Field | GET | POST | SAML Assertion Attribute | RelayState Request Parameter | RelayState Encryption | SSO NVP | Format | Required | Min. | Max. | Comments | ||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
EmpGroupNumber | ✓ | ✓ | ✓ | ✓ | Alphanumeric, dash | 1 | 80* | Member's Group/Policy Number. Required when userID is not submitted. | All | ||||||||||||
EEID | ✓ | ✓ | ✓ | ✓ | Alphanumeric, dash | 1 | 80* | Member's Employee ID Required when userID is not submitted. | All | ||||||||||||
EmpSequenceNumber | ✓ | ✓ | ✓ | ✓ | Number | 1 | 10* | Member's Dependent Sequence Number Required when userID is not submitted. | All | ||||||||||||
userEmail | ✓ | ✓ | ✓ | Valid email | 5 | 80 | All | ||||||||||||||
claimNumber | ✓ | ✓ | ✓ | ✓ | Any | ✓ | 1 | 50 | Claim Number | New Payment | |||||||||||
patientServiceBeginDate | ✓ | ✓ | ✓ | MM/DD/YYYY or YYYY-MM-DD | ✓ | 1 | 10 | Service From Date | New Payment | ||||||||||||
patientServiceEndDate | ✓ | ✓ | ✓ | MM/DD/YYYY or YYYY-MM-DD | ✓ | 1 | 10 | Service To Date | New Payment | ||||||||||||
amountDue | ✓ | ✓ | ✓ | Decimal with up to 2 decimal places, no dollar sign should be included | ✓ | 1 | 10 | Amount Due | New Payment | ||||||||||||
patientFirstName | ✓ | ✓ | ✓ | ✓ | PaymentFieldType.NAME characters | ✓ | 1 | 50 | Patient First Name | New Payment | |||||||||||
patientLastName | ✓ | ✓ | ✓ | ✓ | PaymentFieldType.NAME characters | ✓ | 1 | 50 | Patient Last Name | New Payment | |||||||||||
patientID | ✓ | ✓ | ✓ | ✓ | Any | ✓ | 1 | 80 | Patient Account Number | New Payment | |||||||||||
claimReferenceNumber | ✓ | ✓ | ✓ | ✓ | Any | ✓ | 1 | 200 | Claim Reference Number | New Payment | |||||||||||
providerBillingTIN | ✓ | ✓ | ✓ | ✓ | 9 digits number | ✓ | 9 | 9 | Provider TIN | New Payment | |||||||||||
payToProviderName | ✓ | ✓ | ✓ | ✓ | Any | ✓ | 1 | 100 | Provider Business Name | New Payment | |||||||||||
payToProviderAddress1 | ✓ | ✓ | ✓ | ✓ | Any | ✓ | 1 | 200 | Provider Address 1 | New Payment | |||||||||||
payToProviderAddress2 | ✓ | ✓ | ✓ | ✓ | Any | ✓ | 1 | 200 | Provider Address 2 | New Payment | |||||||||||
payToProviderCity | ✓ | ✓ | ✓ | ✓ | Any | ✓ | 1 | 50 | Provider City | New Payment | |||||||||||
payToProviderState | ✓ | ✓ | ✓ | ✓ | Valid two digit state | ✓ | 1 | 2 | Provider State | New Payment | |||||||||||
payToProviderZip | ✓ | ✓ | ✓ | ✓ | Valid zip code | ✓ | 1 | 10 | Provider Zip | New Payment | |||||||||||
templateID | ✓ | ✓ | Any | ✓ | 1 | 100 | TemplateID | All | |||||||||||||
payToProviderPhone | ✓ | ✓ | ✓ | ✓ | Any | ✓ | 1 | 50 | Provider Phone | New Payment | |||||||||||
renderingProviderName | ✓ | ✓ | ✓ | ✓ | Any | ✓ | 1 | 50 | Rendering Provider Name | New Payment | |||||||||||
payerInternalProviderID | ✓ | ✓ | ✓ | ✓ | Any | 1 | 80 | Internal Provider ID | New Payment | ||||||||||||
EMPHSAACCTNUM | ✓ | ✓ | ✓ | ✓ | Numeric; can be “NA” if no information is available | 1 | 50 | HSA Account Number | New Payment | ||||||||||||
EMPHSAACCTBAL | ✓ | ✓ | ✓ | ✓ | Decimal; can be “NA” if no information is available | 1 | 10 | HSA Account Balance | New Payment | ||||||||||||
EMPFIRSTNAME | ✓ | ✓ | ✓ | ✓ | X12FieldType.NAME characters; can be “NA” if no information is available | 1 | 50 | HSA Account Holder First Name | New Payment | ||||||||||||
EMPLASTNAME | ✓ | ✓ | ✓ | ✓ | X12FieldType.NAME characters; can be “NA” if no information is available | 1 | 50 | HSA Account Holder Last Name | New Payment | ||||||||||||
EMPSTREETADDRESS1 | ✓ | ✓ | ✓ | ✓ | X12FieldType.ADDRESS; can be “NA” if no information is available | 1 | 50 | HSA Account Holder Address 1 | New Payment | ||||||||||||
EMPSTREETADDRESS2 | ✓ | ✓ | ✓ | ✓ | X12FieldType.ADDRESS; can be “NA” if no information is available | 1 | 50 | HSA Account Holder Address 2 | New Payment | ||||||||||||
EMPCITY | ✓ | ✓ | ✓ | ✓ | X12FieldType.ADDRESS; can be “NA” if no information is available | 1 | 30 | HSA Account Holder City | New Payment | ||||||||||||
EMPSTATE | ✓ | ✓ | ✓ | ✓ | Two letter state; can be “NA” if no information is available | 1 | 2 | HSA Account Holder State | New Payment | ||||||||||||
EMPZIP | ✓ | ✓ | ✓ | ✓ | Numeric; can be “NA” if no information is available | 1 | 5 | HAS Account Holder Zip | New Payment | ||||||||||||
PATDATEOFBIRTH | ✓ | ✓ | ✓ | MM/DD/YYYY or YYYY-MM-DD; can be “NA” if no information is available | 1 | 10 | Patient Date of Birth | New Payment | |||||||||||||
PROVIDEREMAIL | ✓ | ✓ | ✓ | Valid email; can be “NA” if no information is available | 5 | 80 | Provider Email | New Payment | |||||||||||||
PROVNPI | ✓ | ✓ | ✓ | 10 digits number | 10 | 10 | Provider NPI | New Payment | |||||||||||||
transactionID | ✓ | ✓ | ✓ | AN | ✓ | 1 | 50 | Payment transaction ID | View Receipt |