Claim - FHIR v3.2.0

R4 Draft for Comment

This page is part of the FHIR Specification (v3.2.0: R4 Ballot 1). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4

13.6.8 Resource Claim - Operations

Financial Management

Work Group

Maturity Level: 2

Trial Use

Compartments: Encounter, Patient, Practitioner, RelatedPerson

This resource has 1 operation associated with it:

$submit

Submit a Claim resource for adjudication

For more information about operations, including how they are invoked, see Operations.

13.6.8.1 Submit a Claim resource for adjudication

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 official 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

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

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.

13.6.8.1.1 Examples

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/ex-claimtype"/>
			<code value="oral"/>
		</coding>	
	</type>

	<use value="complete"/>

	<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"/>
		<service>
			<coding>
				<code value="1200"/>
			</coding> 
		</service>
		<servicedDate value="2014-08-16"/>
		<unitPrice>
			<value value="135.57"/>
			<system value="urn:iso:std:iso:4217"/>
			<code value="USD"/> 
		</unitPrice> 
		<net>
			<value value="135.57"/>
			<system value="urn:iso:std:iso:4217"/>
			<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"/>

	<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"/>
				<system value="urn:iso:std:iso:4217"/>
				<code value="USD"/>
			</amount>
		</adjudication>

		<adjudication>
			<category>
				<coding>
					<code value="copay"/>
				</coding>
			</category>
			<amount>
				<value value="10.00"/>
				<system value="urn:iso:std:iso:4217"/>
				<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"/>
				<system value="urn:iso:std:iso:4217"/>
				<code value="USD"/>
			</amount>	
		</adjudication>

	</item>

	<totalCost>
		<value value="135.57"/>
		<system value="urn:iso:std:iso:4217"/>
		<code value="USD"/>
	</totalCost>	

	<totalBenefit>
		<value value="90.47"/>
		<system value="urn:iso:std:iso:4217"/>
		<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"/>
			<system value="urn:iso:std:iso:4217"/>
			<code value="USD"/>
		</amount>	

		<identifier>
			<system value="http://www.BenefitsInc.com/fhir/paymentidentifier"/>
			<value value="201408-2-1569478"/>
		</identifier>	
	</payment>
</ClaimResponse>