Claim - FHIR Resource (dstu2)


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

Validate an Claim FHIR Resource (dstu2)



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