STU 3 Ballot
This page is part of the FHIR Specification (v1.6.0: STU 3 Ballot 4). 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
StructureDefinition for claim
Financial
{
"resourceType": "StructureDefinition",
"id": "Claim",
"meta": {
"lastUpdated": "2016-08-11T17:02:54.322+10:00"
},
"text": {
"status": "generated",
"div": "<div>!-- Snipped for Brevity --></div>"
},
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm",
"valueInteger": 1
}
],
"url": "http://hl7.org/fhir/StructureDefinition/Claim",
"name": "Claim",
"status": "draft",
"publisher": "Health Level Seven International (Financial Management)",
"contact": [
{
"telecom": [
{
"system": "other",
"value": "http://hl7.org/fhir"
}
]
},
{
"telecom": [
{
"system": "other",
"value": "http://www.hl7.org/Special/committees/fm/index.cfm"
}
]
}
],
"date": "2016-08-11T17:02:54+10:00",
"description": "Base StructureDefinition for Claim Resource",
"fhirVersion": "1.6.0",
"mapping": [
{
"identity": "w5",
"uri": "http://hl7.org/fhir/w5",
"name": "W5 Mapping"
},
{
"identity": "rim",
"uri": "http://hl7.org/v3",
"name": "RIM Mapping"
}
],
"kind": "resource",
"abstract": false,
"type": "Claim",
"baseDefinition": "http://hl7.org/fhir/StructureDefinition/DomainResource",
"derivation": "specialization",
"snapshot": {
"element": [
{
"id": "Claim",
"path": "Claim",
"short": "Claim, Pre-determination or Pre-authorization",
"definition": "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.",
"min": 0,
"max": "*",
"constraint": [
{
"key": "dom-2",
"severity": "error",
"human": "If the resource is contained in another resource, it SHALL NOT contain nested Resources",
"expression": "contained.contained.empty()",
"xpath": "not(parent::f:contained and f:contained)"
},
{
"key": "dom-1",
"severity": "error",
"human": "If the resource is contained in another resource, it SHALL NOT contain any narrative",
"expression": "contained.text.empty()",
"xpath": "not(parent::f:contained and f:text)"
},
{
"key": "dom-4",
"severity": "error",
"human": "If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated",
"expression": "contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()",
"xpath": "not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))"
},
{
"key": "dom-3",
"severity": "error",
"human": "If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource",
"expression": "contained.where(('#'+id in %resource.descendants().reference).not()).empty()",
"xpath": "not(exists(for $id in f:contained/*/@id return $id[not(ancestor::f:contained/parent::*/descendant::f:reference/@value=concat('#', $id))]))"
}
],
"mapping": [
{
"identity": "rim",
"map": "Entity. Role, or Act"
},
{
"identity": "w5",
"map": "financial.billing"
}
]
},
{
"id": "Claim.id",
"path": "Claim.id",
"short": "Logical id of this artifact",
"definition": "The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.",
"comments": "The only time that a resource does not have an id is when it is being submitted to the server using a create operation.",
"min": 0,
"max": "1",
"base": {
"path": "Resource.id",
"min": 0,
"max": "*"
},
"type": [
{
"code": "id"
}
],
"isSummary": true
},
{
"id": "Claim.meta",
"path": "Claim.meta",
"short": "Metadata about the resource",
"definition": "The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content may not always be associated with version changes to the resource.",
"min": 0,
"max": "1",
"base": {
"path": "Resource.meta",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Meta"
}
],
"isSummary": true
},
{
"id": "Claim.implicitRules",
"path": "Claim.implicitRules",
"short": "A set of rules under which this content was created",
"definition": "A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content.",
"comments": "Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element as much as possible.",
"min": 0,
"max": "1",
"base": {
"path": "Resource.implicitRules",
"min": 0,
"max": "*"
},
"type": [
{
"code": "uri"
}
],
"isModifier": true,
"isSummary": true
},
{
"id": "Claim.language",
"path": "Claim.language",
"short": "Language of the resource content",
"definition": "The base language in which the resource is written.",
"comments": "Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).",
"min": 0,
"max": "1",
"base": {
"path": "Resource.language",
"min": 0,
"max": "*"
},
"type": [
{
"code": "code"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-maxValueSet",
"valueReference": {
"reference": "http://hl7.org/fhir/ValueSet/all-languages"
}
}
],
"strength": "extensible",
"description": "A human language.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/languages"
}
}
},
{
"id": "Claim.text",
"path": "Claim.text",
"short": "Text summary of the resource, for human interpretation",
"definition": "A human-readable narrative that contains a summary of the resource, and may be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it \"clinically safe\" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.",
"comments": "Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a \"text blob\" or where text is additionally entered raw or narrated and encoded in formation is added later.",
"alias": [
"narrative",
"html",
"xhtml",
"display"
],
"min": 0,
"max": "1",
"base": {
"path": "DomainResource.text",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Narrative"
}
],
"condition": [
"dom-1"
],
"mapping": [
{
"identity": "rim",
"map": "Act.text?"
}
]
},
{
"id": "Claim.contained",
"path": "Claim.contained",
"short": "Contained, inline Resources",
"definition": "These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.",
"comments": "This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again.",
"alias": [
"inline resources",
"anonymous resources",
"contained resources"
],
"min": 0,
"max": "*",
"base": {
"path": "DomainResource.contained",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Resource"
}
],
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "Claim.extension",
"path": "Claim.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the resource. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "DomainResource.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "Claim.modifierExtension",
"path": "Claim.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the resource, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "DomainResource.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "Claim.identifier",
"path": "Claim.identifier",
"short": "Claim number",
"definition": "The business identifier for the instance: claim number, pre-determination or pre-authorization number.",
"min": 0,
"max": "*",
"type": [
{
"code": "Identifier"
}
],
"mapping": [
{
"identity": "w5",
"map": "id"
}
]
},
{
"id": "Claim.status",
"path": "Claim.status",
"short": "active | cancelled | draft | entered-in-error",
"definition": "The status of the resource instance.",
"min": 1,
"max": "1",
"type": [
{
"code": "code"
}
],
"isModifier": true,
"isSummary": true,
"binding": {
"strength": "required",
"description": "A code specifying the state of the resource instance.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-status"
}
},
"mapping": [
{
"identity": "w5",
"map": "status"
}
]
},
{
"id": "Claim.type",
"path": "Claim.type",
"short": "Type or discipline",
"definition": "The category of claim, eg, oral, pharmacy, vision, insitutional, professional.",
"comments": "Affects which fields and value sets are used.",
"min": 1,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "required",
"description": "The type or discipline-style of the claim",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-type"
}
},
"mapping": [
{
"identity": "w5",
"map": "class"
}
]
},
{
"id": "Claim.subType",
"path": "Claim.subType",
"short": "Finer grained claim type information",
"definition": "A finer grained suite of claim subtype codes which may convey Inpatient vs Outpatient and/or a specialty service. In the US the BillType.",
"comments": "This may contain the local bill type codes such as the US UB-04 bill type code.",
"min": 0,
"max": "*",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "A more granular claim typecode",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-subtype"
}
},
"mapping": [
{
"identity": "w5",
"map": "class"
}
]
},
{
"id": "Claim.ruleset",
"path": "Claim.ruleset",
"short": "Current specification followed",
"definition": "The version of the specification on which this instance relies.",
"alias": [
"BusinessVersion"
],
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "The static and dynamic model to which contents conform, which may be business version or standard/version.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ruleset"
}
},
"mapping": [
{
"identity": "w5",
"map": "id.version"
}
]
},
{
"id": "Claim.originalRuleset",
"path": "Claim.originalRuleset",
"short": "Original specification followed",
"definition": "The version of the specification from which the original instance was created.",
"alias": [
"OriginalBusinessVersion"
],
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "The static and dynamic model to which contents conform, which may be business version or standard/version.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ruleset"
}
}
},
{
"id": "Claim.created",
"path": "Claim.created",
"short": "Creation date",
"definition": "The date when the enclosed suite of services were performed or completed.",
"min": 0,
"max": "1",
"type": [
{
"code": "dateTime"
}
],
"mapping": [
{
"identity": "w5",
"map": "when.recorded"
}
]
},
{
"id": "Claim.billablePeriod",
"path": "Claim.billablePeriod",
"short": "Period for charge submission",
"definition": "The billable period for which charges are being submitted.",
"min": 0,
"max": "1",
"type": [
{
"code": "Period"
}
],
"mapping": [
{
"identity": "w5",
"map": "when.done"
}
]
},
{
"id": "Claim.insurer[x]",
"path": "Claim.insurer[x]",
"short": "Target",
"definition": "The Insurer who is target of the request.",
"min": 0,
"max": "1",
"type": [
{
"code": "Identifier"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Organization"
}
]
},
{
"id": "Claim.provider[x]",
"path": "Claim.provider[x]",
"short": "Responsible provider",
"definition": "The provider which is responsible for the bill, claim pre-determination, pre-authorization.",
"min": 0,
"max": "1",
"type": [
{
"code": "Identifier"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Practitioner"
}
],
"mapping": [
{
"identity": "w5",
"map": "who.source"
}
]
},
{
"id": "Claim.organization[x]",
"path": "Claim.organization[x]",
"short": "Responsible organization",
"definition": "The organization which is responsible for the bill, claim pre-determination, pre-authorization.",
"min": 0,
"max": "1",
"type": [
{
"code": "Identifier"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Organization"
}
],
"mapping": [
{
"identity": "w5",
"map": "who.source"
}
]
},
{
"id": "Claim.use",
"path": "Claim.use",
"short": "complete | proposed | exploratory | other",
"definition": "Complete (Bill or Claim), Proposed (Pre-Authorization), Exploratory (Pre-determination).",
"min": 0,
"max": "1",
"type": [
{
"code": "code"
}
],
"binding": {
"strength": "required",
"description": "Complete, proposed, exploratory, other",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-use"
}
},
"mapping": [
{
"identity": "w5",
"map": "class"
}
]
},
{
"id": "Claim.priority",
"path": "Claim.priority",
"short": "Desired processing priority",
"definition": "Immediate (STAT), best effort (NORMAL), deferred (DEFER).",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "The timeliness with which processing is required: STAT, normal, Deferred",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/process-priority"
}
}
},
{
"id": "Claim.fundsReserve",
"path": "Claim.fundsReserve",
"short": "Funds requested to be reserved",
"definition": "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 requested.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "For whom funds are to be reserved: (Patient, Provider, None).",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/fundsreserve"
}
}
},
{
"id": "Claim.enterer[x]",
"path": "Claim.enterer[x]",
"short": "Author",
"definition": "Person who created the invoice/claim/pre-determination or pre-authorization.",
"min": 0,
"max": "1",
"type": [
{
"code": "Identifier"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Practitioner"
}
],
"mapping": [
{
"identity": "w5",
"map": "who.author"
}
]
},
{
"id": "Claim.facility[x]",
"path": "Claim.facility[x]",
"short": "Servicing Facility",
"definition": "Facility where the services were provided.",
"min": 0,
"max": "1",
"type": [
{
"code": "Identifier"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Location"
}
],
"mapping": [
{
"identity": "w5",
"map": "where"
}
]
},
{
"id": "Claim.related",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "RelatedClaim"
}
],
"path": "Claim.related",
"short": "Related Claims which may be revelant to processing this claimn",
"definition": "Other claims which are related to this claim such as prior claim versions or for related services.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "Claim.related.id",
"path": "Claim.related.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "*"
},
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Claim.related.extension",
"path": "Claim.related.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Claim.related.modifierExtension",
"path": "Claim.related.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "Claim.related.claim[x]",
"path": "Claim.related.claim[x]",
"short": "Reference to the related claim",
"definition": "Other claims which are related to this claim such as prior claim versions or for related services.",
"comments": "Do we need a relationship code?",
"min": 0,
"max": "1",
"type": [
{
"code": "Identifier"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Claim"
}
]
},
{
"id": "Claim.related.relationship",
"path": "Claim.related.relationship",
"short": "How the reference claim is related",
"definition": "For example prior or umbrella.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "Relationship of this claim to a related Claim",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/related-claim-relationship"
}
}
},
{
"id": "Claim.related.reference",
"path": "Claim.related.reference",
"short": "Related file or case reference",
"definition": "An alternate organizational reference to the case or file to which this particular claim pertains - eg Property/Casualy insurer claim # or Workers Compensation case # .",
"min": 0,
"max": "1",
"type": [
{
"code": "Identifier"
}
]
},
{
"id": "Claim.prescription[x]",
"path": "Claim.prescription[x]",
"short": "Prescription",
"definition": "Prescription to support the dispensing of Pharmacy or Vision products.",
"comments": "Should we create a group to hold multiple prescriptions and add a sequence number and on the line items a link to the sequence.",
"requirements": "For type=Pharmacy and Vision only.",
"min": 0,
"max": "1",
"type": [
{
"code": "Identifier"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/MedicationOrder"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/VisionPrescription"
}
]
},
{
"id": "Claim.originalPrescription[x]",
"path": "Claim.originalPrescription[x]",
"short": "Original Prescription",
"definition": "Original prescription which has been superceded by this prescription to support the dispensing of pharmacy services, medications or products.",
"comments": "as above.",
"min": 0,
"max": "1",
"type": [
{
"code": "Identifier"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/MedicationOrder"
}
]
},
{
"id": "Claim.payee",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Payee"
}
],
"path": "Claim.payee",
"short": "Party to be paid any benefits payable",
"definition": "The party to be reimbursed for the services.",
"min": 0,
"max": "1",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "Claim.payee.id",
"path": "Claim.payee.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "*"
},
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Claim.payee.extension",
"path": "Claim.payee.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Claim.payee.modifierExtension",
"path": "Claim.payee.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "Claim.payee.type",
"path": "Claim.payee.type",
"short": "Type of party: Subscriber, Provider, other",
"definition": "Type of Party to be reimbursed: Subscriber, provider, other.",
"min": 1,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "A code for the party to be reimbursed.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/payeetype"
}
}
},
{
"id": "Claim.payee.resourceType",
"path": "Claim.payee.resourceType",
"short": "organization | patient | practitioner | relatedperson",
"definition": "organization | patient | practitioner | relatedperson.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "The type of payee Resource",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-payee-resource-type"
}
}
},
{
"id": "Claim.payee.party[x]",
"path": "Claim.payee.party[x]",
"short": "Party to receive the payable",
"definition": "Party to be reimbursed: Subscriber, provider, other.",
"min": 0,
"max": "1",
"type": [
{
"code": "Identifier"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Practitioner"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Organization"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Patient"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/RelatedPerson"
}
]
},
{
"id": "Claim.referral[x]",
"path": "Claim.referral[x]",
"short": "Treatment Referral",
"definition": "The referral resource which lists the date, practitioner, reason and other supporting information.",
"min": 0,
"max": "1",
"type": [
{
"code": "Identifier"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/ReferralRequest"
}
],
"mapping": [
{
"identity": "w5",
"map": "who.cause"
}
]
},
{
"id": "Claim.information",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "SpecialCondition"
}
],
"path": "Claim.information",
"definition": "Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. Often there are mutiple jurisdiction specific valuesets which are required.",
"requirements": "Typically these information codes are required to support the services rendered or the adjudication of the services rendered.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "Claim.information.id",
"path": "Claim.information.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "*"
},
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Claim.information.extension",
"path": "Claim.information.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Claim.information.modifierExtension",
"path": "Claim.information.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "Claim.information.category",
"path": "Claim.information.category",
"short": "Category of information",
"definition": "The general class of the information supplied: information; exception; accident, employment; onset, etc.",
"comments": "This may contain the local bill type codes such as the US UB-04 bill type code.",
"min": 1,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "The valuset used for additional information category codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-informationcategory"
}
}
},
{
"id": "Claim.information.code",
"path": "Claim.information.code",
"short": "Type of information",
"definition": "System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought which may influence the adjudication.",
"comments": "This may contain the local bill type codes such as the US UB-04 bill type code.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "The valuset used for additional information codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-exception"
}
}
},
{
"id": "Claim.information.timing[x]",
"path": "Claim.information.timing[x]",
"short": "When it occurred",
"definition": "The date when or period to which this information refers.",
"min": 0,
"max": "1",
"type": [
{
"code": "date"
},
{
"code": "Period"
}
]
},
{
"id": "Claim.information.value[x]",
"path": "Claim.information.value[x]",
"short": "Additional Data",
"definition": "Additional data.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
},
{
"code": "Quantity"
}
]
},
{
"id": "Claim.diagnosis",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Diagnosis"
}
],
"path": "Claim.diagnosis",
"short": "Diagnosis",
"definition": "Ordered list of patient diagnosis for which care is sought.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "Claim.diagnosis.id",
"path": "Claim.diagnosis.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "*"
},
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Claim.diagnosis.extension",
"path": "Claim.diagnosis.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Claim.diagnosis.modifierExtension",
"path": "Claim.diagnosis.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "Claim.diagnosis.sequence",
"path": "Claim.diagnosis.sequence",
"short": "Number to covey order of diagnosis",
"definition": "Sequence of diagnosis which serves to order and provide a link.",
"requirements": "Required to maintain order of the diagnoses.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "Claim.diagnosis.diagnosis",
"path": "Claim.diagnosis.diagnosis",
"short": "Patient's diagnosis",
"definition": "The diagnosis.",
"requirements": "Required to adjudicate services rendered to condition presented.",
"min": 1,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "ICD10 Diagnostic codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/icd-10"
}
}
},
{
"id": "Claim.diagnosis.type",
"path": "Claim.diagnosis.type",
"short": "Type of Diagnosis",
"definition": "The type of the Diagnosis, for example: admitting,.",
"comments": "Diagnosis are presented in list order to their expected importance: primary, secondary, etc.",
"requirements": "Required to adjudicate services rendered to the mandated diagnosis grouping system.",
"min": 0,
"max": "*",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "The type of the diagnosis: admitting, principal, discharge",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-diagnosistype"
}
}
},
{
"id": "Claim.diagnosis.drg",
"path": "Claim.diagnosis.drg",
"short": "Diagnosis Related Group",
"definition": "The Diagnosis Related Group (DRG) code based on the assigned grouping code system.",
"requirements": "Required to adjudicate services rendered to the mandated diagnosis grouping system.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "The DRG codes associated with the diagnosis",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup"
}
}
},
{
"id": "Claim.procedure",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Procedure"
}
],
"path": "Claim.procedure",
"short": "Procedures performed",
"definition": "Ordered list of patient procedures performed to support the adjudication.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "Claim.procedure.id",
"path": "Claim.procedure.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "*"
},
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Claim.procedure.extension",
"path": "Claim.procedure.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Claim.procedure.modifierExtension",
"path": "Claim.procedure.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "Claim.procedure.sequence",
"path": "Claim.procedure.sequence",
"short": "Procedure sequence for reference",
"definition": "Sequence of procedures which serves to order and provide a link.",
"requirements": "Required to maintain order of the procudures.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "Claim.procedure.date",
"path": "Claim.procedure.date",
"short": "When the procedure was performed",
"definition": "Date and optionally time the procedure was performed .",
"comments": "SB DateTime??",
"requirements": "Required to adjudicate services rendered.",
"min": 0,
"max": "1",
"type": [
{
"code": "dateTime"
}
]
},
{
"id": "Claim.procedure.procedure[x]",
"path": "Claim.procedure.procedure[x]",
"short": "Patient's list of procedures performed",
"definition": "The procedure code.",
"requirements": "Required to adjudicate services rendered.",
"min": 1,
"max": "1",
"type": [
{
"code": "Coding"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Procedure"
}
],
"binding": {
"strength": "example",
"description": "ICD10 Procedure codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/icd-10-procedures"
}
}
},
{
"id": "Claim.patient[x]",
"path": "Claim.patient[x]",
"short": "The subject of the Products and Services",
"definition": "Patient Resource.",
"min": 1,
"max": "1",
"type": [
{
"code": "Identifier"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Patient"
}
],
"mapping": [
{
"identity": "w5",
"map": "who.focus"
}
]
},
{
"id": "Claim.coverage",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Coverage"
}
],
"path": "Claim.coverage",
"short": "Insurance or medical plan",
"definition": "Financial instrument by which payment information for health care.",
"requirements": "Health care programs and insurers are significant payors of health service costs.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"mapping": [
{
"identity": "rim",
"map": "Coverage"
}
]
},
{
"id": "Claim.coverage.id",
"path": "Claim.coverage.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "*"
},
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Claim.coverage.extension",
"path": "Claim.coverage.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Claim.coverage.modifierExtension",
"path": "Claim.coverage.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "Claim.coverage.sequence",
"path": "Claim.coverage.sequence",
"short": "Service instance identifier",
"definition": "A service line item.",
"requirements": "To maintain order of the coverages.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "Claim.coverage.focal",
"path": "Claim.coverage.focal",
"short": "Is the focal Coverage",
"definition": "The instance number of the Coverage which is the focus for adjudication. The Coverage against which the claim is to be adjudicated.",
"requirements": "To identify which coverage is being adjudicated.",
"min": 1,
"max": "1",
"type": [
{
"code": "boolean"
}
]
},
{
"id": "Claim.coverage.coverage[x]",
"path": "Claim.coverage.coverage[x]",
"short": "Insurance information",
"definition": "Reference to the program or plan identification, underwriter or payor.",
"requirements": "Need to identify the issuer to target for processing and for coordination of benefit processing.",
"min": 1,
"max": "1",
"type": [
{
"code": "Identifier"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Coverage"
}
]
},
{
"id": "Claim.coverage.businessArrangement",
"path": "Claim.coverage.businessArrangement",
"short": "Business agreement",
"definition": "The contract number of a business agreement which describes the terms and conditions.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
]
},
{
"id": "Claim.coverage.preAuthRef",
"path": "Claim.coverage.preAuthRef",
"short": "Pre-Authorization/Determination Reference",
"definition": "A list of references from the Insurer to which these services pertain.",
"requirements": "To provide any pre=determination or prior authorization reference.",
"min": 0,
"max": "*",
"type": [
{
"code": "string"
}
]
},
{
"id": "Claim.coverage.claimResponse",
"path": "Claim.coverage.claimResponse",
"short": "Adjudication results",
"definition": "The Coverages adjudication details.",
"requirements": "Used by downstream payers to determine what balance remains and the net payable.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/ClaimResponse"
}
]
},
{
"id": "Claim.coverage.originalRuleset",
"path": "Claim.coverage.originalRuleset",
"short": "Original version",
"definition": "The style (standard) and version of the original material which was converted into this resource.",
"requirements": "Knowledge of the original version can inform the processing of this instance so that information which is processable by the originating system may be generated.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "The static and dynamic model to which contents conform, which may be business version or standard/version.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ruleset"
}
}
},
{
"id": "Claim.accident",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Accident"
}
],
"path": "Claim.accident",
"definition": "An accident which resulted in the need for healthcare services.",
"min": 0,
"max": "1",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "Claim.accident.id",
"path": "Claim.accident.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "*"
},
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Claim.accident.extension",
"path": "Claim.accident.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Claim.accident.modifierExtension",
"path": "Claim.accident.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "Claim.accident.date",
"path": "Claim.accident.date",
"short": "When the accident occurred\nsee information codes\nsee information codes",
"definition": "Date of an accident which these services are addressing.",
"requirements": "Coverage may be dependant on accidents.",
"min": 1,
"max": "1",
"type": [
{
"code": "date"
}
]
},
{
"id": "Claim.accident.type",
"path": "Claim.accident.type",
"short": "The nature of the accident",
"definition": "Type of accident: work, auto, etc.",
"requirements": "Coverage may be dependant on the type of accident.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "required",
"description": "Type of accident: work place, auto, etc.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/v3-ActIncidentCode"
}
}
},
{
"id": "Claim.accident.location[x]",
"path": "Claim.accident.location[x]",
"short": "Accident Place",
"definition": "Accident Place.",
"min": 0,
"max": "1",
"type": [
{
"code": "Address"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Location"
}
]
},
{
"id": "Claim.employmentImpacted",
"path": "Claim.employmentImpacted",
"short": "Period unable to work",
"definition": "The start and optional end dates of when the patient was precluded from working due to the treatable condition(s).",
"min": 0,
"max": "1",
"type": [
{
"code": "Period"
}
]
},
{
"id": "Claim.hospitalization",
"path": "Claim.hospitalization",
"short": "Period in hospital",
"definition": "The start and optional end dates of when the patient was confined to a treatment center.",
"min": 0,
"max": "1",
"type": [
{
"code": "Period"
}
]
},
{
"id": "Claim.item",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Item"
}
],
"path": "Claim.item",
"short": "Goods and Services",
"definition": "First tier of goods and services.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "Claim.item.id",
"path": "Claim.item.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "*"
},
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Claim.item.extension",
"path": "Claim.item.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Claim.item.modifierExtension",
"path": "Claim.item.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "Claim.item.sequence",
"path": "Claim.item.sequence",
"short": "Service instance",
"definition": "A service line number.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "Claim.item.careTeam",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "CareTeam"
}
],
"path": "Claim.item.careTeam",
"definition": "The members of the team who provided the overall service as well as their role and whether responsible and qualifications.",
"requirements": "Role and Responsible may not be required when there is only a single provider listed.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "Claim.item.careTeam.id",
"path": "Claim.item.careTeam.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "*"
},
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Claim.item.careTeam.extension",
"path": "Claim.item.careTeam.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Claim.item.careTeam.modifierExtension",
"path": "Claim.item.careTeam.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "Claim.item.careTeam.provider[x]",
"path": "Claim.item.careTeam.provider[x]",
"short": "Provider individual or organization",
"definition": "Member of the team who provided the overall service.",
"min": 1,
"max": "1",
"type": [
{
"code": "Identifier"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Practitioner"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Organization"
}
],
"mapping": [
{
"identity": "w5",
"map": "who.actor"
}
]
},
{
"id": "Claim.item.careTeam.responsible",
"path": "Claim.item.careTeam.responsible",
"short": "Billing provider",
"definition": "The party who is billing and responsible for the claimed good or service rendered to the patient.",
"min": 0,
"max": "1",
"type": [
{
"code": "boolean"
}
]
},
{
"id": "Claim.item.careTeam.role",
"path": "Claim.item.careTeam.role",
"short": "Role on the team",
"definition": "The lead, assisting or supervising practitioner and their discipline if a multidisiplinary team.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "The role codes for the care team members.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-careteamrole"
}
}
},
{
"id": "Claim.item.careTeam.qualification",
"path": "Claim.item.careTeam.qualification",
"short": "Type, classification or Specialization",
"definition": "The qualification which is applicable for this service.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "Provider professional qualifications",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/provider-qualification"
}
}
},
{
"id": "Claim.item.diagnosisLinkId",
"path": "Claim.item.diagnosisLinkId",
"short": "Applicable diagnoses",
"definition": "Diagnosis applicable for this service or product line.",
"min": 0,
"max": "*",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "Claim.item.revenue",
"path": "Claim.item.revenue",
"short": "Revenue or cost center code",
"definition": "The type of reveneu or cost center providing the product and/or service.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "Codes for the revenue or cost centers supplying the service and/or products.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-revenue-center"
}
}
},
{
"id": "Claim.item.category",
"path": "Claim.item.category",
"short": "Type of service or product",
"definition": "Health Care Service Type Codes to identify the classification of service or benefits.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "Benefit subcategories such as: oral-basic, major, glasses",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-subcategory"
}
}
},
{
"id": "Claim.item.service",
"path": "Claim.item.service",
"short": "Billing Code",
"definition": "If this is an actual service or product line, ie. not a Group, then use code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "Allowable service and product codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
}
},
{
"id": "Claim.item.modifier",
"path": "Claim.item.modifier",
"short": "Service/Product billing modifiers",
"definition": "Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.",
"requirements": "May impact on adjudication.",
"min": 0,
"max": "*",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-modifiers"
}
}
},
{
"id": "Claim.item.programCode",
"path": "Claim.item.programCode",
"short": "Program specific reason for item inclusion",
"definition": "For programs which require reason codes for the inclusion or covering of this billed item under the program or sub-program.",
"min": 0,
"max": "*",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "Program specific reason codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-program-code"
}
}
},
{
"id": "Claim.item.serviced[x]",
"path": "Claim.item.serviced[x]",
"short": "Date or dates of Service",
"definition": "The date or dates when the enclosed suite of services were performed or completed.",
"min": 0,
"max": "1",
"type": [
{
"code": "date"
},
{
"code": "Period"
}
],
"mapping": [
{
"identity": "w5",
"map": "when.done"
}
]
},
{
"id": "Claim.item.location[x]",
"path": "Claim.item.location[x]",
"short": "Place of service",
"definition": "Where the service was provided.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
},
{
"code": "Address"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Location"
}
],
"binding": {
"strength": "example",
"description": "Place of service: pharmcy,school, prison, etc.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-place"
}
},
"mapping": [
{
"identity": "w5",
"map": "where"
}
]
},
{
"id": "Claim.item.quantity",
"path": "Claim.item.quantity",
"short": "Count of Products or Services",
"definition": "The number of repetitions of a service or product.",
"min": 0,
"max": "1",
"type": [
{
"code": "Quantity",
"profile": "http://hl7.org/fhir/StructureDefinition/SimpleQuantity"
}
]
},
{
"id": "Claim.item.unitPrice",
"path": "Claim.item.unitPrice",
"short": "Fee, charge or cost per point",
"definition": "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 group.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "Claim.item.factor",
"path": "Claim.item.factor",
"short": "Price scaling factor",
"definition": "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.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "decimal"
}
]
},
{
"id": "Claim.item.points",
"path": "Claim.item.points",
"short": "Difficulty scaling factor",
"definition": "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 point.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "decimal"
}
]
},
{
"id": "Claim.item.net",
"path": "Claim.item.net",
"short": "Total item cost",
"definition": "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 supplied.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "Claim.item.udi",
"path": "Claim.item.udi",
"short": "Unique Device Identifier",
"definition": "List of Unique Device Identifiers associated with this line item.",
"requirements": "The UDI code and issuer if applicable for the supplied product.",
"min": 0,
"max": "*",
"type": [
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Device"
}
]
},
{
"id": "Claim.item.bodySite",
"path": "Claim.item.bodySite",
"short": "Service Location",
"definition": "Physical service site on the patient (limb, tooth, etc).",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "The code for the teeth, quadrant, sextant and arch",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/tooth"
}
}
},
{
"id": "Claim.item.subSite",
"path": "Claim.item.subSite",
"short": "Service Sub-location",
"definition": "A region or surface of the site, eg. limb region or tooth surface(s).",
"min": 0,
"max": "*",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "The code for the tooth surface and surface combinations",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/surface"
}
}
},
{
"id": "Claim.item.detail",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Detail"
}
],
"path": "Claim.item.detail",
"short": "Additional items",
"definition": "Second tier of goods and services.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "Claim.item.detail.id",
"path": "Claim.item.detail.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "*"
},
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Claim.item.detail.extension",
"path": "Claim.item.detail.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Claim.item.detail.modifierExtension",
"path": "Claim.item.detail.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "Claim.item.detail.sequence",
"path": "Claim.item.detail.sequence",
"short": "Service instance",
"definition": "A service line number.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "Claim.item.detail.revenue",
"path": "Claim.item.detail.revenue",
"short": "Revenue or cost center code",
"definition": "The type of reveneu or cost center providing the product and/or service.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "Codes for the revenue or cost centers supplying the service and/or products.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-revenue-center"
}
}
},
{
"id": "Claim.item.detail.category",
"path": "Claim.item.detail.category",
"short": "Type of service or product",
"definition": "Health Care Service Type Codes to identify the classification of service or benefits.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "Benefit subcategories such as: oral-basic, major, glasses",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-subcategory"
}
}
},
{
"id": "Claim.item.detail.service",
"path": "Claim.item.detail.service",
"short": "Billing Code",
"definition": "If this is an actual service or product line, ie. not a Group, then use code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "Allowable service and product codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
}
},
{
"id": "Claim.item.detail.modifier",
"path": "Claim.item.detail.modifier",
"short": "Service/Product billing modifiers",
"definition": "Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.",
"requirements": "May impact on adjudication.",
"min": 0,
"max": "*",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-modifiers"
}
}
},
{
"id": "Claim.item.detail.programCode",
"path": "Claim.item.detail.programCode",
"short": "Program specific reason for item inclusion",
"definition": "For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program.",
"min": 0,
"max": "*",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "Program specific reason codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-program-code"
}
}
},
{
"id": "Claim.item.detail.quantity",
"path": "Claim.item.detail.quantity",
"short": "Count of Products or Services",
"definition": "The number of repetitions of a service or product.",
"min": 0,
"max": "1",
"type": [
{
"code": "Quantity",
"profile": "http://hl7.org/fhir/StructureDefinition/SimpleQuantity"
}
]
},
{
"id": "Claim.item.detail.unitPrice",
"path": "Claim.item.detail.unitPrice",
"short": "Fee, charge or cost per point",
"definition": "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 group.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "Claim.item.detail.factor",
"path": "Claim.item.detail.factor",
"short": "Price scaling factor",
"definition": "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.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "decimal"
}
]
},
{
"id": "Claim.item.detail.points",
"path": "Claim.item.detail.points",
"short": "Difficulty scaling factor",
"definition": "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 point.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "decimal"
}
]
},
{
"id": "Claim.item.detail.net",
"path": "Claim.item.detail.net",
"short": "Total additional item cost",
"definition": "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 supplied.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "Claim.item.detail.udi",
"path": "Claim.item.detail.udi",
"short": "Unique Device Identifier",
"definition": "List of Unique Device Identifiers associated with this line item.",
"requirements": "The UDI code and issuer if applicable for the supplied product.",
"min": 0,
"max": "*",
"type": [
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Device"
}
]
},
{
"id": "Claim.item.detail.subDetail",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "SubDetail"
}
],
"path": "Claim.item.detail.subDetail",
"short": "Additional items",
"definition": "Third tier of goods and services.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "Claim.item.detail.subDetail.id",
"path": "Claim.item.detail.subDetail.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "*"
},
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Claim.item.detail.subDetail.extension",
"path": "Claim.item.detail.subDetail.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Claim.item.detail.subDetail.modifierExtension",
"path": "Claim.item.detail.subDetail.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "Claim.item.detail.subDetail.sequence",
"path": "Claim.item.detail.subDetail.sequence",
"short": "Service instance",
"definition": "A service line number.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "Claim.item.detail.subDetail.revenue",
"path": "Claim.item.detail.subDetail.revenue",
"short": "Revenue or cost center code",
"definition": "The type of reveneu or cost center providing the product and/or service.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "Codes for the revenue or cost centers supplying the service and/or products.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-revenue-center"
}
}
},
{
"id": "Claim.item.detail.subDetail.category",
"path": "Claim.item.detail.subDetail.category",
"short": "Type of service or product",
"definition": "Health Care Service Type Codes to identify the classification of service or benefits.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "Benefit subcategories such as: oral-basic, major, glasses",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-subcategory"
}
}
},
{
"id": "Claim.item.detail.subDetail.service",
"path": "Claim.item.detail.subDetail.service",
"short": "Billing Code",
"definition": "A code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI).",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "Allowable service and product codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
}
},
{
"id": "Claim.item.detail.subDetail.modifier",
"path": "Claim.item.detail.subDetail.modifier",
"short": "Service/Product billing modifiers",
"definition": "Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.",
"requirements": "May impact on adjudication.",
"min": 0,
"max": "*",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-modifiers"
}
}
},
{
"id": "Claim.item.detail.subDetail.programCode",
"path": "Claim.item.detail.subDetail.programCode",
"short": "Program specific reason for item inclusion",
"definition": "For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program.",
"min": 0,
"max": "*",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "Program specific reason codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-program-code"
}
}
},
{
"id": "Claim.item.detail.subDetail.quantity",
"path": "Claim.item.detail.subDetail.quantity",
"short": "Count of Products or Services",
"definition": "The number of repetitions of a service or product.",
"min": 0,
"max": "1",
"type": [
{
"code": "Quantity",
"profile": "http://hl7.org/fhir/StructureDefinition/SimpleQuantity"
}
]
},
{
"id": "Claim.item.detail.subDetail.unitPrice",
"path": "Claim.item.detail.subDetail.unitPrice",
"short": "Fee, charge or cost per point",
"definition": "The fee for an addittional service or product or charge.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "Claim.item.detail.subDetail.factor",
"path": "Claim.item.detail.subDetail.factor",
"short": "Price scaling factor",
"definition": "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.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "decimal"
}
]
},
{
"id": "Claim.item.detail.subDetail.points",
"path": "Claim.item.detail.subDetail.points",
"short": "Difficulty scaling factor",
"definition": "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 point.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "decimal"
}
]
},
{
"id": "Claim.item.detail.subDetail.net",
"path": "Claim.item.detail.subDetail.net",
"short": "Net additional item cost",
"definition": "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 supplied.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "Claim.item.detail.subDetail.udi",
"path": "Claim.item.detail.subDetail.udi",
"short": "Unique Device Identifier",
"definition": "List of Unique Device Identifiers associated with this line item.",
"requirements": "The UDI code and issuer if applicable for the supplied product.",
"min": 0,
"max": "*",
"type": [
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Device"
}
]
},
{
"id": "Claim.item.prosthesis",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Prosthesis"
}
],
"path": "Claim.item.prosthesis",
"short": "Prosthetic details",
"definition": "The materials and placement date of prior fixed prosthesis.",
"min": 0,
"max": "1",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "Claim.item.prosthesis.id",
"path": "Claim.item.prosthesis.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "*"
},
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Claim.item.prosthesis.extension",
"path": "Claim.item.prosthesis.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Claim.item.prosthesis.modifierExtension",
"path": "Claim.item.prosthesis.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "Claim.item.prosthesis.initial",
"path": "Claim.item.prosthesis.initial",
"short": "Is this the initial service",
"definition": "Indicates whether this is the initial placement of a fixed prosthesis.",
"requirements": "May impact on adjudication.",
"min": 0,
"max": "1",
"type": [
{
"code": "boolean"
}
]
},
{
"id": "Claim.item.prosthesis.priorDate",
"path": "Claim.item.prosthesis.priorDate",
"short": "Initial service Date",
"definition": "Date of the initial placement.",
"requirements": "May impact on adjudication.",
"min": 0,
"max": "1",
"type": [
{
"code": "date"
}
]
},
{
"id": "Claim.item.prosthesis.priorMaterial",
"path": "Claim.item.prosthesis.priorMaterial",
"short": "Prosthetic Material",
"definition": "Material of the prior denture or bridge prosthesis. (Oral).",
"requirements": "May impact on adjudication.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "Material of the prior denture or bridge prosthesis. (Oral)",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/oral-prosthodontic-material"
}
}
},
{
"id": "Claim.total",
"path": "Claim.total",
"short": "Total claim cost",
"definition": "The total value of the claim.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "Claim.missingTeeth",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "MissingTeeth"
}
],
"path": "Claim.missingTeeth",
"short": "Only if type = oral",
"definition": "A list of teeth which would be expected but are not found due to having been previously extracted or for other reasons.",
"requirements": "The list of missing teeth may influence the adjudication of services for example with Bridges.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "Claim.missingTeeth.id",
"path": "Claim.missingTeeth.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "*"
},
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Claim.missingTeeth.extension",
"path": "Claim.missingTeeth.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Claim.missingTeeth.modifierExtension",
"path": "Claim.missingTeeth.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "Claim.missingTeeth.tooth",
"path": "Claim.missingTeeth.tooth",
"short": "Tooth Code",
"definition": "The code identifying which tooth is missing.",
"requirements": "Provides the tooth number of the missing tooth.",
"min": 1,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "The codes for the teeth, subset of OralSites",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/teeth"
}
}
},
{
"id": "Claim.missingTeeth.reason",
"path": "Claim.missingTeeth.reason",
"short": "Indicates whether it was extracted or other reason",
"definition": "Missing reason may be: E-extraction, O-other.",
"requirements": "Provides the reason for the missing tooth.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "Reason codes for the missing teeth",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/missing-tooth-reason"
}
}
},
{
"id": "Claim.missingTeeth.extractionDate",
"path": "Claim.missingTeeth.extractionDate",
"short": "Date tooth was extracted if known",
"definition": "The date of the extraction either known from records or patient reported estimate.",
"requirements": "Some services and adjudications require this information.",
"min": 0,
"max": "1",
"type": [
{
"code": "date"
}
]
}
]
},
"differential": {
"element": [
{
"id": "Claim",
"path": "Claim",
"short": "Claim, Pre-determination or Pre-authorization",
"definition": "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.",
"min": 0,
"max": "*",
"mapping": [
{
"identity": "w5",
"map": "financial.billing"
}
]
},
{
"id": "Claim.identifier",
"path": "Claim.identifier",
"short": "Claim number",
"definition": "The business identifier for the instance: claim number, pre-determination or pre-authorization number.",
"min": 0,
"max": "*",
"type": [
{
"code": "Identifier"
}
],
"mapping": [
{
"identity": "w5",
"map": "id"
}
]
},
{
"id": "Claim.status",
"path": "Claim.status",
"short": "active | cancelled | draft | entered-in-error",
"definition": "The status of the resource instance.",
"min": 1,
"max": "1",
"type": [
{
"code": "code"
}
],
"isModifier": true,
"isSummary": true,
"binding": {
"strength": "required",
"description": "A code specifying the state of the resource instance.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-status"
}
},
"mapping": [
{
"identity": "w5",
"map": "status"
}
]
},
{
"id": "Claim.type",
"path": "Claim.type",
"short": "Type or discipline",
"definition": "The category of claim, eg, oral, pharmacy, vision, insitutional, professional.",
"comments": "Affects which fields and value sets are used.",
"min": 1,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "required",
"description": "The type or discipline-style of the claim",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-type"
}
},
"mapping": [
{
"identity": "w5",
"map": "class"
}
]
},
{
"id": "Claim.subType",
"path": "Claim.subType",
"short": "Finer grained claim type information",
"definition": "A finer grained suite of claim subtype codes which may convey Inpatient vs Outpatient and/or a specialty service. In the US the BillType.",
"comments": "This may contain the local bill type codes such as the US UB-04 bill type code.",
"min": 0,
"max": "*",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "A more granular claim typecode",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-subtype"
}
},
"mapping": [
{
"identity": "w5",
"map": "class"
}
]
},
{
"id": "Claim.ruleset",
"path": "Claim.ruleset",
"short": "Current specification followed",
"definition": "The version of the specification on which this instance relies.",
"alias": [
"BusinessVersion"
],
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "The static and dynamic model to which contents conform, which may be business version or standard/version.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ruleset"
}
},
"mapping": [
{
"identity": "w5",
"map": "id.version"
}
]
},
{
"id": "Claim.originalRuleset",
"path": "Claim.originalRuleset",
"short": "Original specification followed",
"definition": "The version of the specification from which the original instance was created.",
"alias": [
"OriginalBusinessVersion"
],
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "The static and dynamic model to which contents conform, which may be business version or standard/version.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ruleset"
}
}
},
{
"id": "Claim.created",
"path": "Claim.created",
"short": "Creation date",
"definition": "The date when the enclosed suite of services were performed or completed.",
"min": 0,
"max": "1",
"type": [
{
"code": "dateTime"
}
],
"mapping": [
{
"identity": "w5",
"map": "when.recorded"
}
]
},
{
"id": "Claim.billablePeriod",
"path": "Claim.billablePeriod",
"short": "Period for charge submission",
"definition": "The billable period for which charges are being submitted.",
"min": 0,
"max": "1",
"type": [
{
"code": "Period"
}
],
"mapping": [
{
"identity": "w5",
"map": "when.done"
}
]
},
{
"id": "Claim.insurer[x]",
"path": "Claim.insurer[x]",
"short": "Target",
"definition": "The Insurer who is target of the request.",
"min": 0,
"max": "1",
"type": [
{
"code": "Identifier"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Organization"
}
]
},
{
"id": "Claim.provider[x]",
"path": "Claim.provider[x]",
"short": "Responsible provider",
"definition": "The provider which is responsible for the bill, claim pre-determination, pre-authorization.",
"min": 0,
"max": "1",
"type": [
{
"code": "Identifier"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Practitioner"
}
],
"mapping": [
{
"identity": "w5",
"map": "who.source"
}
]
},
{
"id": "Claim.organization[x]",
"path": "Claim.organization[x]",
"short": "Responsible organization",
"definition": "The organization which is responsible for the bill, claim pre-determination, pre-authorization.",
"min": 0,
"max": "1",
"type": [
{
"code": "Identifier"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Organization"
}
],
"mapping": [
{
"identity": "w5",
"map": "who.source"
}
]
},
{
"id": "Claim.use",
"path": "Claim.use",
"short": "complete | proposed | exploratory | other",
"definition": "Complete (Bill or Claim), Proposed (Pre-Authorization), Exploratory (Pre-determination).",
"min": 0,
"max": "1",
"type": [
{
"code": "code"
}
],
"binding": {
"strength": "required",
"description": "Complete, proposed, exploratory, other",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-use"
}
},
"mapping": [
{
"identity": "w5",
"map": "class"
}
]
},
{
"id": "Claim.priority",
"path": "Claim.priority",
"short": "Desired processing priority",
"definition": "Immediate (STAT), best effort (NORMAL), deferred (DEFER).",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "The timeliness with which processing is required: STAT, normal, Deferred",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/process-priority"
}
}
},
{
"id": "Claim.fundsReserve",
"path": "Claim.fundsReserve",
"short": "Funds requested to be reserved",
"definition": "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 requested.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "For whom funds are to be reserved: (Patient, Provider, None).",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/fundsreserve"
}
}
},
{
"id": "Claim.enterer[x]",
"path": "Claim.enterer[x]",
"short": "Author",
"definition": "Person who created the invoice/claim/pre-determination or pre-authorization.",
"min": 0,
"max": "1",
"type": [
{
"code": "Identifier"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Practitioner"
}
],
"mapping": [
{
"identity": "w5",
"map": "who.author"
}
]
},
{
"id": "Claim.facility[x]",
"path": "Claim.facility[x]",
"short": "Servicing Facility",
"definition": "Facility where the services were provided.",
"min": 0,
"max": "1",
"type": [
{
"code": "Identifier"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Location"
}
],
"mapping": [
{
"identity": "w5",
"map": "where"
}
]
},
{
"id": "Claim.related",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "RelatedClaim"
}
],
"path": "Claim.related",
"short": "Related Claims which may be revelant to processing this claimn",
"definition": "Other claims which are related to this claim such as prior claim versions or for related services.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "Claim.related.claim[x]",
"path": "Claim.related.claim[x]",
"short": "Reference to the related claim",
"definition": "Other claims which are related to this claim such as prior claim versions or for related services.",
"comments": "Do we need a relationship code?",
"min": 0,
"max": "1",
"type": [
{
"code": "Identifier"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Claim"
}
]
},
{
"id": "Claim.related.relationship",
"path": "Claim.related.relationship",
"short": "How the reference claim is related",
"definition": "For example prior or umbrella.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "Relationship of this claim to a related Claim",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/related-claim-relationship"
}
}
},
{
"id": "Claim.related.reference",
"path": "Claim.related.reference",
"short": "Related file or case reference",
"definition": "An alternate organizational reference to the case or file to which this particular claim pertains - eg Property/Casualy insurer claim # or Workers Compensation case # .",
"min": 0,
"max": "1",
"type": [
{
"code": "Identifier"
}
]
},
{
"id": "Claim.prescription[x]",
"path": "Claim.prescription[x]",
"short": "Prescription",
"definition": "Prescription to support the dispensing of Pharmacy or Vision products.",
"comments": "Should we create a group to hold multiple prescriptions and add a sequence number and on the line items a link to the sequence.",
"requirements": "For type=Pharmacy and Vision only.",
"min": 0,
"max": "1",
"type": [
{
"code": "Identifier"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/MedicationOrder"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/VisionPrescription"
}
]
},
{
"id": "Claim.originalPrescription[x]",
"path": "Claim.originalPrescription[x]",
"short": "Original Prescription",
"definition": "Original prescription which has been superceded by this prescription to support the dispensing of pharmacy services, medications or products.",
"comments": "as above.",
"min": 0,
"max": "1",
"type": [
{
"code": "Identifier"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/MedicationOrder"
}
]
},
{
"id": "Claim.payee",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Payee"
}
],
"path": "Claim.payee",
"short": "Party to be paid any benefits payable",
"definition": "The party to be reimbursed for the services.",
"min": 0,
"max": "1",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "Claim.payee.type",
"path": "Claim.payee.type",
"short": "Type of party: Subscriber, Provider, other",
"definition": "Type of Party to be reimbursed: Subscriber, provider, other.",
"min": 1,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "A code for the party to be reimbursed.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/payeetype"
}
}
},
{
"id": "Claim.payee.resourceType",
"path": "Claim.payee.resourceType",
"short": "organization | patient | practitioner | relatedperson",
"definition": "organization | patient | practitioner | relatedperson.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "The type of payee Resource",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-payee-resource-type"
}
}
},
{
"id": "Claim.payee.party[x]",
"path": "Claim.payee.party[x]",
"short": "Party to receive the payable",
"definition": "Party to be reimbursed: Subscriber, provider, other.",
"min": 0,
"max": "1",
"type": [
{
"code": "Identifier"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Practitioner"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Organization"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Patient"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/RelatedPerson"
}
]
},
{
"id": "Claim.referral[x]",
"path": "Claim.referral[x]",
"short": "Treatment Referral",
"definition": "The referral resource which lists the date, practitioner, reason and other supporting information.",
"min": 0,
"max": "1",
"type": [
{
"code": "Identifier"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/ReferralRequest"
}
],
"mapping": [
{
"identity": "w5",
"map": "who.cause"
}
]
},
{
"id": "Claim.information",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "SpecialCondition"
}
],
"path": "Claim.information",
"definition": "Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. Often there are mutiple jurisdiction specific valuesets which are required.",
"requirements": "Typically these information codes are required to support the services rendered or the adjudication of the services rendered.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "Claim.information.category",
"path": "Claim.information.category",
"short": "Category of information",
"definition": "The general class of the information supplied: information; exception; accident, employment; onset, etc.",
"comments": "This may contain the local bill type codes such as the US UB-04 bill type code.",
"min": 1,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "The valuset used for additional information category codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-informationcategory"
}
}
},
{
"id": "Claim.information.code",
"path": "Claim.information.code",
"short": "Type of information",
"definition": "System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought which may influence the adjudication.",
"comments": "This may contain the local bill type codes such as the US UB-04 bill type code.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "The valuset used for additional information codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-exception"
}
}
},
{
"id": "Claim.information.timing[x]",
"path": "Claim.information.timing[x]",
"short": "When it occurred",
"definition": "The date when or period to which this information refers.",
"min": 0,
"max": "1",
"type": [
{
"code": "date"
},
{
"code": "Period"
}
]
},
{
"id": "Claim.information.value[x]",
"path": "Claim.information.value[x]",
"short": "Additional Data",
"definition": "Additional data.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
},
{
"code": "Quantity"
}
]
},
{
"id": "Claim.diagnosis",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Diagnosis"
}
],
"path": "Claim.diagnosis",
"short": "Diagnosis",
"definition": "Ordered list of patient diagnosis for which care is sought.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "Claim.diagnosis.sequence",
"path": "Claim.diagnosis.sequence",
"short": "Number to covey order of diagnosis",
"definition": "Sequence of diagnosis which serves to order and provide a link.",
"requirements": "Required to maintain order of the diagnoses.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "Claim.diagnosis.diagnosis",
"path": "Claim.diagnosis.diagnosis",
"short": "Patient's diagnosis",
"definition": "The diagnosis.",
"requirements": "Required to adjudicate services rendered to condition presented.",
"min": 1,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "ICD10 Diagnostic codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/icd-10"
}
}
},
{
"id": "Claim.diagnosis.type",
"path": "Claim.diagnosis.type",
"short": "Type of Diagnosis",
"definition": "The type of the Diagnosis, for example: admitting,.",
"comments": "Diagnosis are presented in list order to their expected importance: primary, secondary, etc.",
"requirements": "Required to adjudicate services rendered to the mandated diagnosis grouping system.",
"min": 0,
"max": "*",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "The type of the diagnosis: admitting, principal, discharge",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-diagnosistype"
}
}
},
{
"id": "Claim.diagnosis.drg",
"path": "Claim.diagnosis.drg",
"short": "Diagnosis Related Group",
"definition": "The Diagnosis Related Group (DRG) code based on the assigned grouping code system.",
"requirements": "Required to adjudicate services rendered to the mandated diagnosis grouping system.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "The DRG codes associated with the diagnosis",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup"
}
}
},
{
"id": "Claim.procedure",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Procedure"
}
],
"path": "Claim.procedure",
"short": "Procedures performed",
"definition": "Ordered list of patient procedures performed to support the adjudication.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "Claim.procedure.sequence",
"path": "Claim.procedure.sequence",
"short": "Procedure sequence for reference",
"definition": "Sequence of procedures which serves to order and provide a link.",
"requirements": "Required to maintain order of the procudures.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "Claim.procedure.date",
"path": "Claim.procedure.date",
"short": "When the procedure was performed",
"definition": "Date and optionally time the procedure was performed .",
"comments": "SB DateTime??",
"requirements": "Required to adjudicate services rendered.",
"min": 0,
"max": "1",
"type": [
{
"code": "dateTime"
}
]
},
{
"id": "Claim.procedure.procedure[x]",
"path": "Claim.procedure.procedure[x]",
"short": "Patient's list of procedures performed",
"definition": "The procedure code.",
"requirements": "Required to adjudicate services rendered.",
"min": 1,
"max": "1",
"type": [
{
"code": "Coding"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Procedure"
}
],
"binding": {
"strength": "example",
"description": "ICD10 Procedure codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/icd-10-procedures"
}
}
},
{
"id": "Claim.patient[x]",
"path": "Claim.patient[x]",
"short": "The subject of the Products and Services",
"definition": "Patient Resource.",
"min": 1,
"max": "1",
"type": [
{
"code": "Identifier"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Patient"
}
],
"mapping": [
{
"identity": "w5",
"map": "who.focus"
}
]
},
{
"id": "Claim.coverage",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Coverage"
}
],
"path": "Claim.coverage",
"short": "Insurance or medical plan",
"definition": "Financial instrument by which payment information for health care.",
"requirements": "Health care programs and insurers are significant payors of health service costs.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"mapping": [
{
"identity": "rim",
"map": "Coverage"
}
]
},
{
"id": "Claim.coverage.sequence",
"path": "Claim.coverage.sequence",
"short": "Service instance identifier",
"definition": "A service line item.",
"requirements": "To maintain order of the coverages.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "Claim.coverage.focal",
"path": "Claim.coverage.focal",
"short": "Is the focal Coverage",
"definition": "The instance number of the Coverage which is the focus for adjudication. The Coverage against which the claim is to be adjudicated.",
"requirements": "To identify which coverage is being adjudicated.",
"min": 1,
"max": "1",
"type": [
{
"code": "boolean"
}
]
},
{
"id": "Claim.coverage.coverage[x]",
"path": "Claim.coverage.coverage[x]",
"short": "Insurance information",
"definition": "Reference to the program or plan identification, underwriter or payor.",
"requirements": "Need to identify the issuer to target for processing and for coordination of benefit processing.",
"min": 1,
"max": "1",
"type": [
{
"code": "Identifier"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Coverage"
}
]
},
{
"id": "Claim.coverage.businessArrangement",
"path": "Claim.coverage.businessArrangement",
"short": "Business agreement",
"definition": "The contract number of a business agreement which describes the terms and conditions.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
]
},
{
"id": "Claim.coverage.preAuthRef",
"path": "Claim.coverage.preAuthRef",
"short": "Pre-Authorization/Determination Reference",
"definition": "A list of references from the Insurer to which these services pertain.",
"requirements": "To provide any pre=determination or prior authorization reference.",
"min": 0,
"max": "*",
"type": [
{
"code": "string"
}
]
},
{
"id": "Claim.coverage.claimResponse",
"path": "Claim.coverage.claimResponse",
"short": "Adjudication results",
"definition": "The Coverages adjudication details.",
"requirements": "Used by downstream payers to determine what balance remains and the net payable.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/ClaimResponse"
}
]
},
{
"id": "Claim.coverage.originalRuleset",
"path": "Claim.coverage.originalRuleset",
"short": "Original version",
"definition": "The style (standard) and version of the original material which was converted into this resource.",
"requirements": "Knowledge of the original version can inform the processing of this instance so that information which is processable by the originating system may be generated.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "The static and dynamic model to which contents conform, which may be business version or standard/version.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ruleset"
}
}
},
{
"id": "Claim.accident",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Accident"
}
],
"path": "Claim.accident",
"definition": "An accident which resulted in the need for healthcare services.",
"min": 0,
"max": "1",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "Claim.accident.date",
"path": "Claim.accident.date",
"short": "When the accident occurred\nsee information codes\nsee information codes",
"definition": "Date of an accident which these services are addressing.",
"requirements": "Coverage may be dependant on accidents.",
"min": 1,
"max": "1",
"type": [
{
"code": "date"
}
]
},
{
"id": "Claim.accident.type",
"path": "Claim.accident.type",
"short": "The nature of the accident",
"definition": "Type of accident: work, auto, etc.",
"requirements": "Coverage may be dependant on the type of accident.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "required",
"description": "Type of accident: work place, auto, etc.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/v3-ActIncidentCode"
}
}
},
{
"id": "Claim.accident.location[x]",
"path": "Claim.accident.location[x]",
"short": "Accident Place",
"definition": "Accident Place.",
"min": 0,
"max": "1",
"type": [
{
"code": "Address"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Location"
}
]
},
{
"id": "Claim.employmentImpacted",
"path": "Claim.employmentImpacted",
"short": "Period unable to work",
"definition": "The start and optional end dates of when the patient was precluded from working due to the treatable condition(s).",
"min": 0,
"max": "1",
"type": [
{
"code": "Period"
}
]
},
{
"id": "Claim.hospitalization",
"path": "Claim.hospitalization",
"short": "Period in hospital",
"definition": "The start and optional end dates of when the patient was confined to a treatment center.",
"min": 0,
"max": "1",
"type": [
{
"code": "Period"
}
]
},
{
"id": "Claim.item",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Item"
}
],
"path": "Claim.item",
"short": "Goods and Services",
"definition": "First tier of goods and services.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "Claim.item.sequence",
"path": "Claim.item.sequence",
"short": "Service instance",
"definition": "A service line number.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "Claim.item.careTeam",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "CareTeam"
}
],
"path": "Claim.item.careTeam",
"definition": "The members of the team who provided the overall service as well as their role and whether responsible and qualifications.",
"requirements": "Role and Responsible may not be required when there is only a single provider listed.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "Claim.item.careTeam.provider[x]",
"path": "Claim.item.careTeam.provider[x]",
"short": "Provider individual or organization",
"definition": "Member of the team who provided the overall service.",
"min": 1,
"max": "1",
"type": [
{
"code": "Identifier"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Practitioner"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Organization"
}
],
"mapping": [
{
"identity": "w5",
"map": "who.actor"
}
]
},
{
"id": "Claim.item.careTeam.responsible",
"path": "Claim.item.careTeam.responsible",
"short": "Billing provider",
"definition": "The party who is billing and responsible for the claimed good or service rendered to the patient.",
"min": 0,
"max": "1",
"type": [
{
"code": "boolean"
}
]
},
{
"id": "Claim.item.careTeam.role",
"path": "Claim.item.careTeam.role",
"short": "Role on the team",
"definition": "The lead, assisting or supervising practitioner and their discipline if a multidisiplinary team.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "The role codes for the care team members.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-careteamrole"
}
}
},
{
"id": "Claim.item.careTeam.qualification",
"path": "Claim.item.careTeam.qualification",
"short": "Type, classification or Specialization",
"definition": "The qualification which is applicable for this service.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "Provider professional qualifications",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/provider-qualification"
}
}
},
{
"id": "Claim.item.diagnosisLinkId",
"path": "Claim.item.diagnosisLinkId",
"short": "Applicable diagnoses",
"definition": "Diagnosis applicable for this service or product line.",
"min": 0,
"max": "*",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "Claim.item.revenue",
"path": "Claim.item.revenue",
"short": "Revenue or cost center code",
"definition": "The type of reveneu or cost center providing the product and/or service.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "Codes for the revenue or cost centers supplying the service and/or products.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-revenue-center"
}
}
},
{
"id": "Claim.item.category",
"path": "Claim.item.category",
"short": "Type of service or product",
"definition": "Health Care Service Type Codes to identify the classification of service or benefits.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "Benefit subcategories such as: oral-basic, major, glasses",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-subcategory"
}
}
},
{
"id": "Claim.item.service",
"path": "Claim.item.service",
"short": "Billing Code",
"definition": "If this is an actual service or product line, ie. not a Group, then use code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "Allowable service and product codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
}
},
{
"id": "Claim.item.modifier",
"path": "Claim.item.modifier",
"short": "Service/Product billing modifiers",
"definition": "Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.",
"requirements": "May impact on adjudication.",
"min": 0,
"max": "*",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-modifiers"
}
}
},
{
"id": "Claim.item.programCode",
"path": "Claim.item.programCode",
"short": "Program specific reason for item inclusion",
"definition": "For programs which require reason codes for the inclusion or covering of this billed item under the program or sub-program.",
"min": 0,
"max": "*",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "Program specific reason codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-program-code"
}
}
},
{
"id": "Claim.item.serviced[x]",
"path": "Claim.item.serviced[x]",
"short": "Date or dates of Service",
"definition": "The date or dates when the enclosed suite of services were performed or completed.",
"min": 0,
"max": "1",
"type": [
{
"code": "date"
},
{
"code": "Period"
}
],
"mapping": [
{
"identity": "w5",
"map": "when.done"
}
]
},
{
"id": "Claim.item.location[x]",
"path": "Claim.item.location[x]",
"short": "Place of service",
"definition": "Where the service was provided.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
},
{
"code": "Address"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Location"
}
],
"binding": {
"strength": "example",
"description": "Place of service: pharmcy,school, prison, etc.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-place"
}
},
"mapping": [
{
"identity": "w5",
"map": "where"
}
]
},
{
"id": "Claim.item.quantity",
"path": "Claim.item.quantity",
"short": "Count of Products or Services",
"definition": "The number of repetitions of a service or product.",
"min": 0,
"max": "1",
"type": [
{
"code": "Quantity",
"profile": "http://hl7.org/fhir/StructureDefinition/SimpleQuantity"
}
]
},
{
"id": "Claim.item.unitPrice",
"path": "Claim.item.unitPrice",
"short": "Fee, charge or cost per point",
"definition": "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 group.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "Claim.item.factor",
"path": "Claim.item.factor",
"short": "Price scaling factor",
"definition": "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.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "decimal"
}
]
},
{
"id": "Claim.item.points",
"path": "Claim.item.points",
"short": "Difficulty scaling factor",
"definition": "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 point.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "decimal"
}
]
},
{
"id": "Claim.item.net",
"path": "Claim.item.net",
"short": "Total item cost",
"definition": "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 supplied.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "Claim.item.udi",
"path": "Claim.item.udi",
"short": "Unique Device Identifier",
"definition": "List of Unique Device Identifiers associated with this line item.",
"requirements": "The UDI code and issuer if applicable for the supplied product.",
"min": 0,
"max": "*",
"type": [
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Device"
}
]
},
{
"id": "Claim.item.bodySite",
"path": "Claim.item.bodySite",
"short": "Service Location",
"definition": "Physical service site on the patient (limb, tooth, etc).",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "The code for the teeth, quadrant, sextant and arch",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/tooth"
}
}
},
{
"id": "Claim.item.subSite",
"path": "Claim.item.subSite",
"short": "Service Sub-location",
"definition": "A region or surface of the site, eg. limb region or tooth surface(s).",
"min": 0,
"max": "*",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "The code for the tooth surface and surface combinations",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/surface"
}
}
},
{
"id": "Claim.item.detail",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Detail"
}
],
"path": "Claim.item.detail",
"short": "Additional items",
"definition": "Second tier of goods and services.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "Claim.item.detail.sequence",
"path": "Claim.item.detail.sequence",
"short": "Service instance",
"definition": "A service line number.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "Claim.item.detail.revenue",
"path": "Claim.item.detail.revenue",
"short": "Revenue or cost center code",
"definition": "The type of reveneu or cost center providing the product and/or service.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "Codes for the revenue or cost centers supplying the service and/or products.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-revenue-center"
}
}
},
{
"id": "Claim.item.detail.category",
"path": "Claim.item.detail.category",
"short": "Type of service or product",
"definition": "Health Care Service Type Codes to identify the classification of service or benefits.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "Benefit subcategories such as: oral-basic, major, glasses",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-subcategory"
}
}
},
{
"id": "Claim.item.detail.service",
"path": "Claim.item.detail.service",
"short": "Billing Code",
"definition": "If this is an actual service or product line, ie. not a Group, then use code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "Allowable service and product codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
}
},
{
"id": "Claim.item.detail.modifier",
"path": "Claim.item.detail.modifier",
"short": "Service/Product billing modifiers",
"definition": "Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.",
"requirements": "May impact on adjudication.",
"min": 0,
"max": "*",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-modifiers"
}
}
},
{
"id": "Claim.item.detail.programCode",
"path": "Claim.item.detail.programCode",
"short": "Program specific reason for item inclusion",
"definition": "For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program.",
"min": 0,
"max": "*",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "Program specific reason codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-program-code"
}
}
},
{
"id": "Claim.item.detail.quantity",
"path": "Claim.item.detail.quantity",
"short": "Count of Products or Services",
"definition": "The number of repetitions of a service or product.",
"min": 0,
"max": "1",
"type": [
{
"code": "Quantity",
"profile": "http://hl7.org/fhir/StructureDefinition/SimpleQuantity"
}
]
},
{
"id": "Claim.item.detail.unitPrice",
"path": "Claim.item.detail.unitPrice",
"short": "Fee, charge or cost per point",
"definition": "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 group.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "Claim.item.detail.factor",
"path": "Claim.item.detail.factor",
"short": "Price scaling factor",
"definition": "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.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "decimal"
}
]
},
{
"id": "Claim.item.detail.points",
"path": "Claim.item.detail.points",
"short": "Difficulty scaling factor",
"definition": "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 point.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "decimal"
}
]
},
{
"id": "Claim.item.detail.net",
"path": "Claim.item.detail.net",
"short": "Total additional item cost",
"definition": "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 supplied.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "Claim.item.detail.udi",
"path": "Claim.item.detail.udi",
"short": "Unique Device Identifier",
"definition": "List of Unique Device Identifiers associated with this line item.",
"requirements": "The UDI code and issuer if applicable for the supplied product.",
"min": 0,
"max": "*",
"type": [
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Device"
}
]
},
{
"id": "Claim.item.detail.subDetail",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "SubDetail"
}
],
"path": "Claim.item.detail.subDetail",
"short": "Additional items",
"definition": "Third tier of goods and services.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "Claim.item.detail.subDetail.sequence",
"path": "Claim.item.detail.subDetail.sequence",
"short": "Service instance",
"definition": "A service line number.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "Claim.item.detail.subDetail.revenue",
"path": "Claim.item.detail.subDetail.revenue",
"short": "Revenue or cost center code",
"definition": "The type of reveneu or cost center providing the product and/or service.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "Codes for the revenue or cost centers supplying the service and/or products.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-revenue-center"
}
}
},
{
"id": "Claim.item.detail.subDetail.category",
"path": "Claim.item.detail.subDetail.category",
"short": "Type of service or product",
"definition": "Health Care Service Type Codes to identify the classification of service or benefits.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "Benefit subcategories such as: oral-basic, major, glasses",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-subcategory"
}
}
},
{
"id": "Claim.item.detail.subDetail.service",
"path": "Claim.item.detail.subDetail.service",
"short": "Billing Code",
"definition": "A code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI).",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "Allowable service and product codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
}
},
{
"id": "Claim.item.detail.subDetail.modifier",
"path": "Claim.item.detail.subDetail.modifier",
"short": "Service/Product billing modifiers",
"definition": "Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.",
"requirements": "May impact on adjudication.",
"min": 0,
"max": "*",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-modifiers"
}
}
},
{
"id": "Claim.item.detail.subDetail.programCode",
"path": "Claim.item.detail.subDetail.programCode",
"short": "Program specific reason for item inclusion",
"definition": "For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program.",
"min": 0,
"max": "*",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "Program specific reason codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-program-code"
}
}
},
{
"id": "Claim.item.detail.subDetail.quantity",
"path": "Claim.item.detail.subDetail.quantity",
"short": "Count of Products or Services",
"definition": "The number of repetitions of a service or product.",
"min": 0,
"max": "1",
"type": [
{
"code": "Quantity",
"profile": "http://hl7.org/fhir/StructureDefinition/SimpleQuantity"
}
]
},
{
"id": "Claim.item.detail.subDetail.unitPrice",
"path": "Claim.item.detail.subDetail.unitPrice",
"short": "Fee, charge or cost per point",
"definition": "The fee for an addittional service or product or charge.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "Claim.item.detail.subDetail.factor",
"path": "Claim.item.detail.subDetail.factor",
"short": "Price scaling factor",
"definition": "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.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "decimal"
}
]
},
{
"id": "Claim.item.detail.subDetail.points",
"path": "Claim.item.detail.subDetail.points",
"short": "Difficulty scaling factor",
"definition": "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 point.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "decimal"
}
]
},
{
"id": "Claim.item.detail.subDetail.net",
"path": "Claim.item.detail.subDetail.net",
"short": "Net additional item cost",
"definition": "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 supplied.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "Claim.item.detail.subDetail.udi",
"path": "Claim.item.detail.subDetail.udi",
"short": "Unique Device Identifier",
"definition": "List of Unique Device Identifiers associated with this line item.",
"requirements": "The UDI code and issuer if applicable for the supplied product.",
"min": 0,
"max": "*",
"type": [
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Device"
}
]
},
{
"id": "Claim.item.prosthesis",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Prosthesis"
}
],
"path": "Claim.item.prosthesis",
"short": "Prosthetic details",
"definition": "The materials and placement date of prior fixed prosthesis.",
"min": 0,
"max": "1",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "Claim.item.prosthesis.initial",
"path": "Claim.item.prosthesis.initial",
"short": "Is this the initial service",
"definition": "Indicates whether this is the initial placement of a fixed prosthesis.",
"requirements": "May impact on adjudication.",
"min": 0,
"max": "1",
"type": [
{
"code": "boolean"
}
]
},
{
"id": "Claim.item.prosthesis.priorDate",
"path": "Claim.item.prosthesis.priorDate",
"short": "Initial service Date",
"definition": "Date of the initial placement.",
"requirements": "May impact on adjudication.",
"min": 0,
"max": "1",
"type": [
{
"code": "date"
}
]
},
{
"id": "Claim.item.prosthesis.priorMaterial",
"path": "Claim.item.prosthesis.priorMaterial",
"short": "Prosthetic Material",
"definition": "Material of the prior denture or bridge prosthesis. (Oral).",
"requirements": "May impact on adjudication.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "Material of the prior denture or bridge prosthesis. (Oral)",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/oral-prosthodontic-material"
}
}
},
{
"id": "Claim.total",
"path": "Claim.total",
"short": "Total claim cost",
"definition": "The total value of the claim.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "Claim.missingTeeth",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "MissingTeeth"
}
],
"path": "Claim.missingTeeth",
"short": "Only if type = oral",
"definition": "A list of teeth which would be expected but are not found due to having been previously extracted or for other reasons.",
"requirements": "The list of missing teeth may influence the adjudication of services for example with Bridges.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "Claim.missingTeeth.tooth",
"path": "Claim.missingTeeth.tooth",
"short": "Tooth Code",
"definition": "The code identifying which tooth is missing.",
"requirements": "Provides the tooth number of the missing tooth.",
"min": 1,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "The codes for the teeth, subset of OralSites",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/teeth"
}
}
},
{
"id": "Claim.missingTeeth.reason",
"path": "Claim.missingTeeth.reason",
"short": "Indicates whether it was extracted or other reason",
"definition": "Missing reason may be: E-extraction, O-other.",
"requirements": "Provides the reason for the missing tooth.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"strength": "example",
"description": "Reason codes for the missing teeth",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/missing-tooth-reason"
}
}
},
{
"id": "Claim.missingTeeth.extractionDate",
"path": "Claim.missingTeeth.extractionDate",
"short": "Date tooth was extracted if known",
"definition": "The date of the extraction either known from records or patient reported estimate.",
"requirements": "Some services and adjudications require this information.",
"min": 0,
"max": "1",
"type": [
{
"code": "date"
}
]
}
]
}
}
Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.
© HL7.org 2011+. FHIR STU3 Ballot (v1.6.0-9663) generated on Thu, Aug 11, 2016 17:06+1000. QA Page
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