Oystehr
Oystehr Services
RCM
Claim Preparation

Claim Preparation

When submitting claims, Oystehr assembles the claim data stored in your FHIR database and sends it as X12 to a clearinghouse. Preparing the data for transmission is the bulk of your responsibility when implementing against the Oystehr RCM Service.

This page describes the bare-minimum requirements for Oystehr to submit an 837 Professional claim. Additional data and features, including required fields for 837 Institutional claims, are discussed in Additional Claim Data.

Data Required for Claim Submission

The Claim resource is the central model for claim submission in Oystehr. The resources referenced on your Claim are queried dynamically at the time of claim submission. Only internal FHIR references are accepted (Practitioner/abcdef12-...), and contained resources will not be used.

Claim Required Fields

  • .id
  • .provider.reference
  • .facility.reference
  • .insurance[0].coverage.reference ("primary" coverage)
  • .diagnosis[0] ("primary" diagnosis)
  • .total.value
  • .item[0].locationCodeableConcept[system='http://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set.html'].code
  • .item[*].careTeamSequence[0]
  • .item[*].productOrService[system='http://terminology.hl7.org/CodeSystem/HCPCS'].code
  • .item[*].net.value
  • .item[*].quantity.value
  • .item[*].diagnosisSequence
  • .item[*].servicePeriod.start
  • .extension[url='https://extensions.fhir.oystehr.com/rcm-claim-insurance-type'].valueString
  • .extension[url='https://extensions.fhir.oystehr.com/rcm-claim-provider-signature-indicator'].valueBoolean
  • .extension[url='https://extensions.fhir.oystehr.com/rcm-claim-release-of-information-code'].valueString

One of:

  • .diagnosis[0].diagnosisCodeableConcept[system='http://hl7.org/fhir/sid/icd-9-cm'].code
  • .diagnosis[0].diagnosisCodeableConcept[system='http://hl7.org/fhir/sid/icd-10-cm'].code

Coverage Required Fields

  • .payor[0].reference
  • .class[0].value
  • .class[0].name
  • .relationship.coding[system='http://terminology.hl7.org/CodeSystem/subscriber-relationship']
  • .subscriber.reference
  • .subscriberId

Organization (billing provider) Required Fields

  • .name
  • .address[0].line[0]
  • .address[0].city
  • .address[0].state
  • .address[0].postalCode
  • .identifier[type=('http://terminology.hl7.org/CodeSystem/v2-0203', 'NPI')]
  • .identifier[type=(''https://terminology.fhir.oystehr.com/CodeSystem/rcm-claim-secondary-identifier-type', 'ETIN')]
  • .telecom[system=phone]

Organization (payor) Required Fields

The Organization resources returned by the Oystehr RCM Service payer list are guaranteed to have the required identifiers. References of the form https://rcm.zapehr.com/v1/payer/12345 are accepted by claim submission.

  • .name

One of:

  • .identifier[system='https://identifiers.fhir.oystehr.com/rcm-payer-id']
  • .identifier[coding=('http://terminology.hl7.org/CodeSystem/v2-0203', 'NIIP')]
  • .identifier[coding=('http://terminology.hl7.org/CodeSystem/v2-0203', 'PAYERID')]
  • .identifier[coding=('http://terminology.hl7.org/CodeSystem/v2-0203', 'XX')]
  • .identifier[coding=('http://terminology.hl7.org/CodeSystem/v2-0203', 'XV')]

Location (service facility) Required Fields

  • .name
  • .address[0].line[0]
  • .address[0].city
  • .address[0].state
  • .address[0].postalCode

Patient Required Fields

When the Coverage relationship coding is set to self, the Patient resource will be used for subscriber information

  • .name[use=official].family
  • .name[use=official].given[0]
  • .address[0].line[0]
  • .address[0].city
  • .address[0].state
  • .address[0].postalCode
  • .birthDate

RelatedPerson Required Fields

When the Coverage relationship coding is not set to self, a RelatedPerson resource is required and will be used for subscriber information

  • .name[use=official].family
  • .name[use=official].given[0]
  • .address[0].line[0]
  • .address[0].city
  • .address[0].state
  • .address[0].postalCode
  • .birthDate

Practitioner (rendering, supervising, and referring providers) Required Fields

  • .name[use=official].family
  • .name[use=official].given[0]
  • .identifier[type=('http://terminology.hl7.org/CodeSystem/v2-0203', 'NPI')]

Submitting a Claim

After you have assembled all data as required, you're ready to perform claim submission.

RCMAdditional Claim Data