Implementation Guide
23.1.0 - R4 APIs

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Logical Model: Profile - Athena Custom Claim

Official URL: https://docs.mydata.athenahealth.com/fhir-r4/StructureDefinition/athena-claim-profile Version: 23.1.0
Active as of 2023-03-01 Computable Name: Claim

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.


This custom Claim is part of the set of resource profiles supported by the API Server used with the athenaPractice 23.0.0. This is not a FHIR Conformant Resource. It further describes read and search capabilities of these products.
Note: Create and Update operations are NOT supported for this resource.

Overview

A financial tool for tracking value accrued for a particular purpose. In the healthcare field, used to track Claim for a patient, cost centers, etc

Scope and Usage

This profile is used to define the content that will be returned by the API Server in response to requests to access Claim resources. All elements listed in the differential profile view are Supported, which means that the API Server is capable of supplying these fields from the product database when they have been populated via the product or its APIs.

Source

The Claim resource is used to track charges for a patient, cost centers, Claim filing method etc. It is derived from PatientVisit, Guarantor, PatientProfile, DoctorFacility tables in athenaPractice.

Example

Example for the athena-claim-profile Profile.

Claim Example

Usage:

  • This Logical Model Profile is not used by any profiles in this Implementation Guide

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from Base

NameFlagsCard.TypeDescription & Constraintsdoco
.. athena-claim-profile 0..* Base Instances of this logical model are not marked to be the target of a Reference
... id SΣ 1..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... pid Σ 1..1 integer PID is internal numeric value used in the Chart module and clinical data. This will be the same as the resource id in the Patient resource.
.... reference 0..1 string Reference to the Patient
.... display 0..1 string Patient name
... patientProfileId SΣ 1..1 unsignedInt Patient specific id for practice management data including financial information
... batchNumber 0..1 unsignedInt Batch containing this claim
... charges 0..1 Money The sum of the charges to be claimed.
.... value 0..1 decimal Amount of money
.... currency 0..1 code Currency
... filingMethod 0..1 string The ID of the filing method for ths electronic athena-claim-profile. This column should be linked to the MedLists table MedListsId column with a TableName of FilingMethods.
... claimFileId 0..1 unsignedInt The ID of the EDICLaim.
... fileName 0..1 string EDI Claim file name
... fileCreated 0..1 dateTime Date that claim file was created.
... filedBy 0..1 string Person name who filed claim
... fileTransmitted 0..1 string Claim file transmission date
... submissionNumber 0..1 integer Electronic claim submission Number
... transmissionStatus 0..1 string The transmission status of this electronic claim file (i.e. 'Ready To Transmit', 'Transmission Failed', 'Transmitted')
... failureReason 0..1 string A description of the reason for the unsuccessful transmission of this electronic claim (applies only to files with TransmissionStatus = 'Transmission Failed'))
... claimData 0..1 string The actual contents of this electronic claim file.
... lineDelimiter 0..1 string The line delimiter used when this electronic claim file was created by the plug-in.
... fieldDelimiter 0..1 string The field delimiter used when this electronic claim file was created by the plug-in.
... recordDelimiter 0..1 string The record delimiter used when this electronic claim file was created by the plug-in.
... lineLength 0..1 string The maximum line length allowed when this electronic claim file was created by the plug-in.
... recordLength 0..1 string The maximum record length allowed when this electronic claim file was created by the plug-in.
... clearinghouseName 0..1 string Clearinghouse for the electronic claim file.
... insuranceCarrier 0..1 Reference(Organization) Insurance carrier for the electronic claim.
.... reference 0..1 string Insurance Carrier Id refering to Organization
.... display 0..1 string Insurance carrier Name

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. athena-claim-profile 0..* Base Instances of this logical model are not marked to be the target of a Reference
... id SΣ 1..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... pid Σ 1..1 integer PID is internal numeric value used in the Chart module and clinical data. This will be the same as the resource id in the Patient resource.
.... reference ΣC 0..1 string Reference to the Patient
.... display Σ 0..1 string Patient name
... patientProfileId SΣ 1..1 unsignedInt Patient specific id for practice management data including financial information
... batchNumber 0..1 unsignedInt Batch containing this claim
... charges 0..1 Money The sum of the charges to be claimed.
.... value Σ 0..1 decimal Amount of money
.... currency Σ 0..1 code Currency
Binding: Currencies (required): A code indicating the currency, taken from ISO 4217.

... filingMethod 0..1 string The ID of the filing method for ths electronic athena-claim-profile. This column should be linked to the MedLists table MedListsId column with a TableName of FilingMethods.
... claimFileId 0..1 unsignedInt The ID of the EDICLaim.
... fileName 0..1 string EDI Claim file name
... fileCreated 0..1 dateTime Date that claim file was created.
... filedBy 0..1 string Person name who filed claim
... fileTransmitted 0..1 string Claim file transmission date
... submissionNumber 0..1 integer Electronic claim submission Number
... transmissionStatus 0..1 string The transmission status of this electronic claim file (i.e. 'Ready To Transmit', 'Transmission Failed', 'Transmitted')
... failureReason 0..1 string A description of the reason for the unsuccessful transmission of this electronic claim (applies only to files with TransmissionStatus = 'Transmission Failed'))
... claimData 0..1 string The actual contents of this electronic claim file.
... lineDelimiter 0..1 string The line delimiter used when this electronic claim file was created by the plug-in.
... fieldDelimiter 0..1 string The field delimiter used when this electronic claim file was created by the plug-in.
... recordDelimiter 0..1 string The record delimiter used when this electronic claim file was created by the plug-in.
... lineLength 0..1 string The maximum line length allowed when this electronic claim file was created by the plug-in.
... recordLength 0..1 string The maximum record length allowed when this electronic claim file was created by the plug-in.
... clearinghouseName 0..1 string Clearinghouse for the electronic claim file.
... insuranceCarrier C 0..1 Reference(Organization) Insurance carrier for the electronic claim.
ref-1: SHALL have a contained resource if a local reference is provided
.... reference ΣC 0..1 string Insurance Carrier Id refering to Organization
.... display Σ 0..1 string Insurance carrier Name

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
athena-claim-profile.charges.currencyrequiredCurrencies (a valid code from urn:iso:std:iso:4217)
http://hl7.org/fhir/ValueSet/currencies|4.0.1
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
ref-1errorathena-claim-profile.patient, athena-claim-profile.insuranceCarrierSHALL have a contained resource if a local reference is provided
: reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
NameFlagsCard.TypeDescription & Constraintsdoco
.. athena-claim-profile 0..* Base Instances of this logical model are not marked to be the target of a Reference
... id SΣ 1..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... pid Σ 1..1 integer PID is internal numeric value used in the Chart module and clinical data. This will be the same as the resource id in the Patient resource.
.... @id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 0..1 string Reference to the Patient
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Patient name
... patientProfileId SΣ 1..1 unsignedInt Patient specific id for practice management data including financial information
... batchNumber 0..1 unsignedInt Batch containing this claim
... charges 0..1 Money The sum of the charges to be claimed.
.... @id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... value Σ 0..1 decimal Amount of money
.... currency Σ 0..1 code Currency
Binding: Currencies (required): A code indicating the currency, taken from ISO 4217.

... filingMethod 0..1 string The ID of the filing method for ths electronic athena-claim-profile. This column should be linked to the MedLists table MedListsId column with a TableName of FilingMethods.
... claimFileId 0..1 unsignedInt The ID of the EDICLaim.
... fileName 0..1 string EDI Claim file name
... fileCreated 0..1 dateTime Date that claim file was created.
... filedBy 0..1 string Person name who filed claim
... fileTransmitted 0..1 string Claim file transmission date
... submissionNumber 0..1 integer Electronic claim submission Number
... transmissionStatus 0..1 string The transmission status of this electronic claim file (i.e. 'Ready To Transmit', 'Transmission Failed', 'Transmitted')
... failureReason 0..1 string A description of the reason for the unsuccessful transmission of this electronic claim (applies only to files with TransmissionStatus = 'Transmission Failed'))
... claimData 0..1 string The actual contents of this electronic claim file.
... lineDelimiter 0..1 string The line delimiter used when this electronic claim file was created by the plug-in.
... fieldDelimiter 0..1 string The field delimiter used when this electronic claim file was created by the plug-in.
... recordDelimiter 0..1 string The record delimiter used when this electronic claim file was created by the plug-in.
... lineLength 0..1 string The maximum line length allowed when this electronic claim file was created by the plug-in.
... recordLength 0..1 string The maximum record length allowed when this electronic claim file was created by the plug-in.
... clearinghouseName 0..1 string Clearinghouse for the electronic claim file.
... insuranceCarrier C 0..1 Reference(Organization) Insurance carrier for the electronic claim.
ref-1: SHALL have a contained resource if a local reference is provided
.... @id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 0..1 string Insurance Carrier Id refering to Organization
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Insurance carrier Name

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
athena-claim-profile.patient.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
athena-claim-profile.charges.currencyrequiredCurrencies (a valid code from urn:iso:std:iso:4217)
http://hl7.org/fhir/ValueSet/currencies|4.0.1
from the FHIR Standard
athena-claim-profile.insuranceCarrier.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
ref-1errorathena-claim-profile.patient, athena-claim-profile.insuranceCarrierSHALL have a contained resource if a local reference is provided
: reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

This structure is derived from Base

Summary

Mandatory: 0 element(4 nested mandatory elements)
Must-Support: 2 elements

Differential View

This structure is derived from Base

NameFlagsCard.TypeDescription & Constraintsdoco
.. athena-claim-profile 0..* Base Instances of this logical model are not marked to be the target of a Reference
... id SΣ 1..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... pid Σ 1..1 integer PID is internal numeric value used in the Chart module and clinical data. This will be the same as the resource id in the Patient resource.
.... reference 0..1 string Reference to the Patient
.... display 0..1 string Patient name
... patientProfileId SΣ 1..1 unsignedInt Patient specific id for practice management data including financial information
... batchNumber 0..1 unsignedInt Batch containing this claim
... charges 0..1 Money The sum of the charges to be claimed.
.... value 0..1 decimal Amount of money
.... currency 0..1 code Currency
... filingMethod 0..1 string The ID of the filing method for ths electronic athena-claim-profile. This column should be linked to the MedLists table MedListsId column with a TableName of FilingMethods.
... claimFileId 0..1 unsignedInt The ID of the EDICLaim.
... fileName 0..1 string EDI Claim file name
... fileCreated 0..1 dateTime Date that claim file was created.
... filedBy 0..1 string Person name who filed claim
... fileTransmitted 0..1 string Claim file transmission date
... submissionNumber 0..1 integer Electronic claim submission Number
... transmissionStatus 0..1 string The transmission status of this electronic claim file (i.e. 'Ready To Transmit', 'Transmission Failed', 'Transmitted')
... failureReason 0..1 string A description of the reason for the unsuccessful transmission of this electronic claim (applies only to files with TransmissionStatus = 'Transmission Failed'))
... claimData 0..1 string The actual contents of this electronic claim file.
... lineDelimiter 0..1 string The line delimiter used when this electronic claim file was created by the plug-in.
... fieldDelimiter 0..1 string The field delimiter used when this electronic claim file was created by the plug-in.
... recordDelimiter 0..1 string The record delimiter used when this electronic claim file was created by the plug-in.
... lineLength 0..1 string The maximum line length allowed when this electronic claim file was created by the plug-in.
... recordLength 0..1 string The maximum record length allowed when this electronic claim file was created by the plug-in.
... clearinghouseName 0..1 string Clearinghouse for the electronic claim file.
... insuranceCarrier 0..1 Reference(Organization) Insurance carrier for the electronic claim.
.... reference 0..1 string Insurance Carrier Id refering to Organization
.... display 0..1 string Insurance carrier Name

doco Documentation for this format

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. athena-claim-profile 0..* Base Instances of this logical model are not marked to be the target of a Reference
... id SΣ 1..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... pid Σ 1..1 integer PID is internal numeric value used in the Chart module and clinical data. This will be the same as the resource id in the Patient resource.
.... reference ΣC 0..1 string Reference to the Patient
.... display Σ 0..1 string Patient name
... patientProfileId SΣ 1..1 unsignedInt Patient specific id for practice management data including financial information
... batchNumber 0..1 unsignedInt Batch containing this claim
... charges 0..1 Money The sum of the charges to be claimed.
.... value Σ 0..1 decimal Amount of money
.... currency Σ 0..1 code Currency
Binding: Currencies (required): A code indicating the currency, taken from ISO 4217.

... filingMethod 0..1 string The ID of the filing method for ths electronic athena-claim-profile. This column should be linked to the MedLists table MedListsId column with a TableName of FilingMethods.
... claimFileId 0..1 unsignedInt The ID of the EDICLaim.
... fileName 0..1 string EDI Claim file name
... fileCreated 0..1 dateTime Date that claim file was created.
... filedBy 0..1 string Person name who filed claim
... fileTransmitted 0..1 string Claim file transmission date
... submissionNumber 0..1 integer Electronic claim submission Number
... transmissionStatus 0..1 string The transmission status of this electronic claim file (i.e. 'Ready To Transmit', 'Transmission Failed', 'Transmitted')
... failureReason 0..1 string A description of the reason for the unsuccessful transmission of this electronic claim (applies only to files with TransmissionStatus = 'Transmission Failed'))
... claimData 0..1 string The actual contents of this electronic claim file.
... lineDelimiter 0..1 string The line delimiter used when this electronic claim file was created by the plug-in.
... fieldDelimiter 0..1 string The field delimiter used when this electronic claim file was created by the plug-in.
... recordDelimiter 0..1 string The record delimiter used when this electronic claim file was created by the plug-in.
... lineLength 0..1 string The maximum line length allowed when this electronic claim file was created by the plug-in.
... recordLength 0..1 string The maximum record length allowed when this electronic claim file was created by the plug-in.
... clearinghouseName 0..1 string Clearinghouse for the electronic claim file.
... insuranceCarrier C 0..1 Reference(Organization) Insurance carrier for the electronic claim.
ref-1: SHALL have a contained resource if a local reference is provided
.... reference ΣC 0..1 string Insurance Carrier Id refering to Organization
.... display Σ 0..1 string Insurance carrier Name

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
athena-claim-profile.charges.currencyrequiredCurrencies (a valid code from urn:iso:std:iso:4217)
http://hl7.org/fhir/ValueSet/currencies|4.0.1
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
ref-1errorathena-claim-profile.patient, athena-claim-profile.insuranceCarrierSHALL have a contained resource if a local reference is provided
: reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. athena-claim-profile 0..* Base Instances of this logical model are not marked to be the target of a Reference
... id SΣ 1..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... pid Σ 1..1 integer PID is internal numeric value used in the Chart module and clinical data. This will be the same as the resource id in the Patient resource.
.... @id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 0..1 string Reference to the Patient
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Patient name
... patientProfileId SΣ 1..1 unsignedInt Patient specific id for practice management data including financial information
... batchNumber 0..1 unsignedInt Batch containing this claim
... charges 0..1 Money The sum of the charges to be claimed.
.... @id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... value Σ 0..1 decimal Amount of money
.... currency Σ 0..1 code Currency
Binding: Currencies (required): A code indicating the currency, taken from ISO 4217.

... filingMethod 0..1 string The ID of the filing method for ths electronic athena-claim-profile. This column should be linked to the MedLists table MedListsId column with a TableName of FilingMethods.
... claimFileId 0..1 unsignedInt The ID of the EDICLaim.
... fileName 0..1 string EDI Claim file name
... fileCreated 0..1 dateTime Date that claim file was created.
... filedBy 0..1 string Person name who filed claim
... fileTransmitted 0..1 string Claim file transmission date
... submissionNumber 0..1 integer Electronic claim submission Number
... transmissionStatus 0..1 string The transmission status of this electronic claim file (i.e. 'Ready To Transmit', 'Transmission Failed', 'Transmitted')
... failureReason 0..1 string A description of the reason for the unsuccessful transmission of this electronic claim (applies only to files with TransmissionStatus = 'Transmission Failed'))
... claimData 0..1 string The actual contents of this electronic claim file.
... lineDelimiter 0..1 string The line delimiter used when this electronic claim file was created by the plug-in.
... fieldDelimiter 0..1 string The field delimiter used when this electronic claim file was created by the plug-in.
... recordDelimiter 0..1 string The record delimiter used when this electronic claim file was created by the plug-in.
... lineLength 0..1 string The maximum line length allowed when this electronic claim file was created by the plug-in.
... recordLength 0..1 string The maximum record length allowed when this electronic claim file was created by the plug-in.
... clearinghouseName 0..1 string Clearinghouse for the electronic claim file.
... insuranceCarrier C 0..1 Reference(Organization) Insurance carrier for the electronic claim.
ref-1: SHALL have a contained resource if a local reference is provided
.... @id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 0..1 string Insurance Carrier Id refering to Organization
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Insurance carrier Name

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
athena-claim-profile.patient.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
athena-claim-profile.charges.currencyrequiredCurrencies (a valid code from urn:iso:std:iso:4217)
http://hl7.org/fhir/ValueSet/currencies|4.0.1
from the FHIR Standard
athena-claim-profile.insuranceCarrier.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
ref-1errorathena-claim-profile.patient, athena-claim-profile.insuranceCarrierSHALL have a contained resource if a local reference is provided
: reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

This structure is derived from Base

Summary

Mandatory: 0 element(4 nested mandatory elements)
Must-Support: 2 elements

 

Other representations of profile: CSV, Excel

Notes:

Supported Interactions

The Interactions supported by this resource are listed below.

Search Parameters

Search parameters are executed as specified in the HL7 FHIR RESTful API implementation definition. To search for Account resources, an application shall perform an HTTP GET, specifying the query parameters associated with the resource.

GET [base]/customresource/Claim?{search-parameters}

Where:

Name Description
[base] Specifies the base URL of the FHIR Server, e.g., https://ap22sandbox.athenahealth.com/demoAPIServer
_id (token) The ID of the resource
patientProfileId known id of the patient.
patient (reference) Who the sensitivity is for
[_include] Specifies the supported hl7 resources include which are defined as reference in examples. Note: The Patient and Organization resources are supported via the _include parameter.
HTTP Response Codes

The following HTTP response codes are returned by this API call:

200 OK The query was performed and any results found are contained within the body of the HTTP response. Note: The search API will return 200 OK when the query itself is successful, regardless of whether or not any matching results were found.
401 Unauthorized Authorization is required for this request, and either the Authorization header is missing or the supplied user credentials in the Authorization header are not valid or have expired. The body of the HTTP response will contain an OperationOutcome resource that indicates that Authorization is required.
500 Server Error The server may return other error codes to indicate other error conditions. The body of the HTTP response will contain an OperationOutcome resource that indicates the nature of the error.