Claim $inquiry

Inquire about the status of a previously requested preauthorization claim. This operation may only include a minimal payload including the Claim.identifier and optionally an administrativeReferenceNumber in the Claim.item.extension. For fields required by FHIR, a data-absent-reason extension is sent.

Request Fields and Example
resourceType
required, string

Identifies the type of the resource

Value: Bundle
identifier
required, object

A persistent identifier for the bundle that won't change as a bundle is copied from server to server.

system
string

Establishes the namespace for the value - that is, a URL that describes a set values that are unique.

value
string

The portion of the identifier typically relevant to the user and which is unique within the context of the system.

type
required, string

Indicates the purpose of this bundle - how it is intended to be used.

Value: collection
timestamp
required, string

The date/time that the bundle was assembled - i.e. when the resources were placed in the bundle.

entry
required, [Claim, Patient, MedicationRequest, ServiceRequest, Coverage, Organization, PractitionerRole, Practitioner, RelatedPerson, DocumentReference, Other]

When inquiring about the status of previously requested claim, the only resource and field explicity required is the Claim.identifier which is used to look up the original claim.

Additional resources relating to the claim may also be sent, but most are unnecessary as long as the identifier is present.

Any of:

An entry in a bundle resource - will either contain a resource or information about a resource (transactions and history only).

resource
required, object

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.

resourceType
required, string

Identifies the type of the resource

Value: Claim
identifier
required, [object]

An identifier - identifies some entity uniquely and unambiguously. Typically this is used for business identifiers.

value
string

The portion of the identifier typically relevant to the user and which is unique within the context of the system.

status
required, string

The status of the resource instance.

Value: active
type
required, object

Type of claim. Example Codes

The recommended system is http://terminology.hl7.org/CodeSystem/claim-type. Typical values include

  • pharmacy - Pharmacy claims for goods and services
  • professional - Typically outpatient claims such as Psychological, Chiropractor, rehabilitative, consulting
  • institutional - Hospital, clinic and other inpatient claims
coding
[object]

A reference to a code defined by a terminology system.

system
string

The identification of the code system that defines the meaning of the symbol in the code.

code
string

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

text
string

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

use
required, string

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.

Value: preauthorization
patient
required, 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.

Must be a resource of type Patient.

reference
string

A reference to a Patient resource

created
required, string

The date this resource was created.

provider
required, object

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

Must be a resource of type Organization.

reference
string

A reference to an Organization resource

priority
required, object

The provider-required urgency of processing the request. Typical values include: stat, routine, and deferred. If sending one of these statuses, use the system http://terminology.hl7.org/CodeSystem/processpriority

coding
[object]

A reference to a code defined by a terminology system.

system
string

The identification of the code system that defines the meaning of the symbol in the code.

code
string

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

text
string

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

insurance
required, [object]

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

sequence
required, number

A number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order.

focal
required, boolean

A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.

Value: true
coverage
required, object

Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.

Must be a resource of type Coverage.

reference
string

A reference to another resource. This is typically either a relative reference which includes the resource type and ID, or an internal reference which starts with # and refers to a contained resource.

item
required, [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.

sequence
required, number

A number to uniquely identify item entries.

productOrService
required, object

For prior auth, the requestedService extension carries more information than this field, and this field should just duplicate the product or service code found in that resource.

coding
[object]

A reference to a code defined by a terminology system.

system
string

The identification of the code system that defines the meaning of the symbol in the code.

code
string

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

text
string

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

extension
[itemTraceNumber, administrationReferenceNumber, requestedService, Other]

A set of additional fields about the item. For medication prior auth, the requestedService extension must be present with a reference to a MedicationRequest resource. For procedures, a ServiceRequest resource is used.

Any of:

Uniquely identifies this claim item. (2000F-TRN)

See http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber for more information

url
required, string

Source of the definition for the extension code - a logical name or a URL.

Value: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
valueIdentifier
object

Uniquely identifies this claim item

value
string

The portion of the identifier typically relevant to the user and which is unique within the context of the system.

informationSequence
[number]

Exceptions, special conditions and supporting information applicable for this service or product.

modifier
[object]

Item typification or modifiers codes to convey additional context for the product or service.

coding
[object]

A reference to a code defined by a terminology system.

system
string

The identification of the code system that defines the meaning of the symbol in the code.

code
string

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

text
string

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

quantity
object

The number of repetitions of a service or product.

value
number

The value of the measured amount. The value includes an implicit precision in the presentation of the value.

_value
object

This element contains extensions for value. Depending on the extensions present it could be used in place of value or contain additional information about value. See the extension element for more details on the possible extensions being sent.

extension
[Precision, Other]

A Precision extension allows the communication of values more precise than a JSON number, for example, 3.10 as opposed to just 3.1.

Any of:

Explicit precision of the number. If the actual value is 3.10, the value field will contain the number 3.1 while the precision extension will contain 2.

See http://hl7.org/fhir/StructureDefinition/quantity-precision for more information

url
required, string

Source of the definition for the extension code - a logical name or a URL.

Value: http://hl7.org/fhir/StructureDefinition/quantity-precision
valueInteger
required, number

Number of significant decimal places after the decimal.

unit
string

A human-readable form of the unit.

enterer
object

Individual who created the claim, predetermination or preauthorization.

Must be a resource of type PractitionerRole.

reference
string

A reference to PractitionerRole resource, which should point to both Practitioner and Organization.

insurer
object

The Insurer who is target of the request.

Must be a resource of type Organization.

reference
string

A reference to an Organization resource

related
[object]

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

claim
object

Reference to a related claim.

Must be a resource of type Claim.

reference
string

Contains the resource ID of the original claim that this resource is updating

relationship
object

When modifying a prior claim, set this to code='prior' and system='http://terminology.hl7.org/CodeSystem/ex-relatedclaimrelationship'

coding
[object]

A reference to a code defined by a terminology system.

system
string

The identification of the code system that defines the meaning of the symbol in the code.

code
string

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

text
string

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

careTeam
[OverallClaimMember, ItemClaimMember, Other]

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

Any of:
extension
required, [careTeamClaimScope, Other]

An Extension

Any of:

A flag that indicates whether the care team applies to the entire claim or a single item.

See http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope for more information

url
required, string

Source of the definition for the extension code - a logical name or a URL.

Value: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
sequence
required, number

A number to uniquely identify care team entries.

provider
required, object

Member of the team who provided the product or service.

Must reference one of the following types of resources:

  • Practitioner
  • Organization
reference
string

A reference to another resource. This is typically either a relative reference which includes the resource type and ID, or an internal reference which starts with # and refers to a contained resource.

supportingInfo
[AdmissionDates, DischargeDates, AdditionalInformation, MessageText, Other]

An array of supporting information for the claim. Each piece of information is is linked to a claim line item via sequence and its type is identified by category

Any of:

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

sequence
required, number

A number to uniquely identify supporting information entries.

category
required, object

The general class of the information supplied: information; exception; accident, employment; onset, etc.

coding
required, [object]

A reference to a code defined by a terminology system.

system
required, string

The identification of the code system that defines the meaning of the symbol in the code.

Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASSupportingInfoType
code
required, string

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

Value: admissionDates
text
string

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

timingDate
required, string

The date when or period to which this information refers.

Only one of timingDate, timingPeriod may be present.

timingPeriod
required, object

The date when or period to which this information refers.

Only one of timingDate, timingPeriod may be present.

id
string

A sequence of Unicode characters

extension
[object]

May be used to represent additional information that is not part of the basic definition of the element. 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.

id
string

A sequence of Unicode characters

url
string

String of characters used to identify a name or a resource

valueBase64Binary
string

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

start
string

A date, date-time or partial date (e.g. just year or year + month). If hours and minutes are specified, a time zone SHALL be populated. The format is a union of the schema types gYear, gYearMonth, date and dateTime. Seconds must be provided due to schema type constraints but may be zero-filled and may be ignored. Dates SHALL be valid dates.

_start
object

Extensions for start

id
string

A sequence of Unicode characters

extension
[object]

May be used to represent additional information that is not part of the basic definition of the element. 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.

id
string

A sequence of Unicode characters

url
string

String of characters used to identify a name or a resource

valueBase64Binary
string

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

end
string

A date, date-time or partial date (e.g. just year or year + month). If hours and minutes are specified, a time zone SHALL be populated. The format is a union of the schema types gYear, gYearMonth, date and dateTime. Seconds must be provided due to schema type constraints but may be zero-filled and may be ignored. Dates SHALL be valid dates.

_end
object

Extensions for end

id
string

A sequence of Unicode characters

extension
[object]

May be used to represent additional information that is not part of the basic definition of the element. 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.

id
string

A sequence of Unicode characters

url
string

String of characters used to identify a name or a resource

valueBase64Binary
string

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

diagnosis
[object]

Information about diagnoses relevant to the claim items.

sequence
required, number

A number to uniquely identify diagnosis entries.

diagnosisCodeableConcept
required, object

The nature of illness or problem in a coded form or as a reference to an external defined Condition.

coding
[object]

A reference to a code defined by a terminology system.

system
string

The identification of the code system that defines the meaning of the symbol in the code.

code
string

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

text
string

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

accident
object

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

date
required, string

Date of an accident event related to the products and services contained in the claim.

type
object

The type or context of the accident event for the purposes of selection of potential insurance coverages and determination of coordination between insurers.

coding
[object]

A reference to a code defined by a terminology system.

system
string

The identification of the code system that defines the meaning of the symbol in the code.

code
string

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

text
string

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

post/Claim/$inquiry
RedoxMedicationClaimInquiryBundleExample

A minimal inquiry bundle containing only a Claim resource with an identifier. Other fields required by the schema are omitted using the data-absent-reason extension since they are not used by an inquiry operation.

Response Fields and Example
resourceType
required, string

Identifies the type of the resource

Value: Bundle
type
required, string

Indicates the purpose of this bundle - how it is intended to be used.

Value: collection
entry
required, [ClaimResponse, Patient, Coverage, Location, Practitioner, RelatedPerson, Other]

An array of FHIR resources. At a minimum, a the claim status response should include the following entries:

  • ClaimResponse - the most important part of the request - contains references to all other resources, details adjudication at the appropriate levels.
  • Patient - the patient the claim is for.
  • Organization - at least one resource representing the party responsible for making the claim. Additional organization resources may carry information such as pharmacy, payor, or policy holder.
  • Practitioner - for professional claims the provider submitting the claim
  • Coverage - the patient's insurance
Any of:
resource
required, object

The Resource for the entry. The purpose/meaning of the resource is determined by the Bundle.type.

resourceType
required, string

Identifies the type of the resource

Value: ClaimResponse
status
required, string

The status of the resource instance.

Value: active
type
required, object

Type of claim. Example Codes The recommended system is http://terminology.hl7.org/CodeSystem/claim-type. Typical values include

  • pharmacy - Pharmacy claims for goods and services
  • professional - Typically outpatient claims such as Psychological, Chiropractor, rehabilitative, consulting
  • institutional - Hospital, clinic and other inpatient claims
coding
[object]

A reference to a code defined by a terminology system.

system
string

The identification of the code system that defines the meaning of the symbol in the code.

code
string

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

text
string

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

use
required, string

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.

Value: claim
patient
required, object

The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for facast reimbursement is sought.

Must be a resource of type Patient.

reference
string

A reference to a Patient resource

created
required, string

The date this resource was created.

insurer
required, object

The party responsible for authorization, adjudication and reimbursement.

Must be a resource of type Organization.

reference
string

A reference to another resource. This is typically either a relative reference which includes the resource type and ID, or an internal reference which starts with # and refers to a contained resource.

outcome
required, string

The outcome of the claim, predetermination, or preauthorization processing.

Possible Values: queued, complete, error, partial
id
string

A response detailing the status of each line item.

requestor
object

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

Must reference one of the following types of resources:

  • Practitioner
  • Organization
reference
string

A reference to a Practitioner or Organization resource, depending on the setting.

item
[object]

A claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-details.

itemSequence
required, number

A number to uniquely reference the claim item entries.

adjudication
required, [object]

If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item.

category
required, object

A code to indicate the information type of this adjudication record. Information types may include the value submitted, maximum values or percentages allowed or payable under the plan, amounts that: the patient is responsible for in aggregate or pertaining to this item; amounts paid by other coverages; and, the benefit payable for this item.

coding
[object]

A reference to a code defined by a terminology system.

system
string

The identification of the code system that defines the meaning of the symbol in the code.

code
string

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

text
string

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

reason
object

A code supporting the understanding of the adjudication result and explaining variance from expected amount.

coding
[object]

A reference to a code defined by a terminology system.

system
string

The identification of the code system that defines the meaning of the symbol in the code.

code
string

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

text
string

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

adjudication
[object]

The adjudication results which are presented at the header level rather than at the line-item or add-item levels.

category
required, object

A code to indicate the information type of this adjudication record. Information types may include the value submitted, maximum values or percentages allowed or payable under the plan, amounts that: the patient is responsible for in aggregate or pertaining to this item; amounts paid by other coverages; and, the benefit payable for this item.

coding
[object]

A reference to a code defined by a terminology system.

system
string

The identification of the code system that defines the meaning of the symbol in the code.

code
string

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

text
string

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

reason
object

A code supporting the understanding of the adjudication result and explaining variance from expected amount.

coding
[object]

A reference to a code defined by a terminology system.

system
string

The identification of the code system that defines the meaning of the symbol in the code.

code
string

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

text
string

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

insurance
[object]

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

sequence
required, number

A number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order.

focal
required, boolean

A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.

coverage
required, object

Reference to Coverage resource for patient.

Must be a resource of type Coverage.

reference
string

A reference to another resource. This is typically either a relative reference which includes the resource type and ID, or an internal reference which starts with # and refers to a contained resource.

businessArrangement
string

A business agreement number established between the provider and the insurer for special business processing purposes.

Open dropdown

A claim for one patient receiving inpatient services for blood work and an EKG. Attending Provider was Pat Granite, and Referring provider was Joan Fishman.