The ProfessionalClaim is one of a suite of similar resources (OralClaim, VisionClaim, PharmacyClaim, ProfessionalClaim, InstitutionalClaim) which are used by providers to exchange the financial information, and supporting clinical information, regarding the provision of healthcare goods and services. The primary uses of this resource is to support eClaims, the exchange of proposed or supplied products and services to benefit payors, insurers and national health programs, for treatment payment planning and reimbursement. The primary use is for OutPatient Care billing by providers such as: Medical, Chiropractors, Physiotherapists, Rehab Therapists and other Health care providers both licensed and unlicensed.
The Claim is intended to support:
Claims, and the variants of Pre-Determinations and Pre-Authorizations, are the means through which Providers submit patient rendered services to the Patient's insurers for reimbursement. The reimbursement may or may not be assigned to the Provider. There are generally agreed types of claims based on the class of health discipline and adjudication engines are often segmented along these same lines of: OralHealth, Vision, Pharmacy, Professional (Medical and Chiro,Physio, Rehab - typically outpatient care) and Institutional (Hospital, clinic, etc).
This is a key resource expected by most Healthcare billing implementations where Health care is provided.
Existing normative V3 and V2 specifications, Canadian Specifications, X12
Refers to Patient, Practitioner, Organization, Coverage, Referral, ClaimResponse. Is referred to by ClaimResponse, ReconciliationResponse, Reversal, Readjudication, PaymentNotice, StatusRequest, FinancialAttachment, InformationCheck, ExplanationOfBenefit and occasionally by a Claim resource.
Ready for DSTU 2