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FHIR® resources
Claim
$status

Claim $status

post/Claim/$status
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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.

$status

Check the status of a previously submitted claim and associated line items.

The claim must have been successfully submitted, and you must have the generated claim ID to check the status.

Request parameters and payload

cURL request example

bash
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curl 'https://api.redoxengine.com/fhir/R4/{destinationSlug}/{environmentFlag}/Claim/$status' \
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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": "InstitutionalClaimStatusCheckBundle",
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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:59f129cf-2eca-4965-88f2-452558af1934"
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  },
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  "timestamp": "2021-10-21T19:09:02.452Z",
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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": "InstitutionalClaimStatusCheck",
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        "status": "active",
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        "use": "claim",
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        "identifier": [
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          {
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            "system": "http://myclaim.id",
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            "value": "123476789"
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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": "institutional",
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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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        "patient": {
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          "reference": "Patient/RedoxPABeneficiaryExample"
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        },
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        "created": "2022-01-18T16:27:49.101Z",
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        "total": {
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          "value": 89.93,
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          "currency": "USD"
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        },
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        "provider": {
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          "reference": "Organization/RedoxPARequestorOrganizationExample"
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        },
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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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        "insurance": [
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          {
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            "sequence": 1,
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            "focal": true,
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            "coverage": {
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              "reference": "Coverage/RedoxPACoverageExample"
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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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            "sequence": 1,
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            "id": "12387414",
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            "productOrService": {
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              "coding": [
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                {
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                  "code": "85025",
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                  "system": "http://www.ama-assn.org/go/cpt",
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                  "display": "Blood count; complete (CBC)"
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                }
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              ],
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              "text": "Blood count; complete (CBC)"
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            },
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            "revenue": {
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              "coding": [
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                {
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                  "code": "0305",
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                  "system": "https://www.nubc.org/CodeSystem/RevenueCodes",
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                  "display": "Laboratory"
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                }
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              ]
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            },
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            "quantity": {
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              "value": 1
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            },
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            "unitPrice": {
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              "value": 13.39,
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              "currency": "USD"
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            },
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            "servicedPeriod": {
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              "start": "2022-01-18T16:20:00.101Z",
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              "end": "2022-01-19T16:20:00.101Z"
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            }
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          },
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          {
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            "sequence": 2,
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            "id": "5352523553",
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            "productOrService": {
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              "coding": [
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                {
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                  "code": "93005",
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                  "system": "http://www.ama-assn.org/go/cpt",
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                  "display": "Electrocardiogram, routine ECG with at least 12 leads"
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                }
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              ],
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              "text": "Electrocardiogram, routine"
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            },
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            "revenue": {
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              "coding": [
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                {
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                  "code": "0730",
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                  "system": "https://www.nubc.org/CodeSystem/RevenueCodes",
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                  "display": "EKG/ECG (Electrocardiogram)"
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                }
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              ]
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            },
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            "quantity": {
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              "value": 3
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            },
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            "locationCodeableConcept": {
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              "coding": [
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                {
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                  "code": "21",
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                  "system": "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
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                  "display": "HOSPITAL - INPATIENT HOSPITAL"
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                }
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              ]
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            },
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            "unitPrice": {
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              "value": 76.54,
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              "currency": "USD"
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            },
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            "servicedPeriod": {
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              "start": "2022-01-18T17:20:00.101Z",
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              "end": "2022-01-18T17:40:00.101Z"
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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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      "resource": {
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        "resourceType": "Patient",
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        "id": "RedoxPABeneficiaryExample",
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        "identifier": [
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          {
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            "system": "urn:redox:MRN",
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            "value": "M23462346"
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          }
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        ],
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        "name": [
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          {
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            "given": [
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              "Timothy",
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              "Paul"
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            ],
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            "family": "Bixby"
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          }
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        ],
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        "gender": "male",
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        "birthDate": "2008-01-06"
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      }
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    },
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    {
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      "resource": {
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        "resourceType": "Coverage",
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        "id": "RedoxPACoverageExample",
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        "class": [
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          {
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            "type": {
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              "coding": [
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                {
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                  "code": "group",
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                  "system": "http://terminology.hl7.org/CodeSystem/coverage-class"
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                }
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              ]
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            },
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            "value": "GRP2245"
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          }
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        ],
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        "status": "active",
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        "beneficiary": {
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          "reference": "Patient/RedoxPABeneficiaryExample"
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        },
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        "payor": [
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          {
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            "reference": "Organization/RedoxPAInsurerOrganizationExample"
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          }
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        ],
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        "subscriber": {
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          "reference": "Patient/RedoxPABeneficiaryExample"
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        },
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        "subscriberId": "T75644"
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      }
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    },
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    {
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      "resource": {
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        "resourceType": "Organization",
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        "id": "RedoxPARequestorOrganizationExample",
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        "active": true,
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        "name": "Good Health Clinics",
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        "address": [
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          {
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            "line": [
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              "123 Main St."
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            ],
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            "city": "Madison",
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            "district": "Dane",
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            "state": "WI",
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            "postalCode": "53703",
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            "country": "USA"
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          }
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        ]
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      }
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    },
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    {
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      "resource": {
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        "resourceType": "Organization",
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        "id": "RedoxPAInsurerOrganizationExample",
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        "active": true,
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        "name": "Aetna",
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        "address": [
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          {
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            "line": [
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              "PO Box 14080"
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            ],
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            "city": "Lexington",
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            "district": "Fayette",
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            "state": "KY",
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            "postalCode": "40512-4079",
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            "country": "USA"
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          }
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        ]
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      }
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    },
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    {
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      "resource": {
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        "resourceType": "Practitioner",
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        "id": "RedoxPractitionerExamplePat",
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        "identifier": [
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          {
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            "system": "http://hl7.org/fhir/sid/us-npi",
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            "value": "4356789876"
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          }
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        ],
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        "name": [
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          {
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            "given": [
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              "Pat"
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            ],
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            "family": "Granite"
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          }
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        ],
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        "address": [
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          {
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            "line": [
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              "123 Main St."
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            ],
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            "city": "Madison",
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            "district": "Dane",
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            "state": "WI",
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            "postalCode": "53703",
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            "country": "USA"
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          }
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        ],
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        "telecom": [
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          {
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            "value": "+16085551234"
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          }
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        ]
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      }
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    },
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    {
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      "resource": {
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        "resourceType": "Practitioner",
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        "id": "RedoxPractitionerExampleJoan",
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        "identifier": [
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          {
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            "system": "http://hl7.org/fhir/sid/us-npi",
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            "value": "4336749876"
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          }
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        ],
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        "name": [
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          {
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            "given": [
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              "Joan"
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            ],
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            "family": "Fishman"
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          }
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        ],
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        "address": [
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          {
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            "line": [
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              "4762 Hickory St."
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            ],
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            "city": "Monroe",
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            "district": "Green",
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            "state": "WI",
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            "postalCode": "53566",
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            "country": "USA"
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          }
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        ],
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        "telecom": [
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          {
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            "value": "+16085558899"
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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
  • type
    required, string

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

    Value: collection
  • entry
    required, Array of Claim, Patient, Coverage, Location, Practitioner, RelatedPerson or Other

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

    • Claim - 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
    • 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 global unique identifier for the Claim - this should correspond to the initial Claim.id sent.

      • 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
          Array of 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
          Array of 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, Array of 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.

      • 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

      • item
        Array of 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
            Array of 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.

        • 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
              Array of Precision or 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.

                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.

        • 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
            Array of 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)

Response fields and example

Example payload generated from schema
1
{
2
  "resourceType": "OperationOutcome",
3
  "issue": [
4
    {
5
      "id": "string",
6
      "severity": "fatal",
7
      "code": "string",
8
      "details": {
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        "coding": [
10
          {
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            "system": "string",
12
            "code": "string"
13
          }
14
        ],
15
        "text": "string"
16
      },
17
      "diagnostics": "string"
18
    }
19
  ]
20
}
  • resourceType
    required, string

    Identifies the type of the resource

    Value: OperationOutcome
  • issue
    required, Array of 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
        Array of 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.