Resources
Claim
Resources
Claim
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.
Properties
| Name | Required | Type | Description |
|---|---|---|---|
| identifier | No | Identifier[] | Business Identifier for claim |
| status | Yes | code | active / cancelled / draft / entered-in-error |
| type | Yes | CodeableConcept | Category or discipline |
| subType | No | CodeableConcept | More granular claim type |
| use | Yes | code | claim / preauthorization / predetermination |
| patient | Yes | Reference<Patient> | The recipient of the products and services |
| billablePeriod | No | Period | Relevant time frame for the claim |
| created | Yes | dateTime | Resource creation date |
| enterer | No | Reference<Practitioner / PractitionerRole> | Author of the claim |
| insurer | No | Reference<Organization> | Target |
| provider | Yes | Reference<Practitioner / PractitionerRole / Organization> | Party responsible for the claim |
| priority | Yes | CodeableConcept | Desired processing ugency |
| fundsReserve | No | CodeableConcept | For whom to reserve funds |
| related | No | ClaimRelated | Prior or corollary claims |
| - id | No | string | Unique id for inter-element referencing |
| - extension | No | Extension[] | Additional content defined by implementations |
| - modifierExtension | No | Extension[] | Extensions that cannot be ignored even if unrecognized |
| - claim | No | Reference<Claim> | Reference to the related claim |
| - relationship | No | CodeableConcept | How the reference claim is related |
| - reference | No | Identifier | File or case reference |
| prescription | No | Reference<DeviceRequest / MedicationRequest / VisionPrescription> | Prescription authorizing services and products |
| originalPrescription | No | Reference<DeviceRequest / MedicationRequest / VisionPrescription> | Original prescription if superseded by fulfiller |
| payee | No | ClaimPayee | Recipient of benefits payable |
| - id | No | string | Unique id for inter-element referencing |
| - extension | No | Extension[] | Additional content defined by implementations |
| - modifierExtension | No | Extension[] | Extensions that cannot be ignored even if unrecognized |
| - type | Yes | CodeableConcept | Category of recipient |
| - party | No | Reference<Practitioner / PractitionerRole / Organization / Patient / RelatedPerson> | Recipient reference |
| referral | No | Reference<ServiceRequest> | Treatment referral |
| facility | No | Reference<Location> | Servicing facility |
| careTeam | No | ClaimCareTeam | Members of the care team |
| - id | No | string | Unique id for inter-element referencing |
| - extension | No | Extension[] | Additional content defined by implementations |
| - modifierExtension | No | Extension[] | Extensions that cannot be ignored even if unrecognized |
| - sequence | Yes | positiveInt | Order of care team |
| - provider | Yes | Reference<Practitioner / PractitionerRole / Organization> | Practitioner or organization |
| - responsible | No | boolean | Indicator of the lead practitioner |
| - role | No | CodeableConcept | Function within the team |
| - qualification | No | CodeableConcept | Practitioner credential or specialization |
| supportingInfo | No | ClaimSupportingInfo | Supporting information |
| - id | No | string | Unique id for inter-element referencing |
| - extension | No | Extension[] | Additional content defined by implementations |
| - modifierExtension | No | Extension[] | Extensions that cannot be ignored even if unrecognized |
| - sequence | Yes | positiveInt | Information instance identifier |
| - category | Yes | CodeableConcept | Classification of the supplied information |
| - code | No | CodeableConcept | Type of information |
| - timing[x] | No | date, Period | When it occurred |
| - value[x] | No | boolean, string, Quantity, Attachment, Reference<Resource> | Data to be provided |
| - reason | No | CodeableConcept | Explanation for the information |
| diagnosis | No | ClaimDiagnosis | Pertinent diagnosis information |
| - id | No | string | Unique id for inter-element referencing |
| - extension | No | Extension[] | Additional content defined by implementations |
| - modifierExtension | No | Extension[] | Extensions that cannot be ignored even if unrecognized |
| - sequence | Yes | positiveInt | Diagnosis instance identifier |
| - diagnosis[x] | Yes | CodeableConcept, Reference<Condition> | Nature of illness or problem |
| - type | No | CodeableConcept[] | Timing or nature of the diagnosis |
| - onAdmission | No | CodeableConcept | Present on admission |
| - packageCode | No | CodeableConcept | Package billing code |
| procedure | No | ClaimProcedure | Clinical procedures performed |
| - id | No | string | Unique id for inter-element referencing |
| - extension | No | Extension[] | Additional content defined by implementations |
| - modifierExtension | No | Extension[] | Extensions that cannot be ignored even if unrecognized |
| - sequence | Yes | positiveInt | Procedure instance identifier |
| - type | No | CodeableConcept[] | Category of Procedure |
| - date | No | dateTime | When the procedure was performed |
| - procedure[x] | Yes | CodeableConcept, Reference<Procedure> | Specific clinical procedure |
| - udi | No | Reference<Device>[] | Unique device identifier |
| insurance | Yes | ClaimInsurance | Patient insurance information |
| - id | No | string | Unique id for inter-element referencing |
| - extension | No | Extension[] | Additional content defined by implementations |
| - modifierExtension | No | Extension[] | Extensions that cannot be ignored even if unrecognized |
| - sequence | Yes | positiveInt | Insurance instance identifier |
| - focal | Yes | boolean | Coverage to be used for adjudication |
| - identifier | No | Identifier | Pre-assigned Claim number |
| - coverage | Yes | Reference<Coverage> | Insurance information |
| - businessArrangement | No | string | Additional provider contract number |
| - preAuthRef | No | string[] | Prior authorization reference number |
| - claimResponse | No | Reference<ClaimResponse> | Adjudication results |
| accident | No | ClaimAccident | Details of the event |
| - id | No | string | Unique id for inter-element referencing |
| - extension | No | Extension[] | Additional content defined by implementations |
| - modifierExtension | No | Extension[] | Extensions that cannot be ignored even if unrecognized |
| - date | Yes | date | When the incident occurred |
| - type | No | CodeableConcept | The nature of the accident |
| - location[x] | No | Address, Reference<Location> | Where the event occurred |
| item | No | ClaimItem | Product or service provided |
| - id | No | string | Unique id for inter-element referencing |
| - extension | No | Extension[] | Additional content defined by implementations |
| - modifierExtension | No | Extension[] | Extensions that cannot be ignored even if unrecognized |
| - sequence | Yes | positiveInt | Item instance identifier |
| - careTeamSequence | No | positiveInt[] | Applicable careTeam members |
| - diagnosisSequence | No | positiveInt[] | Applicable diagnoses |
| - procedureSequence | No | positiveInt[] | Applicable procedures |
| - informationSequence | No | positiveInt[] | Applicable exception and supporting information |
| - revenue | No | CodeableConcept | Revenue or cost center code |
| - category | No | CodeableConcept | Benefit classification |
| - productOrService | Yes | CodeableConcept | Billing, service, product, or drug code |
| - modifier | No | CodeableConcept[] | Product or service billing modifiers |
| - programCode | No | CodeableConcept[] | Program the product or service is provided under |
| - serviced[x] | No | date, Period | Date or dates of service or product delivery |
| - location[x] | No | CodeableConcept, Address, Reference<Location> | Place of service or where product was supplied |
| - quantity | No | Quantity | Count of products or services |
| - unitPrice | No | Money | Fee, charge or cost per item |
| - factor | No | decimal | Price scaling factor |
| - net | No | Money | Total item cost |
| - udi | No | Reference<Device>[] | Unique device identifier |
| - bodySite | No | CodeableConcept | Anatomical location |
| - subSite | No | CodeableConcept[] | Anatomical sub-location |
| - encounter | No | Reference<Encounter>[] | Encounters related to this billed item |
| - detail | No | ClaimItemDetail | Product or service provided |
| - id | No | string | Unique id for inter-element referencing |
| - extension | No | Extension[] | Additional content defined by implementations |
| - modifierExtension | No | Extension[] | Extensions that cannot be ignored even if unrecognized |
| - sequence | Yes | positiveInt | Item instance identifier |
| - revenue | No | CodeableConcept | Revenue or cost center code |
| - category | No | CodeableConcept | Benefit classification |
| - productOrService | Yes | CodeableConcept | Billing, service, product, or drug code |
| - modifier | No | CodeableConcept[] | Service/Product billing modifiers |
| - programCode | No | CodeableConcept[] | Program the product or service is provided under |
| - quantity | No | Quantity | Count of products or services |
| - unitPrice | No | Money | Fee, charge or cost per item |
| - factor | No | decimal | Price scaling factor |
| - net | No | Money | Total item cost |
| - udi | No | Reference<Device>[] | Unique device identifier |
| - subDetail | No | ClaimItemDetailSubDetail | Product or service provided |
| - id | No | string | Unique id for inter-element referencing |
| - extension | No | Extension[] | Additional content defined by implementations |
| - modifierExtension | No | Extension[] | Extensions that cannot be ignored even if unrecognized |
| - sequence | Yes | positiveInt | Item instance identifier |
| - revenue | No | CodeableConcept | Revenue or cost center code |
| - category | No | CodeableConcept | Benefit classification |
| - productOrService | Yes | CodeableConcept | Billing, service, product, or drug code |
| - modifier | No | CodeableConcept[] | Service/Product billing modifiers |
| - programCode | No | CodeableConcept[] | Program the product or service is provided under |
| - quantity | No | Quantity | Count of products or services |
| - unitPrice | No | Money | Fee, charge or cost per item |
| - factor | No | decimal | Price scaling factor |
| - net | No | Money | Total item cost |
| - udi | No | Reference<Device>[] | Unique device identifier |
| total | No | Money | Total claim cost |
Search Parameters
| 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 Properties
| Name | Required | Type | Description |
|---|---|---|---|
| id | No | string | Logical id of this artifact |
| meta | No | Meta | Metadata about the resource |
| implicitRules | No | uri | A set of rules under which this content was created |
| language | No | code | Language of the resource content |
| text | No | Narrative | Text summary of the resource, for human interpretation |
| contained | No | Resource[] | Contained, inline Resources |
| extension | No | Extension[] | Additional content defined by implementations |
| modifierExtension | No | Extension[] | Extensions that cannot be ignored |
To view the FHIR specification for this resource, see Claim.