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See the Directory of published versions
Financial Management Work Group | Maturity Level: 2 | Trial Use | Compartments: N/A |
This operation is used to submit a Claim, Pre-Authorization or Pre-Determination (all instances of Claim resources) for adjudication either as a single Claim resource instance or as a Bundle containing the Claim and other referenced resources, or Bundle containing a batch of Claim resources, either as single Claims resources or Bundle resources, for processing. The only input parameter is the single Claim or Bundle resource and the only output is a single ClaimResponse, Bundle of ClaimResponses or an OperationOutcome resource.
The canonical URL for this operation definition is
http://hl7.org/fhir/OperationDefinition/Claim-submit
Formal Definition (as a OperationDefinition).
URL: [base]/Claim/$submit
This is not an idempotent operation
In Parameters: | ||||||
Name | Scope | Cardinality | Type | Binding | Profile | Documentation |
resource | 1..1 | Resource | A Claim resource or Bundle of claims, either as individual Claim resources or as Bundles each containing a single Claim plus referenced resources. | |||
Out Parameters: | ||||||
Name | Scope | Cardinality | Type | Binding | Profile | Documentation |
return | 1..1 | Resource | A ClaimResponse resource or Bundle of claim responses, either as individual ClaimResponse resources or as Bundles each containing a single ClaimResponse plus referenced resources. Note: as this is the only out parameter, it is a resource, and it has the name 'return', the result of this operation is returned directly as a resource |
Request:
POST [baseurl]/Claim/$submit [headers] <?xml version="1.0" encoding="UTF-8"?> <Claim xmlns="http://hl7.org/fhir" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:schemaLocation="http://hl7.org/fhir ../../schema/coverage.xsd"> <id value="100150"/> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml">A human-readable rendering of the Oral Health Claim</div> </text> <identifier> <system value="http://happyvalley.com/claim"/> <value value="12345"/> </identifier> <status value = "active"/> <type> <coding> <system value="http://hl7.org/fhir/claim-type"/> <code value="oral"/> </coding> </type> <use value="claim"/> <patient> <reference value="Patient/1"/> </patient> <created value="2014-08-16"/> <insurer> <reference value="Organization/2"/> </insurer> <organization> <reference value="Organization/1"/> </organization> <priority> <coding> <code value="normal"/> </coding> </priority> <payee> <type> <coding> <code value="provider"/> </coding> </type> </payee> <careTeam> <sequence value="1"/> <provider> <reference value="Practitioner/example"/> </provider> </careTeam> <diagnosis> <sequence value="1"/> <diagnosisCodeableConcept> <coding> <code value="123456"/> </coding> </diagnosisCodeableConcept> </diagnosis> <insurance> <sequence value="1"/> <focal value="true"/> <identifier> <system value="http://happyvalley.com/claim"/> <value value="12345"/> </identifier> <coverage> <reference value="Coverage/9876B1"/> </coverage> </insurance> <item> <sequence value="1"/> <careTeamLinkId value="1"/> <billcode> <coding> <code value="1200"/> </coding> </billcode> <servicedDate value="2014-08-16"/> <unitPrice> <value value="135.57"/> <code value="USD"/> </unitPrice> <net> <value value="135.57"/> <code value="USD"/> </net> </item> </Claim>
Response:
HTTP/1.1 200 OK [headers] <?xml version="1.0" encoding="UTF-8"?> <ClaimResponse xmlns="http://hl7.org/fhir" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:schemaLocation="http://hl7.org/fhir ../../schema/claimresponse.xsd"> <id value="R3500"/> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml">A human-readable rendering of the ClaimResponse</div> </text> <identifier> <system value="http://www.BenefitsInc.com/fhir/remittance"/> <value value="R3500"/> </identifier> <status value="active"/> <type> <coding> <system value="http://hl7.org/fhir/claim-type"/> <code value="oral"/> </coding> </type> <use value="claim"/> <patient> <reference value="Patient/1"/> </patient> <created value="2014-08-16"/> <insurer> <identifier> <system value="http://www.jurisdiction.org/insurers"/> <value value="555123"/> </identifier> </insurer> <requestProvider> <reference value="Practitioner/1"/> </requestProvider> <requestOrganization> <reference value="Organization/1"/> </requestOrganization> <request> <reference value="http://www.BenefitsInc.com/fhir/oralhealthclaim/15476332402"/> </request> <outcome value="complete" /> <disposition value="Claim settled as per contract."/> <payeeType> <coding> <system value="http://hl7.org/fhir/payeetype"/> <code value="provider"/> </coding> </payeeType> <!-- Adjudication details --> <item> <sequenceLinkId value="1"/> <adjudication> <category> <coding> <code value="eligible"/> </coding> </category> <amount> <value value="135.57"/> <code value="USD"/> </amount> </adjudication> <adjudication> <category> <coding> <code value="copay"/> </coding> </category> <amount> <value value="10.00"/> <code value="USD"/> </amount> </adjudication> <adjudication> <category> <coding> <code value="eligpercent"/> </coding> </category> <value value="80.00"/> </adjudication> <adjudication> <category> <coding> <code value="benefit"/> </coding> </category> <reason> <coding> <system value="http://hl7.org/fhir/adjudication-reason"/> <code value="ar002"/> <display value="Plan Limit Reached"/> <!-- should have paid 100.47 --> </coding> </reason> <amount> <value value="90.47"/> <code value="USD"/> </amount> </adjudication> </item> <totalCost> <value value="135.57"/> <code value="USD"/> </totalCost> <totalBenefit> <value value="90.47"/> <code value="USD"/> </totalBenefit> <!-- Payment details --> <payment> <type> <coding> <system value="http://hl7.org/fhir/ex-paymenttype"/> <code value="complete"/> </coding> </type> <date value="2014-08-31"/> <amount> <value value="100.47"/> <code value="USD"/> </amount> <identifier> <system value="http://www.BenefitsInc.com/fhir/paymentidentifier"/> <value value="201408-2-1569478"/> </identifier> </payment> </ClaimResponse>
For more information about operations, including how they are invoked, see Operations.