Claim

Overview

The Claim resource represents a request for payment for healthcare services. Claims are submitted to insurers for reimbursement of services provided to patients.

FHIR R4 Specification

See the official HL7 specification: https://hl7.org/fhir/R4/claim.html

Supported Fields

Field	Type	Description
id	string	Logical ID of the resource
meta	Meta	Resource metadata
identifier	Identifier[]	Business identifiers
status	code	active, cancelled, draft, entered-in-error
type	CodeableConcept	Claim type (professional, institutional, etc.)
subType	CodeableConcept	Claim subtype
use	code	claim, preauthorization, predetermination
patient	Reference(Patient)	Patient
billablePeriod	Period	Service period
created	dateTime	Creation date
enterer	Reference	Person entering claim
insurer	Reference(Organization)	Target insurer
provider	Reference	Billing provider
priority	CodeableConcept	Desired processing priority
fundsReserve	CodeableConcept	Funds reservation
related	BackboneElement[]	Related claims
prescription	Reference	Prescription
payee	BackboneElement	Recipient of payment
referral	Reference	Treatment referral
facility	Reference(Location)	Service facility
careTeam	BackboneElement[]	Care team members
supportingInfo	BackboneElement[]	Supporting info
diagnosis	BackboneElement[]	Diagnoses
procedure	BackboneElement[]	Procedures
insurance	BackboneElement[]	Insurance coverage
accident	BackboneElement	Accident info
item	BackboneElement[]	Service line items
total	Money	Total claim amount

Search Parameters

Parameter	Type	Description	Example
_id	token	Resource ID	_id=claim-001
identifier	token	Business identifier	identifier=CLM-12345
patient	reference	Patient reference	patient=Patient/123
status	token	Claim status	status=active
created	date	Creation date	created=2024-01-15
provider	reference	Provider	provider=Practitioner/456
use	token	Claim use	use=claim
priority	token	Priority	priority=normal
insurer	reference	Insurer	insurer=Organization/789
facility	reference	Facility	facility=Location/123
care-team	reference	Care team member	care-team=Practitioner/456

Examples

Create a Claim

curl -X POST http://localhost:8080/baseR4/Claim \
  -H "Content-Type: application/fhir+json" \
  -d '{
    "resourceType": "Claim",
    "status": "active",
    "type": {
      "coding": [{
        "system": "http://terminology.hl7.org/CodeSystem/claim-type",
        "code": "professional",
        "display": "Professional"
      }]
    },
    "use": "claim",
    "patient": {
      "reference": "Patient/patient-001"
    },
    "billablePeriod": {
      "start": "2024-01-15",
      "end": "2024-01-15"
    },
    "created": "2024-01-20",
    "provider": {
      "reference": "Practitioner/practitioner-001"
    },
    "priority": {
      "coding": [{
        "system": "http://terminology.hl7.org/CodeSystem/processpriority",
        "code": "normal"
      }]
    },
    "insurance": [{
      "sequence": 1,
      "focal": true,
      "coverage": {
        "reference": "Coverage/coverage-001"
      }
    }],
    "diagnosis": [{
      "sequence": 1,
      "diagnosisCodeableConcept": {
        "coding": [{
          "system": "http://hl7.org/fhir/sid/icd-10",
          "code": "E11.9",
          "display": "Type 2 diabetes mellitus without complications"
        }]
      }
    }],
    "item": [{
      "sequence": 1,
      "productOrService": {
        "coding": [{
          "system": "http://www.ama-assn.org/go/cpt",
          "code": "99213",
          "display": "Office visit"
        }]
      },
      "servicedDate": "2024-01-15",
      "unitPrice": {
        "value": 150.00,
        "currency": "USD"
      },
      "net": {
        "value": 150.00,
        "currency": "USD"
      }
    }],
    "total": {
      "value": 150.00,
      "currency": "USD"
    }
  }'

Search Claims

# By patient
curl "http://localhost:8080/baseR4/Claim?patient=Patient/123"

# By status
curl "http://localhost:8080/baseR4/Claim?status=active"

# By created date
curl "http://localhost:8080/baseR4/Claim?created=2024-01-20"

# By provider
curl "http://localhost:8080/baseR4/Claim?provider=Practitioner/456"

Patient Compartment

# Get all claims for a patient
curl "http://localhost:8080/baseR4/Patient/123/Claim"

Status Codes

Code	Display
active	Active
cancelled	Cancelled
draft	Draft
entered-in-error	Entered in Error

Use Codes

Code	Display	Description
claim	Claim	Actual claim submission
preauthorization	Pre-Authorization	Pre-authorization request
predetermination	Pre-Determination	Benefits determination

Claim Types

Code	Display
institutional	Institutional
oral	Oral
pharmacy	Pharmacy
professional	Professional
vision	Vision