Claim

A unique identifier assigned to this claim.

Allows claims to be distinguished and referenced.

The status of the resource instance.

Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.

This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

A code specifying the state of the resource instance.

The category of claim, e.g. oral, pharmacy, vision, institutional, professional.

Claim type determine the general sets of business rules applied for information requirements and adjudication.

The majority of jurisdictions use: oral, pharmacy, vision, professional and institutional, or variants on those terms, as the general styles of claims. The valueset is extensible to accommodate other jurisdictional requirements.

The type or discipline-style of the claim.

A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.

Some jurisdictions need a finer grained claim type for routing and adjudication.

This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.

A more granular claim typecode.

A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future.

This element is required to understand the nature of the request for adjudication.

Note that FHIR strings SHALL NOT exceed 1MB in size

The purpose of the Claim: predetermination, preauthorization, claim.

The party to whom the professional services and/or products have been supplied or are being considered and for whom actual or forecast reimbursement is sought.

The patient must be supplied to the insurer so that confirmation of coverage and service history may be considered as part of the authorization and/or adjudiction.

References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

The period for which charges are being submitted.

A number jurisdictions required the submission of the billing period when submitting claims for example for hospital stays or long-term care.

Typically this would be today or in the past for a claim, and today or in the future for preauthorizations and predeterminations. Typically line item dates of service should fall within the billing period if one is specified.

The date this resource was created.

Need to record a timestamp for use by both the recipient and the issuer.

This field is independent of the date of creation of the resource as it may reflect the creation date of a source document prior to digitization. Typically for claims all services must be completed as of this date.

Individual who created the claim, predetermination or preauthorization.

Some jurisdictions require the contact information for personnel completing claims.

References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

The Insurer who is target of the request.

References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

The provider which is responsible for the claim, predetermination or preauthorization.

Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below.

The provider-required urgency of processing the request. Typical values include: stat, routine deferred.

The provider may need to indicate their processing requirements so that the processor can indicate if they are unable to comply.

If a claim processor is unable to complete the processing as per the priority then they should generate and error and not process the request.

The timeliness with which processing is required: stat, normal, deferred.

A code to indicate whether and for whom funds are to be reserved for future claims.

In the case of a Pre-Determination/Pre-Authorization the provider may request that funds in the amount of the expected Benefit be reserved ('Patient' or 'Provider') to pay for the Benefits determined on the subsequent claim(s). 'None' explicitly indicates no funds reserving is requested.

This field is only used for preauthorizations.

For whom funds are to be reserved: (Patient, Provider, None).

Reference to a related claim.

For workplace or other accidents it is common to relate separate claims arising from the same event.

References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

A code to convey how the claims are related.

Some insurers need a declaration of the type of relationship.

For example, prior claim or umbrella.

Relationship of this claim to a related Claim.

An alternate organizational reference to the case or file to which this particular claim pertains.

In cases where an event-triggered claim is being submitted to an insurer which requires a reference number to be specified on all exchanges.

For example, Property/Casualty insurer claim # or Workers Compensation case # .

Prescription to support the dispensing of pharmacy, device or vision products.

Required to authorize the dispensing of controlled substances and devices.

References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

Original prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or products.

Often required when a fulfiller varies what is fulfilled from that authorized on the original prescription.

For example, a physician may prescribe a medication which the pharmacy determines is contraindicated, or for which the patient has an intolerance, and therefore issues a new prescription for an alternate medication which has the same therapeutic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription'.

Type of Party to be reimbursed: subscriber, provider, other.

Need to know who should receive payment with the most common situations being the Provider (assignment of benefits) or the Subscriber.

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

A code for the party to be reimbursed.

Reference to the individual or organization to whom any payment will be made.

Need to provide demographics if the payee is not 'subscriber' nor 'provider'.

Not required if the payee is 'subscriber' or 'provider'.

A reference to a referral resource.

Some insurers require proof of referral to pay for services or to pay specialist rates for services.

The referral resource which lists the date, practitioner, reason and other supporting information.

Facility where the services were provided.

Insurance adjudication can be dependant on where services were delivered.

References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

A number to uniquely identify care team entries.

Necessary to maintain the order of the care team and provide a mechanism to link individuals to claim details.

32 bit number; for values larger than this, use decimal

Member of the team who provided the product or service.

Often a regulatory requirement to specify the responsible provider.

References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

The party who is billing and/or responsible for the claimed products or services.

When multiple parties are present it is required to distinguish the lead or responsible individual.

Responsible might not be required when there is only a single provider listed.

The lead, assisting or supervising practitioner and their discipline if a multidisciplinary team.

When multiple parties are present it is required to distinguish the roles performed by each member.

Role might not be required when there is only a single provider listed.

The role codes for the care team members.

The qualification of the practitioner which is applicable for this service.

Need to specify which qualification a provider is delivering the product or service under.

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Provider professional qualifications.

A number to uniquely identify supporting information entries.

Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details.

32 bit number; for values larger than this, use decimal

The general class of the information supplied: information; exception; accident, employment; onset, etc.

Required to group or associate information items with common characteristics. For example: admission information or prior treatments.

This may contain a category for the local bill type codes.

The valuset used for additional information category codes.

System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought.

Required to identify the kind of additional information.

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

The valuset used for additional information codes.

Provides the reason in the situation where a reason code is required in addition to the content.

Needed when the supporting information has both a date and amount/value and requires explanation.

For example: the reason for the additional stay, or why a tooth is missing.

Reason codes for the missing teeth.

A number to uniquely identify diagnosis entries.

Necessary to maintain the order of the diagnosis items and provide a mechanism to link to claim details.

Diagnosis are presented in list order to their expected importance: primary, secondary, etc.

When the condition was observed or the relative ranking.

Often required to capture a particular diagnosis, for example: primary or discharge.

For example: admitting, primary, secondary, discharge.

The type of the diagnosis: admitting, principal, discharge.

Indication of whether the diagnosis was present on admission to a facility.

Many systems need to understand for adjudication if the diagnosis was present a time of admission.

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Present on admission.

A package billing code or bundle code used to group products and services to a particular health condition (such as heart attack) which is based on a predetermined grouping code system.

Required to relate the current diagnosis to a package billing code that is then referenced on the individual claim items which are specific to the health condition covered by the package code.

For example DRG (Diagnosis Related Group) or a bundled billing code. A patient may have a diagnosis of a Myocardial Infarction and a DRG for HeartAttack would be assigned. The Claim item (and possible subsequent claims) would refer to the DRG for those line items that were for services related to the heart attack event.

The DRG codes associated with the diagnosis.

A number to uniquely identify procedure entries.

Necessary to provide a mechanism to link to claim details.

32 bit number; for values larger than this, use decimal

When the condition was observed or the relative ranking.

Often required to capture a particular diagnosis, for example: primary or discharge.

For example: primary, secondary.

Example procedure type codes.

Date and optionally time the procedure was performed.

Required for auditing purposes.

Unique Device Identifiers associated with this line item.

The UDI code allows the insurer to obtain device level information on the product supplied.

References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

A number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order.

To maintain order of the coverages.

32 bit number; for values larger than this, use decimal

A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.

To identify which coverage in the list is being used to adjudicate this claim.

A patient may (will) have multiple insurance policies which provide reimbursement for healthcare services and products. For example a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for adjudicating this claim. Other claims would be created to request adjudication against the other listed policies.

The business identifier to be used when the claim is sent for adjudication against this insurance policy.

This will be the claim number should it be necessary to create this claim in the future. This is provided so that payors may forward claims to other payors in the Coordination of Benefit for adjudication rather than the provider being required to initiate each adjudication.

Only required in jurisdictions where insurers, rather than the provider, are required to send claims to insurers that appear after them in the list. This element is not required when 'subrogation=true'.

Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.

Required to allow the adjudicator to locate the correct policy and history within their information system.

References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

A business agreement number established between the provider and the insurer for special business processing purposes.

Providers may have multiple business arrangements with a given insurer and must supply the specific contract number for adjudication.

Note that FHIR strings SHALL NOT exceed 1MB in size

Reference numbers previously provided by the insurer to the provider to be quoted on subsequent claims containing services or products related to the prior authorization.

Providers must quote previously issued authorization reference numbers in order to obtain adjudication as previously advised on the Preauthorization.

This value is an alphanumeric string that may be provided over the phone, via text, via paper, or within a ClaimResponse resource and is not a FHIR Identifier.

The result of the adjudication of the line items for the Coverage specified in this insurance.

An insurer need the adjudication results from prior insurers to determine the outstanding balance remaining by item for the items in the curent claim.

Must not be specified when 'focal=true' for this insurance.

Date of an accident event related to the products and services contained in the claim.

Required for audit purposes and adjudication.

The date of the accident has to precede the dates of the products and services but within a reasonable timeframe.