FHIR Financial Resources in ESUS
ESUS implements the core billing surface today, with payer-integration resources on the roadmap.
Implemented today
| Resource | Purpose |
|---|
| Claim | Request for payment for services |
| ClaimResponse | Payer’s response to a claim |
| ExplanationOfBenefit | Detailed explanation of benefits |
| Account | Financial account aggregating charges for a patient |
| Invoice | Itemized invoice issued to a payer or patient |
| VisionPrescription | Prescription for corrective lenses |
Roadmap (not exposed yet)
| Resource | Planned use |
|---|
| Coverage | Standalone insurance-coverage resource (currently stored inline in Claim.insurance[].coverage and Account.coverage[].coverage). |
| CoverageEligibilityRequest / Response | Payer eligibility verification. For now, integrate with your payer’s API directly. |
| PaymentNotice / PaymentReconciliation | Payment notification and reconciliation. For now, use Account + Invoice to track payments. |
Key Concepts
- Patient responsibility — the amount a patient owes after insurance payments.
- Adjudication — the process of evaluating insurance claims.
- EOB (Explanation of Benefit) — a complete statement showing care, costs, and payments.
Billing Workflow (today)
Care delivery → Create Claim → Receive ClaimResponse → Generate ExplanationOfBenefit → Settle via Account / Invoice
Common Use Cases
- Submit claims for reimbursement.
- Track adjudication outcomes per claim.
- Produce patient statements from ExplanationOfBenefit + Account.
- Manage billing errors and appeals.