The Claim Response resource provides application level adjudication results, or an application level error, which are the result of processing a submitted Claim resource where that Claim may be the functional corollary of a Claim, Predetermination or a Preauthorization.This resource is the only appropriate response to a Claim which a processing system recognizes as a Claim resource.
This dataset details the strength of the payment aspect of the response that is matching to the strength of the original request. For a Claim the adjudication indicates payment which is intended to be made. For Preauthorization no payment will actually be made however funds may be reserved to settle a claim submitted later. For Predetermination, no payment will actually be made and no assurance is given that the adjudication of a claim submitted later will match the adjudication provided, for example, funds may have been exhausted in the interim. Only an actual claim may be expected to result in actual payment.
The Claim Response resource may also be returned with the response for the submission of Re-adjudication and Reversals. The Claim Response resource is an “event” resource from an FHIR workflow perspective.
The Claim Response resource is used to provide the results of the adjudication and/or authorization of a set of healthcare-related products and services for a patient against the patient’s insurance coverages, or to respond with what the adjudication would be for a supplied set of products or services should they be actually supplied to the patient.
The Explanation Of Benefit resource is for reporting out to patients or transferring data to patient centered applications, such as patient health Record (PHR) application, the Explanation O fBenefit should be used instead of the Claim and Claim Response resources as those resources may contain provider and payer specific information which is not appropriate for sharing with the patient.
When using the resources for reporting and transferring claims data, which may have originated in some standard other than FHIR, the Claim resource is useful if only the request side of the information exchange is of interest. If, however, both the request and the adjudication information is to be reported then the Explanation Of Benefit should be used instead.
When responding whether the patient’s coverage is inforce, whether it is valid at this or a specified date, or returning the benefit details or preauthorization requirements associated with a coverage Coverage Eligibility Response should be used instead and be the response to a Coverage Eligibility Request.
Fast Healthcare Interoperability Resources (FHIR) is a draft standard describing data formats and elements (known as “resources”) and an application programming interface (API) for exchanging electronic health records. The standard was created by the Health Level Seven International (HL7) health-care standards organization.
Its goal is to facilitate interoperation between legacy healthcare systems, to make it easy to provide healthcare information to healthcare providers and individuals on a wide variety of devices from computers to tablets to cell phones, and to allow third-party application developers to provide medical applications which can be easily integrated into existing systems.
FHIR provides an alternative to document-centric approaches by directly exposing discrete data elements as services. For example, basic elements of healthcare like patients, admissions, diagnostic reports and medications can each be retrieved and manipulated via their own resource URLs (Uniform Resource Locators). FHIR was supported at an American Medical Informatics Association meeting by many EHR (Electronic Health Record) vendors which value its open and extensible nature.