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Claims

A claim in ARC is the record the provider sends to the sponsor to get paid for products or services actually delivered to a beneficiary. It's the reimbursement side of the operation — the pre-authorization guarantees the sponsor will pay; the claim tells the sponsor what to pay for.

The dominant case: point-of-delivery providers​

The most common claim in ARC comes from a point-of-delivery provider — a pharmacy, a laboratory, or an imaging centre — that hands over a discrete product or study to the beneficiary against a pre-authorization. All three share the same set of endpoints and the same claim shape.

When the provider delivers what the authorization covered (dispensed medications, performed labs, produced imaging), the record of that transaction contains everything the sponsor needs to reimburse: the beneficiary, the products/studies, the quantities, the prices, the authorization they were delivered against. That record is the claim.

Two integration paths, picked at onboarding:

  • Via Dispensing (the recommended path). The provider calls the Dispensing endpoints to redeem an authorization, and Osigu creates the claim automatically behind the scenes. Pharmacies, labs and imaging centres all use this — one integration handles both an uninsured electronic prescription redemption and an insured authorization redemption (with its claim generated for it).
  • Directly against Claims. A provider that wants (or is required by its own POS/LIS/RIS) to talk to the Claims API directly can create the claim itself.

We built the "Dispensing creates the claim" path so providers don't have to integrate twice — one integration for electronic prescriptions and another for claiming an insured redemption. One POS/LIS/RIS integration, both flows covered.

Non-pharmacy claims: outpatient and medical procedure​

Not every claim comes from a pharmacy. Providers that render services (a consultation, a lab, an imaging study, a surgical procedure) file claims through two dedicated shapes:

Outpatient care claim​

Used for outpatient encounters — consultations, minor procedures, physical therapy sessions, or a bundle (consultation + labs + on-site meds). Multiple line items in one claim.

Endpoints:

Medical-procedure claim​

Used for a specific one-off procedure that isn't part of a broader outpatient encounter — a surgery, a stand-alone diagnostic test. Single line item, tied to a specific authorization.

Endpoints:

Lifecycle​

Whichever path created the claim (auto-generated by Dispensing, direct pharmacy integration, outpatient, medical procedure), the lifecycle is the same:

  • OPEN — freshly created. Modifiable until you complete it. Claims born from Dispensing typically skip this state: they arrive COMPLETED because Dispensing completed the transaction atomically.
  • COMPLETED — closed, waiting to be included in a settlement.
  • SETTLED — part of a dispatched settlement batch (see below).
  • VOIDED — cancelled before settlement. Cannot be un-voided; if you need to fix something, void and create a new one.

Attaching support files​

Claims can carry support documentation — the prescription that justified the medication, the medical order that justified the imaging, etc. Retrieve the attached files with GET /arc/v1/claims/{claimId}/authorization-files. Each entry includes an S3 URL where the document can be downloaded.

The upload of these files happens either:

  • Via the authorization flow (pre-service) — the indication attached to the authorization request travels with the claim later.
  • Via the settlement batch (post-service) — additional evidence attached at radicación time. See the Settlement Batches (Radicaciones) endpoints in the API reference.

The exact split depends on the sponsor.

Settlement batches (Radicaciones)​

In the Dominican Republic, completed claims aren't dispatched to the sponsor one-by-one — they're grouped into a settlement batch (radicación) and sent as a package. See the endpoints under the Settlement Batches (Radicaciones) tag in the API reference.

Newer country integrations use Osigu's Revenue Cycle Management (RCM) product instead, which handles claim-to-invoice batching. See rcm-docs.osigu.com.

  • Dispensing — the pharmacy-side flow that generates claims automatically when an authorization is dispensed.
  • Authorizations — the pre-service approval that a pharmacy claim redeems.
  • Provider Products — the catalogue of items you can put on a claim.