Release 4 5 Preview #3
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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 sent to an insurer for 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):

  • claim - where the provision of goods and services is complete and adjudication under a plan and payment is sought.
  • preauthorization - where the provision of goods and services is proposed and authorization and/or the reservation of funds is desired.
  • 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 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 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

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 Business Identifier for claim
. . . status ?! Σ 1..1 code active | cancelled | draft | entered-in-error
Financial Resource Status Codes ( Required )
. . . type Σ 1..1 CodeableConcept Category or discipline
Claim Type Codes ( Extensible )
. . . subType 0..1 CodeableConcept More granular claim type
Example Claim SubType Codes ( Example )
. . . use Σ 1..1 code claim | preauthorization | predetermination
Use ( Required )
. . . patient Σ 1..1 Reference ( Patient ) The recipient of the products and services
. . . billablePeriod Σ 0..1 Period Relevant time frame for the claim
. . . created Σ 1..1 dateTime Resource creation date
. . . enterer 0..1 Reference ( Practitioner | PractitionerRole ) Author of the claim
. . . insurer Σ 0..1 Reference ( Organization ) Target
. . . provider Σ 1..1 Reference ( Practitioner | PractitionerRole | Organization ) Party responsible for the claim
. . . priority Σ 1..1 CodeableConcept Desired processing ugency
Process Priority Codes ( Example )
. . . fundsReserve 0..1 CodeableConcept For whom to reserve funds
FundsReserve ( Example )
. . . related 0..* BackboneElement 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 File or case reference
. . . prescription 0..1 Reference ( DeviceRequest | MedicationRequest | VisionPrescription ) Prescription authorizing services and products
. . . originalPrescription 0..1 Reference ( DeviceRequest | MedicationRequest | VisionPrescription ) Original prescription if superseded by fulfiller
. . . payee 0..1 BackboneElement Recipient of benefits payable
. . . . type 1..1 CodeableConcept Category of recipient
PayeeType ( Example )
. . . . party 0..1 Reference ( Practitioner | PractitionerRole | Organization | Patient | RelatedPerson ) Recipient reference
. . . referral 0..1 Reference ( ServiceRequest ) Treatment referral
. . . facility 0..1 Reference ( Location ) Servicing facility
. . . careTeam 0..* BackboneElement Members of the care team
. . . . sequence 1..1 positiveInt Order of care team
. . . . provider 1..1 Reference ( Practitioner | PractitionerRole | Organization ) Practitioner or organization
. . . . responsible 0..1 boolean Indicator of the lead practitioner
. . . . role 0..1 CodeableConcept Function within the team
Claim Care Team Role Codes ( Example )
. . . . qualification 0..1 CodeableConcept Practitioner credential or specialization
Example Provider Qualification Codes ( Example )
. . . supportingInfo 0..* BackboneElement Supporting information
. . . . sequence 1..1 positiveInt Information instance identifier
. . . . category 1..1 CodeableConcept 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 Data to be provided
. . . . . valueBoolean boolean
. . . . . valueString string
. . . . . valueQuantity Quantity
. . . . . valueAttachment Attachment
. . . . . valueReference Reference ( Any )
. . . . reason 0..1 CodeableConcept Explanation for the information
Missing Tooth Reason Codes ( Example )
. . . diagnosis 0..* BackboneElement Pertinent diagnosis information
. . . . sequence 1..1 positiveInt Diagnosis instance identifier
. . . . diagnosis[x] 1..1 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 Clinical procedures performed
. . . . sequence 1..1 positiveInt Procedure 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 Specific clinical procedure
ICD-10 Procedure Codes ( Example )
. . . . . procedureCodeableConcept CodeableConcept
. . . . . procedureReference Reference ( Procedure )
. . . . udi 0..* Reference ( Device ) Unique device identifier
. . . insurance Σ 1..* BackboneElement Patient insurance information
. . . . sequence Σ 1..1 positiveInt Insurance instance identifier
. . . . focal Σ 1..1 boolean 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 Additional provider contract number
. . . . preAuthRef 0..* string Prior authorization reference number
. . . . claimResponse 0..1 Reference ( ClaimResponse ) Adjudication results
. . . accident 0..1 BackboneElement Details of the event
. . . . date 1..1 date When the incident occurred
. . . . type 0..1 CodeableConcept The nature of the accident
V3 Value SetActIncidentCode ActIncidentCode ( Extensible )
. . . . location[x] 0..1 Where the event occurred
. . . . . locationAddress Address
. . . . . locationReference Reference ( Location )
. . . item 0..* BackboneElement Product or service provided
. . . . sequence 1..1 positiveInt 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 Benefit classification
Benefit Category Codes ( Example )
. . . . productOrService 1..1 CodeableConcept Billing, service, product, or drug code
USCLS Codes ( Example )
. . . . modifier 0..* CodeableConcept Product or service billing modifiers
Modifier type Codes ( Example )
. . . . programCode 0..* CodeableConcept Program the product or service is provided under
Example Program Reason Codes ( Example )
. . . . serviced[x] 0..1 Date or dates of 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 or services
. . . . unitPrice 0..1 Money Fee, charge or cost per item
. . . . factor 0..1 decimal Price scaling factor
. . . . net 0..1 Money Total item cost
. . . . udi 0..* Reference ( Device ) Unique device identifier
. . . . bodySite 0..1 CodeableConcept Anatomical location
Oral Site Codes ( Example )
. . . . subSite 0..* CodeableConcept Anatomical sub-location
Surface Codes ( Example )
. . . . encounter 0..* Reference ( Encounter ) Encounters related to this billed item
. . . . detail 0..* BackboneElement Product or service provided
. . . . . sequence 1..1 positiveInt Item instance identifier
. . . . . revenue 0..1 CodeableConcept Revenue or cost center code
Example Revenue Center Codes ( Example )
. . . . . category 0..1 CodeableConcept Benefit classification
Benefit Category Codes ( Example )
. . . . . productOrService 1..1 CodeableConcept Billing, service, product, or drug code
USCLS Codes ( Example )
. . . . . modifier 0..* CodeableConcept Service/Product billing modifiers
Modifier type Codes ( Example )
. . . . . programCode 0..* CodeableConcept Program the product or service is provided under
Example Program Reason Codes ( Example )
. . . . . quantity 0..1 SimpleQuantity Count of products or services
. . . . . unitPrice 0..1 Money Fee, charge or cost per item
. . . . . factor 0..1 decimal Price scaling factor
. . . . . net 0..1 Money Total item cost
. . . . . udi 0..* Reference ( Device ) Unique device identifier
. . . . . subDetail 0..* BackboneElement Product or service provided
. . . . . . sequence 1..1 positiveInt Item instance identifier
. . . . . . revenue 0..1 CodeableConcept Revenue or cost center code
Example Revenue Center Codes ( Example )
. . . . . . category 0..1 CodeableConcept Benefit classification
Benefit Category Codes ( Example )
. . . . . . productOrService 1..1 CodeableConcept Billing, service, product, or drug code
USCLS Codes ( Example )
. . . . . . modifier 0..* CodeableConcept Service/Product billing modifiers
Modifier type Codes ( Example )
. . . . . . programCode 0..* CodeableConcept Program the product or service is provided under
Example Program Reason Codes ( Example )
. . . . . . quantity 0..1 SimpleQuantity Count of products or services
. . . . . . unitPrice 0..1 Money Fee, charge or cost per item
. . . . . . factor 0..1 decimal Price scaling factor
. . . . . . net 0..1 Money Total item cost
. . . . . . udi 0..* Reference ( Device ) Unique device identifier
. . . total 0..1 Money Total claim cost

doco Documentation for this format

UML Diagram ( Legend )

Claim ( DomainResource ) A unique identifier assigned to this claim identifier : Identifier [0..*] The status of the resource instance (this element modifies the meaning of other elements) status : code [1..1] « A code specifying the state of the resource instance. (Strength=Required) FinancialResourceStatusCodes ! » The category of claim, e.g. oral, pharmacy, vision, institutional, professional type : CodeableConcept [1..1] « The type or discipline-style of the claim. (Strength=Extensible) ClaimTypeCodes + » A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service subType : CodeableConcept [0..1] « A more granular claim typecode. (Strength=Example) ExampleClaimSubTypeCodes ?? » A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or 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 [1..1] « The purpose of the Claim: predetermination, preauthorization, claim. (Strength=Required) Use ! » 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 [1..1] « Patient » The period for which charges are being submitted billablePeriod : Period [0..1] The date this resource was created created : dateTime [1..1] Individual who created the claim, predetermination or 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 claim, predetermination or preauthorization provider : Reference [1..1] « Practitioner | PractitionerRole | Organization » The provider-required urgency of processing the request. Typical values include: stat, routine deferred priority : CodeableConcept [1..1] « The timeliness with which processing is required: stat, normal, deferred. (Strength=Example) ProcessPriorityCodes ?? » A code to indicate whether and for whom funds are to be reserved for 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, device or vision products prescription : Reference [0..1] « DeviceRequest | MedicationRequest | VisionPrescription » Original prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or products originalPrescription : Reference [0..1] « DeviceRequest | MedicationRequest | VisionPrescription » A reference to a referral resource 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 Reference to a related claim claim : Reference [0..1] « Claim » A code to convey how the claims are related relationship : CodeableConcept [0..1] « Relationship of this claim to a related Claim. (Strength=Example) ExampleRelatedClaimRelationsh... ?? » An alternate organizational reference to the case or file to which this particular claim pertains reference : Identifier [0..1] Payee Type of Party to be reimbursed: 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 to whom any payment will be made party : Reference [0..1] « Practitioner | PractitionerRole | Organization | Patient | RelatedPerson » CareTeam A number to uniquely identify care team entries sequence : positiveInt [1..1] Member of the team who provided the product or service provider : Reference [1..1] « Practitioner | PractitionerRole | Organization » The party who is billing and/or responsible for the claimed products or services responsible : boolean [0..1] The lead, assisting or supervising practitioner and their discipline if a multidisciplinary team role : CodeableConcept [0..1] « The role codes for the care team members. (Strength=Example) ClaimCareTeamRoleCodes ?? » The qualification of the practitioner which is applicable for this service qualification : CodeableConcept [0..1] « Provider professional qualifications. (Strength=Example) ExampleProviderQualificationC... ?? » SupportingInformation A number to 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) ClaimInformationCategoryCodes ?? » System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought code : CodeableConcept [0..1] « The valuset used for additional information codes. (Strength=Example) ExceptionCodes ?? » The date when or period to which this information refers timing[x] : Type DataType [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 DataType [0..1] « boolean | string | Quantity | Attachment | Reference ( Any ) » Provides the reason in the situation where a reason code is required in addition to the content reason : CodeableConcept [0..1] « Reason codes for the missing teeth. (Strength=Example) MissingToothReasonCodes ?? » Diagnosis A number to uniquely identify diagnosis entries sequence : positiveInt [1..1] The nature of illness or problem in a coded form or as a reference to an external defined Condition diagnosis[x] : Type DataType [1..1] « CodeableConcept | Reference ( Condition ); Example ICD10 Diagnostic codes. (Strength=Example) ICD-10Codes ?? » When the condition was observed or the relative ranking type : CodeableConcept [0..*] « The type of the diagnosis: admitting, principal, discharge. (Strength=Example) ExampleDiagnosisTypeCodes ?? » 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 or bundle code used to group products and services to a particular health condition (such as heart attack) which is based on a predetermined grouping code system packageCode : CodeableConcept [0..1] « The DRG codes associated with the diagnosis. (Strength=Example) ExampleDiagnosisRelatedGroupC... ?? » Procedure A number to 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 code or reference to a Procedure resource which identifies the clinical intervention performed procedure[x] : Type DataType [1..1] « CodeableConcept | Reference ( Procedure ); Example ICD10 Procedure codes. (Strength=Example) ICD-10ProcedureCodes ?? » Unique Device Identifiers associated with this line item udi : Reference [0..*] « Device » Insurance A number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order sequence : positiveInt [1..1] A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true focal : boolean [1..1] The business identifier to be used when the claim is sent for adjudication against this insurance policy identifier : Identifier [0..1] Reference to the 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 » A business agreement number established between the provider and the insurer for special business processing purposes businessArrangement : string [0..1] Reference numbers previously provided by the insurer to the provider to be quoted on subsequent claims containing services or products related to the prior authorization preAuthRef : string [0..*] The result of the adjudication of the line items for the Coverage specified in this insurance claimResponse : Reference [0..1] « ClaimResponse » Accident Date of an accident event related to the products and services contained in the claim date : date [1..1] The type or context of 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) v3.ActIncidentCode ActIncidentCode + » The physical location of the accident event location[x] : Type DataType [0..1] « Address | Reference ( Location ) » Item A number to uniquely identify item entries sequence : positiveInt [1..1] CareTeam members related to this service or product careTeamSequence : positiveInt [0..*] Diagnosis applicable for this service or product diagnosisSequence : positiveInt [0..*] Procedures applicable for this service or product procedureSequence : positiveInt [0..*] Exceptions, special conditions and supporting information applicable for this service or product informationSequence : positiveInt [0..*] The type of 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) ExampleRevenueCenterCodes ?? » Code to identify the general type of benefits under which products and services are provided category : CodeableConcept [0..1] « Benefit categories such as: oral-basic, major, glasses. (Strength=Example) BenefitCategoryCodes ?? » When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item productOrService : CodeableConcept [1..1] « Allowable service and product codes. (Strength=Example) USCLSCodes ?? » Item typification or modifiers codes to convey additional context for the product or 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) ModifierTypeCodes ?? » Identifies the program under which this may be recovered programCode : CodeableConcept [0..*] « Program specific reason codes. (Strength=Example) ExampleProgramReasonCodes ?? » The date or dates when the service or product was supplied, performed or completed serviced[x] : Type DataType [0..1] « date | Period » Where the product or service was provided location[x] : Type DataType [0..1] « CodeableConcept | Address | Reference ( Location ); Place of service: pharmacy, school, prison, etc. (Strength=Example) ExampleServicePlaceCodes ?? » The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] If the item is not a group then this is the fee for the product or 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 additional service or product or charge net : Money [0..1] 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. (Strength=Example) OralSiteCodes ?? » A region or surface of the bodySite, e.g. limb region or tooth surface(s) subSite : CodeableConcept [0..*] « The code for the tooth surface and surface combinations. (Strength=Example) SurfaceCodes ?? » The Encounters during which this Claim was created or to which the creation of this record is tightly associated encounter : Reference [0..*] « Encounter » Detail A number to uniquely identify item entries sequence : positiveInt [1..1] The type of 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) ExampleRevenueCenterCodes ?? » Code to identify the general type of benefits under which products and services are provided category : CodeableConcept [0..1] « Benefit categories such as: oral-basic, major, glasses. (Strength=Example) BenefitCategoryCodes ?? » When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item productOrService : CodeableConcept [1..1] « Allowable service and product codes. (Strength=Example) USCLSCodes ?? » Item typification or modifiers codes to convey additional context for the product or 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) ModifierTypeCodes ?? » Identifies the program under which this may be recovered programCode : CodeableConcept [0..*] « Program specific reason codes. (Strength=Example) ExampleProgramReasonCodes ?? » The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] If the item is not a group then this is the fee for the product or 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 additional service or product or charge net : Money [0..1] Unique Device Identifiers associated with this line item udi : Reference [0..*] « Device » SubDetail A number to uniquely identify item entries sequence : positiveInt [1..1] The type of 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) ExampleRevenueCenterCodes ?? » Code to identify the general type of benefits under which products and services are provided category : CodeableConcept [0..1] « Benefit categories such as: oral-basic, major, glasses. (Strength=Example) BenefitCategoryCodes ?? » When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item productOrService : CodeableConcept [1..1] « Allowable service and product codes. (Strength=Example) USCLSCodes ?? » Item typification or modifiers codes to convey additional context for the product or 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) ModifierTypeCodes ?? » Identifies the program under which this may be recovered programCode : CodeableConcept [0..*] « Program specific reason codes. (Strength=Example) ExampleProgramReasonCodes ?? » The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] If the item is not a group then this is the fee for the product or 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 additional service or product or charge net : Money [0..1] Unique Device Identifiers associated with this line item udi : Reference [0..*] « Device » Other claims which are related to this claim such as prior 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 products and services careTeam [0..*] Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues supportingInfo [0..*] Information about diagnoses relevant to the claim items diagnosis [0..*] Procedures performed on the patient relevant to the billing items with the claim procedure [0..*] Financial instruments for reimbursement for the health care products and services specified on the claim insurance [1..*] Details of an accident which resulted in injuries which required the products and services listed in the claim accident [0..1] A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items subDetail [0..*] A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items detail [0..*] A claim line. Either a simple product or service or a 'group' of 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><!-- 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>

 <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><!-- 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><!-- 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>

  <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>
 <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>  <!-- 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>
 <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>
 <accident>  <!-- 0..1 Details of the event -->
  <date value="[date]"/><!-- 1..1 When the incident occurred -->
  <</type>

  <type><!-- 0..1 CodeableConcept The nature of the accident  --></type>

  <location[x]><!-- 0..1 Address|Reference(Location) Where the event occurred --></location[x]>
 </accident>
 <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><!-- 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><!-- 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><!-- 0..1 Money Total item cost --></net>
    <udi><!-- 0..* Reference(Device) Unique device identifier --></udi>
   </subDetail>
  </detail>
 </item>
 <total><!-- 0..1 Money Total claim cost --></total>
</Claim>

JSON Template

{doco
  "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
  }],
  "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: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: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: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: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:

    fhir:Claim.payee.party [ Reference(Organization|Patient|Practitioner|PractitionerRole|RelatedPerson) ]; # 0..1 Recipient reference

  ];
  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:

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

Changes since R3

Claim
Claim.status
  • Min Cardinality changed from 0 to 1 Change value set from http://hl7.org/fhir/ValueSet/fm-status to http://hl7.org/fhir/ValueSet/fm-status|4.0.1 Claim.type Min Cardinality changed from 0 to 1 Change binding strength from required to extensible Claim.subType Max Cardinality changed from * http://hl7.org/fhir/ValueSet/fm-status|4.0.0 to 1 http://hl7.org/fhir/ValueSet/fm-status|4.5.0
Claim.use
  • Min Cardinality changed from 0 to 1 Change value set from http://hl7.org/fhir/ValueSet/claim-use to http://hl7.org/fhir/ValueSet/claim-use|4.0.1 Claim.patient Min Cardinality changed from 0 to 1 Claim.created Min Cardinality changed from 0 to 1 Claim.enterer Type Reference: Added Target Type PractitionerRole Claim.provider Min Cardinality changed from 0 to 1 Type Reference: Added Target Types PractitionerRole, Organization Claim.priority Min Cardinality changed from 0 to 1 Claim.prescription Type Reference: Added Target Type DeviceRequest Claim.originalPrescription Type Reference: Added Target Types DeviceRequest, VisionPrescription Claim.payee.party Type Reference: Added Target Type PractitionerRole Claim.referral Type Reference: Added Target Type ServiceRequest Type Reference: Removed Target Type ReferralRequest Claim.careTeam.provider Type Reference: Added Target Type PractitionerRole Claim.supportingInfo Renamed from information to supportingInfo Claim.supportingInfo.sequence Moved from Claim.information to Claim.supportingInfo Claim.supportingInfo.category Moved from Claim.information to Claim.supportingInfo Claim.supportingInfo.code Moved from Claim.information to Claim.supportingInfo Claim.supportingInfo.timing[x] Moved from Claim.information to Claim.supportingInfo Claim.supportingInfo.value[x] Moved from Claim.information to Claim.supportingInfo Add Type boolean Claim.supportingInfo.reason Moved from Claim.information to Claim.supportingInfo Claim.diagnosis.onAdmission Added Element Claim.procedure.type Added Element Claim.procedure.udi Added Element Claim.insurance Min Cardinality changed from 0 to 1 Claim.insurance.identifier Added Element Claim.accident.type Change binding strength from required to extensible Claim.item.careTeamSequence Renamed from careTeamLinkId to careTeamSequence Claim.item.diagnosisSequence Renamed from diagnosisLinkId to diagnosisSequence Claim.item.procedureSequence Renamed from procedureLinkId to procedureSequence Claim.item.informationSequence Renamed from informationLinkId to informationSequence Claim.item.productOrService Renamed from service to productOrService Min Cardinality changed from 0 to 1 Claim.item.detail.productOrService Renamed from service to productOrService Min Cardinality changed from 0 to 1 Claim.item.detail.subDetail.productOrService Renamed from service to productOrService Min Cardinality changed from 0 http://hl7.org/fhir/ValueSet/claim-use|4.0.0 to 1 Claim.organization deleted Claim.payee.resourceType deleted Claim.employmentImpacted deleted Claim.hospitalization deleted http://hl7.org/fhir/ValueSet/claim-use|4.5.0

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

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 Business Identifier for claim
. . . status ?! Σ 1..1 code active | cancelled | draft | entered-in-error
Financial Resource Status Codes ( Required )
. . . type Σ 1..1 CodeableConcept Category or discipline
Claim Type Codes ( Extensible )
. . . subType 0..1 CodeableConcept More granular claim type
Example Claim SubType Codes ( Example )
. . . use Σ 1..1 code claim | preauthorization | predetermination
Use ( Required )
. . . patient Σ 1..1 Reference ( Patient ) The recipient of the products and services
. . . billablePeriod Σ 0..1 Period Relevant time frame for the claim
. . . created Σ 1..1 dateTime Resource creation date
. . . enterer 0..1 Reference ( Practitioner | PractitionerRole ) Author of the claim
. . . insurer Σ 0..1 Reference ( Organization ) Target
. . . provider Σ 1..1 Reference ( Practitioner | PractitionerRole | Organization ) Party responsible for the claim
. . . priority Σ 1..1 CodeableConcept Desired processing ugency
Process Priority Codes ( Example )
. . . fundsReserve 0..1 CodeableConcept For whom to reserve funds
FundsReserve ( Example )
. . . related 0..* BackboneElement 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 File or case reference
. . . prescription 0..1 Reference ( DeviceRequest | MedicationRequest | VisionPrescription ) Prescription authorizing services and products
. . . originalPrescription 0..1 Reference ( DeviceRequest | MedicationRequest | VisionPrescription ) Original prescription if superseded by fulfiller
. . . payee 0..1 BackboneElement Recipient of benefits payable
. . . . type 1..1 CodeableConcept Category of recipient
PayeeType ( Example )
. . . . party 0..1 Reference ( Practitioner | PractitionerRole | Organization | Patient | RelatedPerson ) Recipient reference
. . . referral 0..1 Reference ( ServiceRequest ) Treatment referral
. . . facility 0..1 Reference ( Location ) Servicing facility
. . . careTeam 0..* BackboneElement Members of the care team
. . . . sequence 1..1 positiveInt Order of care team
. . . . provider 1..1 Reference ( Practitioner | PractitionerRole | Organization ) Practitioner or organization
. . . . responsible 0..1 boolean Indicator of the lead practitioner
. . . . role 0..1 CodeableConcept Function within the team
Claim Care Team Role Codes ( Example )
. . . . qualification 0..1 CodeableConcept Practitioner credential or specialization
Example Provider Qualification Codes ( Example )
. . . supportingInfo 0..* BackboneElement Supporting information
. . . . sequence 1..1 positiveInt Information instance identifier
. . . . category 1..1 CodeableConcept 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 Data to be provided
. . . . . valueBoolean boolean
. . . . . valueString string
. . . . . valueQuantity Quantity
. . . . . valueAttachment Attachment
. . . . . valueReference Reference ( Any )
. . . . reason 0..1 CodeableConcept Explanation for the information
Missing Tooth Reason Codes ( Example )
. . . diagnosis 0..* BackboneElement Pertinent diagnosis information
. . . . sequence 1..1 positiveInt Diagnosis instance identifier
. . . . diagnosis[x] 1..1 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 Clinical procedures performed
. . . . sequence 1..1 positiveInt Procedure 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 Specific clinical procedure
ICD-10 Procedure Codes ( Example )
. . . . . procedureCodeableConcept CodeableConcept
. . . . . procedureReference Reference ( Procedure )
. . . . udi 0..* Reference ( Device ) Unique device identifier
. . . insurance Σ 1..* BackboneElement Patient insurance information
. . . . sequence Σ 1..1 positiveInt Insurance instance identifier
. . . . focal Σ 1..1 boolean 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 Additional provider contract number
. . . . preAuthRef 0..* string Prior authorization reference number
. . . . claimResponse 0..1 Reference ( ClaimResponse ) Adjudication results
. . . accident 0..1 BackboneElement Details of the event
. . . . date 1..1 date When the incident occurred
. . . . type 0..1 CodeableConcept The nature of the accident
V3 Value SetActIncidentCode ActIncidentCode ( Extensible )
. . . . location[x] 0..1 Where the event occurred
. . . . . locationAddress Address
. . . . . locationReference Reference ( Location )
. . . item 0..* BackboneElement Product or service provided
. . . . sequence 1..1 positiveInt 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 Benefit classification
Benefit Category Codes ( Example )
. . . . productOrService 1..1 CodeableConcept Billing, service, product, or drug code
USCLS Codes ( Example )
. . . . modifier 0..* CodeableConcept Product or service billing modifiers
Modifier type Codes ( Example )
. . . . programCode 0..* CodeableConcept Program the product or service is provided under
Example Program Reason Codes ( Example )
. . . . serviced[x] 0..1 Date or dates of 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 or services
. . . . unitPrice 0..1 Money Fee, charge or cost per item
. . . . factor 0..1 decimal Price scaling factor
. . . . net 0..1 Money Total item cost
. . . . udi 0..* Reference ( Device ) Unique device identifier
. . . . bodySite 0..1 CodeableConcept Anatomical location
Oral Site Codes ( Example )
. . . . subSite 0..* CodeableConcept Anatomical sub-location
Surface Codes ( Example )
. . . . encounter 0..* Reference ( Encounter ) Encounters related to this billed item
. . . . detail 0..* BackboneElement Product or service provided
. . . . . sequence 1..1 positiveInt Item instance identifier
. . . . . revenue 0..1 CodeableConcept Revenue or cost center code
Example Revenue Center Codes ( Example )
. . . . . category 0..1 CodeableConcept Benefit classification
Benefit Category Codes ( Example )
. . . . . productOrService 1..1 CodeableConcept Billing, service, product, or drug code
USCLS Codes ( Example )
. . . . . modifier 0..* CodeableConcept Service/Product billing modifiers
Modifier type Codes ( Example )
. . . . . programCode 0..* CodeableConcept Program the product or service is provided under
Example Program Reason Codes ( Example )
. . . . . quantity 0..1 SimpleQuantity Count of products or services
. . . . . unitPrice 0..1 Money Fee, charge or cost per item
. . . . . factor 0..1 decimal Price scaling factor
. . . . . net 0..1 Money Total item cost
. . . . . udi 0..* Reference ( Device ) Unique device identifier
. . . . . subDetail 0..* BackboneElement Product or service provided
. . . . . . sequence 1..1 positiveInt Item instance identifier
. . . . . . revenue 0..1 CodeableConcept Revenue or cost center code
Example Revenue Center Codes ( Example )
. . . . . . category 0..1 CodeableConcept Benefit classification
Benefit Category Codes ( Example )
. . . . . . productOrService 1..1 CodeableConcept Billing, service, product, or drug code
USCLS Codes ( Example )
. . . . . . modifier 0..* CodeableConcept Service/Product billing modifiers
Modifier type Codes ( Example )
. . . . . . programCode 0..* CodeableConcept Program the product or service is provided under
Example Program Reason Codes ( Example )
. . . . . . quantity 0..1 SimpleQuantity Count of products or services
. . . . . . unitPrice 0..1 Money Fee, charge or cost per item
. . . . . . factor 0..1 decimal Price scaling factor
. . . . . . net 0..1 Money Total item cost
. . . . . . udi 0..* Reference ( Device ) Unique device identifier
. . . total 0..1 Money Total claim cost

doco Documentation for this format

UML Diagram ( Legend )

Claim ( DomainResource ) A unique identifier assigned to this claim identifier : Identifier [0..*] The status of the resource instance (this element modifies the meaning of other elements) status : code [1..1] « A code specifying the state of the resource instance. (Strength=Required) FinancialResourceStatusCodes ! » The category of claim, e.g. oral, pharmacy, vision, institutional, professional type : CodeableConcept [1..1] « The type or discipline-style of the claim. (Strength=Extensible) ClaimTypeCodes + » A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service subType : CodeableConcept [0..1] « A more granular claim typecode. (Strength=Example) ExampleClaimSubTypeCodes ?? » A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or 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 [1..1] « The purpose of the Claim: predetermination, preauthorization, claim. (Strength=Required) Use ! » 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 [1..1] « Patient » The period for which charges are being submitted billablePeriod : Period [0..1] The date this resource was created created : dateTime [1..1] Individual who created the claim, predetermination or 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 claim, predetermination or preauthorization provider : Reference [1..1] « Practitioner | PractitionerRole | Organization » The provider-required urgency of processing the request. Typical values include: stat, routine deferred priority : CodeableConcept [1..1] « The timeliness with which processing is required: stat, normal, deferred. (Strength=Example) ProcessPriorityCodes ?? » A code to indicate whether and for whom funds are to be reserved for 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, device or vision products prescription : Reference [0..1] « DeviceRequest | MedicationRequest | VisionPrescription » Original prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or products originalPrescription : Reference [0..1] « DeviceRequest | MedicationRequest | VisionPrescription » A reference to a referral resource 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 Reference to a related claim claim : Reference [0..1] « Claim » A code to convey how the claims are related relationship : CodeableConcept [0..1] « Relationship of this claim to a related Claim. (Strength=Example) ExampleRelatedClaimRelationsh... ?? » An alternate organizational reference to the case or file to which this particular claim pertains reference : Identifier [0..1] Payee Type of Party to be reimbursed: 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 to whom any payment will be made party : Reference [0..1] « Practitioner | PractitionerRole | Organization | Patient | RelatedPerson » CareTeam A number to uniquely identify care team entries sequence : positiveInt [1..1] Member of the team who provided the product or service provider : Reference [1..1] « Practitioner | PractitionerRole | Organization » The party who is billing and/or responsible for the claimed products or services responsible : boolean [0..1] The lead, assisting or supervising practitioner and their discipline if a multidisciplinary team role : CodeableConcept [0..1] « The role codes for the care team members. (Strength=Example) ClaimCareTeamRoleCodes ?? » The qualification of the practitioner which is applicable for this service qualification : CodeableConcept [0..1] « Provider professional qualifications. (Strength=Example) ExampleProviderQualificationC... ?? » SupportingInformation A number to 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) ClaimInformationCategoryCodes ?? » System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought code : CodeableConcept [0..1] « The valuset used for additional information codes. (Strength=Example) ExceptionCodes ?? » The date when or period to which this information refers timing[x] : Type DataType [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 DataType [0..1] « boolean | string | Quantity | Attachment | Reference ( Any ) » Provides the reason in the situation where a reason code is required in addition to the content reason : CodeableConcept [0..1] « Reason codes for the missing teeth. (Strength=Example) MissingToothReasonCodes ?? » Diagnosis A number to uniquely identify diagnosis entries sequence : positiveInt [1..1] The nature of illness or problem in a coded form or as a reference to an external defined Condition diagnosis[x] : Type DataType [1..1] « CodeableConcept | Reference ( Condition ); Example ICD10 Diagnostic codes. (Strength=Example) ICD-10Codes ?? » When the condition was observed or the relative ranking type : CodeableConcept [0..*] « The type of the diagnosis: admitting, principal, discharge. (Strength=Example) ExampleDiagnosisTypeCodes ?? » 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 or bundle code used to group products and services to a particular health condition (such as heart attack) which is based on a predetermined grouping code system packageCode : CodeableConcept [0..1] « The DRG codes associated with the diagnosis. (Strength=Example) ExampleDiagnosisRelatedGroupC... ?? » Procedure A number to 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 code or reference to a Procedure resource which identifies the clinical intervention performed procedure[x] : Type DataType [1..1] « CodeableConcept | Reference ( Procedure ); Example ICD10 Procedure codes. (Strength=Example) ICD-10ProcedureCodes ?? » Unique Device Identifiers associated with this line item udi : Reference [0..*] « Device » Insurance A number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order sequence : positiveInt [1..1] A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true focal : boolean [1..1] The business identifier to be used when the claim is sent for adjudication against this insurance policy identifier : Identifier [0..1] Reference to the 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 » A business agreement number established between the provider and the insurer for special business processing purposes businessArrangement : string [0..1] Reference numbers previously provided by the insurer to the provider to be quoted on subsequent claims containing services or products related to the prior authorization preAuthRef : string [0..*] The result of the adjudication of the line items for the Coverage specified in this insurance claimResponse : Reference [0..1] « ClaimResponse » Accident Date of an accident event related to the products and services contained in the claim date : date [1..1] The type or context of 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) v3.ActIncidentCode ActIncidentCode + » The physical location of the accident event location[x] : Type DataType [0..1] « Address | Reference ( Location ) » Item A number to uniquely identify item entries sequence : positiveInt [1..1] CareTeam members related to this service or product careTeamSequence : positiveInt [0..*] Diagnosis applicable for this service or product diagnosisSequence : positiveInt [0..*] Procedures applicable for this service or product procedureSequence : positiveInt [0..*] Exceptions, special conditions and supporting information applicable for this service or product informationSequence : positiveInt [0..*] The type of 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) ExampleRevenueCenterCodes ?? » Code to identify the general type of benefits under which products and services are provided category : CodeableConcept [0..1] « Benefit categories such as: oral-basic, major, glasses. (Strength=Example) BenefitCategoryCodes ?? » When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item productOrService : CodeableConcept [1..1] « Allowable service and product codes. (Strength=Example) USCLSCodes ?? » Item typification or modifiers codes to convey additional context for the product or 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) ModifierTypeCodes ?? » Identifies the program under which this may be recovered programCode : CodeableConcept [0..*] « Program specific reason codes. (Strength=Example) ExampleProgramReasonCodes ?? » The date or dates when the service or product was supplied, performed or completed serviced[x] : Type DataType [0..1] « date | Period » Where the product or service was provided location[x] : Type DataType [0..1] « CodeableConcept | Address | Reference ( Location ); Place of service: pharmacy, school, prison, etc. (Strength=Example) ExampleServicePlaceCodes ?? » The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] If the item is not a group then this is the fee for the product or 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 additional service or product or charge net : Money [0..1] 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. (Strength=Example) OralSiteCodes ?? » A region or surface of the bodySite, e.g. limb region or tooth surface(s) subSite : CodeableConcept [0..*] « The code for the tooth surface and surface combinations. (Strength=Example) SurfaceCodes ?? » The Encounters during which this Claim was created or to which the creation of this record is tightly associated encounter : Reference [0..*] « Encounter » Detail A number to uniquely identify item entries sequence : positiveInt [1..1] The type of 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) ExampleRevenueCenterCodes ?? » Code to identify the general type of benefits under which products and services are provided category : CodeableConcept [0..1] « Benefit categories such as: oral-basic, major, glasses. (Strength=Example) BenefitCategoryCodes ?? » When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item productOrService : CodeableConcept [1..1] « Allowable service and product codes. (Strength=Example) USCLSCodes ?? » Item typification or modifiers codes to convey additional context for the product or 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) ModifierTypeCodes ?? » Identifies the program under which this may be recovered programCode : CodeableConcept [0..*] « Program specific reason codes. (Strength=Example) ExampleProgramReasonCodes ?? » The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] If the item is not a group then this is the fee for the product or 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 additional service or product or charge net : Money [0..1] Unique Device Identifiers associated with this line item udi : Reference [0..*] « Device » SubDetail A number to uniquely identify item entries sequence : positiveInt [1..1] The type of 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) ExampleRevenueCenterCodes ?? » Code to identify the general type of benefits under which products and services are provided category : CodeableConcept [0..1] « Benefit categories such as: oral-basic, major, glasses. (Strength=Example) BenefitCategoryCodes ?? » When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item productOrService : CodeableConcept [1..1] « Allowable service and product codes. (Strength=Example) USCLSCodes ?? » Item typification or modifiers codes to convey additional context for the product or 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) ModifierTypeCodes ?? » Identifies the program under which this may be recovered programCode : CodeableConcept [0..*] « Program specific reason codes. (Strength=Example) ExampleProgramReasonCodes ?? » The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] If the item is not a group then this is the fee for the product or 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 additional service or product or charge net : Money [0..1] Unique Device Identifiers associated with this line item udi : Reference [0..*] « Device » Other claims which are related to this claim such as prior 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 products and services careTeam [0..*] Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues supportingInfo [0..*] Information about diagnoses relevant to the claim items diagnosis [0..*] Procedures performed on the patient relevant to the billing items with the claim procedure [0..*] Financial instruments for reimbursement for the health care products and services specified on the claim insurance [1..*] Details of an accident which resulted in injuries which required the products and services listed in the claim accident [0..1] A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items subDetail [0..*] A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items detail [0..*] A claim line. Either a simple product or service or a 'group' of 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><!-- 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>

 <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><!-- 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><!-- 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>

  <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>
 <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>  <!-- 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>
 <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>
 <accident>  <!-- 0..1 Details of the event -->
  <date value="[date]"/><!-- 1..1 When the incident occurred -->
  <</type>

  <type><!-- 0..1 CodeableConcept The nature of the accident  --></type>

  <location[x]><!-- 0..1 Address|Reference(Location) Where the event occurred --></location[x]>
 </accident>
 <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><!-- 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><!-- 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><!-- 0..1 Money Total item cost --></net>
    <udi><!-- 0..* Reference(Device) Unique device identifier --></udi>
   </subDetail>
  </detail>
 </item>
 <total><!-- 0..1 Money Total claim cost --></total>
</Claim>

JSON Template

{doco
  "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
  }],
  "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: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: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: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: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:

    fhir:Claim.payee.party [ Reference(Organization|Patient|Practitioner|PractitionerRole|RelatedPerson) ]; # 0..1 Recipient reference

  ];
  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:

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

Changes since Release 3

Claim
Claim.status
  • Min Cardinality changed from 0 to 1 Change value set from http://hl7.org/fhir/ValueSet/fm-status to http://hl7.org/fhir/ValueSet/fm-status|4.0.1 Claim.type Min Cardinality changed from 0 to 1 Change binding strength from required to extensible Claim.subType Max Cardinality changed from * http://hl7.org/fhir/ValueSet/fm-status|4.0.0 to 1 http://hl7.org/fhir/ValueSet/fm-status|4.5.0
Claim.use
  • Min Cardinality changed from 0 to 1 Change value set from http://hl7.org/fhir/ValueSet/claim-use to http://hl7.org/fhir/ValueSet/claim-use|4.0.1 Claim.patient Min Cardinality changed from 0 to 1 Claim.created Min Cardinality changed from 0 to 1 Claim.enterer Type Reference: Added Target Type PractitionerRole Claim.provider Min Cardinality changed from 0 to 1 Type Reference: Added Target Types PractitionerRole, Organization Claim.priority Min Cardinality changed from 0 to 1 Claim.prescription Type Reference: Added Target Type DeviceRequest Claim.originalPrescription Type Reference: Added Target Types DeviceRequest, VisionPrescription Claim.payee.party Type Reference: Added Target Type PractitionerRole Claim.referral Type Reference: Added Target Type ServiceRequest Type Reference: Removed Target Type ReferralRequest Claim.careTeam.provider Type Reference: Added Target Type PractitionerRole Claim.supportingInfo Renamed from information to supportingInfo Claim.supportingInfo.sequence Moved from Claim.information to Claim.supportingInfo Claim.supportingInfo.category Moved from Claim.information to Claim.supportingInfo Claim.supportingInfo.code Moved from Claim.information to Claim.supportingInfo Claim.supportingInfo.timing[x] Moved from Claim.information to Claim.supportingInfo Claim.supportingInfo.value[x] Moved from Claim.information to Claim.supportingInfo Add Type boolean Claim.supportingInfo.reason Moved from Claim.information to Claim.supportingInfo Claim.diagnosis.onAdmission Added Element Claim.procedure.type Added Element Claim.procedure.udi Added Element Claim.insurance Min Cardinality changed from 0 to 1 Claim.insurance.identifier Added Element Claim.accident.type Change binding strength from required to extensible Claim.item.careTeamSequence Renamed from careTeamLinkId to careTeamSequence Claim.item.diagnosisSequence Renamed from diagnosisLinkId to diagnosisSequence Claim.item.procedureSequence Renamed from procedureLinkId to procedureSequence Claim.item.informationSequence Renamed from informationLinkId to informationSequence Claim.item.productOrService Renamed from service to productOrService Min Cardinality changed from 0 to 1 Claim.item.detail.productOrService Renamed from service to productOrService Min Cardinality changed from 0 to 1 Claim.item.detail.subDetail.productOrService Renamed from service to productOrService Min Cardinality changed from 0 http://hl7.org/fhir/ValueSet/claim-use|4.0.0 to 1 Claim.organization deleted Claim.payee.resourceType deleted Claim.employmentImpacted deleted Claim.hospitalization deleted http://hl7.org/fhir/ValueSet/claim-use|4.5.0

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). )

 

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

Path Definition Type Reference
Claim.status A code specifying the state of the resource instance. Required FinancialResourceStatusCodes
Claim.type The type or discipline-style of the claim. Extensible ClaimTypeCodes
Claim.subType A more granular claim typecode. Example ExampleClaimSubTypeCodes
Claim.use The purpose of the Claim: predetermination, preauthorization, claim. Required Use
Claim.priority The timeliness with which processing is required: stat, normal, deferred. Example 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. Example 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 ClaimCareTeamRoleCodes
Claim.careTeam.qualification Provider professional qualifications. Example ExampleProviderQualificationCodes
Claim.supportingInfo.category The valuset used for additional information category codes. Example ClaimInformationCategoryCodes
Claim.supportingInfo.code The valuset used for additional information codes. Example ExceptionCodes
Claim.supportingInfo.reason Reason codes for the missing teeth. Example MissingToothReasonCodes
Claim.diagnosis.diagnosis[x] Example ICD10 Diagnostic codes. Example ICD-10Codes
Claim.diagnosis.type The type of the diagnosis: admitting, principal, discharge. Example ExampleDiagnosisTypeCodes
Claim.diagnosis.onAdmission Present on admission. Example ExampleDiagnosisOnAdmissionCodes
Claim.diagnosis.packageCode The DRG codes associated with the diagnosis. Example ExampleDiagnosisRelatedGroupCodes
Claim.procedure.type Example procedure type codes. Example ExampleProcedureTypeCodes
Claim.procedure.procedure[x] Example ICD10 Procedure codes. Example ICD-10ProcedureCodes
Claim.accident.type Type of accident: work place, auto, etc. Extensible v3.ActIncidentCode 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 ExampleRevenueCenterCodes
Claim.item.category
Claim.item.detail.category
Claim.item.detail.subDetail.category
Benefit categories such as: oral-basic, major, glasses. Example BenefitCategoryCodes
Claim.item.productOrService
Claim.item.detail.productOrService
Claim.item.detail.subDetail.productOrService
Allowable service and product codes. Example 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 ModifierTypeCodes
Claim.item.programCode
Claim.item.detail.programCode
Claim.item.detail.subDetail.programCode
Program specific reason codes. Example ExampleProgramReasonCodes
Claim.item.location[x] Place of service: pharmacy, school, prison, etc. Example ExampleServicePlaceCodes
Claim.item.bodySite The code for the teeth, quadrant, sextant and arch. Example OralSiteCodes
Claim.item.subSite The code for the tooth surface and surface combinations. Example 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 N 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 where the 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 N 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 N token The kind of financial resource Claim.use