claim and ClaimResponse resources contain partially adjudicated claims data and production access is limited to REACH ACOs using BCDA. Any organization can access these resources in sandbox by using the sample credentials for either the Small REACH ACO or the Large REACH ACO provided under the instructions to Try the API.

Thanks,
The BCDA Team