FHIR R4 Claim Library

Overview

This asset is a component of MuleSoft Accelerator for Healthcare.

MuleSoft Accelerator for Healthcare enables healthcare providers to unlock critical patient data to build a patient 360 within Salesforce Health Cloud, faster and easier than ever before. The solution includes pre-built APIs, connectors, integration templates, and prescriptive end-to-end reference architecture to bring patient demographics information and COVID-19 test results from any EHR into Health Cloud using HL7 V2 or FHIR standards.

The solution also provides a library of United States Core Data for Interoperability (USCDI) and FHIR R4 resources to help healthcare developers adhere to interoperability needs and jumpstart the development of healthcare digital transformation initiatives.

Use case covered

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 uses 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 is a "request" resource from a FHIR workflow perspective - see Workflow Request.

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.

Mapping to other Claim specifications: Mappings are currently maintained by the Financial Management Work Group to UB04 and CMS1500 and are available at https://confluence.hl7.org/display/FM/FHIR+Resource+Development . Mappings to other specifications may be made available where IP restrictions permit.

This library is used by FHIR R4 Claim API.

More information about FHIR R4 Claim specification can be found here.