Submit a claim or a request for prior authorization of a claim. This operation is included for completeness and compliance with the DaVinci PAS specification. Redox recommends using the submit-* operations for clarity.
Identifies the type of the resource
A persistent identifier for the bundle that won't change as a bundle is copied from server to server.
Establishes the namespace for the value - that is, a URL that describes a set values that are unique.
The portion of the identifier typically relevant to the user and which is unique within the context of the system.
Indicates the purpose of this bundle - how it is intended to be used.
The date/time that the bundle was assembled - i.e. when the resources were placed in the bundle.
An array of FHIR resources. At a minimum, a Claim Request should include the following entries:
Additional resources such as MedicationRequest or ServiceRequest may also be included to communicate additional information about the claim.
An entry in a bundle resource - will either contain a resource or information about a resource (transactions and history only).
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.
Identifies the type of the resource
An identifier - identifies some entity uniquely and unambiguously. Typically this is used for business identifiers.
The portion of the identifier typically relevant to the user and which is unique within the context of the system.
The status of the resource instance.
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 servicesprofessional - Typically outpatient claims such as Psychological, Chiropractor, rehabilitative, consultinginstitutional - Hospital, clinic and other inpatient claimsA reference to a code defined by a terminology system.
The identification of the code system that defines the meaning of the symbol in the code.
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).
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.
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.
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.
A reference to a Patient resource
The date this resource was created.
The provider which is responsible for the claim, predetermination or preauthorization.
Must be a resource of type Organization.
A reference to an Organization resource
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
A reference to a code defined by a terminology system.
The identification of the code system that defines the meaning of the symbol in the code.
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).
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.
Financial instruments for reimbursement for the health care products and services specified on the claim.
A number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order.
A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.
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.
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.
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.
A number to uniquely identify item entries.
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.
A reference to a code defined by a terminology system.
The identification of the code system that defines the meaning of the symbol in the code.
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).
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.
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.
Uniquely identifies this claim item. (2000F-TRN)
See http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber for more information
Source of the definition for the extension code - a logical name or a URL.
Uniquely identifies this claim item
The portion of the identifier typically relevant to the user and which is unique within the context of the system.
Exceptions, special conditions and supporting information applicable for this service or product.
Item typification or modifiers codes to convey additional context for the product or service.
A reference to a code defined by a terminology system.
The identification of the code system that defines the meaning of the symbol in the code.
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).
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.
The number of repetitions of a service or product.
The value of the measured amount. The value includes an implicit precision in the presentation of the value.
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.
A Precision extension allows the communication of values more precise than a JSON number, for example, 3.10 as opposed to just 3.1.
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
Source of the definition for the extension code - a logical name or a URL.
Number of significant decimal places after the decimal.
A human-readable form of the unit.
Individual who created the claim, predetermination or preauthorization.
Must be a resource of type PractitionerRole.
A reference to PractitionerRole resource, which should point to both Practitioner and Organization.
The Insurer who is target of the request.
Must be a resource of type Organization.
A reference to an Organization resource
Other claims which are related to this claim such as prior submissions or claims for related services or for the same event.
Reference to a related claim.
Must be a resource of type Claim.
Contains the resource ID of the original claim that this resource is updating
When modifying a prior claim, set this to code='prior' and system='http://terminology.hl7.org/CodeSystem/ex-relatedclaimrelationship'
A reference to a code defined by a terminology system.
The identification of the code system that defines the meaning of the symbol in the code.
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).
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.
The members of the team who provided the products and services.
An Extension
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
Source of the definition for the extension code - a logical name or a URL.
A number to uniquely identify care team entries.
Member of the team who provided the product or service.
Must reference one of the following types of resources:
PractitionerOrganizationA 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.
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
Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.
A number to uniquely identify supporting information entries.
The general class of the information supplied: information; exception; accident, employment; onset, etc.
A reference to a code defined by a terminology system.
The identification of the code system that defines the meaning of the symbol in the code.
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).
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.
The date when or period to which this information refers.
Only one of timingDate, timingPeriod may be present.
The date when or period to which this information refers.
Only one of timingDate, timingPeriod may be present.
A sequence of Unicode characters
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.
A sequence of Unicode characters
String of characters used to identify a name or a resource
Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).
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.
Extensions for start
A sequence of Unicode characters
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.
A sequence of Unicode characters
String of characters used to identify a name or a resource
Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).
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.
Extensions for end
A sequence of Unicode characters
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.
A sequence of Unicode characters
String of characters used to identify a name or a resource
Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).
Information about diagnoses relevant to the claim items.
A number to uniquely identify diagnosis entries.
The nature of illness or problem in a coded form or as a reference to an external defined Condition.
A reference to a code defined by a terminology system.
The identification of the code system that defines the meaning of the symbol in the code.
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).
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.
Details of an accident which resulted in injuries which required the products and services listed in the claim.
Date of an accident event related to the products and services contained in the claim.
The type or context of the accident event for the purposes of selection of potential insurance coverages and determination of coordination between insurers.
A reference to a code defined by a terminology system.
The identification of the code system that defines the meaning of the symbol in the code.
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).
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.
A request to authorize payment for a blood pressure medication
Identifies the type of the resource
Indicates the purpose of this bundle - how it is intended to be used.
The date/time that the bundle was assembled - i.e. when the resources were placed in the bundle.
An array of FHIR resources including the following:
The ClaimResponse is the only resource that must be present in the bundle. It references several other of the above resources which should already be known to the requesting system.
However, some workflows may not always persist the information, so it is best practice for the responding system to preserve and re-include all referenced resources in the Claim Response bundle.
An entry in a bundle resource - will either contain a resource or information about a resource (transactions and history only).
This resource provides the adjudication details from the processing of a Claim resource.
Identifies the type of the resource
The status of the resource instance.
Type of claim. Example Codes
For prescriptions, typically code='pharmacy' and system='http://terminology.hl7.org/CodeSystem/claim-type'
A reference to a code defined by a terminology system.
The identification of the code system that defines the meaning of the symbol in the code.
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).
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.
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.
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.
A reference to a Patient resource
The date this resource was created.
The party responsible for authorization, adjudication and reimbursement.
Must be a resource of type Organization.
A reference to an Organization resource
The outcome of the claim, predetermination, or preauthoirization processing.
queued | complete | error | partial
The provider which is responsible for the claim, predetermination or preauthorization.
Must be a resource of type Organization.
A reference to an Organization resource
A reference to the Claim resource triggering adjudication. This can be either the same identifier as the original Claim.identifier or else reference can point to the Claim.id value. When sending only the reference, it is helpful to also include the original Claim resource in the request.
Must be a resource of type Claim.
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.
An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.
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.
Source of the definition for the extension code - a logical name or a URL.
A single value for the extension.
The purpose of this identifier.
Establishes the namespace for the value - that is, a URL that describes a set values that are unique.
The portion of the identifier typically relevant to the user and which is unique within the context of the system.
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.
A number to uniquely reference the claim item entries.
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.
Type of adjudication information. Example Codes
A reference to a code defined by a terminology system.
The identification of the code system that defines the meaning of the symbol in the code.
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).
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.
An Extension
The details of the review action that is necessary for the authorization.
See http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction for more information
Source of the definition for the extension code - a logical name or a URL.
Details of the review action that is necessary for the authorization, carried in sub-extension properties.
The code describing the result of the review.
See http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode for more information
Source of the definition for the extension code - a logical name or a URL.
Code indicating the type of action, from the X12 306 code set.
A reference to a code defined by a terminology system.
The identification of the code system that defines the meaning of the symbol in the code.
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).
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.
Monetary amount associated with the category.
Numerical value (with implicit precision).
ISO 4217 Currency Code (e.g. USD for US Dollar)
Non-monetary value. Used, for example, when the adjudication is a percentage.
Additional information about the item
Uniquely identifies this claim item. (2000F-TRN)
See http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber for more information
Source of the definition for the extension code - a logical name or a URL.
Uniquely identifies this claim item
The portion of the identifier typically relevant to the user and which is unique within the context of the system.
A note that describes or explains adjudication results in a human readable form.
The explanation or description associated with the processing.
A claim response demonstrating inclusion of the original resources associated with the claim request. Many of these resources are redundant and need not actually be sent with a response bundle.