R4 Ballot #1 (Mixed Normative/Trial use)
This page is part of the FHIR Specification (v3.3.0: R4 Ballot 2). 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
| Financial Management Work Group | Maturity Level: N/A | Ballot Status: Informative | Compartments: Encounter, Patient, Practitioner, RelatedPerson |
StructureDefinition for claim
Financial
{
"resourceType": "StructureDefinition",
"id": "Claim",
"meta": {
"lastUpdated": "2018-04-03T12:05:46.262+10:00"
},
"text": {
"status": "generated",
"div": "<div>!-- Snipped for Brevity --></div>"
},
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-ballot-status",
"valueString": "Trial Use"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm",
"valueInteger": 2
},
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
"valueCode": "fm"
}
],
"url": "http://hl7.org/fhir/StructureDefinition/Claim",
"name": "Claim",
"status": "draft",
"date": "2018-04-03T12:05:46+10:00",
"publisher": "Health Level Seven International (Financial Management)",
"contact": [
{
"telecom": [
{
"system": "url",
"value": "http://hl7.org/fhir"
}
]
},
{
"telecom": [
{
"system": "url",
"value": "http://www.hl7.org/Special/committees/fm/index.cfm"
}
]
}
],
"description": "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.",
"fhirVersion": "3.3.0",
"mapping": [
{
"identity": "workflow",
"uri": "http://hl7.org/fhir/workflow",
"name": "Workflow Pattern"
},
{
"identity": "w5",
"uri": "http://hl7.org/fhir/fivews",
"name": "FiveWs Pattern"
},
{
"identity": "rim",
"uri": "http://hl7.org/v3",
"name": "RIM Mapping"
}
],
"kind": "resource",
"abstract": false,
"type": "Claim",
"baseDefinition": "http://hl7.org/fhir/StructureDefinition/DomainResource",
"derivation": "specialization",
"snapshot": {
"element": [
{
"id": "Claim",
"path": "Claim",
"short": "Claim, Pre-determination or Pre-authorization",
"definition": "A provider issued list of services and products provided, or to be provided, to a patient which is provided to an insurer for payment recovery.",
"min": 0,
"max": "*",
"base": {
"path": "Claim",
"min": 0,
"max": "*"
},
"constraint": [
{
"key": "dom-2",
"severity": "error",
"human": "If the resource is contained in another resource, it SHALL NOT contain nested Resources",
"expression": "contained.contained.empty()",
"xpath": "not(parent::f:contained and f:contained)",
"source": "DomainResource"
},
{
"key": "dom-1",
"severity": "error",
"human": "If the resource is contained in another resource, it SHALL NOT contain any narrative",
"expression": "contained.text.empty()",
"xpath": "not(parent::f:contained and f:text)",
"source": "DomainResource"
},
{
"key": "dom-4",
"severity": "error",
"human": "If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated",
"expression": "contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()",
"xpath": "not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))",
"source": "DomainResource"
},
{
"key": "dom-3",
"severity": "error",
"human": "If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource",
"expression": "contained.all(('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists())",
"xpath": "not(exists(for $contained in f:contained return $contained[not(parent::*/descendant::f:reference/@value=concat('#', $contained/*/id/@value) or descendant::f:reference[@value='#'])]))",
"source": "DomainResource"
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "rim",
"map": "Entity. Role, or Act"
},
{
"identity": "workflow",
"map": "Request"
}
]
},
{
"id": "Claim.id",
"path": "Claim.id",
"short": "Logical id of this artifact",
"definition": "The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.",
"comment": "The only time that a resource does not have an id is when it is being submitted to the server using a create operation.",
"min": 0,
"max": "1",
"base": {
"path": "Resource.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "id"
}
],
"isModifier": false,
"isSummary": true
},
{
"id": "Claim.meta",
"path": "Claim.meta",
"short": "Metadata about the resource",
"definition": "The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.",
"min": 0,
"max": "1",
"base": {
"path": "Resource.meta",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Meta"
}
],
"isModifier": false,
"isSummary": true
},
{
"id": "Claim.implicitRules",
"path": "Claim.implicitRules",
"short": "A set of rules under which this content was created",
"definition": "A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.",
"comment": "Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.",
"min": 0,
"max": "1",
"base": {
"path": "Resource.implicitRules",
"min": 0,
"max": "1"
},
"type": [
{
"code": "uri"
}
],
"isModifier": true,
"isModifierReason": "This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation",
"isSummary": true
},
{
"id": "Claim.language",
"path": "Claim.language",
"short": "Language of the resource content",
"definition": "The base language in which the resource is written.",
"comment": "Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).",
"min": 0,
"max": "1",
"base": {
"path": "Resource.language",
"min": 0,
"max": "1"
},
"type": [
{
"code": "code"
}
],
"isModifier": false,
"isSummary": false,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-maxValueSet",
"valueReference": {
"reference": "http://hl7.org/fhir/ValueSet/all-languages"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Language"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
}
],
"strength": "extensible",
"description": "A human language.",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/languages"
}
},
{
"id": "Claim.text",
"path": "Claim.text",
"short": "Text summary of the resource, for human interpretation",
"definition": "A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it \"clinically safe\" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.",
"comment": "Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a \"text blob\" or where text is additionally entered raw or narrated and encoded in formation is added later.",
"alias": [
"narrative",
"html",
"xhtml",
"display"
],
"min": 0,
"max": "1",
"base": {
"path": "DomainResource.text",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Narrative"
}
],
"condition": [
"dom-1"
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "rim",
"map": "Act.text?"
}
]
},
{
"id": "Claim.contained",
"path": "Claim.contained",
"short": "Contained, inline Resources",
"definition": "These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.",
"comment": "This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again.",
"alias": [
"inline resources",
"anonymous resources",
"contained resources"
],
"min": 0,
"max": "*",
"base": {
"path": "DomainResource.contained",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Resource"
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "Claim.extension",
"path": "Claim.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "DomainResource.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "Claim.modifierExtension",
"path": "Claim.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the resource, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "DomainResource.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isModifierReason": "Not known why this is labelled a modifier",
"isSummary": false,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "Claim.identifier",
"path": "Claim.identifier",
"short": "Claim number",
"definition": "The business identifier for the instance: claim number, pre-determination or pre-authorization number.",
"min": 0,
"max": "*",
"base": {
"path": "Claim.identifier",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Identifier"
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "workflow",
"map": "Request.identifier"
},
{
"identity": "w5",
"map": "FiveWs.identifier"
}
]
},
{
"id": "Claim.status",
"path": "Claim.status",
"short": "active | cancelled | draft | entered-in-error",
"definition": "The status of the resource instance.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.status",
"min": 0,
"max": "1"
},
"type": [
{
"code": "code"
}
],
"isModifier": true,
"isModifierReason": "This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid",
"isSummary": true,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ClaimStatus"
}
],
"strength": "required",
"description": "A code specifying the state of the resource instance.",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/fm-status"
},
"mapping": [
{
"identity": "workflow",
"map": "Request.status"
},
{
"identity": "w5",
"map": "FiveWs.status"
}
]
},
{
"id": "Claim.type",
"path": "Claim.type",
"short": "Type or discipline",
"definition": "The category of claim, eg, oral, pharmacy, vision, insitutional, professional.",
"comment": "Affects which fields and value sets are used.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.type",
"min": 0,
"max": "1"
},
"type": [
{
"code": "CodeableConcept"
}
],
"isModifier": false,
"isSummary": false,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ClaimType"
}
],
"strength": "extensible",
"description": "The type or discipline-style of the claim",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/claim-type"
},
"mapping": [
{
"identity": "w5",
"map": "FiveWs.class"
}
]
},
{
"id": "Claim.subType",
"path": "Claim.subType",
"short": "Finer grained claim type information",
"definition": "A finer grained suite of claim subtype codes which may convey Inpatient vs Outpatient and/or a specialty service. In the US the BillType.",
"comment": "This may contain the local bill type codes such as the US UB-04 bill type code.",
"min": 0,
"max": "*",
"base": {
"path": "Claim.subType",
"min": 0,
"max": "*"
},
"type": [
{
"code": "CodeableConcept"
}
],
"isModifier": false,
"isSummary": false,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ClaimSubType"
}
],
"strength": "example",
"description": "A more granular claim typecode",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/claim-subtype"
},
"mapping": [
{
"identity": "w5",
"map": "FiveWs.class"
}
]
},
{
"id": "Claim.use",
"path": "Claim.use",
"short": "complete | proposed | exploratory | other",
"definition": "Complete (Bill or Claim), Proposed (Pre-Authorization), Exploratory (Pre-determination).",
"min": 0,
"max": "1",
"base": {
"path": "Claim.use",
"min": 0,
"max": "1"
},
"type": [
{
"code": "code"
}
],
"isModifier": false,
"isSummary": false,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Use"
}
],
"strength": "required",
"description": "Complete, proposed, exploratory, other",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/claim-use"
},
"mapping": [
{
"identity": "w5",
"map": "FiveWs.class"
}
]
},
{
"id": "Claim.patient",
"path": "Claim.patient",
"short": "The subject of the Products and Services",
"definition": "Patient Resource.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.patient",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Patient"
]
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "workflow",
"map": "Request.subject"
},
{
"identity": "w5",
"map": "FiveWs.subject[x]"
},
{
"identity": "w5",
"map": "FiveWs.subject"
}
]
},
{
"id": "Claim.billablePeriod",
"path": "Claim.billablePeriod",
"short": "Period for charge submission",
"definition": "The billable period for which charges are being submitted.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.billablePeriod",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Period"
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "w5",
"map": "FiveWs.done[x]"
}
]
},
{
"id": "Claim.created",
"path": "Claim.created",
"short": "Creation date",
"definition": "The date when the enclosed suite of services were performed or completed.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.created",
"min": 0,
"max": "1"
},
"type": [
{
"code": "dateTime"
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "workflow",
"map": "Request.authoredOn"
},
{
"identity": "w5",
"map": "FiveWs.recorded"
}
]
},
{
"id": "Claim.enterer",
"path": "Claim.enterer",
"short": "Author",
"definition": "Person who created the invoice/claim/pre-determination or pre-authorization.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.enterer",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Practitioner",
"http://hl7.org/fhir/StructureDefinition/PractitionerRole"
]
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "w5",
"map": "FiveWs.author"
}
]
},
{
"id": "Claim.insurer",
"path": "Claim.insurer",
"short": "Target",
"definition": "The Insurer who is target of the request.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.insurer",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Organization"
]
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "workflow",
"map": "Request.performer"
}
]
},
{
"id": "Claim.provider",
"path": "Claim.provider",
"short": "Responsible provider",
"definition": "The provider which is responsible for the bill, claim pre-determination, pre-authorization.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.provider",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Practitioner",
"http://hl7.org/fhir/StructureDefinition/PractitionerRole",
"http://hl7.org/fhir/StructureDefinition/Organization"
]
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "workflow",
"map": "Request.requester"
},
{
"identity": "w5",
"map": "FiveWs.source"
}
]
},
{
"id": "Claim.priority",
"path": "Claim.priority",
"short": "Desired processing priority",
"definition": "Immediate (STAT), best effort (NORMAL), deferred (DEFER).",
"min": 0,
"max": "1",
"base": {
"path": "Claim.priority",
"min": 0,
"max": "1"
},
"type": [
{
"code": "CodeableConcept"
}
],
"isModifier": false,
"isSummary": false,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProcessPriority"
}
],
"strength": "example",
"description": "The timeliness with which processing is required: STAT, normal, Deferred",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/process-priority"
},
"mapping": [
{
"identity": "workflow",
"map": "Request.priority"
}
]
},
{
"id": "Claim.fundsReserve",
"path": "Claim.fundsReserve",
"short": "Funds requested to be reserved",
"definition": "In the case of a Pre-Determination/Pre-Authorization the provider may request that funds in the amount of the expected Benefit be reserved ('Patient' or 'Provider') to pay for the Benefits determined on the subsequent claim(s). 'None' explicitly indicates no funds reserving is requested.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.fundsReserve",
"min": 0,
"max": "1"
},
"type": [
{
"code": "CodeableConcept"
}
],
"isModifier": false,
"isSummary": false,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "FundsReserve"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
}
],
"strength": "example",
"description": "For whom funds are to be reserved: (Patient, Provider, None).",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/fundsreserve"
}
},
{
"id": "Claim.related",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "RelatedClaim"
}
],
"path": "Claim.related",
"short": "Related Claims which may be revelant to processing this claimn",
"definition": "Other claims which are related to this claim such as prior claim versions or for related services.",
"min": 0,
"max": "*",
"base": {
"path": "Claim.related",
"min": 0,
"max": "*"
},
"type": [
{
"code": "BackboneElement"
}
],
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "Claim.related.id",
"path": "Claim.related.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Claim.related.extension",
"path": "Claim.related.extension",
"short": "Additional content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Claim.related.modifierExtension",
"path": "Claim.related.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isModifierReason": "modifierExtension is reserved for use where modifier extensions must be used",
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "Claim.related.claim",
"path": "Claim.related.claim",
"short": "Reference to the related claim",
"definition": "Other claims which are related to this claim such as prior claim versions or for related services.",
"comment": "Do we need a relationship code?",
"min": 0,
"max": "1",
"base": {
"path": "Claim.related.claim",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Claim"
]
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "workflow",
"map": "Request.replaces"
}
]
},
{
"id": "Claim.related.relationship",
"path": "Claim.related.relationship",
"short": "How the reference claim is related",
"definition": "For example prior or umbrella.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.related.relationship",
"min": 0,
"max": "1"
},
"type": [
{
"code": "CodeableConcept"
}
],
"isModifier": false,
"isSummary": false,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "RelatedClaimRelationship"
}
],
"strength": "example",
"description": "Relationship of this claim to a related Claim",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/related-claim-relationship"
}
},
{
"id": "Claim.related.reference",
"path": "Claim.related.reference",
"short": "Related file or case reference",
"definition": "An alternate organizational reference to the case or file to which this particular claim pertains - eg Property/Casualy insurer claim # or Workers Compensation case # .",
"min": 0,
"max": "1",
"base": {
"path": "Claim.related.reference",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Identifier"
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "Claim.prescription",
"path": "Claim.prescription",
"short": "Prescription authorizing services or products",
"definition": "Prescription to support the dispensing of Pharmacy or Vision products.",
"comment": "Should we create a group to hold multiple prescriptions and add a sequence number and on the line items a link to the sequence.",
"requirements": "For type=Pharmacy and Vision only.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.prescription",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/MedicationRequest",
"http://hl7.org/fhir/StructureDefinition/VisionPrescription"
]
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "Claim.originalPrescription",
"path": "Claim.originalPrescription",
"short": "Original prescription if superceded by fulfiller",
"definition": "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'.",
"comment": "as above.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.originalPrescription",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/MedicationRequest"
]
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "Claim.payee",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Payee"
}
],
"path": "Claim.payee",
"short": "Party to be paid any benefits payable",
"definition": "The party to be reimbursed for the services.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.payee",
"min": 0,
"max": "1"
},
"type": [
{
"code": "BackboneElement"
}
],
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "Claim.payee.id",
"path": "Claim.payee.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Claim.payee.extension",
"path": "Claim.payee.extension",
"short": "Additional content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Claim.payee.modifierExtension",
"path": "Claim.payee.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isModifierReason": "modifierExtension is reserved for use where modifier extensions must be used",
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "Claim.payee.type",
"path": "Claim.payee.type",
"short": "Type of party: Subscriber, Provider, other",
"definition": "Type of Party to be reimbursed: Subscriber, provider, other.",
"min": 1,
"max": "1",
"base": {
"path": "Claim.payee.type",
"min": 1,
"max": "1"
},
"type": [
{
"code": "CodeableConcept"
}
],
"isModifier": false,
"isSummary": false,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "PayeeType"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
}
],
"strength": "example",
"description": "A code for the party to be reimbursed.",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/payeetype"
}
},
{
"id": "Claim.payee.resource",
"path": "Claim.payee.resource",
"short": "organization | patient | practitioner | relatedperson",
"definition": "organization | patient | practitioner | relatedperson.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.payee.resource",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Coding"
}
],
"isModifier": false,
"isSummary": false,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ClaimPayeeResourceType"
}
],
"strength": "extensible",
"description": "The type of Claim payee Resource",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/ex-payee-resource-type"
}
},
{
"id": "Claim.payee.party",
"path": "Claim.payee.party",
"short": "Party to receive the payable",
"definition": "Party to be reimbursed: Subscriber, provider, other.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.payee.party",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Practitioner",
"http://hl7.org/fhir/StructureDefinition/PractitionerRole",
"http://hl7.org/fhir/StructureDefinition/Organization",
"http://hl7.org/fhir/StructureDefinition/Patient",
"http://hl7.org/fhir/StructureDefinition/RelatedPerson"
]
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "Claim.referral",
"path": "Claim.referral",
"short": "Treatment Referral",
"definition": "The referral resource which lists the date, practitioner, reason and other supporting information.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.referral",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/ServiceRequest"
]
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "w5",
"map": "FiveWs.cause"
}
]
},
{
"id": "Claim.facility",
"path": "Claim.facility",
"short": "Servicing Facility",
"definition": "Facility where the services were provided.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.facility",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Location"
]
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "w5",
"map": "FiveWs.where[x]"
}
]
},
{
"id": "Claim.careTeam",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "CareTeam"
}
],
"path": "Claim.careTeam",
"short": "Members of the care team",
"definition": "The members of the team who provided the overall service as well as their role and whether responsible and qualifications.",
"requirements": "Role and Responsible might not be required when there is only a single provider listed.",
"min": 0,
"max": "*",
"base": {
"path": "Claim.careTeam",
"min": 0,
"max": "*"
},
"type": [
{
"code": "BackboneElement"
}
],
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "Claim.careTeam.id",
"path": "Claim.careTeam.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Claim.careTeam.extension",
"path": "Claim.careTeam.extension",
"short": "Additional content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Claim.careTeam.modifierExtension",
"path": "Claim.careTeam.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isModifierReason": "modifierExtension is reserved for use where modifier extensions must be used",
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "Claim.careTeam.sequence",
"path": "Claim.careTeam.sequence",
"short": "Number to convey order of careTeam",
"definition": "Sequence of the careTeam which serves to order and provide a link.",
"requirements": "Required to maintain order of the careTeam.",
"min": 1,
"max": "1",
"base": {
"path": "Claim.careTeam.sequence",
"min": 1,
"max": "1"
},
"type": [
{
"code": "positiveInt"
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "Claim.careTeam.provider",
"path": "Claim.careTeam.provider",
"short": "Provider individual or organization",
"definition": "Member of the team who provided the overall service.",
"min": 1,
"max": "1",
"base": {
"path": "Claim.careTeam.provider",
"min": 1,
"max": "1"
},
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Practitioner",
"http://hl7.org/fhir/StructureDefinition/PractitionerRole",
"http://hl7.org/fhir/StructureDefinition/Organization"
]
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "w5",
"map": "FiveWs.actor"
}
]
},
{
"id": "Claim.careTeam.responsible",
"path": "Claim.careTeam.responsible",
"short": "Billing provider",
"definition": "The party who is billing and responsible for the claimed good or service rendered to the patient.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.careTeam.responsible",
"min": 0,
"max": "1"
},
"type": [
{
"code": "boolean"
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "Claim.careTeam.role",
"path": "Claim.careTeam.role",
"short": "Role on the team",
"definition": "The lead, assisting or supervising practitioner and their discipline if a multidisiplinary team.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.careTeam.role",
"min": 0,
"max": "1"
},
"type": [
{
"code": "CodeableConcept"
}
],
"isModifier": false,
"isSummary": false,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CareTeamRole"
}
],
"strength": "example",
"description": "The role codes for the care team members.",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/claim-careteamrole"
}
},
{
"id": "Claim.careTeam.qualification",
"path": "Claim.careTeam.qualification",
"short": "Type, classification or Specialization",
"definition": "The qualification which is applicable for this service.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.careTeam.qualification",
"min": 0,
"max": "1"
},
"type": [
{
"code": "CodeableConcept"
}
],
"isModifier": false,
"isSummary": false,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProviderQualification"
}
],
"strength": "example",
"description": "Provider professional qualifications",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/provider-qualification"
}
},
{
"id": "Claim.information",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "SpecialCondition"
}
],
"path": "Claim.information",
"short": "Exceptions, special considerations, the condition, situation, prior or concurrent issues",
"definition": "Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. Often there are mutiple jurisdiction specific valuesets which are required.",
"requirements": "Typically these information codes are required to support the services rendered or the adjudication of the services rendered.",
"min": 0,
"max": "*",
"base": {
"path": "Claim.information",
"min": 0,
"max": "*"
},
"type": [
{
"code": "BackboneElement"
}
],
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "workflow",
"map": "Request.supportingInfo"
}
]
},
{
"id": "Claim.information.id",
"path": "Claim.information.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Claim.information.extension",
"path": "Claim.information.extension",
"short": "Additional content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Claim.information.modifierExtension",
"path": "Claim.information.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isModifierReason": "modifierExtension is reserved for use where modifier extensions must be used",
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "Claim.information.sequence",
"path": "Claim.information.sequence",
"short": "Information instance identifier",
"definition": "Sequence of the information element which serves to provide a link.",
"requirements": "To provide a reference link.",
"min": 1,
"max": "1",
"base": {
"path": "Claim.information.sequence",
"min": 1,
"max": "1"
},
"type": [
{
"code": "positiveInt"
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "Claim.information.category",
"path": "Claim.information.category",
"short": "General class of information",
"definition": "The general class of the information supplied: information; exception; accident, employment; onset, etc.",
"comment": "This may contain the local bill type codes such as the US UB-04 bill type code.",
"min": 1,
"max": "1",
"base": {
"path": "Claim.information.category",
"min": 1,
"max": "1"
},
"type": [
{
"code": "CodeableConcept"
}
],
"isModifier": false,
"isSummary": false,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "InformationCategory"
}
],
"strength": "example",
"description": "The valuset used for additional information category codes.",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/claim-informationcategory"
}
},
{
"id": "Claim.information.code",
"path": "Claim.information.code",
"short": "Type of information",
"definition": "System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought which may influence the adjudication.",
"comment": "This may contain the local bill type codes such as the US UB-04 bill type code.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.information.code",
"min": 0,
"max": "1"
},
"type": [
{
"code": "CodeableConcept"
}
],
"isModifier": false,
"isSummary": false,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "InformationCode"
}
],
"strength": "example",
"description": "The valuset used for additional information codes.",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/claim-exception"
}
},
{
"id": "Claim.information.timing[x]",
"path": "Claim.information.timing[x]",
"short": "When it occurred",
"definition": "The date when or period to which this information refers.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.information.timing[x]",
"min": 0,
"max": "1"
},
"type": [
{
"code": "date"
},
{
"code": "Period"
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "Claim.information.value[x]",
"path": "Claim.information.value[x]",
"short": "Additional Data or supporting information",
"definition": "Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.information.value[x]",
"min": 0,
"max": "1"
},
"type": [
{
"code": "boolean"
},
{
"code": "string"
},
{
"code": "Quantity"
},
{
"code": "Attachment"
},
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Resource"
]
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "Claim.information.reason",
"path": "Claim.information.reason",
"short": "Reason associated with the information",
"definition": "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 content.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.information.reason",
"min": 0,
"max": "1"
},
"type": [
{
"code": "CodeableConcept"
}
],
"isModifier": false,
"isSummary": false,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "MissingReason"
}
],
"strength": "example",
"description": "Reason codes for the missing teeth",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/missing-tooth-reason"
}
},
{
"id": "Claim.diagnosis",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Diagnosis"
}
],
"path": "Claim.diagnosis",
"short": "List of Diagnosis",
"definition": "List of patient diagnosis for which care is sought.",
"min": 0,
"max": "*",
"base": {
"path": "Claim.diagnosis",
"min": 0,
"max": "*"
},
"type": [
{
"code": "BackboneElement"
}
],
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "workflow",
"map": "Request.reasonReference"
}
]
},
{
"id": "Claim.diagnosis.id",
"path": "Claim.diagnosis.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Claim.diagnosis.extension",
"path": "Claim.diagnosis.extension",
"short": "Additional content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Claim.diagnosis.modifierExtension",
"path": "Claim.diagnosis.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isModifierReason": "modifierExtension is reserved for use where modifier extensions must be used",
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "Claim.diagnosis.sequence",
"path": "Claim.diagnosis.sequence",
"short": "Number to convey order of diagnosis",
"definition": "Sequence of diagnosis which serves to provide a link.",
"requirements": "Required to allow line items to reference the diagnoses.",
"min": 1,
"max": "1",
"base": {
"path": "Claim.diagnosis.sequence",
"min": 1,
"max": "1"
},
"type": [
{
"code": "positiveInt"
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "Claim.diagnosis.diagnosis[x]",
"path": "Claim.diagnosis.diagnosis[x]",
"short": "Patient's diagnosis",
"definition": "The diagnosis.",
"requirements": "Required to adjudicate services rendered to condition presented.",
"min": 1,
"max": "1",
"base": {
"path": "Claim.diagnosis.diagnosis[x]",
"min": 1,
"max": "1"
},
"type": [
{
"code": "CodeableConcept"
},
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Condition"
]
}
],
"isModifier": false,
"isSummary": false,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ICD10"
}
],
"strength": "example",
"description": "ICD10 Diagnostic codes",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/icd-10"
}
},
{
"id": "Claim.diagnosis.type",
"path": "Claim.diagnosis.type",
"short": "Timing or nature of the diagnosis",
"definition": "The type of the Diagnosis, for example: admitting, primary, secondary, discharge.",
"comment": "Diagnosis are presented in list order to their expected importance: primary, secondary, etc.",
"requirements": "May be required to adjudicate services rendered.",
"min": 0,
"max": "*",
"base": {
"path": "Claim.diagnosis.type",
"min": 0,
"max": "*"
},
"type": [
{
"code": "CodeableConcept"
}
],
"isModifier": false,
"isSummary": false,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "DiagnosisType"
}
],
"strength": "example",
"description": "The type of the diagnosis: admitting, principal, discharge",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/ex-diagnosistype"
}
},
{
"id": "Claim.diagnosis.packageCode",
"path": "Claim.diagnosis.packageCode",
"short": "Package billing code",
"definition": "The package billing code, for example DRG, based on the assigned grouping code system.",
"requirements": "May be required to adjudicate services rendered to the mandated grouping system.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.diagnosis.packageCode",
"min": 0,
"max": "1"
},
"type": [
{
"code": "CodeableConcept"
}
],
"isModifier": false,
"isSummary": false,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "DiagnosisRelatedGroup"
}
],
"strength": "example",
"description": "The DRG codes associated with the diagnosis",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup"
}
},
{
"id": "Claim.procedure",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Procedure"
}
],
"path": "Claim.procedure",
"short": "Procedures performed",
"definition": "Ordered list of patient procedures performed to support the adjudication.",
"min": 0,
"max": "*",
"base": {
"path": "Claim.procedure",
"min": 0,
"max": "*"
},
"type": [
{
"code": "BackboneElement"
}
],
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "Claim.procedure.id",
"path": "Claim.procedure.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Claim.procedure.extension",
"path": "Claim.procedure.extension",
"short": "Additional content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Claim.procedure.modifierExtension",
"path": "Claim.procedure.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isModifierReason": "modifierExtension is reserved for use where modifier extensions must be used",
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "Claim.procedure.sequence",
"path": "Claim.procedure.sequence",
"short": "Procedure sequence for reference",
"definition": "Sequence of procedures which serves to order and provide a link.",
"requirements": "Required to maintain order of the procudures.",
"min": 1,
"max": "1",
"base": {
"path": "Claim.procedure.sequence",
"min": 1,
"max": "1"
},
"type": [
{
"code": "positiveInt"
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "Claim.procedure.date",
"path": "Claim.procedure.date",
"short": "When the procedure was performed",
"definition": "Date and optionally time the procedure was performed .",
"comment": "SB DateTime??",
"requirements": "Required to adjudicate services rendered.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.procedure.date",
"min": 0,
"max": "1"
},
"type": [
{
"code": "dateTime"
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "Claim.procedure.procedure[x]",
"path": "Claim.procedure.procedure[x]",
"short": "Patient's list of procedures performed",
"definition": "The procedure code.",
"requirements": "Required to adjudicate services rendered.",
"min": 1,
"max": "1",
"base": {
"path": "Claim.procedure.procedure[x]",
"min": 1,
"max": "1"
},
"type": [
{
"code": "CodeableConcept"
},
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Procedure"
]
}
],
"isModifier": false,
"isSummary": false,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ICD10_Procedures"
}
],
"strength": "example",
"description": "ICD10 Procedure codes",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/icd-10-procedures"
}
},
{
"id": "Claim.insurance",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Insurance"
}
],
"path": "Claim.insurance",
"short": "Insurance or medical plan",
"definition": "Financial instrument by which payment information for health care.",
"requirements": "Health care programs and insurers are significant payors of health service costs.",
"min": 0,
"max": "*",
"base": {
"path": "Claim.insurance",
"min": 0,
"max": "*"
},
"type": [
{
"code": "BackboneElement"
}
],
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "rim",
"map": "Coverage"
}
]
},
{
"id": "Claim.insurance.id",
"path": "Claim.insurance.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Claim.insurance.extension",
"path": "Claim.insurance.extension",
"short": "Additional content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Claim.insurance.modifierExtension",
"path": "Claim.insurance.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isModifierReason": "modifierExtension is reserved for use where modifier extensions must be used",
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "Claim.insurance.sequence",
"path": "Claim.insurance.sequence",
"short": "Service instance identifier",
"definition": "Sequence of coverage which serves to provide a link and convey coordination of benefit order.",
"requirements": "To maintain order of the coverages.",
"min": 1,
"max": "1",
"base": {
"path": "Claim.insurance.sequence",
"min": 1,
"max": "1"
},
"type": [
{
"code": "positiveInt"
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "Claim.insurance.focal",
"path": "Claim.insurance.focal",
"short": "Is the focal Coverage",
"definition": "A flag to indicate that this Coverage is the focus for adjudication. The Coverage against which the claim is to be adjudicated.",
"requirements": "To identify which coverage is being adjudicated.",
"min": 1,
"max": "1",
"base": {
"path": "Claim.insurance.focal",
"min": 1,
"max": "1"
},
"type": [
{
"code": "boolean"
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "Claim.insurance.identifier",
"path": "Claim.insurance.identifier",
"short": "Claim number",
"definition": "The business identifier for the instance: claim number, pre-determination or pre-authorization number.",
"requirements": "This will be the claim number should it be necessary to create this claim in the future. This is provided so that payors may forward claims to other payors in the Coordination of Benefit for adjudication rather than the provider being required to initiate each adjudication.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.insurance.identifier",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Identifier"
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "workflow",
"map": "Request.identifier"
},
{
"identity": "w5",
"map": "FiveWs.identifier"
}
]
},
{
"id": "Claim.insurance.coverage",
"path": "Claim.insurance.coverage",
"short": "Insurance information",
"definition": "Reference to the program or plan identification, underwriter or payor.",
"requirements": "Need to identify the issuer to target for processing and for coordination of benefit processing.",
"min": 1,
"max": "1",
"base": {
"path": "Claim.insurance.coverage",
"min": 1,
"max": "1"
},
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Coverage"
]
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "Claim.insurance.businessArrangement",
"path": "Claim.insurance.businessArrangement",
"short": "Business agreement",
"definition": "The contract number of a business agreement which describes the terms and conditions.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.insurance.businessArrangement",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "Claim.insurance.preAuthRef",
"path": "Claim.insurance.preAuthRef",
"short": "Pre-Authorization/Determination Reference",
"definition": "A list of references from the Insurer to which these services pertain.",
"requirements": "To provide any pre=determination or prior authorization reference.",
"min": 0,
"max": "*",
"base": {
"path": "Claim.insurance.preAuthRef",
"min": 0,
"max": "*"
},
"type": [
{
"code": "string"
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "Claim.insurance.claimResponse",
"path": "Claim.insurance.claimResponse",
"short": "Adjudication results",
"definition": "The Coverages adjudication details.",
"requirements": "Used by downstream payers to determine what balance remains and the net payable.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.insurance.claimResponse",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/ClaimResponse"
]
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "Claim.accident",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Accident"
}
],
"path": "Claim.accident",
"short": "Details about an accident",
"definition": "An accident which resulted in the need for healthcare services.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.accident",
"min": 0,
"max": "1"
},
"type": [
{
"code": "BackboneElement"
}
],
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "Claim.accident.id",
"path": "Claim.accident.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Claim.accident.extension",
"path": "Claim.accident.extension",
"short": "Additional content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Claim.accident.modifierExtension",
"path": "Claim.accident.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isModifierReason": "modifierExtension is reserved for use where modifier extensions must be used",
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "Claim.accident.date",
"path": "Claim.accident.date",
"short": "When the accident occurred\nsee information codes\nsee information codes",
"definition": "Date of an accident which these services are addressing.",
"requirements": "Coverage may be dependant on accidents.",
"min": 1,
"max": "1",
"base": {
"path": "Claim.accident.date",
"min": 1,
"max": "1"
},
"type": [
{
"code": "date"
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "Claim.accident.type",
"path": "Claim.accident.type",
"short": "The nature of the accident",
"definition": "Type of accident: work, auto, etc.",
"requirements": "Coverage may be dependant on the type of accident.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.accident.type",
"min": 0,
"max": "1"
},
"type": [
{
"code": "CodeableConcept"
}
],
"isModifier": false,
"isSummary": false,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "AccidentType"
}
],
"strength": "extensible",
"description": "Type of accident: work place, auto, etc.",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/v3-ActIncidentCode"
}
},
{
"id": "Claim.accident.location[x]",
"path": "Claim.accident.location[x]",
"short": "Accident Place",
"definition": "Accident Place.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.accident.location[x]",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Address"
},
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Location"
]
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "Claim.item",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Item"
}
],
"path": "Claim.item",
"short": "Goods and Services",
"definition": "First tier of goods and services.",
"min": 0,
"max": "*",
"base": {
"path": "Claim.item",
"min": 0,
"max": "*"
},
"type": [
{
"code": "BackboneElement"
}
],
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "Claim.item.id",
"path": "Claim.item.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Claim.item.extension",
"path": "Claim.item.extension",
"short": "Additional content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Claim.item.modifierExtension",
"path": "Claim.item.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isModifierReason": "modifierExtension is reserved for use where modifier extensions must be used",
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "Claim.item.sequence",
"path": "Claim.item.sequence",
"short": "Service instance",
"definition": "A service line number.",
"min": 1,
"max": "1",
"base": {
"path": "Claim.item.sequence",
"min": 1,
"max": "1"
},
"type": [
{
"code": "positiveInt"
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "Claim.item.careTeamSequence",
"path": "Claim.item.careTeamSequence",
"short": "Applicable careTeam members",
"definition": "CareTeam applicable for this service or product line.",
"min": 0,
"max": "*",
"base": {
"path": "Claim.item.careTeamSequence",
"min": 0,
"max": "*"
},
"type": [
{
"code": "positiveInt"
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "Claim.item.diagnosisSequence",
"path": "Claim.item.diagnosisSequence",
"short": "Applicable diagnoses",
"definition": "Diagnosis applicable for this service or product line.",
"min": 0,
"max": "*",
"base": {
"path": "Claim.item.diagnosisSequence",
"min": 0,
"max": "*"
},
"type": [
{
"code": "positiveInt"
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "Claim.item.procedureSequence",
"path": "Claim.item.procedureSequence",
"short": "Applicable procedures",
"definition": "Procedures applicable for this service or product line.",
"min": 0,
"max": "*",
"base": {
"path": "Claim.item.procedureSequence",
"min": 0,
"max": "*"
},
"type": [
{
"code": "positiveInt"
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "Claim.item.informationSequence",
"path": "Claim.item.informationSequence",
"short": "Applicable exception and supporting information",
"definition": "Exceptions, special conditions and supporting information pplicable for this service or product line.",
"min": 0,
"max": "*",
"base": {
"path": "Claim.item.informationSequence",
"min": 0,
"max": "*"
},
"type": [
{
"code": "positiveInt"
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "Claim.item.revenue",
"path": "Claim.item.revenue",
"short": "Revenue or cost center code",
"definition": "The type of reveneu or cost center providing the product and/or service.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.item.revenue",
"min": 0,
"max": "1"
},
"type": [
{
"code": "CodeableConcept"
}
],
"isModifier": false,
"isSummary": false,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "RevenueCenter"
}
],
"strength": "example",
"description": "Codes for the revenue or cost centers supplying the service and/or products.",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/ex-revenue-center"
}
},
{
"id": "Claim.item.category",
"path": "Claim.item.category",
"short": "Type of service or product",
"definition": "Health Care Service Type Codes to identify the classification of service or benefits.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.item.category",
"min": 0,
"max": "1"
},
"type": [
{
"code": "CodeableConcept"
}
],
"isModifier": false,
"isSummary": false,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitSubCategory"
}
],
"strength": "example",
"description": "Benefit subcategories such as: oral-basic, major, glasses",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/benefit-subcategory"
}
},
{
"id": "Claim.item.service",
"path": "Claim.item.service",
"short": "Billing Code",
"definition": "If this is an actual service or product line, ie. not a Group, then use code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,RXNorm,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.item.service",
"min": 0,
"max": "1"
},
"type": [
{
"code": "CodeableConcept"
}
],
"isModifier": false,
"isSummary": false,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
}
],
"strength": "example",
"description": "Allowable service and product codes",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/service-uscls"
}
},
{
"id": "Claim.item.modifier",
"path": "Claim.item.modifier",
"short": "Service/Product billing modifiers",
"definition": "Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.",
"requirements": "May impact on adjudication.",
"min": 0,
"max": "*",
"base": {
"path": "Claim.item.modifier",
"min": 0,
"max": "*"
},
"type": [
{
"code": "CodeableConcept"
}
],
"isModifier": false,
"isSummary": false,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Modifiers"
}
],
"strength": "example",
"description": "Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/claim-modifiers"
}
},
{
"id": "Claim.item.programCode",
"path": "Claim.item.programCode",
"short": "Program specific reason for item inclusion",
"definition": "For programs which require reason codes for the inclusion or covering of this billed item under the program or sub-program.",
"min": 0,
"max": "*",
"base": {
"path": "Claim.item.programCode",
"min": 0,
"max": "*"
},
"type": [
{
"code": "CodeableConcept"
}
],
"isModifier": false,
"isSummary": false,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProgramCode"
}
],
"strength": "example",
"description": "Program specific reason codes",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/ex-program-code"
}
},
{
"id": "Claim.item.serviced[x]",
"path": "Claim.item.serviced[x]",
"short": "Date or dates of Service",
"definition": "The date or dates when the enclosed suite of services were performed or completed.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.item.serviced[x]",
"min": 0,
"max": "1"
},
"type": [
{
"code": "date"
},
{
"code": "Period"
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "w5",
"map": "FiveWs.done[x]"
}
]
},
{
"id": "Claim.item.location[x]",
"path": "Claim.item.location[x]",
"short": "Place of service",
"definition": "Where the service was provided.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.item.location[x]",
"min": 0,
"max": "1"
},
"type": [
{
"code": "CodeableConcept"
},
{
"code": "Address"
},
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Location"
]
}
],
"isModifier": false,
"isSummary": false,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServicePlace"
}
],
"strength": "example",
"description": "Place of service: pharmacy,school, prison, etc.",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/service-place"
},
"mapping": [
{
"identity": "w5",
"map": "FiveWs.where[x]"
}
]
},
{
"id": "Claim.item.quantity",
"path": "Claim.item.quantity",
"short": "Count of Products or Services",
"definition": "The number of repetitions of a service or product.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.item.quantity",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Quantity",
"profile": [
"http://hl7.org/fhir/StructureDefinition/SimpleQuantity"
]
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "Claim.item.unitPrice",
"path": "Claim.item.unitPrice",
"short": "Fee, charge or cost per point",
"definition": "If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.item.unitPrice",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Money"
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "Claim.item.factor",
"path": "Claim.item.factor",
"short": "Price scaling factor",
"definition": "A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.item.factor",
"min": 0,
"max": "1"
},
"type": [
{
"code": "decimal"
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "Claim.item.net",
"path": "Claim.item.net",
"short": "Total item cost",
"definition": "The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.item.net",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Money"
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "Claim.item.udi",
"path": "Claim.item.udi",
"short": "Unique Device Identifier",
"definition": "List of Unique Device Identifiers associated with this line item.",
"requirements": "The UDI code and issuer if applicable for the supplied product.",
"min": 0,
"max": "*",
"base": {
"path": "Claim.item.udi",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Device"
]
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "Claim.item.bodySite",
"path": "Claim.item.bodySite",
"short": "Service Location",
"definition": "Physical service site on the patient (limb, tooth, etc.).",
"min": 0,
"max": "1",
"base": {
"path": "Claim.item.bodySite",
"min": 0,
"max": "1"
},
"type": [
{
"code": "CodeableConcept"
}
],
"isModifier": false,
"isSummary": false,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "OralSites"
}
],
"strength": "example",
"description": "The code for the teeth, quadrant, sextant and arch",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/tooth"
}
},
{
"id": "Claim.item.subSite",
"path": "Claim.item.subSite",
"short": "Service Sub-location",
"definition": "A region or surface of the site, eg. limb region or tooth surface(s).",
"min": 0,
"max": "*",
"base": {
"path": "Claim.item.subSite",
"min": 0,
"max": "*"
},
"type": [
{
"code": "CodeableConcept"
}
],
"isModifier": false,
"isSummary": false,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Surface"
}
],
"strength": "example",
"description": "The code for the tooth surface and surface combinations",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/surface"
}
},
{
"id": "Claim.item.encounter",
"path": "Claim.item.encounter",
"short": "Encounters related to this billed item",
"definition": "A billed item may include goods or services provided in multiple encounters.",
"min": 0,
"max": "*",
"base": {
"path": "Claim.item.encounter",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Encounter"
]
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "workflow",
"map": "Request.context"
}
]
},
{
"id": "Claim.item.detail",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Detail"
}
],
"path": "Claim.item.detail",
"short": "Additional items",
"definition": "Second tier of goods and services.",
"min": 0,
"max": "*",
"base": {
"path": "Claim.item.detail",
"min": 0,
"max": "*"
},
"type": [
{
"code": "BackboneElement"
}
],
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "Claim.item.detail.id",
"path": "Claim.item.detail.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Claim.item.detail.extension",
"path": "Claim.item.detail.extension",
"short": "Additional content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Claim.item.detail.modifierExtension",
"path": "Claim.item.detail.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isModifierReason": "modifierExtension is reserved for use where modifier extensions must be used",
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "Claim.item.detail.sequence",
"path": "Claim.item.detail.sequence",
"short": "Service instance",
"definition": "A service line number.",
"min": 1,
"max": "1",
"base": {
"path": "Claim.item.detail.sequence",
"min": 1,
"max": "1"
},
"type": [
{
"code": "positiveInt"
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "Claim.item.detail.revenue",
"path": "Claim.item.detail.revenue",
"short": "Revenue or cost center code",
"definition": "The type of reveneu or cost center providing the product and/or service.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.item.detail.revenue",
"min": 0,
"max": "1"
},
"type": [
{
"code": "CodeableConcept"
}
],
"isModifier": false,
"isSummary": false,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "RevenueCenter"
}
],
"strength": "example",
"description": "Codes for the revenue or cost centers supplying the service and/or products.",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/ex-revenue-center"
}
},
{
"id": "Claim.item.detail.category",
"path": "Claim.item.detail.category",
"short": "Type of service or product",
"definition": "Health Care Service Type Codes to identify the classification of service or benefits.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.item.detail.category",
"min": 0,
"max": "1"
},
"type": [
{
"code": "CodeableConcept"
}
],
"isModifier": false,
"isSummary": false,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitSubCategory"
}
],
"strength": "example",
"description": "Benefit subcategories such as: oral-basic, major, glasses",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/benefit-subcategory"
}
},
{
"id": "Claim.item.detail.service",
"path": "Claim.item.detail.service",
"short": "Billing Code",
"definition": "If this is an actual service or product line, ie. not a Group, then use code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.item.detail.service",
"min": 0,
"max": "1"
},
"type": [
{
"code": "CodeableConcept"
}
],
"isModifier": false,
"isSummary": false,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
}
],
"strength": "example",
"description": "Allowable service and product codes",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/service-uscls"
}
},
{
"id": "Claim.item.detail.modifier",
"path": "Claim.item.detail.modifier",
"short": "Service/Product billing modifiers",
"definition": "Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.",
"requirements": "May impact on adjudication.",
"min": 0,
"max": "*",
"base": {
"path": "Claim.item.detail.modifier",
"min": 0,
"max": "*"
},
"type": [
{
"code": "CodeableConcept"
}
],
"isModifier": false,
"isSummary": false,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Modifiers"
}
],
"strength": "example",
"description": "Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/claim-modifiers"
}
},
{
"id": "Claim.item.detail.programCode",
"path": "Claim.item.detail.programCode",
"short": "Program specific reason for item inclusion",
"definition": "For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program.",
"min": 0,
"max": "*",
"base": {
"path": "Claim.item.detail.programCode",
"min": 0,
"max": "*"
},
"type": [
{
"code": "CodeableConcept"
}
],
"isModifier": false,
"isSummary": false,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProgramCode"
}
],
"strength": "example",
"description": "Program specific reason codes",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/ex-program-code"
}
},
{
"id": "Claim.item.detail.quantity",
"path": "Claim.item.detail.quantity",
"short": "Count of Products or Services",
"definition": "The number of repetitions of a service or product.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.item.detail.quantity",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Quantity",
"profile": [
"http://hl7.org/fhir/StructureDefinition/SimpleQuantity"
]
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "Claim.item.detail.unitPrice",
"path": "Claim.item.detail.unitPrice",
"short": "Fee, charge or cost per point",
"definition": "If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.item.detail.unitPrice",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Money"
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "Claim.item.detail.factor",
"path": "Claim.item.detail.factor",
"short": "Price scaling factor",
"definition": "A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.item.detail.factor",
"min": 0,
"max": "1"
},
"type": [
{
"code": "decimal"
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "Claim.item.detail.net",
"path": "Claim.item.detail.net",
"short": "Total additional item cost",
"definition": "The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.item.detail.net",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Money"
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "Claim.item.detail.udi",
"path": "Claim.item.detail.udi",
"short": "Unique Device Identifier",
"definition": "List of Unique Device Identifiers associated with this line item.",
"requirements": "The UDI code and issuer if applicable for the supplied product.",
"min": 0,
"max": "*",
"base": {
"path": "Claim.item.detail.udi",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Device"
]
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "Claim.item.detail.subDetail",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "SubDetail"
}
],
"path": "Claim.item.detail.subDetail",
"short": "Additional items",
"definition": "Third tier of goods and services.",
"min": 0,
"max": "*",
"base": {
"path": "Claim.item.detail.subDetail",
"min": 0,
"max": "*"
},
"type": [
{
"code": "BackboneElement"
}
],
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "Claim.item.detail.subDetail.id",
"path": "Claim.item.detail.subDetail.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Claim.item.detail.subDetail.extension",
"path": "Claim.item.detail.subDetail.extension",
"short": "Additional content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": false,
"isSummary": false,
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Claim.item.detail.subDetail.modifierExtension",
"path": "Claim.item.detail.subDetail.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isModifierReason": "modifierExtension is reserved for use where modifier extensions must be used",
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "Claim.item.detail.subDetail.sequence",
"path": "Claim.item.detail.subDetail.sequence",
"short": "Service instance",
"definition": "A service line number.",
"min": 1,
"max": "1",
"base": {
"path": "Claim.item.detail.subDetail.sequence",
"min": 1,
"max": "1"
},
"type": [
{
"code": "positiveInt"
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "Claim.item.detail.subDetail.revenue",
"path": "Claim.item.detail.subDetail.revenue",
"short": "Revenue or cost center code",
"definition": "The type of reveneu or cost center providing the product and/or service.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.item.detail.subDetail.revenue",
"min": 0,
"max": "1"
},
"type": [
{
"code": "CodeableConcept"
}
],
"isModifier": false,
"isSummary": false,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "RevenueCenter"
}
],
"strength": "example",
"description": "Codes for the revenue or cost centers supplying the service and/or products.",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/ex-revenue-center"
}
},
{
"id": "Claim.item.detail.subDetail.category",
"path": "Claim.item.detail.subDetail.category",
"short": "Type of service or product",
"definition": "Health Care Service Type Codes to identify the classification of service or benefits.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.item.detail.subDetail.category",
"min": 0,
"max": "1"
},
"type": [
{
"code": "CodeableConcept"
}
],
"isModifier": false,
"isSummary": false,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitSubCategory"
}
],
"strength": "example",
"description": "Benefit subcategories such as: oral-basic, major, glasses",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/benefit-subcategory"
}
},
{
"id": "Claim.item.detail.subDetail.service",
"path": "Claim.item.detail.subDetail.service",
"short": "Billing Code",
"definition": "A code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI).",
"min": 0,
"max": "1",
"base": {
"path": "Claim.item.detail.subDetail.service",
"min": 0,
"max": "1"
},
"type": [
{
"code": "CodeableConcept"
}
],
"isModifier": false,
"isSummary": false,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
}
],
"strength": "example",
"description": "Allowable service and product codes",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/service-uscls"
}
},
{
"id": "Claim.item.detail.subDetail.modifier",
"path": "Claim.item.detail.subDetail.modifier",
"short": "Service/Product billing modifiers",
"definition": "Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.",
"requirements": "May impact on adjudication.",
"min": 0,
"max": "*",
"base": {
"path": "Claim.item.detail.subDetail.modifier",
"min": 0,
"max": "*"
},
"type": [
{
"code": "CodeableConcept"
}
],
"isModifier": false,
"isSummary": false,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Modifiers"
}
],
"strength": "example",
"description": "Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/claim-modifiers"
}
},
{
"id": "Claim.item.detail.subDetail.programCode",
"path": "Claim.item.detail.subDetail.programCode",
"short": "Program specific reason for item inclusion",
"definition": "For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program.",
"min": 0,
"max": "*",
"base": {
"path": "Claim.item.detail.subDetail.programCode",
"min": 0,
"max": "*"
},
"type": [
{
"code": "CodeableConcept"
}
],
"isModifier": false,
"isSummary": false,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProgramCode"
}
],
"strength": "example",
"description": "Program specific reason codes",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/ex-program-code"
}
},
{
"id": "Claim.item.detail.subDetail.quantity",
"path": "Claim.item.detail.subDetail.quantity",
"short": "Count of Products or Services",
"definition": "The number of repetitions of a service or product.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.item.detail.subDetail.quantity",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Quantity",
"profile": [
"http://hl7.org/fhir/StructureDefinition/SimpleQuantity"
]
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "Claim.item.detail.subDetail.unitPrice",
"path": "Claim.item.detail.subDetail.unitPrice",
"short": "Fee, charge or cost per point",
"definition": "The fee for an addittional service or product or charge.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.item.detail.subDetail.unitPrice",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Money"
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "Claim.item.detail.subDetail.factor",
"path": "Claim.item.detail.subDetail.factor",
"short": "Price scaling factor",
"definition": "A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.item.detail.subDetail.factor",
"min": 0,
"max": "1"
},
"type": [
{
"code": "decimal"
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "Claim.item.detail.subDetail.net",
"path": "Claim.item.detail.subDetail.net",
"short": "Net additional item cost",
"definition": "The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.item.detail.subDetail.net",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Money"
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "Claim.item.detail.subDetail.udi",
"path": "Claim.item.detail.subDetail.udi",
"short": "Unique Device Identifier",
"definition": "List of Unique Device Identifiers associated with this line item.",
"requirements": "The UDI code and issuer if applicable for the supplied product.",
"min": 0,
"max": "*",
"base": {
"path": "Claim.item.detail.subDetail.udi",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Device"
]
}
],
"isModifier": false,
"isSummary": false
},
{
"id": "Claim.total",
"path": "Claim.total",
"short": "Total claim cost",
"definition": "The total value of the claim.",
"min": 0,
"max": "1",
"base": {
"path": "Claim.total",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Money"
}
],
"isModifier": false,
"isSummary": false
}
]
},
"differential": {
"element": [
{
"id": "Claim",
"path": "Claim",
"short": "Claim, Pre-determination or Pre-authorization",
"definition": "A provider issued list of services and products provided, or to be provided, to a patient which is provided to an insurer for payment recovery.",
"min": 0,
"max": "*",
"mapping": [
{
"identity": "workflow",
"map": "Request"
}
]
},
{
"id": "Claim.identifier",
"path": "Claim.identifier",
"short": "Claim number",
"definition": "The business identifier for the instance: claim number, pre-determination or pre-authorization number.",
"min": 0,
"max": "*",
"type": [
{
"code": "Identifier"
}
],
"mapping": [
{
"identity": "workflow",
"map": "Request.identifier"
},
{
"identity": "w5",
"map": "FiveWs.identifier"
}
]
},
{
"id": "Claim.status",
"path": "Claim.status",
"short": "active | cancelled | draft | entered-in-error",
"definition": "The status of the resource instance.",
"min": 0,
"max": "1",
"type": [
{
"code": "code"
}
],
"isModifier": true,
"isModifierReason": "This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid",
"isSummary": true,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ClaimStatus"
}
],
"strength": "required",
"description": "A code specifying the state of the resource instance.",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/fm-status"
},
"mapping": [
{
"identity": "workflow",
"map": "Request.status"
},
{
"identity": "w5",
"map": "FiveWs.status"
}
]
},
{
"id": "Claim.type",
"path": "Claim.type",
"short": "Type or discipline",
"definition": "The category of claim, eg, oral, pharmacy, vision, insitutional, professional.",
"comment": "Affects which fields and value sets are used.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ClaimType"
}
],
"strength": "extensible",
"description": "The type or discipline-style of the claim",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/claim-type"
},
"mapping": [
{
"identity": "w5",
"map": "FiveWs.class"
}
]
},
{
"id": "Claim.subType",
"path": "Claim.subType",
"short": "Finer grained claim type information",
"definition": "A finer grained suite of claim subtype codes which may convey Inpatient vs Outpatient and/or a specialty service. In the US the BillType.",
"comment": "This may contain the local bill type codes such as the US UB-04 bill type code.",
"min": 0,
"max": "*",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ClaimSubType"
}
],
"strength": "example",
"description": "A more granular claim typecode",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/claim-subtype"
},
"mapping": [
{
"identity": "w5",
"map": "FiveWs.class"
}
]
},
{
"id": "Claim.use",
"path": "Claim.use",
"short": "complete | proposed | exploratory | other",
"definition": "Complete (Bill or Claim), Proposed (Pre-Authorization), Exploratory (Pre-determination).",
"min": 0,
"max": "1",
"type": [
{
"code": "code"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Use"
}
],
"strength": "required",
"description": "Complete, proposed, exploratory, other",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/claim-use"
},
"mapping": [
{
"identity": "w5",
"map": "FiveWs.class"
}
]
},
{
"id": "Claim.patient",
"path": "Claim.patient",
"short": "The subject of the Products and Services",
"definition": "Patient Resource.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Patient"
]
}
],
"mapping": [
{
"identity": "workflow",
"map": "Request.subject"
},
{
"identity": "w5",
"map": "FiveWs.subject[x]"
},
{
"identity": "w5",
"map": "FiveWs.subject"
}
]
},
{
"id": "Claim.billablePeriod",
"path": "Claim.billablePeriod",
"short": "Period for charge submission",
"definition": "The billable period for which charges are being submitted.",
"min": 0,
"max": "1",
"type": [
{
"code": "Period"
}
],
"mapping": [
{
"identity": "w5",
"map": "FiveWs.done[x]"
}
]
},
{
"id": "Claim.created",
"path": "Claim.created",
"short": "Creation date",
"definition": "The date when the enclosed suite of services were performed or completed.",
"min": 0,
"max": "1",
"type": [
{
"code": "dateTime"
}
],
"mapping": [
{
"identity": "workflow",
"map": "Request.authoredOn"
},
{
"identity": "w5",
"map": "FiveWs.recorded"
}
]
},
{
"id": "Claim.enterer",
"path": "Claim.enterer",
"short": "Author",
"definition": "Person who created the invoice/claim/pre-determination or pre-authorization.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Practitioner",
"http://hl7.org/fhir/StructureDefinition/PractitionerRole"
]
}
],
"mapping": [
{
"identity": "w5",
"map": "FiveWs.author"
}
]
},
{
"id": "Claim.insurer",
"path": "Claim.insurer",
"short": "Target",
"definition": "The Insurer who is target of the request.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Organization"
]
}
],
"mapping": [
{
"identity": "workflow",
"map": "Request.performer"
}
]
},
{
"id": "Claim.provider",
"path": "Claim.provider",
"short": "Responsible provider",
"definition": "The provider which is responsible for the bill, claim pre-determination, pre-authorization.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Practitioner",
"http://hl7.org/fhir/StructureDefinition/PractitionerRole",
"http://hl7.org/fhir/StructureDefinition/Organization"
]
}
],
"mapping": [
{
"identity": "workflow",
"map": "Request.requester"
},
{
"identity": "w5",
"map": "FiveWs.source"
}
]
},
{
"id": "Claim.priority",
"path": "Claim.priority",
"short": "Desired processing priority",
"definition": "Immediate (STAT), best effort (NORMAL), deferred (DEFER).",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProcessPriority"
}
],
"strength": "example",
"description": "The timeliness with which processing is required: STAT, normal, Deferred",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/process-priority"
},
"mapping": [
{
"identity": "workflow",
"map": "Request.priority"
}
]
},
{
"id": "Claim.fundsReserve",
"path": "Claim.fundsReserve",
"short": "Funds requested to be reserved",
"definition": "In the case of a Pre-Determination/Pre-Authorization the provider may request that funds in the amount of the expected Benefit be reserved ('Patient' or 'Provider') to pay for the Benefits determined on the subsequent claim(s). 'None' explicitly indicates no funds reserving is requested.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "FundsReserve"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
}
],
"strength": "example",
"description": "For whom funds are to be reserved: (Patient, Provider, None).",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/fundsreserve"
}
},
{
"id": "Claim.related",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "RelatedClaim"
}
],
"path": "Claim.related",
"short": "Related Claims which may be revelant to processing this claimn",
"definition": "Other claims which are related to this claim such as prior claim versions or for related services.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "Claim.related.claim",
"path": "Claim.related.claim",
"short": "Reference to the related claim",
"definition": "Other claims which are related to this claim such as prior claim versions or for related services.",
"comment": "Do we need a relationship code?",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Claim"
]
}
],
"mapping": [
{
"identity": "workflow",
"map": "Request.replaces"
}
]
},
{
"id": "Claim.related.relationship",
"path": "Claim.related.relationship",
"short": "How the reference claim is related",
"definition": "For example prior or umbrella.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "RelatedClaimRelationship"
}
],
"strength": "example",
"description": "Relationship of this claim to a related Claim",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/related-claim-relationship"
}
},
{
"id": "Claim.related.reference",
"path": "Claim.related.reference",
"short": "Related file or case reference",
"definition": "An alternate organizational reference to the case or file to which this particular claim pertains - eg Property/Casualy insurer claim # or Workers Compensation case # .",
"min": 0,
"max": "1",
"type": [
{
"code": "Identifier"
}
]
},
{
"id": "Claim.prescription",
"path": "Claim.prescription",
"short": "Prescription authorizing services or products",
"definition": "Prescription to support the dispensing of Pharmacy or Vision products.",
"comment": "Should we create a group to hold multiple prescriptions and add a sequence number and on the line items a link to the sequence.",
"requirements": "For type=Pharmacy and Vision only.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/MedicationRequest",
"http://hl7.org/fhir/StructureDefinition/VisionPrescription"
]
}
]
},
{
"id": "Claim.originalPrescription",
"path": "Claim.originalPrescription",
"short": "Original prescription if superceded by fulfiller",
"definition": "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'.",
"comment": "as above.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/MedicationRequest"
]
}
]
},
{
"id": "Claim.payee",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Payee"
}
],
"path": "Claim.payee",
"short": "Party to be paid any benefits payable",
"definition": "The party to be reimbursed for the services.",
"min": 0,
"max": "1",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "Claim.payee.type",
"path": "Claim.payee.type",
"short": "Type of party: Subscriber, Provider, other",
"definition": "Type of Party to be reimbursed: Subscriber, provider, other.",
"min": 1,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "PayeeType"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
}
],
"strength": "example",
"description": "A code for the party to be reimbursed.",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/payeetype"
}
},
{
"id": "Claim.payee.resource",
"path": "Claim.payee.resource",
"short": "organization | patient | practitioner | relatedperson",
"definition": "organization | patient | practitioner | relatedperson.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ClaimPayeeResourceType"
}
],
"strength": "extensible",
"description": "The type of Claim payee Resource",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/ex-payee-resource-type"
}
},
{
"id": "Claim.payee.party",
"path": "Claim.payee.party",
"short": "Party to receive the payable",
"definition": "Party to be reimbursed: Subscriber, provider, other.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Practitioner",
"http://hl7.org/fhir/StructureDefinition/PractitionerRole",
"http://hl7.org/fhir/StructureDefinition/Organization",
"http://hl7.org/fhir/StructureDefinition/Patient",
"http://hl7.org/fhir/StructureDefinition/RelatedPerson"
]
}
]
},
{
"id": "Claim.referral",
"path": "Claim.referral",
"short": "Treatment Referral",
"definition": "The referral resource which lists the date, practitioner, reason and other supporting information.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/ServiceRequest"
]
}
],
"mapping": [
{
"identity": "w5",
"map": "FiveWs.cause"
}
]
},
{
"id": "Claim.facility",
"path": "Claim.facility",
"short": "Servicing Facility",
"definition": "Facility where the services were provided.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Location"
]
}
],
"mapping": [
{
"identity": "w5",
"map": "FiveWs.where[x]"
}
]
},
{
"id": "Claim.careTeam",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "CareTeam"
}
],
"path": "Claim.careTeam",
"short": "Members of the care team",
"definition": "The members of the team who provided the overall service as well as their role and whether responsible and qualifications.",
"requirements": "Role and Responsible might not be required when there is only a single provider listed.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "Claim.careTeam.sequence",
"path": "Claim.careTeam.sequence",
"short": "Number to convey order of careTeam",
"definition": "Sequence of the careTeam which serves to order and provide a link.",
"requirements": "Required to maintain order of the careTeam.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "Claim.careTeam.provider",
"path": "Claim.careTeam.provider",
"short": "Provider individual or organization",
"definition": "Member of the team who provided the overall service.",
"min": 1,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Practitioner",
"http://hl7.org/fhir/StructureDefinition/PractitionerRole",
"http://hl7.org/fhir/StructureDefinition/Organization"
]
}
],
"mapping": [
{
"identity": "w5",
"map": "FiveWs.actor"
}
]
},
{
"id": "Claim.careTeam.responsible",
"path": "Claim.careTeam.responsible",
"short": "Billing provider",
"definition": "The party who is billing and responsible for the claimed good or service rendered to the patient.",
"min": 0,
"max": "1",
"type": [
{
"code": "boolean"
}
]
},
{
"id": "Claim.careTeam.role",
"path": "Claim.careTeam.role",
"short": "Role on the team",
"definition": "The lead, assisting or supervising practitioner and their discipline if a multidisiplinary team.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CareTeamRole"
}
],
"strength": "example",
"description": "The role codes for the care team members.",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/claim-careteamrole"
}
},
{
"id": "Claim.careTeam.qualification",
"path": "Claim.careTeam.qualification",
"short": "Type, classification or Specialization",
"definition": "The qualification which is applicable for this service.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProviderQualification"
}
],
"strength": "example",
"description": "Provider professional qualifications",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/provider-qualification"
}
},
{
"id": "Claim.information",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "SpecialCondition"
}
],
"path": "Claim.information",
"short": "Exceptions, special considerations, the condition, situation, prior or concurrent issues",
"definition": "Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. Often there are mutiple jurisdiction specific valuesets which are required.",
"requirements": "Typically these information codes are required to support the services rendered or the adjudication of the services rendered.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"mapping": [
{
"identity": "workflow",
"map": "Request.supportingInfo"
}
]
},
{
"id": "Claim.information.sequence",
"path": "Claim.information.sequence",
"short": "Information instance identifier",
"definition": "Sequence of the information element which serves to provide a link.",
"requirements": "To provide a reference link.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "Claim.information.category",
"path": "Claim.information.category",
"short": "General class of information",
"definition": "The general class of the information supplied: information; exception; accident, employment; onset, etc.",
"comment": "This may contain the local bill type codes such as the US UB-04 bill type code.",
"min": 1,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "InformationCategory"
}
],
"strength": "example",
"description": "The valuset used for additional information category codes.",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/claim-informationcategory"
}
},
{
"id": "Claim.information.code",
"path": "Claim.information.code",
"short": "Type of information",
"definition": "System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought which may influence the adjudication.",
"comment": "This may contain the local bill type codes such as the US UB-04 bill type code.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "InformationCode"
}
],
"strength": "example",
"description": "The valuset used for additional information codes.",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/claim-exception"
}
},
{
"id": "Claim.information.timing[x]",
"path": "Claim.information.timing[x]",
"short": "When it occurred",
"definition": "The date when or period to which this information refers.",
"min": 0,
"max": "1",
"type": [
{
"code": "date"
},
{
"code": "Period"
}
]
},
{
"id": "Claim.information.value[x]",
"path": "Claim.information.value[x]",
"short": "Additional Data or supporting information",
"definition": "Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.",
"min": 0,
"max": "1",
"type": [
{
"code": "boolean"
},
{
"code": "string"
},
{
"code": "Quantity"
},
{
"code": "Attachment"
},
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Resource"
]
}
]
},
{
"id": "Claim.information.reason",
"path": "Claim.information.reason",
"short": "Reason associated with the information",
"definition": "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 content.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "MissingReason"
}
],
"strength": "example",
"description": "Reason codes for the missing teeth",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/missing-tooth-reason"
}
},
{
"id": "Claim.diagnosis",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Diagnosis"
}
],
"path": "Claim.diagnosis",
"short": "List of Diagnosis",
"definition": "List of patient diagnosis for which care is sought.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"mapping": [
{
"identity": "workflow",
"map": "Request.reasonReference"
}
]
},
{
"id": "Claim.diagnosis.sequence",
"path": "Claim.diagnosis.sequence",
"short": "Number to convey order of diagnosis",
"definition": "Sequence of diagnosis which serves to provide a link.",
"requirements": "Required to allow line items to reference the diagnoses.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "Claim.diagnosis.diagnosis[x]",
"path": "Claim.diagnosis.diagnosis[x]",
"short": "Patient's diagnosis",
"definition": "The diagnosis.",
"requirements": "Required to adjudicate services rendered to condition presented.",
"min": 1,
"max": "1",
"type": [
{
"code": "CodeableConcept"
},
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Condition"
]
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ICD10"
}
],
"strength": "example",
"description": "ICD10 Diagnostic codes",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/icd-10"
}
},
{
"id": "Claim.diagnosis.type",
"path": "Claim.diagnosis.type",
"short": "Timing or nature of the diagnosis",
"definition": "The type of the Diagnosis, for example: admitting, primary, secondary, discharge.",
"comment": "Diagnosis are presented in list order to their expected importance: primary, secondary, etc.",
"requirements": "May be required to adjudicate services rendered.",
"min": 0,
"max": "*",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "DiagnosisType"
}
],
"strength": "example",
"description": "The type of the diagnosis: admitting, principal, discharge",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/ex-diagnosistype"
}
},
{
"id": "Claim.diagnosis.packageCode",
"path": "Claim.diagnosis.packageCode",
"short": "Package billing code",
"definition": "The package billing code, for example DRG, based on the assigned grouping code system.",
"requirements": "May be required to adjudicate services rendered to the mandated grouping system.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "DiagnosisRelatedGroup"
}
],
"strength": "example",
"description": "The DRG codes associated with the diagnosis",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup"
}
},
{
"id": "Claim.procedure",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Procedure"
}
],
"path": "Claim.procedure",
"short": "Procedures performed",
"definition": "Ordered list of patient procedures performed to support the adjudication.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "Claim.procedure.sequence",
"path": "Claim.procedure.sequence",
"short": "Procedure sequence for reference",
"definition": "Sequence of procedures which serves to order and provide a link.",
"requirements": "Required to maintain order of the procudures.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "Claim.procedure.date",
"path": "Claim.procedure.date",
"short": "When the procedure was performed",
"definition": "Date and optionally time the procedure was performed .",
"comment": "SB DateTime??",
"requirements": "Required to adjudicate services rendered.",
"min": 0,
"max": "1",
"type": [
{
"code": "dateTime"
}
]
},
{
"id": "Claim.procedure.procedure[x]",
"path": "Claim.procedure.procedure[x]",
"short": "Patient's list of procedures performed",
"definition": "The procedure code.",
"requirements": "Required to adjudicate services rendered.",
"min": 1,
"max": "1",
"type": [
{
"code": "CodeableConcept"
},
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Procedure"
]
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ICD10_Procedures"
}
],
"strength": "example",
"description": "ICD10 Procedure codes",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/icd-10-procedures"
}
},
{
"id": "Claim.insurance",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Insurance"
}
],
"path": "Claim.insurance",
"short": "Insurance or medical plan",
"definition": "Financial instrument by which payment information for health care.",
"requirements": "Health care programs and insurers are significant payors of health service costs.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"mapping": [
{
"identity": "rim",
"map": "Coverage"
}
]
},
{
"id": "Claim.insurance.sequence",
"path": "Claim.insurance.sequence",
"short": "Service instance identifier",
"definition": "Sequence of coverage which serves to provide a link and convey coordination of benefit order.",
"requirements": "To maintain order of the coverages.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "Claim.insurance.focal",
"path": "Claim.insurance.focal",
"short": "Is the focal Coverage",
"definition": "A flag to indicate that this Coverage is the focus for adjudication. The Coverage against which the claim is to be adjudicated.",
"requirements": "To identify which coverage is being adjudicated.",
"min": 1,
"max": "1",
"type": [
{
"code": "boolean"
}
]
},
{
"id": "Claim.insurance.identifier",
"path": "Claim.insurance.identifier",
"short": "Claim number",
"definition": "The business identifier for the instance: claim number, pre-determination or pre-authorization number.",
"requirements": "This will be the claim number should it be necessary to create this claim in the future. This is provided so that payors may forward claims to other payors in the Coordination of Benefit for adjudication rather than the provider being required to initiate each adjudication.",
"min": 0,
"max": "1",
"type": [
{
"code": "Identifier"
}
],
"mapping": [
{
"identity": "workflow",
"map": "Request.identifier"
},
{
"identity": "w5",
"map": "FiveWs.identifier"
}
]
},
{
"id": "Claim.insurance.coverage",
"path": "Claim.insurance.coverage",
"short": "Insurance information",
"definition": "Reference to the program or plan identification, underwriter or payor.",
"requirements": "Need to identify the issuer to target for processing and for coordination of benefit processing.",
"min": 1,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Coverage"
]
}
]
},
{
"id": "Claim.insurance.businessArrangement",
"path": "Claim.insurance.businessArrangement",
"short": "Business agreement",
"definition": "The contract number of a business agreement which describes the terms and conditions.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
]
},
{
"id": "Claim.insurance.preAuthRef",
"path": "Claim.insurance.preAuthRef",
"short": "Pre-Authorization/Determination Reference",
"definition": "A list of references from the Insurer to which these services pertain.",
"requirements": "To provide any pre=determination or prior authorization reference.",
"min": 0,
"max": "*",
"type": [
{
"code": "string"
}
]
},
{
"id": "Claim.insurance.claimResponse",
"path": "Claim.insurance.claimResponse",
"short": "Adjudication results",
"definition": "The Coverages adjudication details.",
"requirements": "Used by downstream payers to determine what balance remains and the net payable.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/ClaimResponse"
]
}
]
},
{
"id": "Claim.accident",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Accident"
}
],
"path": "Claim.accident",
"short": "Details about an accident",
"definition": "An accident which resulted in the need for healthcare services.",
"min": 0,
"max": "1",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "Claim.accident.date",
"path": "Claim.accident.date",
"short": "When the accident occurred\nsee information codes\nsee information codes",
"definition": "Date of an accident which these services are addressing.",
"requirements": "Coverage may be dependant on accidents.",
"min": 1,
"max": "1",
"type": [
{
"code": "date"
}
]
},
{
"id": "Claim.accident.type",
"path": "Claim.accident.type",
"short": "The nature of the accident",
"definition": "Type of accident: work, auto, etc.",
"requirements": "Coverage may be dependant on the type of accident.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "AccidentType"
}
],
"strength": "extensible",
"description": "Type of accident: work place, auto, etc.",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/v3-ActIncidentCode"
}
},
{
"id": "Claim.accident.location[x]",
"path": "Claim.accident.location[x]",
"short": "Accident Place",
"definition": "Accident Place.",
"min": 0,
"max": "1",
"type": [
{
"code": "Address"
},
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Location"
]
}
]
},
{
"id": "Claim.item",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Item"
}
],
"path": "Claim.item",
"short": "Goods and Services",
"definition": "First tier of goods and services.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "Claim.item.sequence",
"path": "Claim.item.sequence",
"short": "Service instance",
"definition": "A service line number.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "Claim.item.careTeamSequence",
"path": "Claim.item.careTeamSequence",
"short": "Applicable careTeam members",
"definition": "CareTeam applicable for this service or product line.",
"min": 0,
"max": "*",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "Claim.item.diagnosisSequence",
"path": "Claim.item.diagnosisSequence",
"short": "Applicable diagnoses",
"definition": "Diagnosis applicable for this service or product line.",
"min": 0,
"max": "*",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "Claim.item.procedureSequence",
"path": "Claim.item.procedureSequence",
"short": "Applicable procedures",
"definition": "Procedures applicable for this service or product line.",
"min": 0,
"max": "*",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "Claim.item.informationSequence",
"path": "Claim.item.informationSequence",
"short": "Applicable exception and supporting information",
"definition": "Exceptions, special conditions and supporting information pplicable for this service or product line.",
"min": 0,
"max": "*",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "Claim.item.revenue",
"path": "Claim.item.revenue",
"short": "Revenue or cost center code",
"definition": "The type of reveneu or cost center providing the product and/or service.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "RevenueCenter"
}
],
"strength": "example",
"description": "Codes for the revenue or cost centers supplying the service and/or products.",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/ex-revenue-center"
}
},
{
"id": "Claim.item.category",
"path": "Claim.item.category",
"short": "Type of service or product",
"definition": "Health Care Service Type Codes to identify the classification of service or benefits.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitSubCategory"
}
],
"strength": "example",
"description": "Benefit subcategories such as: oral-basic, major, glasses",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/benefit-subcategory"
}
},
{
"id": "Claim.item.service",
"path": "Claim.item.service",
"short": "Billing Code",
"definition": "If this is an actual service or product line, ie. not a Group, then use code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,RXNorm,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
}
],
"strength": "example",
"description": "Allowable service and product codes",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/service-uscls"
}
},
{
"id": "Claim.item.modifier",
"path": "Claim.item.modifier",
"short": "Service/Product billing modifiers",
"definition": "Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.",
"requirements": "May impact on adjudication.",
"min": 0,
"max": "*",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Modifiers"
}
],
"strength": "example",
"description": "Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/claim-modifiers"
}
},
{
"id": "Claim.item.programCode",
"path": "Claim.item.programCode",
"short": "Program specific reason for item inclusion",
"definition": "For programs which require reason codes for the inclusion or covering of this billed item under the program or sub-program.",
"min": 0,
"max": "*",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProgramCode"
}
],
"strength": "example",
"description": "Program specific reason codes",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/ex-program-code"
}
},
{
"id": "Claim.item.serviced[x]",
"path": "Claim.item.serviced[x]",
"short": "Date or dates of Service",
"definition": "The date or dates when the enclosed suite of services were performed or completed.",
"min": 0,
"max": "1",
"type": [
{
"code": "date"
},
{
"code": "Period"
}
],
"mapping": [
{
"identity": "w5",
"map": "FiveWs.done[x]"
}
]
},
{
"id": "Claim.item.location[x]",
"path": "Claim.item.location[x]",
"short": "Place of service",
"definition": "Where the service was provided.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
},
{
"code": "Address"
},
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Location"
]
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServicePlace"
}
],
"strength": "example",
"description": "Place of service: pharmacy,school, prison, etc.",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/service-place"
},
"mapping": [
{
"identity": "w5",
"map": "FiveWs.where[x]"
}
]
},
{
"id": "Claim.item.quantity",
"path": "Claim.item.quantity",
"short": "Count of Products or Services",
"definition": "The number of repetitions of a service or product.",
"min": 0,
"max": "1",
"type": [
{
"code": "Quantity",
"profile": [
"http://hl7.org/fhir/StructureDefinition/SimpleQuantity"
]
}
]
},
{
"id": "Claim.item.unitPrice",
"path": "Claim.item.unitPrice",
"short": "Fee, charge or cost per point",
"definition": "If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "Claim.item.factor",
"path": "Claim.item.factor",
"short": "Price scaling factor",
"definition": "A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "decimal"
}
]
},
{
"id": "Claim.item.net",
"path": "Claim.item.net",
"short": "Total item cost",
"definition": "The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "Claim.item.udi",
"path": "Claim.item.udi",
"short": "Unique Device Identifier",
"definition": "List of Unique Device Identifiers associated with this line item.",
"requirements": "The UDI code and issuer if applicable for the supplied product.",
"min": 0,
"max": "*",
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Device"
]
}
]
},
{
"id": "Claim.item.bodySite",
"path": "Claim.item.bodySite",
"short": "Service Location",
"definition": "Physical service site on the patient (limb, tooth, etc.).",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "OralSites"
}
],
"strength": "example",
"description": "The code for the teeth, quadrant, sextant and arch",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/tooth"
}
},
{
"id": "Claim.item.subSite",
"path": "Claim.item.subSite",
"short": "Service Sub-location",
"definition": "A region or surface of the site, eg. limb region or tooth surface(s).",
"min": 0,
"max": "*",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Surface"
}
],
"strength": "example",
"description": "The code for the tooth surface and surface combinations",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/surface"
}
},
{
"id": "Claim.item.encounter",
"path": "Claim.item.encounter",
"short": "Encounters related to this billed item",
"definition": "A billed item may include goods or services provided in multiple encounters.",
"min": 0,
"max": "*",
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Encounter"
]
}
],
"mapping": [
{
"identity": "workflow",
"map": "Request.context"
}
]
},
{
"id": "Claim.item.detail",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Detail"
}
],
"path": "Claim.item.detail",
"short": "Additional items",
"definition": "Second tier of goods and services.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "Claim.item.detail.sequence",
"path": "Claim.item.detail.sequence",
"short": "Service instance",
"definition": "A service line number.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "Claim.item.detail.revenue",
"path": "Claim.item.detail.revenue",
"short": "Revenue or cost center code",
"definition": "The type of reveneu or cost center providing the product and/or service.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "RevenueCenter"
}
],
"strength": "example",
"description": "Codes for the revenue or cost centers supplying the service and/or products.",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/ex-revenue-center"
}
},
{
"id": "Claim.item.detail.category",
"path": "Claim.item.detail.category",
"short": "Type of service or product",
"definition": "Health Care Service Type Codes to identify the classification of service or benefits.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitSubCategory"
}
],
"strength": "example",
"description": "Benefit subcategories such as: oral-basic, major, glasses",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/benefit-subcategory"
}
},
{
"id": "Claim.item.detail.service",
"path": "Claim.item.detail.service",
"short": "Billing Code",
"definition": "If this is an actual service or product line, ie. not a Group, then use code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
}
],
"strength": "example",
"description": "Allowable service and product codes",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/service-uscls"
}
},
{
"id": "Claim.item.detail.modifier",
"path": "Claim.item.detail.modifier",
"short": "Service/Product billing modifiers",
"definition": "Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.",
"requirements": "May impact on adjudication.",
"min": 0,
"max": "*",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Modifiers"
}
],
"strength": "example",
"description": "Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/claim-modifiers"
}
},
{
"id": "Claim.item.detail.programCode",
"path": "Claim.item.detail.programCode",
"short": "Program specific reason for item inclusion",
"definition": "For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program.",
"min": 0,
"max": "*",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProgramCode"
}
],
"strength": "example",
"description": "Program specific reason codes",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/ex-program-code"
}
},
{
"id": "Claim.item.detail.quantity",
"path": "Claim.item.detail.quantity",
"short": "Count of Products or Services",
"definition": "The number of repetitions of a service or product.",
"min": 0,
"max": "1",
"type": [
{
"code": "Quantity",
"profile": [
"http://hl7.org/fhir/StructureDefinition/SimpleQuantity"
]
}
]
},
{
"id": "Claim.item.detail.unitPrice",
"path": "Claim.item.detail.unitPrice",
"short": "Fee, charge or cost per point",
"definition": "If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "Claim.item.detail.factor",
"path": "Claim.item.detail.factor",
"short": "Price scaling factor",
"definition": "A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "decimal"
}
]
},
{
"id": "Claim.item.detail.net",
"path": "Claim.item.detail.net",
"short": "Total additional item cost",
"definition": "The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "Claim.item.detail.udi",
"path": "Claim.item.detail.udi",
"short": "Unique Device Identifier",
"definition": "List of Unique Device Identifiers associated with this line item.",
"requirements": "The UDI code and issuer if applicable for the supplied product.",
"min": 0,
"max": "*",
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Device"
]
}
]
},
{
"id": "Claim.item.detail.subDetail",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "SubDetail"
}
],
"path": "Claim.item.detail.subDetail",
"short": "Additional items",
"definition": "Third tier of goods and services.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "Claim.item.detail.subDetail.sequence",
"path": "Claim.item.detail.subDetail.sequence",
"short": "Service instance",
"definition": "A service line number.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "Claim.item.detail.subDetail.revenue",
"path": "Claim.item.detail.subDetail.revenue",
"short": "Revenue or cost center code",
"definition": "The type of reveneu or cost center providing the product and/or service.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "RevenueCenter"
}
],
"strength": "example",
"description": "Codes for the revenue or cost centers supplying the service and/or products.",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/ex-revenue-center"
}
},
{
"id": "Claim.item.detail.subDetail.category",
"path": "Claim.item.detail.subDetail.category",
"short": "Type of service or product",
"definition": "Health Care Service Type Codes to identify the classification of service or benefits.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitSubCategory"
}
],
"strength": "example",
"description": "Benefit subcategories such as: oral-basic, major, glasses",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/benefit-subcategory"
}
},
{
"id": "Claim.item.detail.subDetail.service",
"path": "Claim.item.detail.subDetail.service",
"short": "Billing Code",
"definition": "A code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI).",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
}
],
"strength": "example",
"description": "Allowable service and product codes",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/service-uscls"
}
},
{
"id": "Claim.item.detail.subDetail.modifier",
"path": "Claim.item.detail.subDetail.modifier",
"short": "Service/Product billing modifiers",
"definition": "Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.",
"requirements": "May impact on adjudication.",
"min": 0,
"max": "*",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Modifiers"
}
],
"strength": "example",
"description": "Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/claim-modifiers"
}
},
{
"id": "Claim.item.detail.subDetail.programCode",
"path": "Claim.item.detail.subDetail.programCode",
"short": "Program specific reason for item inclusion",
"definition": "For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program.",
"min": 0,
"max": "*",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProgramCode"
}
],
"strength": "example",
"description": "Program specific reason codes",
"valueSetCanonical": "http://hl7.org/fhir/ValueSet/ex-program-code"
}
},
{
"id": "Claim.item.detail.subDetail.quantity",
"path": "Claim.item.detail.subDetail.quantity",
"short": "Count of Products or Services",
"definition": "The number of repetitions of a service or product.",
"min": 0,
"max": "1",
"type": [
{
"code": "Quantity",
"profile": [
"http://hl7.org/fhir/StructureDefinition/SimpleQuantity"
]
}
]
},
{
"id": "Claim.item.detail.subDetail.unitPrice",
"path": "Claim.item.detail.subDetail.unitPrice",
"short": "Fee, charge or cost per point",
"definition": "The fee for an addittional service or product or charge.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "Claim.item.detail.subDetail.factor",
"path": "Claim.item.detail.subDetail.factor",
"short": "Price scaling factor",
"definition": "A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "decimal"
}
]
},
{
"id": "Claim.item.detail.subDetail.net",
"path": "Claim.item.detail.subDetail.net",
"short": "Net additional item cost",
"definition": "The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "Claim.item.detail.subDetail.udi",
"path": "Claim.item.detail.subDetail.udi",
"short": "Unique Device Identifier",
"definition": "List of Unique Device Identifiers associated with this line item.",
"requirements": "The UDI code and issuer if applicable for the supplied product.",
"min": 0,
"max": "*",
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Device"
]
}
]
},
{
"id": "Claim.total",
"path": "Claim.total",
"short": "Total claim cost",
"definition": "The total value of the claim.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
}
]
}
}
Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.
®© HL7.org 2011+. FHIR Mixed Nomative/Trial Use Ballot (v3.3.0-13671) generated on Tue, Apr 3, 2018 12:14+1000. QA Page
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