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The Claim data model is used for transactions between a healthcare organization and a payer, which can include a preauthorization for patient services, payment request, claim status, payment details, and the explanation of benefits (EOB).

We support submitting claims and sending payment notifications in batches. Typically, the claims workflow kicks off with healthcare organizations grouping (i.e., batching) and sending claims to payers with details about services rendered to a patient and a request for payment. After processing the claims, payers send batched payment notifications to the healthcare organization with a status of whether the payment request was accepted or denied. In some cases, the status may indicate that a third party transferred funds to the healthcare organization.

The Claim data model differs from the Financial data model in that claims are generally a summary of patient care that's sent or received after an admission or encounter is concluded. If you're looking for handling financial charges on the fly during a patient's care, check out the Financial data model.