Claim $inquiry

post/Claim/$inquiry

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This resource contains the financial details for provider services for a patient visit or treatment. Healthcare organizations can use this resource to request reimbursement, while payers can review this resource to process claims and respond with the ClaimResponse resource.

You can submit, check, or add to claim information using one of the supported operations.

Supported fields and schema examples

We support any valid FHIR® field. However, we only display fields we’ve defined in our schema, which are usually based on what’s included in the U.S. Core profile. We recommend relying on U.S. Core requirements.

Our schema examples show the shape and possibility of each FHIR® resource; they aren’t code for real-time API calls. We don’t currently recommend copying and pasting these schema examples for your API calls. Consider reviewing FHIR® API actions for realistic examples for particular use cases.

$inquiry

Check the status of a previously submitted preauthorization request.

We support this operation for completeness and compliance with the DaVinci PAS specification. However, we recommend using the $status operation for clarity.

If you choose this operation, you may use the data-absent-reason extension for required fields like patient. This allows you to quickly check the status of a claim with only the Claim.identifier. You can also optionally add an administrativeReferenceNumber in the Claim.item.extension.

Request parameters and payload

cURL request example

bash

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curl 'https://api.redoxengine.com/fhir/R4/{destinationSlug}/{environmentFlag}/Claim/$inquiry' \
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--request POST \
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--header 'Authorization: Bearer $API_TOKEN' \
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--header 'Content-Type: application/fhir+json' \
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--data '{
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  "resourceType": "Bundle",
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  "id": "RedoxMedicationClaimInquiryBundleExample",
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  "type": "collection",
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  "identifier": {
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    "system": "urn:ietf:rfc:3986",
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    "value": "urn:uuid:0825e908-b107-4958-b333-9ebc090f1ab6"
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  },
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  "timestamp": "2021-09-10T17:30:13.303Z",
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  "entry": [
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    {
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      "resource": {
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        "resourceType": "Claim",
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        "id": "RedoxPAMedicationClaimInquiryExample",
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        "status": "active",
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        "use": "preauthorization",
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        "insurance": [
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          {
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            "focal": true,
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            "sequence": 1,
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            "coverage": {
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              "extension": [
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                {
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                  "url": "http://hl7.org/fhir/StructureDefinition/data-absent-reason",
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                  "valueCode": "unsupported"
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                }
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              ]
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            }
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          }
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        ],
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        "item": [
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          {
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            "extension": [
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              {
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                "url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber",
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                "valueString": "REF456"
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              }
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            ],
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            "sequence": 1,
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            "productOrService": {
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              "extension": [
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                {
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                  "url": "http://hl7.org/fhir/StructureDefinition/data-absent-reason",
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                  "valueCode": "unsupported"
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                }
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              ]
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            }
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          }
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        ],
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        "identifier": [
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          {
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            "type": {
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              "coding": [
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                {
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                  "code": "ClaimID"
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                }
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              ]
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            },
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            "value": "urn:uuid:97b8d6d0-ac3d-411a-b32a-e1d237aceb6a"
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          }
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        ],
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        "type": {
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          "coding": [
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            {
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              "code": "pharmacy",
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              "system": "http://terminology.hl7.org/CodeSystem/claim-type"
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            }
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          ]
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        },
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        "created": "2021-08-18T16:27:49.101Z",
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        "priority": {
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          "coding": [
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            {
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              "code": "normal",
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              "system": "http://terminology.hl7.org/CodeSystem/processpriority"
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            }
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          ]
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        },
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        "patient": {
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          "extension": [
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            {
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              "url": "http://hl7.org/fhir/StructureDefinition/data-absent-reason",
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              "valueCode": "unsupported"
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            }
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          ]
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        },
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        "insurer": {
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          "extension": [
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            {
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              "url": "http://hl7.org/fhir/StructureDefinition/data-absent-reason",
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              "valueCode": "unsupported"
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            }
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          ]
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        },
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        "provider": {
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          "extension": [
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            {
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              "url": "http://hl7.org/fhir/StructureDefinition/data-absent-reason",
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              "valueCode": "unsupported"
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            }
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          ]
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        }
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      }
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    }
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  ]
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}'

Request Body Schema

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, Array of Claim, Patient, MedicationRequest, ServiceRequest
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.

Response fields and example

json

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{}

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, Array of ClaimResponse, Patient, Coverage, Location
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

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