STU 3 Candidate

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

7.1.5 Resource Claim - Detailed Descriptions

Detailed Descriptions for the elements in the Claim resource.

Claim
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.

Control1..1
Summarytrue
Claim.type
Definition

The category of claim.

Control1..1
BindingClaimType: The type or discipline-style of the claim (Required)
Typecode
Summarytrue
Comments

Affects which fields and value sets are used.

Claim.subType
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.

Control0..*
BindingExample Claim SubType Codes: A more granulat claim typecode (Example)
TypeCoding
Summarytrue
Comments

This may contain the local bill type codes such as the US UB-04 bill type code.

Claim.identifier
Definition

The business identifier for the instance: claim number, pre-determination or pre-authorization number.

NoteThis is a business identifer, not a resource identifier (see discussion)
Control0..*
TypeIdentifier
Summarytrue
Claim.ruleset
Definition

The version of the specification on which this instance relies.

Control0..1
BindingRuleset Codes: The static and dynamic model to which contents conform, which may be business version or standard/version. (Example)
TypeCoding
Alternate NamesBusinessVersion
Summarytrue
Claim.originalRuleset
Definition

The version of the specification from which the original instance was created.

Control0..1
BindingRuleset Codes: The static and dynamic model to which contents conform, which may be business version or standard/version. (Example)
TypeCoding
Alternate NamesOriginalBusinessVersion
Summarytrue
Claim.created
Definition

The date when the enclosed suite of services were performed or completed.

Control0..1
TypedateTime
Summarytrue
Claim.billablePeriod
Definition

The billable period for which charges are being submitted.

Control0..1
TypePeriod
Summarytrue
Claim.target[x]
Definition

Insurer Identifier, typical BIN number (6 digit).

Control0..1
TypeIdentifier|Reference(Organization)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Summarytrue
Claim.provider[x]
Definition

The provider which is responsible for the bill, claim pre-determination, pre-authorization.

Control0..1
TypeIdentifier|Reference(Practitioner)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Summarytrue
Claim.organization[x]
Definition

The organization which is responsible for the bill, claim pre-determination, pre-authorization.

Control0..1
TypeIdentifier|Reference(Organization)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Summarytrue
Claim.use
Definition

Complete (Bill or Claim), Proposed (Pre-Authorization), Exploratory (Pre-determination).

Control0..1
BindingUse: Complete, proposed, exploratory, other (Required)
Typecode
Summarytrue
Claim.priority
Definition

Immediate (STAT), best effort (NORMAL), deferred (DEFER).

Control0..1
BindingPriority Codes: The timeliness with which processing is required: STAT, normal, Deferred (Example)
TypeCoding
Summarytrue
Claim.fundsReserve
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.

Control0..1
BindingFunds Reservation Codes: For whom funds are to be reserved: (Patient, Provider, None). (Example)
TypeCoding
Summarytrue
Claim.enterer[x]
Definition

Person who created the invoice/claim/pre-determination or pre-authorization.

Control0..1
TypeIdentifier|Reference(Practitioner)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Summarytrue
Claim.facility[x]
Definition

Facility where the services were provided.

Control0..1
TypeIdentifier|Reference(Location)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Summarytrue
Claim.related
Definition

Other claims which are related to this claim such as prior claim versions or for related services.

Control0..*
Summarytrue
Claim.related.claim[x]
Definition

Other claims which are related to this claim such as prior claim versions or for related services.

Control0..1
TypeIdentifier|Reference(Claim)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Summarytrue
Comments

Do we need a relationship code?

Claim.related.relationship
Definition

For example prior or umbrella.

Control0..1
BindingExample Related Claim Relationship Codes: Relationship of this claim to a related Claim (Example)
TypeCoding
Summarytrue
Claim.related.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 # .

Control0..1
TypeIdentifier
Summarytrue
Claim.prescription[x]
Definition

Prescription to support the dispensing of Pharmacy or Vision products.

Control0..1
TypeIdentifier|Reference(MedicationOrder | VisionPrescription)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

For type=Pharmacy and Vision only.

Summarytrue
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.

Claim.originalPrescription[x]
Definition

Original prescription which has been superceded by this prescription to support the dispensing of pharmacy services, medications or products.

Control0..1
TypeIdentifier|Reference(MedicationOrder)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Summarytrue
Comments

as above.

Claim.payee
Definition

The party to be reimbursed for the services.

Control0..1
Summarytrue
Claim.payee.type
Definition

Type of Party to be reimbursed: Subscriber, provider, other.

Control1..1
BindingPayee Type Codes: A code for the party to be reimbursed. (Example)
TypeCoding
Summarytrue
Claim.payee.party[x]
Definition

Party to be reimbursed: Subscriber, provider, other.

Control0..1
TypeIdentifier|Reference(Practitioner | Organization | Patient | RelatedPerson)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Summarytrue
Claim.referral[x]
Definition

The referral resource which lists the date, practitioner, reason and other supporting information.

Control0..1
TypeIdentifier|Reference(ReferralRequest)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Summarytrue
Claim.occurrenceCode
Definition

**Insert definition of Occurrence codes.

Control0..*
BindingExample Occurrance Codes: Occurrence codes (Example)
TypeCoding
Summarytrue
Comments

This may contain the local bill type codes such as the US UB-04 bill type code.

Claim.occurenceSpanCode
Definition

**Insert definition of Occurrence Span codes.

Control0..*
BindingExample Occurrance Span Codes: Occurrence Span codes (Example)
TypeCoding
Summarytrue
Comments

This may contain the local bill type codes such as the US UB-04 bill type code.

Claim.valueCode
Definition

**Insert definition of Value codes.

Control0..*
BindingExample Value Codes: Value code (Example)
TypeCoding
Summarytrue
Comments

This may contain the local bill type codes such as the US UB-04 bill type code.

Claim.diagnosis
Definition

Ordered list of patient diagnosis for which care is sought.

Control0..*
Summarytrue
Claim.diagnosis.sequence
Definition

Sequence of diagnosis which serves to order and provide a link.

Control1..1
TypepositiveInt
Requirements

Required to maintain order of the diagnoses.

Summarytrue
Claim.diagnosis.diagnosis
Definition

The diagnosis.

Control1..1
BindingICD-10 Codes: ICD10 Diagnostic codes (Example)
TypeCoding
Requirements

Required to adjudicate services rendered to condition presented.

Summarytrue
Claim.procedure
Definition

Ordered list of patient procedures performed to support the adjudication.

Control0..*
Summarytrue
Claim.procedure.sequence
Definition

Sequence of procedures which serves to order and provide a link.

Control1..1
TypepositiveInt
Requirements

Required to maintain order of the procudures.

Summarytrue
Claim.procedure.date
Definition

Date and optionally time the procedure was performed .

Control0..1
TypedateTime
Requirements

Required to adjudicate services rendered.

Summarytrue
Comments

SB DateTime??

Claim.procedure.procedure[x]
Definition

The procedure code.

Control1..1
BindingICD-10 Procedure Codes: ICD10 Procedure codes (Example)
TypeCoding|Reference(Procedure)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

Required to adjudicate services rendered.

Summarytrue
Claim.specialCondition
Definition

List of special conditions relating to the setting, treatment or patient for which care is sought which may influence the adjudication.

Control0..*
BindingConditions Codes: Patient conditions and symptoms (Example)
TypeCoding
Summarytrue
Claim.patient[x]
Definition

Patient Resource.

Control1..1
TypeIdentifier|Reference(Patient)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Summarytrue
Claim.coverage
Definition

Financial instrument by which payment information for health care.

Control0..*
Requirements

Health care programs and insurers are significant payors of health service costs.

Summarytrue
Claim.coverage.sequence
Definition

A service line item.

Control1..1
TypepositiveInt
Requirements

To maintain order of the coverages.

Summarytrue
Claim.coverage.focal
Definition

The instance number of the Coverage which is the focus for adjudication. The Coverage against which the claim is to be adjudicated.

Control1..1
Typeboolean
Requirements

To identify which coverage is being adjudicated.

Summarytrue
Claim.coverage.coverage[x]
Definition

Reference to the program or plan identification, underwriter or payor.

Control1..1
TypeIdentifier|Reference(Coverage)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

Need to identify the issuer to target for processing and for coordination of benefit processing.

Summarytrue
Claim.coverage.businessArrangement
Definition

The contract number of a business agreement which describes the terms and conditions.

Control0..1
Typestring
Summarytrue
Claim.coverage.preAuthRef
Definition

A list of references from the Insurer to which these services pertain.

Control0..*
Typestring
Requirements

To provide any pre=determination or prior authorization reference.

Summarytrue
Claim.coverage.claimResponse
Definition

The Coverages adjudication details.

Control0..1
TypeReference(ClaimResponse)
Requirements

Used by downstream payers to determine what balance remains and the net payable.

Summarytrue
Claim.coverage.originalRuleset
Definition

The style (standard) and version of the original material which was converted into this resource.

Control0..1
BindingRuleset Codes: The static and dynamic model to which contents conform, which may be business version or standard/version. (Example)
TypeCoding
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.

Summarytrue
Claim.accidentDate
Definition

Date of an accident which these services are addressing.

Control0..1
Typedate
Requirements

Coverage may be dependant on accidents.

Summarytrue
Claim.accidentType
Definition

Type of accident: work, auto, etc.

Control0..1
BindingActIncidentCode: Type of accident: work place, auto, etc. (Required)
TypeCoding
Requirements

Coverage may be dependant on the type of accident.

Summarytrue
Claim.accidentLocation[x]
Definition

Accident Place.

Control0..1
TypeAddress|Reference(Location)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Summarytrue
Claim.interventionException
Definition

A list of intervention and exception codes which may influence the adjudication of the claim.

Control0..*
BindingIntervention Codes: Intervention and exception codes (Pharm) (Example)
TypeCoding
Requirements

Coverage may be modified based on exception information provided.

Summarytrue
Claim.onset
Definition

Period, start and last dates of aspects of the Condition or related services.

Control0..*
Summarytrue
Claim.onset.time[x]
Definition

The start or start and end dates for the treatable condition.

Control0..1
Typedate|Period
[x] NoteSee Choice of Data Types for further information about how to use [x]
Summarytrue
Claim.onset.type
Definition

Onset typifications eg. Start of pregnancy, start of illnes, etc.

Control0..1
BindingExample Onset Type (Reason) Codes: Condition related start, end and period codes (Example)
TypeCoding
Summarytrue
Claim.employmentImpacted
Definition

The start and optional end dates of when the patient was precluded from working due to the treatable condition(s).

Control0..1
TypePeriod
Summarytrue
Claim.hospitalization
Definition

The start and optional end dates of when the patient was confined to a treatment center.

Control0..1
TypePeriod
Summarytrue
Claim.item
Definition

First tier of goods and services.

Control0..*
Summarytrue
Claim.item.sequence
Definition

A service line number.

Control1..1
TypepositiveInt
Summarytrue
Claim.item.type
Definition

The type of product or service.

Control1..1
BindingException Codes: Group, Service, Product. (Required)
TypeCoding
Summarytrue
Claim.item.provider[x]
Definition

The practitioner who is responsible for the services rendered to the patient.

Control0..1
TypeIdentifier|Reference(Practitioner)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Summarytrue
Claim.item.supervisor[x]
Definition

The practitioner who is supervising the work of the servicing provider(s).

Control0..1
TypeIdentifier|Reference(Practitioner)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Summarytrue
Claim.item.providerQualification
Definition

The qualification which is applicable for this service.

Control0..1
BindingExample Provider Qualification Codes: Provider professional qualifications (Example)
TypeCoding
Summarytrue
Claim.item.diagnosisLinkId
Definition

Diagnosis applicable for this service or product line.

Control0..*
TypepositiveInt
Summarytrue
Claim.item.service
Definition

If a grouping item then 'GROUP' otherwise it is a node therefore a code to indicate the Professional Service or Product supplied.

Control1..1
BindingUSCLS Codes: Allowable service and product codes (Example)
TypeCoding
Summarytrue
Claim.item.serviceModifier
Definition

Unusual circumstances which may influence adjudication.

Control0..*
BindingExample Service Modifier Codes: Factors which may influce adjudication of services (Example)
TypeCoding
Requirements

May impact on adjudication.

Summarytrue
Claim.item.modifier
Definition

Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.

Control0..*
BindingModifier type Codes: Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Example)
TypeCoding
Requirements

May impact on adjudication.

Summarytrue
Claim.item.programCode
Definition

For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program.

Control0..*
BindingExample Program Reason Codes: Program specific reason codes (Example)
TypeCoding
Summarytrue
Claim.item.serviced[x]
Definition

The date or dates when the enclosed suite of services were performed or completed.

Control0..1
Typedate|Period
[x] NoteSee Choice of Data Types for further information about how to use [x]
Summarytrue
Claim.item.place
Definition

Where the service was provided.

Control0..1
BindingExample Service Place Codes: (Example)
TypeCoding
Summarytrue
Claim.item.quantity
Definition

The number of repetitions of a service or product.

Control0..1
TypeSimpleQuantity
Summarytrue
Claim.item.unitPrice
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.

Control0..1
TypeMoney
Summarytrue
Claim.item.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.

Control0..1
Typedecimal
Requirements

If a fee is present the associated product/service code must be present.

Summarytrue
Claim.item.points
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.

Control0..1
Typedecimal
Requirements

If a fee is present the associated product/service code must be present.

Summarytrue
Claim.item.net
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.

Control0..1
TypeMoney
Requirements

If a fee is present the associated product/service code must be present.

Summarytrue
Claim.item.udi
Definition

List of Unique Device Identifiers associated with this line item.

Control0..*
TypeReference(Device)
Requirements

The UDI code and issuer if applicable for the supplied product.

Summarytrue
Claim.item.bodySite
Definition

Physical service site on the patient (limb, tooth, etc).

Control0..1
BindingOral Site Codes: The code for the teeth, quadrant, sextant and arch (Example)
TypeCoding
Summarytrue
Claim.item.subSite
Definition

A region or surface of the site, eg. limb region or tooth surface(s).

Control0..*
BindingSurface Codes: The code for the tooth surface and surface combinations (Example)
TypeCoding
Summarytrue
Claim.item.detail
Definition

Second tier of goods and services.

Control0..*
Summarytrue
Claim.item.detail.sequence
Definition

A service line number.

Control1..1
TypepositiveInt
Summarytrue
Claim.item.detail.type
Definition

The type of product or service.

Control1..1
BindingException Codes: Group, Service, Product. (Required)
TypeCoding
Summarytrue
Claim.item.detail.service
Definition

If a grouping item then 'GROUP' otherwise it is a node therefore a code to indicate the Professional Service or Product supplied.

Control1..1
BindingUSCLS Codes: Allowable service and product codes (Example)
TypeCoding
Summarytrue
Claim.item.detail.programCode
Definition

For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program.

Control0..*
BindingExample Program Reason Codes: Program specific reason codes (Example)
TypeCoding
Summarytrue
Claim.item.detail.quantity
Definition

The number of repetitions of a service or product.

Control0..1
TypeSimpleQuantity
Summarytrue
Claim.item.detail.unitPrice
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.

Control0..1
TypeMoney
Requirements

If a fee is present the associated product/service code must be present.

Summarytrue
Claim.item.detail.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.

Control0..1
Typedecimal
Requirements

If a fee is present the associated product/service code must be present.

Summarytrue
Claim.item.detail.points
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.

Control0..1
Typedecimal
Requirements

If a fee is present the associated product/service code must be present.

Summarytrue
Claim.item.detail.net
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.

Control0..1
TypeMoney
Requirements

If a fee is present the associated product/service code must be present.

Summarytrue
Claim.item.detail.udi
Definition

List of Unique Device Identifiers associated with this line item.

Control0..*
TypeReference(Device)
Requirements

The UDI code and issuer if applicable for the supplied product.

Summarytrue
Claim.item.detail.subDetail
Definition

Third tier of goods and services.

Control0..*
Summarytrue
Claim.item.detail.subDetail.sequence
Definition

A service line number.

Control1..1
TypepositiveInt
Summarytrue
Claim.item.detail.subDetail.type
Definition

The type of product or service.

Control1..1
BindingException Codes: Group, Service, Product. (Required)
TypeCoding
Summarytrue
Claim.item.detail.subDetail.service
Definition

The fee for an addittional service or product or charge.

Control1..1
BindingUSCLS Codes: Allowable service and product codes (Example)
TypeCoding
Summarytrue
Claim.item.detail.subDetail.programCode
Definition

For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program.

Control0..*
BindingExample Program Reason Codes: Program specific reason codes (Example)
TypeCoding
Summarytrue
Claim.item.detail.subDetail.quantity
Definition

The number of repetitions of a service or product.

Control0..1
TypeSimpleQuantity
Summarytrue
Claim.item.detail.subDetail.unitPrice
Definition

The fee for an addittional service or product or charge.

Control0..1
TypeMoney
Requirements

If a fee is present the associated product/service code must be present.

Summarytrue
Claim.item.detail.subDetail.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.

Control0..1
Typedecimal
Requirements

If a fee is present the associated product/service code must be present.

Summarytrue
Claim.item.detail.subDetail.points
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.

Control0..1
Typedecimal
Requirements

If a fee is present the associated product/service code must be present.

Summarytrue
Claim.item.detail.subDetail.net
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.

Control0..1
TypeMoney
Requirements

If a fee is present the associated product/service code must be present.

Summarytrue
Claim.item.detail.subDetail.udi
Definition

List of Unique Device Identifiers associated with this line item.

Control0..*
TypeReference(Device)
Requirements

The UDI code and issuer if applicable for the supplied product.

Summarytrue
Claim.item.prosthesis
Definition

The materials and placement date of prior fixed prosthesis.

Control0..1
Summarytrue
Claim.item.prosthesis.initial
Definition

Indicates whether this is the initial placement of a fixed prosthesis.

Control0..1
Typeboolean
Requirements

May impact on adjudication.

Summarytrue
Claim.item.prosthesis.priorDate
Definition

Date of the initial placement.

Control0..1
Typedate
Requirements

May impact on adjudication.

Summarytrue
Claim.item.prosthesis.priorMaterial
Definition

Material of the prior denture or bridge prosthesis. (Oral).

Control0..1
BindingOral Prostho Material type Codes: Material of the prior denture or bridge prosthesis. (Oral) (Example)
TypeCoding
Requirements

May impact on adjudication.

Summarytrue
Claim.total
Definition

The total value of the claim.

Control0..1
TypeMoney
Summarytrue
Claim.additionalMaterial
Definition

Code to indicate that Xrays, images, emails, documents, models or attachments are being sent in support of this submission.

Control0..*
BindingAdditional Material Codes: Code to indicate that Xrays, images, emails, documents, models or attachments are being sent in support of this submission. (Example)
TypeCoding
Summarytrue
Claim.missingTeeth
Definition

A list of teeth which would be expected but are not found due to having been previously extracted or for other reasons.

Control0..*
Requirements

The list of missing teeth may influence the adjudication of services for example with Bridges.

Summarytrue
Claim.missingTeeth.tooth
Definition

The code identifying which tooth is missing.

Control1..1
BindingTeeth Codes: The codes for the teeth, subset of OralSites (Example)
TypeCoding
Requirements

Provides the tooth number of the missing tooth.

Summarytrue
Claim.missingTeeth.reason
Definition

Missing reason may be: E-extraction, O-other.

Control0..1
BindingMissing Tooth Reason Codes: Reason codes for the missing teeth (Example)
TypeCoding
Requirements

Provides the reason for the missing tooth.

Summarytrue
Claim.missingTeeth.extractionDate
Definition

The date of the extraction either known from records or patient reported estimate.

Control0..1
Typedate
Requirements

Some services and adjudications require this information.

Summarytrue