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Claims

Claims (FHIR Claim) represent healthcare billing requests submitted to insurers for reimbursement. ClinikAPI simplifies the most common claim fields — for advanced scenarios like coordination of benefits or detailed sub-items, use the FHIR passthrough.

Submit a Professional Claim

const { data: claim } = await clinik.claims.create({
  status: 'active',
  type: 'professional',
  use: 'claim',
  patientId: 'pt_abc123',
  providerId: 'Practitioner/prac_dr456',
  priority: 'normal',
  billablePeriod: {
    start: '2024-03-15',
    end: '2024-03-15',
  },
  insurance: [
    { sequence: 1, focal: true, coverageId: 'cov_primary789' },
  ],
  diagnosis: [
    { sequence: 1, code: 'E11.9' },  // Type 2 diabetes
    { sequence: 2, code: 'I10' },     // Essential hypertension
  ],
  item: [
    {
      sequence: 1,
      productOrService: '99214',
      unitPrice: { value: 200.00, currency: 'USD' },
      net: { value: 200.00, currency: 'USD' },
    },
    {
      sequence: 2,
      productOrService: '85025',
      quantity: { value: 1, unit: 'test' },
      unitPrice: { value: 45.00, currency: 'USD' },
      net: { value: 45.00, currency: 'USD' },
    },
  ],
  total: { value: 245.00, currency: 'USD' },
});

Pre-Authorization Request

const { data: preAuth } = await clinik.claims.create({
  status: 'active',
  type: 'professional',
  use: 'preauthorization',
  patientId: 'pt_abc123',
  providerId: 'Practitioner/prac_surgeon456',
  priority: 'normal',
  insurance: [
    { sequence: 1, focal: true, coverageId: 'cov_primary789' },
  ],
  diagnosis: [
    { sequence: 1, code: 'M17.11' },  // Primary osteoarthritis, right knee
  ],
  procedure: [
    { sequence: 1, code: '27447', date: '2024-04-15' },  // Total knee replacement
  ],
  item: [
    {
      sequence: 1,
      productOrService: '27447',
      unitPrice: { value: 35000.00, currency: 'USD' },
      net: { value: 35000.00, currency: 'USD' },
    },
  ],
  total: { value: 35000.00, currency: 'USD' },
  note: 'Conservative treatment failed after 6 months of physical therapy',
});

Search Claims

// All claims for a patient
const { data } = await clinik.claims.search({
  patientId: 'pt_abc123',
});

// Filter by status and use
const { data: activeClaims } = await clinik.claims.search({
  patientId: 'pt_abc123',
  status: 'active',
  use: 'claim',
});

// Filter by date range
const { data: recent } = await clinik.claims.search({
  dateFrom: '2024-01-01',
  dateTo: '2024-03-31',
  providerId: 'Practitioner/prac_dr456',
});

Claim Types

TypeDescription
institutionalHospital / facility claims
oralDental claims
pharmacyPharmacy claims
professionalPhysician / provider claims
visionVision care claims