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.

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

The status of the resource instance.

The category of claim, e.g. oral, pharmacy, vision, institutional, professional.

Affects which fields and value sets are used.

A finer grained suite of claim subtype codes which may convey Inpatient vs Outpatient and/or a specialty service. In the US the CMS Bill Type.

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

A claim, a list of completed goods and services; a preauthorization, a list or proposed goods and services; or a predetermination, a set of goods and services being considered, for which insurer adjudication is sought.

Patient Resource.

The billable period for which charges are being submitted.

The date when this resource was created.

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

The Insurer who is target of the request.

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

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

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.

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

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

Do we need a relationship code?

For example, prior or umbrella.

An alternate organizational reference to the case or file to which this particular claim pertains - e.g. Property/Casualty insurer claim # or Workers Compensation case # .

Prescription to support the dispensing of Pharmacy or Vision products.

For type=Pharmacy and Vision only.

Should we create a group to hold multiple prescriptions and add a sequence number and on the line items a link to the sequence.

Original prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or products.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 prescription for an alternate medication which has the same therapeutic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription'.

as above.

The party to be reimbursed for the services.

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

organization | patient | practitioner | relatedperson.

Party to be reimbursed: Subscriber, provider, other.

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

Facility where the services were provided.

The members of the team who provided the overall service as well as their role and whether responsible and qualifications.

Role and Responsible might not be required when there is only a single provider listed.

Sequence of the careTeam which serves to order and provide a link.

Required to maintain order of the careTeam.

Member of the team who provided the overall service.

The party who is billing and responsible for the claimed good or service rendered to the patient.

The lead, assisting or supervising practitioner and their discipline if a multidisciplinary team.

The qualification which is applicable for this service.

Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. Often there are multiple jurisdiction specific valuesets which are required.

Typically these information codes are required to support the services rendered or the adjudication of the services rendered.

Sequence of the information element which serves to provide a link.

To provide a reference link.

The general class of the information supplied: information; exception; accident, employment; onset, etc.

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

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.

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

The date when or period to which this information refers.

Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.

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.

List of patient diagnosis for which care is sought.

Sequence of diagnosis which serves to provide a link.

Required to allow line items to reference the diagnoses.

The diagnosis.

Required to adjudicate services rendered to condition presented.

The type of the Diagnosis, for example: admitting, primary, secondary, discharge.

May be required to adjudicate services rendered.

Diagnosis are presented in list order to their expected importance: primary, secondary, etc.

Indication of whether the diagnosis was present on admission to a facility.

The package billing code, for example DRG, based on the assigned grouping code system.

May be required to adjudicate services rendered to the mandated grouping system.

Ordered list of patient procedures performed to support the adjudication.

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

Required to maintain order of the procudures.

Date and optionally time the procedure was performed .

Required to adjudicate services rendered.

SB DateTime??

The procedure code.

Required to adjudicate services rendered.

Financial instrument by which payment information for health care.

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

Sequence of coverage which serves to provide a link and convey coordination of benefit order.

To maintain order of the coverages.

A flag to indicate that this Coverage is the focus for adjudication. The Coverage against which the claim is to be adjudicated.

To identify which coverage is being adjudicated.

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

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.

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

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

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

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

To provide any pre=determination or prior authorization reference.

The Coverages adjudication details.

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

An accident which resulted in the need for healthcare services.

Date of an accident which these services are addressing.

Coverage may be dependant on accidents.

Type of accident: work, auto, etc.

Coverage may be dependant on the type of accident.

Accident Place.

First tier of goods and services.

A service line number.

CareTeam applicable for this service or product line.

Diagnosis applicable for this service or product line.

Procedures applicable for this service or product line.

Exceptions, special conditions and supporting information applicable for this service or product line.

The type of revenue or cost center providing the product and/or service.

Health Care Service Type Codes to identify the classification of service or benefits.

If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. 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 e.g. 'glasses' or 'compound'.

Item typification or modifiers codes, e.g. 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.

May impact on adjudication.

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

The date or dates when the service or product was supplied, performed or completed.

Where the service was provided.

The number of repetitions of a service or product.

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.

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.

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

The quantity times the unit price for an additional 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.

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

List of Unique Device Identifiers associated with this line item.

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

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

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

A billed item may include goods or services provided in multiple encounters.

Second tier of goods and services.

A service line number.

The type of revenue or cost center providing the product and/or service.

Health Care Service Type Codes to identify the classification of service or benefits.

If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. 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'.

Item typification or modifiers codes, e.g. 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.

May impact on adjudication.

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

The number of repetitions of a service or product.

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.

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

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.

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

The quantity times the unit price for an additional 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.

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

List of Unique Device Identifiers associated with this line item.

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

Third tier of goods and services.

A service line number.

The type of revenue or cost center providing the product and/or service.

Health Care Service Type Codes to identify the classification of service or benefits.

A code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI).

Item typification or modifiers codes, e.g. 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.

May impact on adjudication.

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

The number of repetitions of a service or product.

The fee for an addittional service or product or charge.

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

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.

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

The quantity times the unit price for an additional 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.

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

List of Unique Device Identifiers associated with this line item.

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

The total value of the claim.