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13.6 Resource Claim - Content

Financial Management icon Work GroupMaturity Level: 2 Trial UseSecurity Category: Patient Compartments: Device, Encounter, Patient, Practitioner, RelatedPerson

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.

13.6.1 Scope and Usage

The Claim is used by providers and payors, insurers, to exchange the financial information, and supporting clinical information, regarding the provision of health care services with payors and for reporting to regulatory bodies and firms which provide data analytics. The primary uses of this resource is to support eClaims, the exchange of information relating to the proposed or actual provision of healthcare-related goods and services for patients to their benefit payors, insurers and national health programs, for treatment payment planning and reimbursement.

The Claim resource is a "request" resource from a FHIR workflow perspective - see Workflow Request.

The Claim resource may be interpreted differently depending on its intended use (and the Claim.use element contains the code to indicate):

  • claim - where the provision of goods and services is complete and adjudication under a plan and payment is sought.
  • preauthorization - where the provision of goods and services is proposed and authorization and/or the reservation of funds is desired.
  • predetermination - where the provision of goods and services is explored to determine what services may be covered and to what amount. Essentially a 'what if' claim.

The Claim.type code system provides oral, pharmacy, vision, professional and institutional claim types. Claim types supported are influenced by the requirements of the implementing jurisdiction. The valueset is extensible to accommodate other types of claims as required by the jurisdiction.

The Claim also supports:

  • Up to a 3-tier hierarchy of Goods, products, and Services, to support simple to complex billing, see 3-Tier Line Item Hierarchy.
  • Multiple insurance programs arranged in a Coordination of Benefit sequence to enable exchange with primary, secondary, tertiary etc. insurance coverages.
  • Assignment of benefit - the benefit may be requested to be directed to the subscriber, the provider or another party.

Mapping to other Claim specifications: Mappings are currently maintained by the Financial Management Work Group to UB04 and CMS1500 and are available at https://confluence.hl7.org/display/FM/FHIR+Resource+Development icon. Mappings to other specifications may be made available where IP restrictions permit.

13.6.1.1 Additional Information

Additional information regarding electronic claims content and usage may be found at:

  • Financial Resource Status Lifecycle: how .status is used in the financial resources.
  • Secondary Use of Resources: how resources such as Claim and ExplanationOfBenefit may used for reporting and data exchange for analytics, not just for eClaims exchange between providers and payors.
  • Subrogation: how eClaims may handle patient insurance coverages when another insurer rather than the provider will settle the claim and potentially recover costs against specified coverages.
  • Coordination of Benefit: how eClaims may handle multiple patient insurance coverages.
  • Batches: how eClaims may handle batches of eligibility, claims and responses.
  • Attachments and Supporting Information: how eClaims may handle the provision of supporting information, whether provided by content or reference, within the eClaim resource when submitted to the payor or later in a resource which refers to the subject eClaim resource. This also includes how payors may request additional supporting information from providers.
  • 3-Tier Line Item Hierarchy: 3-tier hierarchy of Goods, products, and Services, to support simple to complex billing.
  • Tax: Tax handling of Goods, products, and Services.

13.6.2 Boundaries and Relationships

The Claim resource is used to request the adjudication and/or authorization of a set of healthcare-related goods and services for a patient against the patient's insurance coverages, or to request what the adjudication would be for a supplied set of goods or services should they be actually supplied to the patient.

When requesting whether the patient's coverage is inforce, whether it is valid at this or a specified date, or requesting the benefit details or preauthorization requirements associated with a coverage, then CoverageEligibilityRequest should be used instead.

When using the resources for reporting and transferring claims data, which may have originated in some standard other than FHIR, the Claim resource is useful if only the request side of the information exchange is of interest. If, however, both the request and the adjudication information is to be reported then the ExplanationOfBenefit should be used instead.

For reporting out to patients or transferring data to patient centered applications, such as Personal Health Record (PHR) application, the ExplanationOfBenefit should be used instead of the Claim and ClaimResponse resources as those resources may contain provider and payer specific information which is not appropriate for sharing with the patient.

The eClaim domain includes a number of related resources

Claim A suite of goods and services and insurances coverages under which adjudication or authorization is requested.
CoverageEligibilityRequest A request to a payor to: ascertain whether a coverage is in-force at the current or at a specified time; list the table of benefits; determine whether coverage is provided for specified categories or specific services; and whether preauthorization is required, and if so what supporting information would be required.
ClaimResponse A payor's adjudication and/or authorization response to the suite of services provided in a Claim. Typically the ClaimResponse references the Claim but does not duplicate the clinical or financial information provided in the claim.
ExplanationOfBenefit This resource combines the information from the Claim and the ClaimResponse, stripping out any provider or payor proprietary information, into a unified information model suitable for use for: patient reporting; transferring information to a Patient Health Record system; and, supporting complete claim and adjudication information exchange with regulatory and analytics organizations and other parts of the provider's organization.

13.6.3 References to this Resource

13.6.4 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim TU DomainResource Claim, Pre-determination or Pre-authorization

Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier 0..* Identifier Business Identifier for claim

... traceNumber 0..* Identifier Number for tracking

... status ?!Σ 1..1 code active | cancelled | draft | entered-in-error
Binding: Financial Resource Status Codes (Required)
... type Σ 1..1 CodeableConcept Category or discipline
Binding: Claim Type Codes (Extensible)
... subType 0..1 CodeableConcept More granular claim type
Binding: Example Claim SubType Codes (Example)
... use Σ 1..1 code claim | preauthorization | predetermination
Binding: Use (Required)
... patient Σ 1..1 Reference(Patient) The recipient of the products and services
... billablePeriod Σ 0..1 Period Relevant time frame for the claim
... created Σ 1..1 dateTime Resource creation date
... enterer 0..1 Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) Author of the claim
... insurer Σ 0..1 Reference(Organization) Target
... provider Σ 0..1 Reference(Practitioner | PractitionerRole | Organization) Party responsible for the claim
... priority Σ 0..1 CodeableConcept Desired processing urgency
Binding: Process Priority Codes (Example)
... fundsReserve 0..1 CodeableConcept For whom to reserve funds
Binding: Funds Reservation Codes (Example)
... 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 related
Binding: Example Related Claim Relationship Codes (Example)
.... 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
.... type 1..1 CodeableConcept Category of recipient
Binding: Claim Payee Type Codes (Example)
.... party 0..1 Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) Recipient reference
... referral 0..1 Reference(ServiceRequest) Treatment referral
... encounter 0..* Reference(Encounter) Encounters associated with the listed treatments

... facility 0..1 Reference(Location | Organization) Servicing facility
... diagnosisRelatedGroup 0..1 CodeableConcept Package billing code
Binding: Example Diagnosis Related Group Codes (Example)
... event 0..* BackboneElement Event information

.... type 1..1 CodeableConcept Specific event
Binding: Dates Type Codes (Example)
.... when[x] 1..1 Occurance date or period
..... whenDateTime dateTime
..... whenPeriod Period
... careTeam 0..* BackboneElement Members of the care team

.... sequence 1..1 positiveInt Order of care team
.... provider 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 team
Binding: Claim Care Team Role Codes (Example)
.... specialty 0..1 CodeableConcept Practitioner or provider specialization
Binding: Example Provider Qualification Codes (Example)
... supportingInfo 0..* BackboneElement Supporting information

.... sequence 1..1 positiveInt Information instance identifier
.... category 1..1 CodeableConcept Classification of the supplied information
Binding: Claim Information Category Codes (Example)
.... code 0..1 CodeableConcept Type of information
Binding: Exception Codes (Example)
.... timing[x] 0..1 When it occurred
..... timingDate date
..... timingPeriod Period
.... value[x] 0..1 Data to be provided
..... valueBoolean boolean
..... valueString string
..... valueQuantity Quantity
..... valueAttachment Attachment
..... valueReference Reference(Any)
..... valueIdentifier Identifier
.... reason 0..1 CodeableConcept Explanation for the information
Binding: Missing Tooth Reason Codes (Example)
... diagnosis 0..* BackboneElement Pertinent diagnosis information

.... sequence 1..1 positiveInt Diagnosis instance identifier
.... diagnosis[x] 1..1 Nature of illness or problem
Binding: ICD-10 Codes (Example)
..... diagnosisCodeableConcept CodeableConcept
..... diagnosisReference Reference(Condition)
.... type 0..* CodeableConcept Timing or nature of the diagnosis
Binding: Example Diagnosis Type Codes (Example)

.... onAdmission 0..1 CodeableConcept Present on admission
Binding: Example Diagnosis on Admission Codes (Example)
... procedure 0..* BackboneElement Clinical procedures performed

.... sequence 1..1 positiveInt Procedure instance identifier
.... type 0..* CodeableConcept Category of Procedure
Binding: Example Procedure Type Codes (Example)

.... date 0..1 dateTime When the procedure was performed
.... procedure[x] 1..1 Specific clinical procedure
Binding: ICD-10 Procedure Codes (Example)
..... procedureCodeableConcept CodeableConcept
..... procedureReference Reference(Procedure)
.... udi 0..* Reference(Device) Unique device identifier

... insurance Σ 0..* BackboneElement Patient insurance information

.... sequence Σ 1..1 positiveInt Insurance instance identifier
.... focal Σ 1..1 boolean Coverage to be used for adjudication
.... identifier 0..1 Identifier Pre-assigned Claim number
.... coverage Σ 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
.... date 1..1 date When the incident occurred
.... type 0..1 CodeableConcept The nature of the accident
Binding: ActIncidentCode icon (Extensible)
.... location[x] 0..1 Where the event occurred
..... locationAddress Address
..... locationReference Reference(Location)
... patientPaid 0..1 Money Paid by the patient
... item 0..* BackboneElement Product or service provided

.... sequence 1..1 positiveInt Item instance identifier
.... traceNumber 0..* Identifier Number for tracking

.... 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 code
Binding: Example Revenue Center Codes (Example)
.... category 0..1 CodeableConcept Benefit classification
Binding: Benefit Category Codes (Example)
.... productOrService 0..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLS Codes (Example)
.... productOrServiceEnd 0..1 CodeableConcept End of a range of codes
Binding: USCLS Codes (Example)
.... request 0..* Reference(DeviceRequest | MedicationRequest | NutritionOrder | ServiceRequest | SupplyRequest | VisionPrescription) Request or Referral for Service

.... modifier 0..* CodeableConcept Product or service billing modifiers
Binding: Modifier type Codes (Example)

.... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: Example Program Reason Codes (Example)

.... serviced[x] 0..1 Date or dates of service or product delivery
..... servicedDate date
..... servicedPeriod Period
.... location[x] 0..1 Place of service or where product was supplied
Binding: Example Service Place Codes (Example)
..... locationCodeableConcept CodeableConcept
..... locationAddress Address
..... locationReference Reference(Location)
.... patientPaid 0..1 Money Paid by the patient
.... quantity 0..1 SimpleQuantity Count of products or services
.... unitPrice 0..1 Money Fee, charge or cost per item
.... factor 0..1 decimal Price scaling factor
.... tax 0..1 Money Total tax
.... net 0..1 Money Total item cost
.... udi 0..* Reference(Device) Unique device identifier

.... bodySite 0..* BackboneElement Anatomical location

..... site 1..* CodeableReference(BodyStructure) Location
Binding: Oral Site Codes (Example)

..... subSite 0..* CodeableConcept Sub-location
Binding: Surface Codes (Example)

.... encounter 0..* Reference(Encounter) Encounters associated with the listed treatments

.... detail 0..* BackboneElement Product or service provided

..... sequence 1..1 positiveInt Item instance identifier
..... traceNumber 0..* Identifier Number for tracking

..... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: Example Revenue Center Codes (Example)
..... category 0..1 CodeableConcept Benefit classification
Binding: Benefit Category Codes (Example)
..... productOrService 0..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLS Codes (Example)
..... productOrServiceEnd 0..1 CodeableConcept End of a range of codes
Binding: USCLS Codes (Example)
..... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: Modifier type Codes (Example)

..... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: Example Program Reason Codes (Example)

..... patientPaid 0..1 Money Paid by the patient
..... quantity 0..1 SimpleQuantity Count of products or services
..... unitPrice 0..1 Money Fee, charge or cost per item
..... factor 0..1 decimal Price scaling factor
..... tax 0..1 Money Total tax
..... net 0..1 Money Total item cost
..... udi 0..* Reference(Device) Unique device identifier

..... subDetail 0..* BackboneElement Product or service provided

...... sequence 1..1 positiveInt Item instance identifier
...... traceNumber 0..* Identifier Number for tracking

...... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: Example Revenue Center Codes (Example)
...... category 0..1 CodeableConcept Benefit classification
Binding: Benefit Category Codes (Example)
...... productOrService 0..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLS Codes (Example)
...... productOrServiceEnd 0..1 CodeableConcept End of a range of codes
Binding: USCLS Codes (Example)
...... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: Modifier type Codes (Example)

...... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: Example Program Reason Codes (Example)

...... patientPaid 0..1 Money Paid by the patient
...... quantity 0..1 SimpleQuantity Count of products or services
...... unitPrice 0..1 Money Fee, charge or cost per item
...... factor 0..1 decimal Price scaling factor
...... tax 0..1 Money Total tax
...... net 0..1 Money Total item cost
...... udi 0..* Reference(Device) Unique device identifier

... total 0..1 Money Total claim cost

doco Documentation for this format icon

See the Extensions for this resource

 

Additional definitions: Master Definition XML + JSON, XML Schema/Schematron + JSON Schema, ShEx (for Turtle) + see the extensions, the spreadsheet version & the dependency analysis

13.6.4.1 Terminology Bindings

Path ValueSet Type Documentation
Claim.status FinancialResourceStatusCodes Required

This value set includes Status codes.
Claim.type ClaimTypeCodes Extensible

This value set includes Claim Type codes.
Claim.subType ExampleClaimSubTypeCodes Example

This value set includes sample Claim SubType codes which are used to distinguish the claim types for example within type institutional there may be subtypes for emergency services, bed stay and transportation.
Claim.use Use Required

The purpose of the Claim: predetermination, preauthorization, claim.
Claim.priority ProcessPriorityCodes Example

This value set includes the financial processing priority codes.
Claim.fundsReserve FundsReservationCodes Example

This value set includes sample funds reservation type codes.
Claim.related.relationship ExampleRelatedClaimRelationshipCodes Example

This value set includes sample Related Claim Relationship codes.
Claim.payee.type ClaimPayeeTypeCodes (a valid code from Payee Type Codes icon) Example

This value set includes sample Payee Type codes.
Claim.diagnosisRelatedGroup ExampleDiagnosisRelatedGroupCodes Example

This value set includes example Diagnosis Related Group codes.
Claim.event.type DatesTypeCodes (a valid code from Dates Event Type Codes) Example

This value set includes sample Dates Type codes.
Claim.careTeam.role ClaimCareTeamRoleCodes Example

This value set includes sample Claim Care Team Role codes.
Claim.careTeam.specialty ExampleProviderQualificationCodes Example

This value set includes sample Provider Qualification codes.
Claim.supportingInfo.category ClaimInformationCategoryCodes Example

This value set includes sample Information Category codes.
Claim.supportingInfo.code ExceptionCodes Example

This value set includes sample Exception codes.
Claim.supportingInfo.reason MissingToothReasonCodes Example

This value set includes sample Missing Tooth Reason codes.
Claim.diagnosis.diagnosis[x] ICD10Codes (a valid code from ICD-10 icon) Example

This value set includes sample ICD-10 codes.
Claim.diagnosis.type ExampleDiagnosisTypeCodes Example

This value set includes example Diagnosis Type codes.
Claim.diagnosis.onAdmission ExampleDiagnosisOnAdmissionCodes Example

This value set includes example Diagnosis on Admission codes.
Claim.procedure.type ExampleProcedureTypeCodes Example

This value set includes example Procedure Type codes.
Claim.procedure.procedure[x] ICD10ProcedureCodes (a valid code from ICD-10 Procedure Codes) Example

This value set includes sample ICD-10 Procedure codes.
Claim.accident.type ActIncidentCode icon Extensible

Set of codes indicating the type of incident or accident.
Claim.item.revenue ExampleRevenueCenterCodes Example

This value set includes sample Revenue Center codes.
Claim.item.category BenefitCategoryCodes Example

This value set includes examples of Benefit Category codes.
Claim.item.productOrService USCLSCodes Example

This value set includes a smattering of USCLS codes.
Claim.item.productOrServiceEnd USCLSCodes Example

This value set includes a smattering of USCLS codes.
Claim.item.modifier ModifierTypeCodes Example

This value set includes sample Modifier type codes.
Claim.item.programCode ExampleProgramReasonCodes Example

This value set includes sample Program Reason Span codes.
Claim.item.location[x] ExampleServicePlaceCodes Example

This value set includes a smattering of Service Place codes.
Claim.item.bodySite.site OralSiteCodes Example

This value set includes a smattering of FDI oral site codes.
Claim.item.bodySite.subSite SurfaceCodes Example

This value set includes a smattering of FDI tooth surface codes.
Claim.item.detail.revenue ExampleRevenueCenterCodes Example

This value set includes sample Revenue Center codes.
Claim.item.detail.category BenefitCategoryCodes Example

This value set includes examples of Benefit Category codes.
Claim.item.detail.productOrService USCLSCodes Example

This value set includes a smattering of USCLS codes.
Claim.item.detail.productOrServiceEnd USCLSCodes Example

This value set includes a smattering of USCLS codes.
Claim.item.detail.modifier ModifierTypeCodes Example

This value set includes sample Modifier type codes.
Claim.item.detail.programCode ExampleProgramReasonCodes Example

This value set includes sample Program Reason Span codes.
Claim.item.detail.subDetail.revenue ExampleRevenueCenterCodes Example

This value set includes sample Revenue Center codes.
Claim.item.detail.subDetail.category BenefitCategoryCodes Example

This value set includes examples of Benefit Category codes.
Claim.item.detail.subDetail.productOrService USCLSCodes Example

This value set includes a smattering of USCLS codes.
Claim.item.detail.subDetail.productOrServiceEnd USCLSCodes Example

This value set includes a smattering of USCLS codes.
Claim.item.detail.subDetail.modifier ModifierTypeCodes Example

This value set includes sample Modifier type codes.
Claim.item.detail.subDetail.programCode ExampleProgramReasonCodes Example

This value set includes sample Program Reason Span codes.

13.6.5 Additional Information

The information presented in different backbone elements, such as .supportingInfo or .adjudication, has a different context based on the .category code presented in each, for example, adjudication occurrence may represent an amount paid by the patient while another may represent the amount paid to the provider.

Additionally, there are several places in the resource which point to other sections of the resource via the use of a .sequence number in the referred-to element and an .elementSequence in the referring element. Sequence numbers appear in such element as .careTeam referred to by .careTeamSequence, .diagnosis referred to by .diagnosisSequence, .procedure referred to by .procedureSequence, .supportingInfo referred to by .informationSequence and .item referred to by .itemSequence.

13.6.6 Search Parameters

Search parameters for this resource. See also the full list of search parameters for this resource, and check the Extensions registry for search parameters on extensions related to this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.

Name Type Description Expression In Common
care-team reference Member of the CareTeam Claim.careTeam.provider
(Practitioner, Organization, PractitionerRole)
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
(Device)
encounter reference Encounters associated with a billed line item Claim.item.encounter
(Encounter)		 29 Resources
enterer reference The party responsible for the entry of the Claim Claim.enterer
(Practitioner, Patient, PractitionerRole, RelatedPerson)
facility reference Facility where the products or services have been or will be provided Claim.facility
(Organization, Location)
identifier token The primary identifier of the financial resource Claim.identifier 65 Resources
insurer reference The target payor/insurer for the Claim Claim.insurer
(Organization)
item-udi reference UDI associated with a line item product or service Claim.item.udi
(Device)
patient reference Patient receiving the products or services Claim.patient
(Patient)		 65 Resources
payee reference The party receiving any payment for the Claim Claim.payee.party
(Practitioner, Organization, Patient, PractitionerRole, RelatedPerson)
priority token Processing priority requested Claim.priority
procedure-udi reference UDI associated with a procedure Claim.procedure.udi
(Device)
provider reference Provider responsible for the Claim Claim.provider
(Practitioner, Organization, PractitionerRole)
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
(Device)
use token The kind of financial resource Claim.use