Claim - FHIR Resource (stu3)


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

Validate an Claim FHIR Resource (stu3)



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originalPrescriptionfalseReference# Original prescription if superceded by fulfiller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