Claim

Claim Resource

This HL7 FHIR-compliant resource endpoint providing a provider-issued list of professional services and products which have been provided, or are to be provided, to a patient which is sent to an insurer for reimbursement.

The Claim service is used by providers, payers, and insurers to exchange financial information and supporting clinical information regarding the provision of health care services. This service is also used for sending reports to regulatory bodies and firms which provide data analytics. The primary use of this resource is to support eClaims, a system that facilitates the exchange of relevant information from patients to their benefit payers, insurers, and national health programs, for treatment payment planning and reimbursement. Dispense recordings are submitted through Claims.

Supported HL7-v2 Interactions

"contentType": "x-application/hl7-v2+er7"

PharmaNet Interaction	Version	Hl7-v2 Request	Required System Scope
Adjudicate a Dispense Claim	PNet-R70.5	TACTDU_01_REQUEST	system/Claim.write
Adjudicate a Dispense Claim Reversal	PNet-R70.5	TACTDU_11_REQUEST	system/Claim.write
Adjudicate a Dispense Claim TAC/TDU/TRP	PNet-R70.5	TACTDUTRP_01_REQUEST	system/Claim.write
Adjudicate a Dispense Claim TAC/TDU/TRR	PNet-R70.5	TACTDUTRR_01_REQUEST	system/Claim.write
Adjudicate a Dispense Claim TAC/TDU/TRS	PNet-R70.5	TACTDUTRS_01_REQUEST	system/Claim.write
Accumulated Totals Request	PNet-R70.5	TDT_30_REQUEST	system/Claim.read
Claim Details	PNet-R70.5	TDT_31_REQUEST	system/Claim.read
Same-Day Reversals	PNet-R70.5	TDT_32_REQUEST	system.Claim.read
Prior Days Reversals	PNet-R70.5	TDT_33_REQUEST	system.Claim.read

Example TDT Message

TDT_30_REQUEST-666784

• Transaction: TDT_30_REQUEST
• Source: PNET R70

TBD

Comments:

1. userID - must be replaced with the actual authenticated ID of an individual user