"An accident which resulted in the need for healthcare services." - HL7 FHIR, Claim.accident

"A financial tool for tracking value accrued for a particular purpose. In the healthcare field, used to track charges for a patient, cost centers, etc." - HL7 FHIR, Account

Ambulatory Patient Group (APG) is a classification system for outpatient services reimbursement developed for Medicare by the Health Care Financing Administration. It classifies patients into nearly 300 pathology groups rather than the 14,000 of the International Classification of Diseases. The APG system is similar to the Diagnosis-related groups (DRG), which apply to urgent care. – Adapted from Wikipedia.

"Benefits used to date." - HL7 FHIR, CoverageEligibilityResponse.insurance.item.benefit

Medicare Part D provides prescription benefits in several "stages", including an Initial Coverage Benefit Stage, the Coverage Gap or Out-of-Pocket Benefit Stage, and the Catastrophic Coverage Benefit Stage. This class identifies the number and dollar amount of payments made in each stage.

This class represents the provision of a healthcare-related product, procedure, or service that may be charged to the patient or to the patient's Health Plan. This class serves to connect the clinical information that may be recorded in an EHR, such as a procedure or the dispensing of a drug, to the financial information detailing the billing and adjudication of charges for that clinical activity. "The resource ChargeItem describes the provision of healthcare provider products for a certain patient, therefore referring not only to the product, but containing in addition details of the provision, like date, time, amounts and participating organizations and persons. Main Usage of the ChargeItem is to enable the billing process and internal cost allocation." - HL7 FHIR, ChargeItem

This class represents an invoice or bill for a Billable Service. A single Billable Service may have multiple Billing Events due to the coordination of multiple payers (e.g.,, Health Plan A is billed for 70%, Health Plan B is billed for 20%, and the Patient is billed for the remaining 10%), and a single Payer may be billed multiple times as payment is negotiated electronically (e.g., the Payer might initially reject a bill, and may accept it upon submission of a second bill containing more information).

This class contains data sent by a Payer in response to a Billing Event detailing the components and reasons for any payments made or not made.

This class links the Billable Service with the Billing Events in which the Health Plans are invoiced for the service There will typically be one or more Billing Events for a Billable Service: one if benefits are not coordinated among multiple payers (assuming no re-billing is needed); many if benefits coordination takes place (or if some kind of re-billing is needed for a single payer). This relationship is modeled as zero to many because a Billable Service may exist before a Billing Event is created for it, and it is possible that no Billing Event might occur in the case of cash payments or if the fee is written off.

This class contains data sent to a Payer as part of a Billing Event detailing the components and reasons for the charges being billed.

"A method of paying for medical services on a per-person rather than a per-procedure basis. Under capitation, an HMO pays a doctor a fixed amount each month to take care of HMO members, regardless of how much or how little care each member needs." -eHealthInsurance.org

A Certificate of Medical Necessity is a document required by Centers for Medicare and Medicaid Services to substantiate the medical necessity of an item (e.g., a durable medical equipment) or service furnished to a Medicare beneficiary. Medical necessity is a legal doctrine, related to activities which may be justified as reasonable, necessary, and/or appropriate, based on evidence-based clinical standards of care. By statute, Medicare may only pay for items and services that are "reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member", unless there is another statutory authorization for payment. - adapted from wikipedia.

"A provider issued list of services and products provided, or to be provided, to a patient which is provided to an insurer for payment recovery." - HL7 FHIR, Claim

This class represents the results of prior Billing Events, including previous payments, which are used in part to determine the liability of the Payer and of the Patient for the current Billing Event.

"A suite of codes indicating the cost category and associated amount which have been detailed in the policy and may have been included on the health card." - HL7 FHIR, Coverage.costToBeneficiary

This class contains information about the patient's use of a manufacturers coupon to reduce the patient's out-of-pocket cost for the prescription. "A coupon is used to reduce the patient out of pocket prescription cost – by either reducing the cost of a cash prescription or the patient financial responsibility from a Third Party payer who allows coupon usage. The coupon processor is the LAST payer. (Note: Some Federal and State programs do not allow the reduction of patient’s financial responsibility.) When a customer has a coupon, the Usual And Customary Charge field is not reduced by the amount of the coupon." - NCPDP Telecommunication D.6, Coupon Segment.

"Financial instrument which may be used to reimburse or pay for health care products and services. Includes both insurance and self-payment." - HL7 FHIR, Coverage

"The CoverageEligibilityRequest provides patient and insurance coverage information to an insurer for them to respond, in the form of an CoverageEligibilityResponse, with information regarding whether the stated coverage is valid and in-force and optionally to provide the insurance details of the policy." - HL7 FHIR, CoverageEligibilityRequest

"This resource provides eligibility and plan details from the processing of an CoverageEligibilityRequest resource." - HL7 FHIR, CoverageEligibilityResponse

"The specific limits on the benefit." - HL7 FHIR, InsurancePlan.coverage.benefit.limit

This class represents the Role of a Patient from a financial, rather than a clinical point of view. This class contains information concerning who is going to pay for services / materials provided, and links to Health Plan information via relationships to Subscriber. Covered Patient serves to link the financial aspects to the clinical Patient without encumbering clinical information with the financial or administrative considerations.

This class represents the Role that a Person plays when he or she receives healthcare benefits as a Dependent of someone else who is the named beneficiary of a Health Policy.

"List of individual settlement amounts and the corresponding transaction." - HL7 FHIR, PaymentReconciliation.detail

Diagnosis-related group (DRG) is a system to classify the "products" that a hospital provides. One example of a "product" is an appendectomy. The system was developed to replace "cost based" reimbursement. DRGs are assigned by a "grouper" program based on ICD (International Classification of Diseases) diagnoses, procedures, age, sex, discharge status, and the presence of complications or comorbidities. DRGs have been used in the US since 1982 to determine how much Medicare pays the hospital for each "product", since patients within each category are clinically similar and are expected to use the same level of hospital resources. – Adapted from Wikipedia. Note that DRGs are primarily used for inpatient settings.

"A method of classifying [medical] services. It is used as a method of determining financing to reimburse various providers for services performed." -eHealthInsurance.org

This class represents the billable aspects of the provision of Durable Medical Equipment (DME). This class will link the clinical data related to a DME dispense to the administrative data needed to bill for the dispense.

" A list of preferred pharmaceutical products to be used by a managed care plan's network physicians. Formularies are based on evaluations of the efficacy, safety, and cost-effectiveness of drugs." -eHealthInsurance.org

This class represents the billable aspects of a pharmacy dispense. It serves to link the clinical data related to a dispense to the administrative data needed to bill for the dispense. As a sub-type of Billable Service, it inherits all of the data related to billing and Coodination Of Benefits, adds some data elements specifically needed to bill for the pharmacy dispense, and points to the Pharmacy Dispense clinical data for any remaining data needed for billing. Note that this class also points to Professional Service Provision to handle any professional servies charges related to the dispense, such as patient counseling. Note that this class contains some properties that are clearly billing oriented, which are modeled here rather than in Billable Service, because they're only needed for the billing of Drug Provision.