Data model

Insurance claims

A data model of an insurance claim as it is assembled, submitted to a payer and settled, and the states it passes through.

An insurance claim is the hospital's request to a payer to settle part or all of a patient's bill. This page sets out the claim record, how it is assembled and submitted to a payer, and the states it passes through from pre-authorisation to settlement.

The claim record

A claim is a record that binds one encounter to one payer and tracks the money that payer owes. Vault assembles it from the encounter's charges, the patient's coverage and the clinical coding, and holds one claim for each encounter.

payer reference Required	The insurer, administrator or scheme being billed.
claimType string Required	Cashless or reimbursement, setting how the payer settles.
encounter reference Required	The admission the claim covers.
approvedCeiling amount	The amount the payer has authorised so far.
coding list Required	The diagnosis and procedure codes the claim is built on.
status string Required	The state the claim holds in its lifecycle.

Two kinds of claim

A claim runs one of two ways, set by how the payer settles.

The payer settles the hospital directly. The claim moves through pre-authorisation, in-stay accrual and a discharge sign-off, and the hospital carries the balance until the payer pays.

The cashless claim lifecycle

A cashless claim is authorised before care, accrues against that authorisation through the stay, and is signed off at discharge before the final claim is filed. The diagram traces the spine of that path.

The table sets out the full set of states a cashless claim can hold.

State	What it means
Opened	The claim record exists, ahead of any filing.
Pre-authorisation filed	Submitted to the payer, awaiting a decision.
Pre-authorisation approved	The ceiling is authorised, in full or in part.
Pre-authorisation declined	The payer refuses the request.
In stay	Charges accrue against the approved ceiling.
Enhancement filed	A mid-stay request to raise the ceiling.
Discharge bill filed	The final bill is filed for cashless sign-off.
Discharge approved	The payer signs off the bill.
Final claim filed	The post-discharge claim is filed for settlement.
Settled in full	The payer pays the claim in full.
Settled in part	The payer pays less, with documented deductions.
Declined	The payer refuses on adjudication grounds, often correctable.
Repudiated	The payer rejects on policy grounds, the gravest outcome.
Disputed	The hospital formally contests the outcome.
Resubmitted	A corrected claim is re-filed.
Appealed	The outcome is escalated to a higher forum.
Written off	The loss is accepted, recorded as a credit note.
Closed	The claim is finished, the single resting state.

Assembling and submitting

The claim is assembled with its coding complete before it is submitted. A primary diagnosis and the relevant procedure codes are in place, and a scheme claim carries its package code. Vault builds the claim as a FHIR R4 bundle and files it over the national health claims exchange.

Pre-authorisation opens the claim. Once the payer authorises a ceiling, the patient is admitted against it, and charges accrue in stay. A mid-stay top-up is filed as an enhancement when the ceiling runs low. At discharge the final bill is filed for sign-off, and the final claim follows for settlement.

When a claim is settled short or refused

A claim settled short of the amount claimed carries documented deductions. A claim declined on adjudication grounds is often correctable, and the hospital may dispute, resubmit or appeal it. A claim repudiated on policy grounds is disputed first, and a loss the hospital accepts is written off as a credit note.

A repudiation is disputed first

A repudiation is the gravest outcome, resting on the policy itself. The claim is disputed before any write-off, so a rejection on policy grounds carries a formal contest on the record.

Reimbursement claims

A reimbursement claim follows a shorter path, because the patient settles the bill and claims from the payer afterwards. The hospital's account closes the moment the patient pays in full.

State	What it means
Intimation	The claim is intimated to the payer.
Patient paid in full	The patient settles the whole bill, and the hospital account closes here.
Documents issued	The hospital issues the claim documents to the patient.
Patient filed	The patient files the claim with the payer.
Reimbursed	The payer reimburses the patient.

Common confusions

Who does the payer pay in a cashless claim?

The hospital, directly. The hospital carries the balance from admission until the payer settles.

When does the hospital account close on a reimbursement claim?

When the patient pays the bill in full at discharge. The claim risk then sits with the patient.

What is the difference between a declined and a repudiated claim?

A declined claim is refused on adjudication grounds and is often correctable. A repudiated claim is rejected on policy grounds, and it is disputed before any write-off.

Read how the discharge finance gate confirms the account before a patient leaves.