Claim/$submit

Submit a claim or a request for prior authorization of a claim.

Request Fields and Example
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, [Claim, Patient, MedicationRequest, ServiceRequest, Coverage, Organization, PractitionerRole, Practitioner, RelatedPerson, Other]

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

  • Claim - the main prior auth request resource
  • Patient - the patient the claim is about
  • 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.
  • Coverage - the patient's insurance

Additional resources such as MedicationRequest or ServiceRequest may also be included to communicate additional information about the claim.

Any of:
resource
required, object

A provider issued list of professional services and products which have been provided, or are to be provided, to a patient which is sent to an insurer for reimbursement.

resourceType
required, string

Identifies the type of the resource

Value: Claim
identifier
required, [object]

A unique identifier assigned to this claim.

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.

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
[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: preauthorization
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.

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.

reference
string

A reference to an Organization resource

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.

Value: true
coverage
required, object

Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.

reference
string

A reference to a Coverage resource

item
required, [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.

extension
[itemTraceNumber, administrationReferenceNumber, requestedService, Other]

A set of additional fields about the item. For medication prior auth, the requestedService extension must be present with a reference to a MedicationRequest resource. For procedures, a ServiceRequest resource is used.

Any of:
url
required, string

Source of the definition for the extension code - a logical name or a URL.

Value: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
valueIdentifier
object

Uniquely identifies this claim item

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.

insurer
object

The Insurer who is target of the request.

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.

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.

diagnosis
[object]

Information about diagnoses relevant to the claim items.

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.

id
string

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

extension
[object]

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

id
string

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

url
string

Source of the definition for the extension code - a logical name or a URL.

valueBase64Binary
string

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

coding
[object]

A reference to a code defined by a terminology system.

id
string

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

extension
[object]

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

id
string

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

url
string

Source of the definition for the extension code - a logical name or a URL.

valueBase64Binary
string

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

system
string

The identification of the code system that defines the meaning of the symbol in the code.

_system
object

Extensions for system

id
string

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

extension
[object]

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

id
string

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

url
string

Source of the definition for the extension code - a logical name or a URL.

valueBase64Binary
string

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

version
string

The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.

_version
object

Extensions for version

id
string

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

extension
[object]

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

id
string

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

url
string

Source of the definition for the extension code - a logical name or a URL.

valueBase64Binary
string

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

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).

_code
object

Extensions for code

id
string

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

extension
[object]

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

id
string

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

url
string

Source of the definition for the extension code - a logical name or a URL.

valueBase64Binary
string

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

display
string

A representation of the meaning of the code in the system, following the rules of the system.

_display
object

Extensions for display

id
string

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

extension
[object]

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

id
string

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

url
string

Source of the definition for the extension code - a logical name or a URL.

valueBase64Binary
string

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

userSelected
boolean

Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays).

_userSelected
object

Extensions for userSelected

id
string

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

extension
[object]

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

id
string

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

url
string

Source of the definition for the extension code - a logical name or a URL.

valueBase64Binary
string

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

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.

_text
object

Extensions for text

id
string

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

extension
[object]

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

id
string

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

url
string

Source of the definition for the extension code - a logical name or a URL.

valueBase64Binary
string

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

post/Claim/$submit
double-caret-vertical
A request to authorize payment for a blood pressure medication
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