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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. If the element is present, it must have either a @value, an @id, or extensions

type Claim implements Resource {
  identifier: [Identifier]
  status: String
  type: CodeableConcept
  subType: CodeableConcept
  use: String
  patient: Reference
  billablePeriod: Period
  created: Date
  enterer: Reference
  insurer: Reference
  provider: Reference
  priority: CodeableConcept
  fundsReserve: CodeableConcept
  related: [ClaimRelated]
  prescription: Reference
  originalPrescription: Reference
  payee: ClaimPayee
  referral: Reference
  facility: Reference
  careTeam: [ClaimCareTeam]
  supportingInfo: [ClaimSupportingInfo]
  diagnosis: [ClaimDiagnosis]
  procedure: [ClaimProcedure]
  insurance: [ClaimInsurance]
  accident: ClaimAccident
  item: [ClaimItem]
  total: Money
  text: Narrative
  contained: [Resource]
  extension: [Extension]
  modifierExtension: [Extension]
  id: String
  meta: Meta
  implicitRules: Uri
  language: String
}

Fields​

Claim.identifier ● [Identifier] list object​

A unique identifier assigned to this claim.

Claim.status ● String scalar​

The status of the resource instance.

Claim.type ● CodeableConcept object​

The category of claim, e.g. oral, pharmacy, vision, institutional, professional.

Claim.subType ● CodeableConcept object​

A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.

Claim.use ● String scalar​

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.

Claim.patient ● Reference object​

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.

Claim.billablePeriod ● Period object​

The period for which charges are being submitted.

Claim.created ● Date scalar​

The date this resource was created.

Claim.enterer ● Reference object​

Individual who created the claim, predetermination or preauthorization.

Claim.insurer ● Reference object​

The Insurer who is target of the request.

Claim.provider ● Reference object​

The provider which is responsible for the claim, predetermination or preauthorization.

Claim.priority ● CodeableConcept object​

The provider-required urgency of processing the request. Typical values include: stat, routine deferred.

Claim.fundsReserve ● CodeableConcept object​

A code to indicate whether and for whom funds are to be reserved for future claims.

Claim.related ● [ClaimRelated] list object​

Other claims which are related to this claim such as prior submissions or claims for related services or for the same event.

Claim.prescription ● Reference object​

Prescription to support the dispensing of pharmacy, device or vision products.

Claim.originalPrescription ● Reference object​

Original prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or products.

Claim.payee ● ClaimPayee object​

The party to be reimbursed for cost of the products and services according to the terms of the policy.

Claim.referral ● Reference object​

A reference to a referral resource.

Claim.facility ● Reference object​

Facility where the services were provided.

Claim.careTeam ● [ClaimCareTeam] list object​

The members of the team who provided the products and services.

Claim.supportingInfo ● [ClaimSupportingInfo] list object​

Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.

Claim.diagnosis ● [ClaimDiagnosis] list object​

Information about diagnoses relevant to the claim items.

Claim.procedure ● [ClaimProcedure] list object​

Procedures performed on the patient relevant to the billing items with the claim.

Claim.insurance ● [ClaimInsurance] list object​

Financial instruments for reimbursement for the health care products and services specified on the claim.

Claim.accident ● ClaimAccident object​

Details of an accident which resulted in injuries which required the products and services listed in the claim.

Claim.item ● [ClaimItem] list object​

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.

Claim.total ● Money object​

The total value of the all the items in the claim.

Claim.text ● Narrative object​

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.

Claim.contained ● [Resource] list interface​

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.

Claim.extension ● [Extension] list object​

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.

Claim.modifierExtension ● [Extension] list object​

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).

Claim.id ● String scalar​

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

Claim.meta ● Meta object​

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.

Claim.implicitRules ● Uri scalar​

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.

Claim.language ● String scalar​

The base language in which the resource is written.

Interfaces​

Resource interface​

This is the base resource type for everything.

Returned By​

Claim query ● ClaimCreate mutation ● ClaimList query ● ClaimUpdate mutation