Claim - FHIR Resource (stu3)


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

Resource Attributes

AttributeField is listTypeDescription
accidentfalseData Type Details about an accident
billablePeriodfalsePeriod Period for charge submission
careTeamtrueData Type Members of the care team
createdfalsedateTime Creation date
diagnosistrueData Type List of Diagnosis
employmentImpactedfalsePeriod Period unable to work
entererfalseReference Author
facilityfalseReference Servicing Facility
fundsReservefalseCodeableConcept Funds requested to be reserved
hospitalizationfalsePeriod Period in hospital
identifiertrueIdentifier Claim number
informationtrueData Type Exceptions, special considerations, the condition, situation, prior or concurrent issues
insurancetrueData Type Insurance or medical plan
insurerfalseReference Target
itemtrueData Type Goods and Services
organizationfalseReference Responsible organization
originalPrescriptionfalseReference Original prescription if superceded by fulfiller
patientfalseReference The subject of the Products and Services
payeefalseData Type Party to be paid any benefits payable
prescriptionfalseReference Prescription authorizing services or products
priorityfalseCodeableConcept Desired processing priority
proceduretrueData Type Procedures performed
providerfalseReference Responsible provider
referralfalseReference Treatment Referral
relatedtrueData Type Related Claims which may be revelant to processing this claimn
statusfalsecode active | cancelled | draft | entered-in-error
subTypetrueCodeableConcept Finer grained claim type information
totalfalseMoney Total claim cost
typefalseCodeableConcept Type or discipline
usefalsecode complete | proposed | exploratory | other

Claim Example

{
  "status": "active",
  "use": "complete",
  "patient": {
    "reference": "Patient/1"
  },
  "created": "2014-08-16",
  "resourceType": "Claim",
  "text": {
    "status": "generated",
    "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the Oral Health Claim</div>"
  },
  "insurer": {
    "reference": "Organization/2"
  },
  "insurance": [
    {
      "coverage": {
        "reference": "Coverage/9876B1"
      },
      "focal": true,
      "sequence": 1
    }
  ],
  "priority": {
    "coding": [
      {
        "code": "normal"
      }
    ]
  },
  "payee": {
    "type": {
      "coding": [
        {
          "code": "provider"
        }
      ]
    }
  },
  "item": [
    {
      "service": {
        "coding": [
          {
            "code": "1200"
          }
        ]
      },
      "sequence": 1,
      "servicedDate": "2014-08-16",
      "careTeamLinkId": [
        1
      ],
      "net": {
        "code": "USD",
        "system": "urn:iso:std:iso:4217",
        "value": 135.57
      },
      "unitPrice": {
        "code": "USD",
        "system": "urn:iso:std:iso:4217",
        "value": 135.57
      }
    }
  ],
  "diagnosis": [
    {
      "diagnosisCodeableConcept": {
        "coding": [
          {
            "code": "123456"
          }
        ]
      },
      "sequence": 1
    }
  ],
  "careTeam": [
    {
      "provider": {
        "reference": "Practitioner/example"
      },
      "sequence": 1
    }
  ],
  "organization": {
    "reference": "Organization/1"
  },
  "identifier": [
    {
      "system": "http://happyvalley.com/claim",
      "value": "12345"
    }
  ],
  "type": {
    "coding": [
      {
        "code": "oral",
        "system": "http://hl7.org/fhir/ex-claimtype"
      }
    ]
  },
  "id": "100150"
}

Claim Structure


  
{
  "resourceType" : "Claim",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Claim number
  "status" : "<code>", // active | cancelled | draft | entered-in-error
  "type" : { CodeableConcept }, // Type or discipline
  "subType" : [{ CodeableConcept }], // Finer grained claim type information
  "use" : "<code>", // complete | proposed | exploratory | other
  "patient" : { Reference(Patient) }, // The subject of the Products and Services
  "billablePeriod" : { Period }, // Period for charge submission
  "created" : "<dateTime>", // Creation date
  "enterer" : { Reference(Practitioner) }, // Author
  "insurer" : { Reference(Organization) }, // Target
  "provider" : { Reference(Practitioner) }, // Responsible provider
  "organization" : { Reference(Organization) }, // Responsible organization
  "priority" : { CodeableConcept }, // Desired processing priority
  "fundsReserve" : { CodeableConcept }, // Funds requested to be reserved
  "related" : [{ // Related Claims which may be revelant to processing this claimn
    "claim" : { Reference(Claim) }, // Reference to the related claim
    "relationship" : { CodeableConcept }, // How the reference claim is related
    "reference" : { Identifier } // Related file or case reference
  }],
  "prescription" : { Reference(MedicationRequest|VisionPrescription) }, // Prescription authorizing services or products
  "originalPrescription" : { Reference(MedicationRequest) }, // Original prescription if superceded by fulfiller
  "payee" : { // Party to be paid any benefits payable
    "type" : { CodeableConcept }, // R!  Type of party: Subscriber, Provider, other
    "resourceType" : { Coding }, // organization | patient | practitioner | relatedperson
    "party" : { Reference(Practitioner|Organization|Patient|RelatedPerson) } // Party to receive the payable
  },
  "referral" : { Reference(ReferralRequest) }, // Treatment Referral
  "facility" : { Reference(Location) }, // Servicing Facility
  "careTeam" : [{ // Members of the care team
    "sequence" : "<positiveInt>", // R!  Number to covey order of careTeam
    "provider" : { Reference(Practitioner|Organization) }, // R!  Provider individual or organization
    "responsible" : <boolean>, // Billing provider
    "role" : { CodeableConcept }, // Role on the team
    "qualification" : { CodeableConcept } // Type, classification or Specialization
  }],
  "information" : [{ // Exceptions, special considerations, the condition, situation, prior or concurrent issues
    "sequence" : "<positiveInt>", // R!  Information instance identifier
    "category" : { CodeableConcept }, // R!  General class of information
    "code" : { CodeableConcept }, // Type of information
    // timing[x]: When it occurred. One of these 2:
    "timingDate" : "<date>",
    "timingPeriod" : { Period },
    // value[x]: Additional Data or supporting information. One of these 4:
    "valueString" : "<string>",
    "valueQuantity" : { Quantity },
    "valueAttachment" : { Attachment },
    "valueReference" : { Reference(Any) },
    "reason" : { CodeableConcept } // Reason associated with the information
  }],
  "diagnosis" : [{ // List of Diagnosis
    "sequence" : "<positiveInt>", // R!  Number to covey order of diagnosis
    // diagnosis[x]: Patient's diagnosis. One of these 2:
    "diagnosisCodeableConcept" : { CodeableConcept },
    "diagnosisReference" : { Reference(Condition) },
    "type" : [{ CodeableConcept }], // Timing or nature of the diagnosis
    "packageCode" : { CodeableConcept } // Package billing code
  }],
  "procedure" : [{ // Procedures performed
    "sequence" : "<positiveInt>", // R!  Procedure sequence for reference
    "date" : "<dateTime>", // When the procedure was performed
    // procedure[x]: Patient's list of procedures performed. One of these 2:
    "procedureCodeableConcept" : { CodeableConcept }
    "procedureReference" : { Reference(Procedure) }
  }],
  "insurance" : [{ // Insurance or medical plan
    "sequence" : "<positiveInt>", // R!  Service instance identifier
    "focal" : <boolean>, // R!  Is the focal Coverage
    "coverage" : { Reference(Coverage) }, // R!  Insurance information
    "businessArrangement" : "<string>", // Business agreement
    "preAuthRef" : ["<string>"], // Pre-Authorization/Determination Reference
    "claimResponse" : { Reference(ClaimResponse) } // Adjudication results
  }],
  "accident" : { // Details about an accident
    "date" : "<date>", // R!  When the accident occurred
see information codes
see information codes
    "type" : { CodeableConcept }, // The nature of the accident
    // location[x]: Accident Place. One of these 2:
    "locationAddress" : { Address }
    "locationReference" : { Reference(Location) }
  },
  "employmentImpacted" : { Period }, // Period unable to work
  "hospitalization" : { Period }, // Period in hospital
  "item" : [{ // Goods and Services
    "sequence" : "<positiveInt>", // R!  Service instance
    "careTeamLinkId" : ["<positiveInt>"], // Applicable careTeam members
    "diagnosisLinkId" : ["<positiveInt>"], // Applicable diagnoses
    "procedureLinkId" : ["<positiveInt>"], // Applicable procedures
    "informationLinkId" : ["<positiveInt>"], // Applicable exception and supporting information
    "revenue" : { CodeableConcept }, // Revenue or cost center code
    "category" : { CodeableConcept }, // Type of service or product
    "service" : { CodeableConcept }, // Billing Code
    "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
    "programCode" : [{ CodeableConcept }], // Program specific reason for item inclusion
    // serviced[x]: Date or dates of Service. One of these 2:
    "servicedDate" : "<date>",
    "servicedPeriod" : { Period },
    // location[x]: Place of service. One of these 3:
    "locationCodeableConcept" : { CodeableConcept },
    "locationAddress" : { Address },
    "locationReference" : { Reference(Location) },
    "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
    "unitPrice" : { Money }, // Fee, charge or cost per point
    "factor" : <decimal>, // Price scaling factor
    "net" : { Money }, // Total item cost
    "udi" : [{ Reference(Device) }], // Unique Device Identifier
    "bodySite" : { CodeableConcept }, // Service Location
    "subSite" : [{ CodeableConcept }], // Service Sub-location
    "encounter" : [{ Reference(Encounter) }], // Encounters related to this billed item
    "detail" : [{ // Additional items
      "sequence" : "<positiveInt>", // R!  Service instance
      "revenue" : { CodeableConcept }, // Revenue or cost center code
      "category" : { CodeableConcept }, // Type of service or product
      "service" : { CodeableConcept }, // Billing Code
      "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
      "programCode" : [{ CodeableConcept }], // Program specific reason for item inclusion
      "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
      "unitPrice" : { Money }, // Fee, charge or cost per point
      "factor" : <decimal>, // Price scaling factor
      "net" : { Money }, // Total additional item cost
      "udi" : [{ Reference(Device) }], // Unique Device Identifier
      "subDetail" : [{ // Additional items
        "sequence" : "<positiveInt>", // R!  Service instance
        "revenue" : { CodeableConcept }, // Revenue or cost center code
        "category" : { CodeableConcept }, // Type of service or product
        "service" : { CodeableConcept }, // Billing Code
        "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
        "programCode" : [{ CodeableConcept }], // Program specific reason for item inclusion
        "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
        "unitPrice" : { Money }, // Fee, charge or cost per point
        "factor" : <decimal>, // Price scaling factor
        "net" : { Money }, // Net additional item cost
        "udi" : [{ Reference(Device) }] // Unique Device Identifier
      }]
    }]
  }],
  "total" : { Money } // Total claim cost
}


 

Claim Search Parameters

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

https://api.1up.health/fhir/stu3/Claim?query-param=queryvalue
Search ParameterField TypeResource Fields Searched
care-teamreferencecareTeam.provider
createddatecreated
encounterreferenceitem.encounter
entererreferenceenterer
facilityreferencefacility
identifiertextidentifier
insurerreferenceinsurer
organizationreferenceorganization
patientreferencepatient
payeereferencepayee.party
prioritytextpriority
providerreferenceprovider
usetextuse