Claim - FHIR Resource (stu3)
This Claim Resource uses the FHIR API standard for access and structure.
Validate an Claim FHIR Resource (stu3)
Claim Attributes
AttributeField is listTypeDescription
Description: Servicing Facility
FHIR Version: stu3
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: Related Claims which may be revelant to processing this claimn
FHIR Version: stu3
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: Funds requested to be reserved
FHIR Version: stu3
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Description: Original prescription if superceded by fulfiller
FHIR Version: stu3
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: Period for charge submission
FHIR Version: stu3
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: Total claim cost
FHIR Version: stu3
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
Description: Insurance or medical plan
FHIR Version: stu3
Attribute Type : Data Type
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"insurance": [
{
"coverage": {
"reference": "Coverage/9876B1"
},
"focal": true,
"sequence": 1
}
]Learn more about the (Claim) insurance FHIR attribute
Description: Exceptions, special considerations, the condition, situation, prior or concurrent issues
FHIR Version: stu3
Attribute Type : Data Type
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"information": Learn more about the (Claim) information FHIR attribute
Description: complete | proposed | exploratory | other
FHIR Version: stu3
Attribute Type : code
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"use": "complete"Learn more about the (Claim) use FHIR attribute
Description: Party to be paid any benefits payable
FHIR Version: stu3
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: Author
FHIR Version: stu3
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: Desired processing priority
FHIR Version: stu3
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: Responsible provider
FHIR Version: stu3
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: Type or discipline
FHIR Version: stu3
Attribute Type : CodeableConcept
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"type": {
"coding": [
{
"code": "oral",
"system": "http://hl7.org/fhir/ex-claimtype"
}
]
}Learn more about the (Claim) type FHIR attribute
Description: active | cancelled | draft | entered-in-error
FHIR Version: stu3
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: The subject of the Products and Services
FHIR Version: stu3
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: Period in hospital
FHIR Version: stu3
Attribute Type : Period
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"hospitalization": Learn more about the (Claim) hospitalization FHIR attribute
Description: Target
FHIR Version: stu3
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: Treatment Referral
FHIR Version: stu3
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: Period unable to work
FHIR Version: stu3
Attribute Type : Period
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"employmentImpacted": Learn more about the (Claim) employmentImpacted FHIR attribute
Description: Details about an accident
FHIR Version: stu3
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: Prescription authorizing services or products
FHIR Version: stu3
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: Creation date
FHIR Version: stu3
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: Goods and Services
FHIR Version: stu3
Attribute Type : Data Type
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"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
}
}
]Learn more about the (Claim) item FHIR attribute
Description: Finer grained claim type information
FHIR Version: stu3
Attribute Type : CodeableConcept
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"subType": Learn more about the (Claim) subType FHIR attribute
Description: List of Diagnosis
FHIR Version: stu3
Attribute Type : Data Type
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"diagnosis": [
{
"diagnosisCodeableConcept": {
"coding": [
{
"code": "123456"
}
]
},
"sequence": 1
}
]Learn more about the (Claim) diagnosis FHIR attribute
Description: Members of the care team
FHIR Version: stu3
Attribute Type : Data Type
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"careTeam": [
{
"provider": {
"reference": "Practitioner/example"
},
"sequence": 1
}
]Learn more about the (Claim) careTeam FHIR attribute
Description: Responsible organization
FHIR Version: stu3
Attribute Type : Reference
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"organization": {
"reference": "Organization/1"
}Learn more about the (Claim) organization FHIR attribute
Description: Claim number
FHIR Version: stu3
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: Procedures performed
FHIR Version: stu3
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
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 them like so:
https://api.1up.health/fhir/stu3/Claim?query-param=queryvalue| Search Parameter | Field Type | Resource Fields Searched |
|---|---|---|
care-team | reference | careTeam.provider |
created | date | created |
encounter | reference | item.encounter |
enterer | reference | enterer |
facility | reference | facility |
identifier | text | identifier |
insurer | reference | insurer |
organization | reference | organization |
patient | reference | patient |
payee | reference | payee.party |
priority | text | priority |
provider | reference | provider |
use | text | use |
