NHCX Claim

Overview

A claim is the formal request for reimbursement sent to the payer after treatment. The NHCX claim form collects the items, diagnoses, and discharge details, builds a FHIR Claim bundle, and submits it to the payer.

Claims build on the earlier steps in the workflow: the eligibility check and pre-authorization provide the policy identity and approved items, which the claim references.

Where to find it

Open the patient's NHCX page, find the relevant workflow, and choose Claim. The form is pre-populated from the pre-authorization and eligibility data already recorded for that workflow.

What the claim form captures

The claim form includes:

• Claim items — the procedures/services performed, with their codes, quantities, and amounts.
• Diagnosis — the diagnoses tied to the claim, referenced by the items.
• Admission and discharge date/time — the claim's billable period (Start Date / End Date), captured as a date and time and sent to the payer in IST.
• Discharge disposition and discharge status — how the patient left (relevant for IPD claims).
• Questionnaire answers — payer-specific discharge/plan questions.
• Biometric verification — for admission and discharge capture (see NHCX Biometric).

For a newborn claim, the parent relation and proof-of-birth documents are carried in automatically. See NHCX Newborn Claim.

Enhancement

If the treatment requires more than what was pre-authorized, the claim can be submitted as an enhancement. This adds new items on top of the existing pre-authorization. The system maps the pre-authorized items to the new claim items so only the additional work is charged.

Common Issues

• Serialization error when loading the claim — this is typically a malformed value in the pre-authorization data; re-check the workflow for any failed/partial rows before retrying.
• Items not showing — the claim reads from the pre-authorization; ensure the pre-auth was submitted successfully first.

FAQ

Q: What is the difference between a pre-auth and a claim? A: A pre-auth is approval sought before treatment. A claim is the request for payment submitted after treatment.

Q: What is an enhancement? A: An enhancement adds extra procedures/items to an already-approved pre-authorization, so the claim reflects the full treatment while only charging for the additional work.

Q: When is a claim for a newborn filed under the parent? A: When the eligibility check linked a parent UHID, the claim automatically uses the parent's policy identity. See NHCX Newborn Claim.