Claims Processing API¶

The Claims Processing API provides a unified interface for grouping, editing, and pricing healthcare claims across multiple care settings. It wraps official CMS logic to ensure accurate reimbursement calculations.

Overview¶

The API accepts a standardized Claim object and processes it through one or more requested Modules (Groupers, Editors, or Pricers).

Base Path: /api/v1/myelin

Authentication: Required (Bearer token or API Key)

Endpoints¶

Process Claim¶

Submit a claim for processing. The specific logic applied depends on the modules list provided in the request body.

Endpoint: POST /myelin/process/pps

Request Body: Claim object (JSON)

Response: MyelinOutput object (JSON)

Example Request:

curl -X POST \
  -H "Authorization: sk_live_abc123..." \
  -H "Content-Type: application/json" \
  -d '{
    "claimid": "TEST-001",
    "modules": ["MSDRG", "IPPS"],
    "from_date": "2025-01-01",
    "thru_date": "2025-01-05",
    "admit_date": "2025-01-01",
    "bill_type": "111",
    "patient_status": "01",
    "total_charges": 15000.00,
    "principal_dx": { "code": "I50.21" },
    "billing_provider": {
        "npi": "1234567890",
        "other_id": "123456",
        "additional_data": {
            "ipsf": {
                "operating_cost_to_charge_ratio": 0.25
            }
        }
    }
  }' \
  "https://api.example.com/api/v1/myelin/process/pps"

Data Models¶

Claim Object¶

The Claim object is the central input structure. Not all fields are required for every module.

Supported Modules¶

Sub-Objects¶

DiagnosisCode¶

{
  "code": "I50.21",
  "poa": "Y",       // Present on Admission: Y, N, U, W, 1, or blank
  "dx_type": 1      // 1=Primary, 2=Secondary (optional, inferred from position)
}

ProcedureCode¶

{
  "code": "02HV33Z",
  "date": "2025-01-02"
}

LineItem¶

Used primarily for outpatient (OPPS), HHA, and Hospice claims.

{
  "revenue_code": "0450",
  "hcpcs": "99285",
  "service_date": "2025-01-01",
  "units": 1,
  "charges": 500.00,
  "modifiers": ["25"]
}

Provider¶

{
  "npi": "1234567890",
  "other_id": "123456", // CMS Certification Number (CCN)
  "additional_data": {
      "ipsf": {
          // Overrides for provider-specific factors
          "operating_cost_to_charge_ratio": 0.25,
          "special_wage_index": 1.05
      }
  }
}

Response Structure¶

The response contains a field for each module run, plus any errors.

{
  "msdrg": {
    "drg": "291",
    "description": "HEART FAILURE & SHOCK W MCC",
    "weight": 1.2345,
    "mdc": "05",
    "geometric_mean_los": 4.5,
    "arithmetic_mean_los": 5.2
  },
  "ipps": {
    "total_payment": 12500.50,
    "federal_payment": 11000.00,
    "outlier_payment": 0.0,
    "capital_payment": 1500.50,
    "return_code": "00"
  },
  "error": null
}

Error Handling¶

If a critical error occurs (e.g., missing required fields for a module), the error field will be populated, and the HTTP status code may be 400 or 500.

Common Workflows¶

Inpatient Coding & Pricing (IPPS)¶

1. Modules: ["MCE", "MSDRG", "IPPS"]
2. Required Fields: admit_date, bill_type, principal_dx, inpatient_pxs (if any), patient_status, total_charges, provider.

Outpatient Pricing (OPPS)¶

1. Modules: ["IOCE", "OPPS"]
2. Required Fields: bill_type (e.g., "131"), lines (with HCPCS/CPT), diagnosis_codes.

Home Health (PDGM)¶

1. Modules: ["HHAG", "HHA"]
2. Required Fields: from_date, thru_date, admit_date, principal_dx, oasis_assessment (clinical/functional levels).

Health Check¶

Check the status of the Myelin service.

Endpoint: GET /myelin/health

Response:

{
  "message": "Myelin service is healthy"
}

Usage Limits & Rate Limiting¶

The Claims Processing API is subject to organization-level usage limits based on your subscription plan.

• Monthly Limit: The number of claims you can process per month is determined by your plan.
• Rate Limit: Standard API rate limits (100 req/min) also apply.

Exceeding Limits¶

If you exceed your monthly claim limit, the API will return a 429 Too Many Requests error.

{
  "detail": "Usage limit exceeded. Your organization has reached its monthly limit of 1000 claims (current: 1001). Contact support to increase your limit."
}

The Retry-After header will indicate when the limit resets (typically the start of the next billing cycle).