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type: resourceresource: Claim

Claim

Introduction

Scope and Usage

The Claim is used by providers and payers, insurers, to exchange the financial information, and supporting clinical information, regarding the provision of health care services with payers 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 payers, 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):

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:

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

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

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

ClaimA suite of goods and services and insurances coverages under which adjudication or authorization is requested.
CoverageEligibilityRequestA request to a payer 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.
ClaimResponseA payer'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.
ExplanationOfBenefitThis resource combines the information from the Claim and the ClaimResponse, stripping out any provider or payer 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.

Notes

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 ._element_Sequence 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.

StructureDefinition

Elements (Simplified)

Mappings

Operations

Full Operations

Resource Packs

list-Claim-packs.xml

<?xml version="1.0" encoding="UTF-8"?>

<List xmlns="http://hl7.org/fhir" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:schemaLocation="http://hl7.org/fhir ../../publish/List.xsd">
  <id value="Claim-packs"/>
  <status value="current"/>
  <mode value="working"/>
</List>

Search Parameters

Full Search Parameters

Examples

Full Examples

Mapping Exceptions

claim-fivews-mapping-exceptions.xml

Unmapped Elements

claim-request-mapping-exceptions.xml

Divergent Elements

Note: This is a business identifier, not a resource identifier (see discussion). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and a Person resource instance might share the same social insurance number.

Note: This is a business identifier, not a resource identifier (see discussion). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and a Person resource instance might share the same social insurance number. | resource=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'.

A status of completed for a "doNotPerform" request indicates that the period of non-performance is now satisfied and the request no longer holds. | resource=This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

Unmapped Elements