Claim Submission

Oystehr provides the ability to submit claims through the ClaimMD clearinghouse. Claims are assembled from the data in your FHIR database and sent as X12.

The Oystehr RCM service supports the following claim formats:

• 837p (CMS-1500)

Data Required for Claim Submission

The Oystehr RCM service assembles the X12 representation of your claim based on the data stored in your FHIR database. The resources referenced on your Claim are queried dynamically at the time of claim submission. In general, 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 endpoints are guaranteed to have the required identifiers.

• .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 can perform claim submission with either the Typescript SDK or the API:

import Oystehr from '@oystehr/sdk';
 
const oystehr = new Oystehr({
  accessToken: "<your_access_token>",
});
 
const result = await oystehr.rcm.submitClaim({
  claimId: "7cb4321f-8d52-4d27-93ba-f20c86cbceaf",
})

Access Policy

To submit a claim, your user or M2M client needs to have the following access policy:

{
  "rule": [
    {
      "action": "RCM:SubmitClaim",
      "effect": "Allow",
      "resource": "RCM:Claim"
    },
  ],
}