Adjudication Complete Event

The adjudication_complete event is sent when a claim adjudication has finished processing. This is the primary webhook event for receiving adjudication results in real time.

Payload

The eventPayload contains the full claim data — the same structure returned by GET /v1/claims?id={claim_id} — including the original claim fields, parsed evidence, and adjudication results.

{
  "eventId": "evt_adj_001",
  "eventType": "adjudication_complete",
  "eventPayload": {
    "id": "a1b2c3d4-e5f6-7890-abcd-ef1234567890",
    "claim_number": "CLM-2025-00042",
    "claim_amount": 15000,
    "service_start_date": "2025-03-10",
    "service_end_date": "2025-03-10",
    "submission_date": "2025-03-15",
    "provider": "Lakewood Family Dentistry",
    "employer": "Acme Corp",
    "description": "Routine dental cleaning and X-rays",
    "expense_category": "Dental",
    "expense_type": "Preventive Care",
    "plan_name": "Acme 2025 Medical FSA",
    "plan_type": "medical_fsa",
    "plan_year_start": "2025-01-01",
    "plan_year_end": "2025-12-31",
    "final_submission_date": "2026-03-31",
    "final_service_date": "2025-12-31",
    "adjudication_results": {
      "silver_recommendation": "approve",
      "valid_service_date": true,
      "valid_total_amount": true,
      "out_of_pocket_total": 15000,
      "suggested_service_date_start": null,
      "suggested_service_date_end": null,
      "deny_code": null,
      "deny_text": null,
      "suggested_provider_name": null
    },
    "receipts": [
      {
        "merchant": "Lakewood Family Dentistry",
        "purchased_at": "2025-03-10",
        "total_eligible_amount": 15000,
        "items": [
          {
            "title": "Dental Cleaning",
            "sku": "D1110",
            "sku_type": "CDT",
            "line_item_price": 10000,
            "claimable_amount": 10000,
            "eligible": true
          },
          {
            "title": "Dental X-Rays (Bitewing)",
            "sku": "D0274",
            "sku_type": "CDT",
            "line_item_price": 5000,
            "claimable_amount": 5000,
            "eligible": true
          }
        ]
      }
    ],
    "medical_invoices": [],
    "dependent_care_invoices": [],
    "statement_of_accounts": []
  }
}

Amounts are in cents

All monetary values are integers representing cents. For example, 15000 represents $150.00.

Field Reference

Top-Level Fields

Field	Type	Description
`eventId`	string	Unique event identifier — use for idempotency
`eventType`	string	Always `"adjudication_complete"` for this event
`eventPayload`	object	Full claim data including adjudication results

Adjudication Results

The adjudication_results object within eventPayload contains:

Field	Type	Description
`silver_recommendation`	string	Silver's recommendation (see below)
`valid_service_date`	boolean	Whether the claimed service dates are within the plan year
`valid_total_amount`	boolean	Whether the claimed amount matches the evidence
`out_of_pocket_total`	integer	Total out-of-pocket amount from evidence (in cents)
`suggested_service_date_start`	string	Corrected start date if evidence suggests a different date
`suggested_service_date_end`	string	Corrected end date if evidence suggests a different date
`deny_code`	string	Machine-readable denial reason code (null if not denied)
`deny_text`	string	Human-readable denial explanation (null if not denied)
`suggested_provider_name`	string	Provider name from evidence if it differs from the submitted name

Recommendation Values

Value	Description
`approve`	The claim is recommended for approval. The evidence supports the claim.
`deny`	The claim is recommended for denial. The evidence does not support the claim.
`needs_review`	The claim requires manual review. The automated system could not make a confident determination.
`not_needed`	Adjudication is not needed for this claim type.
`request_more_information`	Additional information or evidence is needed before a determination can be made.

Parsed Evidence

The eventPayload includes parsed evidence in four arrays:

Field	Description
`receipts`	Purchase receipts with merchant, line items, and eligibility per item
`medical_invoices`	Medical invoices/EOBs with service-level charges, insurance payments, and patient responsibility
`dependent_care_invoices`	Dependent care invoices with charges, payments, and DCFSA eligibility
`statement_of_accounts`	Provider account statements with ledger entries

Handling the Event

def handle_adjudication_complete(event_payload):
    recommendation = event_payload["adjudication_results"]["silver_recommendation"]
    claim_number = event_payload["claim_number"]

    if recommendation == "approve":
        # Process approval — initiate reimbursement
        amount_cents = event_payload["adjudication_results"]["out_of_pocket_total"]
        process_approval(claim_number, amount_cents)
    elif recommendation == "deny":
        # Handle denial — notify relevant parties
        deny_reason = event_payload["adjudication_results"]["deny_text"]
        process_denial(claim_number, deny_reason)
    elif recommendation == "needs_review":
        # Queue for manual review
        queue_for_review(claim_number, event_payload)
    elif recommendation == "request_more_information":
        # Request additional evidence from the participant
        request_more_info(claim_number, event_payload)

Payload​

Field Reference​

Top-Level Fields​

Adjudication Results​

Recommendation Values​

Parsed Evidence​

Handling the Event​