Name Flags Card. Type Description & Constraints doco
. . Claim TU DomainResource Claim, Pre-determination or Pre-authorization
Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
. . . identifier 0..* Identifier Claim number
. . . status ?! Σ 0..1 code active | cancelled | draft | entered-in-error
Financial Resource Status Codes ( Required)
. . . type 0..1 CodeableConcept Type or discipline
Claim Type Codes ( Extensible)
. . . subType 0..* CodeableConcept Finer grained claim type information
Example Claim SubType Codes ( Example)
. . . use 0..1 code complete | proposed | exploratory | other
Use ( Required)
. . . patient 0..1 Reference( Patient) The subject of the Products and Services
. . . billablePeriod 0..1 Period Period for charge submission
. . . created 0..1 dateTime Creation date
. . . enterer 0..1 Reference( Practitioner | PractitionerRole) Author
. . . insurer 0..1 Reference( Organization) Target
. . . provider 0..1 Reference( Practitioner | PractitionerRole | Organization) Responsible provider
. . . priority 0..1 CodeableConcept Desired processing priority
Process Priority Codes ( Example)
. . . fundsReserve 0..1 CodeableConcept Funds requested to be reserved
Funds Reservation Codes ( Example)
. . . related 0..* BackboneElement Related Claims which may be revelant to processing this claimn
. . . . claim 0..1 Reference( Claim) Reference to the related claim
. . . . relationship 0..1 CodeableConcept How the reference claim is related
Example Related Claim Relationship Codes ( Example)
. . . . reference 0..1 Identifier Related file or case reference
. . . prescription 0..1 Reference( MedicationRequest | VisionPrescription) Prescription authorizing services or products
. . . originalPrescription 0..1 Reference( MedicationRequest) Original prescription if superceded by fulfiller
. . . payee 0..1 BackboneElement Party to be paid any benefits payable
. . . . type 1..1 CodeableConcept Type of party: Subscriber, Provider, other
Claim Payee Type Codes ( Example)
. . . . resource 0..1 Coding organization | patient | practitioner | relatedperson
ClaimPayeeResourceType ( Extensible)
. . . . party 0..1 Reference( Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) Party to receive the payable
. . . referral 0..1 Reference( ServiceRequest) Treatment Referral
. . . facility 0..1 Reference( Location) Servicing Facility
. . . careTeam 0..* BackboneElement Members of the care team
. . . . sequence 1..1 positiveInt Number to convey order of careTeam
. . . . provider 1..1 Reference( Practitioner | PractitionerRole | Organization) Provider individual or organization
. . . . responsible 0..1 boolean Billing provider
. . . . role 0..1 CodeableConcept Role on the team
Claim Care Team Role Codes ( Example)
. . . . qualification 0..1 CodeableConcept Type, classification or Specialization
Example Provider Qualification Codes ( Example)
. . . information 0..* BackboneElement Exceptions, special considerations, the condition, situation, prior or concurrent issues
. . . . sequence 1..1 positiveInt Information instance identifier
. . . . category 1..1 CodeableConcept General class of information
Claim Information Category Codes ( Example)
. . . . code 0..1 CodeableConcept Type of information
Exception Codes ( Example)
. . . . timing[x] 0..1 When it occurred
. . . . . timingDate date
. . . . . timingPeriod Period
. . . . value[x] 0..1 Additional Data or supporting information
. . . . . valueBoolean boolean
. . . . . valueString string
. . . . . valueQuantity Quantity
. . . . . valueAttachment Attachment
. . . . . valueReference Reference( Any)
. . . . reason 0..1 CodeableConcept Reason associated with the information
Missing Tooth Reason Codes ( Example)
. . . diagnosis 0..* BackboneElement List of Diagnosis
. . . . sequence 1..1 positiveInt Number to convey order of diagnosis
. . . . diagnosis[x] 1..1 Patient's diagnosis
ICD-10 Codes ( Example)
. . . . . diagnosisCodeableConcept CodeableConcept
. . . . . diagnosisReference Reference( Condition)
. . . . type 0..* CodeableConcept Timing or nature of the diagnosis
Example Diagnosis Type Codes ( Example)
. . . . packageCode 0..1 CodeableConcept Package billing code
Example Diagnosis Related Group Codes ( Example)
. . . procedure 0..* BackboneElement Procedures performed
. . . . sequence 1..1 positiveInt Procedure sequence for reference
. . . . date 0..1 dateTime When the procedure was performed
. . . . procedure[x] 1..1 Patient's list of procedures performed
ICD-10 Procedure Codes ( Example)
. . . . . procedureCodeableConcept CodeableConcept
. . . . . procedureReference Reference( Procedure)
. . . insurance 0..* BackboneElement Insurance or medical plan
. . . . sequence 1..1 positiveInt Service instance identifier
. . . . focal 1..1 boolean Is the focal Coverage
. . . . identifier 0..1 Identifier Claim number
. . . . coverage 1..1 Reference( Coverage) Insurance information
. . . . businessArrangement 0..1 string Business agreement
. . . . preAuthRef 0..* string Pre-Authorization/Determination Reference
. . . . claimResponse 0..1 Reference( ClaimResponse) Adjudication results
. . . accident 0..1 BackboneElement Details about an accident
. . . . date 1..1 date When the accident occurred see information codes see information codes
. . . . type 0..1 CodeableConcept The nature of the accident
ActIncidentCode ( Extensible)
. . . . location[x] 0..1 Accident Place
. . . . . locationAddress Address
. . . . . locationReference Reference( Location)
. . . item 0..* BackboneElement Goods and Services
. . . . sequence 1..1 positiveInt Service instance
. . . . careTeamSequence 0..* positiveInt Applicable careTeam members
. . . . diagnosisSequence 0..* positiveInt Applicable diagnoses
. . . . procedureSequence 0..* positiveInt Applicable procedures
. . . . informationSequence 0..* positiveInt Applicable exception and supporting information
. . . . revenue 0..1 CodeableConcept Revenue or cost center code
Example Revenue Center Codes ( Example)
. . . . category 0..1 CodeableConcept Type of service or product
Benefit SubCategory Codes ( Example)
. . . . service 0..1 CodeableConcept Billing Code
USCLS Codes ( Example)
. . . . modifier 0..* CodeableConcept Service/Product billing modifiers
Modifier type Codes ( Example)
. . . . programCode 0..* CodeableConcept Program specific reason for item inclusion
Example Program Reason Codes ( Example)
. . . . serviced[x] 0..1 Date or dates of Service
. . . . . servicedDate date
. . . . . servicedPeriod Period
. . . . location[x] 0..1 Place of service
Example Service Place Codes ( Example)
. . . . . locationCodeableConcept CodeableConcept
. . . . . locationAddress Address
. . . . . locationReference Reference( Location)
. . . . quantity 0..1 SimpleQuantity Count of Products or Services
. . . . unitPrice 0..1 Money Fee, charge or cost per point
. . . . factor 0..1 decimal Price scaling factor
. . . . net 0..1 Money Total item cost
. . . . udi 0..* Reference( Device) Unique Device Identifier
. . . . bodySite 0..1 CodeableConcept Service Location
Oral Site Codes ( Example)
. . . . subSite 0..* CodeableConcept Service Sub-location
Surface Codes ( Example)
. . . . encounter 0..* Reference( Encounter) Encounters related to this billed item
. . . . detail 0..* BackboneElement Additional items
. . . . . sequence 1..1 positiveInt Service instance
. . . . . revenue 0..1 CodeableConcept Revenue or cost center code
Example Revenue Center Codes ( Example)
. . . . . category 0..1 CodeableConcept Type of service or product
Benefit SubCategory Codes ( Example)
. . . . . service 0..1 CodeableConcept Billing Code
USCLS Codes ( Example)
. . . . . modifier 0..* CodeableConcept Service/Product billing modifiers
Modifier type Codes ( Example)
. . . . . programCode 0..* CodeableConcept Program specific reason for item inclusion
Example Program Reason Codes ( Example)
. . . . . quantity 0..1 SimpleQuantity Count of Products or Services
. . . . . unitPrice 0..1 Money Fee, charge or cost per point
. . . . . factor 0..1 decimal Price scaling factor
. . . . . net 0..1 Money Total additional item cost
. . . . . udi 0..* Reference( Device) Unique Device Identifier
. . . . . subDetail 0..* BackboneElement Additional items
. . . . . . sequence 1..1 positiveInt Service instance
. . . . . . revenue 0..1 CodeableConcept Revenue or cost center code
Example Revenue Center Codes ( Example)
. . . . . . category 0..1 CodeableConcept Type of service or product
Benefit SubCategory Codes ( Example)
. . . . . . service 0..1 CodeableConcept Billing Code
USCLS Codes ( Example)
. . . . . . modifier 0..* CodeableConcept Service/Product billing modifiers
Modifier type Codes ( Example)
. . . . . . programCode 0..* CodeableConcept Program specific reason for item inclusion
Example Program Reason Codes ( Example)
. . . . . . quantity 0..1 SimpleQuantity Count of Products or Services
. . . . . . unitPrice 0..1 Money Fee, charge or cost per point
. . . . . . factor 0..1 decimal Price scaling factor
. . . . . . net 0..1 Money Net additional item cost
. . . . . . udi 0..* Reference( Device) Unique Device Identifier
. . . total 0..1 Money Total claim cost

doco Documentation for this format