Claim - FHIR Resource (r4)
This Claim Resource uses the FHIR API standard for access and structure.
Validate an Claim FHIR Resource (r4)
Claim Attributes
AttributeField is listTypeDescription
Description: Business Identifier for claim
FHIR Version: r4
Attribute Type : Identifier
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"identifier": [
{
"system": "http://happyvalley.com/claim",
"value": "12345"
}
]Learn more about the (Claim) identifier FHIR attribute
Description: active | cancelled | draft | entered-in-error
FHIR Version: r4
Attribute Type : code
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"status": "active"Learn more about the (Claim) status FHIR attribute
Description: Category or discipline
FHIR Version: r4
Attribute Type : CodeableConcept
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
"code": "oral"
}
]
}Learn more about the (Claim) type FHIR attribute
Description: More granular claim type
FHIR Version: r4
Attribute Type : CodeableConcept
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"subType": Learn more about the (Claim) subType FHIR attribute
Description: claim | preauthorization | predetermination
FHIR Version: r4
Attribute Type : code
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"use": "claim"Learn more about the (Claim) use FHIR attribute
Description: The recipient of the products and services
FHIR Version: r4
Attribute Type : Reference
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"patient": {
"reference": "Patient/1"
}Learn more about the (Claim) patient FHIR attribute
Description: Relevant time frame for the claim
FHIR Version: r4
Attribute Type : Period
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"billablePeriod": Learn more about the (Claim) billablePeriod FHIR attribute
Description: Resource creation date
FHIR Version: r4
Attribute Type : dateTime
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"created": "2014-08-16"Learn more about the (Claim) created FHIR attribute
Description: Author of the claim
FHIR Version: r4
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: Target
FHIR Version: r4
Attribute Type : Reference
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"insurer": {
"reference": "Organization/2"
}Learn more about the (Claim) insurer FHIR attribute
Description: Party responsible for the claim
FHIR Version: r4
Attribute Type : Reference
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"provider": {
"reference": "Organization/1"
}Learn more about the (Claim) provider FHIR attribute
Description: Desired processing ugency
FHIR Version: r4
Attribute Type : CodeableConcept
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"priority": {
"coding": [
{
"code": "normal"
}
]
}Learn more about the (Claim) priority FHIR attribute
Description: For whom to reserve funds
FHIR Version: r4
Attribute Type : CodeableConcept
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: Prior or corollary claims
FHIR Version: r4
Attribute Type : Data Type
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"related": Learn more about the (Claim) related FHIR attribute
Description: "prescription" : { Reference(DeviceRequest|MedicationRequest|
FHIR Version: r4
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: "originalPrescription" : { Reference(DeviceRequest|MedicationRequest|
FHIR Version: r4
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: Recipient of benefits payable
FHIR Version: r4
Attribute Type : Data Type
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"payee": {
"type": {
"coding": [
{
"code": "provider"
}
]
}
}Learn more about the (Claim) payee FHIR attribute
Description: Treatment referral
FHIR Version: r4
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: Servicing facility
FHIR Version: r4
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: Members of the care team
FHIR Version: r4
Attribute Type : Data Type
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"careTeam": [
{
"sequence": 1,
"provider": {
"reference": "Practitioner/example"
}
}
]Learn more about the (Claim) careTeam FHIR attribute
Description: Supporting information
FHIR Version: r4
Attribute Type : Data Type
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"supportingInfo": Learn more about the (Claim) supportingInfo FHIR attribute
Description: Pertinent diagnosis information
FHIR Version: r4
Attribute Type : Data Type
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"diagnosis": [
{
"sequence": 1,
"diagnosisCodeableConcept": {
"coding": [
{
"code": "123456"
}
]
}
}
]Learn more about the (Claim) diagnosis FHIR attribute
Description: Clinical procedures performed
FHIR Version: r4
Attribute Type : Data Type
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"procedure": Learn more about the (Claim) procedure FHIR attribute
Description: Patient insurance information
FHIR Version: r4
Attribute Type : Data Type
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"insurance": [
{
"sequence": 1,
"focal": true,
"identifier": {
"system": "http://happyvalley.com/claim",
"value": "12345"
},
"coverage": {
"reference": "Coverage/9876B1"
}
}
]Learn more about the (Claim) insurance FHIR attribute
Description: Details of the event
FHIR Version: r4
Attribute Type : Data Type
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: Product or service provided
FHIR Version: r4
Attribute Type : Data Type
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"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"
}
}
]Learn more about the (Claim) item FHIR attribute
Description: Total claim cost
FHIR Version: r4
Attribute Type : Money
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"total": Learn more about the (Claim) total FHIR attribute
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 Parameter | Field Type | Resource Fields Searched |
|---|---|---|
care-team | reference | careTeam.provider |
created | date | created |
detail-udi | reference | item.detail.udi |
encounter | reference | item.encounter |
enterer | reference | enterer |
facility | reference | facility |
identifier | text | identifier |
insurer | reference | insurer |
item-udi | reference | item.udi |
patient | reference | patient |
payee | reference | payee.party |
priority | text | priority |
procedure-udi | reference | procedure.udi |
provider | reference | provider |
status | text | status |
subdetail-udi | reference | item.detail.subDetail.udi |
use | text | use |
