Suitable Claim Resource

#1

Hi!
I’m working on mapping Claim FHIR resource in my database and I am little doubtful about what resource will best suite my needs. The options being ExplanationOfBenefits, Claim and ClaimResponse

I want a resource that provides all information related to providers, diagnosis, procedures, amounts ,claimlines etc.
Should I use ExplanationOfBenefits or both Claim and ClaimResponse?
If I choose ExplanationOfBenefits, then would I have to store Claim and ClaimResponse too as ExplanationOfBenefits has reference to both resources?

Thanks!

#2

Claim represents insurance claims, prior-auth requests and predetermination requests. ClaimResponse represents claim adjudications, prior authorization results and pre-determination results. ExplanationOfBenefits represents a summary of what was covered by a plan. You might well want any or all of these resources.

1 Like
#3

Thanks @lloyd for your quick response. Can you please help me with a few more questions.

  1. I’m mapping claims from a client into my database. A client provides a claim number for each claim which uniquely identifies it. Would it be a right choice to use ExplanationOfBenefits.identifier or could you please suggest an appropriate field for claim number.

  2. As you said ExplanationOfBenefits represents a summary of what was covered by a plan, so does it mean that we’ll have only that information in ExplanationOfBenefits that has been verified and doesn’t contain any error?

#4
  1. That would be the Claim.identifier. The EOB can have a pointer to the claims it’s summarizing.
  2. Right. It’ll be the list of Claims that have been fully (or perhaps partially) processed. It won’t generally contain rejected claims or claims submitted but not yet processed.