Claim
Source Object: Claim
Overview and Usage: The "Claim" source object in athena EHR is a comprehensive data model designed to capture and manage information related to patient claim alerts, including billing and insurance details. It is essential for tracking billing and insurance-related information associated with patient claims. Here's an overview of key fields and their usage:
- Billed Provider ID: "billedproviderid" identifies the provider responsible for billing and processing insurance claims.
- Billed Service Date: "billedservicedate" records the date when the billed service was provided to the patient.
- Charge Amount: "chargeamount" specifies the amount charged for the service or procedure.
- Claim Created Date: "claimcreateddate" indicates the date when the insurance claim was created or processed.
- Claim ID: "claimid" serves as a unique identifier for the insurance claim.
- Diagnoses: The "diagnoses" section contains information about patient diagnoses, including codes, descriptions, and category.
- Patient ID: "patientid" links the chart alert to the specific patient's record.
- Patient Payer: "patientpayer" includes details about the patient's insurance payer, status, and related notes.
- Primary Insurance Payer: The "primaryinsurancepayer" section provides information about the primary insurance payer, including package ID, status, and related details.
- Procedures: The "procedures" section records details about procedures performed, including allowable amounts, codes, descriptions, and related transaction information.
- Secondary Insurance Payer: The "secondaryinsurancepayer" section offers details about the secondary insurance payer, including package ID, status, and related information.
- Appointment ID: "appointmentid" associates the chart alert with a specific patient appointment.
- Department ID: "departmentid" specifies the department or healthcare unit associated with the chart alert.
- Referral Authorization ID: "referralauthid" contains the identification of a referral authorization associated with the alert.
- Referring Provider ID: "referringproviderid" identifies the provider who referred the patient for the services or procedures.
- Reserved Field: "reserved19" represents a field that may have a specific use within athena EHR.
- Transaction Details: The "transactiondetails" section includes information related to claim charges, allowable amounts, codes, and notes.
- Custom Fields: "customfields" provides flexibility for adding custom data fields and options.
The "Claim" source object is vital for managing billing and insurance-related information associated with patient charts. It is used to track claims, procedures, and diagnoses, ensuring accurate billing and insurance processing. Developers can leverage this source object to build features and applications that support billing, claims management, and insurance-related processes within athena EHR.
Mapping Table
| Data Field | Example Value | Source Data Field Description | Source Field Data Type | Source Data Field Cardinality | Mapped FHIR++ Resource | Mapped FHIR Data Field | Augmented Mapping | Associated Coding System | Associated FHIR Data Field Extension | Mapping Context |
|---|---|---|---|---|---|---|---|---|---|---|
| billedproviderid | - | The provider ID of the billing provider for this claim. | Integer | 0..1 | Claim | provider.reference | - | - | billed-provider-id | Top Level |
| billedservicedate | - | The billed date of service. | String | 0..1 | Claim | billablePeriod.end | - | - | - | Top Level |
| chargeamount | - | The total amount billed for all services from this claim. | String | 0..1 | Claim | total | - | - | - | Top Level |
| claimcreateddate | - | The date the claim was created. | String | 0..1 | Claim | created | - | - | - | Top Level |
| claimid | - | athenaNet's internal ID for this claim, specific to the practice. | String | 0..1 | Claim | id | - | - | - | Top Level |
| diagnoses | - | Diagnoses is an array of all diagnoses. Each entry in the array is a hash with several fields. /ccda is a better clinical representation. These fields are: | Object | 0..* | Claim | - | - | - | - | Top Level |
| diagnoses.deleteddiagnosis | - | In certain cases, diagnoses may be added and then removed from a particular claim. In normal circumstances, this will be false. However, if a diagnosis was removed, this will be true. | String | 0..1 | Claim | diagnosis[}.extension[].valueString | - | - | deleted-diagnosis | Top Level |
| diagnoses.diagnosiscategory | - | The category for this diagnosis. | String | 0..1 | Claim | diagnosis[].type[].text | - | - | - | Top Level |
| diagnoses.diagnosiscodeset | - | Either ICD9 or ICD10. | String | 0..1 | Claim | diagnosis[].diagnosis.CodeableConcept.coding[].system | - | ICD10,ICD9 | - | Top Level |
| diagnoses.diagnosisdescription | - | A description of this diagnosis. | String | 0..1 | Claim | diagnosis[].diagnosis.CodeableConcept.coding[].display | - | - | - | Top Level |
| diagnoses.diagnosisid | - | A unique ID related to this diagnosis. | String | 0..1 | Claim | diagnosis[*].diagnosisReference.reference | - | - | - | Top Level |
| diagnoses.diagnosisrawcode | - | The raw ICD-9 code. This will migrate to ICD-10 in the future. | String | 0..1 | Claim | diagnosis[].diagnosis.CodeableConcept.coding[].code | - | - | - | Top Level |
| patientid | - | The patient ID associated with this claim. | Integer | 1..1 | Claim | patient.reference | - | - | - | Top Level |
| patientpayer | - | The status and notes of a responsible payer. This payer is the patient. | Object | 0..* | Claim | - | - | - | - | Top Level |
| patientpayer.note | - | The status associated with this responsible payer. | String | 0..1 | Claim | extension[*].valueString | - | - | patient-payer-note | Top Level |
| patientpayer.status | - | The status and notes of a responsible payer. This payer is the primary insurace. | String | 0..1 | Claim | status | - | - | - | Top Level |
| primaryinsurancepayer | - | The primary insurance id associated with this claim. | Object | 0..* | Claim | - | - | - | - | Top Level |
| primaryinsurancepayer.primarypatientinsuranceid | - | - | Integer | 0..1 | Claim | insurance[0].coverage.reference | - | - | - | Top Level |
| procedures | - | Procedures is an array of all procedures. /ccda is a better clinical representation. These fields are: | Object | 0..* | Claim | - | - | - | - | Top Level |
| procedures.chargeamount | - | The amount charged for this procedure. | String | 0..1 | Claim | procedure[].extension[].valueString | - | - | procedure-charge-amount | Top Level |
| procedures.procedurecode | - | The CPT code associated with this procedure. | String | 0..1 | Claim | procedure[].procedureCodeableConcept.coding[].code | - | - | - | Top Level |
| procedures.proceduredescription | - | A description of this procedure. | String | 0..1 | Claim | procedure[].procedureCodeableConcept.coding[].display | - | - | - | Top Level |
| secondaryinsurancepayer | - | The status and notes of a responsible payer. This payer is the secondary insurace. | Object | 0..* | Claim | - | - | - | - | Top Level |
| secondaryinsurancepayer.secondarypatientinsuranceid | - | The secondary insurance id associated with this claim. | Integer | 0..1 | Claim | insurance[1].coverage.reference | - | - | - | Top Level |
| appointmentid | - | The appointment ID associated with this claim. | String | 0..1 | Claim | extension[*].valueString | - | - | appointment-id | Top Level |
| departmentid | - | The department ID associated with this claim. | Integer | 1..1 | Claim | extension[*].valueInteger | - | - | department-id | Top Level |
| referralauthid | - | The referral authorization ID for this claim. | Integer | 0..1 | Claim | extension[*].valueInteger | - | - | referral-auth-id | Top Level |
| referringproviderid | - | The referring provider ID for this claim. See /referringproviders. This is not the same as the ID from the /providers call. | Integer | 0..1 | Claim | provider.extensions[*].valueInteger | - | - | referring-provider-id | Top Level |
| reserved19 | - | The text in the Reserved 19 field. | String | 0..1 | Claim | extension[*].valueString | - | - | reserved19 | Top Level |
| transactiondetails | - | A hash of ids (transactionid) to amounts; these should sum to the chargeamount. | Object | 0..* | Claim | extension[*].valueString | - | - | transaction-details | Top Level |
| transactionid | - | A unique ID for the primary transaction this claim represents. May be useful for debugging. | String | 0..1 | Claim | extension[*].valueString | - | - | transaction-id | Top Level |
| customfields | - | The claim custom field values may or may not be the same between departments. | Object | 0..* | Claim | - | - | - | custom-fields | Top Level |
| customfields.customfieldid | - | Corresponds to the /customfields customfieldid. | String | 0..1 | Claim | extension[].valueCodeableConcept[0].coding[].code | - | - | - | Top Level |
| customfields.customfieldvalue | - | For a non-select custom field, the value. | String | 0..1 | Claim | extension[].valueCodeableConcept[0].coding[].display | - | - | - | Top Level |
| customfields.optionid | - | For a select custom field, the selectid value (from /customfield's selectlist). | String | 0..1 | Claim | extension[].valueCodeableConcept[0].coding[].id | - | - | option-id | Top Level |
| primaryinsurancepayer | - | The status and notes of a responsible payer. This payer is the patient. | Object | 0..* | Claim | - | - | - | - | Top Level |
| primaryinsurancepayer.primaryinsurancepackageid | - | The primary insurance Package id associated with this claim. | String | 0..1 | Claim | insurance[0].extension[*].valueString | - | - | primary-insurance-package-id | Top Level |
| primaryinsurancepayer.status | - | The status associated with this responsible payer. | String | 0..1 | Claim | insurance[0].extension[*].valueString | - | - | primary-insurance-status | Top Level |
| procedures | - | Procedures is an array of all procedures. /ccda is a better clinical representation. These fields are: | Object | 0..* | Claim | - | - | - | - | Top Level |
| procedures.allowableamount | - | The total amount expected from payer for all services from this procedure. | String | 0..1 | Claim | procedure[].extension[].valueString | - | - | allowable-amount | Top Level |
| procedures.allowablemax | - | The maximum amount expected from payer for all services from this procedure. | String | 0..1 | Claim | procedure[].extension[].valueString | - | - | allowable-max | Top Level |
| procedures.allowablemin | - | The minimum amount expected from payer for all services from this procedure. | String | 0..1 | Claim | procedure[].extension[].valueString | - | - | allowable-min | Top Level |
| procedures.procedurecategory | - | The category name associated with this procedure. | String | 0..1 | Claim | procedure[].type[].coding[0].display | - | - | - | Top Level |
| procedures.transactionid | - | The ID of the last transaction associated with the claim. | String | 0..1 | Claim | procedure[].extension[].valueString | - | - | procedure-transaction-id | Top Level |
| secondaryinsurancepayer | - | The status and notes of a responsible payer. This payer is the secondary insurace. | Object | 0..* | Claim | - | - | - | - | Top Level |
| secondaryinsurancepayer.secondaryinsurancepackageid | - | The secondary insurance id associated with this claim. | Integer | 0..1 | Claim | insurance[1].extension[*].valueString | - | - | secondary-insurance-package-id | Top Level |
| orderingproviderid | - | The ordering provider id. | Integer | 0..1 | Claim | provider.extensions[*].valueInteger | ordering-provider-id | Top Level | ||
| renderingproviderid | - | The rendering provider id. | Integer | 0..1 | Claim | provider.extensions[*].valueInteger | rendering-provider-id | Top Level | ||
| servicedate | - | A date string that corresponds with when the patient was seen. | String | 0..1 | Claim | extensions[*].valueString | service-date | Top Level | ||
| supervisingproviderid | - | The supervising provider ID. | Integer | 0..1 | Claim | provider.reference | Top Level | |||
| claimcharges.allowableamount | - | The total expected allowable amount for this charge. If passed, will override the amount that would be calculated from the usual practice allowable schedule. | Number | 0..1 | Claim | procedure[].extension[].valueInteger | claim-charges-allowable-amount | Top Level | ||
| claimcharges.allowablemax | - | The total maximum allowable amount for this charge. If passed, will override the amount that would be calculated from the usual practice allowable schedule. | Number | 0..1 | Claim | procedure[].extension[].valueInteger | claim-charges-allowable-max | Top Level | ||
| claimcharges.allowablemin | - | The total minimum allowable amount for this charge. If passed, will override the amount that would be calculated from the usual practice allowable schedule. | Number | 0..1 | Claim | procedure[].extension[].valueInteger | claim-charges-allowable-min | Top Level | ||
| claimcharges.allowablescheduleid | - | The ID of the athenaNet allowable schedule to associated with this charge. If passed, will override the usual practice allowable schedule. | Integer | 0..1 | Claim | procedure[].extension[].valueInteger | claim-charges-allowable-schedule-id | Top Level | ||
| claimcharges.icd10code1 | - | Primary ICD-10 diagnosis for this charge. | String | 0..1 | Claim | diagnosis.diagnosesCodeableConcept.coding[*].code | system=ICD10 | ICD10 | icd-codes | Top Level |
| claimcharges.icd9code1 | - | Primary ICD-9 diagnosis for this charge. | String | 0..1 | Claim | diagnosis.diagnosesCodeableConcept.coding[*].code | system-ICD9 | ICD9 | - | Top Level |
| claimcharges.linenote | - | Optional line note for this charge. Any value for this field will be truncated to 80 characters. | String | 0..1 | Claim | procedure[].extension[].valueString | line-note | Top Level | ||
| claimcharges.procedurecode | - | CPT code for this procedure, including any modifiers (e.g. 99213,26,59). | String | 0..1 | Claim | procedure[*].procedureCoadableConcept.coding.code | procedure-code | Top Level | ||
| claimcharges.unitamount | - | The per-unit amount for this charge. If passed, will overwrite the amount defined in the practice fee schedule. | Number | 0..1 | Claim | procedure[].extension[].valueInteger | unit-amount | Top Level | ||
| claimcharges.units | - | The number of units to bill for this charge. If not specified, defaults to 1. | Integer | 0..1 | Claim | procedure[].extension[].valueInteger | units | Top Level | ||
| primarypatientinsuranceid | - | The athena primary patient insurance ID. Defaults to the patient's active primary insurance. | Integer | 0..1 | Claim | insurance[0].coverage.reference | - | Top Level | ||
| secondarypatientinsuranceid | - | The athena secondary patient insurance ID. Defaults to the patient's active secondary insurance. | Integer | 0..1 | Claim | insurance[1].coverage.reference | - | Top Level | ||
| claimcharges | Claim | extensions[*].extension | claim-charges | Top Level |