Claim | Medplum
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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.
- Schema
- Usage
- Relationships
- Referenced By
Elements [](/content/docs/api/fhir/resources/claim#elements "Direct link to Elements"/index.html)
| Name | Required | Type | Description |
|---|---|---|---|
| identifier | Identifier[] | Business Identifier for claim Details A unique identifier assigned to this claim. |
|
| status | ✓ | code | active | cancelled | draft | entered-in-error Details The status of the resource instance. This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. |
| type | ✓ | CodeableConcept | Category or discipline Details The category of claim, e.g. oral, pharmacy, vision, institutional, professional. 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. |
| subType | CodeableConcept | More granular claim type Details A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service. This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type. |
|
| use | ✓ | code | claim | preauthorization | predetermination Details 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. |
| patient | ✓ | Reference< Patient > | The recipient of the products and services Details 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. |
| billablePeriod | Period | Relevant time frame for the claim Details The period for which charges are being submitted. 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. |
|
| created | ✓ | dateTime | Resource creation date Details The date this resource was created. 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. |
| enterer | Reference< Practitioner | PractitionerRole > | Author of the claim Details Individual who created the claim, predetermination or preauthorization. |
|
| insurer | Reference< Organization > | Target Details The Insurer who is target of the request. |
|
| provider | ✓ | Reference< Practitioner | PractitionerRole | Organization > |
Party responsible for the claim Details 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. |
| priority | ✓ | CodeableConcept | Desired processing ugency Details The provider-required urgency of processing the request. Typical values include: stat, routine deferred. 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. |
| fundsReserve | CodeableConcept | For whom to reserve funds Details A code to indicate whether and for whom funds are to be reserved for future claims. This field is only used for preauthorizations. |
|
| related | ClaimRelated[] | Prior or corollary claims Details Other claims which are related to this claim such as prior submissions or claims for related services or for the same event. For example, for the original treatment and follow-up exams. |
|
| id | string | Unique id for inter-element referencing Details Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. |
|
| extension | Extension[] | Additional content defined by implementations Details May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
|
| modifierExtension | Extension[] | Extensions that cannot be ignored even if unrecognized Details May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
|
| claim | Reference< Claim > | Reference to the related claim Details Reference to a related claim. |
|
| relationship | CodeableConcept | How the reference claim is related Details A code to convey how the claims are related. For example, prior claim or umbrella. |
|
| reference | Identifier | File or case reference Details An alternate organizational reference to the case or file to which this particular claim pertains. For example, Property/Casualty insurer claim # or Workers Compensation case # . |
|
| prescription | Reference< DeviceRequest | MedicationRequest | VisionPrescription > |
Prescription authorizing services and products Details Prescription to support the dispensing of pharmacy, device or vision products. |
|
| originalPrescription | Reference< DeviceRequest | MedicationRequest | VisionPrescription > |
Original prescription if superseded by fulfiller Details Original prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or products. 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'. |
|
| payee | ClaimPayee | Recipient of benefits payable Details The party to be reimbursed for cost of the products and services according to the terms of the policy. Often providers agree to receive the benefits payable to reduce the near-term costs to the patient. The insurer may decline to pay the provider and choose to pay the subscriber instead. |
|
| id | string | Unique id for inter-element referencing Details Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. |
|
| extension | Extension[] | Additional content defined by implementations Details May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
|
| modifierExtension | Extension[] | Extensions that cannot be ignored even if unrecognized Details May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
|
| type | ✓ | CodeableConcept | Category of recipient Details Type of Party to be reimbursed: subscriber, provider, other. |
| party | Reference< Practitioner | PractitionerRole | Organization | Patient | RelatedPerson > |
Recipient reference Details Reference to the individual or organization to whom any payment will be made. Not required if the payee is 'subscriber' or 'provider'. |
|
| referral | Reference< ServiceRequest > | Treatment referral Details A reference to a referral resource. The referral resource which lists the date, practitioner, reason and other supporting information. |
|
| facility | Reference< Location > | Servicing facility Details Facility where the services were provided. |
|
| careTeam | ClaimCareTeam[] | Members of the care team Details The members of the team who provided the products and services. |
|
| id | string | Unique id for inter-element referencing Details Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. |
|
| extension | Extension[] | Additional content defined by implementations Details May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
|
| modifierExtension | Extension[] | Extensions that cannot be ignored even if unrecognized Details May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
|
| sequence | ✓ | positiveInt | Order of care team Details A number to uniquely identify care team entries. |
| provider | ✓ | Reference< Practitioner | PractitionerRole | Organization > |
Practitioner or organization Details Member of the team who provided the product or service. |
| responsible | boolean | Indicator of the lead practitioner Details The party who is billing and/or responsible for the claimed products or services. Responsible might not be required when there is only a single provider listed. |
|
| role | CodeableConcept | Function within the team Details The lead, assisting or supervising practitioner and their discipline if a multidisciplinary team. Role might not be required when there is only a single provider listed. |
|
| qualification | CodeableConcept | Practitioner credential or specialization Details The qualification of the practitioner which is applicable for this service. |
|
| supportingInfo | ClaimSupportingInfo[] | Supporting information Details Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. Often there are multiple jurisdiction specific valuesets which are required. |
|
| id | string | Unique id for inter-element referencing Details Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. |
|
| extension | Extension[] | Additional content defined by implementations Details May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
|
| modifierExtension | Extension[] | Extensions that cannot be ignored even if unrecognized Details May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
|
| sequence | ✓ | positiveInt | Information instance identifier Details A number to uniquely identify supporting information entries. |
| category | ✓ | CodeableConcept | Classification of the supplied information Details The general class of the information supplied: information; exception; accident, employment; onset, etc. This may contain a category for the local bill type codes. |
| code | CodeableConcept | Type of information Details System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought. |
|
| timing[x] | date, Period | When it occurred Details The date when or period to which this information refers. |
|
| value[x] | boolean, string, Quantity, Attachment, Reference |
Data to be provided Details Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data. Could be used to provide references to other resources, document. For example could contain a PDF in an Attachment of the Police Report for an Accident. |
|
| reason | CodeableConcept | Explanation for the information Details Provides the reason in the situation where a reason code is required in addition to the content. For example: the reason for the additional stay, or why a tooth is missing. |
|
| diagnosis | ClaimDiagnosis[] | Pertinent diagnosis information Details Information about diagnoses relevant to the claim items. |
|
| id | string | Unique id for inter-element referencing Details Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. |
|
| extension | Extension[] | Additional content defined by implementations Details May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
|
| modifierExtension | Extension[] | Extensions that cannot be ignored even if unrecognized Details May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
|
| sequence | ✓ | positiveInt | Diagnosis instance identifier Details A number to uniquely identify diagnosis entries. Diagnosis are presented in list order to their expected importance: primary, secondary, etc. |
| diagnosis[x] | ✓ | CodeableConcept, Reference< Condition > | Nature of illness or problem Details The nature of illness or problem in a coded form or as a reference to an external defined Condition. |
| type | CodeableConcept[] | Timing or nature of the diagnosis Details When the condition was observed or the relative ranking. For example: admitting, primary, secondary, discharge. |
|
| onAdmission | CodeableConcept | Present on admission Details Indication of whether the diagnosis was present on admission to a facility. |
|
| packageCode | CodeableConcept | Package billing code Details 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. 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. |
|
| procedure | ClaimProcedure[] | Clinical procedures performed Details Procedures performed on the patient relevant to the billing items with the claim. |
|
| id | string | Unique id for inter-element referencing Details Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. |
|
| extension | Extension[] | Additional content defined by implementations Details May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
|
| modifierExtension | Extension[] | Extensions that cannot be ignored even if unrecognized Details May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
|
| sequence | ✓ | positiveInt | Procedure instance identifier Details A number to uniquely identify procedure entries. |
| type | CodeableConcept[] | Category of Procedure Details When the condition was observed or the relative ranking. For example: primary, secondary. |
|
| date | dateTime | When the procedure was performed Details Date and optionally time the procedure was performed. |
|
| procedure[x] | ✓ | CodeableConcept, Reference< Procedure > | Specific clinical procedure Details The code or reference to a Procedure resource which identifies the clinical intervention performed. |
| udi | Reference< Device >[] | Unique device identifier Details Unique Device Identifiers associated with this line item. |
|
| insurance | ✓ | ClaimInsurance[] | Patient insurance information Details Financial instruments for reimbursement for the health care products and services specified on the claim. All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. Coverages appearing before the focal Coverage in the list, and where 'Coverage.subrogation=false', should provide a reference to the ClaimResponse containing the adjudication results of the prior claim. |
| id | string | Unique id for inter-element referencing Details Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. |
|
| extension | Extension[] | Additional content defined by implementations Details May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
|
| modifierExtension | Extension[] | Extensions that cannot be ignored even if unrecognized Details May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
|
| sequence | ✓ | positiveInt | Insurance instance identifier Details A number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order. |
| focal | ✓ | boolean | Coverage to be used for adjudication Details A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true. 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. |
| identifier | Identifier | Pre-assigned Claim number Details The business identifier to be used when the claim is sent for adjudication against this insurance policy. 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'. |
|
| coverage | ✓ | Reference< Coverage > | Insurance information Details 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. |
| businessArrangement | string | Additional provider contract number Details A business agreement number established between the provider and the insurer for special business processing purposes. |
|
| preAuthRef | string[] | Prior authorization reference number Details 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. 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. |
|
| claimResponse | Reference< ClaimResponse > | Adjudication results Details The result of the adjudication of the line items for the Coverage specified in this insurance. Must not be specified when 'focal=true' for this insurance. |
|
| accident | ClaimAccident | Details of the event Details Details of an accident which resulted in injuries which required the products and services listed in the claim. |
|
| id | string | Unique id for inter-element referencing Details Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. |
|
| extension | Extension[] | Additional content defined by implementations Details May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
|
| modifierExtension | Extension[] | Extensions that cannot be ignored even if unrecognized Details May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
|
| date | ✓ | date | When the incident occurred Details Date of an accident event related to the products and services contained in the claim. The date of the accident has to precede the dates of the products and services but within a reasonable timeframe. |
| type | CodeableConcept | The nature of the accident Details The type or context of the accident event for the purposes of selection of potential insurance coverages and determination of coordination between insurers. |
|
| location[x] | Address, Reference< Location > | Where the event occurred Details The physical location of the accident event. |
|
| item | ClaimItem[] | Product or service provided Details A claim line. Either a simple product or service or a 'group' of details which can each be a simple items or groups of sub-details. |
|
| id | string | Unique id for inter-element referencing Details Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. |
|
| extension | Extension[] | Additional content defined by implementations Details May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
|
| modifierExtension | Extension[] | Extensions that cannot be ignored even if unrecognized Details May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
|
| sequence | ✓ | positiveInt | Item instance identifier Details A number to uniquely identify item entries. |
| careTeamSequence | positiveInt[] | Applicable careTeam members Details CareTeam members related to this service or product. |
|
| diagnosisSequence | positiveInt[] | Applicable diagnoses Details Diagnosis applicable for this service or product. |
|
| procedureSequence | positiveInt[] | Applicable procedures Details Procedures applicable for this service or product. |
|
| informationSequence | positiveInt[] | Applicable exception and supporting information Details Exceptions, special conditions and supporting information applicable for this service or product. |
|
| revenue | CodeableConcept | Revenue or cost center code Details The type of revenue or cost center providing the product and/or service. |
|
| category | CodeableConcept | Benefit classification Details Code to identify the general type of benefits under which products and services are provided. Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage. |
|
| productOrService | ✓ | CodeableConcept | Billing, service, product, or drug code Details When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item. If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'. |
| modifier | CodeableConcept[] | Product or service billing modifiers Details Item typification or modifiers codes to convey additional context for the product or service. For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours. |
|
| programCode | CodeableConcept[] | Program the product or service is provided under Details Identifies the program under which this may be recovered. For example: Neonatal program, child dental program or drug users recovery program. |
|
| serviced[x] | date, Period | Date or dates of service or product delivery Details The date or dates when the service or product was supplied, performed or completed. |
|
| location[x] | CodeableConcept, Address, Reference< Location > | Place of service or where product was supplied Details Where the product or service was provided. |
|
| quantity | Quantity | Count of products or services Details The number of repetitions of a service or product. |
|
| unitPrice | Money | Fee, charge or cost per item Details If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group. |
|
| factor | decimal | Price scaling factor Details A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount. To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10). |
|
| net | Money | Total item cost Details The quantity times the unit price for an additional service or product or charge. For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied. |
|
| udi | Reference< Device >[] | Unique device identifier Details Unique Device Identifiers associated with this line item. |
|
| bodySite | CodeableConcept | Anatomical location Details Physical service site on the patient (limb, tooth, etc.). For example: Providing a tooth code, allows an insurer to identify a provider performing a filling on a tooth that was previously removed. |
|
| subSite | CodeableConcept[] | Anatomical sub-location Details A region or surface of the bodySite, e.g. limb region or tooth surface(s). |
|
| encounter | Reference< Encounter >[] | Encounters related to this billed item Details The Encounters during which this Claim was created or to which the creation of this record is tightly associated. This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter. |
|
| detail | ClaimItemDetail[] | Product or service provided Details A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items. |
|
| id | string | Unique id for inter-element referencing Details Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. |
|
| extension | Extension[] | Additional content defined by implementations Details May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
|
| modifierExtension | Extension[] | Extensions that cannot be ignored even if unrecognized Details May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
|
| sequence | ✓ | positiveInt | Item instance identifier Details A number to uniquely identify item entries. |
| revenue | CodeableConcept | Revenue or cost center code Details The type of revenue or cost center providing the product and/or service. |
|
| category | CodeableConcept | Benefit classification Details Code to identify the general type of benefits under which products and services are provided. Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage. |
|
| productOrService | ✓ | CodeableConcept | Billing, service, product, or drug code Details When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item. If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'. |
| modifier | CodeableConcept[] | Service/Product billing modifiers Details Item typification or modifiers codes to convey additional context for the product or service. For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours. |
|
| programCode | CodeableConcept[] | Program the product or service is provided under Details Identifies the program under which this may be recovered. For example: Neonatal program, child dental program or drug users recovery program. |
|
| quantity | Quantity | Count of products or services Details The number of repetitions of a service or product. |
|
| unitPrice | Money | Fee, charge or cost per item Details If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group. |
|
| factor | decimal | Price scaling factor Details A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount. To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10). |
|
| net | Money | Total item cost Details The quantity times the unit price for an additional service or product or charge. For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied. |
|
| udi | Reference< Device >[] | Unique device identifier Details Unique Device Identifiers associated with this line item. |
|
| subDetail | ClaimItemDetailSubDetail[] | Product or service provided Details A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items. |
|
| id | string | Unique id for inter-element referencing Details Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. |
|
| extension | Extension[] | Additional content defined by implementations Details May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
|
| modifierExtension | Extension[] | Extensions that cannot be ignored even if unrecognized Details May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
|
| sequence | ✓ | positiveInt | Item instance identifier Details A number to uniquely identify item entries. |
| revenue | CodeableConcept | Revenue or cost center code Details The type of revenue or cost center providing the product and/or service. |
|
| category | CodeableConcept | Benefit classification Details Code to identify the general type of benefits under which products and services are provided. Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage. |
|
| productOrService | ✓ | CodeableConcept | Billing, service, product, or drug code Details When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item. If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'. |
| modifier | CodeableConcept[] | Service/Product billing modifiers Details Item typification or modifiers codes to convey additional context for the product or service. For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours. |
|
| programCode | CodeableConcept[] | Program the product or service is provided under Details Identifies the program under which this may be recovered. For example: Neonatal program, child dental program or drug users recovery program. |
|
| quantity | Quantity | Count of products or services Details The number of repetitions of a service or product. |
|
| unitPrice | Money | Fee, charge or cost per item Details If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group. |
|
| factor | decimal | Price scaling factor Details A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount. To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10). |
|
| net | Money | Total item cost Details The quantity times the unit price for an additional service or product or charge. For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied. |
|
| udi | Reference< Device >[] | Unique device identifier Details Unique Device Identifiers associated with this line item. |
|
| total | Money | Total claim cost Details The total value of the all the items in the claim. |
Search Parameters [](/content/docs/api/fhir/resources/claim#search-parameters "Direct link to Search Parameters"/index.html)
| Name | Type | Description | Expression |
|---|---|---|---|
| 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 |
Inherited Elements [](/content/docs/api/fhir/resources/claim#inherited-elements "Direct link to Inherited Elements"/index.html)
| Name | Required | Type | Description |
|---|---|---|---|
| id | string | Logical id of this artifact Details The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. The only time that a resource does not have an id is when it is being submitted to the server using a create operation. |
|
| meta | Meta | Metadata about the resource Details The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource. |
|
| implicitRules | uri | A set of rules under which this content was created Details A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc. |
|
| language | code | Language of the resource content Details The base language in which the resource is written. Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). |
|
| text | Narrative | Text summary of the resource, for human interpretation Details A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later. |
|
| contained | Resource[] | Contained, inline Resources Details These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels. |
|
| extension | Extension[] | Additional content defined by implementations Details May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
|
| modifierExtension | Extension[] | Extensions that cannot be ignored Details May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
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 also supports:
- Up to a 3-tier hierarchy of Goods, products, and Services, to support simple to complex billing.
- 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 . Mappings to other specifications may be made available where IP restrictions permit.
Additional Information link to here
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.
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 patient 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. |