Claim

Overview

The Claim API empowers healthcare developers to efficiently manage and process medical claims, providing a standardized interface to streamline billing procedures, enhance reimbursement accuracy, and optimize the overall financial workflow within clinical applications. By integrating this API, developers can automate claims submission, verification, and tracking, leading to improved revenue cycle management and increased operational efficiency in healthcare settings.

Use Cases:

Billing - Submit claims to insurers to seek reimbursement for items and services.
Eligibility checking - Verify patient insurance coverage for claim.
Claim status - Check the status of submitted claims for payment tracking.
Reconciliation - Compare claims with remittances and payments to reconcile billing.
Reporting - Generate claim-related reports for internal monitoring or reporting to regulators.
Appeals - Initiate appeals for denied claims when appropriate.
Analytics - Analyze claim trends to optimize revenue cycle, utilization, and costs.

EHR Data Model

EHR	Supported?	Mapped Source Object
Athena	✅	Claim
Elation	✅	N/A
Epic	✅	Invoice, Invoice Provider, Invoice Procedure Code Modifier, Invoice Diagnosis Code

Object Definition

{
  "resourceType": "Claim",
  "id": "100150",
  "text": {
    "status": "generated",
    "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the Oral Health Claim</div>"
  },
  "identifier": [
    {
      "system": "http://happyvalley.com/claim",
      "value": "12345"
    }
  ],
  "status": "active",
  "type": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/claim-type",
        "code": "oral"
      }
    ]
  },
  "use": "claim",
  "patient": {
    "reference": "Patient/1"
  },
  "created": "2014-08-16",
  "insurer": {
    "reference": "Organization/2"
  },
  "provider": {
    "reference": "Organization/1"
  },
  "priority": {
    "coding": [
      {
        "code": "normal"
      }
    ]
  },
  "payee": {
    "type": {
      "coding": [
        {
          "code": "provider"
        }
      ]
    }
  },
  "careTeam": [
    {
      "sequence": 1,
      "provider": {
        "reference": "Practitioner/example"
      }
    }
  ],
  "diagnosis": [
    {
      "sequence": 1,
      "diagnosisCodeableConcept": {
        "coding": [
          {
            "code": "123456"
          }
        ]
      }
    }
  ],
  "insurance": [
    {
      "sequence": 1,
      "focal": true,
      "identifier": {
        "system": "http://happyvalley.com/claim",
        "value": "12345"
      },
      "coverage": {
        "reference": "Coverage/9876B1"
      }
    }
  ],
  "item": [
    {
      "sequence": 1,
      "careTeamSequence": [
        1
      ],
      "productOrService": {
        "coding": [
          {
            "code": "1200"
          }
        ]
      },
      "servicedDate": "2014-08-16",
      "unitPrice": {
        "value": 135.57,
        "currency": "USD"
      },
      "net": {
        "value": 135.57,
        "currency": "USD"
      }
    }
  ],
  "meta": {
    "tag": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/v3-ActReason",
        "code": "HTEST",
        "display": "test health data"
      }
    ]
  }
}

Data Fields

Data Field	Type	Description
resourceType	Claim	This is a Claim resource
id	id	The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
meta	Meta	The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
implicitRules	uri	A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.
language	code	The base language in which the resource is written.
text	Narrative	A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.
contained	BackboneElement	These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.
extension	Extension	May be used to represent additional information that is not part of the basic definition of the resource. 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.
modifierExtension	Extension	May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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 is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
identifier	Identifier	A unique identifier assigned to this claim.
status	code	The status of the resource instance.
type	CodeableConcept	The category of claim, e.g. oral, pharmacy, vision, institutional, professional.
subType	CodeableConcept	A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.
use	code	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.
patient	Reference	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.
billablePeriod	Period	The period for which charges are being submitted.
created	dateTime	The date this resource was created.
enterer	Reference	Individual who created the claim, predetermination or preauthorization.
insurer	Reference	The Insurer who is target of the request.
provider	Reference	The provider which is responsible for the claim, predetermination or preauthorization.
priority	CodeableConcept	The provider-required urgency of processing the request. Typical values include: stat, routine deferred.
fundsReserve	CodeableConcept	A code to indicate whether and for whom funds are to be reserved for future claims.
related	BackboneElement	Other claims which are related to this claim such as prior submissions or claims for related services or for the same event.
related.id	string	Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
related.extension	Extension	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.
related.modifierExtension	Extension	May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
related.claim	Reference	Reference to a related claim.
related.relationship	CodeableConcept	A code to convey how the claims are related.
related.reference	Identifier	An alternate organizational reference to the case or file to which this particular claim pertains.
prescription	Reference	Prescription to support the dispensing of pharmacy, device or vision products.
originalPrescription	Reference	Original prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or products.
payee	BackboneElement	The party to be reimbursed for cost of the products and services according to the terms of the policy.
payee.id	string	Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
payee.extension	Extension	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.
payee.modifierExtension	Extension	May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
payee.type	CodeableConcept	Type of Party to be reimbursed: subscriber, provider, other.
payee.party	Reference	Reference to the individual or organization to whom any payment will be made.
referral	Reference	A reference to a referral resource.
facility	Reference	Facility where the services were provided.
careTeam	BackboneElement	The members of the team who provided the products and services.
careTeam.id	string	Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
careTeam.extension	Extension	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.
careTeam.modifierExtension	Extension	May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
careTeam.sequence	positiveInt	A number to uniquely identify care team entries.
careTeam.provider	Reference	Member of the team who provided the product or service.
careTeam.responsible	boolean	The party who is billing and/or responsible for the claimed products or services.
careTeam.role	CodeableConcept	The lead, assisting or supervising practitioner and their discipline if a multidisciplinary team.
careTeam.qualification	CodeableConcept	The qualification of the practitioner which is applicable for this service.
supportingInfo	BackboneElement	Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.
supportingInfo.id	string	Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
supportingInfo.extension	Extension	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.
supportingInfo.modifierExtension	Extension	May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
supportingInfo.sequence	positiveInt	A number to uniquely identify supporting information entries.
supportingInfo.category	CodeableConcept	The general class of the information supplied: information; exception; accident, employment; onset, etc.
supportingInfo.code	CodeableConcept	System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought.
supportingInfo.timingDate	string	The date when or period to which this information refers.
supportingInfo.timingPeriod	Period	The date when or period to which this information refers.
supportingInfo.valueBoolean	boolean	Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.
supportingInfo.valueString	string	Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.
supportingInfo.valueQuantity	Quantity	Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.
supportingInfo.valueAttachment	Attachment	Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.
supportingInfo.valueReference	Reference	Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.
supportingInfo.reason	CodeableConcept	Provides the reason in the situation where a reason code is required in addition to the content.
diagnosis	BackboneElement	Information about diagnoses relevant to the claim items.
diagnosis.id	string	Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
diagnosis.extension	Extension	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.
diagnosis.modifierExtension	Extension	May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
diagnosis.sequence	positiveInt	A number to uniquely identify diagnosis entries.
diagnosis.diagnosisCodeableConcept	CodeableConcept	The nature of illness or problem in a coded form or as a reference to an external defined Condition.
diagnosis.diagnosisReference	Reference	The nature of illness or problem in a coded form or as a reference to an external defined Condition.
diagnosis.type	CodeableConcept	When the condition was observed or the relative ranking.
diagnosis.onAdmission	CodeableConcept	Indication of whether the diagnosis was present on admission to a facility.
diagnosis.packageCode	CodeableConcept	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.
procedure	BackboneElement	Procedures performed on the patient relevant to the billing items with the claim.
procedure.id	string	Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
procedure.extension	Extension	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.
procedure.modifierExtension	Extension	May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
procedure.sequence	positiveInt	A number to uniquely identify procedure entries.
procedure.type	CodeableConcept	When the condition was observed or the relative ranking.
procedure.date	dateTime	Date and optionally time the procedure was performed.
procedure.procedureCodeableConcept	CodeableConcept	The code or reference to a Procedure resource which identifies the clinical intervention performed.
procedure.procedureReference	Reference	The code or reference to a Procedure resource which identifies the clinical intervention performed.
procedure.udi	Reference	Unique Device Identifiers associated with this line item.
insurance	BackboneElement	Financial instruments for reimbursement for the health care products and services specified on the claim.
insurance.id	string	Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
insurance.extension	Extension	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.
insurance.modifierExtension	Extension	May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
insurance.sequence	positiveInt	A number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order.
insurance.focal	boolean	A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.
insurance.identifier	Identifier	The business identifier to be used when the claim is sent for adjudication against this insurance policy.
insurance.coverage	Reference	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.
insurance.businessArrangement	string	A business agreement number established between the provider and the insurer for special business processing purposes.
insurance.preAuthRef	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.
insurance.claimResponse	Reference	The result of the adjudication of the line items for the Coverage specified in this insurance.
accident	BackboneElement	Details of an accident which resulted in injuries which required the products and services listed in the claim.
accident.id	string	Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
accident.extension	Extension	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.
accident.modifierExtension	Extension	May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
accident.date	date	Date of an accident event related to the products and services contained in the claim.
accident.type	CodeableConcept	The type or context of the accident event for the purposes of selection of potential insurance coverages and determination of coordination between insurers.
accident.locationAddress	Address	The physical location of the accident event.
accident.locationReference	Reference	The physical location of the accident event.
item	BackboneElement	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.
item.id	string	Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
item.extension	Extension	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.
item.modifierExtension	Extension	May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
item.sequence	positiveInt	A number to uniquely identify item entries.
item.careTeamSequence	positiveInt	CareTeam members related to this service or product.
item.diagnosisSequence	positiveInt	Diagnosis applicable for this service or product.
item.procedureSequence	positiveInt	Procedures applicable for this service or product.
item.informationSequence	positiveInt	Exceptions, special conditions and supporting information applicable for this service or product.
item.revenue	CodeableConcept	The type of revenue or cost center providing the product and/or service.
item.category	CodeableConcept	Code to identify the general type of benefits under which products and services are provided.
item.productOrService	CodeableConcept	When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.
item.modifier	CodeableConcept	Item typification or modifiers codes to convey additional context for the product or service.
item.programCode	CodeableConcept	Identifies the program under which this may be recovered.
item.servicedDate	string	The date or dates when the service or product was supplied, performed or completed.
item.servicedPeriod	Period	The date or dates when the service or product was supplied, performed or completed.
item.locationCodeableConcept	CodeableConcept	Where the product or service was provided.
item.locationAddress	Address	Where the product or service was provided.
item.locationReference	Reference	Where the product or service was provided.
item.quantity	Quantity	The number of repetitions of a service or product.
item.unitPrice	Money	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.
item.factor	decimal	A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.
item.net	Money	The quantity times the unit price for an additional service or product or charge.
item.udi	Reference	Unique Device Identifiers associated with this line item.
item.bodySite	CodeableConcept	Physical service site on the patient (limb, tooth, etc.).
item.subSite	CodeableConcept	A region or surface of the bodySite, e.g. limb region or tooth surface(s).
item.encounter	Reference	The Encounters during which this Claim was created or to which the creation of this record is tightly associated.
item.detail	BackboneElement	A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.
item.detail.id	string	Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
item.detail.extension	Extension	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.
item.detail.modifierExtension	Extension	May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
item.detail.sequence	positiveInt	A number to uniquely identify item entries.
item.detail.revenue	CodeableConcept	The type of revenue or cost center providing the product and/or service.
item.detail.category	CodeableConcept	Code to identify the general type of benefits under which products and services are provided.
item.detail.productOrService	CodeableConcept	When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.
item.detail.modifier	CodeableConcept	Item typification or modifiers codes to convey additional context for the product or service.
item.detail.programCode	CodeableConcept	Identifies the program under which this may be recovered.
item.detail.quantity	Quantity	The number of repetitions of a service or product.
item.detail.unitPrice	Money	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.
item.detail.factor	decimal	A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.
item.detail.net	Money	The quantity times the unit price for an additional service or product or charge.
item.detail.udi	Reference	Unique Device Identifiers associated with this line item.
item.detail.subDetail	BackboneElement	A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.
item.detail.subDetail.id	string	Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
item.detail.subDetail.extension	Extension	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.
item.detail.subDetail.modifierExtension	Extension	May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
item.detail.subDetail.sequence	positiveInt	A number to uniquely identify item entries.
item.detail.subDetail.revenue	CodeableConcept	The type of revenue or cost center providing the product and/or service.
item.detail.subDetail.category	CodeableConcept	Code to identify the general type of benefits under which products and services are provided.
item.detail.subDetail.productOrService	CodeableConcept	When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.
item.detail.subDetail.modifier	CodeableConcept	Item typification or modifiers codes to convey additional context for the product or service.
item.detail.subDetail.programCode	CodeableConcept	Identifies the program under which this may be recovered.
item.detail.subDetail.quantity	Quantity	The number of repetitions of a service or product.
item.detail.subDetail.unitPrice	Money	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.
item.detail.subDetail.factor	decimal	A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.
item.detail.subDetail.net	Money	The quantity times the unit price for an additional service or product or charge.
item.detail.subDetail.udi	Reference	Unique Device Identifiers associated with this line item.
total	Money	The total value of the all the items in the claim.

Extensions

Name	URL
APPOINTMENTID	http://xcaliber-fhir/structureDefinition/appointment-id
BILLEDPROVIDERID	http://xcaliber-fhir/structureDefinition/billed-provider-id
DEPARTMENTID	http://xcaliber-fhir/structureDefinition/department-id
REFERRALAUTHID	http://xcaliber-fhir/structureDefinition/referral-auth-id
REFERRINGPROVIDERID	http://xcaliber-fhir/structureDefinition/referring-provider-id
RESERVED19	http://xcaliber-fhir/structureDefinition/reserved19
TRANSACTIONDETAILS	http://xcaliber-fhir/structureDefinition/transaction-details
TRANSACTIONID	http://xcaliber-fhir/structureDefinition/transaction-id
SERVICEDATE	http://xcaliber-fhir/structureDefinition/service-date
RENDERINGPROVIDERID	http://xcaliber-fhir/structureDefinition/rendering-provider-id
PATIENTPAYERNOTE	http://xcaliber-fhir/structureDefinition/patient-payer-note
PROCEDURECHARGEAMOUNT	http://xcaliber-fhir/structureDefinition/procedure-charge-amount
ALLOWABLEAMOUNT	http://xcaliber-fhir/structureDefinition/allowable-amount
ALLOWABLEMAX	http://xcaliber-fhir/structureDefinition/allowable-max
ALLOWABLEMIN	http://xcaliber-fhir/structureDefinition/allowable-min
PROCEDURETRANSACTIONID	http://xcaliber-fhir/structureDefinition/procedure-transaction-id
DELETEDDIAGNOSIS	http://xcaliber-fhir/structureDefinition/deleted-diagnosis
PRIMARYINSURANCEPACKAGEID	http://xcaliber-fhir/structureDefinition/primary-insurance-package-id
PRIMARYINSURANCESTATUS	http://xcaliber-fhir/structureDefinition/primary-insurance-status
SECONDARYINSURANCEPACKAGEID	http://xcaliber-fhir/structureDefinition/secondary-insurance-package-id
NOTE_STATUS	http://xcaliber-fhir/structureDefinition/claim-note-status
KICK_CODE	http://xcaliber-fhir/structureDefinition/kick-code
KICK_CODE_NAME	http://xcaliber-fhir/structureDefinition/kick-code-name
ATHENA_KICK_CODE_NAME	http://xcaliber-fhir/structureDefinition/athena-kick-code-name
PENDING_FLAG	http://xcaliber-fhir/structureDefinition/pending-flag
GLOBAL_CLAIM_RULE_NAME	http://xcaliber-fhir/structureDefinition/global-claim-rule-name
CLAIM_NOTE	http://xcaliber-fhir/structureDefinition/claim-note
FIX_TEXT	http://xcaliber-fhir/structureDefinition/fix-text

Claim

Overview

Use Cases:

EHR Data Model

Object Definition

Data Fields

Extensions

Operations & APIs

Claim-GET

Claim-POST

Claim ID-GET

Claim ID-PUT

Claim ID-DELETE

Claim Export-POST