Claim $submit-institutional

Submit a claim for institutional services.

Request 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, [Claim, Patient, Coverage, Practitioner, RelatedPerson, Other]

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

  • Claim - the most important part of the request - contains references to all other resources, and the actual service line items in item
  • 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, primary payer, or addtional payers.
  • Practitioner - Practitioners that were part of the claim - linked to the claim via careTeam.
  • Coverage - the patient's insurance(s)

Additional resources such as RelatedPerson should be included in scenarios where the Patient is a dependent of the coverage holder.

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: Claim
id
required, string

A unique identifier for the claim that will be echoed on status checks and response payloads.

status
required, string

The status of the resource instance.

Value: fm-status-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 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 reference one of the following types of resources:

  • Practitioner
  • Organization
reference
string

A reference to either an Organization or Provider.

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.

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.

preAuthRef
[string]

Reference numbers previously provided by the insurer to the provider to be quoted on subsequent claims containing services or products related to the prior authorization.

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
[object]

An array of care team members. Each piece of information is is linked to a claim line item via sequence, and the type/role is denoted with by role.

sequence
required, number

A number to uniquely identify care team entries.

provider
required, object

Reference to Practitioner who particpated in the claim.

Must be a resource of type Practitioner.

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.

responsible
boolean

The party who is billing and/or responsible for the claimed products or services.

role
object

The lead, assisting or supervising practitioner and their discipline if a multidisciplinary team.

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.

supportingInfo
[object]

An array of supporting information for the claim. Generally this is implementation-specific, key-value pairs identified by code and value[x]. Each piece of information is is linked to a claim line item via sequence and its type is identified by category

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
[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.

code
object

The specific type of information being sent.

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.

timingPeriod
object

The date when or period to which this information refers.

start
string

The start of the period. The boundary is inclusive.

end
string

The end of the period. If the end of the period is missing, it means no end was known or planned at the time the instance was created. The start may be in the past, and the end date in the future, which means that period is expected/planned to end at that time.

valueBoolean
boolean

Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.

Only one of valueBoolean, valueString, valueQuantity, valueReference may be present.

valueString
string

Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.

Only one of valueBoolean, valueString, valueQuantity, valueReference may be present.

valueQuantity
object

Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.

Only one of valueBoolean, valueString, valueQuantity, valueReference may be present.

value
number

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

system
string

The identification of the system that provides the coded form of the unit.

code
string

A computer processable form of the unit in some unit representation system.

valueReference
object

Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.

Only one of valueBoolean, valueString, valueQuantity, valueReference may be present.

Must be a resource of type Resource.

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.

diagnosis
[object]

An array of diagnoses for Patient. Each diagnosis is is linked to a claim line item via sequence

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.

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.

type
[object]

When the condition was observed or the relative ranking.

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.

onAdmission
object

Indication of whether the diagnosis was present on admission to a facility.

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.

packageCode
object

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.

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.

procedure
[object]

An array of procedures for Patient. Each procedure is is linked to a claim line item via sequence

sequence
required, number

A number to uniquely identify procedure entries.

procedureCodeableConcept
required, object

The code or reference to a Procedure resource which identifies the clinical intervention performed.

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.

type
[object]

When the condition was observed or the relative ranking.

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.

date
string

Date and optionally time the procedure was performed.

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.

locationAddress
object

The physical location of the accident event.

use
string

The purpose of this address.

Possible Values: home, work, temp, old, billing
line
[string]

This component contains the house number, apartment number, street name, street direction, P.O. Box number, delivery hints, and similar address information.

city
string

The name of the city, town, suburb, village or other community or delivery center.

district
string

The name of the administrative area (county).

state
string

Sub-unit of a country with limited sovereignty in a federally organized country. A code may be used if codes are in common use (e.g. US 2 letter state codes).

postalCode
string

A postal code designating a region defined by the postal service.

country
string

Country - a nation as commonly understood or generally accepted.

item
[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.

id
string

A unique id for the line item. This can be used on subsequent status checks to get-line-level status information.

careTeamSequence
[number]

An array of sequence numbers from Claim.careTeam that apply to this line item.

diagnosisSequence
[number]

An array of sequence numbers from Claim.diagnosis that apply to this line item.

procedureSequence
[number]

An array of sequence numbers from Claim.procedure that apply to this line item.

informationSequence
[number]

An array of sequence numbers from Claim.supportingInfo that apply to this line item.

revenue
object

The type of revenue or cost center providing the product and/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.

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.

programCode
[object]

Identifies the program under which this may be recovered.

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.

unitPrice
object

If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

value
number

Numerical value (with implicit precision).

currency
string

ISO 4217 Currency Code (e.g. USD for US Dollar)

bodySite
object

Physical service site on the patient (limb, tooth, etc.).

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.

encounter
[object]

The Encounters during which this Claim was created or to which the creation of this record is tightly associated.

Must be a resource of type Encounter.

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.

servicedPeriod
object

The date or dates when the service or product was supplied, performed or completed.

start
string

The start of the period. The boundary is inclusive.

end
string

The end of the period. If the end of the period is missing, it means no end was known or planned at the time the instance was created. The start may be in the past, and the end date in the future, which means that period is expected/planned to end at that time.

locationCodeableConcept
object

Where the product or service was provided.

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.

total
object

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

value
number

Numerical value (with implicit precision).

currency
string

ISO 4217 Currency Code (e.g. USD for US Dollar)

post/Claim/$submit-institutional
InstitutionalClaimBundle

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.

Response Fields and Example
resourceType
required, string

Identifies the type of the resource

Value: OperationOutcome
issue
required, [object]

A structured respresentation of the error that occurred

severity
required, string

Generally error or fatal

Possible Values: fatal, error, warning, information
code
required, string

A FHIR category code that describes the general type of issue. See http://hl7.org/fhir/ValueSet/issue-type for details

id
string

If the error occurs in the RedoxEngine, this corresponds to an Error record in the organization.

details
object

Additional details about the error. This may be a text description of the error or a system code that identifies the error.

coding
[object]

A more granular FHIR code for the specific error. Typically from http://hl7.org/fhir/ValueSet/operation-outcome

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-readable interpretation of the issue code

diagnostics
string

Additional diagnostic information about the issue.