Data Model Libraries
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    Class Claim

    Claim Class

    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.

    The Claim resource is used by providers to exchange services and products rendered to patients or planned to be rendered with insurers for reimbuserment. It is also used by insurers to exchange claims information with statutory reporting and data analytics firms.

    FHIR Specification

    • Short: Claim, Pre-determination or Pre-authorization
    • Definition: 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.
    • Comment: The Claim resource fulfills three information request requirements: Claim - a request for adjudication for reimbursement for products and/or services provided; Preauthorization - a request to authorize the future provision of products and/or services including an anticipated adjudication; and, Predetermination - a request for a non-bind adjudication of possible future products and/or services.
    • FHIR Version: 5.0.0

    FHIR Claim

    Hierarchy (View Summary)

    Implements

    Index

    Constructors

    constructor

    Properties

    identifier? traceNumber? fmStatusEnum status type_ subType? claimUseEnum use patient billablePeriod? created enterer? insurer? provider? priority? fundsReserve? related? prescription? originalPrescription? payee? referral? encounter? facility? diagnosisRelatedGroup? event? careTeam? supportingInfo? diagnosis? procedure? insurance? accident? patientPaid? item? total?

    Methods

    parse getIdentifier setIdentifier addIdentifier hasIdentifier getTraceNumber setTraceNumber addTraceNumber hasTraceNumber getStatusEnumType setStatusEnumType hasStatusEnumType getStatusElement setStatusElement hasStatusElement getStatus setStatus hasStatus getType setType hasType getSubType setSubType hasSubType getUseEnumType setUseEnumType hasUseEnumType getUseElement setUseElement hasUseElement getUse setUse hasUse getPatient setPatient hasPatient getBillablePeriod setBillablePeriod hasBillablePeriod getCreatedElement setCreatedElement hasCreatedElement getCreated setCreated hasCreated getEnterer setEnterer hasEnterer getInsurer setInsurer hasInsurer getProvider setProvider hasProvider getPriority setPriority hasPriority getFundsReserve setFundsReserve hasFundsReserve getRelated setRelated addRelated hasRelated getPrescription setPrescription hasPrescription getOriginalPrescription setOriginalPrescription hasOriginalPrescription getPayee setPayee hasPayee getReferral setReferral hasReferral getEncounter setEncounter addEncounter hasEncounter getFacility setFacility hasFacility getDiagnosisRelatedGroup setDiagnosisRelatedGroup hasDiagnosisRelatedGroup getEvent setEvent addEvent hasEvent getCareTeam setCareTeam addCareTeam hasCareTeam getSupportingInfo setSupportingInfo addSupportingInfo hasSupportingInfo getDiagnosis setDiagnosis addDiagnosis hasDiagnosis getProcedure setProcedure addProcedure hasProcedure getInsurance setInsurance addInsurance hasInsurance getAccident setAccident hasAccident getPatientPaid setPatientPaid hasPatientPaid getItem setItem addItem hasItem getTotal setTotal hasTotal fhirType isEmpty isRequiredFieldsEmpty copy toJSON getText setText hasText getContained setContained addContained hasContained getExtension setExtension hasExtension getExtensionByUrl addExtension removeExtension getModifierExtension setModifierExtension hasModifierExtension getModifierExtensionByUrl addModifierExtension removeModifierExtension resourceType getIdElement setIdElement hasIdElement getId setId hasId getMeta setMeta hasMeta getImplicitRulesElement setImplicitRulesElement hasImplicitRulesElement getImplicitRules setImplicitRules hasImplicitRules getLanguageElement setLanguageElement hasLanguageElement getLanguage setLanguage hasLanguage isResource isDataType isComplexDataType isPrimitive isBooleanPrimitive isStringPrimitive isNumberPrimitive isBigIntPrimitive isDateTimePrimitive copyValues initIdentifier initTraceNumber initRelated initEncounter initEvent initCareTeam initSupportingInfo initDiagnosis initProcedure initInsurance initItem

    Constructors

    Properties

    identifier?: Identifier[]

    Claim.identifier Element

    FHIR Specification

    • Short: Business Identifier for claim
    • Definition: A unique identifier assigned to this claim.
    • Requirements: Allows claims to be distinguished and referenced.
    • FHIR Type: Identifier
    • Cardinality: 0..*
    • isModifier: false
    • isSummary: false
    traceNumber?: Identifier[]

    Claim.traceNumber Element

    FHIR Specification

    • Short: Number for tracking
    • Definition: Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners.
    • Requirements: Allows partners to uniquely identify components for tracking.
    • FHIR Type: Identifier
    • Cardinality: 0..*
    • isModifier: false
    • isSummary: false
    fmStatusEnum: FmStatusEnum

    FHIR CodeSystem: FmStatus

    FmStatusEnum

    status: null | EnumCodeType

    Claim.status Element

    FHIR Specification

    • Short: active | cancelled | draft | entered-in-error
    • Definition: The status of the resource instance.
    • Comment: This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.
    • Requirements: Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.
    • FHIR Type: code
    • Cardinality: 1..1
    • isModifier: true
    • isModifierReason: This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
    • isSummary: true

    CodeSystem Enumeration: FmStatusEnum

    Privatetype_

    type_: null | CodeableConcept

    Claim.type Element

    FHIR Specification

    • Short: Category or discipline
    • Definition: The category of claim, e.g. oral, pharmacy, vision, institutional, professional.
    • Comment: The code system provides oral, pharmacy, vision, professional and institutional claim types. Those supported depends on the requirements of the jurisdiction. The valueset is extensible to accommodate other types of claims as required by the jurisdiction.
    • Requirements: Claim type determine the general sets of business rules applied for information requirements and adjudication.
    • FHIR Type: CodeableConcept
    • Cardinality: 1..1
    • isModifier: false
    • isSummary: true
    subType?: CodeableConcept

    Claim.subType Element

    FHIR Specification

    • Short: More granular claim type
    • Definition: A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.
    • Comment: This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.
    • Requirements: Some jurisdictions need a finer grained claim type for routing and adjudication.
    • FHIR Type: CodeableConcept
    • Cardinality: 0..1
    • isModifier: false
    • isSummary: false
    claimUseEnum: ClaimUseEnum

    FHIR CodeSystem: ClaimUse

    ClaimUseEnum

    use: null | EnumCodeType

    Claim.use Element

    FHIR Specification

    • Short: claim | preauthorization | predetermination
    • Definition: A code to indicate whether the nature of the request is: Claim - A request to an Insurer to adjudicate the supplied charges for health care goods and services under the identified policy and to pay the determined Benefit amount, if any; Preauthorization - A request to an Insurer to adjudicate the supplied proposed future charges for health care goods and services under the identified policy and to approve the services and provide the expected benefit amounts and potentially to reserve funds to pay the benefits when Claims for the indicated services are later submitted; or, Pre-determination - A request to an Insurer to adjudicate the supplied 'what if' charges for health care goods and services under the identified policy and report back what the Benefit payable would be had the services actually been provided.
    • Requirements: This element is required to understand the nature of the request for adjudication.
    • FHIR Type: code
    • Cardinality: 1..1
    • isModifier: false
    • isSummary: true

    CodeSystem Enumeration: ClaimUseEnum

    patient: null | Reference

    Claim.patient Element

    FHIR Specification

    • Short: The recipient of the products and services
    • Definition: 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.
    • Requirements: The patient must be supplied to the insurer so that confirmation of coverage and service history may be considered as part of the authorization and/or adjudiction.
    • FHIR Type: Reference
    • Cardinality: 1..1
    • isModifier: false
    • isSummary: true
    billablePeriod?: Period

    Claim.billablePeriod Element

    FHIR Specification

    • Short: Relevant time frame for the claim
    • Definition: The period for which charges are being submitted.
    • Comment: 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.
    • Requirements: A number jurisdictions required the submission of the billing period when submitting claims for example for hospital stays or long-term care.
    • FHIR Type: Period
    • Cardinality: 0..1
    • isModifier: false
    • isSummary: true
    created: null | DateTimeType

    Claim.created Element

    FHIR Specification

    • Short: Resource creation date
    • Definition: The date this resource was created.
    • Comment: 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.
    • Requirements: Need to record a timestamp for use by both the recipient and the issuer.
    • FHIR Type: dateTime
    • Cardinality: 1..1
    • isModifier: false
    • isSummary: true
    enterer?: Reference

    Claim.enterer Element

    FHIR Specification

    insurer?: Reference

    Claim.insurer Element

    FHIR Specification

    provider?: Reference

    Claim.provider Element

    FHIR Specification

    priority?: CodeableConcept

    Claim.priority Element

    FHIR Specification

    • Short: Desired processing urgency
    • Definition: The provider-required urgency of processing the request. Typical values include: stat, normal, deferred.
    • Comment: If a claim processor is unable to complete the processing as per the priority then they should generate an error and not process the request.
    • Requirements: The provider may need to indicate their processing requirements so that the processor can indicate if they are unable to comply.
    • FHIR Type: CodeableConcept
    • Cardinality: 0..1
    • isModifier: false
    • isSummary: true
    fundsReserve?: CodeableConcept

    Claim.fundsReserve Element

    FHIR Specification

    • Short: For whom to reserve funds
    • Definition: A code to indicate whether and for whom funds are to be reserved for future claims.
    • Comment: This field is only used for preauthorizations.
    • Requirements: In the case of a Pre-Determination/Pre-Authorization the provider may request that funds in the amount of the expected Benefit be reserved ('Patient' or 'Provider') to pay for the Benefits determined on the subsequent claim(s). 'None' explicitly indicates no funds reserving is requested.
    • FHIR Type: CodeableConcept
    • Cardinality: 0..1
    • isModifier: false
    • isSummary: false
    related?: ClaimRelatedComponent[]

    Claim.related Element

    FHIR Specification

    • Short: Prior or corollary claims
    • Definition: Other claims which are related to this claim such as prior submissions or claims for related services or for the same event.
    • Comment: For example, for the original treatment and follow-up exams.
    • Requirements: For workplace or other accidents it is common to relate separate claims arising from the same event.
    • FHIR Type: BackboneElement
    • Cardinality: 0..*
    • isModifier: false
    • isSummary: false
    prescription?: Reference

    Claim.prescription Element

    FHIR Specification

    originalPrescription?: Reference

    Claim.originalPrescription Element

    FHIR Specification

    • Short: Original prescription if superseded by fulfiller
    • Definition: Original prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or products.
    • Comment: 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'.
    • Requirements: Often required when a fulfiller varies what is fulfilled from that authorized on the original prescription.
    • FHIR Type: Reference
    • Cardinality: 0..1
    • isModifier: false
    • isSummary: false
    payee?: ClaimPayeeComponent

    Claim.payee Element

    FHIR Specification

    • Short: Recipient of benefits payable
    • Definition: The party to be reimbursed for cost of the products and services according to the terms of the policy.
    • Comment: 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.
    • Requirements: The provider needs to specify who they wish to be reimbursed and the claims processor needs express who they will reimburse.
    • FHIR Type: BackboneElement
    • Cardinality: 0..1
    • isModifier: false
    • isSummary: false
    referral?: Reference

    Claim.referral Element

    FHIR Specification

    • Short: Treatment referral
    • Definition: The referral information received by the claim author, it is not to be used when the author generates a referral for a patient. A copy of that referral may be provided as supporting information. Some insurers require proof of referral to pay for services or to pay specialist rates for services.
    • Comment: The referral resource which lists the date, practitioner, reason and other supporting information.
    • Requirements: Some insurers require proof of referral to pay for services or to pay specialist rates for services.
    • FHIR Type: Reference
    • Cardinality: 0..1
    • isModifier: false
    • isSummary: false
    encounter?: Reference[]

    Claim.encounter Element

    FHIR Specification

    • Short: Encounters associated with the listed treatments
    • Definition: Healthcare encounters related to this claim.
    • Comment: 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.
    • Requirements: Used in some jurisdictions to link clinical events to claim items.
    • FHIR Type: Reference
    • Cardinality: 0..*
    • isModifier: false
    • isSummary: false
    facility?: Reference

    Claim.facility Element

    FHIR Specification

    diagnosisRelatedGroup?: CodeableConcept

    Claim.diagnosisRelatedGroup Element

    FHIR Specification

    • Short: Package billing code
    • Definition: 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.
    • Comment: 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.
    • Requirements: Required to relate the current diagnosis to a package billing code that is then referenced on the individual claim items which are specific to the health condition covered by the package code.
    • FHIR Type: CodeableConcept
    • Cardinality: 0..1
    • isModifier: false
    • isSummary: false
    event?: ClaimEventComponent[]

    Claim.event Element

    FHIR Specification

    • Short: Event information
    • Definition: Information code for an event with a corresponding date or period.
    • FHIR Type: BackboneElement
    • Cardinality: 0..*
    • isModifier: false
    • isSummary: false
    careTeam?: ClaimCareTeamComponent[]

    Claim.careTeam Element

    FHIR Specification

    • Short: Members of the care team
    • Definition: The members of the team who provided the products and services.
    • Requirements: Common to identify the responsible and supporting practitioners.
    • FHIR Type: BackboneElement
    • Cardinality: 0..*
    • isModifier: false
    • isSummary: false
    supportingInfo?: ClaimSupportingInfoComponent[]

    Claim.supportingInfo Element

    FHIR Specification

    • Short: Supporting information
    • Definition: Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.
    • Comment: Often there are multiple jurisdiction specific valuesets which are required.
    • Requirements: Typically these information codes are required to support the services rendered or the adjudication of the services rendered.
    • FHIR Type: BackboneElement
    • Cardinality: 0..*
    • isModifier: false
    • isSummary: false
    diagnosis?: ClaimDiagnosisComponent[]

    Claim.diagnosis Element

    FHIR Specification

    • Short: Pertinent diagnosis information
    • Definition: Information about diagnoses relevant to the claim items.
    • Requirements: Required for the adjudication by provided context for the services and product listed.
    • FHIR Type: BackboneElement
    • Cardinality: 0..*
    • isModifier: false
    • isSummary: false
    procedure?: ClaimProcedureComponent[]

    Claim.procedure Element

    FHIR Specification

    • Short: Clinical procedures performed
    • Definition: Procedures performed on the patient relevant to the billing items with the claim.
    • Requirements: The specific clinical invention are sometimes required to be provided to justify billing a greater than customary amount for a service.
    • FHIR Type: BackboneElement
    • Cardinality: 0..*
    • isModifier: false
    • isSummary: false
    insurance?: ClaimInsuranceComponent[]

    Claim.insurance Element

    FHIR Specification

    • Short: Patient insurance information
    • Definition: Financial instruments for reimbursement for the health care products and services specified on the claim.
    • Comment: 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.
    • Requirements: At least one insurer is required for a claim to be a claim.
    • FHIR Type: BackboneElement
    • Cardinality: 0..*
    • isModifier: false
    • isSummary: true
    accident?: ClaimAccidentComponent

    Claim.accident Element

    FHIR Specification

    • Short: Details of the event
    • Definition: Details of an accident which resulted in injuries which required the products and services listed in the claim.
    • Requirements: When healthcare products and services are accident related, benefits may be payable under accident provisions of policies, such as automotive, etc before they are payable under normal health insurance.
    • FHIR Type: BackboneElement
    • Cardinality: 0..1
    • isModifier: false
    • isSummary: false
    patientPaid?: Money

    Claim.patientPaid Element

    FHIR Specification

    • Short: Paid by the patient
    • Definition: The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services.
    • Requirements: Necessary to demonstrate that copayments, co-insurance and similar patient payments have been made or accounted for.
    • FHIR Type: Money
    • Cardinality: 0..1
    • isModifier: false
    • isSummary: false
    item?: ClaimItemComponent[]

    Claim.item Element

    FHIR Specification

    • Short: Product or service provided
    • Definition: 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.
    • Requirements: The items to be processed for adjudication.
    • FHIR Type: BackboneElement
    • Cardinality: 0..*
    • isModifier: false
    • isSummary: false
    total?: Money

    Claim.total Element

    FHIR Specification

    • Short: Total claim cost
    • Definition: The total value of the all the items in the claim.
    • Requirements: Used for control total purposes.
    • FHIR Type: Money
    • Cardinality: 0..1
    • isModifier: false
    • isSummary: false

    Methods

    • Parse the provided Claim JSON to instantiate the Claim data model.

      Parameters

      • sourceJson: Value

        JSON representing FHIR Claim

      • OptionaloptSourceField: string

        Optional data source field (e.g. <complexTypeName>.<complexTypeFieldName>); defaults to Claim

      Returns undefined | Claim

      Claim data model or undefined for Claim

      JsonError if the provided JSON is not a valid JSON object

    • Assigns the provided Enterer object value to the enterer property.

      Parameters

      • value: undefined | Reference

        the enterer object value

      Returns this

      this

      @ReferenceTargets('Claim.enterer', ['Practitioner','PractitionerRole','Patient','RelatedPerson',])

      InvalidTypeError for invalid data type or reference value

    • Assigns the provided Provider object value to the provider property.

      Parameters

      • value: undefined | Reference

        the provider object value

      Returns this

      this

      @ReferenceTargets('Claim.provider', ['Practitioner','PractitionerRole','Organization',])

      InvalidTypeError for invalid data type or reference value

    • Assigns the provided Prescription object value to the prescription property.

      Parameters

      • value: undefined | Reference

        the prescription object value

      Returns this

      this

      @ReferenceTargets('Claim.prescription', ['DeviceRequest','MedicationRequest','VisionPrescription',])

      InvalidTypeError for invalid data type or reference value

    • Assigns the provided OriginalPrescription object value to the originalPrescription property.

      Parameters

      • value: undefined | Reference

        the originalPrescription object value

      Returns this

      this

      @ReferenceTargets('Claim.originalPrescription', ['DeviceRequest','MedicationRequest','VisionPrescription',])

      InvalidTypeError for invalid data type or reference value

    • Assigns the provided value to the text property.

      Parameters

      Returns this

      this

    • Returns boolean

      true if the text property exists and has a value; false otherwise

    • Assigns the provided Resource array value to the contained property.

      Parameters

      • value: undefined | IResource[]

        the contained array value

      Returns this

      this

    • Returns boolean

      true if the contained property exists and has a value; false otherwise

    • Assigns the provided array of Extension values to the extension property.

      Parameters

      • extension: undefined | IExtension[]

        array of Extensions

      Returns this

      this

    • Determines if the extension property exists.

      Parameters

      • Optionalurl: string

        the url that identifies a specific Extension

      Returns boolean

      true if an Extension has the provided url; false otherwise

      If the url is provided, determines if an Extension having the provided url exists. If the url is not provided, determines if the extension property exists and has any values.

      AssertionError for invalid url

    • Adds the provided Extension to the extension property array.

      Parameters

      • extension: undefined | IExtension

        the Extension value to add to the extension property array

      Returns this

      this

    • Removes the Extension having the provided url from the extension property array.

      Parameters

      • url: string

        the url that identifies a specific Extension to remove

      Returns void

      AssertionError for invalid url

    • Determines if the modifierExtension property exists.

      Parameters

      • Optionalurl: string

        the url that identifies a specific Extension

      Returns boolean

      true if an Extension has the provided url

      If the url is provided, determines if an Extension having the provided url exists. If the url is not provided, determines if the modifierExtension property exists and has any values.

      AssertionError for invalid url

    • Assigns the provided PrimitiveType value to the id property.

      Parameters

      • element: undefined | IdType

        the id value

      Returns this

      this

    • Returns undefined | string

      the id property value as a primitive value

    • Assigns the provided primitive value to the id property.

      Parameters

      • value: undefined | string

        the id value

      Returns this

      this

      PrimitiveTypeError for invalid primitive types

    • Returns boolean

      true if the id property exists and has a value; false otherwise

    • Assigns the provided value to the meta property.

      Parameters

      • value: undefined | Meta

        the meta value

      Returns this

      this

    • Returns boolean

      true if the meta property exists and has a value; false otherwise

    • Assigns the provided primitive value to the implicitRules property.

      Parameters

      • value: undefined | string

        the implicitRules value

      Returns this

      this

      PrimitiveTypeError for invalid primitive types

    • Returns undefined | string

      the language property value as a primitive value

    • Assigns the provided primitive value to the language property.

      Parameters

      • value: undefined | string

        the language value

      Returns this

      this

      PrimitiveTypeError for invalid primitive types

    • Returns boolean

      true if the language property exists and has a value; false otherwise

    • Returns boolean

      true if the instance is a FHIR complex or primitive datatype; false otherwise

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