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This chapter describes how to create ADF data controls for SOAP and REST web services so that you can better use those services in the user interface.

This chapter includes the following sections:

5.1 About Web Services in Fusion Web Applications

Web services allow enterprises to expose business functionality irrespective of the platform or language of the originating application because the business functionality is exposed in such a way that it is abstracted to a message composed of standard XML constructs that can be recognized and used by other applications.

Web services are modular business services that can be easily integrated and reused, and it is this that makes them ideally suited as components within SOA. JDeveloper helps you to create top-down web services (services created starting from a WSDL), bottom-up web services (created from the underlying implementation such as a Java class or a PL/SQL stored procedure in a database), and services created from existing functionality, such as exposing an application module as a service.

5.1.1 Web Services Use Cases and Examples

You can consume web services in web applications, and common reasons for wanting to do so are:

  • To add functionality which would be time-consuming to develop with the application, but which is readily available as a web service

  • To access an application that runs on different architecture

  • To access an application that is owned by another team when their application must be independently installed, upgraded, and maintained, especially when its data is not replicated locally (for example, when other methods of accessing their application cannot be used)

5.1.2 Additional Functionality for Web Services in Fusion Applications

You may find it helpful to understand other Oracle ADF features before you start working with web services. Following are links to other functionality that may be of interest.

  • You can design a databound user interface by dragging an item from the Data Controls panel and dropping it on a page as a specific UI component. For more information, see Section 2.3.1, 'How to Use the Data Controls Panel.'

  • If you are working behind a firewall and you want to use a web service that is outside the firewall, you must configure the web browser and proxy settings in JDeveloper, as described in 'Setting Browser Proxy Information' in Developing Fusion Web Applications with Oracle Application Development Framework.

The following chapters provide information about specific objects you can use in data controls:

  • For information about using collections on a data control to create forms, see 'Creating a Basic Databound Page' in Developing Fusion Web Applications with Oracle Application Development Framework.

  • For information about using collections to create tables, see 'Creating ADF Databound Tables' in Developing Fusion Web Applications with Oracle Application Development Framework.

  • For information about using master-detail relationships to create UI components, see 'Displaying Master-Detail Data' in Developing Fusion Web Applications with Oracle Application Development Framework.

  • For information about creating lists, see 'Creating Databound Selection Lists and Shuttles' in Developing Fusion Web Applications with Oracle Application Development Framework.

  • For information about creating graphs, charts, and other visualization UI components, see 'Creating Databound Graph and Gauge Components' in Developing Fusion Web Applications with Oracle Application Development Framework.

5.2 Creating Web Service Data Controls

The most common way of using web services in an application developed using Oracle ADF is to create a data control for an external web service. A typical reason for doing this is to add functionality that is readily available as a web service, but which would be time consuming to develop with the application, or to access an application that runs on a different architecture.

Additionally, you can reuse components created by Oracle ADF to make them available as web services for other applications to access.

5.2.1 How to Create a Data Control for a SOAP-based Web Service

JDeveloper allows you to create a data control for an existing web service using just the WSDL for the service. You can browse to a WSDL on the local file system, locate one in a UDDI registry, or enter the WSDL URL directly.

Note:

If you are working behind a firewall and you want to use a web service that is outside the firewall, you must configure the web browser and proxy settings in JDeveloper. For more information, see 'Setting Browser Proxy Information' in Developing Fusion Web Applications with Oracle Application Development Framework.

Before you begin:

It may be helpful to have an understanding of how web service data controls are used in Fusion web applications. For more information, see Section 5.2, 'Creating Web Service Data Controls.'

You may also find it helpful to understand additional functionality that can be added using other web services features. For more information, see Section 5.1.2, 'Additional Functionality for Web Services in Fusion Applications.'

You will need to complete this task:


Create an application workspace and a project in that workspace. Depending on how you are organizing your projects, you can use an existing application workspace and project or create new ones. For information on creating an application workspace, see 'Creating Applications and Projects' in Developing Applications with Oracle JDeveloper.

To create a data control for a SOAP-based web service:

  1. In the Applications window, right-click the project in which you want to create a web service data control and choose New > From Gallery.

  2. In the New Gallery, expand Business Tier, select Web Services and then Web Service Data Control (SOAP/REST), and click OK.

  3. In the Create Web Service Data Control wizard, on the Data Source page, type a name for the data control, select the SOAP radio button, enter a WSDL URL, and the specify the specific web service to be accessed by the data control.

  4. On the Data Control Operations page, shuttle the operations that you want the data control to support to the Selected panel.

    Optionally, select the Include HTTP Header Parameter checkbox. For more information, see Section 5.2.3, 'How to Include a Header Parameter for a Web Service Data Control.'

  5. On the Response Format page, specify the format of the SOAP response.

  6. On the Endpoint Authentication page, specify the authentication details for the endpoint URL, and click Finish.

5.2.2 How to Create a Data Control for a RESTful Web Service

JDeveloper allows you to create a data control for a REST web service using a connection to the web service and schema for the methods that you want to invoke.

Before you begin:

It may be helpful to have an understanding of how web service data controls are used in Fusion web applications. For more information, see Section 5.1, 'About Web Services in Fusion Web Applications.'

You may also find it helpful to understand additional functionality that can be added using other web services features. For more information, see Section 5.1.2, 'Additional Functionality for Web Services in Fusion Applications.'

You will need to complete this task:


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Create an application workspace and a project in that workspace. Depending on how you are organizing your projects, you can use an existing application workspace and project or create new ones. For information on creating an application workspace, see 'Creating Applications and Projects' in Developing Applications with Oracle JDeveloper.Goodbye 3 5.2 Denial Of Service Tool

To create a data control for a RESTful web service:

Service

  1. In the Applications window, right-click the project in which you want to create a web service data control and choose New > From Gallery.

  2. In the New Gallery, expand Business Tier, select Web Services and then Web Service Data Control (SOAP/REST), and click OK.

  3. In the Create Web Service Data Control wizard, on the Data Source page, specify a name for the data control and select the REST radio button.

  4. In the Connection field, select the URL connection to use.

    If you have not established a URL connection, click the Create a new URL connection icon to open the Create URL Connection dialog. In that dialog, enter a name for the connection and a base URL. Do not include any resources or parameters in the URL.

    Note:

    In the Create URL Connection dialog, you can click Test Connection to verify that you can connect to the URL. However, the URL's server may be configured to not accept requests on the base URL, meaning that the test will fail. Regardless of that fact, you can click OK to create the connection.

    If you have such a base URL and would like to make sure that you can connect to the service, you can temporarily add a resource to the URL, test the connection, and then remove the resource before clicking OK.

  5. Insydeflash for win 10. On the Resources page, specify a resource for the connection by completing the following sub-steps for each resource:

    1. Click the Add button to add a resource path.

    2. Type the name of the resource path inline.

      As part of the resource path you can also enter path parameters.

      Enter any path parameters in the form ##paramName##. For example, if the web service to be accessed supplies stock quotes, the full URL for the resource for one of the stocks is http://www.example.com/quotes/ACOMPANY, and the path parameter name is ticker, you would enter the following as the resource path:/quotes/##ticker##.

      Note:

      You can also use a parameter to provide dynamic input for the source path (for example, /##servicename##/##ticker##) where the user would be expected to also provide the service name (such as quote).

      If you wish to create any resources with query parameters (i.e. parameters that take the form ?ParamName=ParamValue), you can specify those parameters on the next page of the wizard.

    3. In the right side of the dialog, select one of the checkboxes to specify a REST method for the resource path and then type a name that you can use to identify that method in the Data Controls panel.

  6. Repeat step 5 for each resource you would like to include in the data control.

    Figure 5-1 shows the Resources page of the wizard with two resources entered, the second of which includes a path parameter. As shown in the figure, the second resource is selected and a GET method is specified for it.

    Figure 5-1 Resources Page of Create Web Service Data Control Wizard


  7. On the Method Details page, select a method and specify an XSD file that provides the response format for that method.

    Tip:

    If you do not have a schema for the response format, you can create one yourself by recreating the XML for the resource based on its documentation and then creating an XSD from that XML file. In JDeveloper, you can generate an XSD file from an XML document by choosing File > New > From Gallery > XML > XML Schema from XML Document.

  8. If the method is a PUT or POST method, specify a schema for the request payload in the Payload XSD field.

  9. For the selected method, specify any URL parameters and default values.

    For parameters that were included in the resource path, the parameter names are included in the URL Parameters list. For these parameters, you need to fill in a default value.

    For example, from the sample parameter shown in step 5, ticker would be the parameter name and ACOMPANY could be the default value.

  10. Optionally, select the Include HTTP Header Parameter checkbox. For more information, see Section 5.2.3, 'How to Include a Header Parameter for a Web Service Data Control.'

  11. Repeat steps 7 through 10 for each method.

    Figure 5-2 shows the Method Details page with the getDetails method selected, a response XSD specified, and default value set for its deptId parameter.

    Figure 5-2 Method Details Page of the Create Web Service Data Control Wizard


  12. On the Finish page, review the details of the data control to be generated, and click Finish.

5.2.3 How to Include a Header Parameter for a Web Service Data Control

When using a web service data control, you may want to add a custom parameter to the HTTP header when invoking the HTTP request. Such a parameter can be useful for a variety of purposes, including for security or for notifications. For example, you may want to add an enterprise ID to the HTTP header when invoking the request. This enterprise ID in the request allows the web service data control to specify which cloud service the request will be directed to.

To configure the web service data control to use a header parameter, you select Include Http Header Parameter in the Create Web Service Data Control wizard. For SOAP-based web service data controls, this is on the Data Control Operations page. For REST-based web service data controls, it is on the Method Details page.

After creating the data control, you will be able to see the HttpHeader parameter in the Data Controls panel under the Parameters node of the web service data control's methods. In addition, the AdapterDataControl element for the web service data control (in the .dcx file) contains an <httpHeaders paramName='HttpHeader'/> element.

5.2

To use the HttpHeader parameter, you will need to create a backing bean in the user interface project for the web service data control. The value for the HttpHeader parameter is provided through the backing bean. The backing bean must have a property of the type Map and the name/value pairs for the HTTP headers should be added to that property. Additionally, the Map must be of type <String, List<String>> or <String,String>, and you should expose the property with getter and setter methods, as shown Example 5-1.

Example 5-1 Backing Bean to Support Http Header Parameters in a Web Service Data Control

When you drag and drop the operation from the Data Controls panel onto a page as an ADF Parameter Form, remove the HttpHeader from the list of fields. Then, in the Edit Action Binding dialog, under the Parameters section specify the value for HttpHeader parameter by providing an expression that points to the backing bean Map property.

5.2.4 How to Adjust the Endpoint for a SOAP Web Service Data Control

After developing a web service data control, you can modify the endpoint. This is useful, for example, when you migrate the application from a test environment to production.

Before you begin:

It may be helpful to have an understanding of how web service data controls are used in Fusion web applications. For more information, see Section 5.2, 'Creating Web Service Data Controls.'

You may also find it helpful to understand additional functionality that can be added using other web services features. For more information, see Section 5.1.2, 'Additional Functionality for Web Services in Fusion Applications.'

To change the endpoint for a web service data control:

  1. In the Applications window, select the DataControls.dcx file for the web service data control.

  2. In the Structure window, right-click the web service data control and choose Edit Web Service Connection.

  3. In the Edit Web Service Connection dialog, make the necessary changes to the endpoint URL and port name.

  4. Click OK.

5.2.5 How to Refresh a Web Service Data Control

After updating a SOAP-based web service data control, you might find that a web service operation has changed in its method signature, return type, or structure. When this happens, you can update the data control without having to re-create it.

Before you begin:

It may be helpful to have an understanding of how web service data controls are used in Fusion web applications. For more information, see Section 5.2, 'Creating Web Service Data Controls.'

You may also find it helpful to understand additional functionality that can be added using other web services features. For more information, see Section 5.1.2, 'Additional Functionality for Web Services in Fusion Applications.'

To refresh an operation in a SOAP-based web service data control:

  1. In the Applications window, select the DataControls.dcx file for the web service data control.

  2. In the Structure window, right-click the desired web service operation and choose Update.

JDeveloper queries the web service and updates the web service data control to reflect the current state of the selected operation.

5.2.6 What You May Need to Know About Primary Keys in SOAP-Based Web Service Data Controls

When you create a data control on a SOAP-based web service, the data control supports primary key operations on any exposed collection.

Zip to dma mapping. If the web service definition references a schema that defines an element or attribute as type xsd:ID, the data control will expose the attribute as a key attribute and make the setCurrentRowWithKey and setCurrentRowWithKeyValue data control operations available for the collection.

For example, your schema could set the deptno attribute as the primary key using the <xsd:attribute> element as shown below:

Or the schema could set the deptno attribute as the primary key using the <xsd:element> element as shown below:

Note:

The XSD entries shown above are generated at runtime if you have created the web service from a Java class and added the JAXB @XmlID annotation and either @XmlAttribute(required=true) or @XmlElement(required=true) to the field or the getter method representing the key.

If no ID is defined for a collection in one of the above ways, the data control creates a hidden attribute for the collection that serves as an index-based primary key. You can then use the setCurrentRowWithKey or setCurrentRowWithKeyValue data control operation to pass the index of the row.

Note:

If you do not see the setCurrentRowWithKey or setCurrentRowWithKeyValue operations for a collection in the Data Controls panel, you may need to manually update the DataControls.dcx file to have those operations exposed. To do so, open the Source view of the DataControls.dcx and change the value of the service's ensureKeyAttribute property to true. Then, in the Data Controls panel, click the Refresh icon to refresh the list of operations.

5.2.7 What You May Need to Know About Web Service Data Controls

As with other kinds of data controls, you can design a databound user interface by dragging an item from the Data Controls panel and dropping it on a page as a specific UI component. For more information, see Section 2.3.1, 'How to Use the Data Controls Panel.'

In the Data Controls panel, each data control object is represented by an icon. Table 5-1 describes what each icon represents, where it appears in the Data Controls panel hierarchy, and what components it can be used to create.

Table 5-1 Data Controls Panel Icons and Object Hierarchy for Web Services

IconNameDescriptionUsed to Create..

Data Control

Represents a data control. You cannot use the data control itself to create UI components, but you can use any of the child objects listed under it. Typically, there is one data control for each web service.

Serves as a container for other objects and is not used to create anything.

Collection

Represents a data collection returned by an operation on the service. Collections also appear as children under method returns, other collections, or structured attributes. The children under a collection may be attributes, other collections, custom methods, and built-in operations that can be performed on the collection.

Forms, tables, graphs, trees, range navigation components, and master-detail components.

For more information, see 'Creating a Basic Databound Page,'Creating ADF Databound Tables,'Displaying Master-Detail Data,' and 'Creating Databound Graph and Gauge Components' in Developing Fusion Web Applications with Oracle Application Development Framework.

Attribute

Represents a discrete data element in an object (for example, an attribute in a row). Attributes appear as children under the collections or method returns to which they belong.

Label, text field, date, list of values, and selection list components.

For more information, see 'Creating Text Fields Using Data Control Attributes' in Developing Fusion Web Applications with Oracle Application Development Framework.

Structured Attribute

Represents a returned object that is a complex type but not a collection. For example, a structured attribute might represent a single user assigned to the current service request.

Label, text field, date, list of values, and selection list components.

For more information, see 'Creating Text Fields Using Data Control Attributes' and 'Creating Databound Selection Lists and Shuttles' in Developing Fusion Web Applications with Oracle Application Development Framework.

Method

Represents an operation in the data control or one of its exposed structures that may accept parameters, perform some business logic and optionally return single value, a structure or a collection of those.

Command components.

For methods that accept parameters: command components and parameterized forms.

For more information, see 'Using Command Components to Invoke Functionality in the View Layer'

Method Return

Represents an object that is returned by a web service method. The returned object can be a single value or a collection.

A method return appears as a child under the method that returns it. The objects that appear as children under a method return can be attributes of the collection, other methods that perform actions related to the parent collection, and operations that can be performed on the parent collection.

When a single-value method return is dropped, the method is not invoked automatically by the framework. You should either drop the corresponding method as a button to invoke the method, or if working with task flows you can create a method activity for it. For more information about executables, see 'Executable Binding Objects Defined in the Page Definition File' in Developing Fusion Web Applications with Oracle Application Development Framework

The same components as for collections and attributes and for query forms.

For more information on query forms, see 'Creating ADF Databound Search Forms' in Developing Fusion Web Applications with Oracle Application Development Framework.

Operation

Represents a built-in data control operation that performs actions on the parent object. Data control operations are located in an Operations node under collections. If an operation requires one or more parameters, they are listed in a Parameters node under the operation.

The following operations for navigation and setting the current row are supported: First, Last, Next, Previous, setCurrentRowWithKey, and SetCurrentRowWithKeyValue. Execute is supported for refreshing queries. Create and Delete are available as applicable, depending on the web service operation. Because the web service data controls are not transactional, Commit and Rollback are not supported.

UI command components, such as buttons, links, and menus.

For more information, see 'Creating Command Components Using Data Control Operations' and 'Creating an Input Form' in Developing Fusion Web Applications with Oracle Application Development Framework.

Parameter

Represents a parameter value that is declared by the method or operation under which it appears. Parameters appear in the Parameters node under a method or operation.

Array and structured parameters are exposed as updatable structured attributes and collections under the data control, which can be dropped as an ADF form or an updatable table on the UI. You can use the UI to build a parameter that is an array or a complex object (not a standard Java type).

Label, text, and selection list components.


5.3 Securing Web Service Data Controls

Web services allow applications to exchange data and information through defined application programming interfaces. SSL (Secure Sockets Layer) provides secure data transfer over unreliable networks, but SSL only works point to point. Once the data reaches the other end, the SSL security is removed and the data becomes accessible in its raw format. A complex web service transaction can have data in multiple messages being sent to different systems, and SSL cannot provide the end-to-end security that would keep the data invulnerable to eavesdropping.

Any form of security for web services has to address the following issues:

  • The authenticity and integrity of data

  • Data privacy and confidentiality

  • Authentication and authorization

  • Non-repudiation

  • Denial of service attacks

Throughout this section the 'client' is the web service data control, which sends SOAP or REST messages to a deployed web service. The deployed web service may be:

  • A web service running on Oracle WebLogic Server

  • A web service running anywhere in the world that is accessible through the Internet

5.3.1 Oracle WSM Policy Framework

You can use Oracle Web Services Manager (WSM) policy framework to manage and secure web services consistently across your organization. The policy framework is built using the WS-Policy standard, which unifies multiple technologies to make secure web services interoperable between systems and platforms.

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Among others, the Oracle WSM Policy Framework addresses the following aspects of web services security issues:

  • Authentication and authorization

    The identity of the sender of the data is verified, and the security system ensures that the sender has privileges to perform the data transaction.

    The type of authentication can be a basic username/password pair transmitted in plain text, or trusted X509 certificate chains. SAML assertion tokens can also be used to allow the client to authenticate against the service, or allow it to participate in a federated SSO environment, where authenticated details are shared between domains in a vendor-independent manner.

  • Data authenticity, integrity, and non-repudiation

    XML digital signatures, which use industry-standard messages, digest algorithms to digitally sign the SOAP message.

  • Data privacy

    XML encryption that uses industry-standard encryption algorithms to encrypt the message.

  • Denial of service attacks

    Defines XML structures to time-stamp the SOAP message. The server uses the time stamp to invalidate the SOAP message after a defined interval.

For more information on web service security, see Understanding Oracle Web Services Manager

5.3.2 Using Key Stores

A web service can be configured for message-level security using key stores. For more information about creating and using key stores for message protection, see Administering Web Services.

5.3.3 How to Define SOAP-Based Web Service Data Control Security

After you create a SOAP-based web service data control in a JDeveloper project, you can define security for the data control using the Edit Data Control Policies dialog.

Before you begin:

It may be helpful to have an understanding of how security is used in web service data controls. For more information, see Section 5.3, 'Securing Web Service Data Controls.'

You may also find it helpful to understand additional functionality that can be added using other web services features. For more information, see Section 5.1.2, 'Additional Functionality for Web Services in Fusion Applications.'

To define security for a web service data control:

  1. In the Applications window, select the web service data control DataControls.dcx file.

  2. In the Structure window, right-click the web service data control and choose Define Web Service Security.

    JDeveloper displays the Edit Data Control Policies dialog, which shows the Policy Store location.

    Note:

    If you want to use an alternative policy store, you must first specify it in the WS Policy Store page of the Preferences dialog. To do so, from the main menu, choose Tools > Preferences and select the WS Policy Store page.

  3. From the Ports dropdown list, select the port to which you want then specified policies applied.

  4. From the MTOM dropdown list, select the MTOM (message transmission optimization mechanism) policy you want to use. If you leave this field blank, no MTOM policy is used.

  5. From the Reliability dropdown list, select the reliability policy you want to use. If you leave this field blank, no reliability policy is used.

  6. From the Addressing dropdown list, select the addressing policy you want to use. If you leave this field blank, no addressing policy is used.

  7. In the Security list, you can optionally specify additional security policies to apply. To add a policy, select its checkbox.

  8. In the Management list, you can optionally specify additional management policies to apply. To add a policy, select its checkbox.

  9. If necessary, you can also remove policies from the Security list and the Management lists by deselecting their corresponding checkboxes.

  10. You can optionally override properties for the policies in the Security list and the Management list by clicking Override Properties.

  11. Click OK.

For more information about predefined policies and configuring policies and their properties, see Administering Web Services.

Denial Codes in Medical Billing – Lists:

CO – Contractual Obligations
OA – Other Adjsutments
PI – Payer Initiated reductions
PR – Patient Responsibility

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Let us see some of the important denial codes in medical billing with solutions:

Denial CodesDenial Codes / Remit Codes Description in Medical BillingDenial Codes in Medical Billing / Remit Codes -Solutions or Questions need to ask with Insurance representative.
PR 1Deductible Amount1) Get the processed date?
2) Get the allowed amount and the amount that was applied towards the patient's deductible?
3) Get the payment details if there was any?
4) Get the patient's calendar year/lifetime deductible and how much of it has been met? (Note: If annual deductible is already met , reprocess the claim)
5) Get if the claim is processed towards in network or out of network deductible and how much deductible?
6) Get the Claim number and Calreference number?
PR 2Coinsurance: Percentage or amount defined in the insurance plan for which the patient is responsible.1) Get the processed date?
2) Get the allowed amount, paid details if any and the amount that was applied towards the patient's Coinsurance?
3) Get the Claim number and Calreference number?
PR 3Copayment1) Get the processed date?
2) Get the allowed amount, paid details if any and the amount that was applied towards the patient's Copayment?
3) Get the Claim number and Calreference number?
4Description for Denial code - 4 is as follows 'The px code is inconsistent with the modifier used or a required modifier is missing'.1) Get the Denial Date?
2) Verify whether modifier is inconsistent with procedure code or modifier missing?
3) Send for reprocess and collect the follow up date, if the denial is incorrect
4) Get the appeals information/ corrected claims address/ TFL to submit corrected claim
5) Get the Claim number and Calreference number
Note: If the modifier is inconsistent with procedure code or modifier missing. Correct the modifier and resubmit the claim as corrected claim.
(If the modifier submitted is correct and if the representative denies to send the claim back for reprocessing, then you have rights to appeal the claim along with medical records.)
5Denial Code - 5 is 'Px code/ bill type is inconsistent with the POS'
POS: It is the place where the services rendered to patient		1) Get the Denial Date?
2) Verify whether procedure code is inconsistent with the place of service or bill type is inconsistent with the POS?
3) Send for reprocess and collect the follow up date, if the denial is incorrect
4) Get the appeals information/ correct claims address/ TFL to submit corrected claim
5) Get the Claim number and Calreference number
Note: Correct and resubmit the claim as corrected claim, if the procedure code or bill type is inconsistent with the place of service.
(If the procedure code/ bill type is correct with the place of service submitted and if the representative denies to send the claim back for reprocessing, then you have rights to appeal the claim along with medical records.)
6The procedure code/ revenue code is inconsistent with the patient's ageAsk the same questions as denial code - 5, but here need check which procedure code submitted is incompatible with patient's age?
May I know which procedure/revenue code invalid for the Patient Age ?
Just to understand consider the below example:
If you see the procedure codes list 99381 to 99387(New patient Initial comprehensive preventive medicine), it should bee coded based on the patient's age.
99381 coded when patient's age younger than 1 year.
99382 coded when patient's age 1 through 4 years.
99383 age 5 through 11 years.
99384 age 12 through 17 years.
99385 age 18 to 39 years.
99386 age 40 to 64 years.
99387 age 65 years and older.
Similar to the above example, there are some CPT's listed which needs to be coded based on patients age.
7The procedure code/ revenue code is inconsistent with the Patient's genderAsk the same questions with representative as denial code - 5, but here check which procedure code submitted is incompatible with patient's gender.
May I know which procedure/revenue code invalid with the Patient Gender ?
8The procedure code is inconsistent with the provider type/speciality (Taxonomy)Ask the same questions as denial code - 5, but here check which procedure code submitted is incompatible with provider type.
9The Diagnosis Code is inconsistent with the patient's ageSame as denial code - 11, but here check which dx code submitted is incompatible with patient's age
May I know which Diagnosis code invalid for the Patient age ?
10The Diagnosis Code is inconsistent with the patient's genderAsk the same questions as denial code 11, but here check which DX code submitted is incompatible with patient's gender
May I know which Diagnosis code invalid with the Patient Gender ?
11Denial code - 11 described as the 'Dx Code is in-consistent with the Px code billed'.1) Get the denial date?
2) Verify the procedure is inconsistent with which Diagnosis?
3) If the denial is incorrect send for reprocess?
4) Inform that we are going to submit the corrected claim with valid codes if the denial is correct and get the corrected claim address and time frame to submit corrected claim?
5) Get the Claim number and Cal reference number?
12The Diagnosis code is inconsistent with the provider typeSame as denial code - 11, but here check which DX code submitted is incompatible with provider type
13The Date of Death Precedes Date of Service1) Get the Claim denial date?
2) Get the date of death and verify with the date service provided?
3) If the date service provided is prior to the date of death, then send the claim back for reprocess?
4) If the denial is correct, then adjust the claims which precedes the date of death
4) Get the Claim# and Calref#
Note: Usually we get this denials when billing DME services
14The DOB follows the DOS
15Denial code - 15.
16Denial Code 16 described as 'Claim/service lacks information or has submission/billing error(s) which is required for adjudication'.1) Get the denial date
2) Check to see what information required from patient or provider to process the claim?
3) If the information requested from patient, then check when the letter was sent requesting that information and also check whether the patient updated the requested info or not?
4) If patient has already updated the requested info, send the claim back for reprocessing. If still patient not updated the requested information, then request representative to resend the letter onceagain to patient.
5) Claim number and Calreference number (Get the appeal information, if claims needs to be appealed)
Note: If the information requested is from provider, then update the requested info to the insurance for processing the claim.
17Denial Code 17
18Denial Code - 18 described as 'Duplicate Claim/ Service'.1) Get the denial date?
2) Get the DOS, billed amount, rendering physcian's name, Procedure code and Diagnosis code?
3) Send the claim back for reprocesisng , if it wasn't a Duplicate claim
4) Get the status of original claim, if the claim was denied as a duplicate claim?
If the claim denied incorrectly and rep disagreed to the claim back for reprocessing (Ge the appeal information, if claim needs to be appealed)
6) Get the Claim number of Duplicate Claim as well as Original Claim and Calreference number
19'Denial Code 19'.
20Denial Code - 20
21Denial code - 21
22Denial Code 22 described as 'This services may be covered by another insurance as per COB'.1) Get Denial Date?
2) Check any letter sent to patient?
3) If yes, check when and have they got any response from patient?
4) If response received (Coordination of Benefit's (COB) updated by patient), then send the claim back for reprocessing?
5) If no, then request representative to send a letter to patient(requesting update COB information)
6) Claim Number and Calreference Number
23Denial Code 231) Get Claim Denial date?
2) Get the allowed amount of the procedure code?
3) Check prior payer paid amount in application, if it is less than secondary insurance allowed amount send the claim back for reprocess
4) Claim number and Calreference Number
24Denial Code 24 described as 'Charges are covered by a capitation agreement/ managed care plan'.1) Get Claim Denial date?
2) Verify, is the beneficiary enrolled in Medicare Advantage plan and get insurance name, id#, conctact#, mailing address?
3) Claim number and Calreference number
Note: Submit the claim to correct payor
26Denial code 26 defined as 'Services rendered prior to health care coverage'.
27Denial code 27 described as 'Expenses incurred after coverage terminated'.1) Get Denial Date?
2) Get Policy effective and termination date?
3) If policy is eligible at the time of service rendered, send the claim back for reprocessing
4) If the services not eligible (terminated), then check for any other active insurance available at the time of service?
5) Claim number and Calreference number?
28Coverage not in effect at the time the service was providedSame as denial code - 27
29Denial code - 29 Described as 'TFL has expired'.
TFL- Time filing limit to submit the claim		1) Get the denial date?
2) Get the date when the claim was received?
3) Get the filing Timely filing limit?
4) Send the claim back for reprocessing if the denial was incorrect(If the claim received within the set time frame)
5)Get the appeal information if claim needs to be appealed with proof of timely filing?
6) Get the claim number and Calreference number?
30Denial code 30 defined as 'Payment adjusted because the patient has not met the required spend down, eligibility, waiting, or residency requirements
31Denial code - 31
38Services not provided or authorized by designated providers
39Denial Code 39 defined as 'Services denied at the time auth/precert was requested'.1) Get the claim denial date?
2) Check in the application for the denied letter from insurance to verify requested authorization/precertification is denied at the time of requested or not.
3) Review other claims for the patient with same CPT/DX combination to see if the claims were paid.
4)If no, then check with representative whether we can get retro authorization for this service?
If yes, then get the retro authorization from retro department and send the claim back for reprocessing
If retro auth not available, You have rights to appeal the claim with medical records (Get the appeal limit and address / fax#, if claim needs to be appealed)
6) Claim# and Calreference#
50Denial code 50 defined as 'These are non covered services because this is not deemed a medical necessity by the payer'.1) Get Claim denial date?
2) Find out whether it as per provider contract or patient plan
3) Collect what type of services are not covered under the contract or plan?
4) Request for a copy of the EOB?
5) Get the appeals information/fax# / time frame to submit appeal
6) Claim number and Calreference number
Note: If the services are covered, and if you found the denial is incorrect, then you have rights to appeal with supporting documentation.
54Denial Code 54 described as 'Multiple Physicians/assistants are not covered in this case'.1) Get the Claim denial date?
2) Check to see why multiple physicians/assistants are not covered for the service provided?
3) Take action as per the status provided?
4) Claim number and Calreference number
Note: Insurance cover only the eligible and listed procedures to be performed by multiple physcians/assistants and should be indicated with appropriate modifiers(80/81/82/AS). If the unlisted/not eligible procedures performed by multiple physicians/assistants then the claim will not be covered.
96Non-Covered Charges1) Get Claim denial date?
2) Check which diagnosis or procedure is not deemed medically necessary by payer?
3) Get the appeals information/fax# / time frame to submit appeal
4) Claim number and Calreference number
Note: If its valid diagnosis and procedure code, then you have rights to appeal with supporting documentation.
97Denial code - 97 described when 'The benefit for this service is included in the payment or allowance for another service/procedure that has already been adjudicated'.1) Claim denial date?
2) Verify which is primary procedure and denied procedure? Also check if the primary procedure code is paid?
3) Suggest that we will submit claim with a valid modifier along with medical records?
4) Get the Appeals info/ Corrected claim address/ TFL to submit corrected claim
5) Send for reprocess and collect follow up date if the denial is incorrect
6) Get the Claim number and Calreference number
Note: 1) Submit with appropriate modifier if its required.
2) If submitted claim is correct, then you have rights to appeal along with documentation.
107Denail code - 107 defined as 'The related or qualifying claim/service was not identified on this claim'.Determine why main procedure was denied or returned as unprocessable and correct as needed. (For example: Supplies and/or accessories are not covered if the main equipment is denied)
109Denial Code described as 'Claim/service not covered by this payer/contractor. You must send the claim/service to the correct carrier'.1) Get the Claim denial date?
2) Verify why the claim/service not covered by this payer/contractor( It may be denied because patient enrolled in Medicare advantage Plan, hence it needs to submit to medicare advantage plan( Id# and mailing address) or it may be denied because beneficiary may be in SNF stay at the time of service))?
3) Claim number and Calreference number
Note: Check eligibility of HMO insurance, update the insurance and submit the claim to the correct payer
119Denial Code 119 defined as 'Benefit maximum for this time period or occurrence has been reached'.1) Get the denial date and the procedure code its denied?
2) Find out whether it maximum amount or visit or unit?
3) Get the maximum amount or maximum number of visits or units under the plans policy?
4) Get the benefits met date?
5) Get the Claim number or Calreference number?
122Psychiatric reduction.
140Denial Code - 140 defined as 'Patient/Insured health identification number and name do not match'.Check eligibility to find out the correct ID# or name.
Update the correct details and resubmit the Claim.
146Denial Code - 146 described as 'Diagnosis was invalid for the DOS reported'.1) Get the Claim denial date?
2) Check which diagnosis code was invalid for the DOS reported?
3) Check in application whether previous DOS with same Diagnosis code received payment or not?
4) If yes, send the claim back for reprocessing?
5) If no, Get the corrected claim address and timely filing limit to resubmit the corrected claim.
6) Claim number and calreference number
181Denial Code - 181 defined as 'Procedure code was invalid on the DOS'.Check to see the procedure code billed on the DOS is valid or not?
Resubmit the claim with valid procedure code.
182Denial Code - 182 defined as 'Procedure modifier was invalid on the DOS.Check to see the indicated modifier code with procedure code on the DOS is valid or not?
Resubmit with valid modifier
183Denial Code - 183 described as 'The referring provider is not eligible to refer the service billed'.1) Get the Denial date and check why this referring provider is not eligible to refer the service billed.
2) Review all claims in the application for this provider with same CPT and DX combinations to see if any were paid.
3) If any of the information is available, send the claim back for reprocessing.
4) Claim number and Calreference number
Note: If there is no information available, place all the claims for the provider with same CPT and DX combinations on hold and escalate to the client
185Denial Code 185 defined as 'The rendering provider is not eligible to perform the service billed'.1) Get the Denial date and check why the rendering provider is not eligible to perform the service billed. (Check PTAN was effective for the DOS billed or not)
2) Review all claims in the application for this provider with same CPT and DX combinations to see if any were paid.
3) If any of the information is available, send the claim back for reprocessing.
4) Claim number and Calreference number
Note: If there is no information available, place all the claims for the provider with same CPT and DX combinations on hold and escalate to the client
197Pre-Certification or Authorization absentThis denial is same as denial code - 15, please refer and ask the question as required
198Precertification/authorization exceeded.This denial is same as denial code - 15, please refer and ask the question as required
204Denial Code - 204 described as 'This service/equipment/drug is not covered under the patient’s current benefit plan'.1) Get Claim denial date?
2) Check eligibility to see the service provided is a covered benefit or not?
3) If it’s a covered benefit, send the claim back for reprocesisng
4) Claim number and calreference number
B9Denial Code B9 indicated when a 'Patient is enrolled in a Hospice'.Check to see, if patient enrolled in a hospice or not at the time of service?