ProfessionalClaim FHIR Resource Proposal

ProfessionalClaim

Owning committee name

Financial Management

Contributing or Reviewing Work Groups

• Claims with Attachments
• Patient Administration

FHIR Resource Development Project Insight ID

994

Scope of coverage

The ProfessionalClaim is one of a suite of similar resources (OralClaim, VisionClaim, PharmacyClaim, ProfessionalClaim, InstitutionalClaim) which are used by providers to exchange the financial information, and supporting clinical information, regarding the provision of healthcare goods and services. The primary uses of this resource is to support eClaims, the exchange of proposed or supplied products and services to benefit payors, insurers and national health programs, for treatment payment planning and reimbursement. The primary use is for OutPatient Care billing by providers such as: Medical, Chiropractors, Physiotherapists, Rehab Therapists and other Health care providers both licensed and unlicensed.

The Claim is intended to support:

Claims - where the provision of goods and services is complete and reimbursement is sought.

Pre-Authorization - where the provision of goods and services is proposed and either authorization and/or the reservation of funds is desired.

Pre-Determination - where the provision of goods and services is explored to determine what services may be covered and to what amount. Essentially a 'what if' claim.

RIM scope

PaymentRequest (classCode=XACT,moodCode=PRP,RQO)

Resource appropriateness

Claims, and the variants of Pre-Determinations and Pre-Authorizations, are the means through which Providers submit patient rendered services to the Patient's insurers for reimbursement. The reimbursement may or may not be assigned to the Provider. There are generally agreed types of claims based on the class of health discipline and adjudication engines are often segmented along these same lines of: OralHealth, Vision, Pharmacy, Professional (Medical and Chiro,Physio, Rehab - typically outpatient care) and Institutional (Hospital, clinic, etc).

Expected implementations

This is a key resource expected by most Healthcare billing implementations where Oral Health care is provided.

Content sources

Existing normative V3 and V2 specifications, Canadian Specifications, X12

Resource Relationships

Refers to Patient, Practitioner, Organization, Coverage, Referral, ClaimResponse. Is referred to by ClaimResponse, ReconciliationResponse, Reversal, Readjudication, PaymentNotice, StatusRequest, FinancialAttachment, InformationCheck, ExplanationOfBenefit and occasionally by a Claim resource.

Timelines

Ready for DSTU 2

gForge Users

paulknapp