POST api/groups/{groupid}/membermanualclaim

Processes a manual claim for a member. This involves validating various claim details and, if valid, processing the claim.

Request Information

URI Parameters

NameDescriptionTypeAdditional information
groupid

integer

Required

Body Parameters

The model containing the claim details.

MemberManualClaimEntryModel
NameDescriptionTypeAdditional information
PharmacyNPI

Gets or sets a Pharmacy NPI. If this field is supplied IngredientCostSubmitted, DispenseFeeSubmitted, IncentiveFeeSubmitted, UsualAndCustomaryAmount, and GrossAmountDue are required.

 string

None.
IngredientCostSubmitted

Gets or sets the ingredient cost submitted. If this field is supplied PharmacyNPI, DispenseFeeSubmitted, IncentiveFeeSubmitted, UsualAndCustomaryAmount, and GrossAmountDue are required.

 decimal number

None.
DispenseFeeSubmitted

Gets or sets the dispense fee submitted. If this field is supplied PharmacyNPI, IngredientCostSubmitted, IncentiveFeeSubmitted, UsualAndCustomaryAmount, and GrossAmountDue are required.

 decimal number

None.
IncentiveFeeSubmitted

Gets or sets the incentive fee submitted. If this field is supplied PharmacyNPI, IngredientCostSubmitted, DispenseFeeSubmitted, UsualAndCustomaryAmount, and GrossAmountDue are required.

 decimal number

None.
UsualAndCustomaryAmount

Gets or sets the usual and customary amount. If this field is supplied PharmacyNPI, IngredientCostSubmitted, DispenseFeeSubmitted, IncentiveFeeSubmitted, and GrossAmountDue are required.

 decimal number

None.
GrossAmountDue

Gets or sets the gross amount due. If this field is supplied PharmacyNPI, IngredientCostSubmitted, DispenseFeeSubmitted, IncentiveFeeSubmitted, and UsualAndCustomaryAmount are required.

 decimal number

None.
RxCPersonID

Gets or sets the patient's RxClearinghouse ID

 integer

None.
NDC

Gets or sets the drug's NDC

 string

None.
PlanContractNo

Gets or sets the plan contract identifier

 integer

None.
PrescriptionReferenceNumber

Gets or sets the claim's Rx Number

 string

None.
FillNumber

Gets or sets the claim's Fill Number

 byte

None.
QuantityDispensed

Gets or sets the claim's Quantity Dispensed

 decimal number

None.
QuantityPrescribed

Gets or sets the claim's quantity prescribed.

 integer

None.
DaysSupply

Gets or sets the claim's Days Supply

 byte

None.
DateOfService

Gets or sets the claim's Date of Service

 date

None.
FlatSalesTax

Gets or sets the claim's flat sales tax.

 decimal number

None.
SalesTaxPercent

Gets or sets the claim's sales tax percent.

 decimal number

None.
DAWCode

Gets or sets the claim's Dispense as Written code

 string

None.
DateWritten

Gets or sets the claim's date the prescription was written.

 date

None.
PrescriberID

Gets or sets the claim's prescriber's ID, typically the NPI number.

 string

None.
PrescriberFirstName

Gets or sets the claim's prescriber's first name.

 string

None.
PrescriberLastName

Gets or sets the claim's prescriber's last name.

 string

None.
SubmissionClarificationCode

Gets or sets the claim's submission clarification code.

 string

None.
ReasonForServiceCode

Gets or sets the claim's reason for service code.

 string

None.
ProfessionalServiceCode

Gets or sets the claim's professional service code.

 string

None.
ResultOfServiceCode

Gets or sets the claim's result of service code.

 string

None.
OtherPayerPatientResponsibilityAmount

Gets or sets the claim's other payer balance if this is a secondary claim.

 decimal number

None.
IsEmergencyPrescription

Gets or sets whether the prescription is an emergency prescription for the claim.

 boolean

None.
IsCompound

Gets or sets whether the prescription is a compound for the claim.

 boolean

None.
CompoundIngredients

Collection of CompoundIngredientModel

None.
IngredientCostPaid

Gets or sets the ingredient cost paid. If this field is supplied DispenseFeePaid, IncentiveFee, and SalesTaxPaid are required.

 decimal number

None.
DispenseFeePaid

Gets or sets the dispense fee paid. If this field is supplied IngredientCostPaid, IncentiveFee, and SalesTaxPaid are required.

 decimal number

None.
IncentiveFee

Gets or sets the incentive fee that is added to the drug price. If this field is supplied IngredientCostPaid, DispenseFeePaid, and SalesTaxPaid are required.

 decimal number

None.
SalesTaxPaid

Gets or sets the total amount of sales tax paid (including flat rate amount). If this field is supplied IngredientCostPaid, DispenseFeePaid, and IncentiveFee are required.

 decimal number

None.
Copay

Gets or sets the member responsible amount. If this field is supplied CoinsuranceRate is required.

 decimal number

None.
CoinsuranceRate

Gets or sets the member responsible rate. If this field is supplied Copay is required.

 decimal number

None.
OOPCopay

Gets or sets the member out of pocket amount. If this field is supplied OOPCoinsuranceRate is required.

 decimal number

None.
OOPCoinsuranceRate

Gets or sets the member out of pocket rate. If this field is supplied OOPCopay is required.

 decimal number

None.
ExemptFromDeductible

Gets or sets a value indicating whether the claim is exempt from deductible.

 boolean

None.
ExemptFromOutOfPocketLimit

Gets or sets a value indicating whether the claim is exempt from out-of-pocket limit.

 boolean

None.
ExternalClaimNo

Gets or sets an external claim number.

 string

None.
Notes

Gets or sets a claim's notes.

 string

None.
DiagnosisCodes

Collection of DiagnosisCodeModel

None.
Url

Gets or sets the link representing a link back to the resource

 string

None.
ID

Gets or sets the identifier for the resource

 integer

None.

Request Formats

application/json, text/json, application/json-patch+json

Sample: 
{
  "url": "sample string 16",
  "id": 17,
  "pharmacyNPI": "sample string 1",
  "ingredientCostSubmitted": 1.0,
  "dispenseFeeSubmitted": 1.0,
  "incentiveFeeSubmitted": 1.0,
  "usualAndCustomaryAmount": 1.0,
  "grossAmountDue": 1.0,
  "rxCPersonID": 2,
  "ndc": "sample string 3",
  "planContractNo": 1,
  "prescriptionReferenceNumber": "sample string 4",
  "fillNumber": 64,
  "quantityDispensed": 1.0,
  "quantityPrescribed": 5,
  "daysSupply": 64,
  "dateOfService": "2025-05-30T13:14:40.5768553-05:00",
  "flatSalesTax": 1.0,
  "salesTaxPercent": 1.0,
  "dawCode": "sample string 6",
  "dateWritten": "2025-05-30T13:14:40.5768553-05:00",
  "prescriberID": "sample string 7",
  "prescriberFirstName": "sample string 8",
  "prescriberLastName": "sample string 9",
  "submissionClarificationCode": "sample string 10",
  "reasonForServiceCode": "sample string 11",
  "professionalServiceCode": "sample string 12",
  "resultOfServiceCode": "sample string 13",
  "otherPayerPatientResponsibilityAmount": 1.0,
  "isEmergencyPrescription": true,
  "isCompound": true,
  "compoundIngredients": [
    {
      "productID": "sample string 1",
      "quantity": 2,
      "drugCost": 1.0,
      "basisOfCostDetermination": "sample string 3"
    },
    {
      "productID": "sample string 1",
      "quantity": 2,
      "drugCost": 1.0,
      "basisOfCostDetermination": "sample string 3"
    }
  ],
  "ingredientCostPaid": 1.0,
  "dispenseFeePaid": 1.0,
  "incentiveFee": 1.0,
  "salesTaxPaid": 1.0,
  "copay": 1.0,
  "coinsuranceRate": 1.0,
  "oopCopay": 1.0,
  "oopCoinsuranceRate": 1.0,
  "exemptFromDeductible": true,
  "exemptFromOutOfPocketLimit": true,
  "externalClaimNo": "sample string 14",
  "notes": "sample string 15",
  "diagnosisCodes": [
    {
      "url": "sample string 3",
      "id": 4,
      "dxCode": "sample string 1",
      "dxCodeDescription": "sample string 2"
    },
    {
      "url": "sample string 3",
      "id": 4,
      "dxCode": "sample string 1",
      "dxCodeDescription": "sample string 2"
    }
  ]
}

application/x-www-form-urlencoded

Sample:

Sample not available.

Response Information

Resource Description

If successful, returns a ManualClaimEntryResultModel with the claim number and other relevant information of the new record.

ManualClaimEntryResultModel
NameDescriptionTypeAdditional information
ClaimNo

integer

None.
TransactionResponseStatus

string

None.
RejectMessage

string

None.
PharmacyPrice

decimal number

None.
PatientPayAmount

decimal number

None.
TotalAmountPaid

decimal number

None.
IsSuccessful

boolean

None.

Response Formats

application/json, text/json, application/json-patch+json

Sample: 
{
  "claimNo": 1,
  "transactionResponseStatus": "sample string 2",
  "rejectMessage": "sample string 3",
  "pharmacyPrice": 4.0,
  "patientPayAmount": 5.0,
  "totalAmountPaid": 6.0,
  "isSuccessful": true
}