STU3 Candidate

This page is part of the FHIR Specification (v1.8.0: STU 3 Draft). 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

13.1 Resource Claim - Content

Financial Management Work GroupMaturity Level: 1Compartments: Not linked to any defined compartments

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.

13.1.1 Scope and Usage

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

The Claim is intended to support:

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

The Claim also supports:

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

This resource is referenced by ClaimResponse and ExplanationOfBenefit

13.1.2 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim DomainResourceClaim, Pre-determination or Pre-authorization
... identifier 0..*IdentifierClaim number
... status ?!Σ0..1codeactive | cancelled | draft | entered-in-error
Financial Resource Status Codes (Required)
... type 0..1CodeableConceptType or discipline
Example Claim Type Codes (Required)
... subType 0..*CodeableConceptFiner grained claim type information
Example Claim SubType Codes (Example)
... use 0..1codecomplete | proposed | exploratory | other
Use (Required)
... patient 0..1Reference(Patient)The subject of the Products and Services
... billablePeriod 0..1PeriodPeriod for charge submission
... created 0..1dateTimeCreation date
... enterer 0..1Reference(Practitioner)Author
... insurer 0..1Reference(Organization)Target
... provider 0..1Reference(Practitioner)Responsible provider
... organization 0..1Reference(Organization)Responsible organization
... priority 0..1CodeableConceptDesired processing priority
Priority Codes (Example)
... fundsReserve 0..1CodeableConceptFunds requested to be reserved
Funds Reservation Codes (Example)
... related 0..*BackboneElementRelated Claims which may be revelant to processing this claimn
.... claim 0..1Reference(Claim)Reference to the related claim
.... relationship 0..1CodeableConceptHow the reference claim is related
Example Related Claim Relationship Codes (Example)
.... reference 0..1IdentifierRelated file or case reference
... prescription 0..1Reference(MedicationRequest | VisionPrescription)Prescription
... originalPrescription 0..1Reference(MedicationRequest)Original Prescription
... payee 0..1BackboneElementParty to be paid any benefits payable
.... type 1..1CodeableConceptType of party: Subscriber, Provider, other
Payee Type Codes (Example)
.... resourceType 0..1Codingorganization | patient | practitioner | relatedperson
PayeeResourceType (Example)
.... party 0..1Reference(Practitioner | Organization | Patient | RelatedPerson)Party to receive the payable
... referral 0..1Reference(ReferralRequest)Treatment Referral
... facility 0..1Reference(Location)Servicing Facility
... careTeam 0..*BackboneElementMembers of the care team
.... sequence 1..1positiveIntNumber to covey order of careTeam
.... provider 1..1Reference(Practitioner | Organization)Provider individual or organization
.... responsible 0..1booleanBilling provider
.... role 0..1CodeableConceptRole on the team
Claim Care Team Role Codes (Example)
.... qualification 0..1CodeableConceptType, classification or Specialization
Example Provider Qualification Codes (Example)
... information 0..*BackboneElementExceptions, special considerations, the condition, situation, prior or concurrent issues
.... category 1..1CodeableConceptCategory of information
Claim Information Category Codes (Example)
.... code 0..1CodeableConceptType of information
Exception Codes (Example)
.... timing[x] 0..1When it occurred
..... timingDatedate
..... timingPeriodPeriod
.... value[x] 0..1Additional Data or supporting information
..... valueStringstring
..... valueQuantityQuantity
..... valueAttachmentAttachment
..... valueReferenceReference(Any)
.... reason 0..1CodeableConceptReason associated with the information
Missing Tooth Reason Codes (Example)
... diagnosis 0..*BackboneElementDiagnosis
.... sequence 1..1positiveIntNumber to covey order of diagnosis
.... diagnosis[x] 1..1Patient's diagnosis
ICD-10 Codes (Example)
..... diagnosisCodeableConceptCodeableConcept
..... diagnosisReferenceReference(Condition)
.... type 0..*CodeableConceptType of Diagnosis
Example Diagnosis Type Codes (Example)
.... packageCode 0..1CodeableConceptPackage billing code
Example Diagnosis Related Group Codes (Example)
... procedure 0..*BackboneElementProcedures performed
.... sequence 1..1positiveIntProcedure sequence for reference
.... date 0..1dateTimeWhen the procedure was performed
.... procedure[x] 1..1Patient's list of procedures performed
ICD-10 Procedure Codes (Example)
..... procedureCodeableConceptCodeableConcept
..... procedureReferenceReference(Procedure)
... insurance 0..*BackboneElementInsurance or medical plan
.... sequence 1..1positiveIntService instance identifier
.... focal 1..1booleanIs the focal Coverage
.... coverage 1..1Reference(Coverage)Insurance information
.... businessArrangement 0..1stringBusiness agreement
.... preAuthRef 0..*stringPre-Authorization/Determination Reference
.... claimResponse 0..1Reference(ClaimResponse)Adjudication results
... accident 0..1BackboneElementDetails about an accident
.... date 1..1dateWhen the accident occurred see information codes see information codes
.... type 0..1CodeableConceptThe nature of the accident
ActIncidentCode (Required)
.... location[x] 0..1Accident Place
..... locationAddressAddress
..... locationReferenceReference(Location)
... employmentImpacted 0..1PeriodPeriod unable to work
... hospitalization 0..1PeriodPeriod in hospital
... item 0..*BackboneElementGoods and Services
.... sequence 1..1positiveIntService instance
.... careTeamLinkId 0..*positiveIntApplicable careTeam members
.... diagnosisLinkId 0..*positiveIntApplicable diagnoses
.... procedureLinkId 0..*positiveIntApplicable procedures
.... informationLinkId 0..*positiveIntApplicable exception and supporting information
.... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
.... category 0..1CodeableConceptType of service or product
Benefit SubCategory Codes (Example)
.... service 0..1CodeableConceptBilling Code
USCLS Codes (Example)
.... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
.... programCode 0..*CodeableConceptProgram specific reason for item inclusion
Example Program Reason Codes (Example)
.... serviced[x] 0..1Date or dates of Service
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service
Example Service Place Codes (Example)
..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1SimpleQuantityCount of Products or Services
.... unitPrice 0..1MoneyFee, charge or cost per point
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... udi 0..*Reference(Device)Unique Device Identifier
.... bodySite 0..1CodeableConceptService Location
Oral Site Codes (Example)
.... subSite 0..*CodeableConceptService Sub-location
Surface Codes (Example)
.... detail 0..*BackboneElementAdditional items
..... sequence 1..1positiveIntService instance
..... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
..... category 0..1CodeableConceptType of service or product
Benefit SubCategory Codes (Example)
..... service 0..1CodeableConceptBilling Code
USCLS Codes (Example)
..... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
..... programCode 0..*CodeableConceptProgram specific reason for item inclusion
Example Program Reason Codes (Example)
..... quantity 0..1SimpleQuantityCount of Products or Services
..... unitPrice 0..1MoneyFee, charge or cost per point
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal additional item cost
..... udi 0..*Reference(Device)Unique Device Identifier
..... subDetail 0..*BackboneElementAdditional items
...... sequence 1..1positiveIntService instance
...... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
...... category 0..1CodeableConceptType of service or product
Benefit SubCategory Codes (Example)
...... service 0..1CodeableConceptBilling Code
USCLS Codes (Example)
...... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
...... programCode 0..*CodeableConceptProgram specific reason for item inclusion
Example Program Reason Codes (Example)
...... quantity 0..1SimpleQuantityCount of Products or Services
...... unitPrice 0..1MoneyFee, charge or cost per point
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyNet additional item cost
...... udi 0..*Reference(Device)Unique Device Identifier
.... prosthesis 0..1BackboneElementProsthetic details
..... initial 0..1booleanIs this the initial service
..... priorDate 0..1dateInitial service Date
..... priorMaterial 0..1CodeableConceptProsthetic Material
Oral Prostho Material type Codes (Example)
... total 0..1MoneyTotal claim cost

doco Documentation for this format

UML Diagram (Legend)

Claim (DomainResource)The business identifier for the instance: claim number, pre-determination or pre-authorization numberidentifier : Identifier [0..*]The status of the resource instance (this element modifies the meaning of other elements)status : code [0..1] « A code specifying the state of the resource instance. (Strength=Required)Financial Resource Status ! »The category of claim, eg, oral, pharmacy, vision, insitutional, professionaltype : CodeableConcept [0..1] « The type or discipline-style of the claim (Strength=Required)Example Claim Type ! »A finer grained suite of claim subtype codes which may convey Inpatient vs Outpatient and/or a specialty service. In the US the BillTypesubType : CodeableConcept [0..*] « A more granular claim typecode (Strength=Example)Example Claim SubType ?? »Complete (Bill or Claim), Proposed (Pre-Authorization), Exploratory (Pre-determination)use : code [0..1] « Complete, proposed, exploratory, other (Strength=Required)Use! »Patient Resourcepatient : Reference [0..1] « Patient »The billable period for which charges are being submittedbillablePeriod : Period [0..1]The date when the enclosed suite of services were performed or completedcreated : dateTime [0..1]Person who created the invoice/claim/pre-determination or pre-authorizationenterer : Reference [0..1] « Practitioner »The Insurer who is target of the requestinsurer : Reference [0..1] « Organization »The provider which is responsible for the bill, claim pre-determination, pre-authorizationprovider : Reference [0..1] « Practitioner »The organization which is responsible for the bill, claim pre-determination, pre-authorizationorganization : Reference [0..1] « Organization »Immediate (STAT), best effort (NORMAL), deferred (DEFER)priority : CodeableConcept [0..1] « The timeliness with which processing is required: STAT, normal, Deferred (Strength=Example)Priority ?? »In the case of a Pre-Determination/Pre-Authorization the provider may request that funds in the amount of the expected Benefit be reserved ('Patient' or 'Provider') to pay for the Benefits determined on the subsequent claim(s). 'None' explicitly indicates no funds reserving is requestedfundsReserve : CodeableConcept [0..1] « For whom funds are to be reserved: (Patient, Provider, None). (Strength=Example)Funds Reservation ?? »Prescription to support the dispensing of Pharmacy or Vision productsprescription : Reference [0..1] « MedicationRequest| VisionPrescription »Original prescription which has been superceded by this prescription to support the dispensing of pharmacy services, medications or products. For example, a physician may prescribe a medication which the pharmacy determines is contraindicated, or for which the patient has an intolerance, and therefor issues a new precription for an alternate medication which has the same theraputic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription'originalPrescription : Reference [0..1] « MedicationRequest »The referral resource which lists the date, practitioner, reason and other supporting informationreferral : Reference [0..1] « ReferralRequest »Facility where the services were providedfacility : Reference [0..1] « Location »The start and optional end dates of when the patient was precluded from working due to the treatable condition(s)employmentImpacted : Period [0..1]The start and optional end dates of when the patient was confined to a treatment centerhospitalization : Period [0..1]The total value of the claimtotal : Money [0..1]RelatedClaimOther claims which are related to this claim such as prior claim versions or for related servicesclaim : Reference [0..1] « Claim »For example prior or umbrellarelationship : CodeableConcept [0..1] « Relationship of this claim to a related Claim (Strength=Example)Example Related Claim Relatio...?? »An alternate organizational reference to the case or file to which this particular claim pertains - eg Property/Casualy insurer claim # or Workers Compensation case # reference : Identifier [0..1]PayeeType of Party to be reimbursed: Subscriber, provider, othertype : CodeableConcept [1..1] « A code for the party to be reimbursed. (Strength=Example)Payee Type ?? »organization | patient | practitioner | relatedpersonresourceType : Coding [0..1] « The type of payee Resource (Strength=Example)PayeeResourceType?? »Party to be reimbursed: Subscriber, provider, otherparty : Reference [0..1] « Practitioner|Organization|Patient| RelatedPerson »CareTeamSequence of the careTeam which serves to order and provide a linksequence : positiveInt [1..1]Member of the team who provided the overall serviceprovider : Reference [1..1] « Practitioner|Organization »The party who is billing and responsible for the claimed good or service rendered to the patientresponsible : boolean [0..1]The lead, assisting or supervising practitioner and their discipline if a multidisiplinary teamrole : CodeableConcept [0..1] « The role codes for the care team members. (Strength=Example)Claim Care Team Role ?? »The qualification which is applicable for this servicequalification : CodeableConcept [0..1] « Provider professional qualifications (Strength=Example)Example Provider Qualificatio...?? »SpecialConditionThe general class of the information supplied: information; exception; accident, employment; onset, etccategory : CodeableConcept [1..1] « The valuset used for additional information category codes. (Strength=Example)Claim Information Category ?? »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 adjudicationcode : CodeableConcept [0..1] « The valuset used for additional information codes. (Strength=Example)Exception ?? »The date when or period to which this information referstiming[x] : Type [0..1] « date|Period »Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the datavalue[x] : Type [0..1] « string|Quantity|Attachment|Reference(Any) »For example, provides the reason for: the additional stay, or missing tooth or any other situation where a reason code is required in addition to the contentreason : CodeableConcept [0..1] « Reason codes for the missing teeth (Strength=Example)Missing Tooth Reason ?? »DiagnosisSequence of diagnosis which serves to order and provide a linksequence : positiveInt [1..1]The diagnosisdiagnosis[x] : Type [1..1] « CodeableConcept|Reference(Condition); ICD10 Diagnostic codes (Strength=Example) ICD-10 ?? »The type of the Diagnosis, for example: admitting,type : CodeableConcept [0..*] « The type of the diagnosis: admitting, principal, discharge (Strength=Example)Example Diagnosis Type ?? »The package billing code, for example DRG, based on the assigned grouping code systempackageCode : CodeableConcept [0..1] « The DRG codes associated with the diagnosis (Strength=Example)Example Diagnosis Related Gro...?? »ProcedureSequence of procedures which serves to order and provide a linksequence : positiveInt [1..1]Date and optionally time the procedure was performed date : dateTime [0..1]The procedure codeprocedure[x] : Type [1..1] « CodeableConcept|Reference(Procedure); ICD10 Procedure codes (Strength=Example) ICD-10 Procedure ?? »InsuranceA service line itemsequence : positiveInt [1..1]A flag to indicate that this Coverage is the focus for adjudication. The Coverage against which the claim is to be adjudicatedfocal : boolean [1..1]Reference to the program or plan identification, underwriter or payorcoverage : Reference [1..1] « Coverage »The contract number of a business agreement which describes the terms and conditionsbusinessArrangement : string [0..1]A list of references from the Insurer to which these services pertainpreAuthRef : string [0..*]The Coverages adjudication detailsclaimResponse : Reference [0..1] « ClaimResponse »AccidentDate of an accident which these services are addressingdate : date [1..1]Type of accident: work, auto, etctype : CodeableConcept [0..1] « Type of accident: work place, auto, etc. (Strength=Required)ActIncidentCode! »Accident Placelocation[x] : Type [0..1] « Address|Reference(Location) »ItemA service line numbersequence : positiveInt [1..1]CareTeam applicable for this service or product linecareTeamLinkId : positiveInt [0..*]Diagnosis applicable for this service or product linediagnosisLinkId : positiveInt [0..*]Procedures applicable for this service or product lineprocedureLinkId : positiveInt [0..*]Exceptions, special conditions and supporting information pplicable for this service or product lineinformationLinkId : positiveInt [0..*]The type of reveneu or cost center providing the product and/or servicerevenue : CodeableConcept [0..1] « Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example)Example Revenue Center ?? »Health Care Service Type Codes to identify the classification of service or benefitscategory : CodeableConcept [0..1] « Benefit subcategories such as: oral-basic, major, glasses (Strength=Example)Benefit SubCategory ?? »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,RXNorm,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'service : CodeableConcept [0..1] « Allowable service and product codes (Strength=Example)USCLS ?? »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 hoursmodifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)Modifier type ?? »For programs which require reason codes for the inclusion or covering of this billed item under the program or sub-programprogramCode : CodeableConcept [0..*] « Program specific reason codes (Strength=Example)Example Program Reason ?? »The date or dates when the enclosed suite of services were performed or completedserviced[x] : Type [0..1] « date|Period »Where the service was providedlocation[x] : Type [0..1] « CodeableConcept|Address|Reference( Location); Place of service: pharmcy,school, prison, etc. (Strength=Example)Example Service Place ?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the groupunitPrice : Money [0..1]A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amountfactor : decimal [0..1]The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not suppliednet : Money [0..1]List of Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »Physical service site on the patient (limb, tooth, etc)bodySite : CodeableConcept [0..1] « The code for the teeth, quadrant, sextant and arch (Strength=Example)Oral Site ?? »A region or surface of the site, eg. limb region or tooth surface(s)subSite : CodeableConcept [0..*] « The code for the tooth surface and surface combinations (Strength=Example)Surface ?? »DetailA service line numbersequence : positiveInt [1..1]The type of reveneu or cost center providing the product and/or servicerevenue : CodeableConcept [0..1] « Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example)Example Revenue Center ?? »Health Care Service Type Codes to identify the classification of service or benefitscategory : CodeableConcept [0..1] « Benefit subcategories such as: oral-basic, major, glasses (Strength=Example)Benefit SubCategory ?? »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'service : CodeableConcept [0..1] « Allowable service and product codes (Strength=Example)USCLS ?? »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 hoursmodifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)Modifier type ?? »For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-programprogramCode : CodeableConcept [0..*] « Program specific reason codes (Strength=Example)Example Program Reason ?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the groupunitPrice : Money [0..1]A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amountfactor : decimal [0..1]The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not suppliednet : Money [0..1]List of Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »SubDetailA service line numbersequence : positiveInt [1..1]The type of reveneu or cost center providing the product and/or servicerevenue : CodeableConcept [0..1] « Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example)Example Revenue Center ?? »Health Care Service Type Codes to identify the classification of service or benefitscategory : CodeableConcept [0..1] « Benefit subcategories such as: oral-basic, major, glasses (Strength=Example)Benefit SubCategory ?? »A code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI)service : CodeableConcept [0..1] « Allowable service and product codes (Strength=Example)USCLS ?? »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 hoursmodifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)Modifier type ?? »For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-programprogramCode : CodeableConcept [0..*] « Program specific reason codes (Strength=Example)Example Program Reason ?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]The fee for an addittional service or product or chargeunitPrice : Money [0..1]A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amountfactor : decimal [0..1]The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not suppliednet : Money [0..1]List of Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »ProsthesisIndicates whether this is the initial placement of a fixed prosthesisinitial : boolean [0..1]Date of the initial placementpriorDate : date [0..1]Material of the prior denture or bridge prosthesis. (Oral)priorMaterial : CodeableConcept [0..1] « Material of the prior denture or bridge prosthesis. (Oral) (Strength=Example)Oral Prostho Material type ?? »Other claims which are related to this claim such as prior claim versions or for related servicesrelated[0..*]The party to be reimbursed for the servicespayee[0..1]The members of the team who provided the overall service as well as their role and whether responsible and qualificationscareTeam[0..*]Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. Often there are mutiple jurisdiction specific valuesets which are requiredinformation[0..*]Ordered list of patient diagnosis for which care is soughtdiagnosis[0..*]Ordered list of patient procedures performed to support the adjudicationprocedure[0..*]Financial instrument by which payment information for health careinsurance[0..*]An accident which resulted in the need for healthcare servicesaccident[0..1]Third tier of goods and servicessubDetail[0..*]Second tier of goods and servicesdetail[0..*]The materials and placement date of prior fixed prosthesisprosthesis[0..1]First tier of goods and servicesitem[0..*]

XML Template

<Claim xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Claim number --></identifier>
 <status value="[code]"/><!-- 0..1 active | cancelled | draft | entered-in-error -->
 <type><!-- 0..1 CodeableConcept Type or discipline --></type>
 <subType><!-- 0..* CodeableConcept Finer grained claim type information --></subType>
 <use value="[code]"/><!-- 0..1 complete | proposed | exploratory | other -->
 <patient><!-- 0..1 Reference(Patient) The subject of the Products and Services --></patient>
 <billablePeriod><!-- 0..1 Period Period for charge submission --></billablePeriod>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <enterer><!-- 0..1 Reference(Practitioner) Author --></enterer>
 <insurer><!-- 0..1 Reference(Organization) Target --></insurer>
 <provider><!-- 0..1 Reference(Practitioner) Responsible provider --></provider>
 <organization><!-- 0..1 Reference(Organization) Responsible organization --></organization>
 <priority><!-- 0..1 CodeableConcept Desired processing priority --></priority>
 <fundsReserve><!-- 0..1 CodeableConcept Funds requested to be reserved --></fundsReserve>
 <related>  <!-- 0..* Related Claims which may be revelant to processing this claimn -->
  <claim><!-- 0..1 Reference(Claim) Reference to the related claim --></claim>
  <relationship><!-- 0..1 CodeableConcept How the reference claim is related --></relationship>
  <reference><!-- 0..1 Identifier Related file or case reference --></reference>
 </related>
 <prescription><!-- 0..1 Reference(MedicationRequest|VisionPrescription) Prescription --></prescription>
 <originalPrescription><!-- 0..1 Reference(MedicationRequest) Original Prescription --></originalPrescription>
 <payee>  <!-- 0..1 Party to be paid any benefits payable -->
  <type><!-- 1..1 CodeableConcept Type of party: Subscriber, Provider, other --></type>
  <resourceType><!-- 0..1 Coding organization | patient | practitioner | relatedperson --></resourceType>
  <party><!-- 0..1 Reference(Practitioner|Organization|Patient|RelatedPerson) Party to receive the payable --></party>
 </payee>
 <referral><!-- 0..1 Reference(ReferralRequest) Treatment Referral --></referral>
 <facility><!-- 0..1 Reference(Location) Servicing Facility --></facility>
 <careTeam>  <!-- 0..* Members of the care team -->
  <sequence value="[positiveInt]"/><!-- 1..1 Number to covey order of careTeam -->
  <provider><!-- 1..1 Reference(Practitioner|Organization) Provider individual or organization --></provider>
  <responsible value="[boolean]"/><!-- 0..1 Billing provider -->
  <role><!-- 0..1 CodeableConcept Role on the team --></role>
  <qualification><!-- 0..1 CodeableConcept Type, classification or Specialization --></qualification>
 </careTeam>
 <information>  <!-- 0..* Exceptions, special considerations, the condition, situation, prior or concurrent issues -->
  <category><!-- 1..1 CodeableConcept Category of information --></category>
  <code><!-- 0..1 CodeableConcept Type of information --></code>
  <timing[x]><!-- 0..1 date|Period When it occurred --></timing[x]>
  <value[x]><!-- 0..1 string|Quantity|Attachment|Reference(Any) Additional Data or supporting information --></value[x]>
  <reason><!-- 0..1 CodeableConcept Reason associated with the information --></reason>
 </information>
 <diagnosis>  <!-- 0..* Diagnosis -->
  <sequence value="[positiveInt]"/><!-- 1..1 Number to covey order of diagnosis -->
  <diagnosis[x]><!-- 1..1 CodeableConcept|Reference(Condition) Patient's diagnosis --></diagnosis[x]>
  <type><!-- 0..* CodeableConcept Type of Diagnosis --></type>
  <packageCode><!-- 0..1 CodeableConcept Package billing code --></packageCode>
 </diagnosis>
 <procedure>  <!-- 0..* Procedures performed -->
  <sequence value="[positiveInt]"/><!-- 1..1 Procedure sequence for reference -->
  <date value="[dateTime]"/><!-- 0..1 When the procedure was performed -->
  <procedure[x]><!-- 1..1 CodeableConcept|Reference(Procedure) Patient's list of procedures performed --></procedure[x]>
 </procedure>
 <insurance>  <!-- 0..* Insurance or medical plan -->
  <sequence value="[positiveInt]"/><!-- 1..1 Service instance identifier -->
  <focal value="[boolean]"/><!-- 1..1 Is the focal Coverage -->
  <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage>
  <businessArrangement value="[string]"/><!-- 0..1 Business agreement -->
  <preAuthRef value="[string]"/><!-- 0..* Pre-Authorization/Determination Reference -->
  <claimResponse><!-- 0..1 Reference(ClaimResponse) Adjudication results --></claimResponse>
 </insurance>
 <accident>  <!-- 0..1 Details about an accident -->
  <date value="[date]"/><!-- 1..1 When the accident occurred
see information codes
see information codes -->
  <type><!-- 0..1 CodeableConcept The nature of the accident --></type>
  <location[x]><!-- 0..1 Address|Reference(Location) Accident Place --></location[x]>
 </accident>
 <employmentImpacted><!-- 0..1 Period Period unable to work --></employmentImpacted>
 <hospitalization><!-- 0..1 Period Period in hospital --></hospitalization>
 <item>  <!-- 0..* Goods and Services -->
  <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
  <careTeamLinkId value="[positiveInt]"/><!-- 0..* Applicable careTeam members -->
  <diagnosisLinkId value="[positiveInt]"/><!-- 0..* Applicable diagnoses -->
  <procedureLinkId value="[positiveInt]"/><!-- 0..* Applicable procedures -->
  <informationLinkId value="[positiveInt]"/><!-- 0..* Applicable exception and supporting information -->
  <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
  <category><!-- 0..1 CodeableConcept Type of service or product --></category>
  <service><!-- 0..1 CodeableConcept Billing Code --></service>
  <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
  <programCode><!-- 0..* CodeableConcept Program specific reason for item inclusion --></programCode>
  <serviced[x]><!-- 0..1 date|Period Date or dates of Service --></serviced[x]>
  <location[x]><!-- 0..1 CodeableConcept|Address|Reference(Location) Place of service --></location[x]>
  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
  <unitPrice><!-- 0..1 Money Fee, charge or cost per point --></unitPrice>
  <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
  <net><!-- 0..1 Money Total item cost --></net>
  <udi><!-- 0..* Reference(Device) Unique Device Identifier --></udi>
  <bodySite><!-- 0..1 CodeableConcept Service Location --></bodySite>
  <subSite><!-- 0..* CodeableConcept Service Sub-location --></subSite>
  <detail>  <!-- 0..* Additional items -->
   <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
   <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
   <category><!-- 0..1 CodeableConcept Type of service or product --></category>
   <service><!-- 0..1 CodeableConcept Billing Code --></service>
   <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
   <programCode><!-- 0..* CodeableConcept Program specific reason for item inclusion --></programCode>
   <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
   <unitPrice><!-- 0..1 Money Fee, charge or cost per point --></unitPrice>
   <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
   <net><!-- 0..1 Money Total additional item cost --></net>
   <udi><!-- 0..* Reference(Device) Unique Device Identifier --></udi>
   <subDetail>  <!-- 0..* Additional items -->
    <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
    <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
    <category><!-- 0..1 CodeableConcept Type of service or product --></category>
    <service><!-- 0..1 CodeableConcept Billing Code --></service>
    <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
    <programCode><!-- 0..* CodeableConcept Program specific reason for item inclusion --></programCode>
    <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
    <unitPrice><!-- 0..1 Money Fee, charge or cost per point --></unitPrice>
    <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
    <net><!-- 0..1 Money Net additional item cost --></net>
    <udi><!-- 0..* Reference(Device) Unique Device Identifier --></udi>
   </subDetail>
  </detail>
  <prosthesis>  <!-- 0..1 Prosthetic details -->
   <initial value="[boolean]"/><!-- 0..1 Is this the initial service -->
   <priorDate value="[date]"/><!-- 0..1 Initial service Date -->
   <priorMaterial><!-- 0..1 CodeableConcept Prosthetic Material --></priorMaterial>
  </prosthesis>
 </item>
 <total><!-- 0..1 Money Total claim cost --></total>
</Claim>

JSON Template

{doco
  "resourceType" : "Claim",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Claim number
  "status" : "<code>", // active | cancelled | draft | entered-in-error
  "type" : { CodeableConcept }, // Type or discipline
  "subType" : [{ CodeableConcept }], // Finer grained claim type information
  "use" : "<code>", // complete | proposed | exploratory | other
  "patient" : { Reference(Patient) }, // The subject of the Products and Services
  "billablePeriod" : { Period }, // Period for charge submission
  "created" : "<dateTime>", // Creation date
  "enterer" : { Reference(Practitioner) }, // Author
  "insurer" : { Reference(Organization) }, // Target
  "provider" : { Reference(Practitioner) }, // Responsible provider
  "organization" : { Reference(Organization) }, // Responsible organization
  "priority" : { CodeableConcept }, // Desired processing priority
  "fundsReserve" : { CodeableConcept }, // Funds requested to be reserved
  "related" : [{ // Related Claims which may be revelant to processing this claimn
    "claim" : { Reference(Claim) }, // Reference to the related claim
    "relationship" : { CodeableConcept }, // How the reference claim is related
    "reference" : { Identifier } // Related file or case reference
  }],
  "prescription" : { Reference(MedicationRequest|VisionPrescription) }, // Prescription
  "originalPrescription" : { Reference(MedicationRequest) }, // Original Prescription
  "payee" : { // Party to be paid any benefits payable
    "type" : { CodeableConcept }, // R!  Type of party: Subscriber, Provider, other
    "resourceType" : { Coding }, // organization | patient | practitioner | relatedperson
    "party" : { Reference(Practitioner|Organization|Patient|RelatedPerson) } // Party to receive the payable
  },
  "referral" : { Reference(ReferralRequest) }, // Treatment Referral
  "facility" : { Reference(Location) }, // Servicing Facility
  "careTeam" : [{ // Members of the care team
    "sequence" : "<positiveInt>", // R!  Number to covey order of careTeam
    "provider" : { Reference(Practitioner|Organization) }, // R!  Provider individual or organization
    "responsible" : <boolean>, // Billing provider
    "role" : { CodeableConcept }, // Role on the team
    "qualification" : { CodeableConcept } // Type, classification or Specialization
  }],
  "information" : [{ // Exceptions, special considerations, the condition, situation, prior or concurrent issues
    "category" : { CodeableConcept }, // R!  Category of information
    "code" : { CodeableConcept }, // Type of information
    // timing[x]: When it occurred. One of these 2:
    "timingDate" : "<date>",
    "timingPeriod" : { Period },
    // value[x]: Additional Data or supporting information. One of these 4:
    "valueString" : "<string>",
    "valueQuantity" : { Quantity },
    "valueAttachment" : { Attachment },
    "valueReference" : { Reference(Any) },
    "reason" : { CodeableConcept } // Reason associated with the information
  }],
  "diagnosis" : [{ // Diagnosis
    "sequence" : "<positiveInt>", // R!  Number to covey order of diagnosis
    // diagnosis[x]: Patient's diagnosis. One of these 2:
    "diagnosisCodeableConcept" : { CodeableConcept },
    "diagnosisReference" : { Reference(Condition) },
    "type" : [{ CodeableConcept }], // Type of Diagnosis
    "packageCode" : { CodeableConcept } // Package billing code
  }],
  "procedure" : [{ // Procedures performed
    "sequence" : "<positiveInt>", // R!  Procedure sequence for reference
    "date" : "<dateTime>", // When the procedure was performed
    // procedure[x]: Patient's list of procedures performed. One of these 2:
    "procedureCodeableConcept" : { CodeableConcept }
    "procedureReference" : { Reference(Procedure) }
  }],
  "insurance" : [{ // Insurance or medical plan
    "sequence" : "<positiveInt>", // R!  Service instance identifier
    "focal" : <boolean>, // R!  Is the focal Coverage
    "coverage" : { Reference(Coverage) }, // R!  Insurance information
    "businessArrangement" : "<string>", // Business agreement
    "preAuthRef" : ["<string>"], // Pre-Authorization/Determination Reference
    "claimResponse" : { Reference(ClaimResponse) } // Adjudication results
  }],
  "accident" : { // Details about an accident
    "date" : "<date>", // R!  When the accident occurred
see information codes
see information codes
    "type" : { CodeableConcept }, // The nature of the accident
    // location[x]: Accident Place. One of these 2:
    "locationAddress" : { Address }
    "locationReference" : { Reference(Location) }
  },
  "employmentImpacted" : { Period }, // Period unable to work
  "hospitalization" : { Period }, // Period in hospital
  "item" : [{ // Goods and Services
    "sequence" : "<positiveInt>", // R!  Service instance
    "careTeamLinkId" : ["<positiveInt>"], // Applicable careTeam members
    "diagnosisLinkId" : ["<positiveInt>"], // Applicable diagnoses
    "procedureLinkId" : ["<positiveInt>"], // Applicable procedures
    "informationLinkId" : ["<positiveInt>"], // Applicable exception and supporting information
    "revenue" : { CodeableConcept }, // Revenue or cost center code
    "category" : { CodeableConcept }, // Type of service or product
    "service" : { CodeableConcept }, // Billing Code
    "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
    "programCode" : [{ CodeableConcept }], // Program specific reason for item inclusion
    // serviced[x]: Date or dates of Service. One of these 2:
    "servicedDate" : "<date>",
    "servicedPeriod" : { Period },
    // location[x]: Place of service. One of these 3:
    "locationCodeableConcept" : { CodeableConcept },
    "locationAddress" : { Address },
    "locationReference" : { Reference(Location) },
    "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
    "unitPrice" : { Money }, // Fee, charge or cost per point
    "factor" : <decimal>, // Price scaling factor
    "net" : { Money }, // Total item cost
    "udi" : [{ Reference(Device) }], // Unique Device Identifier
    "bodySite" : { CodeableConcept }, // Service Location
    "subSite" : [{ CodeableConcept }], // Service Sub-location
    "detail" : [{ // Additional items
      "sequence" : "<positiveInt>", // R!  Service instance
      "revenue" : { CodeableConcept }, // Revenue or cost center code
      "category" : { CodeableConcept }, // Type of service or product
      "service" : { CodeableConcept }, // Billing Code
      "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
      "programCode" : [{ CodeableConcept }], // Program specific reason for item inclusion
      "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
      "unitPrice" : { Money }, // Fee, charge or cost per point
      "factor" : <decimal>, // Price scaling factor
      "net" : { Money }, // Total additional item cost
      "udi" : [{ Reference(Device) }], // Unique Device Identifier
      "subDetail" : [{ // Additional items
        "sequence" : "<positiveInt>", // R!  Service instance
        "revenue" : { CodeableConcept }, // Revenue or cost center code
        "category" : { CodeableConcept }, // Type of service or product
        "service" : { CodeableConcept }, // Billing Code
        "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
        "programCode" : [{ CodeableConcept }], // Program specific reason for item inclusion
        "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
        "unitPrice" : { Money }, // Fee, charge or cost per point
        "factor" : <decimal>, // Price scaling factor
        "net" : { Money }, // Net additional item cost
        "udi" : [{ Reference(Device) }] // Unique Device Identifier
      }]
    }],
    "prosthesis" : { // Prosthetic details
      "initial" : <boolean>, // Is this the initial service
      "priorDate" : "<date>", // Initial service Date
      "priorMaterial" : { CodeableConcept } // Prosthetic Material
    }
  }],
  "total" : { Money } // Total claim cost
}

Turtle Template

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


[ a fhir:Claim;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:Claim.identifier [ Identifier ], ... ; # 0..* Claim number
  fhir:Claim.status [ code ]; # 0..1 active | cancelled | draft | entered-in-error
  fhir:Claim.type [ CodeableConcept ]; # 0..1 Type or discipline
  fhir:Claim.subType [ CodeableConcept ], ... ; # 0..* Finer grained claim type information
  fhir:Claim.use [ code ]; # 0..1 complete | proposed | exploratory | other
  fhir:Claim.patient [ Reference(Patient) ]; # 0..1 The subject of the Products and Services
  fhir:Claim.billablePeriod [ Period ]; # 0..1 Period for charge submission
  fhir:Claim.created [ dateTime ]; # 0..1 Creation date
  fhir:Claim.enterer [ Reference(Practitioner) ]; # 0..1 Author
  fhir:Claim.insurer [ Reference(Organization) ]; # 0..1 Target
  fhir:Claim.provider [ Reference(Practitioner) ]; # 0..1 Responsible provider
  fhir:Claim.organization [ Reference(Organization) ]; # 0..1 Responsible organization
  fhir:Claim.priority [ CodeableConcept ]; # 0..1 Desired processing priority
  fhir:Claim.fundsReserve [ CodeableConcept ]; # 0..1 Funds requested to be reserved
  fhir:Claim.related [ # 0..* Related Claims which may be revelant to processing this claimn
    fhir:Claim.related.claim [ Reference(Claim) ]; # 0..1 Reference to the related claim
    fhir:Claim.related.relationship [ CodeableConcept ]; # 0..1 How the reference claim is related
    fhir:Claim.related.reference [ Identifier ]; # 0..1 Related file or case reference
  ], ...;
  fhir:Claim.prescription [ Reference(MedicationRequest|VisionPrescription) ]; # 0..1 Prescription
  fhir:Claim.originalPrescription [ Reference(MedicationRequest) ]; # 0..1 Original Prescription
  fhir:Claim.payee [ # 0..1 Party to be paid any benefits payable
    fhir:Claim.payee.type [ CodeableConcept ]; # 1..1 Type of party: Subscriber, Provider, other
    fhir:Claim.payee.resourceType [ Coding ]; # 0..1 organization | patient | practitioner | relatedperson
    fhir:Claim.payee.party [ Reference(Practitioner|Organization|Patient|RelatedPerson) ]; # 0..1 Party to receive the payable
  ];
  fhir:Claim.referral [ Reference(ReferralRequest) ]; # 0..1 Treatment Referral
  fhir:Claim.facility [ Reference(Location) ]; # 0..1 Servicing Facility
  fhir:Claim.careTeam [ # 0..* Members of the care team
    fhir:Claim.careTeam.sequence [ positiveInt ]; # 1..1 Number to covey order of careTeam
    fhir:Claim.careTeam.provider [ Reference(Practitioner|Organization) ]; # 1..1 Provider individual or organization
    fhir:Claim.careTeam.responsible [ boolean ]; # 0..1 Billing provider
    fhir:Claim.careTeam.role [ CodeableConcept ]; # 0..1 Role on the team
    fhir:Claim.careTeam.qualification [ CodeableConcept ]; # 0..1 Type, classification or Specialization
  ], ...;
  fhir:Claim.information [ # 0..* Exceptions, special considerations, the condition, situation, prior or concurrent issues
    fhir:Claim.information.category [ CodeableConcept ]; # 1..1 Category of information
    fhir:Claim.information.code [ CodeableConcept ]; # 0..1 Type of information
    # Claim.information.timing[x] : 0..1 When it occurred. One of these 2
      fhir:Claim.information.timingDate [ date ]
      fhir:Claim.information.timingPeriod [ Period ]
    # Claim.information.value[x] : 0..1 Additional Data or supporting information. One of these 4
      fhir:Claim.information.valueString [ string ]
      fhir:Claim.information.valueQuantity [ Quantity ]
      fhir:Claim.information.valueAttachment [ Attachment ]
      fhir:Claim.information.valueReference [ Reference(Any) ]
    fhir:Claim.information.reason [ CodeableConcept ]; # 0..1 Reason associated with the information
  ], ...;
  fhir:Claim.diagnosis [ # 0..* Diagnosis
    fhir:Claim.diagnosis.sequence [ positiveInt ]; # 1..1 Number to covey order of diagnosis
    # Claim.diagnosis.diagnosis[x] : 1..1 Patient's diagnosis. One of these 2
      fhir:Claim.diagnosis.diagnosisCodeableConcept [ CodeableConcept ]
      fhir:Claim.diagnosis.diagnosisReference [ Reference(Condition) ]
    fhir:Claim.diagnosis.type [ CodeableConcept ], ... ; # 0..* Type of Diagnosis
    fhir:Claim.diagnosis.packageCode [ CodeableConcept ]; # 0..1 Package billing code
  ], ...;
  fhir:Claim.procedure [ # 0..* Procedures performed
    fhir:Claim.procedure.sequence [ positiveInt ]; # 1..1 Procedure sequence for reference
    fhir:Claim.procedure.date [ dateTime ]; # 0..1 When the procedure was performed
    # Claim.procedure.procedure[x] : 1..1 Patient's list of procedures performed. One of these 2
      fhir:Claim.procedure.procedureCodeableConcept [ CodeableConcept ]
      fhir:Claim.procedure.procedureReference [ Reference(Procedure) ]
  ], ...;
  fhir:Claim.insurance [ # 0..* Insurance or medical plan
    fhir:Claim.insurance.sequence [ positiveInt ]; # 1..1 Service instance identifier
    fhir:Claim.insurance.focal [ boolean ]; # 1..1 Is the focal Coverage
    fhir:Claim.insurance.coverage [ Reference(Coverage) ]; # 1..1 Insurance information
    fhir:Claim.insurance.businessArrangement [ string ]; # 0..1 Business agreement
    fhir:Claim.insurance.preAuthRef [ string ], ... ; # 0..* Pre-Authorization/Determination Reference
    fhir:Claim.insurance.claimResponse [ Reference(ClaimResponse) ]; # 0..1 Adjudication results
  ], ...;
  fhir:Claim.accident [ # 0..1 Details about an accident
    fhir:Claim.accident.date [ date ]; # 1..1 When the accident occurred
see information codes
see information codes
    fhir:Claim.accident.type [ CodeableConcept ]; # 0..1 The nature of the accident
    # Claim.accident.location[x] : 0..1 Accident Place. One of these 2
      fhir:Claim.accident.locationAddress [ Address ]
      fhir:Claim.accident.locationReference [ Reference(Location) ]
  ];
  fhir:Claim.employmentImpacted [ Period ]; # 0..1 Period unable to work
  fhir:Claim.hospitalization [ Period ]; # 0..1 Period in hospital
  fhir:Claim.item [ # 0..* Goods and Services
    fhir:Claim.item.sequence [ positiveInt ]; # 1..1 Service instance
    fhir:Claim.item.careTeamLinkId [ positiveInt ], ... ; # 0..* Applicable careTeam members
    fhir:Claim.item.diagnosisLinkId [ positiveInt ], ... ; # 0..* Applicable diagnoses
    fhir:Claim.item.procedureLinkId [ positiveInt ], ... ; # 0..* Applicable procedures
    fhir:Claim.item.informationLinkId [ positiveInt ], ... ; # 0..* Applicable exception and supporting information
    fhir:Claim.item.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
    fhir:Claim.item.category [ CodeableConcept ]; # 0..1 Type of service or product
    fhir:Claim.item.service [ CodeableConcept ]; # 0..1 Billing Code
    fhir:Claim.item.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
    fhir:Claim.item.programCode [ CodeableConcept ], ... ; # 0..* Program specific reason for item inclusion
    # Claim.item.serviced[x] : 0..1 Date or dates of Service. One of these 2
      fhir:Claim.item.servicedDate [ date ]
      fhir:Claim.item.servicedPeriod [ Period ]
    # Claim.item.location[x] : 0..1 Place of service. One of these 3
      fhir:Claim.item.locationCodeableConcept [ CodeableConcept ]
      fhir:Claim.item.locationAddress [ Address ]
      fhir:Claim.item.locationReference [ Reference(Location) ]
    fhir:Claim.item.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of Products or Services
    fhir:Claim.item.unitPrice [ Money ]; # 0..1 Fee, charge or cost per point
    fhir:Claim.item.factor [ decimal ]; # 0..1 Price scaling factor
    fhir:Claim.item.net [ Money ]; # 0..1 Total item cost
    fhir:Claim.item.udi [ Reference(Device) ], ... ; # 0..* Unique Device Identifier
    fhir:Claim.item.bodySite [ CodeableConcept ]; # 0..1 Service Location
    fhir:Claim.item.subSite [ CodeableConcept ], ... ; # 0..* Service Sub-location
    fhir:Claim.item.detail [ # 0..* Additional items
      fhir:Claim.item.detail.sequence [ positiveInt ]; # 1..1 Service instance
      fhir:Claim.item.detail.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
      fhir:Claim.item.detail.category [ CodeableConcept ]; # 0..1 Type of service or product
      fhir:Claim.item.detail.service [ CodeableConcept ]; # 0..1 Billing Code
      fhir:Claim.item.detail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
      fhir:Claim.item.detail.programCode [ CodeableConcept ], ... ; # 0..* Program specific reason for item inclusion
      fhir:Claim.item.detail.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of Products or Services
      fhir:Claim.item.detail.unitPrice [ Money ]; # 0..1 Fee, charge or cost per point
      fhir:Claim.item.detail.factor [ decimal ]; # 0..1 Price scaling factor
      fhir:Claim.item.detail.net [ Money ]; # 0..1 Total additional item cost
      fhir:Claim.item.detail.udi [ Reference(Device) ], ... ; # 0..* Unique Device Identifier
      fhir:Claim.item.detail.subDetail [ # 0..* Additional items
        fhir:Claim.item.detail.subDetail.sequence [ positiveInt ]; # 1..1 Service instance
        fhir:Claim.item.detail.subDetail.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
        fhir:Claim.item.detail.subDetail.category [ CodeableConcept ]; # 0..1 Type of service or product
        fhir:Claim.item.detail.subDetail.service [ CodeableConcept ]; # 0..1 Billing Code
        fhir:Claim.item.detail.subDetail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
        fhir:Claim.item.detail.subDetail.programCode [ CodeableConcept ], ... ; # 0..* Program specific reason for item inclusion
        fhir:Claim.item.detail.subDetail.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of Products or Services
        fhir:Claim.item.detail.subDetail.unitPrice [ Money ]; # 0..1 Fee, charge or cost per point
        fhir:Claim.item.detail.subDetail.factor [ decimal ]; # 0..1 Price scaling factor
        fhir:Claim.item.detail.subDetail.net [ Money ]; # 0..1 Net additional item cost
        fhir:Claim.item.detail.subDetail.udi [ Reference(Device) ], ... ; # 0..* Unique Device Identifier
      ], ...;
    ], ...;
    fhir:Claim.item.prosthesis [ # 0..1 Prosthetic details
      fhir:Claim.item.prosthesis.initial [ boolean ]; # 0..1 Is this the initial service
      fhir:Claim.item.prosthesis.priorDate [ date ]; # 0..1 Initial service Date
      fhir:Claim.item.prosthesis.priorMaterial [ CodeableConcept ]; # 0..1 Prosthetic Material
    ];
  ], ...;
  fhir:Claim.total [ Money ]; # 0..1 Total claim cost
]

Changes since DSTU2

Claim
Claim.status added Element
Claim.type Min Cardinality changed from 1 to 0
Type changed from code to CodeableConcept
Change value set from http://hl7.org/fhir/ValueSet/claim-type-link to http://hl7.org/fhir/ValueSet/claim-type
Claim.subType added Element
Claim.use Change value set from http://hl7.org/fhir/ValueSet/claim-use-link to http://hl7.org/fhir/ValueSet/claim-use
Claim.patient Min Cardinality changed from 1 to 0
Claim.billablePeriod added Element
Claim.insurer added Element
Claim.priority Type changed from Coding to CodeableConcept
Claim.fundsReserve Type changed from Coding to CodeableConcept
Claim.related added Element
Claim.related.claim added Element
Claim.related.relationship added Element
Claim.related.reference added Element
Claim.prescription Remove Reference(MedicationOrder), Add Reference(MedicationRequest)
Claim.originalPrescription Type changed from Reference(MedicationOrder) to Reference(MedicationRequest)
Claim.payee.type Min Cardinality changed from 0 to 1
Type changed from Coding to CodeableConcept
Claim.payee.resourceType added Element
Claim.payee.party added Element
Claim.careTeam added Element
Claim.careTeam.sequence added Element
Claim.careTeam.provider added Element
Claim.careTeam.responsible added Element
Claim.careTeam.role added Element
Claim.careTeam.qualification added Element
Claim.information added Element
Claim.information.category added Element
Claim.information.code added Element
Claim.information.timing[x] added Element
Claim.information.value[x] added Element
Claim.information.reason added Element
Claim.diagnosis.diagnosis[x] Renamed from diagnosis to diagnosis[x]
Remove Coding, Add CodeableConcept, Add Reference(Condition)
Claim.diagnosis.type added Element
Claim.diagnosis.packageCode added Element
Claim.procedure added Element
Claim.procedure.sequence added Element
Claim.procedure.date added Element
Claim.procedure.procedure[x] added Element
Claim.insurance added Element
Claim.insurance.sequence added Element
Claim.insurance.focal added Element
Claim.insurance.coverage added Element
Claim.insurance.businessArrangement added Element
Claim.insurance.preAuthRef added Element
Claim.insurance.claimResponse added Element
Claim.accident Type changed from date to BackboneElement
Claim.accident.date added Element
Claim.accident.type added Element
Claim.accident.location[x] added Element
Claim.employmentImpacted added Element
Claim.hospitalization added Element
Claim.item.careTeamLinkId added Element
Claim.item.procedureLinkId added Element
Claim.item.informationLinkId added Element
Claim.item.revenue added Element
Claim.item.category added Element
Claim.item.service Min Cardinality changed from 1 to 0
Type changed from Coding to CodeableConcept
Claim.item.modifier Type changed from Coding to CodeableConcept
Claim.item.programCode added Element
Claim.item.serviced[x] added Element
Claim.item.location[x] added Element
Claim.item.unitPrice Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money
Claim.item.net Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money
Claim.item.udi Max Cardinality changed from 1 to *
Type changed from Coding to Reference(Device)
Claim.item.bodySite Type changed from Coding to CodeableConcept
Claim.item.subSite Type changed from Coding to CodeableConcept
Claim.item.detail.revenue added Element
Claim.item.detail.category added Element
Claim.item.detail.service Min Cardinality changed from 1 to 0
Type changed from Coding to CodeableConcept
Claim.item.detail.modifier added Element
Claim.item.detail.programCode added Element
Claim.item.detail.unitPrice Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money
Claim.item.detail.net Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money
Claim.item.detail.udi Max Cardinality changed from 1 to *
Type changed from Coding to Reference(Device)
Claim.item.detail.subDetail.revenue added Element
Claim.item.detail.subDetail.category added Element
Claim.item.detail.subDetail.service Min Cardinality changed from 1 to 0
Type changed from Coding to CodeableConcept
Claim.item.detail.subDetail.modifier added Element
Claim.item.detail.subDetail.programCode added Element
Claim.item.detail.subDetail.unitPrice Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money
Claim.item.detail.subDetail.net Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money
Claim.item.detail.subDetail.udi Max Cardinality changed from 1 to *
Type changed from Coding to Reference(Device)
Claim.item.prosthesis.priorMaterial Type changed from Coding to CodeableConcept
Claim.total added Element
Claim.ruleset deleted
Claim.originalRuleset deleted
Claim.target deleted
Claim.payee.provider deleted
Claim.payee.organization deleted
Claim.payee.person deleted
Claim.condition deleted
Claim.coverage deleted
Claim.exception deleted
Claim.school deleted
Claim.accidentType deleted
Claim.interventionException deleted
Claim.item.type deleted
Claim.item.provider deleted
Claim.item.serviceDate deleted
Claim.item.points deleted
Claim.item.detail.type deleted
Claim.item.detail.points deleted
Claim.item.detail.subDetail.type deleted
Claim.item.detail.subDetail.points deleted
Claim.additionalMaterials deleted
Claim.missingTeeth deleted

See the Full Difference for further information

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim DomainResourceClaim, Pre-determination or Pre-authorization
... identifier 0..*IdentifierClaim number
... status ?!Σ0..1codeactive | cancelled | draft | entered-in-error
Financial Resource Status Codes (Required)
... type 0..1CodeableConceptType or discipline
Example Claim Type Codes (Required)
... subType 0..*CodeableConceptFiner grained claim type information
Example Claim SubType Codes (Example)
... use 0..1codecomplete | proposed | exploratory | other
Use (Required)
... patient 0..1Reference(Patient)The subject of the Products and Services
... billablePeriod 0..1PeriodPeriod for charge submission
... created 0..1dateTimeCreation date
... enterer 0..1Reference(Practitioner)Author
... insurer 0..1Reference(Organization)Target
... provider 0..1Reference(Practitioner)Responsible provider
... organization 0..1Reference(Organization)Responsible organization
... priority 0..1CodeableConceptDesired processing priority
Priority Codes (Example)
... fundsReserve 0..1CodeableConceptFunds requested to be reserved
Funds Reservation Codes (Example)
... related 0..*BackboneElementRelated Claims which may be revelant to processing this claimn
.... claim 0..1Reference(Claim)Reference to the related claim
.... relationship 0..1CodeableConceptHow the reference claim is related
Example Related Claim Relationship Codes (Example)
.... reference 0..1IdentifierRelated file or case reference
... prescription 0..1Reference(MedicationRequest | VisionPrescription)Prescription
... originalPrescription 0..1Reference(MedicationRequest)Original Prescription
... payee 0..1BackboneElementParty to be paid any benefits payable
.... type 1..1CodeableConceptType of party: Subscriber, Provider, other
Payee Type Codes (Example)
.... resourceType 0..1Codingorganization | patient | practitioner | relatedperson
PayeeResourceType (Example)
.... party 0..1Reference(Practitioner | Organization | Patient | RelatedPerson)Party to receive the payable
... referral 0..1Reference(ReferralRequest)Treatment Referral
... facility 0..1Reference(Location)Servicing Facility
... careTeam 0..*BackboneElementMembers of the care team
.... sequence 1..1positiveIntNumber to covey order of careTeam
.... provider 1..1Reference(Practitioner | Organization)Provider individual or organization
.... responsible 0..1booleanBilling provider
.... role 0..1CodeableConceptRole on the team
Claim Care Team Role Codes (Example)
.... qualification 0..1CodeableConceptType, classification or Specialization
Example Provider Qualification Codes (Example)
... information 0..*BackboneElementExceptions, special considerations, the condition, situation, prior or concurrent issues
.... category 1..1CodeableConceptCategory of information
Claim Information Category Codes (Example)
.... code 0..1CodeableConceptType of information
Exception Codes (Example)
.... timing[x] 0..1When it occurred
..... timingDatedate
..... timingPeriodPeriod
.... value[x] 0..1Additional Data or supporting information
..... valueStringstring
..... valueQuantityQuantity
..... valueAttachmentAttachment
..... valueReferenceReference(Any)
.... reason 0..1CodeableConceptReason associated with the information
Missing Tooth Reason Codes (Example)
... diagnosis 0..*BackboneElementDiagnosis
.... sequence 1..1positiveIntNumber to covey order of diagnosis
.... diagnosis[x] 1..1Patient's diagnosis
ICD-10 Codes (Example)
..... diagnosisCodeableConceptCodeableConcept
..... diagnosisReferenceReference(Condition)
.... type 0..*CodeableConceptType of Diagnosis
Example Diagnosis Type Codes (Example)
.... packageCode 0..1CodeableConceptPackage billing code
Example Diagnosis Related Group Codes (Example)
... procedure 0..*BackboneElementProcedures performed
.... sequence 1..1positiveIntProcedure sequence for reference
.... date 0..1dateTimeWhen the procedure was performed
.... procedure[x] 1..1Patient's list of procedures performed
ICD-10 Procedure Codes (Example)
..... procedureCodeableConceptCodeableConcept
..... procedureReferenceReference(Procedure)
... insurance 0..*BackboneElementInsurance or medical plan
.... sequence 1..1positiveIntService instance identifier
.... focal 1..1booleanIs the focal Coverage
.... coverage 1..1Reference(Coverage)Insurance information
.... businessArrangement 0..1stringBusiness agreement
.... preAuthRef 0..*stringPre-Authorization/Determination Reference
.... claimResponse 0..1Reference(ClaimResponse)Adjudication results
... accident 0..1BackboneElementDetails about an accident
.... date 1..1dateWhen the accident occurred see information codes see information codes
.... type 0..1CodeableConceptThe nature of the accident
ActIncidentCode (Required)
.... location[x] 0..1Accident Place
..... locationAddressAddress
..... locationReferenceReference(Location)
... employmentImpacted 0..1PeriodPeriod unable to work
... hospitalization 0..1PeriodPeriod in hospital
... item 0..*BackboneElementGoods and Services
.... sequence 1..1positiveIntService instance
.... careTeamLinkId 0..*positiveIntApplicable careTeam members
.... diagnosisLinkId 0..*positiveIntApplicable diagnoses
.... procedureLinkId 0..*positiveIntApplicable procedures
.... informationLinkId 0..*positiveIntApplicable exception and supporting information
.... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
.... category 0..1CodeableConceptType of service or product
Benefit SubCategory Codes (Example)
.... service 0..1CodeableConceptBilling Code
USCLS Codes (Example)
.... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
.... programCode 0..*CodeableConceptProgram specific reason for item inclusion
Example Program Reason Codes (Example)
.... serviced[x] 0..1Date or dates of Service
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service
Example Service Place Codes (Example)
..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1SimpleQuantityCount of Products or Services
.... unitPrice 0..1MoneyFee, charge or cost per point
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... udi 0..*Reference(Device)Unique Device Identifier
.... bodySite 0..1CodeableConceptService Location
Oral Site Codes (Example)
.... subSite 0..*CodeableConceptService Sub-location
Surface Codes (Example)
.... detail 0..*BackboneElementAdditional items
..... sequence 1..1positiveIntService instance
..... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
..... category 0..1CodeableConceptType of service or product
Benefit SubCategory Codes (Example)
..... service 0..1CodeableConceptBilling Code
USCLS Codes (Example)
..... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
..... programCode 0..*CodeableConceptProgram specific reason for item inclusion
Example Program Reason Codes (Example)
..... quantity 0..1SimpleQuantityCount of Products or Services
..... unitPrice 0..1MoneyFee, charge or cost per point
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal additional item cost
..... udi 0..*Reference(Device)Unique Device Identifier
..... subDetail 0..*BackboneElementAdditional items
...... sequence 1..1positiveIntService instance
...... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
...... category 0..1CodeableConceptType of service or product
Benefit SubCategory Codes (Example)
...... service 0..1CodeableConceptBilling Code
USCLS Codes (Example)
...... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
...... programCode 0..*CodeableConceptProgram specific reason for item inclusion
Example Program Reason Codes (Example)
...... quantity 0..1SimpleQuantityCount of Products or Services
...... unitPrice 0..1MoneyFee, charge or cost per point
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyNet additional item cost
...... udi 0..*Reference(Device)Unique Device Identifier
.... prosthesis 0..1BackboneElementProsthetic details
..... initial 0..1booleanIs this the initial service
..... priorDate 0..1dateInitial service Date
..... priorMaterial 0..1CodeableConceptProsthetic Material
Oral Prostho Material type Codes (Example)
... total 0..1MoneyTotal claim cost

doco Documentation for this format

UML Diagram (Legend)

Claim (DomainResource)The business identifier for the instance: claim number, pre-determination or pre-authorization numberidentifier : Identifier [0..*]The status of the resource instance (this element modifies the meaning of other elements)status : code [0..1] « A code specifying the state of the resource instance. (Strength=Required)Financial Resource Status ! »The category of claim, eg, oral, pharmacy, vision, insitutional, professionaltype : CodeableConcept [0..1] « The type or discipline-style of the claim (Strength=Required)Example Claim Type ! »A finer grained suite of claim subtype codes which may convey Inpatient vs Outpatient and/or a specialty service. In the US the BillTypesubType : CodeableConcept [0..*] « A more granular claim typecode (Strength=Example)Example Claim SubType ?? »Complete (Bill or Claim), Proposed (Pre-Authorization), Exploratory (Pre-determination)use : code [0..1] « Complete, proposed, exploratory, other (Strength=Required)Use! »Patient Resourcepatient : Reference [0..1] « Patient »The billable period for which charges are being submittedbillablePeriod : Period [0..1]The date when the enclosed suite of services were performed or completedcreated : dateTime [0..1]Person who created the invoice/claim/pre-determination or pre-authorizationenterer : Reference [0..1] « Practitioner »The Insurer who is target of the requestinsurer : Reference [0..1] « Organization »The provider which is responsible for the bill, claim pre-determination, pre-authorizationprovider : Reference [0..1] « Practitioner »The organization which is responsible for the bill, claim pre-determination, pre-authorizationorganization : Reference [0..1] « Organization »Immediate (STAT), best effort (NORMAL), deferred (DEFER)priority : CodeableConcept [0..1] « The timeliness with which processing is required: STAT, normal, Deferred (Strength=Example)Priority ?? »In the case of a Pre-Determination/Pre-Authorization the provider may request that funds in the amount of the expected Benefit be reserved ('Patient' or 'Provider') to pay for the Benefits determined on the subsequent claim(s). 'None' explicitly indicates no funds reserving is requestedfundsReserve : CodeableConcept [0..1] « For whom funds are to be reserved: (Patient, Provider, None). (Strength=Example)Funds Reservation ?? »Prescription to support the dispensing of Pharmacy or Vision productsprescription : Reference [0..1] « MedicationRequest| VisionPrescription »Original prescription which has been superceded by this prescription to support the dispensing of pharmacy services, medications or products. For example, a physician may prescribe a medication which the pharmacy determines is contraindicated, or for which the patient has an intolerance, and therefor issues a new precription for an alternate medication which has the same theraputic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription'originalPrescription : Reference [0..1] « MedicationRequest »The referral resource which lists the date, practitioner, reason and other supporting informationreferral : Reference [0..1] « ReferralRequest »Facility where the services were providedfacility : Reference [0..1] « Location »The start and optional end dates of when the patient was precluded from working due to the treatable condition(s)employmentImpacted : Period [0..1]The start and optional end dates of when the patient was confined to a treatment centerhospitalization : Period [0..1]The total value of the claimtotal : Money [0..1]RelatedClaimOther claims which are related to this claim such as prior claim versions or for related servicesclaim : Reference [0..1] « Claim »For example prior or umbrellarelationship : CodeableConcept [0..1] « Relationship of this claim to a related Claim (Strength=Example)Example Related Claim Relatio...?? »An alternate organizational reference to the case or file to which this particular claim pertains - eg Property/Casualy insurer claim # or Workers Compensation case # reference : Identifier [0..1]PayeeType of Party to be reimbursed: Subscriber, provider, othertype : CodeableConcept [1..1] « A code for the party to be reimbursed. (Strength=Example)Payee Type ?? »organization | patient | practitioner | relatedpersonresourceType : Coding [0..1] « The type of payee Resource (Strength=Example)PayeeResourceType?? »Party to be reimbursed: Subscriber, provider, otherparty : Reference [0..1] « Practitioner|Organization|Patient| RelatedPerson »CareTeamSequence of the careTeam which serves to order and provide a linksequence : positiveInt [1..1]Member of the team who provided the overall serviceprovider : Reference [1..1] « Practitioner|Organization »The party who is billing and responsible for the claimed good or service rendered to the patientresponsible : boolean [0..1]The lead, assisting or supervising practitioner and their discipline if a multidisiplinary teamrole : CodeableConcept [0..1] « The role codes for the care team members. (Strength=Example)Claim Care Team Role ?? »The qualification which is applicable for this servicequalification : CodeableConcept [0..1] « Provider professional qualifications (Strength=Example)Example Provider Qualificatio...?? »SpecialConditionThe general class of the information supplied: information; exception; accident, employment; onset, etccategory : CodeableConcept [1..1] « The valuset used for additional information category codes. (Strength=Example)Claim Information Category ?? »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 adjudicationcode : CodeableConcept [0..1] « The valuset used for additional information codes. (Strength=Example)Exception ?? »The date when or period to which this information referstiming[x] : Type [0..1] « date|Period »Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the datavalue[x] : Type [0..1] « string|Quantity|Attachment|Reference(Any) »For example, provides the reason for: the additional stay, or missing tooth or any other situation where a reason code is required in addition to the contentreason : CodeableConcept [0..1] « Reason codes for the missing teeth (Strength=Example)Missing Tooth Reason ?? »DiagnosisSequence of diagnosis which serves to order and provide a linksequence : positiveInt [1..1]The diagnosisdiagnosis[x] : Type [1..1] « CodeableConcept|Reference(Condition); ICD10 Diagnostic codes (Strength=Example) ICD-10 ?? »The type of the Diagnosis, for example: admitting,type : CodeableConcept [0..*] « The type of the diagnosis: admitting, principal, discharge (Strength=Example)Example Diagnosis Type ?? »The package billing code, for example DRG, based on the assigned grouping code systempackageCode : CodeableConcept [0..1] « The DRG codes associated with the diagnosis (Strength=Example)Example Diagnosis Related Gro...?? »ProcedureSequence of procedures which serves to order and provide a linksequence : positiveInt [1..1]Date and optionally time the procedure was performed date : dateTime [0..1]The procedure codeprocedure[x] : Type [1..1] « CodeableConcept|Reference(Procedure); ICD10 Procedure codes (Strength=Example) ICD-10 Procedure ?? »InsuranceA service line itemsequence : positiveInt [1..1]A flag to indicate that this Coverage is the focus for adjudication. The Coverage against which the claim is to be adjudicatedfocal : boolean [1..1]Reference to the program or plan identification, underwriter or payorcoverage : Reference [1..1] « Coverage »The contract number of a business agreement which describes the terms and conditionsbusinessArrangement : string [0..1]A list of references from the Insurer to which these services pertainpreAuthRef : string [0..*]The Coverages adjudication detailsclaimResponse : Reference [0..1] « ClaimResponse »AccidentDate of an accident which these services are addressingdate : date [1..1]Type of accident: work, auto, etctype : CodeableConcept [0..1] « Type of accident: work place, auto, etc. (Strength=Required)ActIncidentCode! »Accident Placelocation[x] : Type [0..1] « Address|Reference(Location) »ItemA service line numbersequence : positiveInt [1..1]CareTeam applicable for this service or product linecareTeamLinkId : positiveInt [0..*]Diagnosis applicable for this service or product linediagnosisLinkId : positiveInt [0..*]Procedures applicable for this service or product lineprocedureLinkId : positiveInt [0..*]Exceptions, special conditions and supporting information pplicable for this service or product lineinformationLinkId : positiveInt [0..*]The type of reveneu or cost center providing the product and/or servicerevenue : CodeableConcept [0..1] « Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example)Example Revenue Center ?? »Health Care Service Type Codes to identify the classification of service or benefitscategory : CodeableConcept [0..1] « Benefit subcategories such as: oral-basic, major, glasses (Strength=Example)Benefit SubCategory ?? »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,RXNorm,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'service : CodeableConcept [0..1] « Allowable service and product codes (Strength=Example)USCLS ?? »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 hoursmodifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)Modifier type ?? »For programs which require reason codes for the inclusion or covering of this billed item under the program or sub-programprogramCode : CodeableConcept [0..*] « Program specific reason codes (Strength=Example)Example Program Reason ?? »The date or dates when the enclosed suite of services were performed or completedserviced[x] : Type [0..1] « date|Period »Where the service was providedlocation[x] : Type [0..1] « CodeableConcept|Address|Reference( Location); Place of service: pharmcy,school, prison, etc. (Strength=Example)Example Service Place ?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the groupunitPrice : Money [0..1]A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amountfactor : decimal [0..1]The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not suppliednet : Money [0..1]List of Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »Physical service site on the patient (limb, tooth, etc)bodySite : CodeableConcept [0..1] « The code for the teeth, quadrant, sextant and arch (Strength=Example)Oral Site ?? »A region or surface of the site, eg. limb region or tooth surface(s)subSite : CodeableConcept [0..*] « The code for the tooth surface and surface combinations (Strength=Example)Surface ?? »DetailA service line numbersequence : positiveInt [1..1]The type of reveneu or cost center providing the product and/or servicerevenue : CodeableConcept [0..1] « Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example)Example Revenue Center ?? »Health Care Service Type Codes to identify the classification of service or benefitscategory : CodeableConcept [0..1] « Benefit subcategories such as: oral-basic, major, glasses (Strength=Example)Benefit SubCategory ?? »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'service : CodeableConcept [0..1] « Allowable service and product codes (Strength=Example)USCLS ?? »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 hoursmodifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)Modifier type ?? »For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-programprogramCode : CodeableConcept [0..*] « Program specific reason codes (Strength=Example)Example Program Reason ?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the groupunitPrice : Money [0..1]A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amountfactor : decimal [0..1]The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not suppliednet : Money [0..1]List of Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »SubDetailA service line numbersequence : positiveInt [1..1]The type of reveneu or cost center providing the product and/or servicerevenue : CodeableConcept [0..1] « Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example)Example Revenue Center ?? »Health Care Service Type Codes to identify the classification of service or benefitscategory : CodeableConcept [0..1] « Benefit subcategories such as: oral-basic, major, glasses (Strength=Example)Benefit SubCategory ?? »A code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI)service : CodeableConcept [0..1] « Allowable service and product codes (Strength=Example)USCLS ?? »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 hoursmodifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)Modifier type ?? »For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-programprogramCode : CodeableConcept [0..*] « Program specific reason codes (Strength=Example)Example Program Reason ?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]The fee for an addittional service or product or chargeunitPrice : Money [0..1]A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amountfactor : decimal [0..1]The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not suppliednet : Money [0..1]List of Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »ProsthesisIndicates whether this is the initial placement of a fixed prosthesisinitial : boolean [0..1]Date of the initial placementpriorDate : date [0..1]Material of the prior denture or bridge prosthesis. (Oral)priorMaterial : CodeableConcept [0..1] « Material of the prior denture or bridge prosthesis. (Oral) (Strength=Example)Oral Prostho Material type ?? »Other claims which are related to this claim such as prior claim versions or for related servicesrelated[0..*]The party to be reimbursed for the servicespayee[0..1]The members of the team who provided the overall service as well as their role and whether responsible and qualificationscareTeam[0..*]Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. Often there are mutiple jurisdiction specific valuesets which are requiredinformation[0..*]Ordered list of patient diagnosis for which care is soughtdiagnosis[0..*]Ordered list of patient procedures performed to support the adjudicationprocedure[0..*]Financial instrument by which payment information for health careinsurance[0..*]An accident which resulted in the need for healthcare servicesaccident[0..1]Third tier of goods and servicessubDetail[0..*]Second tier of goods and servicesdetail[0..*]The materials and placement date of prior fixed prosthesisprosthesis[0..1]First tier of goods and servicesitem[0..*]

XML Template

<Claim xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Claim number --></identifier>
 <status value="[code]"/><!-- 0..1 active | cancelled | draft | entered-in-error -->
 <type><!-- 0..1 CodeableConcept Type or discipline --></type>
 <subType><!-- 0..* CodeableConcept Finer grained claim type information --></subType>
 <use value="[code]"/><!-- 0..1 complete | proposed | exploratory | other -->
 <patient><!-- 0..1 Reference(Patient) The subject of the Products and Services --></patient>
 <billablePeriod><!-- 0..1 Period Period for charge submission --></billablePeriod>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <enterer><!-- 0..1 Reference(Practitioner) Author --></enterer>
 <insurer><!-- 0..1 Reference(Organization) Target --></insurer>
 <provider><!-- 0..1 Reference(Practitioner) Responsible provider --></provider>
 <organization><!-- 0..1 Reference(Organization) Responsible organization --></organization>
 <priority><!-- 0..1 CodeableConcept Desired processing priority --></priority>
 <fundsReserve><!-- 0..1 CodeableConcept Funds requested to be reserved --></fundsReserve>
 <related>  <!-- 0..* Related Claims which may be revelant to processing this claimn -->
  <claim><!-- 0..1 Reference(Claim) Reference to the related claim --></claim>
  <relationship><!-- 0..1 CodeableConcept How the reference claim is related --></relationship>
  <reference><!-- 0..1 Identifier Related file or case reference --></reference>
 </related>
 <prescription><!-- 0..1 Reference(MedicationRequest|VisionPrescription) Prescription --></prescription>
 <originalPrescription><!-- 0..1 Reference(MedicationRequest) Original Prescription --></originalPrescription>
 <payee>  <!-- 0..1 Party to be paid any benefits payable -->
  <type><!-- 1..1 CodeableConcept Type of party: Subscriber, Provider, other --></type>
  <resourceType><!-- 0..1 Coding organization | patient | practitioner | relatedperson --></resourceType>
  <party><!-- 0..1 Reference(Practitioner|Organization|Patient|RelatedPerson) Party to receive the payable --></party>
 </payee>
 <referral><!-- 0..1 Reference(ReferralRequest) Treatment Referral --></referral>
 <facility><!-- 0..1 Reference(Location) Servicing Facility --></facility>
 <careTeam>  <!-- 0..* Members of the care team -->
  <sequence value="[positiveInt]"/><!-- 1..1 Number to covey order of careTeam -->
  <provider><!-- 1..1 Reference(Practitioner|Organization) Provider individual or organization --></provider>
  <responsible value="[boolean]"/><!-- 0..1 Billing provider -->
  <role><!-- 0..1 CodeableConcept Role on the team --></role>
  <qualification><!-- 0..1 CodeableConcept Type, classification or Specialization --></qualification>
 </careTeam>
 <information>  <!-- 0..* Exceptions, special considerations, the condition, situation, prior or concurrent issues -->
  <category><!-- 1..1 CodeableConcept Category of information --></category>
  <code><!-- 0..1 CodeableConcept Type of information --></code>
  <timing[x]><!-- 0..1 date|Period When it occurred --></timing[x]>
  <value[x]><!-- 0..1 string|Quantity|Attachment|Reference(Any) Additional Data or supporting information --></value[x]>
  <reason><!-- 0..1 CodeableConcept Reason associated with the information --></reason>
 </information>
 <diagnosis>  <!-- 0..* Diagnosis -->
  <sequence value="[positiveInt]"/><!-- 1..1 Number to covey order of diagnosis -->
  <diagnosis[x]><!-- 1..1 CodeableConcept|Reference(Condition) Patient's diagnosis --></diagnosis[x]>
  <type><!-- 0..* CodeableConcept Type of Diagnosis --></type>
  <packageCode><!-- 0..1 CodeableConcept Package billing code --></packageCode>
 </diagnosis>
 <procedure>  <!-- 0..* Procedures performed -->
  <sequence value="[positiveInt]"/><!-- 1..1 Procedure sequence for reference -->
  <date value="[dateTime]"/><!-- 0..1 When the procedure was performed -->
  <procedure[x]><!-- 1..1 CodeableConcept|Reference(Procedure) Patient's list of procedures performed --></procedure[x]>
 </procedure>
 <insurance>  <!-- 0..* Insurance or medical plan -->
  <sequence value="[positiveInt]"/><!-- 1..1 Service instance identifier -->
  <focal value="[boolean]"/><!-- 1..1 Is the focal Coverage -->
  <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage>
  <businessArrangement value="[string]"/><!-- 0..1 Business agreement -->
  <preAuthRef value="[string]"/><!-- 0..* Pre-Authorization/Determination Reference -->
  <claimResponse><!-- 0..1 Reference(ClaimResponse) Adjudication results --></claimResponse>
 </insurance>
 <accident>  <!-- 0..1 Details about an accident -->
  <date value="[date]"/><!-- 1..1 When the accident occurred
see information codes
see information codes -->
  <type><!-- 0..1 CodeableConcept The nature of the accident --></type>
  <location[x]><!-- 0..1 Address|Reference(Location) Accident Place --></location[x]>
 </accident>
 <employmentImpacted><!-- 0..1 Period Period unable to work --></employmentImpacted>
 <hospitalization><!-- 0..1 Period Period in hospital --></hospitalization>
 <item>  <!-- 0..* Goods and Services -->
  <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
  <careTeamLinkId value="[positiveInt]"/><!-- 0..* Applicable careTeam members -->
  <diagnosisLinkId value="[positiveInt]"/><!-- 0..* Applicable diagnoses -->
  <procedureLinkId value="[positiveInt]"/><!-- 0..* Applicable procedures -->
  <informationLinkId value="[positiveInt]"/><!-- 0..* Applicable exception and supporting information -->
  <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
  <category><!-- 0..1 CodeableConcept Type of service or product --></category>
  <service><!-- 0..1 CodeableConcept Billing Code --></service>
  <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
  <programCode><!-- 0..* CodeableConcept Program specific reason for item inclusion --></programCode>
  <serviced[x]><!-- 0..1 date|Period Date or dates of Service --></serviced[x]>
  <location[x]><!-- 0..1 CodeableConcept|Address|Reference(Location) Place of service --></location[x]>
  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
  <unitPrice><!-- 0..1 Money Fee, charge or cost per point --></unitPrice>
  <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
  <net><!-- 0..1 Money Total item cost --></net>
  <udi><!-- 0..* Reference(Device) Unique Device Identifier --></udi>
  <bodySite><!-- 0..1 CodeableConcept Service Location --></bodySite>
  <subSite><!-- 0..* CodeableConcept Service Sub-location --></subSite>
  <detail>  <!-- 0..* Additional items -->
   <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
   <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
   <category><!-- 0..1 CodeableConcept Type of service or product --></category>
   <service><!-- 0..1 CodeableConcept Billing Code --></service>
   <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
   <programCode><!-- 0..* CodeableConcept Program specific reason for item inclusion --></programCode>
   <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
   <unitPrice><!-- 0..1 Money Fee, charge or cost per point --></unitPrice>
   <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
   <net><!-- 0..1 Money Total additional item cost --></net>
   <udi><!-- 0..* Reference(Device) Unique Device Identifier --></udi>
   <subDetail>  <!-- 0..* Additional items -->
    <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
    <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
    <category><!-- 0..1 CodeableConcept Type of service or product --></category>
    <service><!-- 0..1 CodeableConcept Billing Code --></service>
    <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
    <programCode><!-- 0..* CodeableConcept Program specific reason for item inclusion --></programCode>
    <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
    <unitPrice><!-- 0..1 Money Fee, charge or cost per point --></unitPrice>
    <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
    <net><!-- 0..1 Money Net additional item cost --></net>
    <udi><!-- 0..* Reference(Device) Unique Device Identifier --></udi>
   </subDetail>
  </detail>
  <prosthesis>  <!-- 0..1 Prosthetic details -->
   <initial value="[boolean]"/><!-- 0..1 Is this the initial service -->
   <priorDate value="[date]"/><!-- 0..1 Initial service Date -->
   <priorMaterial><!-- 0..1 CodeableConcept Prosthetic Material --></priorMaterial>
  </prosthesis>
 </item>
 <total><!-- 0..1 Money Total claim cost --></total>
</Claim>

JSON Template

{doco
  "resourceType" : "Claim",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Claim number
  "status" : "<code>", // active | cancelled | draft | entered-in-error
  "type" : { CodeableConcept }, // Type or discipline
  "subType" : [{ CodeableConcept }], // Finer grained claim type information
  "use" : "<code>", // complete | proposed | exploratory | other
  "patient" : { Reference(Patient) }, // The subject of the Products and Services
  "billablePeriod" : { Period }, // Period for charge submission
  "created" : "<dateTime>", // Creation date
  "enterer" : { Reference(Practitioner) }, // Author
  "insurer" : { Reference(Organization) }, // Target
  "provider" : { Reference(Practitioner) }, // Responsible provider
  "organization" : { Reference(Organization) }, // Responsible organization
  "priority" : { CodeableConcept }, // Desired processing priority
  "fundsReserve" : { CodeableConcept }, // Funds requested to be reserved
  "related" : [{ // Related Claims which may be revelant to processing this claimn
    "claim" : { Reference(Claim) }, // Reference to the related claim
    "relationship" : { CodeableConcept }, // How the reference claim is related
    "reference" : { Identifier } // Related file or case reference
  }],
  "prescription" : { Reference(MedicationRequest|VisionPrescription) }, // Prescription
  "originalPrescription" : { Reference(MedicationRequest) }, // Original Prescription
  "payee" : { // Party to be paid any benefits payable
    "type" : { CodeableConcept }, // R!  Type of party: Subscriber, Provider, other
    "resourceType" : { Coding }, // organization | patient | practitioner | relatedperson
    "party" : { Reference(Practitioner|Organization|Patient|RelatedPerson) } // Party to receive the payable
  },
  "referral" : { Reference(ReferralRequest) }, // Treatment Referral
  "facility" : { Reference(Location) }, // Servicing Facility
  "careTeam" : [{ // Members of the care team
    "sequence" : "<positiveInt>", // R!  Number to covey order of careTeam
    "provider" : { Reference(Practitioner|Organization) }, // R!  Provider individual or organization
    "responsible" : <boolean>, // Billing provider
    "role" : { CodeableConcept }, // Role on the team
    "qualification" : { CodeableConcept } // Type, classification or Specialization
  }],
  "information" : [{ // Exceptions, special considerations, the condition, situation, prior or concurrent issues
    "category" : { CodeableConcept }, // R!  Category of information
    "code" : { CodeableConcept }, // Type of information
    // timing[x]: When it occurred. One of these 2:
    "timingDate" : "<date>",
    "timingPeriod" : { Period },
    // value[x]: Additional Data or supporting information. One of these 4:
    "valueString" : "<string>",
    "valueQuantity" : { Quantity },
    "valueAttachment" : { Attachment },
    "valueReference" : { Reference(Any) },
    "reason" : { CodeableConcept } // Reason associated with the information
  }],
  "diagnosis" : [{ // Diagnosis
    "sequence" : "<positiveInt>", // R!  Number to covey order of diagnosis
    // diagnosis[x]: Patient's diagnosis. One of these 2:
    "diagnosisCodeableConcept" : { CodeableConcept },
    "diagnosisReference" : { Reference(Condition) },
    "type" : [{ CodeableConcept }], // Type of Diagnosis
    "packageCode" : { CodeableConcept } // Package billing code
  }],
  "procedure" : [{ // Procedures performed
    "sequence" : "<positiveInt>", // R!  Procedure sequence for reference
    "date" : "<dateTime>", // When the procedure was performed
    // procedure[x]: Patient's list of procedures performed. One of these 2:
    "procedureCodeableConcept" : { CodeableConcept }
    "procedureReference" : { Reference(Procedure) }
  }],
  "insurance" : [{ // Insurance or medical plan
    "sequence" : "<positiveInt>", // R!  Service instance identifier
    "focal" : <boolean>, // R!  Is the focal Coverage
    "coverage" : { Reference(Coverage) }, // R!  Insurance information
    "businessArrangement" : "<string>", // Business agreement
    "preAuthRef" : ["<string>"], // Pre-Authorization/Determination Reference
    "claimResponse" : { Reference(ClaimResponse) } // Adjudication results
  }],
  "accident" : { // Details about an accident
    "date" : "<date>", // R!  When the accident occurred
see information codes
see information codes
    "type" : { CodeableConcept }, // The nature of the accident
    // location[x]: Accident Place. One of these 2:
    "locationAddress" : { Address }
    "locationReference" : { Reference(Location) }
  },
  "employmentImpacted" : { Period }, // Period unable to work
  "hospitalization" : { Period }, // Period in hospital
  "item" : [{ // Goods and Services
    "sequence" : "<positiveInt>", // R!  Service instance
    "careTeamLinkId" : ["<positiveInt>"], // Applicable careTeam members
    "diagnosisLinkId" : ["<positiveInt>"], // Applicable diagnoses
    "procedureLinkId" : ["<positiveInt>"], // Applicable procedures
    "informationLinkId" : ["<positiveInt>"], // Applicable exception and supporting information
    "revenue" : { CodeableConcept }, // Revenue or cost center code
    "category" : { CodeableConcept }, // Type of service or product
    "service" : { CodeableConcept }, // Billing Code
    "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
    "programCode" : [{ CodeableConcept }], // Program specific reason for item inclusion
    // serviced[x]: Date or dates of Service. One of these 2:
    "servicedDate" : "<date>",
    "servicedPeriod" : { Period },
    // location[x]: Place of service. One of these 3:
    "locationCodeableConcept" : { CodeableConcept },
    "locationAddress" : { Address },
    "locationReference" : { Reference(Location) },
    "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
    "unitPrice" : { Money }, // Fee, charge or cost per point
    "factor" : <decimal>, // Price scaling factor
    "net" : { Money }, // Total item cost
    "udi" : [{ Reference(Device) }], // Unique Device Identifier
    "bodySite" : { CodeableConcept }, // Service Location
    "subSite" : [{ CodeableConcept }], // Service Sub-location
    "detail" : [{ // Additional items
      "sequence" : "<positiveInt>", // R!  Service instance
      "revenue" : { CodeableConcept }, // Revenue or cost center code
      "category" : { CodeableConcept }, // Type of service or product
      "service" : { CodeableConcept }, // Billing Code
      "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
      "programCode" : [{ CodeableConcept }], // Program specific reason for item inclusion
      "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
      "unitPrice" : { Money }, // Fee, charge or cost per point
      "factor" : <decimal>, // Price scaling factor
      "net" : { Money }, // Total additional item cost
      "udi" : [{ Reference(Device) }], // Unique Device Identifier
      "subDetail" : [{ // Additional items
        "sequence" : "<positiveInt>", // R!  Service instance
        "revenue" : { CodeableConcept }, // Revenue or cost center code
        "category" : { CodeableConcept }, // Type of service or product
        "service" : { CodeableConcept }, // Billing Code
        "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
        "programCode" : [{ CodeableConcept }], // Program specific reason for item inclusion
        "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
        "unitPrice" : { Money }, // Fee, charge or cost per point
        "factor" : <decimal>, // Price scaling factor
        "net" : { Money }, // Net additional item cost
        "udi" : [{ Reference(Device) }] // Unique Device Identifier
      }]
    }],
    "prosthesis" : { // Prosthetic details
      "initial" : <boolean>, // Is this the initial service
      "priorDate" : "<date>", // Initial service Date
      "priorMaterial" : { CodeableConcept } // Prosthetic Material
    }
  }],
  "total" : { Money } // Total claim cost
}

Turtle Template

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


[ a fhir:Claim;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:Claim.identifier [ Identifier ], ... ; # 0..* Claim number
  fhir:Claim.status [ code ]; # 0..1 active | cancelled | draft | entered-in-error
  fhir:Claim.type [ CodeableConcept ]; # 0..1 Type or discipline
  fhir:Claim.subType [ CodeableConcept ], ... ; # 0..* Finer grained claim type information
  fhir:Claim.use [ code ]; # 0..1 complete | proposed | exploratory | other
  fhir:Claim.patient [ Reference(Patient) ]; # 0..1 The subject of the Products and Services
  fhir:Claim.billablePeriod [ Period ]; # 0..1 Period for charge submission
  fhir:Claim.created [ dateTime ]; # 0..1 Creation date
  fhir:Claim.enterer [ Reference(Practitioner) ]; # 0..1 Author
  fhir:Claim.insurer [ Reference(Organization) ]; # 0..1 Target
  fhir:Claim.provider [ Reference(Practitioner) ]; # 0..1 Responsible provider
  fhir:Claim.organization [ Reference(Organization) ]; # 0..1 Responsible organization
  fhir:Claim.priority [ CodeableConcept ]; # 0..1 Desired processing priority
  fhir:Claim.fundsReserve [ CodeableConcept ]; # 0..1 Funds requested to be reserved
  fhir:Claim.related [ # 0..* Related Claims which may be revelant to processing this claimn
    fhir:Claim.related.claim [ Reference(Claim) ]; # 0..1 Reference to the related claim
    fhir:Claim.related.relationship [ CodeableConcept ]; # 0..1 How the reference claim is related
    fhir:Claim.related.reference [ Identifier ]; # 0..1 Related file or case reference
  ], ...;
  fhir:Claim.prescription [ Reference(MedicationRequest|VisionPrescription) ]; # 0..1 Prescription
  fhir:Claim.originalPrescription [ Reference(MedicationRequest) ]; # 0..1 Original Prescription
  fhir:Claim.payee [ # 0..1 Party to be paid any benefits payable
    fhir:Claim.payee.type [ CodeableConcept ]; # 1..1 Type of party: Subscriber, Provider, other
    fhir:Claim.payee.resourceType [ Coding ]; # 0..1 organization | patient | practitioner | relatedperson
    fhir:Claim.payee.party [ Reference(Practitioner|Organization|Patient|RelatedPerson) ]; # 0..1 Party to receive the payable
  ];
  fhir:Claim.referral [ Reference(ReferralRequest) ]; # 0..1 Treatment Referral
  fhir:Claim.facility [ Reference(Location) ]; # 0..1 Servicing Facility
  fhir:Claim.careTeam [ # 0..* Members of the care team
    fhir:Claim.careTeam.sequence [ positiveInt ]; # 1..1 Number to covey order of careTeam
    fhir:Claim.careTeam.provider [ Reference(Practitioner|Organization) ]; # 1..1 Provider individual or organization
    fhir:Claim.careTeam.responsible [ boolean ]; # 0..1 Billing provider
    fhir:Claim.careTeam.role [ CodeableConcept ]; # 0..1 Role on the team
    fhir:Claim.careTeam.qualification [ CodeableConcept ]; # 0..1 Type, classification or Specialization
  ], ...;
  fhir:Claim.information [ # 0..* Exceptions, special considerations, the condition, situation, prior or concurrent issues
    fhir:Claim.information.category [ CodeableConcept ]; # 1..1 Category of information
    fhir:Claim.information.code [ CodeableConcept ]; # 0..1 Type of information
    # Claim.information.timing[x] : 0..1 When it occurred. One of these 2
      fhir:Claim.information.timingDate [ date ]
      fhir:Claim.information.timingPeriod [ Period ]
    # Claim.information.value[x] : 0..1 Additional Data or supporting information. One of these 4
      fhir:Claim.information.valueString [ string ]
      fhir:Claim.information.valueQuantity [ Quantity ]
      fhir:Claim.information.valueAttachment [ Attachment ]
      fhir:Claim.information.valueReference [ Reference(Any) ]
    fhir:Claim.information.reason [ CodeableConcept ]; # 0..1 Reason associated with the information
  ], ...;
  fhir:Claim.diagnosis [ # 0..* Diagnosis
    fhir:Claim.diagnosis.sequence [ positiveInt ]; # 1..1 Number to covey order of diagnosis
    # Claim.diagnosis.diagnosis[x] : 1..1 Patient's diagnosis. One of these 2
      fhir:Claim.diagnosis.diagnosisCodeableConcept [ CodeableConcept ]
      fhir:Claim.diagnosis.diagnosisReference [ Reference(Condition) ]
    fhir:Claim.diagnosis.type [ CodeableConcept ], ... ; # 0..* Type of Diagnosis
    fhir:Claim.diagnosis.packageCode [ CodeableConcept ]; # 0..1 Package billing code
  ], ...;
  fhir:Claim.procedure [ # 0..* Procedures performed
    fhir:Claim.procedure.sequence [ positiveInt ]; # 1..1 Procedure sequence for reference
    fhir:Claim.procedure.date [ dateTime ]; # 0..1 When the procedure was performed
    # Claim.procedure.procedure[x] : 1..1 Patient's list of procedures performed. One of these 2
      fhir:Claim.procedure.procedureCodeableConcept [ CodeableConcept ]
      fhir:Claim.procedure.procedureReference [ Reference(Procedure) ]
  ], ...;
  fhir:Claim.insurance [ # 0..* Insurance or medical plan
    fhir:Claim.insurance.sequence [ positiveInt ]; # 1..1 Service instance identifier
    fhir:Claim.insurance.focal [ boolean ]; # 1..1 Is the focal Coverage
    fhir:Claim.insurance.coverage [ Reference(Coverage) ]; # 1..1 Insurance information
    fhir:Claim.insurance.businessArrangement [ string ]; # 0..1 Business agreement
    fhir:Claim.insurance.preAuthRef [ string ], ... ; # 0..* Pre-Authorization/Determination Reference
    fhir:Claim.insurance.claimResponse [ Reference(ClaimResponse) ]; # 0..1 Adjudication results
  ], ...;
  fhir:Claim.accident [ # 0..1 Details about an accident
    fhir:Claim.accident.date [ date ]; # 1..1 When the accident occurred
see information codes
see information codes
    fhir:Claim.accident.type [ CodeableConcept ]; # 0..1 The nature of the accident
    # Claim.accident.location[x] : 0..1 Accident Place. One of these 2
      fhir:Claim.accident.locationAddress [ Address ]
      fhir:Claim.accident.locationReference [ Reference(Location) ]
  ];
  fhir:Claim.employmentImpacted [ Period ]; # 0..1 Period unable to work
  fhir:Claim.hospitalization [ Period ]; # 0..1 Period in hospital
  fhir:Claim.item [ # 0..* Goods and Services
    fhir:Claim.item.sequence [ positiveInt ]; # 1..1 Service instance
    fhir:Claim.item.careTeamLinkId [ positiveInt ], ... ; # 0..* Applicable careTeam members
    fhir:Claim.item.diagnosisLinkId [ positiveInt ], ... ; # 0..* Applicable diagnoses
    fhir:Claim.item.procedureLinkId [ positiveInt ], ... ; # 0..* Applicable procedures
    fhir:Claim.item.informationLinkId [ positiveInt ], ... ; # 0..* Applicable exception and supporting information
    fhir:Claim.item.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
    fhir:Claim.item.category [ CodeableConcept ]; # 0..1 Type of service or product
    fhir:Claim.item.service [ CodeableConcept ]; # 0..1 Billing Code
    fhir:Claim.item.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
    fhir:Claim.item.programCode [ CodeableConcept ], ... ; # 0..* Program specific reason for item inclusion
    # Claim.item.serviced[x] : 0..1 Date or dates of Service. One of these 2
      fhir:Claim.item.servicedDate [ date ]
      fhir:Claim.item.servicedPeriod [ Period ]
    # Claim.item.location[x] : 0..1 Place of service. One of these 3
      fhir:Claim.item.locationCodeableConcept [ CodeableConcept ]
      fhir:Claim.item.locationAddress [ Address ]
      fhir:Claim.item.locationReference [ Reference(Location) ]
    fhir:Claim.item.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of Products or Services
    fhir:Claim.item.unitPrice [ Money ]; # 0..1 Fee, charge or cost per point
    fhir:Claim.item.factor [ decimal ]; # 0..1 Price scaling factor
    fhir:Claim.item.net [ Money ]; # 0..1 Total item cost
    fhir:Claim.item.udi [ Reference(Device) ], ... ; # 0..* Unique Device Identifier
    fhir:Claim.item.bodySite [ CodeableConcept ]; # 0..1 Service Location
    fhir:Claim.item.subSite [ CodeableConcept ], ... ; # 0..* Service Sub-location
    fhir:Claim.item.detail [ # 0..* Additional items
      fhir:Claim.item.detail.sequence [ positiveInt ]; # 1..1 Service instance
      fhir:Claim.item.detail.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
      fhir:Claim.item.detail.category [ CodeableConcept ]; # 0..1 Type of service or product
      fhir:Claim.item.detail.service [ CodeableConcept ]; # 0..1 Billing Code
      fhir:Claim.item.detail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
      fhir:Claim.item.detail.programCode [ CodeableConcept ], ... ; # 0..* Program specific reason for item inclusion
      fhir:Claim.item.detail.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of Products or Services
      fhir:Claim.item.detail.unitPrice [ Money ]; # 0..1 Fee, charge or cost per point
      fhir:Claim.item.detail.factor [ decimal ]; # 0..1 Price scaling factor
      fhir:Claim.item.detail.net [ Money ]; # 0..1 Total additional item cost
      fhir:Claim.item.detail.udi [ Reference(Device) ], ... ; # 0..* Unique Device Identifier
      fhir:Claim.item.detail.subDetail [ # 0..* Additional items
        fhir:Claim.item.detail.subDetail.sequence [ positiveInt ]; # 1..1 Service instance
        fhir:Claim.item.detail.subDetail.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
        fhir:Claim.item.detail.subDetail.category [ CodeableConcept ]; # 0..1 Type of service or product
        fhir:Claim.item.detail.subDetail.service [ CodeableConcept ]; # 0..1 Billing Code
        fhir:Claim.item.detail.subDetail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
        fhir:Claim.item.detail.subDetail.programCode [ CodeableConcept ], ... ; # 0..* Program specific reason for item inclusion
        fhir:Claim.item.detail.subDetail.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of Products or Services
        fhir:Claim.item.detail.subDetail.unitPrice [ Money ]; # 0..1 Fee, charge or cost per point
        fhir:Claim.item.detail.subDetail.factor [ decimal ]; # 0..1 Price scaling factor
        fhir:Claim.item.detail.subDetail.net [ Money ]; # 0..1 Net additional item cost
        fhir:Claim.item.detail.subDetail.udi [ Reference(Device) ], ... ; # 0..* Unique Device Identifier
      ], ...;
    ], ...;
    fhir:Claim.item.prosthesis [ # 0..1 Prosthetic details
      fhir:Claim.item.prosthesis.initial [ boolean ]; # 0..1 Is this the initial service
      fhir:Claim.item.prosthesis.priorDate [ date ]; # 0..1 Initial service Date
      fhir:Claim.item.prosthesis.priorMaterial [ CodeableConcept ]; # 0..1 Prosthetic Material
    ];
  ], ...;
  fhir:Claim.total [ Money ]; # 0..1 Total claim cost
]

Changes since DSTU2

Claim
Claim.status added Element
Claim.type Min Cardinality changed from 1 to 0
Type changed from code to CodeableConcept
Change value set from http://hl7.org/fhir/ValueSet/claim-type-link to http://hl7.org/fhir/ValueSet/claim-type
Claim.subType added Element
Claim.use Change value set from http://hl7.org/fhir/ValueSet/claim-use-link to http://hl7.org/fhir/ValueSet/claim-use
Claim.patient Min Cardinality changed from 1 to 0
Claim.billablePeriod added Element
Claim.insurer added Element
Claim.priority Type changed from Coding to CodeableConcept
Claim.fundsReserve Type changed from Coding to CodeableConcept
Claim.related added Element
Claim.related.claim added Element
Claim.related.relationship added Element
Claim.related.reference added Element
Claim.prescription Remove Reference(MedicationOrder), Add Reference(MedicationRequest)
Claim.originalPrescription Type changed from Reference(MedicationOrder) to Reference(MedicationRequest)
Claim.payee.type Min Cardinality changed from 0 to 1
Type changed from Coding to CodeableConcept
Claim.payee.resourceType added Element
Claim.payee.party added Element
Claim.careTeam added Element
Claim.careTeam.sequence added Element
Claim.careTeam.provider added Element
Claim.careTeam.responsible added Element
Claim.careTeam.role added Element
Claim.careTeam.qualification added Element
Claim.information added Element
Claim.information.category added Element
Claim.information.code added Element
Claim.information.timing[x] added Element
Claim.information.value[x] added Element
Claim.information.reason added Element
Claim.diagnosis.diagnosis[x] Renamed from diagnosis to diagnosis[x]
Remove Coding, Add CodeableConcept, Add Reference(Condition)
Claim.diagnosis.type added Element
Claim.diagnosis.packageCode added Element
Claim.procedure added Element
Claim.procedure.sequence added Element
Claim.procedure.date added Element
Claim.procedure.procedure[x] added Element
Claim.insurance added Element
Claim.insurance.sequence added Element
Claim.insurance.focal added Element
Claim.insurance.coverage added Element
Claim.insurance.businessArrangement added Element
Claim.insurance.preAuthRef added Element
Claim.insurance.claimResponse added Element
Claim.accident Type changed from date to BackboneElement
Claim.accident.date added Element
Claim.accident.type added Element
Claim.accident.location[x] added Element
Claim.employmentImpacted added Element
Claim.hospitalization added Element
Claim.item.careTeamLinkId added Element
Claim.item.procedureLinkId added Element
Claim.item.informationLinkId added Element
Claim.item.revenue added Element
Claim.item.category added Element
Claim.item.service Min Cardinality changed from 1 to 0
Type changed from Coding to CodeableConcept
Claim.item.modifier Type changed from Coding to CodeableConcept
Claim.item.programCode added Element
Claim.item.serviced[x] added Element
Claim.item.location[x] added Element
Claim.item.unitPrice Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money
Claim.item.net Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money
Claim.item.udi Max Cardinality changed from 1 to *
Type changed from Coding to Reference(Device)
Claim.item.bodySite Type changed from Coding to CodeableConcept
Claim.item.subSite Type changed from Coding to CodeableConcept
Claim.item.detail.revenue added Element
Claim.item.detail.category added Element
Claim.item.detail.service Min Cardinality changed from 1 to 0
Type changed from Coding to CodeableConcept
Claim.item.detail.modifier added Element
Claim.item.detail.programCode added Element
Claim.item.detail.unitPrice Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money
Claim.item.detail.net Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money
Claim.item.detail.udi Max Cardinality changed from 1 to *
Type changed from Coding to Reference(Device)
Claim.item.detail.subDetail.revenue added Element
Claim.item.detail.subDetail.category added Element
Claim.item.detail.subDetail.service Min Cardinality changed from 1 to 0
Type changed from Coding to CodeableConcept
Claim.item.detail.subDetail.modifier added Element
Claim.item.detail.subDetail.programCode added Element
Claim.item.detail.subDetail.unitPrice Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money
Claim.item.detail.subDetail.net Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money
Claim.item.detail.subDetail.udi Max Cardinality changed from 1 to *
Type changed from Coding to Reference(Device)
Claim.item.prosthesis.priorMaterial Type changed from Coding to CodeableConcept
Claim.total added Element
Claim.ruleset deleted
Claim.originalRuleset deleted
Claim.target deleted
Claim.payee.provider deleted
Claim.payee.organization deleted
Claim.payee.person deleted
Claim.condition deleted
Claim.coverage deleted
Claim.exception deleted
Claim.school deleted
Claim.accidentType deleted
Claim.interventionException deleted
Claim.item.type deleted
Claim.item.provider deleted
Claim.item.serviceDate deleted
Claim.item.points deleted
Claim.item.detail.type deleted
Claim.item.detail.points deleted
Claim.item.detail.subDetail.type deleted
Claim.item.detail.subDetail.points deleted
Claim.additionalMaterials deleted
Claim.missingTeeth deleted

See the Full Difference for further information

 

Alternate definitions: Master Definition (XML, JSON), XML Schema/Schematron (for ) + JSON Schema, ShEx (for Turtle), JSON-LD (for RDF as JSON-LD),

13.1.2.1 Terminology Bindings

PathDefinitionTypeReference
Claim.status A code specifying the state of the resource instance.RequiredFinancial Resource Status Codes
Claim.type The type or discipline-style of the claimRequiredExample Claim Type Codes
Claim.subType A more granular claim typecodeExampleExample Claim SubType Codes
Claim.use Complete, proposed, exploratory, otherRequiredUse
Claim.priority The timeliness with which processing is required: STAT, normal, DeferredExamplePriority Codes
Claim.fundsReserve For whom funds are to be reserved: (Patient, Provider, None).ExampleFunds Reservation Codes
Claim.related.relationship Relationship of this claim to a related ClaimExampleExample Related Claim Relationship Codes
Claim.payee.type A code for the party to be reimbursed.ExamplePayee Type Codes
Claim.payee.resourceType The type of payee ResourceExamplePayeeResourceType
Claim.careTeam.role The role codes for the care team members.ExampleClaim Care Team Role Codes
Claim.careTeam.qualification Provider professional qualificationsExampleExample Provider Qualification Codes
Claim.information.category The valuset used for additional information category codes.ExampleClaim Information Category Codes
Claim.information.code The valuset used for additional information codes.ExampleException Codes
Claim.information.reason Reason codes for the missing teethExampleMissing Tooth Reason Codes
Claim.diagnosis.diagnosis[x] ICD10 Diagnostic codesExampleICD-10 Codes
Claim.diagnosis.type The type of the diagnosis: admitting, principal, dischargeExampleExample Diagnosis Type Codes
Claim.diagnosis.packageCode The DRG codes associated with the diagnosisExampleExample Diagnosis Related Group Codes
Claim.procedure.procedure[x] ICD10 Procedure codesExampleICD-10 Procedure Codes
Claim.accident.type Type of accident: work place, auto, etc.RequiredActIncidentCode
Claim.item.revenue
Claim.item.detail.revenue
Claim.item.detail.subDetail.revenue 		Codes for the revenue or cost centers supplying the service and/or products.ExampleExample Revenue Center Codes
Claim.item.category
Claim.item.detail.category
Claim.item.detail.subDetail.category 		Benefit subcategories such as: oral-basic, major, glassesExampleBenefit SubCategory Codes
Claim.item.service
Claim.item.detail.service
Claim.item.detail.subDetail.service 		Allowable service and product codesExampleUSCLS Codes
Claim.item.modifier
Claim.item.detail.modifier
Claim.item.detail.subDetail.modifier 		Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.ExampleModifier type Codes
Claim.item.programCode
Claim.item.detail.programCode
Claim.item.detail.subDetail.programCode 		Program specific reason codesExampleExample Program Reason Codes
Claim.item.location[x] Place of service: pharmcy,school, prison, etc.ExampleExample Service Place Codes
Claim.item.bodySite The code for the teeth, quadrant, sextant and archExampleOral Site Codes
Claim.item.subSite The code for the tooth surface and surface combinationsExampleSurface Codes
Claim.item.prosthesis.priorMaterial Material of the prior denture or bridge prosthesis. (Oral)ExampleOral Prostho Material type Codes

13.1.3 Search Parameters

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

NameTypeDescriptionPathsIn Common
createddateThe creation date for the ClaimClaim.created
facilityreferenceFacility responsible for the goods and servicesClaim.facility
(Location)
identifiertokenThe primary identifier of the financial resourceClaim.identifier
insurerreferenceThe target payor/insurer for the ClaimClaim.insurer
(Organization)
organizationreferenceThe reference to the providing organizationClaim.organization
(Organization)
patientreferencePatient receiving the servicesClaim.patient
(Patient)
prioritytokenProcessing priority requestedClaim.priority
providerreferenceProvider responsible for the ClaimClaim.provider
(Practitioner)
usetokenThe kind of financial resourceClaim.use