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13.6 Resource Claim - Content

Financial Management Work Group Maturity Level : 2   Trial Use Security Category : Patient Compartments : Device , Encounter , Patient , Practitioner , RelatedPerson

A provider issued list of professional services and products which have been provided, or are to be provided, to a patient which is provided sent to an insurer for payment recovery. reimbursement.

The Claim is used by providers and payors, insurers, to exchange the financial information, and supporting clinical information, regarding the provision of health care services with payors and for reporting to regulatory bodies and firms which provide data analytics. The primary uses of this resource is to support eClaims, the exchange of information relating to the proposed or actual provision of healthcare-related goods and services for patients to their benefit payors, insurers and national health programs, for treatment payment planning and reimbursement.

The Claim resource is a "request" resource from a FHIR workflow perspective - see Workflow Request.

The Claim resource may be interpreted differently depending on its intended use (and the Claim.use element contains the code to indicate):

  • Claims claim - where the provision of goods and services is complete and adjudication under a plan and payment is sought.
  • Pre-Authorization preauthorization - where the provision of goods and services is proposed and authorization and/or the reservation of funds is desired.
  • Pre-Determination predetermination - where the provision of goods and services is explored to determine what services may be covered and to what amount. Essentially a 'what if' claim.

The Claim also supports:

  • Up to a 3 tier 3-tier hierarchy of Goods, products, and Services, to support simple to complex billing.
  • Multiple insurance programs arranged in a Coordination of Benefit sequence to enable exchange with primary, secondary, tertiary etc. insurance coverages.
  • Assignment of benefit - the benefit may be requested to be directed to the subscriber, the provider or another party.

Mapping to other Claim specifications: Mappings are currently maintained by the Financial Management Work Group to UB04 and CMS1500 and are available at http://wiki.hl7.org/index.php?title=Financial_Management_FHIR_Resource_Development https://confluence.hl7.org/display/FM/FHIR+Resource+Development . Mappings to other specifications may be made available where IP restrictions permit.

Additional information regarding electronic claims content and usage may be found at:

  • Financial Resource Status Lifecycle : how .status is used in the financial resources.
  • Secondary Use of Resources : how resources such as Claim and ExplanationOfBenefit may used for reporting and data exchange for analytics, not just for eClaims exchange between providers and payors.
  • Subrogation : how eClaims may handle patient insurance coverages when another insurer rather than the provider will settle the claim and potentially recover costs against specified coverages.
  • Coordination of Benefit : how eClaims may handle multiple patient insurance coverages.
  • Batches : how eClaims may handle batches of eligibility, claims and responses.
  • Attachments and Supporting Information : how eClaims may handle the provision of supporting information, whether provided by content or reference, within the eClaim resource when submitted to the payor or later in a resource which refers to the subject eClaim resource. This also includes how payors may request additional supporting information from providers.

The Claim resource is used to request the adjudication and/or authorization of a set of healthcare-related goods and services for a patient against the patient's insurance coverages, or to request what the adjudication would be for a supplied set of goods or services should they be actually supplied to the patient.

When requesting whether the patient's coverage is inforce, whether it is valid at this or a specified date, or requesting the benefit details or preauthorization requirements associated with a coverage, then CoverageEligibilityRequest should be used instead.

When using the resources for reporting and transferring claims data, which may have originated in some standard other than FHIR, the Claim resource is useful if only the request side of the information exchange is of interest. If, however, both the request and the adjudication information is to be reported then the ExplanationOfBenefit should be used instead.

For reporting out to patients or transferring data to patient centered applications, such as patient health Record (PHR) application, the ExplanationOfBenefit should be used instead of the Claim and ClaimResponse resources as those resources may contain provider and payer specific information which is not appropriate for sharing with the patient.

The eClaim domain includes a number of related resources

Claim A suite of goods and services and insurances coverages under which adjudication or authorization is requested.
CoverageEligibilityRequest A request to a payor to: ascertain whether a coverage is in-force at the current or at a specified time; list the table of benefits; determine whether coverage is provided for specified categories or specific services; and whether preauthorization is required, and if so what supporting information would be required.
ClaimResponse A payor's adjudication and/or authorization response to the suite of services provided in a Claim. Typically the ClaimResponse references the Claim but does not duplicate the clinical or financial information provided in the claim.
ExplanationOfBenefit This resource combines the information from the Claim and the ClaimResponse, stripping out any provider or payor proprietary information, into a unified information model suitable for use for: patient reporting; transferring information to a Patient Health Record system; and, supporting complete claim and adjudication information exchange with regulatory and analytics organizations and other parts of the provider's organization.

This resource is referenced by itself, ClaimResponse , DeviceUseStatement and ExplanationOfBenefit .

This resource implements the Request pattern.

Structure

resource 0..1 Coding organization | patient | practitioner | relatedperson ClaimPayeeResourceType ( Extensible )
Name Flags Card. Type Description & Constraints doco
. . Claim TU DomainResource Claim, Pre-determination or Pre-authorization
Elements defined in Ancestors: id , meta , implicitRules , language , text , contained , extension , modifierExtension
. . . identifier 0..* Identifier Claim number Business Identifier for claim
. . . status ?! Σ 0..1 1..1 code active | cancelled | draft | entered-in-error
Financial Resource Status Codes ( Required )
. . . type 0..1 Σ 1..1 CodeableConcept Type Category or discipline
Claim Type Codes ( Extensible )
. . . subType 0..* 0..1 CodeableConcept Finer grained More granular claim type information
Example Claim SubType Codes ( Example )
. . . use 0..1 Σ 1..1 code complete | proposed claim | exploratory preauthorization | other predetermination
Use ( Required )
. . . patient Σ 0..1 1..1 Reference ( Patient ) The subject recipient of the Products products and Services services
. . . billablePeriod Σ 0..1 Period Period Relevant time frame for charge submission the claim
. . . created Σ 0..1 1..1 dateTime Creation Resource creation date
. . . enterer 0..1 Reference ( Practitioner | PractitionerRole ) Author of the claim
. . . insurer Σ 0..1 Reference ( Organization ) Target
. . . provider 0..1 Σ 1..1 Reference ( Practitioner | PractitionerRole | Organization ) Responsible provider Party responsible for the claim
. . . priority Σ 0..1 1..1 CodeableConcept Desired processing priority ugency
Process Priority Codes ( Example )
. . . fundsReserve 0..1 CodeableConcept Funds requested For whom to be reserved reserve funds
Funds Reservation Codes FundsReserve ( Example )
. . . related 0..* BackboneElement Related Claims which may be revelant to processing this claimn Prior or corollary claims
. . . . claim 0..1 Reference ( Claim ) Reference to the related claim
. . . . relationship 0..1 CodeableConcept How the reference claim is related
Example Related Claim Relationship Codes ( Example )
. . . . reference 0..1 Identifier Related file File or case reference
. . . prescription 0..1 Reference ( DeviceRequest | MedicationRequest | VisionPrescription ) Prescription authorizing services or and products
. . . originalPrescription 0..1 Reference ( DeviceRequest | MedicationRequest | VisionPrescription ) Original prescription if superceded superseded by fulfiller
. . . payee 0..1 BackboneElement Party to be paid any Recipient of benefits payable
. . . . type 1..1 CodeableConcept Type Category of party: Subscriber, Provider, other recipient
Claim Payee Type Codes PayeeType ( Example )
. . . . party 0..1 Reference ( Practitioner | PractitionerRole | Organization | Patient | RelatedPerson ) Party to receive the payable Recipient reference
. . . referral 0..1 Reference ( ServiceRequest ) Treatment Referral referral
. . . facility 0..1 Reference ( Location ) Servicing Facility facility
. . . careTeam 0..* BackboneElement Members of the care team
. . . . sequence 1..1 positiveInt Number to convey order Order of careTeam care team
. . . . provider 1..1 Reference ( Practitioner | PractitionerRole | Organization ) Provider individual Practitioner or organization
. . . . responsible 0..1 boolean Billing provider Indicator of the lead practitioner
. . . . role 0..1 CodeableConcept Role on Function within the team
Claim Care Team Role Codes ( Example )
. . . . qualification 0..1 CodeableConcept Type, classification Practitioner credential or Specialization specialization
Example Provider Qualification Codes ( Example )
. . information . supportingInfo 0..* BackboneElement Exceptions, special considerations, the condition, situation, prior or concurrent issues Supporting information
. . . . sequence 1..1 positiveInt Information instance identifier
. . . . category 1..1 CodeableConcept General class Classification of the supplied information
Claim Information Category Codes ( Example )
. . . . code 0..1 CodeableConcept Type of information
Exception Codes ( Example )
. . . . timing[x] 0..1 When it occurred
. . . . . timingDate date
. . . . . timingPeriod Period
. . . . value[x] 0..1 Additional Data or supporting information to be provided
. . . . . valueBoolean boolean
. . . . . valueString string
. . . . . valueQuantity Quantity
. . . . . valueAttachment Attachment
. . . . . valueReference Reference ( Any )
. . . . reason 0..1 CodeableConcept Reason associated with Explanation for the information
Missing Tooth Reason Codes ( Example )
. . . diagnosis 0..* BackboneElement List of Diagnosis Pertinent diagnosis information
. . . . sequence 1..1 positiveInt Number to convey order of diagnosis Diagnosis instance identifier
. . . . diagnosis[x] 1..1 Patient's diagnosis Nature of illness or problem
ICD-10 Codes ( Example )
. . . . . diagnosisCodeableConcept CodeableConcept
. . . . . diagnosisReference Reference ( Condition )
. . . . type 0..* CodeableConcept Timing or nature of the diagnosis
Example Diagnosis Type Codes ( Example )
. . . . onAdmission 0..1 CodeableConcept Present on admission
Example Diagnosis on Admission Codes ( Example )
. . . . packageCode 0..1 CodeableConcept Package billing code
Example Diagnosis Related Group Codes ( Example )
. . . procedure 0..* BackboneElement Procedures Clinical procedures performed
. . . . sequence 1..1 positiveInt Procedure sequence for reference instance identifier
.... type 0..* CodeableConcept Category of Procedure
Example Procedure Type Codes ( Example )
. . . . date 0..1 dateTime When the procedure was performed
. . . . procedure[x] 1..1 Patient's list of procedures performed Specific clinical procedure
ICD-10 Procedure Codes ( Example )
. . . . . procedureCodeableConcept CodeableConcept
. . . . . procedureReference Reference ( Procedure )
. . insurance . . udi 0..* Reference ( Device ) Unique device identifier
... insurance Σ 1..* BackboneElement Insurance or medical plan Patient insurance information
. . . . sequence Σ 1..1 positiveInt Service Insurance instance identifier
. . . . focal Σ 1..1 boolean Is the focal Coverage to be used for adjudication
. . . . identifier 0..1 Identifier Pre-assigned Claim number
. . . . coverage Σ 1..1 Reference ( Coverage ) Insurance information
. . . . businessArrangement 0..1 string Business agreement Additional provider contract number
. . . . preAuthRef 0..* string Pre-Authorization/Determination Reference Prior authorization reference number
. . . . claimResponse 0..1 Reference ( ClaimResponse ) Adjudication results
. . . accident 0..1 BackboneElement Details about an accident of the event
. . . . date 1..1 date When the accident incident occurred see information codes see information codes
. . . . type 0..1 CodeableConcept The nature of the accident
ActIncidentCode V3 Value SetActIncidentCode ( Extensible )
. . . . location[x] 0..1 Accident Place Where the event occurred
. . . . . locationAddress Address
. . . . . locationReference Reference ( Location )
. . . item 0..* BackboneElement Goods and Services Product or service provided
. . . . sequence 1..1 positiveInt Service Item instance identifier
. . . . careTeamSequence 0..* positiveInt Applicable careTeam members
. . . . diagnosisSequence 0..* positiveInt Applicable diagnoses
. . . . procedureSequence 0..* positiveInt Applicable procedures
. . . . informationSequence 0..* positiveInt Applicable exception and supporting information
. . . . revenue 0..1 CodeableConcept Revenue or cost center code
Example Revenue Center Codes ( Example )
. . . . category 0..1 CodeableConcept Type of service or product Benefit classification
Benefit SubCategory Category Codes ( Example )
. . . service . productOrService 0..1 1..1 CodeableConcept Billing Code Billing, service, product, or drug code
USCLS Codes ( Example )
. . . . modifier 0..* CodeableConcept Service/Product Product or service billing modifiers
Modifier type Codes ( Example )
. . . . programCode 0..* CodeableConcept Program specific reason for item inclusion the product or service is provided under
Example Program Reason Codes ( Example )
. . . . serviced[x] 0..1 Date or dates of Service service or product delivery
. . . . . servicedDate date
. . . . . servicedPeriod Period
. . . . location[x] 0..1 Place of service or where product was supplied
Example Service Place Codes ( Example )
. . . . . locationCodeableConcept CodeableConcept
. . . . . locationAddress Address
. . . . . locationReference Reference ( Location )
. . . . quantity 0..1 SimpleQuantity Count of Products products or Services services
. . . . unitPrice 0..1 Money Fee, charge or cost per point item
. . . . factor 0..1 decimal Price scaling factor
. . . . net 0..1 Money Total item cost
. . . . udi 0..* Reference ( Device ) Unique Device Identifier device identifier
. . . . bodySite 0..1 CodeableConcept Service Location Anatomical location
Oral Site Codes ( Example )
. . . . subSite 0..* CodeableConcept Service Sub-location Anatomical sub-location
Surface Codes ( Example )
. . . . encounter 0..* Reference ( Encounter ) Encounters related to this billed item
. . . . detail 0..* BackboneElement Additional items Product or service provided
. . . . . sequence 1..1 positiveInt Service Item instance identifier
. . . . . revenue 0..1 CodeableConcept Revenue or cost center code
Example Revenue Center Codes ( Example )
. . . . . category 0..1 CodeableConcept Type of service or product Benefit classification
Benefit SubCategory Category Codes ( Example )
. . . . service . productOrService 0..1 1..1 CodeableConcept Billing Code Billing, service, product, or drug code
USCLS Codes ( Example )
. . . . . modifier 0..* CodeableConcept Service/Product billing modifiers
Modifier type Codes ( Example )
. . . . . programCode 0..* CodeableConcept Program specific reason for item inclusion the product or service is provided under
Example Program Reason Codes ( Example )
. . . . . quantity 0..1 SimpleQuantity Count of Products products or Services services
. . . . . unitPrice 0..1 Money Fee, charge or cost per point item
. . . . . factor 0..1 decimal Price scaling factor
. . . . . net 0..1 Money Total additional item cost
. . . . . udi 0..* Reference ( Device ) Unique Device Identifier device identifier
. . . . . subDetail 0..* BackboneElement Additional items Product or service provided
. . . . . . sequence 1..1 positiveInt Service Item instance identifier
. . . . . . revenue 0..1 CodeableConcept Revenue or cost center code
Example Revenue Center Codes ( Example )
. . . . . . category 0..1 CodeableConcept Type of service or product Benefit classification
Benefit SubCategory Category Codes ( Example )
. . . . . service . productOrService 0..1 1..1 CodeableConcept Billing Code Billing, service, product, or drug code
USCLS Codes ( Example )
. . . . . . modifier 0..* CodeableConcept Service/Product billing modifiers
Modifier type Codes ( Example )
. . . . . . programCode 0..* CodeableConcept Program specific reason for item inclusion the product or service is provided under
Example Program Reason Codes ( Example )
. . . . . . quantity 0..1 SimpleQuantity Count of Products products or Services services
. . . . . . unitPrice 0..1 Money Fee, charge or cost per point item
. . . . . . factor 0..1 decimal Price scaling factor
. . . . . . net 0..1 Money Net additional Total item cost
. . . . . . udi 0..* Reference ( Device ) Unique Device Identifier device identifier
. . . total 0..1 Money Total claim cost

doco Documentation for this format

UML Diagram ( Legend )

Claim ( DomainResource ) The business A unique identifier for the instance: assigned to this claim number, pre-determination or pre-authorization number identifier : Identifier [0..*] The status of the resource instance (this element modifies the meaning of other elements) status : code [0..1] [1..1] « A code specifying the state of the resource instance. (Strength=Required) Financial Resource Status FinancialResourceStatusCodes ! » The category of claim, eg, e.g. oral, pharmacy, vision, insitutional, institutional, professional type : CodeableConcept [0..1] [1..1] « The type or discipline-style of the claim claim. (Strength=Extensible) Claim Type ClaimTypeCodes + » A finer grained suite of claim subtype type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service. In the US the BillType service subType : CodeableConcept [0..*] [0..1] « A more granular claim typecode typecode. (Strength=Example) Example Claim SubType ExampleClaimSubTypeCodes ?? » Complete (Bill A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or Claim), Proposed (Pre-Authorization), Exploratory (Pre-determination) requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future use : code [0..1] [1..1] « Complete, proposed, exploratory, other The purpose of the Claim: predetermination, preauthorization, claim. (Strength=Required) Use ! » Patient Resource The party to whom the professional services and/or products have been supplied or are being considered and for whom actual or forecast reimbursement is sought patient : Reference [0..1] [1..1] « Patient » The billable period for which charges are being submitted billablePeriod : Period [0..1] The date when the enclosed suite of services were performed or completed this resource was created created : dateTime [0..1] [1..1] Person Individual who created the invoice/claim/pre-determination claim, predetermination or pre-authorization preauthorization enterer : Reference [0..1] « Practitioner | PractitionerRole » The Insurer who is target of the request insurer : Reference [0..1] « Organization » The provider which is responsible for the bill, claim pre-determination, pre-authorization claim, predetermination or preauthorization provider : Reference [0..1] [1..1] « Practitioner | PractitionerRole | Organization » Immediate (STAT), best effort (NORMAL), The provider-required urgency of processing the request. Typical values include: stat, routine deferred (DEFER) priority : CodeableConcept [0..1] [1..1] « The timeliness with which processing is required: STAT, stat, normal, Deferred deferred. (Strength=Example) Process Priority ProcessPriorityCodes ?? » In the case of a Pre-Determination/Pre-Authorization the provider may request that A code to indicate whether and for whom funds in the amount of the expected Benefit are to be reserved ('Patient' or 'Provider') to pay for the Benefits determined on the subsequent claim(s). 'None' explicitly indicates no funds reserving is requested future claims fundsReserve : CodeableConcept [0..1] « For whom funds are to be reserved: (Patient, Provider, None). (Strength=Example) Funds Reservation ?? » Prescription to support the dispensing of Pharmacy pharmacy, device or Vision vision products prescription : Reference [0..1] « DeviceRequest | MedicationRequest | VisionPrescription » Original prescription which has been superceded superseded by this prescription to support the dispensing of pharmacy services, medications or products. For example, a physician may prescribe a medication which the pharmacy determines is contraindicated, or for which the patient has an intolerance, and therefor issues a new precription for an alternate medication which has the same theraputic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription' products originalPrescription : Reference [0..1] « DeviceRequest | MedicationRequest | VisionPrescription » The A reference to a referral resource which lists the date, practitioner, reason and other supporting information referral : Reference [0..1] « ServiceRequest » Facility where the services were provided facility : Reference [0..1] « Location » The total value of the all the items in the claim total : Money [0..1] RelatedClaim Other claims which are related Reference to this claim such as prior claim versions or for a related services claim claim : Reference [0..1] « Claim » For example prior or umbrella A code to convey how the claims are related relationship : CodeableConcept [0..1] « Relationship of this claim to a related Claim Claim. (Strength=Example) Example Related Claim Relatio... ExampleRelatedClaimRelationsh... ?? » An alternate organizational reference to the case or file to which this particular claim pertains - eg Property/Casualy insurer claim # or Workers Compensation case # reference : Identifier [0..1] Payee Type of Party to be reimbursed: Subscriber, subscriber, provider, other type : CodeableConcept [1..1] « A code for the party to be reimbursed. (Strength=Example) Claim Payee Type ?? » Reference to the individual or organization | patient | practitioner | relatedperson resource : Coding [0..1] « The type of Claim payee Resource (Strength=Extensible) ClaimPayeeResourceType + » Party to whom any payment will be reimbursed: Subscriber, provider, other made party : Reference [0..1] « Practitioner | PractitionerRole | Organization | Patient | RelatedPerson » CareTeam Sequence of the careTeam which serves A number to order and provide a link uniquely identify care team entries sequence : positiveInt [1..1] Member of the team who provided the overall product or service provider : Reference [1..1] « Practitioner | PractitionerRole | Organization » The party who is billing and and/or responsible for the claimed good products or service rendered to the patient services responsible : boolean [0..1] The lead, assisting or supervising practitioner and their discipline if a multidisiplinary multidisciplinary team role : CodeableConcept [0..1] « The role codes for the care team members. (Strength=Example) Claim Care Team Role ClaimCareTeamRoleCodes ?? » The qualification of the practitioner which is applicable for this service qualification : CodeableConcept [0..1] « Provider professional qualifications qualifications. (Strength=Example) Example Provider Qualificatio... ExampleProviderQualificationC... ?? » SpecialCondition SupportingInformation Sequence of the information element which serves A number to provide a link uniquely identify supporting information entries sequence : positiveInt [1..1] The general class of the information supplied: information; exception; accident, employment; onset, etc category : CodeableConcept [1..1] « The valuset used for additional information category codes. (Strength=Example) Claim Information Category ClaimInformationCategoryCodes ?? » System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought which may influence the adjudication code : CodeableConcept [0..1] « The valuset used for additional information codes. (Strength=Example) Exception ExceptionCodes ?? » The date when or period to which this information refers timing[x] : Type [0..1] « date | Period » Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data value[x] : Type [0..1] « boolean | string | Quantity | Attachment | Reference ( Any ) » For example, provides Provides the reason for: in the additional stay, or missing tooth or any other situation where a reason code is required in addition to the content reason : CodeableConcept [0..1] « Reason codes for the missing teeth teeth. (Strength=Example) Missing Tooth Reason MissingToothReasonCodes ?? » Diagnosis Sequence of diagnosis which serves A number to provide a link uniquely identify diagnosis entries sequence : positiveInt [1..1] The diagnosis nature of illness or problem in a coded form or as a reference to an external defined Condition diagnosis[x] : Type [1..1] « CodeableConcept | Reference ( Condition ); Example ICD10 Diagnostic codes codes. (Strength=Example) ICD-10 ICD-10Codes ?? » The type of When the Diagnosis, for example: admitting, primary, secondary, discharge condition was observed or the relative ranking type : CodeableConcept [0..*] « The type of the diagnosis: admitting, principal, discharge discharge. (Strength=Example) Example Diagnosis Type ExampleDiagnosisTypeCodes ?? » The Indication of whether the diagnosis was present on admission to a facility onAdmission : CodeableConcept [0..1] « Present on admission. (Strength=Example) ExampleDiagnosisOnAdmissionCo... ?? » A package billing code, for example DRG, code or bundle code used to group products and services to a particular health condition (such as heart attack) which is based on the assigned a predetermined grouping code system packageCode : CodeableConcept [0..1] « The DRG codes associated with the diagnosis diagnosis. (Strength=Example) Example Diagnosis Related Gro... ExampleDiagnosisRelatedGroupC... ?? » Procedure Sequence of procedures which serves A number to order and provide a link uniquely identify procedure entries sequence : positiveInt [1..1] When the condition was observed or the relative ranking type : CodeableConcept [0..*] « Example procedure type codes. (Strength=Example) ExampleProcedureTypeCodes ?? » Date and optionally time the procedure was performed date : dateTime [0..1] The procedure code or reference to a Procedure resource which identifies the clinical intervention performed procedure[x] : Type [1..1] « CodeableConcept | Reference ( Procedure ); Example ICD10 Procedure codes codes. (Strength=Example) ICD-10 Procedure ICD-10ProcedureCodes ?? » Unique Device Identifiers associated with this line item udi : Reference [0..*] « Device » Insurance Sequence of coverage which serves A number to uniquely identify insurance entries and provide a link and sequence of coverages to convey coordination of benefit order sequence : positiveInt [1..1] A flag to indicate that this Coverage is the focus to be used for adjudication. The Coverage against which the adjudication of this claim is when set to be adjudicated true focal : boolean [1..1] The business identifier for to be used when the instance: claim number, pre-determination or pre-authorization number is sent for adjudication against this insurance policy identifier : Identifier [0..1] Reference to the program or plan identification, underwriter or payor insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system coverage : Reference [1..1] « Coverage » The contract number of a A business agreement which describes number established between the terms provider and conditions the insurer for special business processing purposes businessArrangement : string [0..1] A list of references from Reference numbers previously provided by the Insurer insurer to which these the provider to be quoted on subsequent claims containing services pertain or products related to the prior authorization preAuthRef : string [0..*] The Coverages result of the adjudication details of the line items for the Coverage specified in this insurance claimResponse : Reference [0..1] « ClaimResponse » Accident Date of an accident which these event related to the products and services are addressing contained in the claim date : date [1..1] Type The type or context of accident: work, auto, etc the accident event for the purposes of selection of potential insurance coverages and determination of coordination between insurers type : CodeableConcept [0..1] « Type of accident: work place, auto, etc. (Strength=Extensible) ActIncidentCode v3.ActIncidentCode + » Accident Place The physical location of the accident event location[x] : Type [0..1] « Address | Reference ( Location ) » Item A service line number to uniquely identify item entries sequence : positiveInt [1..1] CareTeam applicable for members related to this service or product line careTeamSequence : positiveInt [0..*] Diagnosis applicable for this service or product line diagnosisSequence : positiveInt [0..*] Procedures applicable for this service or product line procedureSequence : positiveInt [0..*] Exceptions, special conditions and supporting information pplicable applicable for this service or product line informationSequence : positiveInt [0..*] The type of reveneu revenue or cost center providing the product and/or service revenue : CodeableConcept [0..1] « Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example) Example Revenue Center ExampleRevenueCenterCodes ?? » Health Care Service Type Codes Code to identify the classification general type of service or benefits under which products and services are provided category : CodeableConcept [0..1] « Benefit subcategories categories such as: oral-basic, major, glasses glasses. (Strength=Example) Benefit SubCategory BenefitCategoryCodes ?? » If this When the value is an actual service or product line, ie. not a Group, then use group code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,RXNorm,ACHI,CCI). If a grouping item then use this item collects a group code to indicate the type set of thing being grouped eg. 'glasses' related claim details, otherwise this contains the product, service, drug or 'compound' other billing code for the item service productOrService : CodeableConcept [0..1] [1..1] « Allowable service and product codes codes. (Strength=Example) USCLS USCLSCodes ?? » Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or codes to convey additional context for medical whether the treatment was outside the clinic product or out of office hours service modifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example) Modifier type ModifierTypeCodes ?? » For programs which require reason codes for the inclusion or covering of this billed item under Identifies the program or sub-program under which this may be recovered programCode : CodeableConcept [0..*] « Program specific reason codes codes. (Strength=Example) Example Program Reason ExampleProgramReasonCodes ?? » The date or dates when the enclosed suite of services were service or product was supplied, performed or completed serviced[x] : Type [0..1] « date | Period » Where the product or service was provided location[x] : Type [0..1] « CodeableConcept | Address | Reference ( Location ); Place of service: pharmacy,school, pharmacy, school, prison, etc. (Strength=Example) Example Service Place ExampleServicePlaceCodes ?? » The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] If the item is not a node group then this is the fee for the product or service, otherwise this is the total of the fees for the children details of the group unitPrice : Money [0..1] A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount factor : decimal [0..1] The quantity times the unit price for an addittional additional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied charge net : Money [0..1] List of Unique Device Identifiers associated with this line item udi : Reference [0..*] « Device » Physical service site on the patient (limb, tooth, etc.) bodySite : CodeableConcept [0..1] « The code for the teeth, quadrant, sextant and arch arch. (Strength=Example) Oral Site OralSiteCodes ?? » A region or surface of the site, eg. bodySite, e.g. limb region or tooth surface(s) subSite : CodeableConcept [0..*] « The code for the tooth surface and surface combinations combinations. (Strength=Example) Surface SurfaceCodes ?? » A billed item may include goods The Encounters during which this Claim was created or services provided in multiple encounters to which the creation of this record is tightly associated encounter : Reference [0..*] « Encounter » Detail A service line number to uniquely identify item entries sequence : positiveInt [1..1] The type of reveneu revenue or cost center providing the product and/or service revenue : CodeableConcept [0..1] « Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example) Example Revenue Center ExampleRevenueCenterCodes ?? » Health Care Service Type Codes Code to identify the classification general type of service or benefits under which products and services are provided category : CodeableConcept [0..1] « Benefit subcategories categories such as: oral-basic, major, glasses glasses. (Strength=Example) Benefit SubCategory BenefitCategoryCodes ?? » If this When the value is an actual service or product line, ie. not a Group, then use group code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). If a grouping item then use this item collects a group code to indicate the type set of thing being grouped eg. 'glasses' related claim details, otherwise this contains the product, service, drug or 'compound' other billing code for the item service productOrService : CodeableConcept [0..1] [1..1] « Allowable service and product codes codes. (Strength=Example) USCLS USCLSCodes ?? » Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or codes to convey additional context for medical whether the treatment was outside the clinic product or out of office hours service modifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example) Modifier type ModifierTypeCodes ?? » For programs which require reson codes for the inclusion, covering, of this billed item under Identifies the program or sub-program under which this may be recovered programCode : CodeableConcept [0..*] « Program specific reason codes codes. (Strength=Example) Example Program Reason ExampleProgramReasonCodes ?? » The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] If the item is not a node group then this is the fee for the product or service, otherwise this is the total of the fees for the children details of the group unitPrice : Money [0..1] A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount factor : decimal [0..1] The quantity times the unit price for an addittional additional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied charge net : Money [0..1] List of Unique Device Identifiers associated with this line item udi : Reference [0..*] « Device » SubDetail A service line number to uniquely identify item entries sequence : positiveInt [1..1] The type of reveneu revenue or cost center providing the product and/or service revenue : CodeableConcept [0..1] « Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example) Example Revenue Center ExampleRevenueCenterCodes ?? » Health Care Service Type Codes Code to identify the classification general type of service or benefits under which products and services are provided category : CodeableConcept [0..1] « Benefit subcategories categories such as: oral-basic, major, glasses glasses. (Strength=Example) Benefit SubCategory BenefitCategoryCodes ?? » A When the value is a group code to indicate then this item collects a set of related claim details, otherwise this contains the Professional Service product, service, drug or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI) other billing code for the item service productOrService : CodeableConcept [0..1] [1..1] « Allowable service and product codes codes. (Strength=Example) USCLS USCLSCodes ?? » Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or codes to convey additional context for medical whether the treatment was outside the clinic product or out of office hours service modifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example) Modifier type ModifierTypeCodes ?? » For programs which require reson codes for the inclusion, covering, of this billed item under Identifies the program or sub-program under which this may be recovered programCode : CodeableConcept [0..*] « Program specific reason codes codes. (Strength=Example) Example Program Reason ExampleProgramReasonCodes ?? » The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] The If the item is not a group then this is the fee for an addittional service or the product or charge service, otherwise this is the total of the fees for the details of the group unitPrice : Money [0..1] A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount factor : decimal [0..1] The quantity times the unit price for an addittional additional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied charge net : Money [0..1] List of Unique Device Identifiers associated with this line item udi : Reference [0..*] « Device » Other claims which are related to this claim such as prior claim versions submissions or claims for related services or for the same event related [0..*] The party to be reimbursed for cost of the products and services according to the terms of the policy payee [0..1] The members of the team who provided the overall service as well as their role and whether responsible products and qualifications services careTeam [0..*] Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. Often there are mutiple jurisdiction specific valuesets which are required issues information supportingInfo [0..*] List of patient diagnosis for which care is sought Information about diagnoses relevant to the claim items diagnosis [0..*] Ordered list of patient procedures Procedures performed on the patient relevant to support the adjudication billing items with the claim procedure [0..*] Financial instrument by which payment information instruments for reimbursement for the health care products and services specified on the claim insurance [0..*] [1..*] An Details of an accident which resulted in injuries which required the need for healthcare products and services listed in the claim accident [0..1] Third tier A claim detail line. Either a simple (a product or service) or a 'group' of goods and services sub-details which are simple items subDetail [0..*] Second tier A claim detail line. Either a simple (a product or service) or a 'group' of goods and services sub-details which are simple items detail [0..*] First tier A claim line. Either a simple product or service or a 'group' of goods and services details which can each be a simple items or groups of sub-details item [0..*]

XML Template

<Claim xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <</identifier>
 <
 <</type>
 <</subType>
 <
 <</patient>
 <</billablePeriod>
 <
 <</enterer>

 <identifier><!-- 0..* Identifier Business Identifier for claim --></identifier>
 <status value="[code]"/><!-- 1..1 active | cancelled | draft | entered-in-error -->
 <type><!-- 1..1 CodeableConcept Category or discipline --></type>
 <subType><!-- 0..1 CodeableConcept More granular claim type --></subType>
 <use value="[code]"/><!-- 1..1 claim | preauthorization | predetermination -->
 <patient><!-- 1..1 Reference(Patient) The recipient of the products and services --></patient>
 <billablePeriod><!-- 0..1 Period Relevant time frame for the claim --></billablePeriod>
 <created value="[dateTime]"/><!-- 1..1 Resource creation date -->
 <enterer><!-- 0..1 Reference(Practitioner|PractitionerRole) Author of the claim --></enterer>

 <insurer><!-- 0..1 Reference(Organization) Target --></insurer>
 <</provider>
 <</priority>
 <</fundsReserve>
 <
  <</claim>
  <</relationship>
  <</reference>

 <provider><!-- 1..1 Reference(Organization|Practitioner|PractitionerRole) Party responsible for the claim --></provider>
 <priority><!-- 1..1 CodeableConcept Desired processing ugency --></priority>
 <fundsReserve><!-- 0..1 CodeableConcept For whom to reserve funds --></fundsReserve>
 <related>  <!-- 0..* Prior or corollary claims -->
  <claim><!-- 0..1 Reference(Claim) Reference to the related claim --></claim>
  <relationship><!-- 0..1 CodeableConcept How the reference claim is related --></relationship>
  <reference><!-- 0..1 Identifier File or case reference --></reference>

 </related>
 <</prescription>
 <</originalPrescription>
 <
  <</type>
  <</resource>
  <|
    </party>

 <prescription><!-- 0..1 Reference(DeviceRequest|MedicationRequest|
   VisionPrescription) Prescription authorizing services and products --></prescription>
 <originalPrescription><!-- 0..1 Reference(DeviceRequest|MedicationRequest|
   VisionPrescription) Original prescription if superseded by fulfiller --></originalPrescription>
 <payee>  <!-- 0..1 Recipient of benefits payable -->
  <type><!-- 1..1 CodeableConcept Category of recipient --></type>
  <party><!-- 0..1 Reference(Organization|Patient|Practitioner|PractitionerRole|
    RelatedPerson) Recipient reference --></party>
 </payee>
 <</referral>
 <</facility>
 <
  <
  <</provider>
  <
  <</role>
  <</qualification>

 <referral><!-- 0..1 Reference(ServiceRequest) Treatment referral --></referral>
 <facility><!-- 0..1 Reference(Location) Servicing facility --></facility>
 <careTeam>  <!-- 0..* Members of the care team -->
  <sequence value="[positiveInt]"/><!-- 1..1 Order of care team -->
  <provider><!-- 1..1 Reference(Organization|Practitioner|PractitionerRole) Practitioner or organization --></provider>
  <responsible value="[boolean]"/><!-- 0..1 Indicator of the lead practitioner -->
  <role><!-- 0..1 CodeableConcept Function within the team --></role>
  <qualification><!-- 0..1 CodeableConcept Practitioner credential or specialization --></qualification>

 </careTeam>
 <
  <
  <</category>
  <</code>
  <</timing[x]>
  <</value[x]>
  <</reason>
 </information>
 <
  <
  <</diagnosis[x]>
  <</type>
  <</packageCode>

 <supportingInfo>  <!-- 0..* Supporting information -->
  <sequence value="[positiveInt]"/><!-- 1..1 Information instance identifier -->
  <category><!-- 1..1 CodeableConcept Classification of the supplied information --></category>
  <code><!-- 0..1 CodeableConcept Type of information --></code>
  <timing[x]><!-- 0..1 date|Period When it occurred --></timing[x]>
  <value[x]><!-- 0..1 boolean|string|Quantity|Attachment|Reference(Any) Data to be provided --></value[x]>
  <reason><!-- 0..1 CodeableConcept Explanation for the information --></reason>
 </supportingInfo>
 <diagnosis>  <!-- 0..* Pertinent diagnosis information -->
  <sequence value="[positiveInt]"/><!-- 1..1 Diagnosis instance identifier -->
  <diagnosis[x]><!-- 1..1 CodeableConcept|Reference(Condition) Nature of illness or problem --></diagnosis[x]>
  <type><!-- 0..* CodeableConcept Timing or nature of the diagnosis --></type>
  <onAdmission><!-- 0..1 CodeableConcept Present on admission --></onAdmission>
  <packageCode><!-- 0..1 CodeableConcept Package billing code --></packageCode>

 </diagnosis>
 <
  <
  <
  <</procedure[x]>

 <procedure>  <!-- 0..* Clinical procedures performed -->
  <sequence value="[positiveInt]"/><!-- 1..1 Procedure instance identifier -->
  <type><!-- 0..* CodeableConcept Category of Procedure --></type>
  <date value="[dateTime]"/><!-- 0..1 When the procedure was performed -->
  <procedure[x]><!-- 1..1 CodeableConcept|Reference(Procedure) Specific clinical procedure --></procedure[x]>
  <udi><!-- 0..* Reference(Device) Unique device identifier --></udi>

 </procedure>
 <
  <
  <
  <</identifier>
  <</coverage>
  <
  <
  <</claimResponse>

 <insurance>  <!-- 1..* Patient insurance information -->
  <sequence value="[positiveInt]"/><!-- 1..1 Insurance instance identifier -->
  <focal value="[boolean]"/><!-- 1..1 Coverage to be used for adjudication -->
  <identifier><!-- 0..1 Identifier Pre-assigned Claim number --></identifier>
  <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage>
  <businessArrangement value="[string]"/><!-- 0..1 Additional provider contract number -->
  <preAuthRef value="[string]"/><!-- 0..* Prior authorization reference number -->
  <claimResponse><!-- 0..1 Reference(ClaimResponse) Adjudication results --></claimResponse>

 </insurance>
 <
  <When the accident occurred
see information codes
see information codes
  <</type>
  <</location[x]>

 <accident>  <!-- 0..1 Details of the event -->
  <date value="[date]"/><!-- 1..1 When the incident occurred -->
  <type><!-- 0..1 CodeableConcept The nature of the accident --></type>
  <location[x]><!-- 0..1 Address|Reference(Location) Where the event occurred --></location[x]>

 </accident>
 <
  <
  <
  <
  <
  <
  <</revenue>
  <</category>
  <</service>
  <</modifier>
  <</programCode>
  <</serviced[x]>
  <</location[x]>
  <</quantity>
  <</unitPrice>

 <item>  <!-- 0..* Product or service provided -->
  <sequence value="[positiveInt]"/><!-- 1..1 Item instance identifier -->
  <careTeamSequence value="[positiveInt]"/><!-- 0..* Applicable careTeam members -->
  <diagnosisSequence value="[positiveInt]"/><!-- 0..* Applicable diagnoses -->
  <procedureSequence value="[positiveInt]"/><!-- 0..* Applicable procedures -->
  <informationSequence value="[positiveInt]"/><!-- 0..* Applicable exception and supporting information -->
  <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
  <category><!-- 0..1 CodeableConcept Benefit classification --></category>
  <productOrService><!-- 1..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
  <modifier><!-- 0..* CodeableConcept Product or service billing modifiers --></modifier>
  <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode>
  <serviced[x]><!-- 0..1 date|Period Date or dates of service or product delivery --></serviced[x]>
  <location[x]><!-- 0..1 CodeableConcept|Address|Reference(Location) Place of service or where product was supplied --></location[x]>
  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
  <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>

  <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
  <</net>
  <</udi>
  <</bodySite>
  <</subSite>
  <</encounter>
  <
   <
   <</revenue>
   <</category>
   <</service>
   <</modifier>
   <</programCode>
   <</quantity>
   <</unitPrice>

  <net><!-- 0..1 Money Total item cost --></net>
  <udi><!-- 0..* Reference(Device) Unique device identifier --></udi>
  <bodySite><!-- 0..1 CodeableConcept Anatomical location --></bodySite>
  <subSite><!-- 0..* CodeableConcept Anatomical sub-location --></subSite>
  <encounter><!-- 0..* Reference(Encounter) Encounters related to this billed item --></encounter>
  <detail>  <!-- 0..* Product or service provided -->
   <sequence value="[positiveInt]"/><!-- 1..1 Item instance identifier -->
   <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
   <category><!-- 0..1 CodeableConcept Benefit classification --></category>
   <productOrService><!-- 1..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
   <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
   <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode>
   <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
   <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>

   <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
   <</net>
   <</udi>
   <
    <
    <</revenue>
    <</category>
    <</service>
    <</modifier>
    <</programCode>
    <</quantity>
    <</unitPrice>

   <net><!-- 0..1 Money Total item cost --></net>
   <udi><!-- 0..* Reference(Device) Unique device identifier --></udi>
   <subDetail>  <!-- 0..* Product or service provided -->
    <sequence value="[positiveInt]"/><!-- 1..1 Item instance identifier -->
    <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
    <category><!-- 0..1 CodeableConcept Benefit classification --></category>
    <productOrService><!-- 1..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
    <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
    <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode>
    <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
    <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>

    <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
    <</net>
    <</udi>

    <net><!-- 0..1 Money Total item cost --></net>
    <udi><!-- 0..* Reference(Device) Unique device identifier --></udi>

   </subDetail>
  </detail>
 </item>
 <</total>

 <total><!-- 0..1 Money Total claim cost --></total>

</Claim>

JSON Template

{doco
  "resourceType" : "",

  "resourceType" : "Claim",

  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "
  "
  "
  "
  "
  "
  "
  "
  "

  "identifier" : [{ Identifier }], // Business Identifier for claim
  "status" : "<code>", // R!  active | cancelled | draft | entered-in-error
  "type" : { CodeableConcept }, // R!  Category or discipline
  "subType" : { CodeableConcept }, // More granular claim type
  "use" : "<code>", // R!  claim | preauthorization | predetermination
  "patient" : { Reference(Patient) }, // R!  The recipient of the products and services
  "billablePeriod" : { Period }, // Relevant time frame for the claim
  "created" : "<dateTime>", // R!  Resource creation date
  "enterer" : { Reference(Practitioner|PractitionerRole) }, // Author of the claim

  "insurer" : { Reference(Organization) }, // Target
  "
  "
  "
  "
    "
    "
    "

  "provider" : { Reference(Organization|Practitioner|PractitionerRole) }, // R!  Party responsible for the claim
  "priority" : { CodeableConcept }, // R!  Desired processing ugency
  "fundsReserve" : { CodeableConcept }, // For whom to reserve funds
  "related" : [{ // Prior or corollary claims
    "claim" : { Reference(Claim) }, // Reference to the related claim
    "relationship" : { CodeableConcept }, // How the reference claim is related
    "reference" : { Identifier } // File or case reference

  }],
  "
  "
  "
    "
    "
    "|
    

  "prescription" : { Reference(DeviceRequest|MedicationRequest|
   VisionPrescription) }, // Prescription authorizing services and products
  "originalPrescription" : { Reference(DeviceRequest|MedicationRequest|
   VisionPrescription) }, // Original prescription if superseded by fulfiller
  "payee" : { // Recipient of benefits payable
    "type" : { CodeableConcept }, // R!  Category of recipient
    "party" : { Reference(Organization|Patient|Practitioner|PractitionerRole|
    RelatedPerson) } // Recipient reference
  },
  "
  "
  "
    "
    "
    "
    "
    "

  "referral" : { Reference(ServiceRequest) }, // Treatment referral
  "facility" : { Reference(Location) }, // Servicing facility
  "careTeam" : [{ // Members of the care team
    "sequence" : "<positiveInt>", // R!  Order of care team
    "provider" : { Reference(Organization|Practitioner|PractitionerRole) }, // R!  Practitioner or organization
    "responsible" : <boolean>, // Indicator of the lead practitioner
    "role" : { CodeableConcept }, // Function within the team
    "qualification" : { CodeableConcept } // Practitioner credential or specialization

  }],
  "
    "
    "
    "

  "supportingInfo" : [{ // Supporting information
    "sequence" : "<positiveInt>", // R!  Information instance identifier
    "category" : { CodeableConcept }, // R!  Classification of the supplied information
    "code" : { CodeableConcept }, // Type of information

    // timing[x]: When it occurred. One of these 2:
    ">",
    " },
    
    ">,
    ">",
    " },
    " },
    " },
    "

    "timingDate" : "<date>",
    "timingPeriod" : { Period },
    // value[x]: Data to be provided. One of these 5:
    "valueBoolean" : <boolean>,
    "valueString" : "<string>",
    "valueQuantity" : { Quantity },
    "valueAttachment" : { Attachment },
    "valueReference" : { Reference(Any) },
    "reason" : { CodeableConcept } // Explanation for the information

  }],
  "
    "
    
    " },
    " },
    "
    "

  "diagnosis" : [{ // Pertinent diagnosis information
    "sequence" : "<positiveInt>", // R!  Diagnosis instance identifier
    // diagnosis[x]: Nature of illness or problem. One of these 2:
    "diagnosisCodeableConcept" : { CodeableConcept },
    "diagnosisReference" : { Reference(Condition) },
    "type" : [{ CodeableConcept }], // Timing or nature of the diagnosis
    "onAdmission" : { CodeableConcept }, // Present on admission
    "packageCode" : { CodeableConcept } // Package billing code

  }],
  "
    "
    "
    
    " }
    " }

  "procedure" : [{ // Clinical procedures performed
    "sequence" : "<positiveInt>", // R!  Procedure instance identifier
    "type" : [{ CodeableConcept }], // Category of Procedure
    "date" : "<dateTime>", // When the procedure was performed
    // procedure[x]: Specific clinical procedure. One of these 2:
    "procedureCodeableConcept" : { CodeableConcept },
    "procedureReference" : { Reference(Procedure) },
    "udi" : [{ Reference(Device) }] // Unique device identifier

  }],
  "
    "
    "
    "
    "
    "
    "
    "

  "insurance" : [{ // R!  Patient insurance information
    "sequence" : "<positiveInt>", // R!  Insurance instance identifier
    "focal" : <boolean>, // R!  Coverage to be used for adjudication
    "identifier" : { Identifier }, // Pre-assigned Claim number
    "coverage" : { Reference(Coverage) }, // R!  Insurance information
    "businessArrangement" : "<string>", // Additional provider contract number
    "preAuthRef" : ["<string>"], // Prior authorization reference number
    "claimResponse" : { Reference(ClaimResponse) } // Adjudication results

  }],
  "
    "When the accident occurred
see information codes
see information codes
    "
    
    " }
    " }

  "accident" : { // Details of the event
    "date" : "<date>", // R!  When the incident occurred
    "type" : { CodeableConcept }, // The nature of the accident
    // location[x]: Where the event occurred. One of these 2:
    "locationAddress" : { Address }
    "locationReference" : { Reference(Location) }

  },
  "
    "
    "
    "
    "
    "
    "
    "
    "
    "
    "
    
    ">",
    " },
    
    " },
    " },
    " },
    "
    "

  "item" : [{ // Product or service provided
    "sequence" : "<positiveInt>", // R!  Item instance identifier
    "careTeamSequence" : ["<positiveInt>"], // Applicable careTeam members
    "diagnosisSequence" : ["<positiveInt>"], // Applicable diagnoses
    "procedureSequence" : ["<positiveInt>"], // Applicable procedures
    "informationSequence" : ["<positiveInt>"], // Applicable exception and supporting information
    "revenue" : { CodeableConcept }, // Revenue or cost center code
    "category" : { CodeableConcept }, // Benefit classification
    "productOrService" : { CodeableConcept }, // R!  Billing, service, product, or drug code
    "modifier" : [{ CodeableConcept }], // Product or service billing modifiers
    "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
    // serviced[x]: Date or dates of service or product delivery. One of these 2:
    "servicedDate" : "<date>",
    "servicedPeriod" : { Period },
    // location[x]: Place of service or where product was supplied. One of these 3:
    "locationCodeableConcept" : { CodeableConcept },
    "locationAddress" : { Address },
    "locationReference" : { Reference(Location) },
    "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
    "unitPrice" : { Money }, // Fee, charge or cost per item

    "factor" : <decimal>, // Price scaling factor
    "
    "
    "
    "
    "
    "
      "
      "
      "
      "
      "
      "
      "
      "

    "net" : { Money }, // Total item cost
    "udi" : [{ Reference(Device) }], // Unique device identifier
    "bodySite" : { CodeableConcept }, // Anatomical location
    "subSite" : [{ CodeableConcept }], // Anatomical sub-location
    "encounter" : [{ Reference(Encounter) }], // Encounters related to this billed item
    "detail" : [{ // Product or service provided
      "sequence" : "<positiveInt>", // R!  Item instance identifier
      "revenue" : { CodeableConcept }, // Revenue or cost center code
      "category" : { CodeableConcept }, // Benefit classification
      "productOrService" : { CodeableConcept }, // R!  Billing, service, product, or drug code
      "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
      "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
      "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
      "unitPrice" : { Money }, // Fee, charge or cost per item

      "factor" : <decimal>, // Price scaling factor
      "
      "
      "
        "
        "
        "
        "
        "
        "
        "
        "

      "net" : { Money }, // Total item cost
      "udi" : [{ Reference(Device) }], // Unique device identifier
      "subDetail" : [{ // Product or service provided
        "sequence" : "<positiveInt>", // R!  Item instance identifier
        "revenue" : { CodeableConcept }, // Revenue or cost center code
        "category" : { CodeableConcept }, // Benefit classification
        "productOrService" : { CodeableConcept }, // R!  Billing, service, product, or drug code
        "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
        "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
        "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
        "unitPrice" : { Money }, // Fee, charge or cost per item

        "factor" : <decimal>, // Price scaling factor
        "
        "

        "net" : { Money }, // Total item cost
        "udi" : [{ Reference(Device) }] // Unique device identifier

      }]
    }]
  }],
  "

  "total" : { Money } // Total claim cost

}

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .doco
[ a fhir:;

[ a fhir:Claim;

  fhir:nodeRole fhir:treeRoot; # if this is the parser root
  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:

  fhir:Claim.identifier [ Identifier ], ... ; # 0..* Business Identifier for claim
  fhir:Claim.status [ code ]; # 1..1 active | cancelled | draft | entered-in-error
  fhir:Claim.type [ CodeableConcept ]; # 1..1 Category or discipline
  fhir:Claim.subType [ CodeableConcept ]; # 0..1 More granular claim type
  fhir:Claim.use [ code ]; # 1..1 claim | preauthorization | predetermination
  fhir:Claim.patient [ Reference(Patient) ]; # 1..1 The recipient of the products and services
  fhir:Claim.billablePeriod [ Period ]; # 0..1 Relevant time frame for the claim
  fhir:Claim.created [ dateTime ]; # 1..1 Resource creation date
  fhir:Claim.enterer [ Reference(Practitioner|PractitionerRole) ]; # 0..1 Author of the claim

  fhir:Claim.insurer [ Reference(Organization) ]; # 0..1 Target
  fhir:
  fhir:
  fhir:
  fhir:
    fhir:
    fhir:
    fhir:

  fhir:Claim.provider [ Reference(Organization|Practitioner|PractitionerRole) ]; # 1..1 Party responsible for the claim
  fhir:Claim.priority [ CodeableConcept ]; # 1..1 Desired processing ugency
  fhir:Claim.fundsReserve [ CodeableConcept ]; # 0..1 For whom to reserve funds
  fhir:Claim.related [ # 0..* Prior or corollary claims
    fhir:Claim.related.claim [ Reference(Claim) ]; # 0..1 Reference to the related claim
    fhir:Claim.related.relationship [ CodeableConcept ]; # 0..1 How the reference claim is related
    fhir:Claim.related.reference [ Identifier ]; # 0..1 File or case reference

  ], ...;
  fhir:
  fhir:
  fhir:
    fhir:
    fhir:
    fhir:

  fhir:Claim.prescription [ Reference(DeviceRequest|MedicationRequest|VisionPrescription) ]; # 0..1 Prescription authorizing services and products
  fhir:Claim.originalPrescription [ Reference(DeviceRequest|MedicationRequest|VisionPrescription) ]; # 0..1 Original prescription if superseded by fulfiller
  fhir:Claim.payee [ # 0..1 Recipient of benefits payable
    fhir:Claim.payee.type [ CodeableConcept ]; # 1..1 Category of recipient
    fhir:Claim.payee.party [ Reference(Organization|Patient|Practitioner|PractitionerRole|RelatedPerson) ]; # 0..1 Recipient reference

  ];
  fhir:
  fhir:
  fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:

  fhir:Claim.referral [ Reference(ServiceRequest) ]; # 0..1 Treatment referral
  fhir:Claim.facility [ Reference(Location) ]; # 0..1 Servicing facility
  fhir:Claim.careTeam [ # 0..* Members of the care team
    fhir:Claim.careTeam.sequence [ positiveInt ]; # 1..1 Order of care team
    fhir:Claim.careTeam.provider [ Reference(Organization|Practitioner|PractitionerRole) ]; # 1..1 Practitioner or organization
    fhir:Claim.careTeam.responsible [ boolean ]; # 0..1 Indicator of the lead practitioner
    fhir:Claim.careTeam.role [ CodeableConcept ]; # 0..1 Function within the team
    fhir:Claim.careTeam.qualification [ CodeableConcept ]; # 0..1 Practitioner credential or specialization

  ], ...;
  fhir:
    fhir:
    fhir:
    fhir:
    # . One of these 2
      fhir: ]
      fhir: ]
    # . One of these 5
      fhir: ]
      fhir: ]
      fhir: ]
      fhir: ]
      fhir:) ]
    fhir:

  fhir:Claim.supportingInfo [ # 0..* Supporting information
    fhir:Claim.supportingInfo.sequence [ positiveInt ]; # 1..1 Information instance identifier
    fhir:Claim.supportingInfo.category [ CodeableConcept ]; # 1..1 Classification of the supplied information
    fhir:Claim.supportingInfo.code [ CodeableConcept ]; # 0..1 Type of information
    # Claim.supportingInfo.timing[x] : 0..1 When it occurred. One of these 2
      fhir:Claim.supportingInfo.timingDate [ date ]
      fhir:Claim.supportingInfo.timingPeriod [ Period ]
    # Claim.supportingInfo.value[x] : 0..1 Data to be provided. One of these 5
      fhir:Claim.supportingInfo.valueBoolean [ boolean ]
      fhir:Claim.supportingInfo.valueString [ string ]
      fhir:Claim.supportingInfo.valueQuantity [ Quantity ]
      fhir:Claim.supportingInfo.valueAttachment [ Attachment ]
      fhir:Claim.supportingInfo.valueReference [ Reference(Any) ]
    fhir:Claim.supportingInfo.reason [ CodeableConcept ]; # 0..1 Explanation for the information

  ], ...;
  fhir:
    fhir:
    # . One of these 2
      fhir: ]
      fhir:) ]
    fhir:
    fhir:

  fhir:Claim.diagnosis [ # 0..* Pertinent diagnosis information
    fhir:Claim.diagnosis.sequence [ positiveInt ]; # 1..1 Diagnosis instance identifier
    # Claim.diagnosis.diagnosis[x] : 1..1 Nature of illness or problem. One of these 2
      fhir:Claim.diagnosis.diagnosisCodeableConcept [ CodeableConcept ]
      fhir:Claim.diagnosis.diagnosisReference [ Reference(Condition) ]
    fhir:Claim.diagnosis.type [ CodeableConcept ], ... ; # 0..* Timing or nature of the diagnosis
    fhir:Claim.diagnosis.onAdmission [ CodeableConcept ]; # 0..1 Present on admission
    fhir:Claim.diagnosis.packageCode [ CodeableConcept ]; # 0..1 Package billing code

  ], ...;
  fhir:
    fhir:
    fhir:
    # . One of these 2
      fhir: ]
      fhir:) ]

  fhir:Claim.procedure [ # 0..* Clinical procedures performed
    fhir:Claim.procedure.sequence [ positiveInt ]; # 1..1 Procedure instance identifier
    fhir:Claim.procedure.type [ CodeableConcept ], ... ; # 0..* Category of Procedure
    fhir:Claim.procedure.date [ dateTime ]; # 0..1 When the procedure was performed
    # Claim.procedure.procedure[x] : 1..1 Specific clinical procedure. One of these 2
      fhir:Claim.procedure.procedureCodeableConcept [ CodeableConcept ]
      fhir:Claim.procedure.procedureReference [ Reference(Procedure) ]
    fhir:Claim.procedure.udi [ Reference(Device) ], ... ; # 0..* Unique device identifier

  ], ...;
  fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:

  fhir:Claim.insurance [ # 1..* Patient insurance information
    fhir:Claim.insurance.sequence [ positiveInt ]; # 1..1 Insurance instance identifier
    fhir:Claim.insurance.focal [ boolean ]; # 1..1 Coverage to be used for adjudication
    fhir:Claim.insurance.identifier [ Identifier ]; # 0..1 Pre-assigned Claim number
    fhir:Claim.insurance.coverage [ Reference(Coverage) ]; # 1..1 Insurance information
    fhir:Claim.insurance.businessArrangement [ string ]; # 0..1 Additional provider contract number
    fhir:Claim.insurance.preAuthRef [ string ], ... ; # 0..* Prior authorization reference number
    fhir:Claim.insurance.claimResponse [ Reference(ClaimResponse) ]; # 0..1 Adjudication results

  ], ...;
  fhir:
    fhir:When the accident occurred
see information codes
see information codes
    fhir:
    # . One of these 2
      fhir: ]
      fhir:) ]

  fhir:Claim.accident [ # 0..1 Details of the event
    fhir:Claim.accident.date [ date ]; # 1..1 When the incident occurred
    fhir:Claim.accident.type [ CodeableConcept ]; # 0..1 The nature of the accident
    # Claim.accident.location[x] : 0..1 Where the event occurred. One of these 2
      fhir:Claim.accident.locationAddress [ Address ]
      fhir:Claim.accident.locationReference [ Reference(Location) ]

  ];
  fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    # . One of these 2
      fhir: ]
      fhir: ]
    # . One of these 3
      fhir: ]
      fhir: ]
      fhir:) ]
    fhir:
    fhir:

  fhir:Claim.item [ # 0..* Product or service provided
    fhir:Claim.item.sequence [ positiveInt ]; # 1..1 Item instance identifier
    fhir:Claim.item.careTeamSequence [ positiveInt ], ... ; # 0..* Applicable careTeam members
    fhir:Claim.item.diagnosisSequence [ positiveInt ], ... ; # 0..* Applicable diagnoses
    fhir:Claim.item.procedureSequence [ positiveInt ], ... ; # 0..* Applicable procedures
    fhir:Claim.item.informationSequence [ positiveInt ], ... ; # 0..* Applicable exception and supporting information
    fhir:Claim.item.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
    fhir:Claim.item.category [ CodeableConcept ]; # 0..1 Benefit classification
    fhir:Claim.item.productOrService [ CodeableConcept ]; # 1..1 Billing, service, product, or drug code
    fhir:Claim.item.modifier [ CodeableConcept ], ... ; # 0..* Product or service billing modifiers
    fhir:Claim.item.programCode [ CodeableConcept ], ... ; # 0..* Program the product or service is provided under
    # Claim.item.serviced[x] : 0..1 Date or dates of service or product delivery. One of these 2
      fhir:Claim.item.servicedDate [ date ]
      fhir:Claim.item.servicedPeriod [ Period ]
    # Claim.item.location[x] : 0..1 Place of service or where product was supplied. One of these 3
      fhir:Claim.item.locationCodeableConcept [ CodeableConcept ]
      fhir:Claim.item.locationAddress [ Address ]
      fhir:Claim.item.locationReference [ Reference(Location) ]
    fhir:Claim.item.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of products or services
    fhir:Claim.item.unitPrice [ Money ]; # 0..1 Fee, charge or cost per item

    fhir:Claim.item.factor [ decimal ]; # 0..1 Price scaling factor
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
      fhir:
      fhir:
      fhir:
      fhir:
      fhir:
      fhir:
      fhir:
      fhir:

    fhir:Claim.item.net [ Money ]; # 0..1 Total item cost
    fhir:Claim.item.udi [ Reference(Device) ], ... ; # 0..* Unique device identifier
    fhir:Claim.item.bodySite [ CodeableConcept ]; # 0..1 Anatomical location
    fhir:Claim.item.subSite [ CodeableConcept ], ... ; # 0..* Anatomical sub-location
    fhir:Claim.item.encounter [ Reference(Encounter) ], ... ; # 0..* Encounters related to this billed item
    fhir:Claim.item.detail [ # 0..* Product or service provided
      fhir:Claim.item.detail.sequence [ positiveInt ]; # 1..1 Item instance identifier
      fhir:Claim.item.detail.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
      fhir:Claim.item.detail.category [ CodeableConcept ]; # 0..1 Benefit classification
      fhir:Claim.item.detail.productOrService [ CodeableConcept ]; # 1..1 Billing, service, product, or drug code
      fhir:Claim.item.detail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
      fhir:Claim.item.detail.programCode [ CodeableConcept ], ... ; # 0..* Program the product or service is provided under
      fhir:Claim.item.detail.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of products or services
      fhir:Claim.item.detail.unitPrice [ Money ]; # 0..1 Fee, charge or cost per item

      fhir:Claim.item.detail.factor [ decimal ]; # 0..1 Price scaling factor
      fhir:
      fhir:
      fhir:
        fhir:
        fhir:
        fhir:
        fhir:
        fhir:
        fhir:
        fhir:
        fhir:

      fhir:Claim.item.detail.net [ Money ]; # 0..1 Total item cost
      fhir:Claim.item.detail.udi [ Reference(Device) ], ... ; # 0..* Unique device identifier
      fhir:Claim.item.detail.subDetail [ # 0..* Product or service provided
        fhir:Claim.item.detail.subDetail.sequence [ positiveInt ]; # 1..1 Item instance identifier
        fhir:Claim.item.detail.subDetail.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
        fhir:Claim.item.detail.subDetail.category [ CodeableConcept ]; # 0..1 Benefit classification
        fhir:Claim.item.detail.subDetail.productOrService [ CodeableConcept ]; # 1..1 Billing, service, product, or drug code
        fhir:Claim.item.detail.subDetail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
        fhir:Claim.item.detail.subDetail.programCode [ CodeableConcept ], ... ; # 0..* Program the product or service is provided under
        fhir:Claim.item.detail.subDetail.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of products or services
        fhir:Claim.item.detail.subDetail.unitPrice [ Money ]; # 0..1 Fee, charge or cost per item

        fhir:Claim.item.detail.subDetail.factor [ decimal ]; # 0..1 Price scaling factor
        fhir:
        fhir:

        fhir:Claim.item.detail.subDetail.net [ Money ]; # 0..1 Total item cost
        fhir:Claim.item.detail.subDetail.udi [ Reference(Device) ], ... ; # 0..* Unique device identifier

      ], ...;
    ], ...;
  ], ...;
  fhir:

  fhir:Claim.total [ Money ]; # 0..1 Total claim cost

]

Changes since R3

Claim
Claim.type Claim.status
  • Change binding strength from required to extensible Claim.enterer Type changed from Reference(Practitioner) to Reference(Practitioner|PractitionerRole) Claim.provider Type changed from Reference(Practitioner) to Reference(Practitioner|PractitionerRole|Organization) Claim.payee.resource Added Element Claim.payee.party Type changed from Reference(Practitioner|Organization|Patient|RelatedPerson) to Reference(Practitioner|PractitionerRole|Organization|Patient|RelatedPerson) Claim.referral Type changed from Reference(ReferralRequest) to Reference(ServiceRequest) Claim.careTeam.provider Type changed value set from Reference(Practitioner|Organization) http://hl7.org/fhir/ValueSet/fm-status|4.0.0 to Reference(Practitioner|PractitionerRole|Organization) Claim.information.value[x] Remove Reference(Resource), Add boolean, Add Reference(Resource) Claim.diagnosis.diagnosis[x] Remove Reference(Condition), Add Reference(Condition) Claim.procedure.procedure[x] Remove Reference(Procedure), Add Reference(Procedure) Claim.insurance.identifier Added Element http://hl7.org/fhir/ValueSet/fm-status|4.1.0
Claim.accident.type Claim.use
  • Change binding strength value set from required http://hl7.org/fhir/ValueSet/claim-use|4.0.0 to extensible Claim.accident.location[x] Remove Reference(Location), Add Reference(Location) Claim.item.careTeamSequence Added Element Claim.item.diagnosisSequence Added Element Claim.item.procedureSequence Added Element Claim.item.informationSequence Added Element Claim.item.location[x] Remove Reference(Location), Add Reference(Location) Claim.organization deleted Claim.payee.resourceType deleted Claim.employmentImpacted deleted Claim.hospitalization deleted Claim.item.careTeamLinkId deleted Claim.item.diagnosisLinkId deleted Claim.item.procedureLinkId deleted Claim.item.informationLinkId deleted http://hl7.org/fhir/ValueSet/claim-use|4.1.0

See the Full Difference for further information

This analysis is available as XML or JSON .

See R3 <--> R4 Conversion Maps (status = 16 tests of which 3 fail to execute . 13 fail round-trip testing and 3 r3 resources are invalid (0 errors). )

Structure

resource 0..1 Coding organization | patient | practitioner | relatedperson ClaimPayeeResourceType ( Extensible )
Name Flags Card. Type Description & Constraints doco
. . Claim TU DomainResource Claim, Pre-determination or Pre-authorization
Elements defined in Ancestors: id , meta , implicitRules , language , text , contained , extension , modifierExtension
. . . identifier 0..* Identifier Claim number Business Identifier for claim
. . . status ?! Σ 0..1 1..1 code active | cancelled | draft | entered-in-error
Financial Resource Status Codes ( Required )
. . . type 0..1 Σ 1..1 CodeableConcept Type Category or discipline
Claim Type Codes ( Extensible )
. . . subType 0..* 0..1 CodeableConcept Finer grained More granular claim type information
Example Claim SubType Codes ( Example )
. . . use 0..1 Σ 1..1 code complete | proposed claim | exploratory preauthorization | other predetermination
Use ( Required )
. . . patient Σ 0..1 1..1 Reference ( Patient ) The subject recipient of the Products products and Services services
. . . billablePeriod Σ 0..1 Period Period Relevant time frame for charge submission the claim
. . . created Σ 0..1 1..1 dateTime Creation Resource creation date
. . . enterer 0..1 Reference ( Practitioner | PractitionerRole ) Author of the claim
. . . insurer Σ 0..1 Reference ( Organization ) Target
. . . provider 0..1 Σ 1..1 Reference ( Practitioner | PractitionerRole | Organization ) Responsible provider Party responsible for the claim
. . . priority Σ 0..1 1..1 CodeableConcept Desired processing priority ugency
Process Priority Codes ( Example )
. . . fundsReserve 0..1 CodeableConcept Funds requested For whom to be reserved reserve funds
Funds Reservation Codes FundsReserve ( Example )
. . . related 0..* BackboneElement Related Claims which may be revelant to processing this claimn Prior or corollary claims
. . . . claim 0..1 Reference ( Claim ) Reference to the related claim
. . . . relationship 0..1 CodeableConcept How the reference claim is related
Example Related Claim Relationship Codes ( Example )
. . . . reference 0..1 Identifier Related file File or case reference
. . . prescription 0..1 Reference ( DeviceRequest | MedicationRequest | VisionPrescription ) Prescription authorizing services or and products
. . . originalPrescription 0..1 Reference ( DeviceRequest | MedicationRequest | VisionPrescription ) Original prescription if superceded superseded by fulfiller
. . . payee 0..1 BackboneElement Party to be paid any Recipient of benefits payable
. . . . type 1..1 CodeableConcept Type Category of party: Subscriber, Provider, other recipient
Claim Payee Type Codes PayeeType ( Example )
. . . . party 0..1 Reference ( Practitioner | PractitionerRole | Organization | Patient | RelatedPerson ) Party to receive the payable Recipient reference
. . . referral 0..1 Reference ( ServiceRequest ) Treatment Referral referral
. . . facility 0..1 Reference ( Location ) Servicing Facility facility
. . . careTeam 0..* BackboneElement Members of the care team
. . . . sequence 1..1 positiveInt Number to convey order Order of careTeam care team
. . . . provider 1..1 Reference ( Practitioner | PractitionerRole | Organization ) Provider individual Practitioner or organization
. . . . responsible 0..1 boolean Billing provider Indicator of the lead practitioner
. . . . role 0..1 CodeableConcept Role on Function within the team
Claim Care Team Role Codes ( Example )
. . . . qualification 0..1 CodeableConcept Type, classification Practitioner credential or Specialization specialization
Example Provider Qualification Codes ( Example )
. . information . supportingInfo 0..* BackboneElement Exceptions, special considerations, the condition, situation, prior or concurrent issues Supporting information
. . . . sequence 1..1 positiveInt Information instance identifier
. . . . category 1..1 CodeableConcept General class Classification of the supplied information
Claim Information Category Codes ( Example )
. . . . code 0..1 CodeableConcept Type of information
Exception Codes ( Example )
. . . . timing[x] 0..1 When it occurred
. . . . . timingDate date
. . . . . timingPeriod Period
. . . . value[x] 0..1 Additional Data or supporting information to be provided
. . . . . valueBoolean boolean
. . . . . valueString string
. . . . . valueQuantity Quantity
. . . . . valueAttachment Attachment
. . . . . valueReference Reference ( Any )
. . . . reason 0..1 CodeableConcept Reason associated with Explanation for the information
Missing Tooth Reason Codes ( Example )
. . . diagnosis 0..* BackboneElement List of Diagnosis Pertinent diagnosis information
. . . . sequence 1..1 positiveInt Number to convey order of diagnosis Diagnosis instance identifier
. . . . diagnosis[x] 1..1 Patient's diagnosis Nature of illness or problem
ICD-10 Codes ( Example )
. . . . . diagnosisCodeableConcept CodeableConcept
. . . . . diagnosisReference Reference ( Condition )
. . . . type 0..* CodeableConcept Timing or nature of the diagnosis
Example Diagnosis Type Codes ( Example )
. . . . onAdmission 0..1 CodeableConcept Present on admission
Example Diagnosis on Admission Codes ( Example )
. . . . packageCode 0..1 CodeableConcept Package billing code
Example Diagnosis Related Group Codes ( Example )
. . . procedure 0..* BackboneElement Procedures Clinical procedures performed
. . . . sequence 1..1 positiveInt Procedure sequence for reference instance identifier
.... type 0..* CodeableConcept Category of Procedure
Example Procedure Type Codes ( Example )
. . . . date 0..1 dateTime When the procedure was performed
. . . . procedure[x] 1..1 Patient's list of procedures performed Specific clinical procedure
ICD-10 Procedure Codes ( Example )
. . . . . procedureCodeableConcept CodeableConcept
. . . . . procedureReference Reference ( Procedure )
. . insurance . . udi 0..* Reference ( Device ) Unique device identifier
... insurance Σ 1..* BackboneElement Insurance or medical plan Patient insurance information
. . . . sequence Σ 1..1 positiveInt Service Insurance instance identifier
. . . . focal Σ 1..1 boolean Is the focal Coverage to be used for adjudication
. . . . identifier 0..1 Identifier Pre-assigned Claim number
. . . . coverage Σ 1..1 Reference ( Coverage ) Insurance information
. . . . businessArrangement 0..1 string Business agreement Additional provider contract number
. . . . preAuthRef 0..* string Pre-Authorization/Determination Reference Prior authorization reference number
. . . . claimResponse 0..1 Reference ( ClaimResponse ) Adjudication results
. . . accident 0..1 BackboneElement Details about an accident of the event
. . . . date 1..1 date When the accident incident occurred see information codes see information codes
. . . . type 0..1 CodeableConcept The nature of the accident
ActIncidentCode V3 Value SetActIncidentCode ( Extensible )
. . . . location[x] 0..1 Accident Place Where the event occurred
. . . . . locationAddress Address
. . . . . locationReference Reference ( Location )
. . . item 0..* BackboneElement Goods and Services Product or service provided
. . . . sequence 1..1 positiveInt Service Item instance identifier
. . . . careTeamSequence 0..* positiveInt Applicable careTeam members
. . . . diagnosisSequence 0..* positiveInt Applicable diagnoses
. . . . procedureSequence 0..* positiveInt Applicable procedures
. . . . informationSequence 0..* positiveInt Applicable exception and supporting information
. . . . revenue 0..1 CodeableConcept Revenue or cost center code
Example Revenue Center Codes ( Example )
. . . . category 0..1 CodeableConcept Type of service or product Benefit classification
Benefit SubCategory Category Codes ( Example )
. . . service . productOrService 0..1 1..1 CodeableConcept Billing Code Billing, service, product, or drug code
USCLS Codes ( Example )
. . . . modifier 0..* CodeableConcept Service/Product Product or service billing modifiers
Modifier type Codes ( Example )
. . . . programCode 0..* CodeableConcept Program specific reason for item inclusion the product or service is provided under
Example Program Reason Codes ( Example )
. . . . serviced[x] 0..1 Date or dates of Service service or product delivery
. . . . . servicedDate date
. . . . . servicedPeriod Period
. . . . location[x] 0..1 Place of service or where product was supplied
Example Service Place Codes ( Example )
. . . . . locationCodeableConcept CodeableConcept
. . . . . locationAddress Address
. . . . . locationReference Reference ( Location )
. . . . quantity 0..1 SimpleQuantity Count of Products products or Services services
. . . . unitPrice 0..1 Money Fee, charge or cost per point item
. . . . factor 0..1 decimal Price scaling factor
. . . . net 0..1 Money Total item cost
. . . . udi 0..* Reference ( Device ) Unique Device Identifier device identifier
. . . . bodySite 0..1 CodeableConcept Service Location Anatomical location
Oral Site Codes ( Example )
. . . . subSite 0..* CodeableConcept Service Sub-location Anatomical sub-location
Surface Codes ( Example )
. . . . encounter 0..* Reference ( Encounter ) Encounters related to this billed item
. . . . detail 0..* BackboneElement Additional items Product or service provided
. . . . . sequence 1..1 positiveInt Service Item instance identifier
. . . . . revenue 0..1 CodeableConcept Revenue or cost center code
Example Revenue Center Codes ( Example )
. . . . . category 0..1 CodeableConcept Type of service or product Benefit classification
Benefit SubCategory Category Codes ( Example )
. . . . service . productOrService 0..1 1..1 CodeableConcept Billing Code Billing, service, product, or drug code
USCLS Codes ( Example )
. . . . . modifier 0..* CodeableConcept Service/Product billing modifiers
Modifier type Codes ( Example )
. . . . . programCode 0..* CodeableConcept Program specific reason for item inclusion the product or service is provided under
Example Program Reason Codes ( Example )
. . . . . quantity 0..1 SimpleQuantity Count of Products products or Services services
. . . . . unitPrice 0..1 Money Fee, charge or cost per point item
. . . . . factor 0..1 decimal Price scaling factor
. . . . . net 0..1 Money Total additional item cost
. . . . . udi 0..* Reference ( Device ) Unique Device Identifier device identifier
. . . . . subDetail 0..* BackboneElement Additional items Product or service provided
. . . . . . sequence 1..1 positiveInt Service Item instance identifier
. . . . . . revenue 0..1 CodeableConcept Revenue or cost center code
Example Revenue Center Codes ( Example )
. . . . . . category 0..1 CodeableConcept Type of service or product Benefit classification
Benefit SubCategory Category Codes ( Example )
. . . . . service . productOrService 0..1 1..1 CodeableConcept Billing Code Billing, service, product, or drug code
USCLS Codes ( Example )
. . . . . . modifier 0..* CodeableConcept Service/Product billing modifiers
Modifier type Codes ( Example )
. . . . . . programCode 0..* CodeableConcept Program specific reason for item inclusion the product or service is provided under
Example Program Reason Codes ( Example )
. . . . . . quantity 0..1 SimpleQuantity Count of Products products or Services services
. . . . . . unitPrice 0..1 Money Fee, charge or cost per point item
. . . . . . factor 0..1 decimal Price scaling factor
. . . . . . net 0..1 Money Net additional Total item cost
. . . . . . udi 0..* Reference ( Device ) Unique Device Identifier device identifier
. . . total 0..1 Money Total claim cost

doco Documentation for this format

UML Diagram ( Legend )

Claim ( DomainResource ) The business A unique identifier for the instance: assigned to this claim number, pre-determination or pre-authorization number identifier : Identifier [0..*] The status of the resource instance (this element modifies the meaning of other elements) status : code [0..1] [1..1] « A code specifying the state of the resource instance. (Strength=Required) Financial Resource Status FinancialResourceStatusCodes ! » The category of claim, eg, e.g. oral, pharmacy, vision, insitutional, institutional, professional type : CodeableConcept [0..1] [1..1] « The type or discipline-style of the claim claim. (Strength=Extensible) Claim Type ClaimTypeCodes + » A finer grained suite of claim subtype type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service. In the US the BillType service subType : CodeableConcept [0..*] [0..1] « A more granular claim typecode typecode. (Strength=Example) Example Claim SubType ExampleClaimSubTypeCodes ?? » Complete (Bill A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or Claim), Proposed (Pre-Authorization), Exploratory (Pre-determination) requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future use : code [0..1] [1..1] « Complete, proposed, exploratory, other The purpose of the Claim: predetermination, preauthorization, claim. (Strength=Required) Use ! » Patient Resource The party to whom the professional services and/or products have been supplied or are being considered and for whom actual or forecast reimbursement is sought patient : Reference [0..1] [1..1] « Patient » The billable period for which charges are being submitted billablePeriod : Period [0..1] The date when the enclosed suite of services were performed or completed this resource was created created : dateTime [0..1] [1..1] Person Individual who created the invoice/claim/pre-determination claim, predetermination or pre-authorization preauthorization enterer : Reference [0..1] « Practitioner | PractitionerRole » The Insurer who is target of the request insurer : Reference [0..1] « Organization » The provider which is responsible for the bill, claim pre-determination, pre-authorization claim, predetermination or preauthorization provider : Reference [0..1] [1..1] « Practitioner | PractitionerRole | Organization » Immediate (STAT), best effort (NORMAL), The provider-required urgency of processing the request. Typical values include: stat, routine deferred (DEFER) priority : CodeableConcept [0..1] [1..1] « The timeliness with which processing is required: STAT, stat, normal, Deferred deferred. (Strength=Example) Process Priority ProcessPriorityCodes ?? » In the case of a Pre-Determination/Pre-Authorization the provider may request that A code to indicate whether and for whom funds in the amount of the expected Benefit are to be reserved ('Patient' or 'Provider') to pay for the Benefits determined on the subsequent claim(s). 'None' explicitly indicates no funds reserving is requested future claims fundsReserve : CodeableConcept [0..1] « For whom funds are to be reserved: (Patient, Provider, None). (Strength=Example) Funds Reservation ?? » Prescription to support the dispensing of Pharmacy pharmacy, device or Vision vision products prescription : Reference [0..1] « DeviceRequest | MedicationRequest | VisionPrescription » Original prescription which has been superceded superseded by this prescription to support the dispensing of pharmacy services, medications or products. For example, a physician may prescribe a medication which the pharmacy determines is contraindicated, or for which the patient has an intolerance, and therefor issues a new precription for an alternate medication which has the same theraputic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription' products originalPrescription : Reference [0..1] « DeviceRequest | MedicationRequest | VisionPrescription » The A reference to a referral resource which lists the date, practitioner, reason and other supporting information referral : Reference [0..1] « ServiceRequest » Facility where the services were provided facility : Reference [0..1] « Location » The total value of the all the items in the claim total : Money [0..1] RelatedClaim Other claims which are related Reference to this claim such as prior claim versions or for a related services claim claim : Reference [0..1] « Claim » For example prior or umbrella A code to convey how the claims are related relationship : CodeableConcept [0..1] « Relationship of this claim to a related Claim Claim. (Strength=Example) Example Related Claim Relatio... ExampleRelatedClaimRelationsh... ?? » An alternate organizational reference to the case or file to which this particular claim pertains - eg Property/Casualy insurer claim # or Workers Compensation case # reference : Identifier [0..1] Payee Type of Party to be reimbursed: Subscriber, subscriber, provider, other type : CodeableConcept [1..1] « A code for the party to be reimbursed. (Strength=Example) Claim Payee Type ?? » Reference to the individual or organization | patient | practitioner | relatedperson resource : Coding [0..1] « The type of Claim payee Resource (Strength=Extensible) ClaimPayeeResourceType + » Party to whom any payment will be reimbursed: Subscriber, provider, other made party : Reference [0..1] « Practitioner | PractitionerRole | Organization | Patient | RelatedPerson » CareTeam Sequence of the careTeam which serves A number to order and provide a link uniquely identify care team entries sequence : positiveInt [1..1] Member of the team who provided the overall product or service provider : Reference [1..1] « Practitioner | PractitionerRole | Organization » The party who is billing and and/or responsible for the claimed good products or service rendered to the patient services responsible : boolean [0..1] The lead, assisting or supervising practitioner and their discipline if a multidisiplinary multidisciplinary team role : CodeableConcept [0..1] « The role codes for the care team members. (Strength=Example) Claim Care Team Role ClaimCareTeamRoleCodes ?? » The qualification of the practitioner which is applicable for this service qualification : CodeableConcept [0..1] « Provider professional qualifications qualifications. (Strength=Example) Example Provider Qualificatio... ExampleProviderQualificationC... ?? » SpecialCondition SupportingInformation Sequence of the information element which serves A number to provide a link uniquely identify supporting information entries sequence : positiveInt [1..1] The general class of the information supplied: information; exception; accident, employment; onset, etc category : CodeableConcept [1..1] « The valuset used for additional information category codes. (Strength=Example) Claim Information Category ClaimInformationCategoryCodes ?? » System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought which may influence the adjudication code : CodeableConcept [0..1] « The valuset used for additional information codes. (Strength=Example) Exception ExceptionCodes ?? » The date when or period to which this information refers timing[x] : Type [0..1] « date | Period » Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data value[x] : Type [0..1] « boolean | string | Quantity | Attachment | Reference ( Any ) » For example, provides Provides the reason for: in the additional stay, or missing tooth or any other situation where a reason code is required in addition to the content reason : CodeableConcept [0..1] « Reason codes for the missing teeth teeth. (Strength=Example) Missing Tooth Reason MissingToothReasonCodes ?? » Diagnosis Sequence of diagnosis which serves A number to provide a link uniquely identify diagnosis entries sequence : positiveInt [1..1] The diagnosis nature of illness or problem in a coded form or as a reference to an external defined Condition diagnosis[x] : Type [1..1] « CodeableConcept | Reference ( Condition ); Example ICD10 Diagnostic codes codes. (Strength=Example) ICD-10 ICD-10Codes ?? » The type of When the Diagnosis, for example: admitting, primary, secondary, discharge condition was observed or the relative ranking type : CodeableConcept [0..*] « The type of the diagnosis: admitting, principal, discharge discharge. (Strength=Example) Example Diagnosis Type ExampleDiagnosisTypeCodes ?? » The Indication of whether the diagnosis was present on admission to a facility onAdmission : CodeableConcept [0..1] « Present on admission. (Strength=Example) ExampleDiagnosisOnAdmissionCo... ?? » A package billing code, for example DRG, code or bundle code used to group products and services to a particular health condition (such as heart attack) which is based on the assigned a predetermined grouping code system packageCode : CodeableConcept [0..1] « The DRG codes associated with the diagnosis diagnosis. (Strength=Example) Example Diagnosis Related Gro... ExampleDiagnosisRelatedGroupC... ?? » Procedure Sequence of procedures which serves A number to order and provide a link uniquely identify procedure entries sequence : positiveInt [1..1] When the condition was observed or the relative ranking type : CodeableConcept [0..*] « Example procedure type codes. (Strength=Example) ExampleProcedureTypeCodes ?? » Date and optionally time the procedure was performed date : dateTime [0..1] The procedure code or reference to a Procedure resource which identifies the clinical intervention performed procedure[x] : Type [1..1] « CodeableConcept | Reference ( Procedure ); Example ICD10 Procedure codes codes. (Strength=Example) ICD-10 Procedure ICD-10ProcedureCodes ?? » Unique Device Identifiers associated with this line item udi : Reference [0..*] « Device » Insurance Sequence of coverage which serves A number to uniquely identify insurance entries and provide a link and sequence of coverages to convey coordination of benefit order sequence : positiveInt [1..1] A flag to indicate that this Coverage is the focus to be used for adjudication. The Coverage against which the adjudication of this claim is when set to be adjudicated true focal : boolean [1..1] The business identifier for to be used when the instance: claim number, pre-determination or pre-authorization number is sent for adjudication against this insurance policy identifier : Identifier [0..1] Reference to the program or plan identification, underwriter or payor insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system coverage : Reference [1..1] « Coverage » The contract number of a A business agreement which describes number established between the terms provider and conditions the insurer for special business processing purposes businessArrangement : string [0..1] A list of references from Reference numbers previously provided by the Insurer insurer to which these the provider to be quoted on subsequent claims containing services pertain or products related to the prior authorization preAuthRef : string [0..*] The Coverages result of the adjudication details of the line items for the Coverage specified in this insurance claimResponse : Reference [0..1] « ClaimResponse » Accident Date of an accident which these event related to the products and services are addressing contained in the claim date : date [1..1] Type The type or context of accident: work, auto, etc the accident event for the purposes of selection of potential insurance coverages and determination of coordination between insurers type : CodeableConcept [0..1] « Type of accident: work place, auto, etc. (Strength=Extensible) ActIncidentCode v3.ActIncidentCode + » Accident Place The physical location of the accident event location[x] : Type [0..1] « Address | Reference ( Location ) » Item A service line number to uniquely identify item entries sequence : positiveInt [1..1] CareTeam applicable for members related to this service or product line careTeamSequence : positiveInt [0..*] Diagnosis applicable for this service or product line diagnosisSequence : positiveInt [0..*] Procedures applicable for this service or product line procedureSequence : positiveInt [0..*] Exceptions, special conditions and supporting information pplicable applicable for this service or product line informationSequence : positiveInt [0..*] The type of reveneu revenue or cost center providing the product and/or service revenue : CodeableConcept [0..1] « Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example) Example Revenue Center ExampleRevenueCenterCodes ?? » Health Care Service Type Codes Code to identify the classification general type of service or benefits under which products and services are provided category : CodeableConcept [0..1] « Benefit subcategories categories such as: oral-basic, major, glasses glasses. (Strength=Example) Benefit SubCategory BenefitCategoryCodes ?? » If this When the value is an actual service or product line, ie. not a Group, then use group code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,RXNorm,ACHI,CCI). If a grouping item then use this item collects a group code to indicate the type set of thing being grouped eg. 'glasses' related claim details, otherwise this contains the product, service, drug or 'compound' other billing code for the item service productOrService : CodeableConcept [0..1] [1..1] « Allowable service and product codes codes. (Strength=Example) USCLS USCLSCodes ?? » Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or codes to convey additional context for medical whether the treatment was outside the clinic product or out of office hours service modifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example) Modifier type ModifierTypeCodes ?? » For programs which require reason codes for the inclusion or covering of this billed item under Identifies the program or sub-program under which this may be recovered programCode : CodeableConcept [0..*] « Program specific reason codes codes. (Strength=Example) Example Program Reason ExampleProgramReasonCodes ?? » The date or dates when the enclosed suite of services were service or product was supplied, performed or completed serviced[x] : Type [0..1] « date | Period » Where the product or service was provided location[x] : Type [0..1] « CodeableConcept | Address | Reference ( Location ); Place of service: pharmacy,school, pharmacy, school, prison, etc. (Strength=Example) Example Service Place ExampleServicePlaceCodes ?? » The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] If the item is not a node group then this is the fee for the product or service, otherwise this is the total of the fees for the children details of the group unitPrice : Money [0..1] A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount factor : decimal [0..1] The quantity times the unit price for an addittional additional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied charge net : Money [0..1] List of Unique Device Identifiers associated with this line item udi : Reference [0..*] « Device » Physical service site on the patient (limb, tooth, etc.) bodySite : CodeableConcept [0..1] « The code for the teeth, quadrant, sextant and arch arch. (Strength=Example) Oral Site OralSiteCodes ?? » A region or surface of the site, eg. bodySite, e.g. limb region or tooth surface(s) subSite : CodeableConcept [0..*] « The code for the tooth surface and surface combinations combinations. (Strength=Example) Surface SurfaceCodes ?? » A billed item may include goods The Encounters during which this Claim was created or services provided in multiple encounters to which the creation of this record is tightly associated encounter : Reference [0..*] « Encounter » Detail A service line number to uniquely identify item entries sequence : positiveInt [1..1] The type of reveneu revenue or cost center providing the product and/or service revenue : CodeableConcept [0..1] « Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example) Example Revenue Center ExampleRevenueCenterCodes ?? » Health Care Service Type Codes Code to identify the classification general type of service or benefits under which products and services are provided category : CodeableConcept [0..1] « Benefit subcategories categories such as: oral-basic, major, glasses glasses. (Strength=Example) Benefit SubCategory BenefitCategoryCodes ?? » If this When the value is an actual service or product line, ie. not a Group, then use group code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). If a grouping item then use this item collects a group code to indicate the type set of thing being grouped eg. 'glasses' related claim details, otherwise this contains the product, service, drug or 'compound' other billing code for the item service productOrService : CodeableConcept [0..1] [1..1] « Allowable service and product codes codes. (Strength=Example) USCLS USCLSCodes ?? » Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or codes to convey additional context for medical whether the treatment was outside the clinic product or out of office hours service modifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example) Modifier type ModifierTypeCodes ?? » For programs which require reson codes for the inclusion, covering, of this billed item under Identifies the program or sub-program under which this may be recovered programCode : CodeableConcept [0..*] « Program specific reason codes codes. (Strength=Example) Example Program Reason ExampleProgramReasonCodes ?? » The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] If the item is not a node group then this is the fee for the product or service, otherwise this is the total of the fees for the children details of the group unitPrice : Money [0..1] A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount factor : decimal [0..1] The quantity times the unit price for an addittional additional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied charge net : Money [0..1] List of Unique Device Identifiers associated with this line item udi : Reference [0..*] « Device » SubDetail A service line number to uniquely identify item entries sequence : positiveInt [1..1] The type of reveneu revenue or cost center providing the product and/or service revenue : CodeableConcept [0..1] « Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example) Example Revenue Center ExampleRevenueCenterCodes ?? » Health Care Service Type Codes Code to identify the classification general type of service or benefits under which products and services are provided category : CodeableConcept [0..1] « Benefit subcategories categories such as: oral-basic, major, glasses glasses. (Strength=Example) Benefit SubCategory BenefitCategoryCodes ?? » A When the value is a group code to indicate then this item collects a set of related claim details, otherwise this contains the Professional Service product, service, drug or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI) other billing code for the item service productOrService : CodeableConcept [0..1] [1..1] « Allowable service and product codes codes. (Strength=Example) USCLS USCLSCodes ?? » Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or codes to convey additional context for medical whether the treatment was outside the clinic product or out of office hours service modifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example) Modifier type ModifierTypeCodes ?? » For programs which require reson codes for the inclusion, covering, of this billed item under Identifies the program or sub-program under which this may be recovered programCode : CodeableConcept [0..*] « Program specific reason codes codes. (Strength=Example) Example Program Reason ExampleProgramReasonCodes ?? » The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] The If the item is not a group then this is the fee for an addittional service or the product or charge service, otherwise this is the total of the fees for the details of the group unitPrice : Money [0..1] A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount factor : decimal [0..1] The quantity times the unit price for an addittional additional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied charge net : Money [0..1] List of Unique Device Identifiers associated with this line item udi : Reference [0..*] « Device » Other claims which are related to this claim such as prior claim versions submissions or claims for related services or for the same event related [0..*] The party to be reimbursed for cost of the products and services according to the terms of the policy payee [0..1] The members of the team who provided the overall service as well as their role and whether responsible products and qualifications services careTeam [0..*] Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. Often there are mutiple jurisdiction specific valuesets which are required issues information supportingInfo [0..*] List of patient diagnosis for which care is sought Information about diagnoses relevant to the claim items diagnosis [0..*] Ordered list of patient procedures Procedures performed on the patient relevant to support the adjudication billing items with the claim procedure [0..*] Financial instrument by which payment information instruments for reimbursement for the health care products and services specified on the claim insurance [0..*] [1..*] An Details of an accident which resulted in injuries which required the need for healthcare products and services listed in the claim accident [0..1] Third tier A claim detail line. Either a simple (a product or service) or a 'group' of goods and services sub-details which are simple items subDetail [0..*] Second tier A claim detail line. Either a simple (a product or service) or a 'group' of goods and services sub-details which are simple items detail [0..*] First tier A claim line. Either a simple product or service or a 'group' of goods and services details which can each be a simple items or groups of sub-details item [0..*]

XML Template

<Claim xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <</identifier>
 <
 <</type>
 <</subType>
 <
 <</patient>
 <</billablePeriod>
 <
 <</enterer>

 <identifier><!-- 0..* Identifier Business Identifier for claim --></identifier>
 <status value="[code]"/><!-- 1..1 active | cancelled | draft | entered-in-error -->
 <type><!-- 1..1 CodeableConcept Category or discipline --></type>
 <subType><!-- 0..1 CodeableConcept More granular claim type --></subType>
 <use value="[code]"/><!-- 1..1 claim | preauthorization | predetermination -->
 <patient><!-- 1..1 Reference(Patient) The recipient of the products and services --></patient>
 <billablePeriod><!-- 0..1 Period Relevant time frame for the claim --></billablePeriod>
 <created value="[dateTime]"/><!-- 1..1 Resource creation date -->
 <enterer><!-- 0..1 Reference(Practitioner|PractitionerRole) Author of the claim --></enterer>

 <insurer><!-- 0..1 Reference(Organization) Target --></insurer>
 <</provider>
 <</priority>
 <</fundsReserve>
 <
  <</claim>
  <</relationship>
  <</reference>

 <provider><!-- 1..1 Reference(Organization|Practitioner|PractitionerRole) Party responsible for the claim --></provider>
 <priority><!-- 1..1 CodeableConcept Desired processing ugency --></priority>
 <fundsReserve><!-- 0..1 CodeableConcept For whom to reserve funds --></fundsReserve>
 <related>  <!-- 0..* Prior or corollary claims -->
  <claim><!-- 0..1 Reference(Claim) Reference to the related claim --></claim>
  <relationship><!-- 0..1 CodeableConcept How the reference claim is related --></relationship>
  <reference><!-- 0..1 Identifier File or case reference --></reference>

 </related>
 <</prescription>
 <</originalPrescription>
 <
  <</type>
  <</resource>
  <|
    </party>

 <prescription><!-- 0..1 Reference(DeviceRequest|MedicationRequest|
   VisionPrescription) Prescription authorizing services and products --></prescription>
 <originalPrescription><!-- 0..1 Reference(DeviceRequest|MedicationRequest|
   VisionPrescription) Original prescription if superseded by fulfiller --></originalPrescription>
 <payee>  <!-- 0..1 Recipient of benefits payable -->
  <type><!-- 1..1 CodeableConcept Category of recipient --></type>
  <party><!-- 0..1 Reference(Organization|Patient|Practitioner|PractitionerRole|
    RelatedPerson) Recipient reference --></party>
 </payee>
 <</referral>
 <</facility>
 <
  <
  <</provider>
  <
  <</role>
  <</qualification>

 <referral><!-- 0..1 Reference(ServiceRequest) Treatment referral --></referral>
 <facility><!-- 0..1 Reference(Location) Servicing facility --></facility>
 <careTeam>  <!-- 0..* Members of the care team -->
  <sequence value="[positiveInt]"/><!-- 1..1 Order of care team -->
  <provider><!-- 1..1 Reference(Organization|Practitioner|PractitionerRole) Practitioner or organization --></provider>
  <responsible value="[boolean]"/><!-- 0..1 Indicator of the lead practitioner -->
  <role><!-- 0..1 CodeableConcept Function within the team --></role>
  <qualification><!-- 0..1 CodeableConcept Practitioner credential or specialization --></qualification>

 </careTeam>
 <
  <
  <</category>
  <</code>
  <</timing[x]>
  <</value[x]>
  <</reason>
 </information>
 <
  <
  <</diagnosis[x]>
  <</type>
  <</packageCode>

 <supportingInfo>  <!-- 0..* Supporting information -->
  <sequence value="[positiveInt]"/><!-- 1..1 Information instance identifier -->
  <category><!-- 1..1 CodeableConcept Classification of the supplied information --></category>
  <code><!-- 0..1 CodeableConcept Type of information --></code>
  <timing[x]><!-- 0..1 date|Period When it occurred --></timing[x]>
  <value[x]><!-- 0..1 boolean|string|Quantity|Attachment|Reference(Any) Data to be provided --></value[x]>
  <reason><!-- 0..1 CodeableConcept Explanation for the information --></reason>
 </supportingInfo>
 <diagnosis>  <!-- 0..* Pertinent diagnosis information -->
  <sequence value="[positiveInt]"/><!-- 1..1 Diagnosis instance identifier -->
  <diagnosis[x]><!-- 1..1 CodeableConcept|Reference(Condition) Nature of illness or problem --></diagnosis[x]>
  <type><!-- 0..* CodeableConcept Timing or nature of the diagnosis --></type>
  <onAdmission><!-- 0..1 CodeableConcept Present on admission --></onAdmission>
  <packageCode><!-- 0..1 CodeableConcept Package billing code --></packageCode>

 </diagnosis>
 <
  <
  <
  <</procedure[x]>

 <procedure>  <!-- 0..* Clinical procedures performed -->
  <sequence value="[positiveInt]"/><!-- 1..1 Procedure instance identifier -->
  <type><!-- 0..* CodeableConcept Category of Procedure --></type>
  <date value="[dateTime]"/><!-- 0..1 When the procedure was performed -->
  <procedure[x]><!-- 1..1 CodeableConcept|Reference(Procedure) Specific clinical procedure --></procedure[x]>
  <udi><!-- 0..* Reference(Device) Unique device identifier --></udi>

 </procedure>
 <
  <
  <
  <</identifier>
  <</coverage>
  <
  <
  <</claimResponse>

 <insurance>  <!-- 1..* Patient insurance information -->
  <sequence value="[positiveInt]"/><!-- 1..1 Insurance instance identifier -->
  <focal value="[boolean]"/><!-- 1..1 Coverage to be used for adjudication -->
  <identifier><!-- 0..1 Identifier Pre-assigned Claim number --></identifier>
  <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage>
  <businessArrangement value="[string]"/><!-- 0..1 Additional provider contract number -->
  <preAuthRef value="[string]"/><!-- 0..* Prior authorization reference number -->
  <claimResponse><!-- 0..1 Reference(ClaimResponse) Adjudication results --></claimResponse>

 </insurance>
 <
  <When the accident occurred
see information codes
see information codes
  <</type>
  <</location[x]>

 <accident>  <!-- 0..1 Details of the event -->
  <date value="[date]"/><!-- 1..1 When the incident occurred -->
  <type><!-- 0..1 CodeableConcept The nature of the accident --></type>
  <location[x]><!-- 0..1 Address|Reference(Location) Where the event occurred --></location[x]>

 </accident>
 <
  <
  <
  <
  <
  <
  <</revenue>
  <</category>
  <</service>
  <</modifier>
  <</programCode>
  <</serviced[x]>
  <</location[x]>
  <</quantity>
  <</unitPrice>

 <item>  <!-- 0..* Product or service provided -->
  <sequence value="[positiveInt]"/><!-- 1..1 Item instance identifier -->
  <careTeamSequence value="[positiveInt]"/><!-- 0..* Applicable careTeam members -->
  <diagnosisSequence value="[positiveInt]"/><!-- 0..* Applicable diagnoses -->
  <procedureSequence value="[positiveInt]"/><!-- 0..* Applicable procedures -->
  <informationSequence value="[positiveInt]"/><!-- 0..* Applicable exception and supporting information -->
  <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
  <category><!-- 0..1 CodeableConcept Benefit classification --></category>
  <productOrService><!-- 1..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
  <modifier><!-- 0..* CodeableConcept Product or service billing modifiers --></modifier>
  <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode>
  <serviced[x]><!-- 0..1 date|Period Date or dates of service or product delivery --></serviced[x]>
  <location[x]><!-- 0..1 CodeableConcept|Address|Reference(Location) Place of service or where product was supplied --></location[x]>
  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
  <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>

  <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
  <</net>
  <</udi>
  <</bodySite>
  <</subSite>
  <</encounter>
  <
   <
   <</revenue>
   <</category>
   <</service>
   <</modifier>
   <</programCode>
   <</quantity>
   <</unitPrice>

  <net><!-- 0..1 Money Total item cost --></net>
  <udi><!-- 0..* Reference(Device) Unique device identifier --></udi>
  <bodySite><!-- 0..1 CodeableConcept Anatomical location --></bodySite>
  <subSite><!-- 0..* CodeableConcept Anatomical sub-location --></subSite>
  <encounter><!-- 0..* Reference(Encounter) Encounters related to this billed item --></encounter>
  <detail>  <!-- 0..* Product or service provided -->
   <sequence value="[positiveInt]"/><!-- 1..1 Item instance identifier -->
   <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
   <category><!-- 0..1 CodeableConcept Benefit classification --></category>
   <productOrService><!-- 1..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
   <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
   <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode>
   <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
   <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>

   <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
   <</net>
   <</udi>
   <
    <
    <</revenue>
    <</category>
    <</service>
    <</modifier>
    <</programCode>
    <</quantity>
    <</unitPrice>

   <net><!-- 0..1 Money Total item cost --></net>
   <udi><!-- 0..* Reference(Device) Unique device identifier --></udi>
   <subDetail>  <!-- 0..* Product or service provided -->
    <sequence value="[positiveInt]"/><!-- 1..1 Item instance identifier -->
    <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
    <category><!-- 0..1 CodeableConcept Benefit classification --></category>
    <productOrService><!-- 1..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
    <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
    <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode>
    <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
    <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>

    <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
    <</net>
    <</udi>

    <net><!-- 0..1 Money Total item cost --></net>
    <udi><!-- 0..* Reference(Device) Unique device identifier --></udi>

   </subDetail>
  </detail>
 </item>
 <</total>

 <total><!-- 0..1 Money Total claim cost --></total>

</Claim>

JSON Template

{doco
  "resourceType" : "",

  "resourceType" : "Claim",

  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "
  "
  "
  "
  "
  "
  "
  "
  "

  "identifier" : [{ Identifier }], // Business Identifier for claim
  "status" : "<code>", // R!  active | cancelled | draft | entered-in-error
  "type" : { CodeableConcept }, // R!  Category or discipline
  "subType" : { CodeableConcept }, // More granular claim type
  "use" : "<code>", // R!  claim | preauthorization | predetermination
  "patient" : { Reference(Patient) }, // R!  The recipient of the products and services
  "billablePeriod" : { Period }, // Relevant time frame for the claim
  "created" : "<dateTime>", // R!  Resource creation date
  "enterer" : { Reference(Practitioner|PractitionerRole) }, // Author of the claim

  "insurer" : { Reference(Organization) }, // Target
  "
  "
  "
  "
    "
    "
    "

  "provider" : { Reference(Organization|Practitioner|PractitionerRole) }, // R!  Party responsible for the claim
  "priority" : { CodeableConcept }, // R!  Desired processing ugency
  "fundsReserve" : { CodeableConcept }, // For whom to reserve funds
  "related" : [{ // Prior or corollary claims
    "claim" : { Reference(Claim) }, // Reference to the related claim
    "relationship" : { CodeableConcept }, // How the reference claim is related
    "reference" : { Identifier } // File or case reference

  }],
  "
  "
  "
    "
    "
    "|
    

  "prescription" : { Reference(DeviceRequest|MedicationRequest|
   VisionPrescription) }, // Prescription authorizing services and products
  "originalPrescription" : { Reference(DeviceRequest|MedicationRequest|
   VisionPrescription) }, // Original prescription if superseded by fulfiller
  "payee" : { // Recipient of benefits payable
    "type" : { CodeableConcept }, // R!  Category of recipient
    "party" : { Reference(Organization|Patient|Practitioner|PractitionerRole|
    RelatedPerson) } // Recipient reference
  },
  "
  "
  "
    "
    "
    "
    "
    "

  "referral" : { Reference(ServiceRequest) }, // Treatment referral
  "facility" : { Reference(Location) }, // Servicing facility
  "careTeam" : [{ // Members of the care team
    "sequence" : "<positiveInt>", // R!  Order of care team
    "provider" : { Reference(Organization|Practitioner|PractitionerRole) }, // R!  Practitioner or organization
    "responsible" : <boolean>, // Indicator of the lead practitioner
    "role" : { CodeableConcept }, // Function within the team
    "qualification" : { CodeableConcept } // Practitioner credential or specialization

  }],
  "
    "
    "
    "

  "supportingInfo" : [{ // Supporting information
    "sequence" : "<positiveInt>", // R!  Information instance identifier
    "category" : { CodeableConcept }, // R!  Classification of the supplied information
    "code" : { CodeableConcept }, // Type of information

    // timing[x]: When it occurred. One of these 2:
    ">",
    " },
    
    ">,
    ">",
    " },
    " },
    " },
    "

    "timingDate" : "<date>",
    "timingPeriod" : { Period },
    // value[x]: Data to be provided. One of these 5:
    "valueBoolean" : <boolean>,
    "valueString" : "<string>",
    "valueQuantity" : { Quantity },
    "valueAttachment" : { Attachment },
    "valueReference" : { Reference(Any) },
    "reason" : { CodeableConcept } // Explanation for the information

  }],
  "
    "
    
    " },
    " },
    "
    "

  "diagnosis" : [{ // Pertinent diagnosis information
    "sequence" : "<positiveInt>", // R!  Diagnosis instance identifier
    // diagnosis[x]: Nature of illness or problem. One of these 2:
    "diagnosisCodeableConcept" : { CodeableConcept },
    "diagnosisReference" : { Reference(Condition) },
    "type" : [{ CodeableConcept }], // Timing or nature of the diagnosis
    "onAdmission" : { CodeableConcept }, // Present on admission
    "packageCode" : { CodeableConcept } // Package billing code

  }],
  "
    "
    "
    
    " }
    " }

  "procedure" : [{ // Clinical procedures performed
    "sequence" : "<positiveInt>", // R!  Procedure instance identifier
    "type" : [{ CodeableConcept }], // Category of Procedure
    "date" : "<dateTime>", // When the procedure was performed
    // procedure[x]: Specific clinical procedure. One of these 2:
    "procedureCodeableConcept" : { CodeableConcept },
    "procedureReference" : { Reference(Procedure) },
    "udi" : [{ Reference(Device) }] // Unique device identifier

  }],
  "
    "
    "
    "
    "
    "
    "
    "

  "insurance" : [{ // R!  Patient insurance information
    "sequence" : "<positiveInt>", // R!  Insurance instance identifier
    "focal" : <boolean>, // R!  Coverage to be used for adjudication
    "identifier" : { Identifier }, // Pre-assigned Claim number
    "coverage" : { Reference(Coverage) }, // R!  Insurance information
    "businessArrangement" : "<string>", // Additional provider contract number
    "preAuthRef" : ["<string>"], // Prior authorization reference number
    "claimResponse" : { Reference(ClaimResponse) } // Adjudication results

  }],
  "
    "When the accident occurred
see information codes
see information codes
    "
    
    " }
    " }

  "accident" : { // Details of the event
    "date" : "<date>", // R!  When the incident occurred
    "type" : { CodeableConcept }, // The nature of the accident
    // location[x]: Where the event occurred. One of these 2:
    "locationAddress" : { Address }
    "locationReference" : { Reference(Location) }

  },
  "
    "
    "
    "
    "
    "
    "
    "
    "
    "
    "
    
    ">",
    " },
    
    " },
    " },
    " },
    "
    "

  "item" : [{ // Product or service provided
    "sequence" : "<positiveInt>", // R!  Item instance identifier
    "careTeamSequence" : ["<positiveInt>"], // Applicable careTeam members
    "diagnosisSequence" : ["<positiveInt>"], // Applicable diagnoses
    "procedureSequence" : ["<positiveInt>"], // Applicable procedures
    "informationSequence" : ["<positiveInt>"], // Applicable exception and supporting information
    "revenue" : { CodeableConcept }, // Revenue or cost center code
    "category" : { CodeableConcept }, // Benefit classification
    "productOrService" : { CodeableConcept }, // R!  Billing, service, product, or drug code
    "modifier" : [{ CodeableConcept }], // Product or service billing modifiers
    "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
    // serviced[x]: Date or dates of service or product delivery. One of these 2:
    "servicedDate" : "<date>",
    "servicedPeriod" : { Period },
    // location[x]: Place of service or where product was supplied. One of these 3:
    "locationCodeableConcept" : { CodeableConcept },
    "locationAddress" : { Address },
    "locationReference" : { Reference(Location) },
    "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
    "unitPrice" : { Money }, // Fee, charge or cost per item

    "factor" : <decimal>, // Price scaling factor
    "
    "
    "
    "
    "
    "
      "
      "
      "
      "
      "
      "
      "
      "

    "net" : { Money }, // Total item cost
    "udi" : [{ Reference(Device) }], // Unique device identifier
    "bodySite" : { CodeableConcept }, // Anatomical location
    "subSite" : [{ CodeableConcept }], // Anatomical sub-location
    "encounter" : [{ Reference(Encounter) }], // Encounters related to this billed item
    "detail" : [{ // Product or service provided
      "sequence" : "<positiveInt>", // R!  Item instance identifier
      "revenue" : { CodeableConcept }, // Revenue or cost center code
      "category" : { CodeableConcept }, // Benefit classification
      "productOrService" : { CodeableConcept }, // R!  Billing, service, product, or drug code
      "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
      "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
      "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
      "unitPrice" : { Money }, // Fee, charge or cost per item

      "factor" : <decimal>, // Price scaling factor
      "
      "
      "
        "
        "
        "
        "
        "
        "
        "
        "

      "net" : { Money }, // Total item cost
      "udi" : [{ Reference(Device) }], // Unique device identifier
      "subDetail" : [{ // Product or service provided
        "sequence" : "<positiveInt>", // R!  Item instance identifier
        "revenue" : { CodeableConcept }, // Revenue or cost center code
        "category" : { CodeableConcept }, // Benefit classification
        "productOrService" : { CodeableConcept }, // R!  Billing, service, product, or drug code
        "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
        "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
        "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
        "unitPrice" : { Money }, // Fee, charge or cost per item

        "factor" : <decimal>, // Price scaling factor
        "
        "

        "net" : { Money }, // Total item cost
        "udi" : [{ Reference(Device) }] // Unique device identifier

      }]
    }]
  }],
  "

  "total" : { Money } // Total claim cost

}

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .doco
[ a fhir:;

[ a fhir:Claim;

  fhir:nodeRole fhir:treeRoot; # if this is the parser root
  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:

  fhir:Claim.identifier [ Identifier ], ... ; # 0..* Business Identifier for claim
  fhir:Claim.status [ code ]; # 1..1 active | cancelled | draft | entered-in-error
  fhir:Claim.type [ CodeableConcept ]; # 1..1 Category or discipline
  fhir:Claim.subType [ CodeableConcept ]; # 0..1 More granular claim type
  fhir:Claim.use [ code ]; # 1..1 claim | preauthorization | predetermination
  fhir:Claim.patient [ Reference(Patient) ]; # 1..1 The recipient of the products and services
  fhir:Claim.billablePeriod [ Period ]; # 0..1 Relevant time frame for the claim
  fhir:Claim.created [ dateTime ]; # 1..1 Resource creation date
  fhir:Claim.enterer [ Reference(Practitioner|PractitionerRole) ]; # 0..1 Author of the claim

  fhir:Claim.insurer [ Reference(Organization) ]; # 0..1 Target
  fhir:
  fhir:
  fhir:
  fhir:
    fhir:
    fhir:
    fhir:

  fhir:Claim.provider [ Reference(Organization|Practitioner|PractitionerRole) ]; # 1..1 Party responsible for the claim
  fhir:Claim.priority [ CodeableConcept ]; # 1..1 Desired processing ugency
  fhir:Claim.fundsReserve [ CodeableConcept ]; # 0..1 For whom to reserve funds
  fhir:Claim.related [ # 0..* Prior or corollary claims
    fhir:Claim.related.claim [ Reference(Claim) ]; # 0..1 Reference to the related claim
    fhir:Claim.related.relationship [ CodeableConcept ]; # 0..1 How the reference claim is related
    fhir:Claim.related.reference [ Identifier ]; # 0..1 File or case reference

  ], ...;
  fhir:
  fhir:
  fhir:
    fhir:
    fhir:
    fhir:

  fhir:Claim.prescription [ Reference(DeviceRequest|MedicationRequest|VisionPrescription) ]; # 0..1 Prescription authorizing services and products
  fhir:Claim.originalPrescription [ Reference(DeviceRequest|MedicationRequest|VisionPrescription) ]; # 0..1 Original prescription if superseded by fulfiller
  fhir:Claim.payee [ # 0..1 Recipient of benefits payable
    fhir:Claim.payee.type [ CodeableConcept ]; # 1..1 Category of recipient
    fhir:Claim.payee.party [ Reference(Organization|Patient|Practitioner|PractitionerRole|RelatedPerson) ]; # 0..1 Recipient reference

  ];
  fhir:
  fhir:
  fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:

  fhir:Claim.referral [ Reference(ServiceRequest) ]; # 0..1 Treatment referral
  fhir:Claim.facility [ Reference(Location) ]; # 0..1 Servicing facility
  fhir:Claim.careTeam [ # 0..* Members of the care team
    fhir:Claim.careTeam.sequence [ positiveInt ]; # 1..1 Order of care team
    fhir:Claim.careTeam.provider [ Reference(Organization|Practitioner|PractitionerRole) ]; # 1..1 Practitioner or organization
    fhir:Claim.careTeam.responsible [ boolean ]; # 0..1 Indicator of the lead practitioner
    fhir:Claim.careTeam.role [ CodeableConcept ]; # 0..1 Function within the team
    fhir:Claim.careTeam.qualification [ CodeableConcept ]; # 0..1 Practitioner credential or specialization

  ], ...;
  fhir:
    fhir:
    fhir:
    fhir:
    # . One of these 2
      fhir: ]
      fhir: ]
    # . One of these 5
      fhir: ]
      fhir: ]
      fhir: ]
      fhir: ]
      fhir:) ]
    fhir:

  fhir:Claim.supportingInfo [ # 0..* Supporting information
    fhir:Claim.supportingInfo.sequence [ positiveInt ]; # 1..1 Information instance identifier
    fhir:Claim.supportingInfo.category [ CodeableConcept ]; # 1..1 Classification of the supplied information
    fhir:Claim.supportingInfo.code [ CodeableConcept ]; # 0..1 Type of information
    # Claim.supportingInfo.timing[x] : 0..1 When it occurred. One of these 2
      fhir:Claim.supportingInfo.timingDate [ date ]
      fhir:Claim.supportingInfo.timingPeriod [ Period ]
    # Claim.supportingInfo.value[x] : 0..1 Data to be provided. One of these 5
      fhir:Claim.supportingInfo.valueBoolean [ boolean ]
      fhir:Claim.supportingInfo.valueString [ string ]
      fhir:Claim.supportingInfo.valueQuantity [ Quantity ]
      fhir:Claim.supportingInfo.valueAttachment [ Attachment ]
      fhir:Claim.supportingInfo.valueReference [ Reference(Any) ]
    fhir:Claim.supportingInfo.reason [ CodeableConcept ]; # 0..1 Explanation for the information

  ], ...;
  fhir:
    fhir:
    # . One of these 2
      fhir: ]
      fhir:) ]
    fhir:
    fhir:

  fhir:Claim.diagnosis [ # 0..* Pertinent diagnosis information
    fhir:Claim.diagnosis.sequence [ positiveInt ]; # 1..1 Diagnosis instance identifier
    # Claim.diagnosis.diagnosis[x] : 1..1 Nature of illness or problem. One of these 2
      fhir:Claim.diagnosis.diagnosisCodeableConcept [ CodeableConcept ]
      fhir:Claim.diagnosis.diagnosisReference [ Reference(Condition) ]
    fhir:Claim.diagnosis.type [ CodeableConcept ], ... ; # 0..* Timing or nature of the diagnosis
    fhir:Claim.diagnosis.onAdmission [ CodeableConcept ]; # 0..1 Present on admission
    fhir:Claim.diagnosis.packageCode [ CodeableConcept ]; # 0..1 Package billing code

  ], ...;
  fhir:
    fhir:
    fhir:
    # . One of these 2
      fhir: ]
      fhir:) ]

  fhir:Claim.procedure [ # 0..* Clinical procedures performed
    fhir:Claim.procedure.sequence [ positiveInt ]; # 1..1 Procedure instance identifier
    fhir:Claim.procedure.type [ CodeableConcept ], ... ; # 0..* Category of Procedure
    fhir:Claim.procedure.date [ dateTime ]; # 0..1 When the procedure was performed
    # Claim.procedure.procedure[x] : 1..1 Specific clinical procedure. One of these 2
      fhir:Claim.procedure.procedureCodeableConcept [ CodeableConcept ]
      fhir:Claim.procedure.procedureReference [ Reference(Procedure) ]
    fhir:Claim.procedure.udi [ Reference(Device) ], ... ; # 0..* Unique device identifier

  ], ...;
  fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:

  fhir:Claim.insurance [ # 1..* Patient insurance information
    fhir:Claim.insurance.sequence [ positiveInt ]; # 1..1 Insurance instance identifier
    fhir:Claim.insurance.focal [ boolean ]; # 1..1 Coverage to be used for adjudication
    fhir:Claim.insurance.identifier [ Identifier ]; # 0..1 Pre-assigned Claim number
    fhir:Claim.insurance.coverage [ Reference(Coverage) ]; # 1..1 Insurance information
    fhir:Claim.insurance.businessArrangement [ string ]; # 0..1 Additional provider contract number
    fhir:Claim.insurance.preAuthRef [ string ], ... ; # 0..* Prior authorization reference number
    fhir:Claim.insurance.claimResponse [ Reference(ClaimResponse) ]; # 0..1 Adjudication results

  ], ...;
  fhir:
    fhir:When the accident occurred
see information codes
see information codes
    fhir:
    # . One of these 2
      fhir: ]
      fhir:) ]

  fhir:Claim.accident [ # 0..1 Details of the event
    fhir:Claim.accident.date [ date ]; # 1..1 When the incident occurred
    fhir:Claim.accident.type [ CodeableConcept ]; # 0..1 The nature of the accident
    # Claim.accident.location[x] : 0..1 Where the event occurred. One of these 2
      fhir:Claim.accident.locationAddress [ Address ]
      fhir:Claim.accident.locationReference [ Reference(Location) ]

  ];
  fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    # . One of these 2
      fhir: ]
      fhir: ]
    # . One of these 3
      fhir: ]
      fhir: ]
      fhir:) ]
    fhir:
    fhir:

  fhir:Claim.item [ # 0..* Product or service provided
    fhir:Claim.item.sequence [ positiveInt ]; # 1..1 Item instance identifier
    fhir:Claim.item.careTeamSequence [ positiveInt ], ... ; # 0..* Applicable careTeam members
    fhir:Claim.item.diagnosisSequence [ positiveInt ], ... ; # 0..* Applicable diagnoses
    fhir:Claim.item.procedureSequence [ positiveInt ], ... ; # 0..* Applicable procedures
    fhir:Claim.item.informationSequence [ positiveInt ], ... ; # 0..* Applicable exception and supporting information
    fhir:Claim.item.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
    fhir:Claim.item.category [ CodeableConcept ]; # 0..1 Benefit classification
    fhir:Claim.item.productOrService [ CodeableConcept ]; # 1..1 Billing, service, product, or drug code
    fhir:Claim.item.modifier [ CodeableConcept ], ... ; # 0..* Product or service billing modifiers
    fhir:Claim.item.programCode [ CodeableConcept ], ... ; # 0..* Program the product or service is provided under
    # Claim.item.serviced[x] : 0..1 Date or dates of service or product delivery. One of these 2
      fhir:Claim.item.servicedDate [ date ]
      fhir:Claim.item.servicedPeriod [ Period ]
    # Claim.item.location[x] : 0..1 Place of service or where product was supplied. One of these 3
      fhir:Claim.item.locationCodeableConcept [ CodeableConcept ]
      fhir:Claim.item.locationAddress [ Address ]
      fhir:Claim.item.locationReference [ Reference(Location) ]
    fhir:Claim.item.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of products or services
    fhir:Claim.item.unitPrice [ Money ]; # 0..1 Fee, charge or cost per item

    fhir:Claim.item.factor [ decimal ]; # 0..1 Price scaling factor
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
      fhir:
      fhir:
      fhir:
      fhir:
      fhir:
      fhir:
      fhir:
      fhir:

    fhir:Claim.item.net [ Money ]; # 0..1 Total item cost
    fhir:Claim.item.udi [ Reference(Device) ], ... ; # 0..* Unique device identifier
    fhir:Claim.item.bodySite [ CodeableConcept ]; # 0..1 Anatomical location
    fhir:Claim.item.subSite [ CodeableConcept ], ... ; # 0..* Anatomical sub-location
    fhir:Claim.item.encounter [ Reference(Encounter) ], ... ; # 0..* Encounters related to this billed item
    fhir:Claim.item.detail [ # 0..* Product or service provided
      fhir:Claim.item.detail.sequence [ positiveInt ]; # 1..1 Item instance identifier
      fhir:Claim.item.detail.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
      fhir:Claim.item.detail.category [ CodeableConcept ]; # 0..1 Benefit classification
      fhir:Claim.item.detail.productOrService [ CodeableConcept ]; # 1..1 Billing, service, product, or drug code
      fhir:Claim.item.detail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
      fhir:Claim.item.detail.programCode [ CodeableConcept ], ... ; # 0..* Program the product or service is provided under
      fhir:Claim.item.detail.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of products or services
      fhir:Claim.item.detail.unitPrice [ Money ]; # 0..1 Fee, charge or cost per item

      fhir:Claim.item.detail.factor [ decimal ]; # 0..1 Price scaling factor
      fhir:
      fhir:
      fhir:
        fhir:
        fhir:
        fhir:
        fhir:
        fhir:
        fhir:
        fhir:
        fhir:

      fhir:Claim.item.detail.net [ Money ]; # 0..1 Total item cost
      fhir:Claim.item.detail.udi [ Reference(Device) ], ... ; # 0..* Unique device identifier
      fhir:Claim.item.detail.subDetail [ # 0..* Product or service provided
        fhir:Claim.item.detail.subDetail.sequence [ positiveInt ]; # 1..1 Item instance identifier
        fhir:Claim.item.detail.subDetail.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
        fhir:Claim.item.detail.subDetail.category [ CodeableConcept ]; # 0..1 Benefit classification
        fhir:Claim.item.detail.subDetail.productOrService [ CodeableConcept ]; # 1..1 Billing, service, product, or drug code
        fhir:Claim.item.detail.subDetail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
        fhir:Claim.item.detail.subDetail.programCode [ CodeableConcept ], ... ; # 0..* Program the product or service is provided under
        fhir:Claim.item.detail.subDetail.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of products or services
        fhir:Claim.item.detail.subDetail.unitPrice [ Money ]; # 0..1 Fee, charge or cost per item

        fhir:Claim.item.detail.subDetail.factor [ decimal ]; # 0..1 Price scaling factor
        fhir:
        fhir:

        fhir:Claim.item.detail.subDetail.net [ Money ]; # 0..1 Total item cost
        fhir:Claim.item.detail.subDetail.udi [ Reference(Device) ], ... ; # 0..* Unique device identifier

      ], ...;
    ], ...;
  ], ...;
  fhir:

  fhir:Claim.total [ Money ]; # 0..1 Total claim cost

]

Changes since DSTU2 Release 3

Claim
Claim.type Claim.status
  • Change binding strength from required to extensible Claim.enterer Type changed from Reference(Practitioner) to Reference(Practitioner|PractitionerRole) Claim.provider Type changed from Reference(Practitioner) to Reference(Practitioner|PractitionerRole|Organization) Claim.payee.resource Added Element Claim.payee.party Type changed from Reference(Practitioner|Organization|Patient|RelatedPerson) to Reference(Practitioner|PractitionerRole|Organization|Patient|RelatedPerson) Claim.referral Type changed from Reference(ReferralRequest) to Reference(ServiceRequest) Claim.careTeam.provider Type changed value set from Reference(Practitioner|Organization) http://hl7.org/fhir/ValueSet/fm-status|4.0.0 to Reference(Practitioner|PractitionerRole|Organization) Claim.information.value[x] Remove Reference(Resource), Add boolean, Add Reference(Resource) Claim.diagnosis.diagnosis[x] Remove Reference(Condition), Add Reference(Condition) Claim.procedure.procedure[x] Remove Reference(Procedure), Add Reference(Procedure) Claim.insurance.identifier Added Element http://hl7.org/fhir/ValueSet/fm-status|4.1.0
Claim.accident.type Claim.use
  • Change binding strength value set from required http://hl7.org/fhir/ValueSet/claim-use|4.0.0 to extensible Claim.accident.location[x] Remove Reference(Location), Add Reference(Location) Claim.item.careTeamSequence Added Element Claim.item.diagnosisSequence Added Element Claim.item.procedureSequence Added Element Claim.item.informationSequence Added Element Claim.item.location[x] Remove Reference(Location), Add Reference(Location) Claim.organization deleted Claim.payee.resourceType deleted Claim.employmentImpacted deleted Claim.hospitalization deleted Claim.item.careTeamLinkId deleted Claim.item.diagnosisLinkId deleted Claim.item.procedureLinkId deleted Claim.item.informationLinkId deleted http://hl7.org/fhir/ValueSet/claim-use|4.1.0

See the Full Difference for further information

This analysis is available as XML or JSON .

See R3 <--> R4 Conversion Maps (status = 16 tests of which 3 fail to execute . 13 fail round-trip testing and 3 r3 resources are invalid (0 errors). )

 

Alternate See the Profiles & Extensions and the alternate definitions: Master Definition XML + JSON , XML Schema / Schematron + JSON Schema , ShEx (for Turtle ) + see the extensions , the spreadsheet version & the dependency analysis a

Claim.payee.resource The type of Claim payee Resource Extensible ClaimPayeeResourceType
Path Definition Type Reference
Claim.status A code specifying the state of the resource instance. Required Financial Resource Status Codes FinancialResourceStatusCodes
Claim.type The type or discipline-style of the claim claim. Extensible Claim Type Codes ClaimTypeCodes
Claim.subType A more granular claim typecode typecode. Example Example Claim SubType Codes ExampleClaimSubTypeCodes
Claim.use Complete, proposed, exploratory, other The purpose of the Claim: predetermination, preauthorization, claim. Required Use
Claim.priority The timeliness with which processing is required: STAT, stat, normal, Deferred deferred. Example Process Priority Codes ProcessPriorityCodes
Claim.fundsReserve For whom funds are to be reserved: (Patient, Provider, None). Example Funds Reservation Codes
Claim.related.relationship Relationship of this claim to a related Claim Claim. Example Example Related Claim Relationship Codes ExampleRelatedClaimRelationshipCodes
Claim.payee.type A code for the party to be reimbursed. Example Claim Payee Type Codes
Claim.careTeam.role The role codes for the care team members. Example Claim Care Team Role Codes ClaimCareTeamRoleCodes
Claim.careTeam.qualification Provider professional qualifications qualifications. Example Example Provider Qualification Codes ExampleProviderQualificationCodes
Claim.information.category Claim.supportingInfo.category The valuset used for additional information category codes. Example Claim Information Category Codes ClaimInformationCategoryCodes
Claim.information.code Claim.supportingInfo.code The valuset used for additional information codes. Example Exception Codes ExceptionCodes
Claim.information.reason Claim.supportingInfo.reason Reason codes for the missing teeth teeth. Example Missing Tooth Reason Codes MissingToothReasonCodes
Claim.diagnosis.diagnosis[x] Example ICD10 Diagnostic codes codes. Example ICD-10 Codes ICD-10Codes
Claim.diagnosis.type The type of the diagnosis: admitting, principal, discharge discharge. Example ExampleDiagnosisTypeCodes
Claim.diagnosis.onAdmission Present on admission. Example Diagnosis Type Codes ExampleDiagnosisOnAdmissionCodes
Claim.diagnosis.packageCode The DRG codes associated with the diagnosis diagnosis. Example ExampleDiagnosisRelatedGroupCodes
Claim.procedure.type Example procedure type codes. Example Diagnosis Related Group Codes ExampleProcedureTypeCodes
Claim.procedure.procedure[x] Example ICD10 Procedure codes codes. Example ICD-10 Procedure Codes ICD-10ProcedureCodes
Claim.accident.type Type of accident: work place, auto, etc. Extensible ActIncidentCode v3.ActIncidentCode
Claim.item.revenue
Claim.item.detail.revenue
Claim.item.detail.subDetail.revenue
Codes for the revenue or cost centers supplying the service and/or products. Example Example Revenue Center Codes ExampleRevenueCenterCodes
Claim.item.category
Claim.item.detail.category
Claim.item.detail.subDetail.category
Benefit subcategories categories such as: oral-basic, major, glasses glasses. Example Benefit SubCategory Codes BenefitCategoryCodes
Claim.item.service Claim.item.productOrService
Claim.item.detail.service Claim.item.detail.productOrService
Claim.item.detail.subDetail.service Claim.item.detail.subDetail.productOrService
Allowable service and product codes codes. Example USCLS Codes USCLSCodes
Claim.item.modifier
Claim.item.detail.modifier
Claim.item.detail.subDetail.modifier
Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. Example Modifier type Codes ModifierTypeCodes
Claim.item.programCode
Claim.item.detail.programCode
Claim.item.detail.subDetail.programCode
Program specific reason codes codes. Example Example Program Reason Codes ExampleProgramReasonCodes
Claim.item.location[x] Place of service: pharmacy,school, pharmacy, school, prison, etc. Example Example Service Place Codes ExampleServicePlaceCodes
Claim.item.bodySite The code for the teeth, quadrant, sextant and arch arch. Example Oral Site Codes OralSiteCodes
Claim.item.subSite The code for the tooth surface and surface combinations combinations. Example Surface Codes SurfaceCodes

Search parameters for this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.

Name Type Description Expression In Common
care-team reference Member of the CareTeam Claim.careTeam.provider
( Practitioner , Organization , PractitionerRole )
created date The creation date for the Claim Claim.created
detail-udi reference UDI associated with a line item, detail product or service Claim.item.detail.udi
( Device )
encounter reference Encounters associated with a billed line item Claim.item.encounter
( Encounter )
enterer reference The party responsible for the entry of the Claim Claim.enterer
( Practitioner , PractitionerRole )
facility reference Facility responsible for where the goods and products or services have been or will be provided Claim.facility
( Location )
identifier token The primary identifier of the financial resource Claim.identifier
insurer reference The target payor/insurer for the Claim Claim.insurer
( Organization )
item-udi reference UDI associated with a line item product or service Claim.item.udi
( Device )
patient reference Patient receiving the products or services Claim.patient
( Patient )
payee reference The party receiving any payment for the Claim Claim.payee.party
( Practitioner , Organization , Patient , PractitionerRole , RelatedPerson )
priority token Processing priority requested Claim.priority
procedure-udi reference UDI associated with a procedure Claim.procedure.udi
( Device )
provider reference Provider responsible for the Claim Claim.provider
( Practitioner , Organization , PractitionerRole )
status token The status of the Claim instance. Claim.status
subdetail-udi reference UDI associated with a line item, detail, subdetail product or service Claim.item.detail.subDetail.udi
( Device )
use token The kind of financial resource Claim.use