EDI-to-JSON API for Claim (837) Transactions

We provide API to convert X12 EDI healthcare (HIPAA) transactions into an easy-to-consume JSON. This API is part of our Claim Insight product.

The API returns a JSON response consisting of business entities such as “claim,” “patient,” “provider,” “diagnosis,” and “service line.” The response schema is independent of the input. Today we support X12 EDI, NCPDP telecom and a comma-delimited file format as the input to the converter.

Here is the API documentation including the schemas; our GitHub repo contains usage examples in Python and other languages.

No knowledge of X12 EDI is required to use the API. We translate EDI loops, segments, and elements into appropriate business entities.

These business entities can be easily mapped to business objects in your language of choice, be it Java, JavaScript, or .NET.

We follow the naming conventions and terminology established by X12 EDI (and, before that, as part of HCFA and UB forms), so field names should be easily recognizable by anyone with healthcare IT experience.

Here is an example showing a billing provider and its representation in JSON produced by the API:

HL*1**20*1~
PRV*BI*PXC*103G00000X~
NM1*85*2*Ben Kildare Service*****XX*9876543210~
N3*234 SEAWAY ST~
N4*MIAMI*FL*33111~
REF*EI*587654321~

{
  "entityRole" : "BILLING_PROVIDER",
  "entityType" : "BUSINESS",
  "identificationType" : "NPI",
  "identifier" : "9876543210",
  "taxId" : "587654321",
  "lastNameOrOrgName" : "Ben Kildare Service",
  "providerTaxonomy" : {
    "type" : "PROVIDER_TAXONOMY",
    "subType" : "PROVIDER_TAXONOMY",
    "code" : "103G00000X",
    "desc" : "Clinical Neuropsychologist (Behavioral Health & Social Service Providers / Clinical Neuropsychologist)",
    "categories" : [ {
      "type" : "PROVIDER_TAXONOMY",
      "subType" : "GROUPING",
      "code" : "Behavioral Health & Social Service Providers"
    }, {
      "type" : "PROVIDER_TAXONOMY",
      "subType" : "CLASSIFICATION",
      "code" : "Clinical Neuropsychologist"
    } ]
  },
  "address" : {
    "line" : "234 SEAWAY ST",
    "city" : "MIAMI",
    "stateCode" : "FL",
    "zipCode" : "33111"
  }
}

We decode all the healthcare codes “on the fly” and return descriptions and metadata for every code. The example above shows that the provider’s NUCC taxonomy has been enriched with the description and categories.

The API also decodes CPT codes, diagnoses, and all the other relevant codes. Below is an example of a service line containing descriptions (abbreviated for the sake of the sample) of the CPT procedure.

We also automatically assign RBCS/BETOS taxonomies to CPT codes. You can use optional parameters to suppress adding taxonomies and descriptions to the codes.

LX*1~
SV1*HC:99213*40*UN*1***1~
DTP*472*D8*20061003~

{
  "chargeAmount" : 40.00,
  "serviceDateFrom" : "2006-10-03",
  "unitType" : "UNIT",
  "unitCount" : 1,
  "procedure" : {
    "type" : "PROCEDURE",
    "subType" : "CPT",
    "code" : "99213",
    "desc" : "OFFICE ...",
    "fullDesc" : "Office or other ...",
    "shortDesc" : "OFFICE O/P ...",
    "startDate" : "1993-01-01",
    "categories" : [ {
      "type" : "RBCS_TAXONOMY",
      "subType" : "RBCS_CATEGORY",
      "code" : "E",
      "desc" : "E & M"
    }, {
      "type" : "RBCS_TAXONOMY",
      "subType" : "RBCS_SUB_CATEGORY",
      "code" : "EV",
      "desc" : "Office/outpatient services"
    } ],
    "diags" : [ {
      "type" : "DIAGNOSIS",
      "subType" : "ICD_10_PRINCIPAL",
      "code" : "J020",
      "desc" : "Streptococcal pharyngitis"
    } ]
  }
}

Finally, here is an abbreviated example of claim-level fields. You can view a complete claim example using this link.

{
  "id" : "63c1b74604ddda6fbb9d16c0",
  "transactionType" : "PROF",
  "patientControlNumber" : "26463774",
  "chargeAmount" : 100.00,
  "dateFrom" : "2006-10-03",
  "dateTo" : "2006-10-10",
  "serviceDateFrom" : "2006-10-03",
  "serviceDateTo" : "2006-10-10",
  "clearinghouseTraceNumber" : "17312345600006351",
  "subscriber" : {
    "relationshipType" : "SELF",
    "groupOrPolicyNumber" : "2222-SJ",
    "claimFilingIndicatorCode" : "CI",
    "payerResponsibilitySequenceNumberCode" : "PRIMARY",
    "person" : {
      "entityRole" : "SUBSCRIBER",
      "entityType" : "INDIVIDUAL",
      "identificationType" : "MEMBER_ID",
      "identifier" : "JS00111223333",
      "lastNameOrOrgName" : "Smith",
      "firstName" : "Jane",
      "birthDate" : "1943-05-01",
      "gender" : "FEMALE"
    }
  },
  "diags" : [ {
    "type" : "DIAGNOSIS",
    "subType" : "ICD_10_PRINCIPAL",
    "code" : "J020",
    "desc" : "Streptococcal pharyngitis"
  }, {
    "type" : "DIAGNOSIS",
    "subType" : "ICD_10",
    "code" : "Z1159",
    "desc" : "Encounter for screening for other viral diseases"
  } ],
  "principalDiagnosis" : {
    "type" : "DIAGNOSIS",
    "subType" : "ICD_10_PRINCIPAL",
    "code" : "J020",
    "desc" : "Streptococcal pharyngitis"
  }
  // ...

You can also convert 835 transactions into payment objects using the same API endpoint.

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