About FHIR Claim Response
The Claim Response resource is an important part of the FHIR Financial module. As explained above, the ClaimResponse is literally the response for the processing and the submission of claims (“FHIR,” 2017). The FHIR Financial set, in general, covers numerous financial services and resources, including ClaimResponse. Note that FHIR defines a Resource as any medical data that can be exchanged online. The FHIR Financial feature deals with eligibility, authorizations, and claims, which aims to help providers, insurers, and patients collaborate effectively. Also, let’s not forget that in a world where data has become a paramount factor in business decision making and marketing solutions, the FHIR Financial module can be used for data analytics.
Documentation
FHIR Specimen: Usage
The ClaimResponse resource is an important part of the FHIR Financial module. As explained above, the ClaimResponse is literally the response for the processing and submission of claims (“FHIR,” 2017).
The FHIR Financial set, in general, covers numerous financial services and resources, including ClaimResponse. Note that FHIR defines a Resource as any medical data that can be exchanged online. The FHIR Financial feature deals with eligibility, authorizations, and claims, which aims to help providers, insurers, and patients collaborate effectively. Also, let’s not forget that in a world where data has become a paramount factor in business decision-making and marketing solutions, the FHIR Financial module can be used for data analytics.
FHIR ClaimResponse & Interoperability
As the ClaimResponse module provides information regarding the response to Claims, it’s one of the crucial FHIR resources that support interoperability and data exchange. Since FHIR (or Fast Healthcare Interoperability Resources) is an open-source standard that supports healthcare technology and app development, vital medical data is available at all times and at no cost. Data integration and management of medical information are essential in research and practice. Simply because data exchange and interoperability can help programmers, practitioners, stakeholders, and insurers work together with the sole purpose to improve medical practices.
The FHIR ClaimResponse resource module makes financial data exchange fast, structured, and transparent. From patients to payors, all parties involved in research and care will have access to financial data and the adjudication details from the processing and the statuses of a Claim.
FHIR ClaimResponse: The Adjudication Process Explained
Medical expenditures often become a burden to providers and patients. Therefore, medical plans and insurers are needed to cover medical bills. Usually, medical services and procedures generate medical bills. Consequently, when reimbursement or other types of payment, such as direct payment, are requested, medical bills are submitted to insurers by healthcare providers. This is how bills become claims. In other words, medical claims contain vital information about services, diagnostics, and costs (Tyree et al., 2006). The insurance companies are responsible for processing the claim. They decide to pay in full or reduce the amount paid to the healthcare provider. They can deny the claim too (“Claims Processing: What is Claims Adjudication?” 2017).
In practice, different claim statuses exist, and there are a few statuses regarding the finalized options for medical requests. Claims can be denied – when the claim has failed the adjudication process, paid – when the claim has been finalized, checks printed, and payment completed, or reversed – when errors have been found in a paid claim and changes are required (“Claim Status Definitions,” 2017). The ClaimResponse resource provides information about all those aspects: the response for the submission of a Claim, Re-adjudication, and Reversal. Note that claims submitted electronically can reduce errors and speed up the payment process.
FHIR ClaimResponse: Search Options
As FHIR is an open protocol, it provides coded and structured data along with narratives for human use. The FHIR ClaimResponse allows many search options, such as general parameters: about the patient, the date of submission, the service provided, the adjudication details, the insurance organization, the processing errors, the medical plan, the total cost, and much more. Let’s say that you need more details about a patient’s oral treatment. The ClaimResponse.addItem.modifier can show you the modifiers codes (in this case, for Oral care) and whether the treatment is cosmetic or linked to temporomandibular disorder (TMD), for example.
In addition, the FHIR protocol combines granular information with the healthcare process as a whole. For instance, the ExplanationOfBenefit resource can answer the need for a bigger medical picture and provide combined information about the Claim details, the ClaimResponse adjudication process, and the account balance information. To sum up, the FHIR ClaimResponse is a vital resource in FHIR and a needed reform in healthcare and insurance practices.
Glossary
Adjudication – Medical services generate bills. When reimbursement is requested, bills are submitted to insurance providers and become claims. As a result, the insurance company is responsible for processing the claim and paying in full, denying the claim, or reducing the amount paid to the healthcare provider. This process is known as claims adjudication.
Claim – Medical claims can be defined as medical bills submitted to insurance providers by healthcare providers.
Pre-authorization – It’s the step when services are proposed, and funds are desired.
Pre-determination – Pre-determination refers to the process of determining what services can be covered and to what extent. It’s also known as the “what if claim.”
TMD – Temporomandibular disorders (TMD) is a term used to describe issues and pain related to jaw movement. Note that the temporomandibular (TM) joints (or jaw joints) connect the jawbone to the skull and are used for talking, chewing, yawning, etc. TMD can be caused by an injury, diseases, such as osteoarthritis, or other abnormalities.
References
- Claims Processing: What is Claims Adjudication? (January 19, 2017). Retrieved from http://www.apexedi.com/what-is-claims-adjudication/
- Claim Status Definitions (July 1, 2017). Retrieved from https://www.securityhealth.org/provider-manual/shared-content/claims-processing-policies-and-procedures/claim-status-definitions
- FHIR (April 19, 2017). Retrieved from https://www.hl7.org/fhir/diagnosticreport.html
- Tyree, P., Lind, B., & Lafferty, W. (2006). Challenges of Using Medical Insurance Claims Data for Utilization Analysis. American Journal of Medical Quality.
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