Claim - FHIR Resource (dstu2)

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

Validate an Claim FHIR Resource (dstu2)

Claim Attributes

AttributeField is listTypeDescription

Description: Servicing Facility

FHIR Version: dstu2

Attribute Type : Reference

Required: N/A

Countability: Singleton

Flags: N/A

Terminology bindings: N/A

Requirements: N/A

Comments: N/A

Example:

"facility":

Learn more about the (Claim) facility FHIR attribute

Description: Accident Type

FHIR Version: dstu2

Attribute Type : Coding

Required: N/A

Countability: Singleton

Flags: N/A

Terminology bindings: N/A

Requirements: N/A

Comments: N/A

Example:

"accidentType":

Learn more about the (Claim) accidentType FHIR attribute

Description: Funds requested to be reserved

FHIR Version: dstu2

Attribute Type : Coding

Required: N/A

Countability: Singleton

Flags: N/A

Terminology bindings: N/A

Requirements: N/A

Comments: N/A

Example:

"fundsReserve":

Learn more about the (Claim) fundsReserve FHIR attribute

Description: Original Prescription

FHIR Version: dstu2

Attribute Type : Reference

Required: N/A

Countability: Singleton

Flags: N/A

Terminology bindings: N/A

Requirements: N/A

Comments: N/A

Example:

"originalPrescription":

Learn more about the (Claim) originalPrescription FHIR attribute

Description: Only if type = oral

FHIR Version: dstu2

Attribute Type : Data Type

Required: N/A

Countability: Array

Flags: N/A

Terminology bindings: N/A

Requirements: N/A

Comments: N/A

Example:

"missingTeeth":

Learn more about the (Claim) missingTeeth FHIR attribute

Description: complete | proposed | exploratory | other

FHIR Version: dstu2

Attribute Type : code

Required: N/A

Countability: Singleton

Flags: N/A

Terminology bindings: N/A

Requirements: N/A

Comments: N/A

Example:

"use":

Learn more about the (Claim) use FHIR attribute

Description: Payee

FHIR Version: dstu2

Attribute Type : Data Type

Required: N/A

Countability: Singleton

Flags: N/A

Terminology bindings: N/A

Requirements: N/A

Comments: N/A

Example:

"payee":

Learn more about the (Claim) payee FHIR attribute

Description: Additional materials, documents, etc.

FHIR Version: dstu2

Attribute Type : Coding

Required: N/A

Countability: Array

Flags: N/A

Terminology bindings: N/A

Requirements: N/A

Comments: N/A

Example:

"additionalMaterials":

Learn more about the (Claim) additionalMaterials FHIR attribute

Description: Author

FHIR Version: dstu2

Attribute Type : Reference

Required: N/A

Countability: Singleton

Flags: N/A

Terminology bindings: N/A

Requirements: N/A

Comments: N/A

Example:

"enterer":

Learn more about the (Claim) enterer FHIR attribute

Description: Eligibility exceptions

FHIR Version: dstu2

Attribute Type : Coding

Required: N/A

Countability: Array

Flags: N/A

Terminology bindings: N/A

Requirements: N/A

Comments: N/A

Example:

"exception":

Learn more about the (Claim) exception FHIR attribute

Description: Desired processing priority

FHIR Version: dstu2

Attribute Type : Coding

Required: N/A

Countability: Singleton

Flags: N/A

Terminology bindings: N/A

Requirements: N/A

Comments: N/A

Example:

"priority":

Learn more about the (Claim) priority FHIR attribute

Description: Current specification followed

FHIR Version: dstu2

Attribute Type : Coding

Required: N/A

Countability: Singleton

Flags: N/A

Terminology bindings: N/A

Requirements: N/A

Comments: N/A

Example:

"ruleset":

Learn more about the (Claim) ruleset FHIR attribute

Description: Responsible provider

FHIR Version: dstu2

Attribute Type : Reference

Required: N/A

Countability: Singleton

Flags: N/A

Terminology bindings: N/A

Requirements: N/A

Comments: N/A

Example:

"provider":

Learn more about the (Claim) provider FHIR attribute

Description: institutional | oral | pharmacy | professional | vision

FHIR Version: dstu2

Attribute Type : code

Required: N/A

Countability: Singleton

Flags: N/A

Terminology bindings: N/A

Requirements: N/A

Comments: N/A

Example:

"type":

Learn more about the (Claim) type FHIR attribute

Description: The subject of the Products and Services

FHIR Version: dstu2

Attribute Type : Reference

Required: N/A

Countability: Singleton

Flags: N/A

Terminology bindings: N/A

Requirements: N/A

Comments: N/A

Example:

"patient":

Learn more about the (Claim) patient FHIR attribute

Description: Intervention and exception code (Pharma)

FHIR Version: dstu2

Attribute Type : Coding

Required: N/A

Countability: Array

Flags: N/A

Terminology bindings: N/A

Requirements: N/A

Comments: N/A

Example:

"interventionException":

Learn more about the (Claim) interventionException FHIR attribute

Description: Original specification followed

FHIR Version: dstu2

Attribute Type : Coding

Required: N/A

Countability: Singleton

Flags: N/A

Terminology bindings: N/A

Requirements: N/A

Comments: N/A

Example:

"originalRuleset":

Learn more about the (Claim) originalRuleset FHIR attribute

Description: Insurance or medical plan

FHIR Version: dstu2

Attribute Type : Data Type

Required: N/A

Countability: Array

Flags: N/A

Terminology bindings: N/A

Requirements: N/A

Comments: N/A

Example:

"coverage":

Learn more about the (Claim) coverage FHIR attribute

Description: List of presenting Conditions

FHIR Version: dstu2

Attribute Type : Coding

Required: N/A

Countability: Array

Flags: N/A

Terminology bindings: N/A

Requirements: N/A

Comments: N/A

Example:

"condition":

Learn more about the (Claim) condition FHIR attribute

Description: Name of School

FHIR Version: dstu2

Attribute Type : string

Required: N/A

Countability: Singleton

Flags: N/A

Terminology bindings: N/A

Requirements: N/A

Comments: N/A

Example:

"school":

Learn more about the (Claim) school FHIR attribute

Description: Accident Date

FHIR Version: dstu2

Attribute Type : date

Required: N/A

Countability: Singleton

Flags: N/A

Terminology bindings: N/A

Requirements: N/A

Comments: N/A

Example:

"accident":

Learn more about the (Claim) accident FHIR attribute

Description: Prescription

FHIR Version: dstu2

Attribute Type : Reference

Required: N/A

Countability: Singleton

Flags: N/A

Terminology bindings: N/A

Requirements: N/A

Comments: N/A

Example:

"prescription":

Learn more about the (Claim) prescription FHIR attribute

Description: Insurer

FHIR Version: dstu2

Attribute Type : Reference

Required: N/A

Countability: Singleton

Flags: N/A

Terminology bindings: N/A

Requirements: N/A

Comments: N/A

Example:

"target":

Learn more about the (Claim) target FHIR attribute

Description: Treatment Referral

FHIR Version: dstu2

Attribute Type : Reference

Required: N/A

Countability: Singleton

Flags: N/A

Terminology bindings: N/A

Requirements: N/A

Comments: N/A

Example:

"referral":

Learn more about the (Claim) referral FHIR attribute

Description: Creation date

FHIR Version: dstu2

Attribute Type : dateTime

Required: N/A

Countability: Singleton

Flags: N/A

Terminology bindings: N/A

Requirements: N/A

Comments: N/A

Example:

"created":

Learn more about the (Claim) created FHIR attribute

Description: Goods and Services

FHIR Version: dstu2

Attribute Type : Data Type

Required: N/A

Countability: Array

Flags: N/A

Terminology bindings: N/A

Requirements: N/A

Comments: N/A

Example:

"item":

Learn more about the (Claim) item FHIR attribute

Description: Diagnosis

FHIR Version: dstu2

Attribute Type : Data Type

Required: N/A

Countability: Array

Flags: N/A

Terminology bindings: N/A

Requirements: N/A

Comments: N/A

Example:

"diagnosis":

Learn more about the (Claim) diagnosis FHIR attribute

Description: Responsible organization

FHIR Version: dstu2

Attribute Type : Reference

Required: N/A

Countability: Singleton

Flags: N/A

Terminology bindings: N/A

Requirements: N/A

Comments: N/A

Example:

"organization":

Learn more about the (Claim) organization FHIR attribute

Description: Claim number

FHIR Version: dstu2

Attribute Type : Identifier

Required: N/A

Countability: Array

Flags: N/A

Terminology bindings: N/A

Requirements: N/A

Comments: N/A

Example:

"identifier":

Learn more about the (Claim) identifier FHIR attribute

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 them like so:

https://api.1up.health/fhir/dstu2/Claim?query-param=queryvalue

Search Parameter	Field Type	Resource Fields Searched
`identifier`	`text`	`identifier`
`patient`	`reference`	`patient`
`priority`	`text`	`priority`
`provider`	`reference`	`provider`
`use`	`text`	`use`