Claim
ResourceFinancial · BillingTrial useMaturity 2
A provider issued list of professional services and products which have been provided, or are to be provided, to a patient which is sent to an insurer for reimbursement.
Tested supportFull test results →
- Backends
- PostgreSQLElasticsearch
- Interactions
- CreateReadUpdatePatchDelete
- Search
- 17 of 17 parameters tested
Structure
| Element | Card. | Type | Description |
|---|---|---|---|
identifier | 0..* | Identifier | Business Identifier for claim |
statusRequired?!Σ | 1..1 | code | active | cancelled | draft | entered-in-errorBinding (required): fm-status |
typeRequiredΣ | 1..1 | CodeableConcept | Category or disciplineBinding (extensible): claim-type |
subType | 0..1 | CodeableConcept | More granular claim typeBinding (example): claim-subtype |
useRequiredΣ | 1..1 | code | claim | preauthorization | predeterminationBinding (required): claim-use |
patientRequiredΣ | 1..1 | Reference(Patient) | The recipient of the products and services |
billablePeriodΣ | 0..1 | Period | Relevant time frame for the claim |
createdRequiredΣ | 1..1 | dateTime | Resource creation date |
enterer | 0..1 | Reference(Practitioner | PractitionerRole) | Author of the claim |
insurerΣ | 0..1 | Reference(Organization) | Target |
providerRequiredΣ | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim |
priorityRequiredΣ | 1..1 | CodeableConcept | Desired processing ugencyBinding (example): process-priority |
fundsReserve | 0..1 | CodeableConcept | For whom to reserve fundsBinding (example): fundsreserve |
related | 0..* | BackboneElement | Prior or corollary claims |
claim | 0..1 | Reference(Claim) | Reference to the related claim |
relationship | 0..1 | CodeableConcept | How the reference claim is relatedBinding (example): related-claim-relationship |
reference | 0..1 | Identifier | File or case reference |
prescription | 0..1 | Reference(DeviceRequest | MedicationRequest | VisionPrescription) | Prescription authorizing services and products |
originalPrescription | 0..1 | Reference(DeviceRequest | MedicationRequest | VisionPrescription) | Original prescription if superseded by fulfiller |
payee | 0..1 | BackboneElement | Recipient of benefits payable |
typeRequired | 1..1 | CodeableConcept | Category of recipientBinding (example): payeetype |
party | 0..1 | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) | Recipient reference |
referral | 0..1 | Reference(ServiceRequest) | Treatment referral |
facility | 0..1 | Reference(Location) | Servicing facility |
careTeam | 0..* | BackboneElement | Members of the care team |
sequenceRequired | 1..1 | positiveInt | Order of care team |
providerRequired | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Practitioner or organization |
responsible | 0..1 | boolean | Indicator of the lead practitioner |
role | 0..1 | CodeableConcept | Function within the teamBinding (example): claim-careteamrole |
qualification | 0..1 | CodeableConcept | Practitioner credential or specializationBinding (example): provider-qualification |
supportingInfo | 0..* | BackboneElement | Supporting information |
sequenceRequired | 1..1 | positiveInt | Information instance identifier |
categoryRequired | 1..1 | CodeableConcept | Classification of the supplied informationBinding (example): claim-informationcategory |
code | 0..1 | CodeableConcept | Type of informationBinding (example): claim-exception |
timing[x] | 0..1 | date | Period | When it occurred |
value[x] | 0..1 | boolean | string | Quantity | Attachment | Reference(Resource) | Data to be provided |
reason | 0..1 | CodeableConcept | Explanation for the informationBinding (example): missing-tooth-reason |
diagnosis | 0..* | BackboneElement | Pertinent diagnosis information |
sequenceRequired | 1..1 | positiveInt | Diagnosis instance identifier |
diagnosis[x]Required | 1..1 | CodeableConcept | Reference(Condition) | Nature of illness or problemBinding (example): icd-10 |
type | 0..* | CodeableConcept | Timing or nature of the diagnosisBinding (example): ex-diagnosistype |
onAdmission | 0..1 | CodeableConcept | Present on admissionBinding (example): ex-diagnosis-on-admission |
packageCode | 0..1 | CodeableConcept | Package billing codeBinding (example): ex-diagnosisrelatedgroup |
procedure | 0..* | BackboneElement | Clinical procedures performed |
sequenceRequired | 1..1 | positiveInt | Procedure instance identifier |
type | 0..* | CodeableConcept | Category of ProcedureBinding (example): ex-procedure-type |
date | 0..1 | dateTime | When the procedure was performed |
procedure[x]Required | 1..1 | CodeableConcept | Reference(Procedure) | Specific clinical procedureBinding (example): icd-10-procedures |
udi | 0..* | Reference(Device) | Unique device identifier |
insuranceRequiredΣ | 1..* | BackboneElement | Patient insurance information |
sequenceRequiredΣ | 1..1 | positiveInt | Insurance instance identifier |
focalRequiredΣ | 1..1 | boolean | Coverage to be used for adjudication |
identifier | 0..1 | Identifier | Pre-assigned Claim number |
coverageRequiredΣ | 1..1 | Reference(Coverage) | Insurance information |
businessArrangement | 0..1 | string | Additional provider contract number |
preAuthRef | 0..* | string | Prior authorization reference number |
claimResponse | 0..1 | Reference(ClaimResponse) | Adjudication results |
accident | 0..1 | BackboneElement | Details of the event |
dateRequired | 1..1 | date | When the incident occurred |
type | 0..1 | CodeableConcept | The nature of the accidentBinding (extensible): v3-ActIncidentCode |
location[x] | 0..1 | Address | Reference(Location) | Where the event occurred |
item | 0..* | BackboneElement | Product or service provided |
sequenceRequired | 1..1 | positiveInt | Item instance identifier |
careTeamSequence | 0..* | positiveInt | Applicable careTeam members |
diagnosisSequence | 0..* | positiveInt | Applicable diagnoses |
procedureSequence | 0..* | positiveInt | Applicable procedures |
informationSequence | 0..* | positiveInt | Applicable exception and supporting information |
revenue | 0..1 | CodeableConcept | Revenue or cost center codeBinding (example): ex-revenue-center |
category | 0..1 | CodeableConcept | Benefit classificationBinding (example): ex-benefitcategory |
productOrServiceRequired | 1..1 | CodeableConcept | Billing, service, product, or drug codeBinding (example): service-uscls |
modifier | 0..* | CodeableConcept | Product or service billing modifiersBinding (example): claim-modifiers |
programCode | 0..* | CodeableConcept | Program the product or service is provided underBinding (example): ex-program-code |
serviced[x] | 0..1 | date | Period | Date or dates of service or product delivery |
location[x] | 0..1 | CodeableConcept | Address | Reference(Location) | Place of service or where product was suppliedBinding (example): service-place |
quantity | 0..1 | Quantity | Count of products or services |
unitPrice | 0..1 | Money | Fee, charge or cost per item |
factor | 0..1 | decimal | Price scaling factor |
net | 0..1 | Money | Total item cost |
udi | 0..* | Reference(Device) | Unique device identifier |
bodySite | 0..1 | CodeableConcept | Anatomical locationBinding (example): tooth |
subSite | 0..* | CodeableConcept | Anatomical sub-locationBinding (example): surface |
encounter | 0..* | Reference(Encounter) | Encounters related to this billed item |
detail | 0..* | BackboneElement | Product or service provided |
sequenceRequired | 1..1 | positiveInt | Item instance identifier |
revenue | 0..1 | CodeableConcept | Revenue or cost center codeBinding (example): ex-revenue-center |
category | 0..1 | CodeableConcept | Benefit classificationBinding (example): ex-benefitcategory |
productOrServiceRequired | 1..1 | CodeableConcept | Billing, service, product, or drug codeBinding (example): service-uscls |
modifier | 0..* | CodeableConcept | Service/Product billing modifiersBinding (example): claim-modifiers |
programCode | 0..* | CodeableConcept | Program the product or service is provided underBinding (example): ex-program-code |
quantity | 0..1 | Quantity | Count of products or services |
unitPrice | 0..1 | Money | Fee, charge or cost per item |
factor | 0..1 | decimal | Price scaling factor |
net | 0..1 | Money | Total item cost |
udi | 0..* | Reference(Device) | Unique device identifier |
subDetail | 0..* | BackboneElement | Product or service provided |
sequenceRequired | 1..1 | positiveInt | Item instance identifier |
revenue | 0..1 | CodeableConcept | Revenue or cost center codeBinding (example): ex-revenue-center |
category | 0..1 | CodeableConcept | Benefit classificationBinding (example): ex-benefitcategory |
productOrServiceRequired | 1..1 | CodeableConcept | Billing, service, product, or drug codeBinding (example): service-uscls |
modifier | 0..* | CodeableConcept | Service/Product billing modifiersBinding (example): claim-modifiers |
programCode | 0..* | CodeableConcept | Program the product or service is provided underBinding (example): ex-program-code |
quantity | 0..1 | Quantity | Count of products or services |
unitPrice | 0..1 | Money | Fee, charge or cost per item |
factor | 0..1 | decimal | Price scaling factor |
net | 0..1 | Money | Total item cost |
udi | 0..* | Reference(Device) | Unique device identifier |
total | 0..1 | Money | Total claim cost |
Σ in _summary results · ?! modifier element · 1.. required · inherited elements in grey
Search parameters
Query with GET [base]/Claim?[parameter]=[value]. Type decides which modifiers and prefixes apply, see search features.
| Parameter | Type | Description | PG | ES |
|---|---|---|---|---|
care-team | reference | Member of the CareTeam Claim.careTeam.provider | ||
created | date | The creation date for the Claim Claim.created | ||
detail-udi | reference | UDI associated with a line item, detail product or service Claim.item.detail.udi | ||
encounter | reference | Encounters associated with a billed line item Claim.item.encounter | ||
enterer | reference | The party responsible for the entry of the Claim Claim.enterer | ||
facility | reference | Facility where the products or services have been or will be provided Claim.facility | ||
identifier | token | The primary identifier of the financial resource Claim.identifier | ||
insurer | reference | The target payor/insurer for the Claim Claim.insurer | ||
item-udi | reference | UDI associated with a line item product or service Claim.item.udi | ||
patient | reference | Patient receiving the products or services Claim.patient | ||
payee | reference | The party receiving any payment for the Claim Claim.payee.party | ||
priority | token | Processing priority requested Claim.priority | ||
procedure-udi | reference | UDI associated with a procedure Claim.procedure.udi | ||
provider | reference | Provider responsible for the Claim Claim.provider | ||
status | token | The status of the Claim instance. Claim.status | ||
subdetail-udi | reference | UDI associated with a line item, detail, subdetail product or service Claim.item.detail.subDetail.udi | ||
use | token | The kind of financial resource Claim.use |
PG: PostgreSQL, ES: Elasticsearch. passes its TestScript checks, fails, not tested yet. The author of the resource Logical id of this artifact When the resource version last changed Profiles this resource claims to conform to Security Labels applied to this resource Identifies where the resource comes from Tags applied to this resource Derived from the R4B DefinitionCommon parameters on every resource (8)
_haste-health-authorreference _idtoken _lastUpdateddate _profileuri _securitytoken _sourceuri _tagtoken _typetoken