The FHIR Claim resource is an essential part of the FHIR Financial module and its Billing set. The Claim can be used by providers and insurers to exchange financial information about the availability and provision of medical services. To be more precise, the FHIR Claim module is defined as “an issued list of services and products provided, or to be provided, to a patient by healthcare providers. The list is then given to an insurer for payment recovery.” (“FHIR”, 2017). Thus, the FHIR Claim resource makes financial data exchange fast, available, clear, and transparent. Note that the Claim resource can be used to obtain and share data analytics.
FHIR Claim can be accessed by stakeholders, providers, insurers, and practitioners. The primary use of it is to support electronic claims by sharing information about the actual medical services and payment planning. With the powerful digital reformation of medicine, eClaims have replaced paper forms. Electronic claims give experts the chance to process and track claims online. What’s more, electronic forms have lower rejection rates and guarantee quicker reimbursements.
As a matter of fact, there are three specific aspects the FHIR Claim module can be used for. First, it can be applied to actual Claims, which is a process that happens after all services have been completed and payments requested. Then, the FHIR Claim can be used for Pre-authorization – or when services are proposed, and funds are desired. Finally, the Claim can be useful for Pre-determination – when it’s about to be determined what services can be covered and to what extent (pre-determination can be described as a “what if claim”) (“FHIR,” 2017).
Although the primary use of the FHIR Claim set is to share billing information to request reimbursement, the Claim can be used to export and integrate data and support data analytics. Depending on the discipline or the type of claim, institutions, pharmaceutical companies, and providers can gain valuable insights from medical services, provider’ claims, and insurance plans. In fact, health insurance administrative data is paramount in research of health utilization and expenditures. Claims show higher congruence with medical records data when compared to traditional surveys (Tyree et al., 2006). Of course, financial information is among the most sensitive health contents, so safety is also a crucial aspect. Not surprisingly, safety and confidentiality have been integrated into the FHIR Security and Privacy module.Since Fast Healthcare Interoperability Resources (FHIR) is an open-source standard that supports healthcare technology, app development, and interoperability, experts can access the FHIR Claim resource at all times and no cost.
The integration, exchange, and management of medical data are crucial in research and healthcare practices. In fact, interoperability is the fundamental link that connects programmers, practitioners, stakeholders, institutions, and patients. Although medical data exchange is often associated with diagnoses, biomarkers, scans, and medical reports, financial information is vital. Thus – while FHIR with its resources and application programming interface does help experts exchange medical information and electronic records – FHIR has optimized another essential module: the FHIR Financial module.
Since clinical trials, digital recruitment, medical services, and healthcare monitoring may become a burden on medical expenditure – the financial aspect of medicine is paramount. Medicine advancement goes hand in hand with business interests, and medical expenditures become an inseparable part of treatment and care. Therefore – by supporting exchange, management, and integration of sensitive financial information – FHIR provides practical solutions for families, insurers, and providers. In general, the FHIR Financial module covers various financial resources and services, including Claims. It supports aspects, such as financial transactions and billing operations within providers. It also deals with eligibility, authorizations, and claims among providers, insurers, subscribers, and patients. Also, the FHIR Financial module can be used for data analytics.
As explained above, claims are essential in practice and research. Claims may record information about diagnostics, treatments, and costs (Tyree et al., 2006). In general, medical claims are defined as medical bills submitted to insurance providers by healthcare professionals. These services refer to all medical procedures patients have obtained. As stated above, treatment and care generate bills. Consequently, when reimbursement or other types of payment (direct payment, for example) are requested, medical bills become claims. Issued claims are sent to patients’ health insurance provider for payment. Thus, from patients to payors – all parties can benefit from the FHIR Claim module. Instead of going through piles of documents and outdated lists of information, experts will have access to granular medical information and will be able to access the specific financial resource (piece of information) they need.The FHIR Claim is vital in research and practice. As mentioned above, the FHIR Claim includes sensitive data, such as insurance details, enrollment, reports, and payment. There’s also supporting information, such as scanned documents, images, and other FHIR resources, which is included in the Claim. In fact, the FHIR Claim Response is another powerful feature as it shows the adjudication details of processing a financial claim (“FHIR,” 2017).
Although the process may seem complicated, the structure of FHIR Claim is clear. Structured data and short narratives support human use. There are various search options integrated into the Claim. One can request information about claim numbers, responsible providers, funds requested to be reserved, case references, original prescriptions, billing provider, diagnosis, medical procedures, insurance, medical plan, hospitalization, total cost, count of products and services, and much more. For instance, the feature Priority shows the Processing of priority requested.
In a nutshell, the Claim is a valuable resource in the FHIR protocol. As the financial aspect of medicine is crucial, the FHIR can help providers, insurers, and patients work together to show that money can’t buy health.Health insurance – Any program that helps patients cover their medical expenses. In the US, insurance can be private, social or funded by the government. For instance, Medicare is one of the popular national social insurance plans funded by the government.
Healthcare providers – People and institutions that provide medical services.
Medical bills – Billing is a common payment practice. Medical services generate bills, and healthcare providers collaborate with insurance companies in order to receive reimbursements and payments for the services provided.
Open-source standard – Open standards are available to the public and facilitate interoperability of products, providers, and services.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.