STU 3 Candidate

This page is part of the FHIR Specification (v1.4.0: STU 3 Ballot 3). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2

7.1 Resource Claim - Content

Financial Management Work GroupMaturity Level: 0Compartments: Patient, Practitioner

A provider issued list of services and products provided, or to be provided, to a patient which is provided to an insurer for payment recovery.

7.1.1 Scope and Usage

The OralHealthClaim is one of a suite of similar resources (VisionClaim, PharmacyClaim, ProfessionalClaim, InstitutionalClaim) which are used by providers to exchange the financial information, and supporting clinical information, regarding the provision of healthcare services. The primary uses of this resource is to support eClaims, the exchange of proposed or actual services to benefit payors, insurers and national health programs, for treatment payment planning and reimbursement.

The Claim is intended to support:

  • Claims - where the provision of goods and services is complete and reimbursement is sought.
  • Pre-Authorization - where the provision of goods and services is proposed and either authorization and/or the reservation of funds is desired.
  • Pre-Determination - 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.

Todo

This resource is referenced by ClaimResponse and ExplanationOfBenefit

7.1.2 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim ΣDomainResourceClaim, Pre-determination or Pre-authorization
... type Σ1..1codeinstitutional | oral | pharmacy | professional | vision
ClaimType (Required)
... subType Σ0..*CodingFiner grained claim type information
Example Claim SubType Codes (Example)
... identifier Σ0..*IdentifierClaim number
... ruleset Σ0..1CodingCurrent specification followed
Ruleset Codes (Example)
... originalRuleset Σ0..1CodingOriginal specification followed
Ruleset Codes (Example)
... created Σ0..1dateTimeCreation date
... billablePeriod Σ0..1PeriodPeriod for charge submission
... target[x] Σ0..1Insurer
.... targetIdentifierIdentifier
.... targetReferenceReference(Organization)
... provider[x] Σ0..1Responsible provider
.... providerIdentifierIdentifier
.... providerReferenceReference(Practitioner)
... organization[x] Σ0..1Responsible organization
.... organizationIdentifierIdentifier
.... organizationReferenceReference(Organization)
... use Σ0..1codecomplete | proposed | exploratory | other
Use (Required)
... priority Σ0..1CodingDesired processing priority
Priority Codes (Example)
... fundsReserve Σ0..1CodingFunds requested to be reserved
Funds Reservation Codes (Example)
... enterer[x] Σ0..1Author
.... entererIdentifierIdentifier
.... entererReferenceReference(Practitioner)
... facility[x] Σ0..1Servicing Facility
.... facilityIdentifierIdentifier
.... facilityReferenceReference(Location)
... related Σ0..*BackboneElementRelated Claims which may be revelant to processing this claimn
.... claim[x] Σ0..1Reference to the related claim
..... claimIdentifierIdentifier
..... claimReferenceReference(Claim)
.... relationship Σ0..1CodingHow the reference claim is related
Example Related Claim Relationship Codes (Example)
.... reference Σ0..1IdentifierRelated file or case reference
... prescription[x] Σ0..1Prescription
.... prescriptionIdentifierIdentifier
.... prescriptionReferenceReference(MedicationOrder | VisionPrescription)
... originalPrescription[x] Σ0..1Original Prescription
.... originalPrescriptionIdentifierIdentifier
.... originalPrescriptionReferenceReference(MedicationOrder)
... payee Σ0..1BackboneElementParty to be paid any benefits payable
.... type Σ1..1CodingType of party: Subscriber, Provider, other
Payee Type Codes (Example)
.... party[x] Σ0..1Party to receive the payable
..... partyIdentifierIdentifier
..... partyReferenceReference(Practitioner | Organization | Patient | RelatedPerson)
... referral[x] Σ0..1Treatment Referral
.... referralIdentifierIdentifier
.... referralReferenceReference(ReferralRequest)
... occurrenceCode Σ0..*CodingOccurrence Codes
Example Occurrance Codes (Example)
... occurenceSpanCode Σ0..*CodingOccurrence Span Codes
Example Occurrance Span Codes (Example)
... valueCode Σ0..*CodingValue Codes
Example Value Codes (Example)
... diagnosis Σ0..*BackboneElementDiagnosis
.... sequence Σ1..1positiveIntNumber to covey order of diagnosis
.... diagnosis Σ1..1CodingPatient's list of diagnosis
ICD-10 Codes (Example)
... procedure Σ0..*BackboneElementProcedures performed
.... sequence Σ1..1positiveIntProcedure sequence for reference
.... date Σ0..1dateTimeWhen the procedure was performed
.... procedure[x] Σ1..1Patient's list of procedures performed
ICD-10 Procedure Codes (Example)
..... procedureCodingCoding
..... procedureReferenceReference(Procedure)
... specialCondition Σ0..*CodingList of special Conditions
Conditions Codes (Example)
... patient[x] Σ1..1The subject of the Products and Services
.... patientIdentifierIdentifier
.... patientReferenceReference(Patient)
... coverage Σ0..*BackboneElementInsurance or medical plan
.... sequence Σ1..1positiveIntService instance identifier
.... focal Σ1..1booleanIs the focal Coverage
.... coverage[x] Σ1..1Insurance information
..... coverageIdentifierIdentifier
..... coverageReferenceReference(Coverage)
.... businessArrangement Σ0..1stringBusiness agreement
.... preAuthRef Σ0..*stringPre-Authorization/Determination Reference
.... claimResponse Σ0..1Reference(ClaimResponse)Adjudication results
.... originalRuleset Σ0..1CodingOriginal version
Ruleset Codes (Example)
... accidentDate Σ0..1dateWhen the accident occurred
... accidentType Σ0..1CodingThe nature of the accident
ActIncidentCode (Required)
... accidentLocation[x] Σ0..1Accident Place
.... accidentLocationAddressAddress
.... accidentLocationReferenceReference(Location)
... interventionException Σ0..*CodingIntervention and exception code (Pharma)
Intervention Codes (Example)
... onset Σ0..*BackboneElementCondition related Onset related dates and codes
.... time[x] Σ0..1Illness, injury or treatable condition date
..... timeDatedate
..... timePeriodPeriod
.... type Σ0..1CodingOnset of what
Example Onset Type (Reason) Codes (Example)
... employmentImpacted Σ0..1PeriodPeriod unable to work
... hospitalization Σ0..1PeriodPeriod in hospital
... item Σ0..*BackboneElementGoods and Services
.... sequence Σ1..1positiveIntService instance
.... type Σ1..1CodingGroup or type of product or service
Exception Codes (Required)
.... provider[x] Σ0..1Responsible practitioner
..... providerIdentifierIdentifier
..... providerReferenceReference(Practitioner)
.... supervisor[x] Σ0..1Supervising Practitioner
..... supervisorIdentifierIdentifier
..... supervisorReferenceReference(Practitioner)
.... providerQualification Σ0..1CodingType, classification or Specialization
Example Provider Qualification Codes (Example)
.... diagnosisLinkId Σ0..*positiveIntApplicable diagnoses
.... service Σ1..1CodingItem Code
USCLS Codes (Example)
.... serviceModifier Σ0..*CodingService/Product modifiers
Example Service Modifier Codes (Example)
.... modifier Σ0..*CodingService/Product billing modifiers
Modifier type Codes (Example)
.... programCode Σ0..*CodingProgram specific reason for item inclusion
Example Program Reason Codes (Example)
.... serviced[x] Σ0..1Date or dates of Service
..... servicedDatedate
..... servicedPeriodPeriod
.... place Σ0..1CodingPlace of service
Example Service Place Codes (Example)
.... quantity Σ0..1SimpleQuantityCount of Products or Services
.... unitPrice Σ0..1MoneyFee, charge or cost per point
.... factor Σ0..1decimalPrice scaling factor
.... points Σ0..1decimalDifficulty scaling factor
.... net Σ0..1MoneyTotal item cost
.... udi Σ0..*Reference(Device)Unique Device Identifier
.... bodySite Σ0..1CodingService Location
Oral Site Codes (Example)
.... subSite Σ0..*CodingService Sub-location
Surface Codes (Example)
.... detail Σ0..*BackboneElementAdditional items
..... sequence Σ1..1positiveIntService instance
..... type Σ1..1CodingGroup or type of product or service
Exception Codes (Required)
..... service Σ1..1CodingAdditional item codes
USCLS Codes (Example)
..... programCode Σ0..*CodingProgram specific reason for item inclusion
Example Program Reason Codes (Example)
..... quantity Σ0..1SimpleQuantityCount of Products or Services
..... unitPrice Σ0..1MoneyFee, charge or cost per point
..... factor Σ0..1decimalPrice scaling factor
..... points Σ0..1decimalDifficulty scaling factor
..... net Σ0..1MoneyTotal additional item cost
..... udi Σ0..*Reference(Device)Unique Device Identifier
..... subDetail Σ0..*BackboneElementAdditional items
...... sequence Σ1..1positiveIntService instance
...... type Σ1..1CodingType of product or service
Exception Codes (Required)
...... service Σ1..1CodingAdditional item codes
USCLS Codes (Example)
...... programCode Σ0..*CodingProgram specific reason for item inclusion
Example Program Reason Codes (Example)
...... quantity Σ0..1SimpleQuantityCount of Products or Services
...... unitPrice Σ0..1MoneyFee, charge or cost per point
...... factor Σ0..1decimalPrice scaling factor
...... points Σ0..1decimalDifficulty scaling factor
...... net Σ0..1MoneyNet additional item cost
...... udi Σ0..*Reference(Device)Unique Device Identifier
.... prosthesis Σ0..1BackboneElementProsthetic details
..... initial Σ0..1booleanIs this the initial service
..... priorDate Σ0..1dateInitial service Date
..... priorMaterial Σ0..1CodingProsthetic Material
Oral Prostho Material type Codes (Example)
... total Σ0..1MoneyTotal claim cost
... additionalMaterial Σ0..*CodingAdditional supporting materials and documents
Additional Material Codes (Example)
... missingTeeth Σ0..*BackboneElementOnly if type = oral
.... tooth Σ1..1CodingTooth Code
Teeth Codes (Example)
.... reason Σ0..1CodingIndicates whether it was extracted or other reason
Missing Tooth Reason Codes (Example)
.... extractionDate Σ0..1dateDate tooth was extracted if known

doco Documentation for this format

UML Diagram

Claim (DomainResource)The category of claimtype : code [1..1] « The type or discipline-style of the claim (Strength=Required)ClaimType! »A finer grained suite of claim subtype codes which may convey Inpatient vs Outpatient and/or a specialty service. In the US the BillTypesubType : Coding [0..*] « A more granulat claim typecode (Strength=Example)Example Claim SubType ?? »The business identifier for the instance: claim number, pre-determination or pre-authorization numberidentifier : Identifier [0..*]The version of the specification on which this instance reliesruleset : Coding [0..1] « The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example)Ruleset ?? »The version of the specification from which the original instance was createdoriginalRuleset : Coding [0..1] « The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example)Ruleset ?? »The date when the enclosed suite of services were performed or completedcreated : dateTime [0..1]The billable period for which charges are being submittedbillablePeriod : Period [0..1]Insurer Identifier, typical BIN number (6 digit)target[x] : Type [0..1] « Identifier|Reference(Organization) »The provider which is responsible for the bill, claim pre-determination, pre-authorizationprovider[x] : Type [0..1] « Identifier|Reference(Practitioner) »The organization which is responsible for the bill, claim pre-determination, pre-authorizationorganization[x] : Type [0..1] « Identifier|Reference(Organization) »Complete (Bill or Claim), Proposed (Pre-Authorization), Exploratory (Pre-determination)use : code [0..1] « Complete, proposed, exploratory, other (Strength=Required)Use! »Immediate (STAT), best effort (NORMAL), deferred (DEFER)priority : Coding [0..1] « The timeliness with which processing is required: STAT, normal, Deferred (Strength=Example)Priority ?? »In the case of a Pre-Determination/Pre-Authorization the provider may request that funds in the amount of the expected Benefit be reserved ('Patient' or 'Provider') to pay for the Benefits determined on the subsequent claim(s). 'None' explicitly indicates no funds reserving is requestedfundsReserve : Coding [0..1] « For whom funds are to be reserved: (Patient, Provider, None). (Strength=Example)Funds Reservation ?? »Person who created the invoice/claim/pre-determination or pre-authorizationenterer[x] : Type [0..1] « Identifier|Reference(Practitioner) »Facility where the services were providedfacility[x] : Type [0..1] « Identifier|Reference(Location) »Prescription to support the dispensing of Pharmacy or Vision productsprescription[x] : Type [0..1] « Identifier|Reference(MedicationOrder| VisionPrescription) »Original prescription which has been superceded by this prescription to support the dispensing of pharmacy services, medications or productsoriginalPrescription[x] : Type [0..1] « Identifier|Reference( MedicationOrder) »The referral resource which lists the date, practitioner, reason and other supporting informationreferral[x] : Type [0..1] « Identifier|Reference(ReferralRequest) »**Insert definition of Occurrence codesoccurrenceCode : Coding [0..*] « Occurrence codes (Strength=Example)Example Occurrance ?? »**Insert definition of Occurrence Span codesoccurenceSpanCode : Coding [0..*] « Occurrence Span codes (Strength=Example)Example Occurrance Span ?? »**Insert definition of Value codesvalueCode : Coding [0..*] « Value code (Strength=Example)Example Value ?? »List of special conditions relating to the setting, treatment or patient for which care is sought which may influence the adjudicationspecialCondition : Coding [0..*] « Patient conditions and symptoms (Strength=Example)Conditions ?? »Patient Resourcepatient[x] : Type [1..1] « Identifier|Reference(Patient) »Date of an accident which these services are addressingaccidentDate : date [0..1]Type of accident: work, auto, etcaccidentType : Coding [0..1] « Type of accident: work place, auto, etc. (Strength=Required)ActIncidentCode! »Accident PlaceaccidentLocation[x] : Type [0..1] « Address|Reference(Location) »A list of intervention and exception codes which may influence the adjudication of the claiminterventionException : Coding [0..*] « Intervention and exception codes (Pharm) (Strength=Example)Intervention ?? »The start and optional end dates of when the patient was precluded from working due to the treatable condition(s)employmentImpacted : Period [0..1]The start and optional end dates of when the patient was confined to a treatment centerhospitalization : Period [0..1]The total value of the claimtotal : Quantity(Money) [0..1]Code to indicate that Xrays, images, emails, documents, models or attachments are being sent in support of this submissionadditionalMaterial : Coding [0..*] « Code to indicate that Xrays, images, emails, documents, models or attachments are being sent in support of this submission. (Strength=Example)Additional Material ?? »RelatedClaimsOther claims which are related to this claim such as prior claim versions or for related servicesclaim[x] : Type [0..1] « Identifier|Reference(Claim) »For example prior or umbrellarelationship : Coding [0..1] « Relationship of this claim to a related Claim (Strength=Example)Example Related Claim Relatio...?? »An alternate organizational reference to the case or file to which this particular claim pertains - eg Property/Casualy insurer claim # or Workers Compensation case # reference : Identifier [0..1]PayeeType of Party to be reimbursed: Subscriber, provider, othertype : Coding [1..1] « A code for the party to be reimbursed. (Strength=Example)Payee Type ?? »Party to be reimbursed: Subscriber, provider, otherparty[x] : Type [0..1] « Identifier|Reference(Practitioner| Organization|Patient|RelatedPerson) »DiagnosisSequence of diagnosis which serves to order and provide a linksequence : positiveInt [1..1]The diagnosisdiagnosis : Coding [1..1] « ICD10 Diagnostic codes (Strength=Example)ICD-10 ?? »ProcedureSequence of procedures which serves to order and provide a linksequence : positiveInt [1..1]Date and optionally time the procedure was performed date : dateTime [0..1]The procedure codeprocedure[x] : Type [1..1] « Coding|Reference(Procedure); ICD10 Procedure codes (Strength=Example)ICD-10 Procedure ?? »CoverageA service line itemsequence : positiveInt [1..1]The instance number of the Coverage which is the focus for adjudication. The Coverage against which the claim is to be adjudicatedfocal : boolean [1..1]Reference to the program or plan identification, underwriter or payorcoverage[x] : Type [1..1] « Identifier|Reference(Coverage) »The contract number of a business agreement which describes the terms and conditionsbusinessArrangement : string [0..1]A list of references from the Insurer to which these services pertainpreAuthRef : string [0..*]The Coverages adjudication detailsclaimResponse : Reference [0..1] « ClaimResponse »The style (standard) and version of the original material which was converted into this resourceoriginalRuleset : Coding [0..1] « The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example)Ruleset ?? »OnsetThe start or start and end dates for the treatable conditiontime[x] : Type [0..1] « date|Period »Onset typifications eg. Start of pregnancy, start of illnes, etctype : Coding [0..1] « Condition related start, end and period codes (Strength=Example)Example Onset Type (Reason) ?? »ItemsA service line numbersequence : positiveInt [1..1]The type of product or servicetype : Coding [1..1] « Group, Service, Product. (Strength=Required)Exception ! »The practitioner who is responsible for the services rendered to the patientprovider[x] : Type [0..1] « Identifier|Reference(Practitioner) »The practitioner who is supervising the work of the servicing provider(s)supervisor[x] : Type [0..1] « Identifier|Reference(Practitioner) »The qualification which is applicable for this serviceproviderQualification : Coding [0..1] « Provider professional qualifications (Strength=Example)Example Provider Qualificatio...?? »Diagnosis applicable for this service or product linediagnosisLinkId : positiveInt [0..*]If a grouping item then 'GROUP' otherwise it is a node therefore a code to indicate the Professional Service or Product suppliedservice : Coding [1..1] « Allowable service and product codes (Strength=Example)USCLS ?? »Unusual circumstances which may influence adjudicationserviceModifier : Coding [0..*] « Factors which may influce adjudication of services (Strength=Example)Example Service Modifier ?? »Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolenmodifier : Coding [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)Modifier type ?? »For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-programprogramCode : Coding [0..*] « Program specific reason codes (Strength=Example)Example Program Reason ?? »The date or dates when the enclosed suite of services were performed or completedserviced[x] : Type [0..1] « date|Period »Where the service was providedplace : Coding [0..1] « (Strength=Example)Example Service Place ?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the groupunitPrice : Quantity(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 amountfactor : decimal [0..1]An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each pointpoints : decimal [0..1]The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not suppliednet : Quantity(Money) [0..1]List of Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »Physical service site on the patient (limb, tooth, etc)bodySite : Coding [0..1] « The code for the teeth, quadrant, sextant and arch (Strength=Example)Oral Site ?? »A region or surface of the site, eg. limb region or tooth surface(s)subSite : Coding [0..*] « The code for the tooth surface and surface combinations (Strength=Example)Surface ?? »DetailA service line numbersequence : positiveInt [1..1]The type of product or servicetype : Coding [1..1] « Group, Service, Product. (Strength=Required)Exception ! »If a grouping item then 'GROUP' otherwise it is a node therefore a code to indicate the Professional Service or Product suppliedservice : Coding [1..1] « Allowable service and product codes (Strength=Example)USCLS ?? »For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-programprogramCode : Coding [0..*] « Program specific reason codes (Strength=Example)Example Program Reason ?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the groupunitPrice : Quantity(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 amountfactor : decimal [0..1]An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each pointpoints : decimal [0..1]The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not suppliednet : Quantity(Money) [0..1]List of Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »SubDetailA service line numbersequence : positiveInt [1..1]The type of product or servicetype : Coding [1..1] « Group, Service, Product. (Strength=Required)Exception ! »The fee for an addittional service or product or chargeservice : Coding [1..1] « Allowable service and product codes (Strength=Example)USCLS ?? »For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-programprogramCode : Coding [0..*] « Program specific reason codes (Strength=Example)Example Program Reason ?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]The fee for an addittional service or product or chargeunitPrice : Quantity(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 amountfactor : decimal [0..1]An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each pointpoints : decimal [0..1]The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not suppliednet : Quantity(Money) [0..1]List of Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »ProsthesisIndicates whether this is the initial placement of a fixed prosthesisinitial : boolean [0..1]Date of the initial placementpriorDate : date [0..1]Material of the prior denture or bridge prosthesis. (Oral)priorMaterial : Coding [0..1] « Material of the prior denture or bridge prosthesis. (Oral) (Strength=Example)Oral Prostho Material type ?? »MissingTeethThe code identifying which tooth is missingtooth : Coding [1..1] « The codes for the teeth, subset of OralSites (Strength=Example)Teeth ?? »Missing reason may be: E-extraction, O-otherreason : Coding [0..1] « Reason codes for the missing teeth (Strength=Example)Missing Tooth Reason ?? »The date of the extraction either known from records or patient reported estimateextractionDate : date [0..1]Other claims which are related to this claim such as prior claim versions or for related servicesrelated[0..*]The party to be reimbursed for the servicespayee[0..1]Ordered list of patient diagnosis for which care is soughtdiagnosis[0..*]Ordered list of patient procedures performed to support the adjudicationprocedure[0..*]Financial instrument by which payment information for health carecoverage[0..*]Period, start and last dates of aspects of the Condition or related servicesonset[0..*]Third tier of goods and servicessubDetail[0..*]Second tier of goods and servicesdetail[0..*]The materials and placement date of prior fixed prosthesisprosthesis[0..1]First tier of goods and servicesitem[0..*]A list of teeth which would be expected but are not found due to having been previously extracted or for other reasonsmissingTeeth[0..*]

XML Template

<Claim xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <type value="[code]"/><!-- 1..1 institutional | oral | pharmacy | professional | vision -->
 <subType><!-- 0..* Coding Finer grained claim type information --></subType>
 <identifier><!-- 0..* Identifier Claim number --></identifier>
 <ruleset><!-- 0..1 Coding Current specification followed --></ruleset>
 <originalRuleset><!-- 0..1 Coding Original specification followed --></originalRuleset>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <billablePeriod><!-- 0..1 Period Period for charge submission --></billablePeriod>
 <target[x]><!-- 0..1 Identifier|Reference(Organization) Insurer --></target[x]>
 <provider[x]><!-- 0..1 Identifier|Reference(Practitioner) Responsible provider --></provider[x]>
 <organization[x]><!-- 0..1 Identifier|Reference(Organization) Responsible organization --></organization[x]>
 <use value="[code]"/><!-- 0..1 complete | proposed | exploratory | other -->
 <priority><!-- 0..1 Coding Desired processing priority --></priority>
 <fundsReserve><!-- 0..1 Coding Funds requested to be reserved --></fundsReserve>
 <enterer[x]><!-- 0..1 Identifier|Reference(Practitioner) Author --></enterer[x]>
 <facility[x]><!-- 0..1 Identifier|Reference(Location) Servicing Facility --></facility[x]>
 <related>  <!-- 0..* Related Claims which may be revelant to processing this claimn -->
  <claim[x]><!-- 0..1 Identifier|Reference(Claim) Reference to the related claim --></claim[x]>
  <relationship><!-- 0..1 Coding How the reference claim is related --></relationship>
  <reference><!-- 0..1 Identifier Related file or case reference --></reference>
 </related>
 <prescription[x]><!-- 0..1 Identifier|Reference(MedicationOrder|
   VisionPrescription) Prescription --></prescription[x]>
 <originalPrescription[x]><!-- 0..1 Identifier|Reference(MedicationOrder) Original Prescription --></originalPrescription[x]>
 <payee>  <!-- 0..1 Party to be paid any benefits payable -->
  <type><!-- 1..1 Coding Type of party: Subscriber, Provider, other --></type>
  <party[x]><!-- 0..1 Identifier|Reference(Practitioner|Organization|Patient|
    RelatedPerson) Party to receive the payable --></party[x]>
 </payee>
 <referral[x]><!-- 0..1 Identifier|Reference(ReferralRequest) Treatment Referral --></referral[x]>
 <occurrenceCode><!-- 0..* Coding Occurrence Codes --></occurrenceCode>
 <occurenceSpanCode><!-- 0..* Coding Occurrence Span Codes --></occurenceSpanCode>
 <valueCode><!-- 0..* Coding Value Codes --></valueCode>
 <diagnosis>  <!-- 0..* Diagnosis -->
  <sequence value="[positiveInt]"/><!-- 1..1 Number to covey order of diagnosis -->
  <diagnosis><!-- 1..1 Coding Patient's list of diagnosis --></diagnosis>
 </diagnosis>
 <procedure>  <!-- 0..* Procedures performed -->
  <sequence value="[positiveInt]"/><!-- 1..1 Procedure sequence for reference -->
  <date value="[dateTime]"/><!-- 0..1 When the procedure was performed -->
  <procedure[x]><!-- 1..1 Coding|Reference(Procedure) Patient's list of procedures performed --></procedure[x]>
 </procedure>
 <specialCondition><!-- 0..* Coding List of special Conditions --></specialCondition>
 <patient[x]><!-- 1..1 Identifier|Reference(Patient) The subject of the Products and Services --></patient[x]>
 <coverage>  <!-- 0..* Insurance or medical plan -->
  <sequence value="[positiveInt]"/><!-- 1..1 Service instance identifier -->
  <focal value="[boolean]"/><!-- 1..1 Is the focal Coverage -->
  <coverage[x]><!-- 1..1 Identifier|Reference(Coverage) Insurance information --></coverage[x]>
  <businessArrangement value="[string]"/><!-- 0..1 Business agreement -->
  <preAuthRef value="[string]"/><!-- 0..* Pre-Authorization/Determination Reference -->
  <claimResponse><!-- 0..1 Reference(ClaimResponse) Adjudication results --></claimResponse>
  <originalRuleset><!-- 0..1 Coding Original version --></originalRuleset>
 </coverage>
 <accidentDate value="[date]"/><!-- 0..1 When the accident occurred -->
 <accidentType><!-- 0..1 Coding The nature of the accident --></accidentType>
 <accidentLocation[x]><!-- 0..1 Address|Reference(Location) Accident Place --></accidentLocation[x]>
 <interventionException><!-- 0..* Coding Intervention and exception code (Pharma) --></interventionException>
 <onset>  <!-- 0..* Condition related Onset related dates and codes -->
  <time[x]><!-- 0..1 date|Period Illness, injury or treatable condition date --></time[x]>
  <type><!-- 0..1 Coding Onset of what --></type>
 </onset>
 <employmentImpacted><!-- 0..1 Period Period unable to work --></employmentImpacted>
 <hospitalization><!-- 0..1 Period Period in hospital --></hospitalization>
 <item>  <!-- 0..* Goods and Services -->
  <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
  <type><!-- 1..1 Coding Group or type of product or service --></type>
  <provider[x]><!-- 0..1 Identifier|Reference(Practitioner) Responsible practitioner --></provider[x]>
  <supervisor[x]><!-- 0..1 Identifier|Reference(Practitioner) Supervising Practitioner --></supervisor[x]>
  <providerQualification><!-- 0..1 Coding Type, classification or Specialization --></providerQualification>
  <diagnosisLinkId value="[positiveInt]"/><!-- 0..* Applicable diagnoses -->
  <service><!-- 1..1 Coding Item Code --></service>
  <serviceModifier><!-- 0..* Coding Service/Product modifiers --></serviceModifier>
  <modifier><!-- 0..* Coding Service/Product billing modifiers --></modifier>
  <programCode><!-- 0..* Coding Program specific reason for item inclusion --></programCode>
  <serviced[x]><!-- 0..1 date|Period Date or dates of Service --></serviced[x]>
  <place><!-- 0..1 Coding Place of service --></place>
  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
  <unitPrice><!-- 0..1 Quantity(Money) Fee, charge or cost per point --></unitPrice>
  <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
  <points value="[decimal]"/><!-- 0..1 Difficulty scaling factor -->
  <net><!-- 0..1 Quantity(Money) Total item cost --></net>
  <udi><!-- 0..* Reference(Device) Unique Device Identifier --></udi>
  <bodySite><!-- 0..1 Coding Service Location --></bodySite>
  <subSite><!-- 0..* Coding Service Sub-location --></subSite>
  <detail>  <!-- 0..* Additional items -->
   <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
   <type><!-- 1..1 Coding Group or type of product or service --></type>
   <service><!-- 1..1 Coding Additional item codes --></service>
   <programCode><!-- 0..* Coding Program specific reason for item inclusion --></programCode>
   <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
   <unitPrice><!-- 0..1 Quantity(Money) Fee, charge or cost per point --></unitPrice>
   <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
   <points value="[decimal]"/><!-- 0..1 Difficulty scaling factor -->
   <net><!-- 0..1 Quantity(Money) Total additional item cost --></net>
   <udi><!-- 0..* Reference(Device) Unique Device Identifier --></udi>
   <subDetail>  <!-- 0..* Additional items -->
    <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
    <type><!-- 1..1 Coding Type of product or service --></type>
    <service><!-- 1..1 Coding Additional item codes --></service>
    <programCode><!-- 0..* Coding Program specific reason for item inclusion --></programCode>
    <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
    <unitPrice><!-- 0..1 Quantity(Money) Fee, charge or cost per point --></unitPrice>
    <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
    <points value="[decimal]"/><!-- 0..1 Difficulty scaling factor -->
    <net><!-- 0..1 Quantity(Money) Net additional item cost --></net>
    <udi><!-- 0..* Reference(Device) Unique Device Identifier --></udi>
   </subDetail>
  </detail>
  <prosthesis>  <!-- 0..1 Prosthetic details -->
   <initial value="[boolean]"/><!-- 0..1 Is this the initial service -->
   <priorDate value="[date]"/><!-- 0..1 Initial service Date -->
   <priorMaterial><!-- 0..1 Coding Prosthetic Material --></priorMaterial>
  </prosthesis>
 </item>
 <total><!-- 0..1 Quantity(Money) Total claim cost --></total>
 <additionalMaterial><!-- 0..* Coding Additional supporting materials and documents --></additionalMaterial>
 <missingTeeth>  <!-- 0..* Only if type = oral -->
  <tooth><!-- 1..1 Coding Tooth Code --></tooth>
  <reason><!-- 0..1 Coding Indicates whether it was extracted or other reason --></reason>
  <extractionDate value="[date]"/><!-- 0..1 Date tooth was extracted if known -->
 </missingTeeth>
</Claim>

JSON Template

{doco
  "resourceType" : "Claim",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "type" : "<code>", // R!  institutional | oral | pharmacy | professional | vision
  "subType" : [{ Coding }], // Finer grained claim type information
  "identifier" : [{ Identifier }], // Claim number
  "ruleset" : { Coding }, // Current specification followed
  "originalRuleset" : { Coding }, // Original specification followed
  "created" : "<dateTime>", // Creation date
  "billablePeriod" : { Period }, // Period for charge submission
  // target[x]: Insurer. One of these 2:
  "targetIdentifier" : { Identifier },
  "targetReference" : { Reference(Organization) },
  // provider[x]: Responsible provider. One of these 2:
  "providerIdentifier" : { Identifier },
  "providerReference" : { Reference(Practitioner) },
  // organization[x]: Responsible organization. One of these 2:
  "organizationIdentifier" : { Identifier },
  "organizationReference" : { Reference(Organization) },
  "use" : "<code>", // complete | proposed | exploratory | other
  "priority" : { Coding }, // Desired processing priority
  "fundsReserve" : { Coding }, // Funds requested to be reserved
  // enterer[x]: Author. One of these 2:
  "entererIdentifier" : { Identifier },
  "entererReference" : { Reference(Practitioner) },
  // facility[x]: Servicing Facility. One of these 2:
  "facilityIdentifier" : { Identifier },
  "facilityReference" : { Reference(Location) },
  "related" : [{ // Related Claims which may be revelant to processing this claimn
    // claim[x]: Reference to the related claim. One of these 2:
    "claimIdentifier" : { Identifier },
    "claimReference" : { Reference(Claim) },
    "relationship" : { Coding }, // How the reference claim is related
    "reference" : { Identifier } // Related file or case reference
  }],
  // prescription[x]: Prescription. One of these 2:
  "prescriptionIdentifier" : { Identifier },
  "prescriptionReference" : { Reference(MedicationOrder|VisionPrescription) },
  // originalPrescription[x]: Original Prescription. One of these 2:
  "originalPrescriptionIdentifier" : { Identifier },
  "originalPrescriptionReference" : { Reference(MedicationOrder) },
  "payee" : { // Party to be paid any benefits payable
    "type" : { Coding }, // R!  Type of party: Subscriber, Provider, other
    // party[x]: Party to receive the payable. One of these 2:
    "partyIdentifier" : { Identifier }
    "partyReference" : { Reference(Practitioner|Organization|Patient|RelatedPerson) }
  },
  // referral[x]: Treatment Referral. One of these 2:
  "referralIdentifier" : { Identifier },
  "referralReference" : { Reference(ReferralRequest) },
  "occurrenceCode" : [{ Coding }], // Occurrence Codes
  "occurenceSpanCode" : [{ Coding }], // Occurrence Span Codes
  "valueCode" : [{ Coding }], // Value Codes
  "diagnosis" : [{ // Diagnosis
    "sequence" : "<positiveInt>", // R!  Number to covey order of diagnosis
    "diagnosis" : { Coding } // R!  Patient's list of diagnosis
  }],
  "procedure" : [{ // Procedures performed
    "sequence" : "<positiveInt>", // R!  Procedure sequence for reference
    "date" : "<dateTime>", // When the procedure was performed
    // procedure[x]: Patient's list of procedures performed. One of these 2:
    "procedureCoding" : { Coding }
    "procedureReference" : { Reference(Procedure) }
  }],
  "specialCondition" : [{ Coding }], // List of special Conditions
  // patient[x]: The subject of the Products and Services. One of these 2:
  "patientIdentifier" : { Identifier },
  "patientReference" : { Reference(Patient) },
  "coverage" : [{ // Insurance or medical plan
    "sequence" : "<positiveInt>", // R!  Service instance identifier
    "focal" : <boolean>, // R!  Is the focal Coverage
    // coverage[x]: Insurance information. One of these 2:
    "coverageIdentifier" : { Identifier },
    "coverageReference" : { Reference(Coverage) },
    "businessArrangement" : "<string>", // Business agreement
    "preAuthRef" : ["<string>"], // Pre-Authorization/Determination Reference
    "claimResponse" : { Reference(ClaimResponse) }, // Adjudication results
    "originalRuleset" : { Coding } // Original version
  }],
  "accidentDate" : "<date>", // When the accident occurred
  "accidentType" : { Coding }, // The nature of the accident
  // accidentLocation[x]: Accident Place. One of these 2:
  "accidentLocationAddress" : { Address },
  "accidentLocationReference" : { Reference(Location) },
  "interventionException" : [{ Coding }], // Intervention and exception code (Pharma)
  "onset" : [{ // Condition related Onset related dates and codes
    // time[x]: Illness, injury or treatable condition date. One of these 2:
    "timeDate" : "<date>",
    "timePeriod" : { Period },
    "type" : { Coding } // Onset of what
  }],
  "employmentImpacted" : { Period }, // Period unable to work
  "hospitalization" : { Period }, // Period in hospital
  "item" : [{ // Goods and Services
    "sequence" : "<positiveInt>", // R!  Service instance
    "type" : { Coding }, // R!  Group or type of product or service
    // provider[x]: Responsible practitioner. One of these 2:
    "providerIdentifier" : { Identifier },
    "providerReference" : { Reference(Practitioner) },
    // supervisor[x]: Supervising Practitioner. One of these 2:
    "supervisorIdentifier" : { Identifier },
    "supervisorReference" : { Reference(Practitioner) },
    "providerQualification" : { Coding }, // Type, classification or Specialization
    "diagnosisLinkId" : ["<positiveInt>"], // Applicable diagnoses
    "service" : { Coding }, // R!  Item Code
    "serviceModifier" : [{ Coding }], // Service/Product modifiers
    "modifier" : [{ Coding }], // Service/Product billing modifiers
    "programCode" : [{ Coding }], // Program specific reason for item inclusion
    // serviced[x]: Date or dates of Service. One of these 2:
    "servicedDate" : "<date>",
    "servicedPeriod" : { Period },
    "place" : { Coding }, // Place of service
    "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
    "unitPrice" : { Quantity(Money) }, // Fee, charge or cost per point
    "factor" : <decimal>, // Price scaling factor
    "points" : <decimal>, // Difficulty scaling factor
    "net" : { Quantity(Money) }, // Total item cost
    "udi" : [{ Reference(Device) }], // Unique Device Identifier
    "bodySite" : { Coding }, // Service Location
    "subSite" : [{ Coding }], // Service Sub-location
    "detail" : [{ // Additional items
      "sequence" : "<positiveInt>", // R!  Service instance
      "type" : { Coding }, // R!  Group or type of product or service
      "service" : { Coding }, // R!  Additional item codes
      "programCode" : [{ Coding }], // Program specific reason for item inclusion
      "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
      "unitPrice" : { Quantity(Money) }, // Fee, charge or cost per point
      "factor" : <decimal>, // Price scaling factor
      "points" : <decimal>, // Difficulty scaling factor
      "net" : { Quantity(Money) }, // Total additional item cost
      "udi" : [{ Reference(Device) }], // Unique Device Identifier
      "subDetail" : [{ // Additional items
        "sequence" : "<positiveInt>", // R!  Service instance
        "type" : { Coding }, // R!  Type of product or service
        "service" : { Coding }, // R!  Additional item codes
        "programCode" : [{ Coding }], // Program specific reason for item inclusion
        "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
        "unitPrice" : { Quantity(Money) }, // Fee, charge or cost per point
        "factor" : <decimal>, // Price scaling factor
        "points" : <decimal>, // Difficulty scaling factor
        "net" : { Quantity(Money) }, // Net additional item cost
        "udi" : [{ Reference(Device) }] // Unique Device Identifier
      }]
    }],
    "prosthesis" : { // Prosthetic details
      "initial" : <boolean>, // Is this the initial service
      "priorDate" : "<date>", // Initial service Date
      "priorMaterial" : { Coding } // Prosthetic Material
    }
  }],
  "total" : { Quantity(Money) }, // Total claim cost
  "additionalMaterial" : [{ Coding }], // Additional supporting materials and documents
  "missingTeeth" : [{ // Only if type = oral
    "tooth" : { Coding }, // R!  Tooth Code
    "reason" : { Coding }, // Indicates whether it was extracted or other reason
    "extractionDate" : "<date>" // Date tooth was extracted if known
  }]
}

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim ΣDomainResourceClaim, Pre-determination or Pre-authorization
... type Σ1..1codeinstitutional | oral | pharmacy | professional | vision
ClaimType (Required)
... subType Σ0..*CodingFiner grained claim type information
Example Claim SubType Codes (Example)
... identifier Σ0..*IdentifierClaim number
... ruleset Σ0..1CodingCurrent specification followed
Ruleset Codes (Example)
... originalRuleset Σ0..1CodingOriginal specification followed
Ruleset Codes (Example)
... created Σ0..1dateTimeCreation date
... billablePeriod Σ0..1PeriodPeriod for charge submission
... target[x] Σ0..1Insurer
.... targetIdentifierIdentifier
.... targetReferenceReference(Organization)
... provider[x] Σ0..1Responsible provider
.... providerIdentifierIdentifier
.... providerReferenceReference(Practitioner)
... organization[x] Σ0..1Responsible organization
.... organizationIdentifierIdentifier
.... organizationReferenceReference(Organization)
... use Σ0..1codecomplete | proposed | exploratory | other
Use (Required)
... priority Σ0..1CodingDesired processing priority
Priority Codes (Example)
... fundsReserve Σ0..1CodingFunds requested to be reserved
Funds Reservation Codes (Example)
... enterer[x] Σ0..1Author
.... entererIdentifierIdentifier
.... entererReferenceReference(Practitioner)
... facility[x] Σ0..1Servicing Facility
.... facilityIdentifierIdentifier
.... facilityReferenceReference(Location)
... related Σ0..*BackboneElementRelated Claims which may be revelant to processing this claimn
.... claim[x] Σ0..1Reference to the related claim
..... claimIdentifierIdentifier
..... claimReferenceReference(Claim)
.... relationship Σ0..1CodingHow the reference claim is related
Example Related Claim Relationship Codes (Example)
.... reference Σ0..1IdentifierRelated file or case reference
... prescription[x] Σ0..1Prescription
.... prescriptionIdentifierIdentifier
.... prescriptionReferenceReference(MedicationOrder | VisionPrescription)
... originalPrescription[x] Σ0..1Original Prescription
.... originalPrescriptionIdentifierIdentifier
.... originalPrescriptionReferenceReference(MedicationOrder)
... payee Σ0..1BackboneElementParty to be paid any benefits payable
.... type Σ1..1CodingType of party: Subscriber, Provider, other
Payee Type Codes (Example)
.... party[x] Σ0..1Party to receive the payable
..... partyIdentifierIdentifier
..... partyReferenceReference(Practitioner | Organization | Patient | RelatedPerson)
... referral[x] Σ0..1Treatment Referral
.... referralIdentifierIdentifier
.... referralReferenceReference(ReferralRequest)
... occurrenceCode Σ0..*CodingOccurrence Codes
Example Occurrance Codes (Example)
... occurenceSpanCode Σ0..*CodingOccurrence Span Codes
Example Occurrance Span Codes (Example)
... valueCode Σ0..*CodingValue Codes
Example Value Codes (Example)
... diagnosis Σ0..*BackboneElementDiagnosis
.... sequence Σ1..1positiveIntNumber to covey order of diagnosis
.... diagnosis Σ1..1CodingPatient's list of diagnosis
ICD-10 Codes (Example)
... procedure Σ0..*BackboneElementProcedures performed
.... sequence Σ1..1positiveIntProcedure sequence for reference
.... date Σ0..1dateTimeWhen the procedure was performed
.... procedure[x] Σ1..1Patient's list of procedures performed
ICD-10 Procedure Codes (Example)
..... procedureCodingCoding
..... procedureReferenceReference(Procedure)
... specialCondition Σ0..*CodingList of special Conditions
Conditions Codes (Example)
... patient[x] Σ1..1The subject of the Products and Services
.... patientIdentifierIdentifier
.... patientReferenceReference(Patient)
... coverage Σ0..*BackboneElementInsurance or medical plan
.... sequence Σ1..1positiveIntService instance identifier
.... focal Σ1..1booleanIs the focal Coverage
.... coverage[x] Σ1..1Insurance information
..... coverageIdentifierIdentifier
..... coverageReferenceReference(Coverage)
.... businessArrangement Σ0..1stringBusiness agreement
.... preAuthRef Σ0..*stringPre-Authorization/Determination Reference
.... claimResponse Σ0..1Reference(ClaimResponse)Adjudication results
.... originalRuleset Σ0..1CodingOriginal version
Ruleset Codes (Example)
... accidentDate Σ0..1dateWhen the accident occurred
... accidentType Σ0..1CodingThe nature of the accident
ActIncidentCode (Required)
... accidentLocation[x] Σ0..1Accident Place
.... accidentLocationAddressAddress
.... accidentLocationReferenceReference(Location)
... interventionException Σ0..*CodingIntervention and exception code (Pharma)
Intervention Codes (Example)
... onset Σ0..*BackboneElementCondition related Onset related dates and codes
.... time[x] Σ0..1Illness, injury or treatable condition date
..... timeDatedate
..... timePeriodPeriod
.... type Σ0..1CodingOnset of what
Example Onset Type (Reason) Codes (Example)
... employmentImpacted Σ0..1PeriodPeriod unable to work
... hospitalization Σ0..1PeriodPeriod in hospital
... item Σ0..*BackboneElementGoods and Services
.... sequence Σ1..1positiveIntService instance
.... type Σ1..1CodingGroup or type of product or service
Exception Codes (Required)
.... provider[x] Σ0..1Responsible practitioner
..... providerIdentifierIdentifier
..... providerReferenceReference(Practitioner)
.... supervisor[x] Σ0..1Supervising Practitioner
..... supervisorIdentifierIdentifier
..... supervisorReferenceReference(Practitioner)
.... providerQualification Σ0..1CodingType, classification or Specialization
Example Provider Qualification Codes (Example)
.... diagnosisLinkId Σ0..*positiveIntApplicable diagnoses
.... service Σ1..1CodingItem Code
USCLS Codes (Example)
.... serviceModifier Σ0..*CodingService/Product modifiers
Example Service Modifier Codes (Example)
.... modifier Σ0..*CodingService/Product billing modifiers
Modifier type Codes (Example)
.... programCode Σ0..*CodingProgram specific reason for item inclusion
Example Program Reason Codes (Example)
.... serviced[x] Σ0..1Date or dates of Service
..... servicedDatedate
..... servicedPeriodPeriod
.... place Σ0..1CodingPlace of service
Example Service Place Codes (Example)
.... quantity Σ0..1SimpleQuantityCount of Products or Services
.... unitPrice Σ0..1MoneyFee, charge or cost per point
.... factor Σ0..1decimalPrice scaling factor
.... points Σ0..1decimalDifficulty scaling factor
.... net Σ0..1MoneyTotal item cost
.... udi Σ0..*Reference(Device)Unique Device Identifier
.... bodySite Σ0..1CodingService Location
Oral Site Codes (Example)
.... subSite Σ0..*CodingService Sub-location
Surface Codes (Example)
.... detail Σ0..*BackboneElementAdditional items
..... sequence Σ1..1positiveIntService instance
..... type Σ1..1CodingGroup or type of product or service
Exception Codes (Required)
..... service Σ1..1CodingAdditional item codes
USCLS Codes (Example)
..... programCode Σ0..*CodingProgram specific reason for item inclusion
Example Program Reason Codes (Example)
..... quantity Σ0..1SimpleQuantityCount of Products or Services
..... unitPrice Σ0..1MoneyFee, charge or cost per point
..... factor Σ0..1decimalPrice scaling factor
..... points Σ0..1decimalDifficulty scaling factor
..... net Σ0..1MoneyTotal additional item cost
..... udi Σ0..*Reference(Device)Unique Device Identifier
..... subDetail Σ0..*BackboneElementAdditional items
...... sequence Σ1..1positiveIntService instance
...... type Σ1..1CodingType of product or service
Exception Codes (Required)
...... service Σ1..1CodingAdditional item codes
USCLS Codes (Example)
...... programCode Σ0..*CodingProgram specific reason for item inclusion
Example Program Reason Codes (Example)
...... quantity Σ0..1SimpleQuantityCount of Products or Services
...... unitPrice Σ0..1MoneyFee, charge or cost per point
...... factor Σ0..1decimalPrice scaling factor
...... points Σ0..1decimalDifficulty scaling factor
...... net Σ0..1MoneyNet additional item cost
...... udi Σ0..*Reference(Device)Unique Device Identifier
.... prosthesis Σ0..1BackboneElementProsthetic details
..... initial Σ0..1booleanIs this the initial service
..... priorDate Σ0..1dateInitial service Date
..... priorMaterial Σ0..1CodingProsthetic Material
Oral Prostho Material type Codes (Example)
... total Σ0..1MoneyTotal claim cost
... additionalMaterial Σ0..*CodingAdditional supporting materials and documents
Additional Material Codes (Example)
... missingTeeth Σ0..*BackboneElementOnly if type = oral
.... tooth Σ1..1CodingTooth Code
Teeth Codes (Example)
.... reason Σ0..1CodingIndicates whether it was extracted or other reason
Missing Tooth Reason Codes (Example)
.... extractionDate Σ0..1dateDate tooth was extracted if known

doco Documentation for this format

UML Diagram

Claim (DomainResource)The category of claimtype : code [1..1] « The type or discipline-style of the claim (Strength=Required)ClaimType! »A finer grained suite of claim subtype codes which may convey Inpatient vs Outpatient and/or a specialty service. In the US the BillTypesubType : Coding [0..*] « A more granulat claim typecode (Strength=Example)Example Claim SubType ?? »The business identifier for the instance: claim number, pre-determination or pre-authorization numberidentifier : Identifier [0..*]The version of the specification on which this instance reliesruleset : Coding [0..1] « The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example)Ruleset ?? »The version of the specification from which the original instance was createdoriginalRuleset : Coding [0..1] « The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example)Ruleset ?? »The date when the enclosed suite of services were performed or completedcreated : dateTime [0..1]The billable period for which charges are being submittedbillablePeriod : Period [0..1]Insurer Identifier, typical BIN number (6 digit)target[x] : Type [0..1] « Identifier|Reference(Organization) »The provider which is responsible for the bill, claim pre-determination, pre-authorizationprovider[x] : Type [0..1] « Identifier|Reference(Practitioner) »The organization which is responsible for the bill, claim pre-determination, pre-authorizationorganization[x] : Type [0..1] « Identifier|Reference(Organization) »Complete (Bill or Claim), Proposed (Pre-Authorization), Exploratory (Pre-determination)use : code [0..1] « Complete, proposed, exploratory, other (Strength=Required)Use! »Immediate (STAT), best effort (NORMAL), deferred (DEFER)priority : Coding [0..1] « The timeliness with which processing is required: STAT, normal, Deferred (Strength=Example)Priority ?? »In the case of a Pre-Determination/Pre-Authorization the provider may request that funds in the amount of the expected Benefit be reserved ('Patient' or 'Provider') to pay for the Benefits determined on the subsequent claim(s). 'None' explicitly indicates no funds reserving is requestedfundsReserve : Coding [0..1] « For whom funds are to be reserved: (Patient, Provider, None). (Strength=Example)Funds Reservation ?? »Person who created the invoice/claim/pre-determination or pre-authorizationenterer[x] : Type [0..1] « Identifier|Reference(Practitioner) »Facility where the services were providedfacility[x] : Type [0..1] « Identifier|Reference(Location) »Prescription to support the dispensing of Pharmacy or Vision productsprescription[x] : Type [0..1] « Identifier|Reference(MedicationOrder| VisionPrescription) »Original prescription which has been superceded by this prescription to support the dispensing of pharmacy services, medications or productsoriginalPrescription[x] : Type [0..1] « Identifier|Reference( MedicationOrder) »The referral resource which lists the date, practitioner, reason and other supporting informationreferral[x] : Type [0..1] « Identifier|Reference(ReferralRequest) »**Insert definition of Occurrence codesoccurrenceCode : Coding [0..*] « Occurrence codes (Strength=Example)Example Occurrance ?? »**Insert definition of Occurrence Span codesoccurenceSpanCode : Coding [0..*] « Occurrence Span codes (Strength=Example)Example Occurrance Span ?? »**Insert definition of Value codesvalueCode : Coding [0..*] « Value code (Strength=Example)Example Value ?? »List of special conditions relating to the setting, treatment or patient for which care is sought which may influence the adjudicationspecialCondition : Coding [0..*] « Patient conditions and symptoms (Strength=Example)Conditions ?? »Patient Resourcepatient[x] : Type [1..1] « Identifier|Reference(Patient) »Date of an accident which these services are addressingaccidentDate : date [0..1]Type of accident: work, auto, etcaccidentType : Coding [0..1] « Type of accident: work place, auto, etc. (Strength=Required)ActIncidentCode! »Accident PlaceaccidentLocation[x] : Type [0..1] « Address|Reference(Location) »A list of intervention and exception codes which may influence the adjudication of the claiminterventionException : Coding [0..*] « Intervention and exception codes (Pharm) (Strength=Example)Intervention ?? »The start and optional end dates of when the patient was precluded from working due to the treatable condition(s)employmentImpacted : Period [0..1]The start and optional end dates of when the patient was confined to a treatment centerhospitalization : Period [0..1]The total value of the claimtotal : Quantity(Money) [0..1]Code to indicate that Xrays, images, emails, documents, models or attachments are being sent in support of this submissionadditionalMaterial : Coding [0..*] « Code to indicate that Xrays, images, emails, documents, models or attachments are being sent in support of this submission. (Strength=Example)Additional Material ?? »RelatedClaimsOther claims which are related to this claim such as prior claim versions or for related servicesclaim[x] : Type [0..1] « Identifier|Reference(Claim) »For example prior or umbrellarelationship : Coding [0..1] « Relationship of this claim to a related Claim (Strength=Example)Example Related Claim Relatio...?? »An alternate organizational reference to the case or file to which this particular claim pertains - eg Property/Casualy insurer claim # or Workers Compensation case # reference : Identifier [0..1]PayeeType of Party to be reimbursed: Subscriber, provider, othertype : Coding [1..1] « A code for the party to be reimbursed. (Strength=Example)Payee Type ?? »Party to be reimbursed: Subscriber, provider, otherparty[x] : Type [0..1] « Identifier|Reference(Practitioner| Organization|Patient|RelatedPerson) »DiagnosisSequence of diagnosis which serves to order and provide a linksequence : positiveInt [1..1]The diagnosisdiagnosis : Coding [1..1] « ICD10 Diagnostic codes (Strength=Example)ICD-10 ?? »ProcedureSequence of procedures which serves to order and provide a linksequence : positiveInt [1..1]Date and optionally time the procedure was performed date : dateTime [0..1]The procedure codeprocedure[x] : Type [1..1] « Coding|Reference(Procedure); ICD10 Procedure codes (Strength=Example)ICD-10 Procedure ?? »CoverageA service line itemsequence : positiveInt [1..1]The instance number of the Coverage which is the focus for adjudication. The Coverage against which the claim is to be adjudicatedfocal : boolean [1..1]Reference to the program or plan identification, underwriter or payorcoverage[x] : Type [1..1] « Identifier|Reference(Coverage) »The contract number of a business agreement which describes the terms and conditionsbusinessArrangement : string [0..1]A list of references from the Insurer to which these services pertainpreAuthRef : string [0..*]The Coverages adjudication detailsclaimResponse : Reference [0..1] « ClaimResponse »The style (standard) and version of the original material which was converted into this resourceoriginalRuleset : Coding [0..1] « The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example)Ruleset ?? »OnsetThe start or start and end dates for the treatable conditiontime[x] : Type [0..1] « date|Period »Onset typifications eg. Start of pregnancy, start of illnes, etctype : Coding [0..1] « Condition related start, end and period codes (Strength=Example)Example Onset Type (Reason) ?? »ItemsA service line numbersequence : positiveInt [1..1]The type of product or servicetype : Coding [1..1] « Group, Service, Product. (Strength=Required)Exception ! »The practitioner who is responsible for the services rendered to the patientprovider[x] : Type [0..1] « Identifier|Reference(Practitioner) »The practitioner who is supervising the work of the servicing provider(s)supervisor[x] : Type [0..1] « Identifier|Reference(Practitioner) »The qualification which is applicable for this serviceproviderQualification : Coding [0..1] « Provider professional qualifications (Strength=Example)Example Provider Qualificatio...?? »Diagnosis applicable for this service or product linediagnosisLinkId : positiveInt [0..*]If a grouping item then 'GROUP' otherwise it is a node therefore a code to indicate the Professional Service or Product suppliedservice : Coding [1..1] « Allowable service and product codes (Strength=Example)USCLS ?? »Unusual circumstances which may influence adjudicationserviceModifier : Coding [0..*] « Factors which may influce adjudication of services (Strength=Example)Example Service Modifier ?? »Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolenmodifier : Coding [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)Modifier type ?? »For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-programprogramCode : Coding [0..*] « Program specific reason codes (Strength=Example)Example Program Reason ?? »The date or dates when the enclosed suite of services were performed or completedserviced[x] : Type [0..1] « date|Period »Where the service was providedplace : Coding [0..1] « (Strength=Example)Example Service Place ?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the groupunitPrice : Quantity(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 amountfactor : decimal [0..1]An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each pointpoints : decimal [0..1]The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not suppliednet : Quantity(Money) [0..1]List of Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »Physical service site on the patient (limb, tooth, etc)bodySite : Coding [0..1] « The code for the teeth, quadrant, sextant and arch (Strength=Example)Oral Site ?? »A region or surface of the site, eg. limb region or tooth surface(s)subSite : Coding [0..*] « The code for the tooth surface and surface combinations (Strength=Example)Surface ?? »DetailA service line numbersequence : positiveInt [1..1]The type of product or servicetype : Coding [1..1] « Group, Service, Product. (Strength=Required)Exception ! »If a grouping item then 'GROUP' otherwise it is a node therefore a code to indicate the Professional Service or Product suppliedservice : Coding [1..1] « Allowable service and product codes (Strength=Example)USCLS ?? »For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-programprogramCode : Coding [0..*] « Program specific reason codes (Strength=Example)Example Program Reason ?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the groupunitPrice : Quantity(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 amountfactor : decimal [0..1]An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each pointpoints : decimal [0..1]The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not suppliednet : Quantity(Money) [0..1]List of Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »SubDetailA service line numbersequence : positiveInt [1..1]The type of product or servicetype : Coding [1..1] « Group, Service, Product. (Strength=Required)Exception ! »The fee for an addittional service or product or chargeservice : Coding [1..1] « Allowable service and product codes (Strength=Example)USCLS ?? »For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-programprogramCode : Coding [0..*] « Program specific reason codes (Strength=Example)Example Program Reason ?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]The fee for an addittional service or product or chargeunitPrice : Quantity(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 amountfactor : decimal [0..1]An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each pointpoints : decimal [0..1]The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not suppliednet : Quantity(Money) [0..1]List of Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »ProsthesisIndicates whether this is the initial placement of a fixed prosthesisinitial : boolean [0..1]Date of the initial placementpriorDate : date [0..1]Material of the prior denture or bridge prosthesis. (Oral)priorMaterial : Coding [0..1] « Material of the prior denture or bridge prosthesis. (Oral) (Strength=Example)Oral Prostho Material type ?? »MissingTeethThe code identifying which tooth is missingtooth : Coding [1..1] « The codes for the teeth, subset of OralSites (Strength=Example)Teeth ?? »Missing reason may be: E-extraction, O-otherreason : Coding [0..1] « Reason codes for the missing teeth (Strength=Example)Missing Tooth Reason ?? »The date of the extraction either known from records or patient reported estimateextractionDate : date [0..1]Other claims which are related to this claim such as prior claim versions or for related servicesrelated[0..*]The party to be reimbursed for the servicespayee[0..1]Ordered list of patient diagnosis for which care is soughtdiagnosis[0..*]Ordered list of patient procedures performed to support the adjudicationprocedure[0..*]Financial instrument by which payment information for health carecoverage[0..*]Period, start and last dates of aspects of the Condition or related servicesonset[0..*]Third tier of goods and servicessubDetail[0..*]Second tier of goods and servicesdetail[0..*]The materials and placement date of prior fixed prosthesisprosthesis[0..1]First tier of goods and servicesitem[0..*]A list of teeth which would be expected but are not found due to having been previously extracted or for other reasonsmissingTeeth[0..*]

XML Template

<Claim xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <type value="[code]"/><!-- 1..1 institutional | oral | pharmacy | professional | vision -->
 <subType><!-- 0..* Coding Finer grained claim type information --></subType>
 <identifier><!-- 0..* Identifier Claim number --></identifier>
 <ruleset><!-- 0..1 Coding Current specification followed --></ruleset>
 <originalRuleset><!-- 0..1 Coding Original specification followed --></originalRuleset>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <billablePeriod><!-- 0..1 Period Period for charge submission --></billablePeriod>
 <target[x]><!-- 0..1 Identifier|Reference(Organization) Insurer --></target[x]>
 <provider[x]><!-- 0..1 Identifier|Reference(Practitioner) Responsible provider --></provider[x]>
 <organization[x]><!-- 0..1 Identifier|Reference(Organization) Responsible organization --></organization[x]>
 <use value="[code]"/><!-- 0..1 complete | proposed | exploratory | other -->
 <priority><!-- 0..1 Coding Desired processing priority --></priority>
 <fundsReserve><!-- 0..1 Coding Funds requested to be reserved --></fundsReserve>
 <enterer[x]><!-- 0..1 Identifier|Reference(Practitioner) Author --></enterer[x]>
 <facility[x]><!-- 0..1 Identifier|Reference(Location) Servicing Facility --></facility[x]>
 <related>  <!-- 0..* Related Claims which may be revelant to processing this claimn -->
  <claim[x]><!-- 0..1 Identifier|Reference(Claim) Reference to the related claim --></claim[x]>
  <relationship><!-- 0..1 Coding How the reference claim is related --></relationship>
  <reference><!-- 0..1 Identifier Related file or case reference --></reference>
 </related>
 <prescription[x]><!-- 0..1 Identifier|Reference(MedicationOrder|
   VisionPrescription) Prescription --></prescription[x]>
 <originalPrescription[x]><!-- 0..1 Identifier|Reference(MedicationOrder) Original Prescription --></originalPrescription[x]>
 <payee>  <!-- 0..1 Party to be paid any benefits payable -->
  <type><!-- 1..1 Coding Type of party: Subscriber, Provider, other --></type>
  <party[x]><!-- 0..1 Identifier|Reference(Practitioner|Organization|Patient|
    RelatedPerson) Party to receive the payable --></party[x]>
 </payee>
 <referral[x]><!-- 0..1 Identifier|Reference(ReferralRequest) Treatment Referral --></referral[x]>
 <occurrenceCode><!-- 0..* Coding Occurrence Codes --></occurrenceCode>
 <occurenceSpanCode><!-- 0..* Coding Occurrence Span Codes --></occurenceSpanCode>
 <valueCode><!-- 0..* Coding Value Codes --></valueCode>
 <diagnosis>  <!-- 0..* Diagnosis -->
  <sequence value="[positiveInt]"/><!-- 1..1 Number to covey order of diagnosis -->
  <diagnosis><!-- 1..1 Coding Patient's list of diagnosis --></diagnosis>
 </diagnosis>
 <procedure>  <!-- 0..* Procedures performed -->
  <sequence value="[positiveInt]"/><!-- 1..1 Procedure sequence for reference -->
  <date value="[dateTime]"/><!-- 0..1 When the procedure was performed -->
  <procedure[x]><!-- 1..1 Coding|Reference(Procedure) Patient's list of procedures performed --></procedure[x]>
 </procedure>
 <specialCondition><!-- 0..* Coding List of special Conditions --></specialCondition>
 <patient[x]><!-- 1..1 Identifier|Reference(Patient) The subject of the Products and Services --></patient[x]>
 <coverage>  <!-- 0..* Insurance or medical plan -->
  <sequence value="[positiveInt]"/><!-- 1..1 Service instance identifier -->
  <focal value="[boolean]"/><!-- 1..1 Is the focal Coverage -->
  <coverage[x]><!-- 1..1 Identifier|Reference(Coverage) Insurance information --></coverage[x]>
  <businessArrangement value="[string]"/><!-- 0..1 Business agreement -->
  <preAuthRef value="[string]"/><!-- 0..* Pre-Authorization/Determination Reference -->
  <claimResponse><!-- 0..1 Reference(ClaimResponse) Adjudication results --></claimResponse>
  <originalRuleset><!-- 0..1 Coding Original version --></originalRuleset>
 </coverage>
 <accidentDate value="[date]"/><!-- 0..1 When the accident occurred -->
 <accidentType><!-- 0..1 Coding The nature of the accident --></accidentType>
 <accidentLocation[x]><!-- 0..1 Address|Reference(Location) Accident Place --></accidentLocation[x]>
 <interventionException><!-- 0..* Coding Intervention and exception code (Pharma) --></interventionException>
 <onset>  <!-- 0..* Condition related Onset related dates and codes -->
  <time[x]><!-- 0..1 date|Period Illness, injury or treatable condition date --></time[x]>
  <type><!-- 0..1 Coding Onset of what --></type>
 </onset>
 <employmentImpacted><!-- 0..1 Period Period unable to work --></employmentImpacted>
 <hospitalization><!-- 0..1 Period Period in hospital --></hospitalization>
 <item>  <!-- 0..* Goods and Services -->
  <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
  <type><!-- 1..1 Coding Group or type of product or service --></type>
  <provider[x]><!-- 0..1 Identifier|Reference(Practitioner) Responsible practitioner --></provider[x]>
  <supervisor[x]><!-- 0..1 Identifier|Reference(Practitioner) Supervising Practitioner --></supervisor[x]>
  <providerQualification><!-- 0..1 Coding Type, classification or Specialization --></providerQualification>
  <diagnosisLinkId value="[positiveInt]"/><!-- 0..* Applicable diagnoses -->
  <service><!-- 1..1 Coding Item Code --></service>
  <serviceModifier><!-- 0..* Coding Service/Product modifiers --></serviceModifier>
  <modifier><!-- 0..* Coding Service/Product billing modifiers --></modifier>
  <programCode><!-- 0..* Coding Program specific reason for item inclusion --></programCode>
  <serviced[x]><!-- 0..1 date|Period Date or dates of Service --></serviced[x]>
  <place><!-- 0..1 Coding Place of service --></place>
  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
  <unitPrice><!-- 0..1 Quantity(Money) Fee, charge or cost per point --></unitPrice>
  <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
  <points value="[decimal]"/><!-- 0..1 Difficulty scaling factor -->
  <net><!-- 0..1 Quantity(Money) Total item cost --></net>
  <udi><!-- 0..* Reference(Device) Unique Device Identifier --></udi>
  <bodySite><!-- 0..1 Coding Service Location --></bodySite>
  <subSite><!-- 0..* Coding Service Sub-location --></subSite>
  <detail>  <!-- 0..* Additional items -->
   <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
   <type><!-- 1..1 Coding Group or type of product or service --></type>
   <service><!-- 1..1 Coding Additional item codes --></service>
   <programCode><!-- 0..* Coding Program specific reason for item inclusion --></programCode>
   <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
   <unitPrice><!-- 0..1 Quantity(Money) Fee, charge or cost per point --></unitPrice>
   <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
   <points value="[decimal]"/><!-- 0..1 Difficulty scaling factor -->
   <net><!-- 0..1 Quantity(Money) Total additional item cost --></net>
   <udi><!-- 0..* Reference(Device) Unique Device Identifier --></udi>
   <subDetail>  <!-- 0..* Additional items -->
    <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
    <type><!-- 1..1 Coding Type of product or service --></type>
    <service><!-- 1..1 Coding Additional item codes --></service>
    <programCode><!-- 0..* Coding Program specific reason for item inclusion --></programCode>
    <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
    <unitPrice><!-- 0..1 Quantity(Money) Fee, charge or cost per point --></unitPrice>
    <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
    <points value="[decimal]"/><!-- 0..1 Difficulty scaling factor -->
    <net><!-- 0..1 Quantity(Money) Net additional item cost --></net>
    <udi><!-- 0..* Reference(Device) Unique Device Identifier --></udi>
   </subDetail>
  </detail>
  <prosthesis>  <!-- 0..1 Prosthetic details -->
   <initial value="[boolean]"/><!-- 0..1 Is this the initial service -->
   <priorDate value="[date]"/><!-- 0..1 Initial service Date -->
   <priorMaterial><!-- 0..1 Coding Prosthetic Material --></priorMaterial>
  </prosthesis>
 </item>
 <total><!-- 0..1 Quantity(Money) Total claim cost --></total>
 <additionalMaterial><!-- 0..* Coding Additional supporting materials and documents --></additionalMaterial>
 <missingTeeth>  <!-- 0..* Only if type = oral -->
  <tooth><!-- 1..1 Coding Tooth Code --></tooth>
  <reason><!-- 0..1 Coding Indicates whether it was extracted or other reason --></reason>
  <extractionDate value="[date]"/><!-- 0..1 Date tooth was extracted if known -->
 </missingTeeth>
</Claim>

JSON Template

{doco
  "resourceType" : "Claim",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "type" : "<code>", // R!  institutional | oral | pharmacy | professional | vision
  "subType" : [{ Coding }], // Finer grained claim type information
  "identifier" : [{ Identifier }], // Claim number
  "ruleset" : { Coding }, // Current specification followed
  "originalRuleset" : { Coding }, // Original specification followed
  "created" : "<dateTime>", // Creation date
  "billablePeriod" : { Period }, // Period for charge submission
  // target[x]: Insurer. One of these 2:
  "targetIdentifier" : { Identifier },
  "targetReference" : { Reference(Organization) },
  // provider[x]: Responsible provider. One of these 2:
  "providerIdentifier" : { Identifier },
  "providerReference" : { Reference(Practitioner) },
  // organization[x]: Responsible organization. One of these 2:
  "organizationIdentifier" : { Identifier },
  "organizationReference" : { Reference(Organization) },
  "use" : "<code>", // complete | proposed | exploratory | other
  "priority" : { Coding }, // Desired processing priority
  "fundsReserve" : { Coding }, // Funds requested to be reserved
  // enterer[x]: Author. One of these 2:
  "entererIdentifier" : { Identifier },
  "entererReference" : { Reference(Practitioner) },
  // facility[x]: Servicing Facility. One of these 2:
  "facilityIdentifier" : { Identifier },
  "facilityReference" : { Reference(Location) },
  "related" : [{ // Related Claims which may be revelant to processing this claimn
    // claim[x]: Reference to the related claim. One of these 2:
    "claimIdentifier" : { Identifier },
    "claimReference" : { Reference(Claim) },
    "relationship" : { Coding }, // How the reference claim is related
    "reference" : { Identifier } // Related file or case reference
  }],
  // prescription[x]: Prescription. One of these 2:
  "prescriptionIdentifier" : { Identifier },
  "prescriptionReference" : { Reference(MedicationOrder|VisionPrescription) },
  // originalPrescription[x]: Original Prescription. One of these 2:
  "originalPrescriptionIdentifier" : { Identifier },
  "originalPrescriptionReference" : { Reference(MedicationOrder) },
  "payee" : { // Party to be paid any benefits payable
    "type" : { Coding }, // R!  Type of party: Subscriber, Provider, other
    // party[x]: Party to receive the payable. One of these 2:
    "partyIdentifier" : { Identifier }
    "partyReference" : { Reference(Practitioner|Organization|Patient|RelatedPerson) }
  },
  // referral[x]: Treatment Referral. One of these 2:
  "referralIdentifier" : { Identifier },
  "referralReference" : { Reference(ReferralRequest) },
  "occurrenceCode" : [{ Coding }], // Occurrence Codes
  "occurenceSpanCode" : [{ Coding }], // Occurrence Span Codes
  "valueCode" : [{ Coding }], // Value Codes
  "diagnosis" : [{ // Diagnosis
    "sequence" : "<positiveInt>", // R!  Number to covey order of diagnosis
    "diagnosis" : { Coding } // R!  Patient's list of diagnosis
  }],
  "procedure" : [{ // Procedures performed
    "sequence" : "<positiveInt>", // R!  Procedure sequence for reference
    "date" : "<dateTime>", // When the procedure was performed
    // procedure[x]: Patient's list of procedures performed. One of these 2:
    "procedureCoding" : { Coding }
    "procedureReference" : { Reference(Procedure) }
  }],
  "specialCondition" : [{ Coding }], // List of special Conditions
  // patient[x]: The subject of the Products and Services. One of these 2:
  "patientIdentifier" : { Identifier },
  "patientReference" : { Reference(Patient) },
  "coverage" : [{ // Insurance or medical plan
    "sequence" : "<positiveInt>", // R!  Service instance identifier
    "focal" : <boolean>, // R!  Is the focal Coverage
    // coverage[x]: Insurance information. One of these 2:
    "coverageIdentifier" : { Identifier },
    "coverageReference" : { Reference(Coverage) },
    "businessArrangement" : "<string>", // Business agreement
    "preAuthRef" : ["<string>"], // Pre-Authorization/Determination Reference
    "claimResponse" : { Reference(ClaimResponse) }, // Adjudication results
    "originalRuleset" : { Coding } // Original version
  }],
  "accidentDate" : "<date>", // When the accident occurred
  "accidentType" : { Coding }, // The nature of the accident
  // accidentLocation[x]: Accident Place. One of these 2:
  "accidentLocationAddress" : { Address },
  "accidentLocationReference" : { Reference(Location) },
  "interventionException" : [{ Coding }], // Intervention and exception code (Pharma)
  "onset" : [{ // Condition related Onset related dates and codes
    // time[x]: Illness, injury or treatable condition date. One of these 2:
    "timeDate" : "<date>",
    "timePeriod" : { Period },
    "type" : { Coding } // Onset of what
  }],
  "employmentImpacted" : { Period }, // Period unable to work
  "hospitalization" : { Period }, // Period in hospital
  "item" : [{ // Goods and Services
    "sequence" : "<positiveInt>", // R!  Service instance
    "type" : { Coding }, // R!  Group or type of product or service
    // provider[x]: Responsible practitioner. One of these 2:
    "providerIdentifier" : { Identifier },
    "providerReference" : { Reference(Practitioner) },
    // supervisor[x]: Supervising Practitioner. One of these 2:
    "supervisorIdentifier" : { Identifier },
    "supervisorReference" : { Reference(Practitioner) },
    "providerQualification" : { Coding }, // Type, classification or Specialization
    "diagnosisLinkId" : ["<positiveInt>"], // Applicable diagnoses
    "service" : { Coding }, // R!  Item Code
    "serviceModifier" : [{ Coding }], // Service/Product modifiers
    "modifier" : [{ Coding }], // Service/Product billing modifiers
    "programCode" : [{ Coding }], // Program specific reason for item inclusion
    // serviced[x]: Date or dates of Service. One of these 2:
    "servicedDate" : "<date>",
    "servicedPeriod" : { Period },
    "place" : { Coding }, // Place of service
    "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
    "unitPrice" : { Quantity(Money) }, // Fee, charge or cost per point
    "factor" : <decimal>, // Price scaling factor
    "points" : <decimal>, // Difficulty scaling factor
    "net" : { Quantity(Money) }, // Total item cost
    "udi" : [{ Reference(Device) }], // Unique Device Identifier
    "bodySite" : { Coding }, // Service Location
    "subSite" : [{ Coding }], // Service Sub-location
    "detail" : [{ // Additional items
      "sequence" : "<positiveInt>", // R!  Service instance
      "type" : { Coding }, // R!  Group or type of product or service
      "service" : { Coding }, // R!  Additional item codes
      "programCode" : [{ Coding }], // Program specific reason for item inclusion
      "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
      "unitPrice" : { Quantity(Money) }, // Fee, charge or cost per point
      "factor" : <decimal>, // Price scaling factor
      "points" : <decimal>, // Difficulty scaling factor
      "net" : { Quantity(Money) }, // Total additional item cost
      "udi" : [{ Reference(Device) }], // Unique Device Identifier
      "subDetail" : [{ // Additional items
        "sequence" : "<positiveInt>", // R!  Service instance
        "type" : { Coding }, // R!  Type of product or service
        "service" : { Coding }, // R!  Additional item codes
        "programCode" : [{ Coding }], // Program specific reason for item inclusion
        "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
        "unitPrice" : { Quantity(Money) }, // Fee, charge or cost per point
        "factor" : <decimal>, // Price scaling factor
        "points" : <decimal>, // Difficulty scaling factor
        "net" : { Quantity(Money) }, // Net additional item cost
        "udi" : [{ Reference(Device) }] // Unique Device Identifier
      }]
    }],
    "prosthesis" : { // Prosthetic details
      "initial" : <boolean>, // Is this the initial service
      "priorDate" : "<date>", // Initial service Date
      "priorMaterial" : { Coding } // Prosthetic Material
    }
  }],
  "total" : { Quantity(Money) }, // Total claim cost
  "additionalMaterial" : [{ Coding }], // Additional supporting materials and documents
  "missingTeeth" : [{ // Only if type = oral
    "tooth" : { Coding }, // R!  Tooth Code
    "reason" : { Coding }, // Indicates whether it was extracted or other reason
    "extractionDate" : "<date>" // Date tooth was extracted if known
  }]
}

 

Alternate definitions: Schema/Schematron, Resource Profile (XML, JSON), Questionnaire

7.1.2.1 Terminology Bindings

PathDefinitionTypeReference
Claim.type The type or discipline-style of the claimRequiredClaimType
Claim.subType A more granulat claim typecodeExampleExample Claim SubType Codes
Claim.ruleset
Claim.originalRuleset
Claim.coverage.originalRuleset 		The static and dynamic model to which contents conform, which may be business version or standard/version.ExampleRuleset Codes
Claim.use Complete, proposed, exploratory, otherRequiredUse
Claim.priority The timeliness with which processing is required: STAT, normal, DeferredExamplePriority Codes
Claim.fundsReserve For whom funds are to be reserved: (Patient, Provider, None).ExampleFunds Reservation Codes
Claim.related.relationship Relationship of this claim to a related ClaimExampleExample Related Claim Relationship Codes
Claim.payee.type A code for the party to be reimbursed.ExamplePayee Type Codes
Claim.occurrenceCode Occurrence codesExampleExample Occurrance Codes
Claim.occurenceSpanCode Occurrence Span codesExampleExample Occurrance Span Codes
Claim.valueCode Value codeExampleExample Value Codes
Claim.diagnosis.diagnosis ICD10 Diagnostic codesExampleICD-10 Codes
Claim.procedure.procedure[x] ICD10 Procedure codesExampleICD-10 Procedure Codes
Claim.specialCondition Patient conditions and symptomsExampleConditions Codes
Claim.accidentType Type of accident: work place, auto, etc.RequiredActIncidentCode
Claim.interventionException Intervention and exception codes (Pharm)ExampleIntervention Codes
Claim.onset.type Condition related start, end and period codesExampleExample Onset Type (Reason) Codes
Claim.item.type
Claim.item.detail.type
Claim.item.detail.subDetail.type 		Group, Service, Product.RequiredException Codes
Claim.item.providerQualification Provider professional qualificationsExampleExample Provider Qualification Codes
Claim.item.service
Claim.item.detail.service
Claim.item.detail.subDetail.service 		Allowable service and product codesExampleUSCLS Codes
Claim.item.serviceModifier Factors which may influce adjudication of servicesExampleExample Service Modifier Codes
Claim.item.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.ExampleModifier type Codes
Claim.item.programCode
Claim.item.detail.programCode
Claim.item.detail.subDetail.programCode 		Program specific reason codesExampleExample Program Reason Codes
Claim.item.place ExampleExample Service Place Codes
Claim.item.bodySite The code for the teeth, quadrant, sextant and archExampleOral Site Codes
Claim.item.subSite The code for the tooth surface and surface combinationsExampleSurface Codes
Claim.item.prosthesis.priorMaterial Material of the prior denture or bridge prosthesis. (Oral)ExampleOral Prostho Material type Codes
Claim.additionalMaterial Code to indicate that Xrays, images, emails, documents, models or attachments are being sent in support of this submission.ExampleAdditional Material Codes
Claim.missingTeeth.tooth The codes for the teeth, subset of OralSitesExampleTeeth Codes
Claim.missingTeeth.reason Reason codes for the missing teethExampleMissing Tooth Reason Codes

7.1.3 Search Parameters

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

NameTypeDescriptionPaths
createddateThe creation date for the ClaimClaim.created
facilityidentifiertokenFacility responsible for the goods and servicesClaim.facilityIdentifier
facilityreferencereferenceFacility responsible for the goods and servicesClaim.facilityReference
(Location)
identifiertokenThe primary identifier of the financial resourceClaim.identifier
organizationidentifiertokenThe reference to the providing organizationClaim.organizationIdentifier
organizationreferencereferenceThe reference to the providing organizationClaim.organizationReference
(Organization)
patientidentifiertokenPatient receiving the servicesClaim.patientIdentifier
patientreferencereferencePatient receiving the servicesClaim.patientReference
(Patient)
prioritytokenProcessing priority requestedClaim.priority
provideridentifiertokenProvider responsible for the ClaimClaim.providerIdentifier
providerreferencereferenceProvider responsible for the ClaimClaim.providerReference
(Practitioner)
targetidentifiertokenThe target payor/insurer for the ClaimClaim.targetIdentifier
targetreferencereferenceThe target payor/insurer for the ClaimClaim.targetReference
(Organization)
usetokenThe kind of financial resourceClaim.use