ClaimSchema
The plan's allowed amount for the billed service(s): the maximum the payer recognizes under its provider contract. Use computed_amount_allowed when this field is missing.
Amount the provider billed for the service(s) on this claim, as reported on the EOB. Use computed_amount_billed when this field is missing.
Portion of the billed amount the plan does not cover (for example, non-covered services or charges above the allowed amount).
Amount the payer paid toward this claim. Use computed_amount_paid when this field is missing.
Amount paid toward this claim by another payer (for example, a primary carrier under coordination of benefits).
Date the payer issued payment for this claim.
Payer's check or EFT reference number for the payment issued on this claim.
Coinsurance the patient owes: the patient's percentage share of the allowed amount. Use computed_coinsurance_patient when this field is missing.
Normalized discount. Prefer this over discount when present.
Fixed copay the patient owes for this claim. Use computed_copayment when this field is missing.
Provider discount or write-off applied against the billed amount. Use computed_discount when this field is missing.
Date of the Explanation of Benefits statement this claim was extracted from.
Name of the employer or plan group the member is enrolled under, as shown on the EOB.
Payer's identifier for the employer or plan group the member is enrolled under.
This claim may have incomplete data. If a claim is marked as incomplete, we typically will not send it until it gets marked as complete. Reasons for an incomplete claim include (1) documentation that isn't yet available but we expect it to be in the near future, and (2) if we notice the claim has data redacted for privacy (example: a dependent over 16 years old), but we expect to get this data when a dependent links their account.
Used as an indicator of when the last substantial change happened to this claim. If this date gets updated, we consider it necessary to re-send the claim for processing (in data exports) / flag it as "unread" in TPA Stream / etc. Typically this date gets updated when the patient_responsibility or status changes, or otherwise when is_incomplete changes to True.
Possible values: [IN, OUT, TIER1, TIER2]
The service provider's internal account number for the patient (often the provider's EMR record ID or chart number, used by the provider's billing system for payment posting). Provider-scoped, not carrier-scoped - the same patient seen at two clinics will have two different patient_account_number values.
Date of birth of the patient the claim is for, when reported on the EOB.
Name of the patient the claim is for. May be the plan subscriber or one of their dependents.
Carrier-issued member ID as it appears on the insurance card (HL7 v2-0203 'MB' code). Identifies the plan member, not the individual patient: the subscriber and every dependent on the same plan typically share this value (sometimes with a per-person suffix appended by the carrier). Not suitable on its own for distinguishing which household member a claim is for - for that, use payer_patient_id. Anthem PAA does NOT populate this field - the FHIR Patient resource's MB-typed identifier is inconsistently present and even when present would be the subscriber's, not the actual claim patient's.
Total amount the patient owes for this claim (deductible reduction, coinsurance, copay, and non-covered charges combined). Use computed_patient_responsibility when this field is missing.
Patient's Social Security Number, when the payer exposes it. Frequently absent or partially redacted.
Carrier-issued stable per-patient identifier captured from EOB metadata (Anthem PAA FHIR patient.reference GUID; analogous fields expected for other Patient Access API payers). Unique per household member: the subscriber and each dependent each have their own value, and it stays stable across crawls even when the member's name is rendered differently. Prefer this over patient_payer_number when distinguishing which household member a claim belongs to.
Date the payer adjudicated (finished processing) the claim.
Attempt to recrawl when True
This is the amount the deductible was reduced by. Most systems refer to this as 'deductible'. Use computed_reduction in case this field is empty.
These are the notes for the Claim.
Service Provider Name. This is the physical name, and is provided by the Payer.
Physical address of Service Provider
Billing address of the service provider (the address tied to service_provider_billing_name), often different from the provider's physical location.
This is the service_provider's Billing name, which is often different from their physical address name.
NPI Number of Billing Service Provider
Federal Tax ID of Billing Service Provider
Billing contact phone number for the service provider.
NAPB Number of Pharmacy
NPI Number of Service Provider
Federal Tax ID of Service Provider
Possible values: [In Process, Processed, Rejected, Adjusted, Partially Approved]
This field is unique for each Payer. Occasionally TPA Stream may append data to the end of this key to enforce uniqueness, such as the date_of_service, patient_responsibility, etc.
{
"all_tenants_claim_medical_read": [
null
],
"amount_allowed": 0,
"amount_billed": 0,
"amount_not_covered": 0,
"amount_paid": 0,
"amount_paid_other": 0,
"check_date": "2024-07-29",
"check_number": "string",
"claim_approval": [
null
],
"claim_medical_id": 0,
"claim_members": [
null
],
"claim_status_id": 0,
"claim_tenants": [
null
],
"claim_tpafile": [
null
],
"coinsurance_patient": 0,
"computed_amount_allowed": 0,
"computed_amount_billed": 0,
"computed_amount_paid": 0,
"computed_coinsurance_patient": 0,
"computed_copayment": 0,
"computed_discount": 0,
"computed_interop_diagnosis_string": "string",
"computed_patient_responsibility": 0,
"computed_reduction": 0,
"copayment": 0,
"createddate": "2024-07-29T15:51:28.071Z",
"dataobject_id": 0,
"date_column": "2024-07-29T15:51:28.071Z",
"discount": 0,
"employers": [
null
],
"eob_date": "2024-07-29",
"group_name": "string",
"group_number": "string",
"id": 0,
"incurred_value": 0,
"is_exported": true,
"is_incomplete": true,
"last_updated_status": "2024-07-29T15:51:28.071Z",
"modifiedby_id": 0,
"modifieddate": "2024-07-29T15:51:28.071Z",
"network": "IN",
"patient_account_number": "string",
"patient_date_of_birth": "2024-07-29",
"patient_name": "string",
"patient_payer_number": "string",
"patient_responsibility": 0,
"patient_ssn": "string",
"payer_group_id": 0,
"payer_patient_id": "string",
"policy_holder_fullname": "string",
"policy_holder_id": 0,
"processed_on": "2024-07-29",
"recrawl_requested": true,
"reduction": 0,
"remarks": "string",
"service_provider": "string",
"service_provider_address": "string",
"service_provider_billing_address": "string",
"service_provider_billing_name": "string",
"service_provider_billing_npi_number": 0,
"service_provider_billing_number": "string",
"service_provider_billing_phone": "string",
"service_provider_napb_number": "string",
"service_provider_npi_number": 0,
"service_provider_number": "string",
"status": "In Process",
"tenants": [
null
],
"total_amount_allowed": 0,
"total_amount_billed": 0,
"total_amount_paid": 0,
"total_coinsurance_patient": 0,
"total_copayment": 0,
"total_patient_responsibility": 0,
"total_reduction": 0,
"tpas_claim_statement_url": "string",
"type_id": 0,
"user_members": [
null
],
"uuid": "3fa85f64-5717-4562-b3fc-2c963f66afa6",
"vendor_system_id": "string"
}