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

Name	Description	Type	Additional information
groupid		integer	Required

Body Parameters

The model containing the claim details.

MemberManualClaimEntryModel

Name	Description	Type	Additional 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": "2025-12-09T20:11:25.0707694-06:00",
  "flatSalesTax": 1.0,
  "salesTaxPercent": 1.0,
  "dawCode": "sample string 6",
  "dateWritten": "2025-12-09T20:11:25.0707694-06:00",
  "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

Name	Description	Type	Additional 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.
ResponseString	NCPDP Response String (Base64 encoded)	string	None.
AdminFee		decimal number	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,
  "responseString": "sample string 8",
  "adminFee": 9.0
}