Healthcare is full of promises about what data can do. But when it comes to claims data, the reality is both more specific and more powerful than even we expected. Claims data doesn't answer every healthcare question, but it definitively answers the questions that matter most for financial transparency, comprehensive medical history, and healthcare utilization.
Here are fifteen key questions that claims data answers instantly—and why these opportunites can be seized to transform healthcare experiences.
Longitudinal data to elimintate record gaps
1. "Where do all my records live, across all my providers?"
🧐 The Problem: Patients struggle to remember their healthcare journey across multiple providers, specialists, and years of care. Medical forms require detailed histories that patients simply can't recall accurately, and pulling data from Health Information Networks may not produce the full picture, unbeknowst to the requestor.
✅ The Solution with Claims Data: Claims data creates a comprehensive, chronological record of every healthcare interaction where insurance information was presented. From routine check-ups to emergency visits, prescriptions to procedures, this complete picture exists regardless of which providers a patient has seen. Use claims as the record locator to end chart chasing.
📊 Flexpa's claims data includes: Provider and organization lists with identifying details, service dates, locations where care was received, place of service codes, and complete care team information across all your healthcare interactions.
2. "When was my last preventive screening?"
🧐 The Problem: People lose track of when they had their last mammogram, colonoscopy, or annual physical. This leads to missed screenings or unnecessary duplicate testing.
✅ The Solution with Claims Data: Claims data shows the exact dates of all past health encounters and the services rendered, making it easy to track when screenings are due.
📊 Flexpa's claims data includes: Service dates, specific HCPCS and CPT procedure codes and descriptions, and provider information to identify what screenings were completed when. Location information to assist in record location if results are needed.
3. "What medications have I been prescribed over time?"
🧐 The Problem: Medication histories are scattered across different pharmacies and providers. This creates safety risks and makes it difficult to track what treatments have been tried.
✅ The Solution with Claims Data: Claims data includes all prescription claims, showing medication names, dosages, dates, and prescribing providers in one unified timeline.
📊 Flexpa's claims data includes: Medication names and details, NDC codes, prescription dates, days supply prescribing provider details, and pharmacy name and address.
4. "Which specialists have I seen and why?"
🧐 The Problem: Referral patterns and specialist visits are often forgotten, making it difficult to coordinate care or understand treatment progressions.
✅ The Solution with Claims Data: Claims data shows every specialist visit with procedure codes and diagnosis codes that indicate why the visit occurred, creating a clear picture of care coordination.
📊 Flexpa's claims data includes: Provider specialty codes, ICD 10 diagnosis codes and descriptions explaining the reason for visits, and HCPCS and CPT procedure codes and descriptions.
5. "What procedures have I had done?"
🧐 The Problem: Patients often can't remember specific procedures, tests, or treatments they've received or with enough detail, especially over multiple years or providers. Getting data from traditional clinical sources has the problem listed in #1.
✅ The Solution with Claims Data: Claims data includes detailed procedure codes for every medical service, creating a comprehensive record of all treatments received. View the information in relation to the encounter where it occured, or as a comprehensive list for review.
📊 Flexpa's claims data includes: Detailed HCPCS, CPT, and ICD procedure codes and descriptions, revenue codes for added detail, procedure dates, service locations, and history of this procedure.
Care Planning & Decision Making
6. "When was I last admitted to the ER for this condition?"
🧐 The Problem: Emergency room visits can be critical information for care coordination and health assessment. However, their details can be the most confusing for patients to recall. Where did it take place? What was the assessment? How was it billed? Who did I see?
✅ The Solution with Claims Data: Claims data provides a clean comprehensive history of inpatient and outpatient visits with all critical details needed for future care planning.
📊 Flexpa's claims data includes: Facility type, facility address, admission and discharge NUBC codes, type of visit codes, point of origin codes, HCPCS, CPT, and ICD procedure and diagnosis codes, rendering providers, and more.
7. "What patterns exist in my healthcare utilization?"
🧐 The Problem: Without visibility into their own care patterns, patients can't make informed decisions about their health or identify potential issues early.
✅ The Solution with Claims Data: Claims data reveals utilization patterns—seasonal healthcare needs, frequency of certain services, and relationships between different types of care.
📊 Flexpa's claims data includes: Service, procedure, and condition frequency data with dates, types of services rendered, place of service patterns, medication history, and encounter type trends.
8. "How do I prove my medical expenses for taxes, reimbursement, appeals, or lawsuits?"
🧐 The Problem: Certain legal processes like taxes, health reimbursements, appeals, or even law suits require detailed medical expense documentation. People spend hours gathering receipts and trying to remember what expenses qualify.
✅ The Solution with Claims Data: Claims data provides comprehensive documentation of all medical expenses with clear categorization and total calculations. They're easy to sift through by any relevant details like date, procedure, provider, location, etc. Because the source of the data is from the payer itself, Flexpa's claims data is admissable in most situations.
📊 Flexpa's claims data includes: Total amounts submitted, patient liability, service dates, detailed service descriptions, provider information, and payment status.
Financial & Administrative Questions
10. "Is this medical expense HSA-eligible?"
🧐 The Problem: People spend hours gathering receipts and documentation to prove medical expenses qualify for HSA reimbursement. Many valid expenses go unreimbursed simply because the paperwork is too complex.
✅ The Solution with Claims Data: Every medical expense that goes through insurance generates a claim with standardized codes that clearly identify HSA-eligible services. Claims data provides instant verification of medical necessity and expense categories, along with medical history as supporting evidence.
📊 Flexpa's claims data includes: Standardized service codes and descriptions, diagnosis codes proving medical necessity, total eligible amounts, patient responsibility amounts, amount applied to deductible, and service dates for HSA documentation.
11. "How much have I spent on healthcare this year?"
🧐 The Problem: Healthcare costs are scattered across multiple providers, pharmacies, and insurance statements. Most people have no idea what they've actually spent until tax season.
✅ The Solution with Claims Data: Claims data tracks every dollar—both patient payments and insurance payments—providing a complete financial picture of healthcare spending across all providers and services.
📊 Flexpa's claims data includes: Total spending breakdowns including amounts submitted, benefits paid, patient liability, deductible amounts applied, service dates for annual calculations, and detailed cost breakdowns by service type.
12. "Why is my bill different from what I expected?"
🧐 The Problem: Medical billing errors are common, but patients lack the tools to verify charges against what insurance actually covered. The result? Overpayments, duplicate billing, and financial confusion.
✅ The Solution with Claims Data: Claims data provides the definitive record of what insurance approved, denied, and paid. By comparing provider bills against EOBs, patients can instantly identify discrepancies.
📊 Flexpa's claims data includes: Detailed payment breakdowns showing amounts paid to providers and by patients, benefit amounts, submitted vs. eligible amounts, and non-covered amounts for billing verification.
12. "What plan should I select next year?"
🧐 The Problem: Plan selection is a major decision we make each year, that has financial implications lasting the full year before you can change it again. Historically plan selection tools rely on individuals digesting Summary of Benefit documents without assistance, and without native context of their past medical history.
✅ The Solution with Claims Data: Claims data provides a complete picture of not only your health situation, but also your financial spend throughout the year so that applications can help recommend the most financially optimized plan.
📊 Flexpa's claims data includes: Encounter history and overall out of pocket spend, conditions and procedures that may have custom plans catered to cost reduction, lists of providers for care continuity, and more.
14. "What benefits am I not using?"
🧐 The Problem: Most people don't fully understand or utilize their health benefits. They pay for coverage they never use while missing opportunities for preventive care.
✅ The Solution with Claims Data: Claims data reveals utilization patterns and shows which covered services haven't been used, helping people maximize their benefits.
📊 Flexpa's claims data includes: Procedure and diagnosis codes for benefits analysis, patient paid amounts for additional reimbursement calculations, and coverage periods.
15. What was my prior authorization result? (Coming soon)
🧐 The Problem: Requests for prior authorization typically takes weeks, after which the patient has either forgotten about the service if it was not urgent, or no longer is interested. These notiifcations are typically lost in the abyss of a member portal messages feature, or indescript email.
✅ The Solution with Claims Data: Soon, Flexpa will be able to process Prior Authorizations in a digitally native way, notifying key care takers, providers, and patients themselves of service estimates.
📊 Flexpa's claims data includes: Authorization status and outcomes, service codes requiring approval, estimated costs including total submitted and patient liability, and provider networks for authorized services.
The Claims Data Advantage
Claims data is the most complete, standardized, and accessible record of healthcare interactions. While it can't tell you clinical details like lab results or treatment notes, it definitively answers the financial and administrative questions that create the most friction in healthcare today. Claims data offers several unique advantages:
- Speed: 93% of records available in under 60 seconds vs. weeks for traditional methods
- Completeness: Every insured healthcare interaction generates a claim
- Standardization: Uniform FHIR format vs. varying provider systems
- Financial Detail: Complete cost breakdown with insurance adjudication
- Regulatory Compliance: Built for CMS patient access requirements
For the questions claims data answers well, it's transformational. For everything else, there are other data sources better suited to the task. The key is knowing which questions to ask and which data source will give you the most reliable answer. If you're not sure whether Claims data covers your use case, take a look at the flowchart below to understand which data source may be best for you.
This diagram was created by Duncan Greenberg, Venture Partner at Oak HC/FT, with input from Flexpa, Jason Kulatunga, Founder Fasten Health, and Brendan Keeler, Interoperability Practice Lead at HTD Health.
For a direct comparison between Flexpa's unified API for patient-consented claims records, claims clearing houses, HIEs, and tokenized data, read our blog post on claims data access patterns here.
How Flexpa Makes Claims Data Accessible
Flexpa's unified API provides instant access to claims data from 300+ health plans covering 260M+ lives. With a single integration, developers can build applications that answer all fifteen questions above—and many more.
Whether you're building HSA administration tools, benefits navigation platforms, or care coordination systems, Flexpa's claims data provides the foundation for answering the questions that matter most to your users.
Ready to build applications that answer these critical questions? Learn more about Flexpa's Patient Access API and how claims data can transform your healthcare application.
