Chapter 5

Claims Submission

GET PROVIDER TARIFFS

The Tariff API provides endpoints for retrieving tariff information.

  • Endpoint: GET /v1/tariffs
  • Description: Retrieves provider tariffs.

Headers:

Header Value
Authorization Bearer <TOKEN>

Example Request:

  curl -X GET \
    'https://your-api-domain/v1/tariffs' \
    -H 'Authorization: Bearer <YOUR_TOKEN>'

Example Success Response (200 OK):

  {
    "success": true,
    "statusCode": 200,
    "message": [
      "Provider Tariffs retrieved successfully"
    ],
    "data": [
        {
            "id": "462323",
            "provider_id": "PROV-001",
            "name": "Consultation",
            "price": 10000,
            "access_type": "direct"
        },
        {
            "id": "462378",
            "provider_id": "PROV-001",
            "name": "Blood Test",
            "price": 15000,
            "access_type": "pre-auth"
        }
    ]
  }

Example Error Response (404 Not Found):

  {
    "success": false,
    "statusCode": 404,
    "message": [
      "No record found"
    ],
    "data": null
  }

GET UPDATED PROVIDER TARIFFS

  • Endpoint: GET /v1/tariffs/update
  • Description: Retrieves provider tariffs that have been updated as of a given date.

Request Body:

Parameter Type Required Description
given_date date Yes The date to check for updates (YYYY-MM-DD).

Headers:

Header Value
Authorization Bearer <TOKEN>

Example Request:

  curl -X GET \
    'https://your-api-domain/v1/tariffs/update' \
    -H 'Authorization: Bearer <YOUR_TOKEN>' \
    -H 'Content-Type: application/json' \
    -d '{
          "given_date":"2025-07-10"
      }'

Example Success Response (200 OK):

  {
    "success": true,
    "statusCode": 200,
    "message": [
      "Provider Tariffs Updates retrieved successfully"
    ],
    "data": [
        {
            "id": "462323",
            "provider_id": "PROV-001",
            "name": "Consultation",
            "price": 12000,
            "access_type": "direct"
        }
    ]
  }

Example Error Response (404 Not Found):

  {
    "success": false,
    "statusCode": 404,
    "message": [
      "No record found"
    ],
    "data": null
  }

Claim API

SUBMIT MEMBER CLAIM

The Claim API provides endpoints for submitting and managing claims, pre-authorizations, and invoices.

  • Endpoint: POST /v1/claims
  • Description: Submits a new claim for processing.

Headers:

Header Value
Authorization Bearer <TOKEN>

Request Body:

The request body must be a JSON object containing the claim details.

{
    "batch_no": "BATCH-2025-001",
    "authorization_no": "ATI-2025-000001",
    "attendance_date": "2025-07-11",
    "doctor": {
        "name": "KENANI KIZINGA",
        "gender": "MALE",
        "phone": "255763774209",
        "email": "kkinga@bnb.co.tz",
        "license": "MC/3495848",
        "speciality": "GYNAECOLOGIST",
        "level": "SPECIALIST",
        "level_code": "D04"
    },
    "complain": "Patient exhibits several concerning symptoms that align with complications commonly associated with maralia",
    "diagnosis": [
        { "code": "O89.6", "type": "Principal" },
        { "code": "N39.0", "type": "Secondary" },
        { "code": "K20", "type": "Secondary" }
    ],
    "breakup": [
        { "id": "648184", "type": "medication", "quantity": 1, "amount": 16500 },
        { "id": "648137", "type": "medication", "quantity": 1, "amount": 17600 },
        { "id": "417028", "type": "investigation", "quantity": 1, "amount": 5000 },
        { "id": "462323", "type": "investigation", "quantity": 1, "amount": 300000 },
    ]
}

Example Request:

  curl -X POST \
    'https://your-api-domain/v1/claims/submit' \
    -H 'Authorization: Bearer <YOUR_TOKEN>' \
    -H 'Content-Type: application/json' \
    -d '{
        "batch_no": "BATCH-2025-001",
        "authorization_no": "ATI-2025-000001",
        "attendance_date": "2025-07-11",
        "doctor": {
            "name": "KENANI KIZINGA",
            "gender": "MALE",
            "phone": "255763774209",
            "email": "kkinga@bnb.co.tz",
            "license": "MC/3495848",
            "speciality": "GYNAECOLOGIST",
            "level": "SPECIALIST",
            "level_code": "D04"
        },
        "complain": "Patient exhibits several concerning symptoms that align with complications commonly associated with maralia",
        "diagnosis": [
            { "code": "O89.6", "type": "Principal" },
            { "code": "N39.0", "type": "Secondary" },
            { "code": "K20", "type": "Secondary" }
        ],
        "breakup": [
            { "id": "648184", "type": "medication", "quantity": 1, "amount": 16500 },
            { "id": "648137", "type": "medication", "quantity": 1, "amount": 17600 },
            { "id": "417028", "type": "investigation", "quantity": 1, "amount": 5000 },
            { "id": "462323", "type": "investigation", "quantity": 1, "amount": 300000 },
        ]
    }'

Example Success Response (200 OK):

  {
    "success": true,
    "statusCode": 200,
    "message": [
      "Claim submitted successfully"
    ],
    "data": {
      "claim_no": "CLM-2025-0001",
      "amount_claimed": 45000
    }
  }

GET SUBMITTED CLAIMS

  • Endpoint: GET /v1/claims/batch/{batch_no}
  • Description: Retrieves a list of submitted claims for the provider using batch number.

Url Parameters:

Parameter Type Required Description
batch_no string No The batch number to filter claims by.

Headers:

Header Value
Authorization Bearer <TOKEN>

Example Request:

  curl -X GET \
    'https://your-api-domain/v1/claims/batch/BATCH-2025-001' \
    -H 'Authorization: Bearer <YOUR_TOKEN>'

Example Success Response (200 OK):

  {
    "success": true,
    "statusCode": 200,
    "message": [
      "Claims retrieved successfully"
    ],
    "data": [
      {
        "claim_no": "CLM-2025-0001",
        "member_name": "John Doe",
        "attendance_date": "2025-06-20",
        "claimed_amount": 45000,
        "status": "Received"
      }
    ]
  }

GET SUBMITTED CLAIM by claim no

  • Endpoint: GET /v1/claims/{claim_no}
  • Description: Retrieves a submitted claim for the provider using claim number.

Url Parameters:

Parameter Type Required Description
claim_no string No The claim number to filter claims by.

Headers:

Header Value
Authorization Bearer <TOKEN>

Example Request:

  curl -X GET \
    'https://your-api-domain/v1/claims/API2508040001' \
    -H 'Authorization: Bearer <YOUR_TOKEN>'

Example Success Response (200 OK):

  {
    "success": true,
    "statusCode": 200,
    "message": [
      "Claims Retrieved"
    ],
    "data": [
      {
        "claim_no": "API2508040001",
        "member_name": "John Doe",
        "attendance_date": "2025-06-20",
        "claimed_amount": 45000,
        "status": "Received"
      }
    ]
  }

UPLOAD CLAIM ATTACHMENT DOCUMENT

  • Endpoint: POST /v1/claims/doc
  • Description: Upload claim attachment document.

Request Body Parameters:

Parameter Type Description
claim_no string The claim number.
attachment string file in base64 string

Headers:

Header Value
Authorization Bearer <TOKEN>

Example Request:

  curl -X POST \
    'https://your-api-domain/v1/claims/doc' \
    -H 'Authorization: Bearer <YOUR_TOKEN>' \
    -H 'Content-Type: application/json' \
    -d '{
          "claim_no": "PA-25-000001",
      "attachment": "data:image\/jpg;base64,\/9j\/4AAQSkZJRgABAQEAyADIAAD...................."
       }'

Example Success Response (200 OK):

  {
    "success": true,
    "statusCode": 200,
    "message": [
      "Document uploaded successful"
    ],
    "data": null
  }

Example Error Response (404 Not Found):

  {
    "success": false,
    "statusCode": 404,
    "message": [
      "Pre Authorization not found"
    ],
    "data": null
  }