Claim - FHIR Resource (r4)


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

Validate an Claim FHIR Resource (r4)



Resource Attributes

AttributeField is listTypeDescription
accidentfalseData Type# Details of the event
billablePeriodfalsePeriod# Relevant time frame for the claim
careTeamtrueData Type# Members of the care team
createdfalsedateTime# Resource creation date
diagnosistrueData Type# Pertinent diagnosis information
entererfalseReference# Author of the claim
facilityfalseReference# Servicing facility
fundsReservefalseCodeableConcept# For whom to reserve funds
identifiertrueIdentifier# Business Identifier for claim
insurancetrueData Type# Patient insurance information
insurerfalseReference# Target
itemtrueData Type# Product or service provided
originalPrescriptionfalseReference# "originalPrescription" : { Reference(DeviceRequest|MedicationRequest|
patientfalseReference# The recipient of the products and services
payeefalseData Type# Recipient of benefits payable
prescriptionfalseReference# "prescription" : { Reference(DeviceRequest|MedicationRequest|
priorityfalseCodeableConcept# Desired processing ugency
proceduretrueData Type# Clinical procedures performed
providerfalseReference# Party responsible for the claim
referralfalseReference# Treatment referral
relatedtrueData Type# Prior or corollary claims
statusfalsecode# active | cancelled | draft | entered-in-error
subTypefalseCodeableConcept# More granular claim type
supportingInfotrueData Type# Supporting information
totalfalseMoney# Total claim cost
typefalseCodeableConcept# Category or discipline
usefalsecode# claim | preauthorization | predetermination

Claim Example

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

Claim Structure

{
  "resourceType" : "Claim",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier for claim
  "status" : "<code>", // R!  active | cancelled | draft | entered-in-error
  "type" : { CodeableConcept }, // R!  Category or discipline
  "subType" : { CodeableConcept }, // More granular claim type
  "use" : "<code>", // R!  claim | preauthorization | predetermination
  "patient" : { Reference(Patient) }, // R!  The recipient of the products and services
  "billablePeriod" : { Period }, // Relevant time frame for the claim
  "created" : "<dateTime>", // R!  Resource creation date
  "enterer" : { Reference(Practitioner|PractitionerRole) }, // Author of the claim
  "insurer" : { Reference(Organization) }, // Target
  "provider" : { Reference(Practitioner|PractitionerRole|Organization) }, // R!  Party responsible for the claim
  "priority" : { CodeableConcept }, // R!  Desired processing ugency
  "fundsReserve" : { CodeableConcept }, // For whom to reserve funds
  "related" : [{ // Prior or corollary claims
    "claim" : { Reference(Claim) }, // Reference to the related claim
    "relationship" : { CodeableConcept }, // How the reference claim is related
    "reference" : { Identifier } // File or case reference
  }],
  "prescription" : { Reference(DeviceRequest|MedicationRequest|
   VisionPrescription) }, // Prescription authorizing services and products
  "originalPrescription" : { Reference(DeviceRequest|MedicationRequest|
   VisionPrescription) }, // Original prescription if superseded by fulfiller
  "payee" : { // Recipient of benefits payable
    "type" : { CodeableConcept }, // R!  Category of recipient
    "party" : { Reference(Practitioner|PractitionerRole|Organization|Patient|
    RelatedPerson) } // Recipient reference
  },
  "referral" : { Reference(ServiceRequest) }, // Treatment referral
  "facility" : { Reference(Location) }, // Servicing facility
  "careTeam" : [{ // Members of the care team
    "sequence" : "<positiveInt>", // R!  Order of care team
    "provider" : { Reference(Practitioner|PractitionerRole|Organization) }, // R!  Practitioner or organization
    "responsible" : <boolean>, // Indicator of the lead practitioner
    "role" : { CodeableConcept }, // Function within the team
    "qualification" : { CodeableConcept } // Practitioner credential or specialization
  }],
  "supportingInfo" : [{ // Supporting information
    "sequence" : "<positiveInt>", // R!  Information instance identifier
    "category" : { CodeableConcept }, // R!  Classification of the supplied information
    "code" : { CodeableConcept }, // Type of information
    // timing[x]: When it occurred. One of these 2:
    "timingDate" : "<date>",
    "timingPeriod" : { Period },
    // value[x]: Data to be provided. One of these 5:
    "valueBoolean" : <boolean>,
    "valueString" : "<string>",
    "valueQuantity" : { Quantity },
    "valueAttachment" : { Attachment },
    "valueReference" : { Reference(Any) },
    "reason" : { CodeableConcept } // Explanation for the information
  }],
  "diagnosis" : [{ // Pertinent diagnosis information
    "sequence" : "<positiveInt>", // R!  Diagnosis instance identifier
    // diagnosis[x]: Nature of illness or problem. One of these 2:
    "diagnosisCodeableConcept" : { CodeableConcept },
    "diagnosisReference" : { Reference(Condition) },
    "type" : [{ CodeableConcept }], // Timing or nature of the diagnosis
    "onAdmission" : { CodeableConcept }, // Present on admission
    "packageCode" : { CodeableConcept } // Package billing code
  }],
  "procedure" : [{ // Clinical procedures performed
    "sequence" : "<positiveInt>", // R!  Procedure instance identifier
    "type" : [{ CodeableConcept }], // Category of Procedure
    "date" : "<dateTime>", // When the procedure was performed
    // procedure[x]: Specific clinical procedure. One of these 2:
    "procedureCodeableConcept" : { CodeableConcept },
    "procedureReference" : { Reference(Procedure) },
    "udi" : [{ Reference(Device) }] // Unique device identifier
  }],
  "insurance" : [{ // R!  Patient insurance information
    "sequence" : "<positiveInt>", // R!  Insurance instance identifier
    "focal" : <boolean>, // R!  Coverage to be used for adjudication
    "identifier" : { Identifier }, // Pre-assigned Claim number
    "coverage" : { Reference(Coverage) }, // R!  Insurance information
    "businessArrangement" : "<string>", // Additional provider contract number
    "preAuthRef" : ["<string>"], // Prior authorization reference number
    "claimResponse" : { Reference(ClaimResponse) } // Adjudication results
  }],
  "accident" : { // Details of the event
    "date" : "<date>", // R!  When the incident occurred
    "type" : { CodeableConcept }, // The nature of the accident
    // location[x]: Where the event occurred. One of these 2:
    "locationAddress" : { Address }
    "locationReference" : { Reference(Location) }
  },
  "item" : [{ // Product or service provided
    "sequence" : "<positiveInt>", // R!  Item instance identifier
    "careTeamSequence" : ["<positiveInt>"], // Applicable careTeam members
    "diagnosisSequence" : ["<positiveInt>"], // Applicable diagnoses
    "procedureSequence" : ["<positiveInt>"], // Applicable procedures
    "informationSequence" : ["<positiveInt>"], // Applicable exception and supporting information
    "revenue" : { CodeableConcept }, // Revenue or cost center code
    "category" : { CodeableConcept }, // Benefit classification
    "productOrService" : { CodeableConcept }, // R!  Billing, service, product, or drug code
    "modifier" : [{ CodeableConcept }], // Product or service billing modifiers
    "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
    // serviced[x]: Date or dates of service or product delivery. One of these 2:
    "servicedDate" : "<date>",
    "servicedPeriod" : { Period },
    // location[x]: Place of service or where product was supplied. 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 item
    "factor" : <decimal>, // Price scaling factor
    "net" : { Money }, // Total item cost
    "udi" : [{ Reference(Device) }], // Unique device identifier
    "bodySite" : { CodeableConcept }, // Anatomical location
    "subSite" : [{ CodeableConcept }], // Anatomical sub-location
    "encounter" : [{ Reference(Encounter) }], // Encounters related to this billed item
    "detail" : [{ // Product or service provided
      "sequence" : "<positiveInt>", // R!  Item instance identifier
      "revenue" : { CodeableConcept }, // Revenue or cost center code
      "category" : { CodeableConcept }, // Benefit classification
      "productOrService" : { CodeableConcept }, // R!  Billing, service, product, or drug code
      "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
      "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
      "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
      "unitPrice" : { Money }, // Fee, charge or cost per item
      "factor" : <decimal>, // Price scaling factor
      "net" : { Money }, // Total item cost
      "udi" : [{ Reference(Device) }], // Unique device identifier
      "subDetail" : [{ // Product or service provided
        "sequence" : "<positiveInt>", // R!  Item instance identifier
        "revenue" : { CodeableConcept }, // Revenue or cost center code
        "category" : { CodeableConcept }, // Benefit classification
        "productOrService" : { CodeableConcept }, // R!  Billing, service, product, or drug code
        "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
        "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
        "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
        "unitPrice" : { Money }, // Fee, charge or cost per item
        "factor" : <decimal>, // Price scaling factor
        "net" : { Money }, // Total 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 them like so:

https://api.1up.health/fhir/r4/Claim?query-param=queryvalue
Search ParameterField TypeResource Fields Searched
care-teamreferencecareTeam.provider
createddatecreated
detail-udireferenceitem.detail.udi
encounterreferenceitem.encounter
entererreferenceenterer
facilityreferencefacility
identifiertextidentifier
insurerreferenceinsurer
item-udireferenceitem.udi
patientreferencepatient
payeereferencepayee.party
prioritytextpriority
procedure-udireferenceprocedure.udi
providerreferenceprovider
statustextstatus
subdetail-udireferenceitem.detail.subDetail.udi
usetextuse