Claim $submit-professional

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, Practitioner

  and 1 more...

  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 - Organization resources may carry information such as primary payer, addtional payers, or the provider organization.
  • Practitioner - Practitioner performing the service - this can be used.
  • 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: ClaimPatientCoveragePractitionerRelatedPersonOther
  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: 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.
    • preAuthRef

      Array of 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

    Array of 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

        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.
  • careTeam

    Array of 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

        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.
  • supportingInfo

    Array of 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

        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.
    • code

      object

      The specific type of information being sent.

      • 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.
    • 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

    Array of 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

      Array of object

      When the condition was observed or the relative ranking.

      • 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.
    • onAdmission

      object

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

      • 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.
    • 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

        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.
  • procedure

    Array of 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

      Array of 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

        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.
    • locationAddress

      object

      The physical location of the accident event.

      • use

        string

        The purpose of this address.

        Possible Values: home, work, temp, old, billing
      • line

        Array of 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

    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.
    • careTeamSequence

      Array of number

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

      Array of number

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

      Array of number

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

      Array of 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

        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.
    • modifier

      Array of object

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

      • 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.
    • programCode

      Array of object

      Identifies the program under which this may be recovered.

      • 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.
    • 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.

          Any of: PrecisionOther
          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

        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.
    • encounter

      Array of 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

        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)