The Claim is used by providers and payors, insurers, to exchange the financial information, and supporting clinical information, regarding the provision of health care services with payors and for reporting to regulatory bodies and firms which provide data analytics. The primary use of this resource is to support eClaims, the exchange of information relating to the proposed or actual provision of healthcare-related goods and services for patients to their benefit payors, insurers and national health programs, for treatment payment planning and reimbursement.
The Claim resource may be interpreted differently depending on its intended use (and the Claim.use element contains the code to indicate):
– claim – where the provision of goods and services is complete and adjudication under a plan and payment is sought.
– preauthorization – where the provision of goods and services is proposed and authorization and/or the reservation of funds is desired.
– predetermination – 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.
The Claim also supports:
– Up to a 3-tier hierarchy of Goods, products, and Services, to support simple to complex billing.
– Multiple insurance programs arranged in a Coordination of Benefit sequence to enable exchange with primary, secondary, tertiary etc. insurance coverages.
– Assignment of benefit – the benefit may be requested to be directed to the subscriber, the provider or another party.
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.