Claim - FHIR Resource (dstu2)


This Claim Resource uses the FHIR API standard for access and structure.

Resource Attributes

AttributeField is listTypeDescription
accidentfalsedate Accident Date
accidentTypefalseCoding Accident Type
additionalMaterialstrueCoding Additional materials, documents, etc.
conditiontrueCoding List of presenting Conditions
coveragetrueData Type Insurance or medical plan
createdfalsedateTime Creation date
diagnosistrueData Type Diagnosis
entererfalseReference Author
exceptiontrueCoding Eligibility exceptions
facilityfalseReference Servicing Facility
fundsReservefalseCoding Funds requested to be reserved
identifiertrueIdentifier Claim number
interventionExceptiontrueCoding Intervention and exception code (Pharma)
itemtrueData Type Goods and Services
missingTeethtrueData Type Only if type = oral
organizationfalseReference Responsible organization
originalPrescriptionfalseReference Original Prescription
originalRulesetfalseCoding Original specification followed
patientfalseReference The subject of the Products and Services
payeefalseData Type Payee
prescriptionfalseReference Prescription
priorityfalseCoding Desired processing priority
providerfalseReference Responsible provider
referralfalseReference Treatment Referral
rulesetfalseCoding Current specification followed
schoolfalsestring Name of School
targetfalseReference Insurer
typefalsecode institutional | oral | pharmacy | professional | vision
usefalsecode complete | proposed | exploratory | other

Claim Structure


  
{
  "resourceType" : "Claim",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "type" : "<code>", // R!  institutional | oral | pharmacy | professional | vision
  "identifier" : [{ Identifier }], // Claim number
  "ruleset" : { Coding }, // Current specification followed
  "originalRuleset" : { Coding }, // Original specification followed
  "created" : "<dateTime>", // Creation date
  "target" : { Reference(Organization) }, // Insurer
  "provider" : { Reference(Practitioner) }, // Responsible provider
  "organization" : { Reference(Organization) }, // Responsible organization
  "use" : "<code>", // complete | proposed | exploratory | other
  "priority" : { Coding }, // Desired processing priority
  "fundsReserve" : { Coding }, // Funds requested to be reserved
  "enterer" : { Reference(Practitioner) }, // Author
  "facility" : { Reference(Location) }, // Servicing Facility
  "prescription" : { Reference(MedicationOrder|VisionPrescription) }, // Prescription
  "originalPrescription" : { Reference(MedicationOrder) }, // Original Prescription
  "payee" : { // Payee
    "type" : { Coding }, // Party to be paid any benefits payable
    "provider" : { Reference(Practitioner) }, // Provider who is the payee
    "organization" : { Reference(Organization) }, // Organization who is the payee
    "person" : { Reference(Patient) } // Other person who is the payee
  },
  "referral" : { Reference(ReferralRequest) }, // Treatment Referral
  "diagnosis" : [{ // Diagnosis
    "sequence" : "<positiveInt>", // R!  Sequence of diagnosis
    "diagnosis" : { Coding } // R!  Patient's list of diagnosis
  }],
  "condition" : [{ Coding }], // List of presenting Conditions
  "patient" : { Reference(Patient) }, // R!  The subject of the Products and Services
  "coverage" : [{ // Insurance or medical plan
    "sequence" : "<positiveInt>", // R!  Service instance identifier
    "focal" : <boolean>, // R!  The focal Coverage
    "coverage" : { Reference(Coverage) }, // R!  Insurance information
    "businessArrangement" : "<string>", // Business agreement
    "relationship" : { Coding }, // R!  Patient relationship to subscriber
    "preAuthRef" : ["<string>"], // Pre-Authorization/Determination Reference
    "claimResponse" : { Reference(ClaimResponse) }, // Adjudication results
    "originalRuleset" : { Coding } // Original version
  }],
  "exception" : [{ Coding }], // Eligibility exceptions
  "school" : "<string>", // Name of School
  "accident" : "<date>", // Accident Date
  "accidentType" : { Coding }, // Accident Type
  "interventionException" : [{ Coding }], // Intervention and exception code (Pharma)
  "item" : [{ // Goods and Services
    "sequence" : "<positiveInt>", // R!  Service instance
    "type" : { Coding }, // R!  Group or type of product or service
    "provider" : { Reference(Practitioner) }, // Responsible practitioner
    "diagnosisLinkId" : ["<positiveInt>"], // Diagnosis Link
    "service" : { Coding }, // R!  Item Code
    "serviceDate" : "<date>", // Date of Service
    "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
    "unitPrice" : { Quantity(Money) }, // Fee, charge or cost per point
    "factor" : <decimal>, // Price scaling factor
    "points" : <decimal>, // Difficulty scaling factor
    "net" : { Quantity(Money) }, // Total item cost
    "udi" : { Coding }, // Unique Device Identifier
    "bodySite" : { Coding }, // Service Location
    "subSite" : [{ Coding }], // Service Sub-location
    "modifier" : [{ Coding }], // Service/Product billing modifiers
    "detail" : [{ // Additional items
      "sequence" : "<positiveInt>", // R!  Service instance
      "type" : { Coding }, // R!  Group or type of product or service
      "service" : { Coding }, // R!  Additional item codes
      "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
      "unitPrice" : { Quantity(Money) }, // Fee, charge or cost per point
      "factor" : <decimal>, // Price scaling factor
      "points" : <decimal>, // Difficulty scaling factor
      "net" : { Quantity(Money) }, // Total additional item cost
      "udi" : { Coding }, // Unique Device Identifier
      "subDetail" : [{ // Additional items
        "sequence" : "<positiveInt>", // R!  Service instance
        "type" : { Coding }, // R!  Type of product or service
        "service" : { Coding }, // R!  Additional item codes
        "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
        "unitPrice" : { Quantity(Money) }, // Fee, charge or cost per point
        "factor" : <decimal>, // Price scaling factor
        "points" : <decimal>, // Difficulty scaling factor
        "net" : { Quantity(Money) }, // Net additional item cost
        "udi" : { Coding } // Unique Device Identifier
      }]
    }],
    "prosthesis" : { // Prosthetic details
      "initial" : <boolean>, // Is this the initial service
      "priorDate" : "<date>", // Initial service Date
      "priorMaterial" : { Coding } // Prosthetic Material
    }
  }],
  "additionalMaterials" : [{ Coding }], // Additional materials, documents, etc.
  "missingTeeth" : [{ // Only if type = oral
    "tooth" : { Coding }, // R!  Tooth Code
    "reason" : { Coding }, // Reason for missing
    "extractionDate" : "<date>" // Date of Extraction
  }]
}


 

Claim Search Parameters

The following search parameters can be used to query Claim resources. Just submit the like so:

https://api.1up.health/fhir/dstu2/Claim?query-param=queryvalue
Search ParameterField TypeResource Fields Searched
identifiertextidentifier
patientreferencepatient
prioritytextpriority
providerreferenceprovider
usetextuse