Release 5 Preview #3

This page is part of the FHIR Specification (v4.5.0: R5 Preview #3). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2

13.6 Resource Claim - Content

Financial Management Work GroupMaturity Level: 2 Trial UseSecurity Category: Patient Compartments: Device, Encounter, Patient, Practitioner, RelatedPerson

A provider issued list of professional services and products which have been provided, or are to be provided, to a patient which is sent to an insurer for reimbursement.

13.6.1 Scope and Usage

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

The Claim resource is a "request" resource from a FHIR workflow perspective - see Workflow Request.

The Claim resource may be interpreted differently depending on its intended use (and the Claim.use element contains the code to indicate):

  • claim - where the provision of goods and services is complete and adjudication under a plan and payment is sought.
  • preauthorization - where the provision of goods and services is proposed and authorization and/or the reservation of funds is desired.
  • predetermination - where the provision of goods and services is explored to determine what services may be covered and to what amount. Essentially a 'what if' claim.

The Claim also supports:

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

Mapping to other Claim specifications: Mappings are currently maintained by the Financial Management Work Group to UB04 and CMS1500 and are available at https://confluence.hl7.org/display/FM/FHIR+Resource+Development . Mappings to other specifications may be made available where IP restrictions permit.

13.6.1.1 Additional Information

Additional information regarding electronic claims content and usage may be found at:

  • Financial Resource Status Lifecycle: how .status is used in the financial resources.
  • Secondary Use of Resources: how resources such as Claim and ExplanationOfBenefit may used for reporting and data exchange for analytics, not just for eClaims exchange between providers and payors.
  • Subrogation: how eClaims may handle patient insurance coverages when another insurer rather than the provider will settle the claim and potentially recover costs against specified coverages.
  • Coordination of Benefit: how eClaims may handle multiple patient insurance coverages.
  • Batches: how eClaims may handle batches of eligibility, claims and responses.
  • Attachments and Supporting Information: how eClaims may handle the provision of supporting information, whether provided by content or reference, within the eClaim resource when submitted to the payor or later in a resource which refers to the subject eClaim resource. This also includes how payors may request additional supporting information from providers.

13.6.2 Boundaries and Relationships

The Claim resource is used to request the adjudication and/or authorization of a set of healthcare-related goods and services for a patient against the patient's insurance coverages, or to request what the adjudication would be for a supplied set of goods or services should they be actually supplied to the patient.

When requesting whether the patient's coverage is inforce, whether it is valid at this or a specified date, or requesting the benefit details or preauthorization requirements associated with a coverage, then CoverageEligibilityRequest should be used instead.

When using the resources for reporting and transferring claims data, which may have originated in some standard other than FHIR, the Claim resource is useful if only the request side of the information exchange is of interest. If, however, both the request and the adjudication information is to be reported then the ExplanationOfBenefit should be used instead.

For reporting out to patients or transferring data to patient centered applications, such as patient health Record (PHR) application, the ExplanationOfBenefit should be used instead of the Claim and ClaimResponse resources as those resources may contain provider and payer specific information which is not appropriate for sharing with the patient.

The eClaim domain includes a number of related resources

Claim A suite of goods and services and insurances coverages under which adjudication or authorization is requested.
CoverageEligibilityRequest A request to a payor to: ascertain whether a coverage is in-force at the current or at a specified time; list the table of benefits; determine whether coverage is provided for specified categories or specific services; and whether preauthorization is required, and if so what supporting information would be required.
ClaimResponse A payor's adjudication and/or authorization response to the suite of services provided in a Claim. Typically the ClaimResponse references the Claim but does not duplicate the clinical or financial information provided in the claim.
ExplanationOfBenefit This resource combines the information from the Claim and the ClaimResponse, stripping out any provider or payor proprietary information, into a unified information model suitable for use for: patient reporting; transferring information to a Patient Health Record system; and, supporting complete claim and adjudication information exchange with regulatory and analytics organizations and other parts of the provider's organization.

13.6.3 References

This resource is referenced by itself, ClaimResponse, DeviceUseStatement and ExplanationOfBenefit.

This resource implements the Request pattern.

13.6.4 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim TUDomainResourceClaim, Pre-determination or Pre-authorization
Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier 0..*IdentifierBusiness Identifier for claim
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Financial Resource Status Codes (Required)
... type Σ1..1CodeableConceptCategory or discipline
Claim Type Codes (Extensible)
... subType 0..1CodeableConceptMore granular claim type
Example Claim SubType Codes (Example)
... use Σ1..1codeclaim | preauthorization | predetermination
Use (Required)
... patient Σ1..1Reference(Patient)The recipient of the products and services
... billablePeriod Σ0..1PeriodRelevant time frame for the claim
... created Σ1..1dateTimeResource creation date
... enterer 0..1Reference(Practitioner | PractitionerRole)Author of the claim
... insurer Σ0..1Reference(Organization)Target
... provider Σ1..1Reference(Practitioner | PractitionerRole | Organization)Party responsible for the claim
... priority Σ1..1CodeableConceptDesired processing ugency
Process Priority Codes (Example)
... fundsReserve 0..1CodeableConceptFor whom to reserve funds
FundsReserve (Example)
... related 0..*BackboneElementPrior or corollary claims
.... claim 0..1Reference(Claim)Reference to the related claim
.... relationship 0..1CodeableConceptHow the reference claim is related
Example Related Claim Relationship Codes (Example)
.... reference 0..1IdentifierFile or case reference
... prescription 0..1Reference(DeviceRequest | MedicationRequest | VisionPrescription)Prescription authorizing services and products
... originalPrescription 0..1Reference(DeviceRequest | MedicationRequest | VisionPrescription)Original prescription if superseded by fulfiller
... payee 0..1BackboneElementRecipient of benefits payable
.... type 1..1CodeableConceptCategory of recipient
PayeeType (Example)
.... party 0..1Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson)Recipient reference
... referral 0..1Reference(ServiceRequest)Treatment referral
... facility 0..1Reference(Location)Servicing facility
... careTeam 0..*BackboneElementMembers of the care team
.... sequence 1..1positiveIntOrder of care team
.... provider 1..1Reference(Practitioner | PractitionerRole | Organization)Practitioner or organization
.... responsible 0..1booleanIndicator of the lead practitioner
.... role 0..1CodeableConceptFunction within the team
Claim Care Team Role Codes (Example)
.... qualification 0..1CodeableConceptPractitioner credential or specialization
Example Provider Qualification Codes (Example)
... supportingInfo 0..*BackboneElementSupporting information
.... sequence 1..1positiveIntInformation instance identifier
.... category 1..1CodeableConceptClassification of the supplied information
Claim Information Category Codes (Example)
.... code 0..1CodeableConceptType of information
Exception Codes (Example)
.... timing[x] 0..1When it occurred
..... timingDatedate
..... timingPeriodPeriod
.... value[x] 0..1Data to be provided
..... valueBooleanboolean
..... valueStringstring
..... valueQuantityQuantity
..... valueAttachmentAttachment
..... valueReferenceReference(Any)
.... reason 0..1CodeableConceptExplanation for the information
Missing Tooth Reason Codes (Example)
... diagnosis 0..*BackboneElementPertinent diagnosis information
.... sequence 1..1positiveIntDiagnosis instance identifier
.... diagnosis[x] 1..1Nature of illness or problem
ICD-10 Codes (Example)
..... diagnosisCodeableConceptCodeableConcept
..... diagnosisReferenceReference(Condition)
.... type 0..*CodeableConceptTiming or nature of the diagnosis
Example Diagnosis Type Codes (Example)
.... onAdmission 0..1CodeableConceptPresent on admission
Example Diagnosis on Admission Codes (Example)
.... packageCode 0..1CodeableConceptPackage billing code
Example Diagnosis Related Group Codes (Example)
... procedure 0..*BackboneElementClinical procedures performed
.... sequence 1..1positiveIntProcedure instance identifier
.... type 0..*CodeableConceptCategory of Procedure
Example Procedure Type Codes (Example)
.... date 0..1dateTimeWhen the procedure was performed
.... procedure[x] 1..1Specific clinical procedure
ICD-10 Procedure Codes (Example)
..... procedureCodeableConceptCodeableConcept
..... procedureReferenceReference(Procedure)
.... udi 0..*Reference(Device)Unique device identifier
... insurance Σ1..*BackboneElementPatient insurance information
.... sequence Σ1..1positiveIntInsurance instance identifier
.... focal Σ1..1booleanCoverage to be used for adjudication
.... identifier 0..1IdentifierPre-assigned Claim number
.... coverage Σ1..1Reference(Coverage)Insurance information
.... businessArrangement 0..1stringAdditional provider contract number
.... preAuthRef 0..*stringPrior authorization reference number
.... claimResponse 0..1Reference(ClaimResponse)Adjudication results
... accident 0..1BackboneElementDetails of the event
.... date 1..1dateWhen the incident occurred
.... type 0..1CodeableConceptThe nature of the accident
ActIncidentCode (Extensible)
.... location[x] 0..1Where the event occurred
..... locationAddressAddress
..... locationReferenceReference(Location)
... item 0..*BackboneElementProduct or service provided
.... sequence 1..1positiveIntItem instance identifier
.... careTeamSequence 0..*positiveIntApplicable careTeam members
.... diagnosisSequence 0..*positiveIntApplicable diagnoses
.... procedureSequence 0..*positiveIntApplicable procedures
.... informationSequence 0..*positiveIntApplicable exception and supporting information
.... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
.... category 0..1CodeableConceptBenefit classification
Benefit Category Codes (Example)
.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
USCLS Codes (Example)
.... modifier 0..*CodeableConceptProduct or service billing modifiers
Modifier type Codes (Example)
.... programCode 0..*CodeableConceptProgram the product or service is provided under
Example Program Reason Codes (Example)
.... serviced[x] 0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service or where product was supplied
Example Service Place Codes (Example)
..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... udi 0..*Reference(Device)Unique device identifier
.... bodySite 0..1CodeableConceptAnatomical location
Oral Site Codes (Example)
.... subSite 0..*CodeableConceptAnatomical sub-location
Surface Codes (Example)
.... encounter 0..*Reference(Encounter)Encounters related to this billed item
.... detail 0..*BackboneElementProduct or service provided
..... sequence 1..1positiveIntItem instance identifier
..... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
..... category 0..1CodeableConceptBenefit classification
Benefit Category Codes (Example)
..... productOrService 1..1CodeableConceptBilling, service, product, or drug code
USCLS Codes (Example)
..... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
..... programCode 0..*CodeableConceptProgram the product or service is provided under
Example Program Reason Codes (Example)
..... quantity 0..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal item cost
..... udi 0..*Reference(Device)Unique device identifier
..... subDetail 0..*BackboneElementProduct or service provided
...... sequence 1..1positiveIntItem instance identifier
...... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
...... category 0..1CodeableConceptBenefit classification
Benefit Category Codes (Example)
...... productOrService 1..1CodeableConceptBilling, service, product, or drug code
USCLS Codes (Example)
...... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
...... programCode 0..*CodeableConceptProgram the product or service is provided under
Example Program Reason Codes (Example)
...... quantity 0..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyTotal item cost
...... udi 0..*Reference(Device)Unique device identifier
... total 0..1MoneyTotal claim cost

doco Documentation for this format

UML Diagram (Legend)

Claim (DomainResource)A unique identifier assigned to this claimidentifier : Identifier [0..*]The status of the resource instance (this element modifies the meaning of other elements)status : code [1..1] « A code specifying the state of the resource instance. (Strength=Required)FinancialResourceStatusCodes! »The category of claim, e.g. oral, pharmacy, vision, institutional, professionaltype : CodeableConcept [1..1] « The type or discipline-style of the claim. (Strength=Extensible)ClaimTypeCodes+ »A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty servicesubType : CodeableConcept [0..1] « A more granular claim typecode. (Strength=Example)ExampleClaimSubTypeCodes?? »A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the futureuse : code [1..1] « The purpose of the Claim: predetermination, preauthorization, claim. (Strength=Required)Use! »The party to whom the professional services and/or products have been supplied or are being considered and for whom actual or forecast reimbursement is soughtpatient : Reference [1..1] « Patient »The period for which charges are being submittedbillablePeriod : Period [0..1]The date this resource was createdcreated : dateTime [1..1]Individual who created the claim, predetermination or preauthorizationenterer : Reference [0..1] « Practitioner|PractitionerRole »The Insurer who is target of the requestinsurer : Reference [0..1] « Organization »The provider which is responsible for the claim, predetermination or preauthorizationprovider : Reference [1..1] « Practitioner|PractitionerRole| Organization »The provider-required urgency of processing the request. Typical values include: stat, routine deferredpriority : CodeableConcept [1..1] « The timeliness with which processing is required: stat, normal, deferred. (Strength=Example)ProcessPriorityCodes?? »A code to indicate whether and for whom funds are to be reserved for future claimsfundsReserve : CodeableConcept [0..1] « For whom funds are to be reserved: (Patient, Provider, None). (Strength=Example)Funds Reservation ?? »Prescription to support the dispensing of pharmacy, device or vision productsprescription : Reference [0..1] « DeviceRequest|MedicationRequest| VisionPrescription »Original prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or productsoriginalPrescription : Reference [0..1] « DeviceRequest| MedicationRequest|VisionPrescription »A reference to a referral resourcereferral : Reference [0..1] « ServiceRequest »Facility where the services were providedfacility : Reference [0..1] « Location »The total value of the all the items in the claimtotal : Money [0..1]RelatedClaimReference to a related claimclaim : Reference [0..1] « Claim »A code to convey how the claims are relatedrelationship : CodeableConcept [0..1] « Relationship of this claim to a related Claim. (Strength=Example) ExampleRelatedClaimRelationsh...?? »An alternate organizational reference to the case or file to which this particular claim pertainsreference : Identifier [0..1]PayeeType of Party to be reimbursed: subscriber, provider, othertype : CodeableConcept [1..1] « A code for the party to be reimbursed. (Strength=Example)Claim Payee Type ?? »Reference to the individual or organization to whom any payment will be madeparty : Reference [0..1] « Practitioner|PractitionerRole| Organization|Patient|RelatedPerson »CareTeamA number to uniquely identify care team entriessequence : positiveInt [1..1]Member of the team who provided the product or serviceprovider : Reference [1..1] « Practitioner|PractitionerRole| Organization »The party who is billing and/or responsible for the claimed products or servicesresponsible : boolean [0..1]The lead, assisting or supervising practitioner and their discipline if a multidisciplinary teamrole : CodeableConcept [0..1] « The role codes for the care team members. (Strength=Example)ClaimCareTeamRoleCodes?? »The qualification of the practitioner which is applicable for this servicequalification : CodeableConcept [0..1] « Provider professional qualifications. (Strength=Example) ExampleProviderQualificationC...?? »SupportingInformationA number to uniquely identify supporting information entriessequence : positiveInt [1..1]The general class of the information supplied: information; exception; accident, employment; onset, etccategory : CodeableConcept [1..1] « The valuset used for additional information category codes. (Strength=Example)ClaimInformationCategoryCodes?? »System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is soughtcode : CodeableConcept [0..1] « The valuset used for additional information codes. (Strength=Example)ExceptionCodes?? »The date when or period to which this information referstiming[x] : DataType [0..1] « date|Period »Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the datavalue[x] : DataType [0..1] « boolean|string|Quantity|Attachment| Reference(Any) »Provides the reason in the situation where a reason code is required in addition to the contentreason : CodeableConcept [0..1] « Reason codes for the missing teeth. (Strength=Example)MissingToothReasonCodes?? »DiagnosisA number to uniquely identify diagnosis entriessequence : positiveInt [1..1]The nature of illness or problem in a coded form or as a reference to an external defined Conditiondiagnosis[x] : DataType [1..1] « CodeableConcept|Reference(Condition); Example ICD10 Diagnostic codes. (Strength=Example) ICD-10Codes?? »When the condition was observed or the relative rankingtype : CodeableConcept [0..*] « The type of the diagnosis: admitting, principal, discharge. (Strength=Example)ExampleDiagnosisTypeCodes?? »Indication of whether the diagnosis was present on admission to a facilityonAdmission : CodeableConcept [0..1] « Present on admission. (Strength=Example) ExampleDiagnosisOnAdmissionCo...?? »A package billing code or bundle code used to group products and services to a particular health condition (such as heart attack) which is based on a predetermined grouping code systempackageCode : CodeableConcept [0..1] « The DRG codes associated with the diagnosis. (Strength=Example) ExampleDiagnosisRelatedGroupC...?? »ProcedureA number to uniquely identify procedure entriessequence : positiveInt [1..1]When the condition was observed or the relative rankingtype : CodeableConcept [0..*] « Example procedure type codes. (Strength=Example)ExampleProcedureTypeCodes?? »Date and optionally time the procedure was performeddate : dateTime [0..1]The code or reference to a Procedure resource which identifies the clinical intervention performedprocedure[x] : DataType [1..1] « CodeableConcept|Reference(Procedure); Example ICD10 Procedure codes. (Strength=Example) ICD-10ProcedureCodes?? »Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »InsuranceA number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit ordersequence : positiveInt [1..1]A flag to indicate that this Coverage is to be used for adjudication of this claim when set to truefocal : boolean [1..1]The business identifier to be used when the claim is sent for adjudication against this insurance policyidentifier : Identifier [0..1]Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information systemcoverage : Reference [1..1] « Coverage »A business agreement number established between the provider and the insurer for special business processing purposesbusinessArrangement : string [0..1]Reference numbers previously provided by the insurer to the provider to be quoted on subsequent claims containing services or products related to the prior authorizationpreAuthRef : string [0..*]The result of the adjudication of the line items for the Coverage specified in this insuranceclaimResponse : Reference [0..1] « ClaimResponse »AccidentDate of an accident event related to the products and services contained in the claimdate : date [1..1]The type or context of the accident event for the purposes of selection of potential insurance coverages and determination of coordination between insurerstype : CodeableConcept [0..1] « Type of accident: work place, auto, etc. (Strength=Extensible)ActIncidentCode+ »The physical location of the accident eventlocation[x] : DataType [0..1] « Address|Reference(Location) »ItemA number to uniquely identify item entriessequence : positiveInt [1..1]CareTeam members related to this service or productcareTeamSequence : positiveInt [0..*]Diagnosis applicable for this service or productdiagnosisSequence : positiveInt [0..*]Procedures applicable for this service or productprocedureSequence : positiveInt [0..*]Exceptions, special conditions and supporting information applicable for this service or productinformationSequence : positiveInt [0..*]The type of revenue or cost center providing the product and/or servicerevenue : CodeableConcept [0..1] « Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example)ExampleRevenueCenterCodes?? »Code to identify the general type of benefits under which products and services are providedcategory : CodeableConcept [0..1] « Benefit categories such as: oral-basic, major, glasses. (Strength=Example)BenefitCategoryCodes?? »When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the itemproductOrService : CodeableConcept [1..1] « Allowable service and product codes. (Strength=Example)USCLSCodes?? »Item typification or modifiers codes to convey additional context for the product or servicemodifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)ModifierTypeCodes?? »Identifies the program under which this may be recoveredprogramCode : CodeableConcept [0..*] « Program specific reason codes. (Strength=Example)ExampleProgramReasonCodes?? »The date or dates when the service or product was supplied, performed or completedserviced[x] : DataType [0..1] « date|Period »Where the product or service was providedlocation[x] : DataType [0..1] « CodeableConcept|Address|Reference( Location); Place of service: pharmacy, school, prison, etc. (Strength=Example)ExampleServicePlaceCodes?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the groupunitPrice : Money [0..1]A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amountfactor : decimal [0..1]The quantity times the unit price for an additional service or product or chargenet : Money [0..1]Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »Physical service site on the patient (limb, tooth, etc.)bodySite : CodeableConcept [0..1] « The code for the teeth, quadrant, sextant and arch. (Strength=Example)OralSiteCodes?? »A region or surface of the bodySite, e.g. limb region or tooth surface(s)subSite : CodeableConcept [0..*] « The code for the tooth surface and surface combinations. (Strength=Example)SurfaceCodes?? »The Encounters during which this Claim was created or to which the creation of this record is tightly associatedencounter : Reference [0..*] « Encounter »DetailA number to uniquely identify item entriessequence : positiveInt [1..1]The type of revenue or cost center providing the product and/or servicerevenue : CodeableConcept [0..1] « Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example)ExampleRevenueCenterCodes?? »Code to identify the general type of benefits under which products and services are providedcategory : CodeableConcept [0..1] « Benefit categories such as: oral-basic, major, glasses. (Strength=Example)BenefitCategoryCodes?? »When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the itemproductOrService : CodeableConcept [1..1] « Allowable service and product codes. (Strength=Example)USCLSCodes?? »Item typification or modifiers codes to convey additional context for the product or servicemodifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)ModifierTypeCodes?? »Identifies the program under which this may be recoveredprogramCode : CodeableConcept [0..*] « Program specific reason codes. (Strength=Example)ExampleProgramReasonCodes?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the groupunitPrice : Money [0..1]A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amountfactor : decimal [0..1]The quantity times the unit price for an additional service or product or chargenet : Money [0..1]Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »SubDetailA number to uniquely identify item entriessequence : positiveInt [1..1]The type of revenue or cost center providing the product and/or servicerevenue : CodeableConcept [0..1] « Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example)ExampleRevenueCenterCodes?? »Code to identify the general type of benefits under which products and services are providedcategory : CodeableConcept [0..1] « Benefit categories such as: oral-basic, major, glasses. (Strength=Example)BenefitCategoryCodes?? »When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the itemproductOrService : CodeableConcept [1..1] « Allowable service and product codes. (Strength=Example)USCLSCodes?? »Item typification or modifiers codes to convey additional context for the product or servicemodifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)ModifierTypeCodes?? »Identifies the program under which this may be recoveredprogramCode : CodeableConcept [0..*] « Program specific reason codes. (Strength=Example)ExampleProgramReasonCodes?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the groupunitPrice : Money [0..1]A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amountfactor : decimal [0..1]The quantity times the unit price for an additional service or product or chargenet : Money [0..1]Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »Other claims which are related to this claim such as prior submissions or claims for related services or for the same eventrelated[0..*]The party to be reimbursed for cost of the products and services according to the terms of the policypayee[0..1]The members of the team who provided the products and servicescareTeam[0..*]Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issuessupportingInfo[0..*]Information about diagnoses relevant to the claim itemsdiagnosis[0..*]Procedures performed on the patient relevant to the billing items with the claimprocedure[0..*]Financial instruments for reimbursement for the health care products and services specified on the claiminsurance[1..*]Details of an accident which resulted in injuries which required the products and services listed in the claimaccident[0..1]A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple itemssubDetail[0..*]A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple itemsdetail[0..*]A claim line. Either a simple product or service or a 'group' of details which can each be a simple items or groups of sub-detailsitem[0..*]

XML Template

<Claim xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Business Identifier for claim --></identifier>
 <status value="[code]"/><!-- 1..1 active | cancelled | draft | entered-in-error -->
 <type><!-- 1..1 CodeableConcept Category or discipline --></type>
 <subType><!-- 0..1 CodeableConcept More granular claim type --></subType>
 <use value="[code]"/><!-- 1..1 claim | preauthorization | predetermination -->
 <patient><!-- 1..1 Reference(Patient) The recipient of the products and services --></patient>
 <billablePeriod><!-- 0..1 Period Relevant time frame for the claim --></billablePeriod>
 <created value="[dateTime]"/><!-- 1..1 Resource creation date -->
 <enterer><!-- 0..1 Reference(Practitioner|PractitionerRole) Author of the claim --></enterer>
 <insurer><!-- 0..1 Reference(Organization) Target --></insurer>
 <provider><!-- 1..1 Reference(Organization|Practitioner|PractitionerRole) Party responsible for the claim --></provider>
 <priority><!-- 1..1 CodeableConcept Desired processing ugency --></priority>
 <fundsReserve><!-- 0..1 CodeableConcept For whom to reserve funds --></fundsReserve>
 <related>  <!-- 0..* Prior or corollary claims -->
  <claim><!-- 0..1 Reference(Claim) Reference to the related claim --></claim>
  <relationship><!-- 0..1 CodeableConcept How the reference claim is related --></relationship>
  <reference><!-- 0..1 Identifier File or case reference --></reference>
 </related>
 <prescription><!-- 0..1 Reference(DeviceRequest|MedicationRequest|
   VisionPrescription) Prescription authorizing services and products --></prescription>
 <originalPrescription><!-- 0..1 Reference(DeviceRequest|MedicationRequest|
   VisionPrescription) Original prescription if superseded by fulfiller --></originalPrescription>
 <payee>  <!-- 0..1 Recipient of benefits payable -->
  <type><!-- 1..1 CodeableConcept Category of recipient --></type>
  <party><!-- 0..1 Reference(Organization|Patient|Practitioner|PractitionerRole|
    RelatedPerson) Recipient reference --></party>
 </payee>
 <referral><!-- 0..1 Reference(ServiceRequest) Treatment referral --></referral>
 <facility><!-- 0..1 Reference(Location) Servicing facility --></facility>
 <careTeam>  <!-- 0..* Members of the care team -->
  <sequence value="[positiveInt]"/><!-- 1..1 Order of care team -->
  <provider><!-- 1..1 Reference(Organization|Practitioner|PractitionerRole) Practitioner or organization --></provider>
  <responsible value="[boolean]"/><!-- 0..1 Indicator of the lead practitioner -->
  <role><!-- 0..1 CodeableConcept Function within the team --></role>
  <qualification><!-- 0..1 CodeableConcept Practitioner credential or specialization --></qualification>
 </careTeam>
 <supportingInfo>  <!-- 0..* Supporting information -->
  <sequence value="[positiveInt]"/><!-- 1..1 Information instance identifier -->
  <category><!-- 1..1 CodeableConcept Classification of the supplied information --></category>
  <code><!-- 0..1 CodeableConcept Type of information --></code>
  <timing[x]><!-- 0..1 date|Period When it occurred --></timing[x]>
  <value[x]><!-- 0..1 boolean|string|Quantity|Attachment|Reference(Any) Data to be provided --></value[x]>
  <reason><!-- 0..1 CodeableConcept Explanation for the information --></reason>
 </supportingInfo>
 <diagnosis>  <!-- 0..* Pertinent diagnosis information -->
  <sequence value="[positiveInt]"/><!-- 1..1 Diagnosis instance identifier -->
  <diagnosis[x]><!-- 1..1 CodeableConcept|Reference(Condition) Nature of illness or problem --></diagnosis[x]>
  <type><!-- 0..* CodeableConcept Timing or nature of the diagnosis --></type>
  <onAdmission><!-- 0..1 CodeableConcept Present on admission --></onAdmission>
  <packageCode><!-- 0..1 CodeableConcept Package billing code --></packageCode>
 </diagnosis>
 <procedure>  <!-- 0..* Clinical procedures performed -->
  <sequence value="[positiveInt]"/><!-- 1..1 Procedure instance identifier -->
  <type><!-- 0..* CodeableConcept Category of Procedure --></type>
  <date value="[dateTime]"/><!-- 0..1 When the procedure was performed -->
  <procedure[x]><!-- 1..1 CodeableConcept|Reference(Procedure) Specific clinical procedure --></procedure[x]>
  <udi><!-- 0..* Reference(Device) Unique device identifier --></udi>
 </procedure>
 <insurance>  <!-- 1..* Patient insurance information -->
  <sequence value="[positiveInt]"/><!-- 1..1 Insurance instance identifier -->
  <focal value="[boolean]"/><!-- 1..1 Coverage to be used for adjudication -->
  <identifier><!-- 0..1 Identifier Pre-assigned Claim number --></identifier>
  <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage>
  <businessArrangement value="[string]"/><!-- 0..1 Additional provider contract number -->
  <preAuthRef value="[string]"/><!-- 0..* Prior authorization reference number -->
  <claimResponse><!-- 0..1 Reference(ClaimResponse) Adjudication results --></claimResponse>
 </insurance>
 <accident>  <!-- 0..1 Details of the event -->
  <date value="[date]"/><!-- 1..1 When the incident occurred -->
  <type><!-- 0..1 CodeableConcept The nature of the accident  --></type>
  <location[x]><!-- 0..1 Address|Reference(Location) Where the event occurred --></location[x]>
 </accident>
 <item>  <!-- 0..* Product or service provided -->
  <sequence value="[positiveInt]"/><!-- 1..1 Item instance identifier -->
  <careTeamSequence value="[positiveInt]"/><!-- 0..* Applicable careTeam members -->
  <diagnosisSequence value="[positiveInt]"/><!-- 0..* Applicable diagnoses -->
  <procedureSequence value="[positiveInt]"/><!-- 0..* Applicable procedures -->
  <informationSequence value="[positiveInt]"/><!-- 0..* Applicable exception and supporting information -->
  <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
  <category><!-- 0..1 CodeableConcept Benefit classification --></category>
  <productOrService><!-- 1..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
  <modifier><!-- 0..* CodeableConcept Product or service billing modifiers --></modifier>
  <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode>
  <serviced[x]><!-- 0..1 date|Period Date or dates of service or product delivery --></serviced[x]>
  <location[x]><!-- 0..1 CodeableConcept|Address|Reference(Location) Place of service or where product was supplied --></location[x]>
  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
  <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
  <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
  <net><!-- 0..1 Money Total item cost --></net>
  <udi><!-- 0..* Reference(Device) Unique device identifier --></udi>
  <bodySite><!-- 0..1 CodeableConcept Anatomical location --></bodySite>
  <subSite><!-- 0..* CodeableConcept Anatomical sub-location --></subSite>
  <encounter><!-- 0..* Reference(Encounter) Encounters related to this billed item --></encounter>
  <detail>  <!-- 0..* Product or service provided -->
   <sequence value="[positiveInt]"/><!-- 1..1 Item instance identifier -->
   <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
   <category><!-- 0..1 CodeableConcept Benefit classification --></category>
   <productOrService><!-- 1..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
   <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
   <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode>
   <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
   <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
   <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
   <net><!-- 0..1 Money Total item cost --></net>
   <udi><!-- 0..* Reference(Device) Unique device identifier --></udi>
   <subDetail>  <!-- 0..* Product or service provided -->
    <sequence value="[positiveInt]"/><!-- 1..1 Item instance identifier -->
    <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
    <category><!-- 0..1 CodeableConcept Benefit classification --></category>
    <productOrService><!-- 1..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
    <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
    <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode>
    <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
    <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
    <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
    <net><!-- 0..1 Money Total item cost --></net>
    <udi><!-- 0..* Reference(Device) Unique device identifier --></udi>
   </subDetail>
  </detail>
 </item>
 <total><!-- 0..1 Money Total claim cost --></total>
</Claim>

JSON Template

{doco
  "resourceType" : "Claim",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier for claim
  "status" : "<code>", // R!  active | cancelled | draft | entered-in-error
  "type" : { CodeableConcept }, // R!  Category or discipline
  "subType" : { CodeableConcept }, // More granular claim type
  "use" : "<code>", // R!  claim | preauthorization | predetermination
  "patient" : { Reference(Patient) }, // R!  The recipient of the products and services
  "billablePeriod" : { Period }, // Relevant time frame for the claim
  "created" : "<dateTime>", // R!  Resource creation date
  "enterer" : { Reference(Practitioner|PractitionerRole) }, // Author of the claim
  "insurer" : { Reference(Organization) }, // Target
  "provider" : { Reference(Organization|Practitioner|PractitionerRole) }, // R!  Party responsible for the claim
  "priority" : { CodeableConcept }, // R!  Desired processing ugency
  "fundsReserve" : { CodeableConcept }, // For whom to reserve funds
  "related" : [{ // Prior or corollary claims
    "claim" : { Reference(Claim) }, // Reference to the related claim
    "relationship" : { CodeableConcept }, // How the reference claim is related
    "reference" : { Identifier } // File or case reference
  }],
  "prescription" : { Reference(DeviceRequest|MedicationRequest|
   VisionPrescription) }, // Prescription authorizing services and products
  "originalPrescription" : { Reference(DeviceRequest|MedicationRequest|
   VisionPrescription) }, // Original prescription if superseded by fulfiller
  "payee" : { // Recipient of benefits payable
    "type" : { CodeableConcept }, // R!  Category of recipient
    "party" : { Reference(Organization|Patient|Practitioner|PractitionerRole|
    RelatedPerson) } // Recipient reference
  },
  "referral" : { Reference(ServiceRequest) }, // Treatment referral
  "facility" : { Reference(Location) }, // Servicing facility
  "careTeam" : [{ // Members of the care team
    "sequence" : "<positiveInt>", // R!  Order of care team
    "provider" : { Reference(Organization|Practitioner|PractitionerRole) }, // R!  Practitioner or organization
    "responsible" : <boolean>, // Indicator of the lead practitioner
    "role" : { CodeableConcept }, // Function within the team
    "qualification" : { CodeableConcept } // Practitioner credential or specialization
  }],
  "supportingInfo" : [{ // Supporting information
    "sequence" : "<positiveInt>", // R!  Information instance identifier
    "category" : { CodeableConcept }, // R!  Classification of the supplied information
    "code" : { CodeableConcept }, // Type of information
    // timing[x]: When it occurred. One of these 2:
    "timingDate" : "<date>",
    "timingPeriod" : { Period },
    // value[x]: Data to be provided. One of these 5:
    "valueBoolean" : <boolean>,
    "valueString" : "<string>",
    "valueQuantity" : { Quantity },
    "valueAttachment" : { Attachment },
    "valueReference" : { Reference(Any) },
    "reason" : { CodeableConcept } // Explanation for the information
  }],
  "diagnosis" : [{ // Pertinent diagnosis information
    "sequence" : "<positiveInt>", // R!  Diagnosis instance identifier
    // diagnosis[x]: Nature of illness or problem. One of these 2:
    "diagnosisCodeableConcept" : { CodeableConcept },
    "diagnosisReference" : { Reference(Condition) },
    "type" : [{ CodeableConcept }], // Timing or nature of the diagnosis
    "onAdmission" : { CodeableConcept }, // Present on admission
    "packageCode" : { CodeableConcept } // Package billing code
  }],
  "procedure" : [{ // Clinical procedures performed
    "sequence" : "<positiveInt>", // R!  Procedure instance identifier
    "type" : [{ CodeableConcept }], // Category of Procedure
    "date" : "<dateTime>", // When the procedure was performed
    // procedure[x]: Specific clinical procedure. One of these 2:
    "procedureCodeableConcept" : { CodeableConcept },
    "procedureReference" : { Reference(Procedure) },
    "udi" : [{ Reference(Device) }] // Unique device identifier
  }],
  "insurance" : [{ // R!  Patient insurance information
    "sequence" : "<positiveInt>", // R!  Insurance instance identifier
    "focal" : <boolean>, // R!  Coverage to be used for adjudication
    "identifier" : { Identifier }, // Pre-assigned Claim number
    "coverage" : { Reference(Coverage) }, // R!  Insurance information
    "businessArrangement" : "<string>", // Additional provider contract number
    "preAuthRef" : ["<string>"], // Prior authorization reference number
    "claimResponse" : { Reference(ClaimResponse) } // Adjudication results
  }],
  "accident" : { // Details of the event
    "date" : "<date>", // R!  When the incident occurred
    "type" : { CodeableConcept }, // The nature of the accident 
    // location[x]: Where the event occurred. One of these 2:
    "locationAddress" : { Address }
    "locationReference" : { Reference(Location) }
  },
  "item" : [{ // Product or service provided
    "sequence" : "<positiveInt>", // R!  Item instance identifier
    "careTeamSequence" : ["<positiveInt>"], // Applicable careTeam members
    "diagnosisSequence" : ["<positiveInt>"], // Applicable diagnoses
    "procedureSequence" : ["<positiveInt>"], // Applicable procedures
    "informationSequence" : ["<positiveInt>"], // Applicable exception and supporting information
    "revenue" : { CodeableConcept }, // Revenue or cost center code
    "category" : { CodeableConcept }, // Benefit classification
    "productOrService" : { CodeableConcept }, // R!  Billing, service, product, or drug code
    "modifier" : [{ CodeableConcept }], // Product or service billing modifiers
    "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
    // serviced[x]: Date or dates of service or product delivery. One of these 2:
    "servicedDate" : "<date>",
    "servicedPeriod" : { Period },
    // location[x]: Place of service or where product was supplied. One of these 3:
    "locationCodeableConcept" : { CodeableConcept },
    "locationAddress" : { Address },
    "locationReference" : { Reference(Location) },
    "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
    "unitPrice" : { Money }, // Fee, charge or cost per item
    "factor" : <decimal>, // Price scaling factor
    "net" : { Money }, // Total item cost
    "udi" : [{ Reference(Device) }], // Unique device identifier
    "bodySite" : { CodeableConcept }, // Anatomical location
    "subSite" : [{ CodeableConcept }], // Anatomical sub-location
    "encounter" : [{ Reference(Encounter) }], // Encounters related to this billed item
    "detail" : [{ // Product or service provided
      "sequence" : "<positiveInt>", // R!  Item instance identifier
      "revenue" : { CodeableConcept }, // Revenue or cost center code
      "category" : { CodeableConcept }, // Benefit classification
      "productOrService" : { CodeableConcept }, // R!  Billing, service, product, or drug code
      "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
      "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
      "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
      "unitPrice" : { Money }, // Fee, charge or cost per item
      "factor" : <decimal>, // Price scaling factor
      "net" : { Money }, // Total item cost
      "udi" : [{ Reference(Device) }], // Unique device identifier
      "subDetail" : [{ // Product or service provided
        "sequence" : "<positiveInt>", // R!  Item instance identifier
        "revenue" : { CodeableConcept }, // Revenue or cost center code
        "category" : { CodeableConcept }, // Benefit classification
        "productOrService" : { CodeableConcept }, // R!  Billing, service, product, or drug code
        "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
        "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
        "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
        "unitPrice" : { Money }, // Fee, charge or cost per item
        "factor" : <decimal>, // Price scaling factor
        "net" : { Money }, // Total item cost
        "udi" : [{ Reference(Device) }] // Unique device identifier
      }]
    }]
  }],
  "total" : { Money } // Total claim cost
}

Turtle Template

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


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

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:Claim.identifier [ Identifier ], ... ; # 0..* Business Identifier for claim
  fhir:Claim.status [ code ]; # 1..1 active | cancelled | draft | entered-in-error
  fhir:Claim.type [ CodeableConcept ]; # 1..1 Category or discipline
  fhir:Claim.subType [ CodeableConcept ]; # 0..1 More granular claim type
  fhir:Claim.use [ code ]; # 1..1 claim | preauthorization | predetermination
  fhir:Claim.patient [ Reference(Patient) ]; # 1..1 The recipient of the products and services
  fhir:Claim.billablePeriod [ Period ]; # 0..1 Relevant time frame for the claim
  fhir:Claim.created [ dateTime ]; # 1..1 Resource creation date
  fhir:Claim.enterer [ Reference(Practitioner|PractitionerRole) ]; # 0..1 Author of the claim
  fhir:Claim.insurer [ Reference(Organization) ]; # 0..1 Target
  fhir:Claim.provider [ Reference(Organization|Practitioner|PractitionerRole) ]; # 1..1 Party responsible for the claim
  fhir:Claim.priority [ CodeableConcept ]; # 1..1 Desired processing ugency
  fhir:Claim.fundsReserve [ CodeableConcept ]; # 0..1 For whom to reserve funds
  fhir:Claim.related [ # 0..* Prior or corollary claims
    fhir:Claim.related.claim [ Reference(Claim) ]; # 0..1 Reference to the related claim
    fhir:Claim.related.relationship [ CodeableConcept ]; # 0..1 How the reference claim is related
    fhir:Claim.related.reference [ Identifier ]; # 0..1 File or case reference
  ], ...;
  fhir:Claim.prescription [ Reference(DeviceRequest|MedicationRequest|VisionPrescription) ]; # 0..1 Prescription authorizing services and products
  fhir:Claim.originalPrescription [ Reference(DeviceRequest|MedicationRequest|VisionPrescription) ]; # 0..1 Original prescription if superseded by fulfiller
  fhir:Claim.payee [ # 0..1 Recipient of benefits payable
    fhir:Claim.payee.type [ CodeableConcept ]; # 1..1 Category of recipient
    fhir:Claim.payee.party [ Reference(Organization|Patient|Practitioner|PractitionerRole|RelatedPerson) ]; # 0..1 Recipient reference
  ];
  fhir:Claim.referral [ Reference(ServiceRequest) ]; # 0..1 Treatment referral
  fhir:Claim.facility [ Reference(Location) ]; # 0..1 Servicing facility
  fhir:Claim.careTeam [ # 0..* Members of the care team
    fhir:Claim.careTeam.sequence [ positiveInt ]; # 1..1 Order of care team
    fhir:Claim.careTeam.provider [ Reference(Organization|Practitioner|PractitionerRole) ]; # 1..1 Practitioner or organization
    fhir:Claim.careTeam.responsible [ boolean ]; # 0..1 Indicator of the lead practitioner
    fhir:Claim.careTeam.role [ CodeableConcept ]; # 0..1 Function within the team
    fhir:Claim.careTeam.qualification [ CodeableConcept ]; # 0..1 Practitioner credential or specialization
  ], ...;
  fhir:Claim.supportingInfo [ # 0..* Supporting information
    fhir:Claim.supportingInfo.sequence [ positiveInt ]; # 1..1 Information instance identifier
    fhir:Claim.supportingInfo.category [ CodeableConcept ]; # 1..1 Classification of the supplied information
    fhir:Claim.supportingInfo.code [ CodeableConcept ]; # 0..1 Type of information
    # Claim.supportingInfo.timing[x] : 0..1 When it occurred. One of these 2
      fhir:Claim.supportingInfo.timingDate [ date ]
      fhir:Claim.supportingInfo.timingPeriod [ Period ]
    # Claim.supportingInfo.value[x] : 0..1 Data to be provided. One of these 5
      fhir:Claim.supportingInfo.valueBoolean [ boolean ]
      fhir:Claim.supportingInfo.valueString [ string ]
      fhir:Claim.supportingInfo.valueQuantity [ Quantity ]
      fhir:Claim.supportingInfo.valueAttachment [ Attachment ]
      fhir:Claim.supportingInfo.valueReference [ Reference(Any) ]
    fhir:Claim.supportingInfo.reason [ CodeableConcept ]; # 0..1 Explanation for the information
  ], ...;
  fhir:Claim.diagnosis [ # 0..* Pertinent diagnosis information
    fhir:Claim.diagnosis.sequence [ positiveInt ]; # 1..1 Diagnosis instance identifier
    # Claim.diagnosis.diagnosis[x] : 1..1 Nature of illness or problem. One of these 2
      fhir:Claim.diagnosis.diagnosisCodeableConcept [ CodeableConcept ]
      fhir:Claim.diagnosis.diagnosisReference [ Reference(Condition) ]
    fhir:Claim.diagnosis.type [ CodeableConcept ], ... ; # 0..* Timing or nature of the diagnosis
    fhir:Claim.diagnosis.onAdmission [ CodeableConcept ]; # 0..1 Present on admission
    fhir:Claim.diagnosis.packageCode [ CodeableConcept ]; # 0..1 Package billing code
  ], ...;
  fhir:Claim.procedure [ # 0..* Clinical procedures performed
    fhir:Claim.procedure.sequence [ positiveInt ]; # 1..1 Procedure instance identifier
    fhir:Claim.procedure.type [ CodeableConcept ], ... ; # 0..* Category of Procedure
    fhir:Claim.procedure.date [ dateTime ]; # 0..1 When the procedure was performed
    # Claim.procedure.procedure[x] : 1..1 Specific clinical procedure. One of these 2
      fhir:Claim.procedure.procedureCodeableConcept [ CodeableConcept ]
      fhir:Claim.procedure.procedureReference [ Reference(Procedure) ]
    fhir:Claim.procedure.udi [ Reference(Device) ], ... ; # 0..* Unique device identifier
  ], ...;
  fhir:Claim.insurance [ # 1..* Patient insurance information
    fhir:Claim.insurance.sequence [ positiveInt ]; # 1..1 Insurance instance identifier
    fhir:Claim.insurance.focal [ boolean ]; # 1..1 Coverage to be used for adjudication
    fhir:Claim.insurance.identifier [ Identifier ]; # 0..1 Pre-assigned Claim number
    fhir:Claim.insurance.coverage [ Reference(Coverage) ]; # 1..1 Insurance information
    fhir:Claim.insurance.businessArrangement [ string ]; # 0..1 Additional provider contract number
    fhir:Claim.insurance.preAuthRef [ string ], ... ; # 0..* Prior authorization reference number
    fhir:Claim.insurance.claimResponse [ Reference(ClaimResponse) ]; # 0..1 Adjudication results
  ], ...;
  fhir:Claim.accident [ # 0..1 Details of the event
    fhir:Claim.accident.date [ date ]; # 1..1 When the incident occurred
    fhir:Claim.accident.type [ CodeableConcept ]; # 0..1 The nature of the accident
    # Claim.accident.location[x] : 0..1 Where the event occurred. One of these 2
      fhir:Claim.accident.locationAddress [ Address ]
      fhir:Claim.accident.locationReference [ Reference(Location) ]
  ];
  fhir:Claim.item [ # 0..* Product or service provided
    fhir:Claim.item.sequence [ positiveInt ]; # 1..1 Item instance identifier
    fhir:Claim.item.careTeamSequence [ positiveInt ], ... ; # 0..* Applicable careTeam members
    fhir:Claim.item.diagnosisSequence [ positiveInt ], ... ; # 0..* Applicable diagnoses
    fhir:Claim.item.procedureSequence [ positiveInt ], ... ; # 0..* Applicable procedures
    fhir:Claim.item.informationSequence [ positiveInt ], ... ; # 0..* Applicable exception and supporting information
    fhir:Claim.item.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
    fhir:Claim.item.category [ CodeableConcept ]; # 0..1 Benefit classification
    fhir:Claim.item.productOrService [ CodeableConcept ]; # 1..1 Billing, service, product, or drug code
    fhir:Claim.item.modifier [ CodeableConcept ], ... ; # 0..* Product or service billing modifiers
    fhir:Claim.item.programCode [ CodeableConcept ], ... ; # 0..* Program the product or service is provided under
    # Claim.item.serviced[x] : 0..1 Date or dates of service or product delivery. One of these 2
      fhir:Claim.item.servicedDate [ date ]
      fhir:Claim.item.servicedPeriod [ Period ]
    # Claim.item.location[x] : 0..1 Place of service or where product was supplied. One of these 3
      fhir:Claim.item.locationCodeableConcept [ CodeableConcept ]
      fhir:Claim.item.locationAddress [ Address ]
      fhir:Claim.item.locationReference [ Reference(Location) ]
    fhir:Claim.item.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of products or services
    fhir:Claim.item.unitPrice [ Money ]; # 0..1 Fee, charge or cost per item
    fhir:Claim.item.factor [ decimal ]; # 0..1 Price scaling factor
    fhir:Claim.item.net [ Money ]; # 0..1 Total item cost
    fhir:Claim.item.udi [ Reference(Device) ], ... ; # 0..* Unique device identifier
    fhir:Claim.item.bodySite [ CodeableConcept ]; # 0..1 Anatomical location
    fhir:Claim.item.subSite [ CodeableConcept ], ... ; # 0..* Anatomical sub-location
    fhir:Claim.item.encounter [ Reference(Encounter) ], ... ; # 0..* Encounters related to this billed item
    fhir:Claim.item.detail [ # 0..* Product or service provided
      fhir:Claim.item.detail.sequence [ positiveInt ]; # 1..1 Item instance identifier
      fhir:Claim.item.detail.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
      fhir:Claim.item.detail.category [ CodeableConcept ]; # 0..1 Benefit classification
      fhir:Claim.item.detail.productOrService [ CodeableConcept ]; # 1..1 Billing, service, product, or drug code
      fhir:Claim.item.detail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
      fhir:Claim.item.detail.programCode [ CodeableConcept ], ... ; # 0..* Program the product or service is provided under
      fhir:Claim.item.detail.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of products or services
      fhir:Claim.item.detail.unitPrice [ Money ]; # 0..1 Fee, charge or cost per item
      fhir:Claim.item.detail.factor [ decimal ]; # 0..1 Price scaling factor
      fhir:Claim.item.detail.net [ Money ]; # 0..1 Total item cost
      fhir:Claim.item.detail.udi [ Reference(Device) ], ... ; # 0..* Unique device identifier
      fhir:Claim.item.detail.subDetail [ # 0..* Product or service provided
        fhir:Claim.item.detail.subDetail.sequence [ positiveInt ]; # 1..1 Item instance identifier
        fhir:Claim.item.detail.subDetail.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
        fhir:Claim.item.detail.subDetail.category [ CodeableConcept ]; # 0..1 Benefit classification
        fhir:Claim.item.detail.subDetail.productOrService [ CodeableConcept ]; # 1..1 Billing, service, product, or drug code
        fhir:Claim.item.detail.subDetail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
        fhir:Claim.item.detail.subDetail.programCode [ CodeableConcept ], ... ; # 0..* Program the product or service is provided under
        fhir:Claim.item.detail.subDetail.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of products or services
        fhir:Claim.item.detail.subDetail.unitPrice [ Money ]; # 0..1 Fee, charge or cost per item
        fhir:Claim.item.detail.subDetail.factor [ decimal ]; # 0..1 Price scaling factor
        fhir:Claim.item.detail.subDetail.net [ Money ]; # 0..1 Total item cost
        fhir:Claim.item.detail.subDetail.udi [ Reference(Device) ], ... ; # 0..* Unique device identifier
      ], ...;
    ], ...;
  ], ...;
  fhir:Claim.total [ Money ]; # 0..1 Total claim cost
]

Changes since R3

Claim
Claim.status
  • Change value set from http://hl7.org/fhir/ValueSet/fm-status|4.0.0 to http://hl7.org/fhir/ValueSet/fm-status|4.5.0
Claim.use
  • Change value set from http://hl7.org/fhir/ValueSet/claim-use|4.0.0 to http://hl7.org/fhir/ValueSet/claim-use|4.5.0

See the Full Difference for further information

This analysis is available as XML or JSON.

See R3 <--> R4 Conversion Maps (status = 16 tests of which 3 fail to execute. 13 fail round-trip testing and 3 r3 resources are invalid (0 errors).)

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim TUDomainResourceClaim, Pre-determination or Pre-authorization
Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier 0..*IdentifierBusiness Identifier for claim
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Financial Resource Status Codes (Required)
... type Σ1..1CodeableConceptCategory or discipline
Claim Type Codes (Extensible)
... subType 0..1CodeableConceptMore granular claim type
Example Claim SubType Codes (Example)
... use Σ1..1codeclaim | preauthorization | predetermination
Use (Required)
... patient Σ1..1Reference(Patient)The recipient of the products and services
... billablePeriod Σ0..1PeriodRelevant time frame for the claim
... created Σ1..1dateTimeResource creation date
... enterer 0..1Reference(Practitioner | PractitionerRole)Author of the claim
... insurer Σ0..1Reference(Organization)Target
... provider Σ1..1Reference(Practitioner | PractitionerRole | Organization)Party responsible for the claim
... priority Σ1..1CodeableConceptDesired processing ugency
Process Priority Codes (Example)
... fundsReserve 0..1CodeableConceptFor whom to reserve funds
FundsReserve (Example)
... related 0..*BackboneElementPrior or corollary claims
.... claim 0..1Reference(Claim)Reference to the related claim
.... relationship 0..1CodeableConceptHow the reference claim is related
Example Related Claim Relationship Codes (Example)
.... reference 0..1IdentifierFile or case reference
... prescription 0..1Reference(DeviceRequest | MedicationRequest | VisionPrescription)Prescription authorizing services and products
... originalPrescription 0..1Reference(DeviceRequest | MedicationRequest | VisionPrescription)Original prescription if superseded by fulfiller
... payee 0..1BackboneElementRecipient of benefits payable
.... type 1..1CodeableConceptCategory of recipient
PayeeType (Example)
.... party 0..1Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson)Recipient reference
... referral 0..1Reference(ServiceRequest)Treatment referral
... facility 0..1Reference(Location)Servicing facility
... careTeam 0..*BackboneElementMembers of the care team
.... sequence 1..1positiveIntOrder of care team
.... provider 1..1Reference(Practitioner | PractitionerRole | Organization)Practitioner or organization
.... responsible 0..1booleanIndicator of the lead practitioner
.... role 0..1CodeableConceptFunction within the team
Claim Care Team Role Codes (Example)
.... qualification 0..1CodeableConceptPractitioner credential or specialization
Example Provider Qualification Codes (Example)
... supportingInfo 0..*BackboneElementSupporting information
.... sequence 1..1positiveIntInformation instance identifier
.... category 1..1CodeableConceptClassification of the supplied information
Claim Information Category Codes (Example)
.... code 0..1CodeableConceptType of information
Exception Codes (Example)
.... timing[x] 0..1When it occurred
..... timingDatedate
..... timingPeriodPeriod
.... value[x] 0..1Data to be provided
..... valueBooleanboolean
..... valueStringstring
..... valueQuantityQuantity
..... valueAttachmentAttachment
..... valueReferenceReference(Any)
.... reason 0..1CodeableConceptExplanation for the information
Missing Tooth Reason Codes (Example)
... diagnosis 0..*BackboneElementPertinent diagnosis information
.... sequence 1..1positiveIntDiagnosis instance identifier
.... diagnosis[x] 1..1Nature of illness or problem
ICD-10 Codes (Example)
..... diagnosisCodeableConceptCodeableConcept
..... diagnosisReferenceReference(Condition)
.... type 0..*CodeableConceptTiming or nature of the diagnosis
Example Diagnosis Type Codes (Example)
.... onAdmission 0..1CodeableConceptPresent on admission
Example Diagnosis on Admission Codes (Example)
.... packageCode 0..1CodeableConceptPackage billing code
Example Diagnosis Related Group Codes (Example)
... procedure 0..*BackboneElementClinical procedures performed
.... sequence 1..1positiveIntProcedure instance identifier
.... type 0..*CodeableConceptCategory of Procedure
Example Procedure Type Codes (Example)
.... date 0..1dateTimeWhen the procedure was performed
.... procedure[x] 1..1Specific clinical procedure
ICD-10 Procedure Codes (Example)
..... procedureCodeableConceptCodeableConcept
..... procedureReferenceReference(Procedure)
.... udi 0..*Reference(Device)Unique device identifier
... insurance Σ1..*BackboneElementPatient insurance information
.... sequence Σ1..1positiveIntInsurance instance identifier
.... focal Σ1..1booleanCoverage to be used for adjudication
.... identifier 0..1IdentifierPre-assigned Claim number
.... coverage Σ1..1Reference(Coverage)Insurance information
.... businessArrangement 0..1stringAdditional provider contract number
.... preAuthRef 0..*stringPrior authorization reference number
.... claimResponse 0..1Reference(ClaimResponse)Adjudication results
... accident 0..1BackboneElementDetails of the event
.... date 1..1dateWhen the incident occurred
.... type 0..1CodeableConceptThe nature of the accident
ActIncidentCode (Extensible)
.... location[x] 0..1Where the event occurred
..... locationAddressAddress
..... locationReferenceReference(Location)
... item 0..*BackboneElementProduct or service provided
.... sequence 1..1positiveIntItem instance identifier
.... careTeamSequence 0..*positiveIntApplicable careTeam members
.... diagnosisSequence 0..*positiveIntApplicable diagnoses
.... procedureSequence 0..*positiveIntApplicable procedures
.... informationSequence 0..*positiveIntApplicable exception and supporting information
.... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
.... category 0..1CodeableConceptBenefit classification
Benefit Category Codes (Example)
.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
USCLS Codes (Example)
.... modifier 0..*CodeableConceptProduct or service billing modifiers
Modifier type Codes (Example)
.... programCode 0..*CodeableConceptProgram the product or service is provided under
Example Program Reason Codes (Example)
.... serviced[x] 0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service or where product was supplied
Example Service Place Codes (Example)
..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... udi 0..*Reference(Device)Unique device identifier
.... bodySite 0..1CodeableConceptAnatomical location
Oral Site Codes (Example)
.... subSite 0..*CodeableConceptAnatomical sub-location
Surface Codes (Example)
.... encounter 0..*Reference(Encounter)Encounters related to this billed item
.... detail 0..*BackboneElementProduct or service provided
..... sequence 1..1positiveIntItem instance identifier
..... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
..... category 0..1CodeableConceptBenefit classification
Benefit Category Codes (Example)
..... productOrService 1..1CodeableConceptBilling, service, product, or drug code
USCLS Codes (Example)
..... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
..... programCode 0..*CodeableConceptProgram the product or service is provided under
Example Program Reason Codes (Example)
..... quantity 0..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal item cost
..... udi 0..*Reference(Device)Unique device identifier
..... subDetail 0..*BackboneElementProduct or service provided
...... sequence 1..1positiveIntItem instance identifier
...... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
...... category 0..1CodeableConceptBenefit classification
Benefit Category Codes (Example)
...... productOrService 1..1CodeableConceptBilling, service, product, or drug code
USCLS Codes (Example)
...... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
...... programCode 0..*CodeableConceptProgram the product or service is provided under
Example Program Reason Codes (Example)
...... quantity 0..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyTotal item cost
...... udi 0..*Reference(Device)Unique device identifier
... total 0..1MoneyTotal claim cost

doco Documentation for this format

UML Diagram (Legend)

Claim (DomainResource)A unique identifier assigned to this claimidentifier : Identifier [0..*]The status of the resource instance (this element modifies the meaning of other elements)status : code [1..1] « A code specifying the state of the resource instance. (Strength=Required)FinancialResourceStatusCodes! »The category of claim, e.g. oral, pharmacy, vision, institutional, professionaltype : CodeableConcept [1..1] « The type or discipline-style of the claim. (Strength=Extensible)ClaimTypeCodes+ »A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty servicesubType : CodeableConcept [0..1] « A more granular claim typecode. (Strength=Example)ExampleClaimSubTypeCodes?? »A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the futureuse : code [1..1] « The purpose of the Claim: predetermination, preauthorization, claim. (Strength=Required)Use! »The party to whom the professional services and/or products have been supplied or are being considered and for whom actual or forecast reimbursement is soughtpatient : Reference [1..1] « Patient »The period for which charges are being submittedbillablePeriod : Period [0..1]The date this resource was createdcreated : dateTime [1..1]Individual who created the claim, predetermination or preauthorizationenterer : Reference [0..1] « Practitioner|PractitionerRole »The Insurer who is target of the requestinsurer : Reference [0..1] « Organization »The provider which is responsible for the claim, predetermination or preauthorizationprovider : Reference [1..1] « Practitioner|PractitionerRole| Organization »The provider-required urgency of processing the request. Typical values include: stat, routine deferredpriority : CodeableConcept [1..1] « The timeliness with which processing is required: stat, normal, deferred. (Strength=Example)ProcessPriorityCodes?? »A code to indicate whether and for whom funds are to be reserved for future claimsfundsReserve : CodeableConcept [0..1] « For whom funds are to be reserved: (Patient, Provider, None). (Strength=Example)Funds Reservation ?? »Prescription to support the dispensing of pharmacy, device or vision productsprescription : Reference [0..1] « DeviceRequest|MedicationRequest| VisionPrescription »Original prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or productsoriginalPrescription : Reference [0..1] « DeviceRequest| MedicationRequest|VisionPrescription »A reference to a referral resourcereferral : Reference [0..1] « ServiceRequest »Facility where the services were providedfacility : Reference [0..1] « Location »The total value of the all the items in the claimtotal : Money [0..1]RelatedClaimReference to a related claimclaim : Reference [0..1] « Claim »A code to convey how the claims are relatedrelationship : CodeableConcept [0..1] « Relationship of this claim to a related Claim. (Strength=Example) ExampleRelatedClaimRelationsh...?? »An alternate organizational reference to the case or file to which this particular claim pertainsreference : Identifier [0..1]PayeeType of Party to be reimbursed: subscriber, provider, othertype : CodeableConcept [1..1] « A code for the party to be reimbursed. (Strength=Example)Claim Payee Type ?? »Reference to the individual or organization to whom any payment will be madeparty : Reference [0..1] « Practitioner|PractitionerRole| Organization|Patient|RelatedPerson »CareTeamA number to uniquely identify care team entriessequence : positiveInt [1..1]Member of the team who provided the product or serviceprovider : Reference [1..1] « Practitioner|PractitionerRole| Organization »The party who is billing and/or responsible for the claimed products or servicesresponsible : boolean [0..1]The lead, assisting or supervising practitioner and their discipline if a multidisciplinary teamrole : CodeableConcept [0..1] « The role codes for the care team members. (Strength=Example)ClaimCareTeamRoleCodes?? »The qualification of the practitioner which is applicable for this servicequalification : CodeableConcept [0..1] « Provider professional qualifications. (Strength=Example) ExampleProviderQualificationC...?? »SupportingInformationA number to uniquely identify supporting information entriessequence : positiveInt [1..1]The general class of the information supplied: information; exception; accident, employment; onset, etccategory : CodeableConcept [1..1] « The valuset used for additional information category codes. (Strength=Example)ClaimInformationCategoryCodes?? »System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is soughtcode : CodeableConcept [0..1] « The valuset used for additional information codes. (Strength=Example)ExceptionCodes?? »The date when or period to which this information referstiming[x] : DataType [0..1] « date|Period »Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the datavalue[x] : DataType [0..1] « boolean|string|Quantity|Attachment| Reference(Any) »Provides the reason in the situation where a reason code is required in addition to the contentreason : CodeableConcept [0..1] « Reason codes for the missing teeth. (Strength=Example)MissingToothReasonCodes?? »DiagnosisA number to uniquely identify diagnosis entriessequence : positiveInt [1..1]The nature of illness or problem in a coded form or as a reference to an external defined Conditiondiagnosis[x] : DataType [1..1] « CodeableConcept|Reference(Condition); Example ICD10 Diagnostic codes. (Strength=Example) ICD-10Codes?? »When the condition was observed or the relative rankingtype : CodeableConcept [0..*] « The type of the diagnosis: admitting, principal, discharge. (Strength=Example)ExampleDiagnosisTypeCodes?? »Indication of whether the diagnosis was present on admission to a facilityonAdmission : CodeableConcept [0..1] « Present on admission. (Strength=Example) ExampleDiagnosisOnAdmissionCo...?? »A package billing code or bundle code used to group products and services to a particular health condition (such as heart attack) which is based on a predetermined grouping code systempackageCode : CodeableConcept [0..1] « The DRG codes associated with the diagnosis. (Strength=Example) ExampleDiagnosisRelatedGroupC...?? »ProcedureA number to uniquely identify procedure entriessequence : positiveInt [1..1]When the condition was observed or the relative rankingtype : CodeableConcept [0..*] « Example procedure type codes. (Strength=Example)ExampleProcedureTypeCodes?? »Date and optionally time the procedure was performeddate : dateTime [0..1]The code or reference to a Procedure resource which identifies the clinical intervention performedprocedure[x] : DataType [1..1] « CodeableConcept|Reference(Procedure); Example ICD10 Procedure codes. (Strength=Example) ICD-10ProcedureCodes?? »Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »InsuranceA number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit ordersequence : positiveInt [1..1]A flag to indicate that this Coverage is to be used for adjudication of this claim when set to truefocal : boolean [1..1]The business identifier to be used when the claim is sent for adjudication against this insurance policyidentifier : Identifier [0..1]Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information systemcoverage : Reference [1..1] « Coverage »A business agreement number established between the provider and the insurer for special business processing purposesbusinessArrangement : string [0..1]Reference numbers previously provided by the insurer to the provider to be quoted on subsequent claims containing services or products related to the prior authorizationpreAuthRef : string [0..*]The result of the adjudication of the line items for the Coverage specified in this insuranceclaimResponse : Reference [0..1] « ClaimResponse »AccidentDate of an accident event related to the products and services contained in the claimdate : date [1..1]The type or context of the accident event for the purposes of selection of potential insurance coverages and determination of coordination between insurerstype : CodeableConcept [0..1] « Type of accident: work place, auto, etc. (Strength=Extensible)ActIncidentCode+ »The physical location of the accident eventlocation[x] : DataType [0..1] « Address|Reference(Location) »ItemA number to uniquely identify item entriessequence : positiveInt [1..1]CareTeam members related to this service or productcareTeamSequence : positiveInt [0..*]Diagnosis applicable for this service or productdiagnosisSequence : positiveInt [0..*]Procedures applicable for this service or productprocedureSequence : positiveInt [0..*]Exceptions, special conditions and supporting information applicable for this service or productinformationSequence : positiveInt [0..*]The type of revenue or cost center providing the product and/or servicerevenue : CodeableConcept [0..1] « Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example)ExampleRevenueCenterCodes?? »Code to identify the general type of benefits under which products and services are providedcategory : CodeableConcept [0..1] « Benefit categories such as: oral-basic, major, glasses. (Strength=Example)BenefitCategoryCodes?? »When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the itemproductOrService : CodeableConcept [1..1] « Allowable service and product codes. (Strength=Example)USCLSCodes?? »Item typification or modifiers codes to convey additional context for the product or servicemodifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)ModifierTypeCodes?? »Identifies the program under which this may be recoveredprogramCode : CodeableConcept [0..*] « Program specific reason codes. (Strength=Example)ExampleProgramReasonCodes?? »The date or dates when the service or product was supplied, performed or completedserviced[x] : DataType [0..1] « date|Period »Where the product or service was providedlocation[x] : DataType [0..1] « CodeableConcept|Address|Reference( Location); Place of service: pharmacy, school, prison, etc. (Strength=Example)ExampleServicePlaceCodes?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the groupunitPrice : Money [0..1]A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amountfactor : decimal [0..1]The quantity times the unit price for an additional service or product or chargenet : Money [0..1]Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »Physical service site on the patient (limb, tooth, etc.)bodySite : CodeableConcept [0..1] « The code for the teeth, quadrant, sextant and arch. (Strength=Example)OralSiteCodes?? »A region or surface of the bodySite, e.g. limb region or tooth surface(s)subSite : CodeableConcept [0..*] « The code for the tooth surface and surface combinations. (Strength=Example)SurfaceCodes?? »The Encounters during which this Claim was created or to which the creation of this record is tightly associatedencounter : Reference [0..*] « Encounter »DetailA number to uniquely identify item entriessequence : positiveInt [1..1]The type of revenue or cost center providing the product and/or servicerevenue : CodeableConcept [0..1] « Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example)ExampleRevenueCenterCodes?? »Code to identify the general type of benefits under which products and services are providedcategory : CodeableConcept [0..1] « Benefit categories such as: oral-basic, major, glasses. (Strength=Example)BenefitCategoryCodes?? »When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the itemproductOrService : CodeableConcept [1..1] « Allowable service and product codes. (Strength=Example)USCLSCodes?? »Item typification or modifiers codes to convey additional context for the product or servicemodifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)ModifierTypeCodes?? »Identifies the program under which this may be recoveredprogramCode : CodeableConcept [0..*] « Program specific reason codes. (Strength=Example)ExampleProgramReasonCodes?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the groupunitPrice : Money [0..1]A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amountfactor : decimal [0..1]The quantity times the unit price for an additional service or product or chargenet : Money [0..1]Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »SubDetailA number to uniquely identify item entriessequence : positiveInt [1..1]The type of revenue or cost center providing the product and/or servicerevenue : CodeableConcept [0..1] « Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example)ExampleRevenueCenterCodes?? »Code to identify the general type of benefits under which products and services are providedcategory : CodeableConcept [0..1] « Benefit categories such as: oral-basic, major, glasses. (Strength=Example)BenefitCategoryCodes?? »When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the itemproductOrService : CodeableConcept [1..1] « Allowable service and product codes. (Strength=Example)USCLSCodes?? »Item typification or modifiers codes to convey additional context for the product or servicemodifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)ModifierTypeCodes?? »Identifies the program under which this may be recoveredprogramCode : CodeableConcept [0..*] « Program specific reason codes. (Strength=Example)ExampleProgramReasonCodes?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the groupunitPrice : Money [0..1]A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amountfactor : decimal [0..1]The quantity times the unit price for an additional service or product or chargenet : Money [0..1]Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »Other claims which are related to this claim such as prior submissions or claims for related services or for the same eventrelated[0..*]The party to be reimbursed for cost of the products and services according to the terms of the policypayee[0..1]The members of the team who provided the products and servicescareTeam[0..*]Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issuessupportingInfo[0..*]Information about diagnoses relevant to the claim itemsdiagnosis[0..*]Procedures performed on the patient relevant to the billing items with the claimprocedure[0..*]Financial instruments for reimbursement for the health care products and services specified on the claiminsurance[1..*]Details of an accident which resulted in injuries which required the products and services listed in the claimaccident[0..1]A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple itemssubDetail[0..*]A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple itemsdetail[0..*]A claim line. Either a simple product or service or a 'group' of details which can each be a simple items or groups of sub-detailsitem[0..*]

XML Template

<Claim xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Business Identifier for claim --></identifier>
 <status value="[code]"/><!-- 1..1 active | cancelled | draft | entered-in-error -->
 <type><!-- 1..1 CodeableConcept Category or discipline --></type>
 <subType><!-- 0..1 CodeableConcept More granular claim type --></subType>
 <use value="[code]"/><!-- 1..1 claim | preauthorization | predetermination -->
 <patient><!-- 1..1 Reference(Patient) The recipient of the products and services --></patient>
 <billablePeriod><!-- 0..1 Period Relevant time frame for the claim --></billablePeriod>
 <created value="[dateTime]"/><!-- 1..1 Resource creation date -->
 <enterer><!-- 0..1 Reference(Practitioner|PractitionerRole) Author of the claim --></enterer>
 <insurer><!-- 0..1 Reference(Organization) Target --></insurer>
 <provider><!-- 1..1 Reference(Organization|Practitioner|PractitionerRole) Party responsible for the claim --></provider>
 <priority><!-- 1..1 CodeableConcept Desired processing ugency --></priority>
 <fundsReserve><!-- 0..1 CodeableConcept For whom to reserve funds --></fundsReserve>
 <related>  <!-- 0..* Prior or corollary claims -->
  <claim><!-- 0..1 Reference(Claim) Reference to the related claim --></claim>
  <relationship><!-- 0..1 CodeableConcept How the reference claim is related --></relationship>
  <reference><!-- 0..1 Identifier File or case reference --></reference>
 </related>
 <prescription><!-- 0..1 Reference(DeviceRequest|MedicationRequest|
   VisionPrescription) Prescription authorizing services and products --></prescription>
 <originalPrescription><!-- 0..1 Reference(DeviceRequest|MedicationRequest|
   VisionPrescription) Original prescription if superseded by fulfiller --></originalPrescription>
 <payee>  <!-- 0..1 Recipient of benefits payable -->
  <type><!-- 1..1 CodeableConcept Category of recipient --></type>
  <party><!-- 0..1 Reference(Organization|Patient|Practitioner|PractitionerRole|
    RelatedPerson) Recipient reference --></party>
 </payee>
 <referral><!-- 0..1 Reference(ServiceRequest) Treatment referral --></referral>
 <facility><!-- 0..1 Reference(Location) Servicing facility --></facility>
 <careTeam>  <!-- 0..* Members of the care team -->
  <sequence value="[positiveInt]"/><!-- 1..1 Order of care team -->
  <provider><!-- 1..1 Reference(Organization|Practitioner|PractitionerRole) Practitioner or organization --></provider>
  <responsible value="[boolean]"/><!-- 0..1 Indicator of the lead practitioner -->
  <role><!-- 0..1 CodeableConcept Function within the team --></role>
  <qualification><!-- 0..1 CodeableConcept Practitioner credential or specialization --></qualification>
 </careTeam>
 <supportingInfo>  <!-- 0..* Supporting information -->
  <sequence value="[positiveInt]"/><!-- 1..1 Information instance identifier -->
  <category><!-- 1..1 CodeableConcept Classification of the supplied information --></category>
  <code><!-- 0..1 CodeableConcept Type of information --></code>
  <timing[x]><!-- 0..1 date|Period When it occurred --></timing[x]>
  <value[x]><!-- 0..1 boolean|string|Quantity|Attachment|Reference(Any) Data to be provided --></value[x]>
  <reason><!-- 0..1 CodeableConcept Explanation for the information --></reason>
 </supportingInfo>
 <diagnosis>  <!-- 0..* Pertinent diagnosis information -->
  <sequence value="[positiveInt]"/><!-- 1..1 Diagnosis instance identifier -->
  <diagnosis[x]><!-- 1..1 CodeableConcept|Reference(Condition) Nature of illness or problem --></diagnosis[x]>
  <type><!-- 0..* CodeableConcept Timing or nature of the diagnosis --></type>
  <onAdmission><!-- 0..1 CodeableConcept Present on admission --></onAdmission>
  <packageCode><!-- 0..1 CodeableConcept Package billing code --></packageCode>
 </diagnosis>
 <procedure>  <!-- 0..* Clinical procedures performed -->
  <sequence value="[positiveInt]"/><!-- 1..1 Procedure instance identifier -->
  <type><!-- 0..* CodeableConcept Category of Procedure --></type>
  <date value="[dateTime]"/><!-- 0..1 When the procedure was performed -->
  <procedure[x]><!-- 1..1 CodeableConcept|Reference(Procedure) Specific clinical procedure --></procedure[x]>
  <udi><!-- 0..* Reference(Device) Unique device identifier --></udi>
 </procedure>
 <insurance>  <!-- 1..* Patient insurance information -->
  <sequence value="[positiveInt]"/><!-- 1..1 Insurance instance identifier -->
  <focal value="[boolean]"/><!-- 1..1 Coverage to be used for adjudication -->
  <identifier><!-- 0..1 Identifier Pre-assigned Claim number --></identifier>
  <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage>
  <businessArrangement value="[string]"/><!-- 0..1 Additional provider contract number -->
  <preAuthRef value="[string]"/><!-- 0..* Prior authorization reference number -->
  <claimResponse><!-- 0..1 Reference(ClaimResponse) Adjudication results --></claimResponse>
 </insurance>
 <accident>  <!-- 0..1 Details of the event -->
  <date value="[date]"/><!-- 1..1 When the incident occurred -->
  <type><!-- 0..1 CodeableConcept The nature of the accident  --></type>
  <location[x]><!-- 0..1 Address|Reference(Location) Where the event occurred --></location[x]>
 </accident>
 <item>  <!-- 0..* Product or service provided -->
  <sequence value="[positiveInt]"/><!-- 1..1 Item instance identifier -->
  <careTeamSequence value="[positiveInt]"/><!-- 0..* Applicable careTeam members -->
  <diagnosisSequence value="[positiveInt]"/><!-- 0..* Applicable diagnoses -->
  <procedureSequence value="[positiveInt]"/><!-- 0..* Applicable procedures -->
  <informationSequence value="[positiveInt]"/><!-- 0..* Applicable exception and supporting information -->
  <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
  <category><!-- 0..1 CodeableConcept Benefit classification --></category>
  <productOrService><!-- 1..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
  <modifier><!-- 0..* CodeableConcept Product or service billing modifiers --></modifier>
  <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode>
  <serviced[x]><!-- 0..1 date|Period Date or dates of service or product delivery --></serviced[x]>
  <location[x]><!-- 0..1 CodeableConcept|Address|Reference(Location) Place of service or where product was supplied --></location[x]>
  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
  <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
  <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
  <net><!-- 0..1 Money Total item cost --></net>
  <udi><!-- 0..* Reference(Device) Unique device identifier --></udi>
  <bodySite><!-- 0..1 CodeableConcept Anatomical location --></bodySite>
  <subSite><!-- 0..* CodeableConcept Anatomical sub-location --></subSite>
  <encounter><!-- 0..* Reference(Encounter) Encounters related to this billed item --></encounter>
  <detail>  <!-- 0..* Product or service provided -->
   <sequence value="[positiveInt]"/><!-- 1..1 Item instance identifier -->
   <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
   <category><!-- 0..1 CodeableConcept Benefit classification --></category>
   <productOrService><!-- 1..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
   <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
   <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode>
   <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
   <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
   <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
   <net><!-- 0..1 Money Total item cost --></net>
   <udi><!-- 0..* Reference(Device) Unique device identifier --></udi>
   <subDetail>  <!-- 0..* Product or service provided -->
    <sequence value="[positiveInt]"/><!-- 1..1 Item instance identifier -->
    <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
    <category><!-- 0..1 CodeableConcept Benefit classification --></category>
    <productOrService><!-- 1..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
    <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
    <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode>
    <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
    <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
    <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
    <net><!-- 0..1 Money Total item cost --></net>
    <udi><!-- 0..* Reference(Device) Unique device identifier --></udi>
   </subDetail>
  </detail>
 </item>
 <total><!-- 0..1 Money Total claim cost --></total>
</Claim>

JSON Template

{doco
  "resourceType" : "Claim",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier for claim
  "status" : "<code>", // R!  active | cancelled | draft | entered-in-error
  "type" : { CodeableConcept }, // R!  Category or discipline
  "subType" : { CodeableConcept }, // More granular claim type
  "use" : "<code>", // R!  claim | preauthorization | predetermination
  "patient" : { Reference(Patient) }, // R!  The recipient of the products and services
  "billablePeriod" : { Period }, // Relevant time frame for the claim
  "created" : "<dateTime>", // R!  Resource creation date
  "enterer" : { Reference(Practitioner|PractitionerRole) }, // Author of the claim
  "insurer" : { Reference(Organization) }, // Target
  "provider" : { Reference(Organization|Practitioner|PractitionerRole) }, // R!  Party responsible for the claim
  "priority" : { CodeableConcept }, // R!  Desired processing ugency
  "fundsReserve" : { CodeableConcept }, // For whom to reserve funds
  "related" : [{ // Prior or corollary claims
    "claim" : { Reference(Claim) }, // Reference to the related claim
    "relationship" : { CodeableConcept }, // How the reference claim is related
    "reference" : { Identifier } // File or case reference
  }],
  "prescription" : { Reference(DeviceRequest|MedicationRequest|
   VisionPrescription) }, // Prescription authorizing services and products
  "originalPrescription" : { Reference(DeviceRequest|MedicationRequest|
   VisionPrescription) }, // Original prescription if superseded by fulfiller
  "payee" : { // Recipient of benefits payable
    "type" : { CodeableConcept }, // R!  Category of recipient
    "party" : { Reference(Organization|Patient|Practitioner|PractitionerRole|
    RelatedPerson) } // Recipient reference
  },
  "referral" : { Reference(ServiceRequest) }, // Treatment referral
  "facility" : { Reference(Location) }, // Servicing facility
  "careTeam" : [{ // Members of the care team
    "sequence" : "<positiveInt>", // R!  Order of care team
    "provider" : { Reference(Organization|Practitioner|PractitionerRole) }, // R!  Practitioner or organization
    "responsible" : <boolean>, // Indicator of the lead practitioner
    "role" : { CodeableConcept }, // Function within the team
    "qualification" : { CodeableConcept } // Practitioner credential or specialization
  }],
  "supportingInfo" : [{ // Supporting information
    "sequence" : "<positiveInt>", // R!  Information instance identifier
    "category" : { CodeableConcept }, // R!  Classification of the supplied information
    "code" : { CodeableConcept }, // Type of information
    // timing[x]: When it occurred. One of these 2:
    "timingDate" : "<date>",
    "timingPeriod" : { Period },
    // value[x]: Data to be provided. One of these 5:
    "valueBoolean" : <boolean>,
    "valueString" : "<string>",
    "valueQuantity" : { Quantity },
    "valueAttachment" : { Attachment },
    "valueReference" : { Reference(Any) },
    "reason" : { CodeableConcept } // Explanation for the information
  }],
  "diagnosis" : [{ // Pertinent diagnosis information
    "sequence" : "<positiveInt>", // R!  Diagnosis instance identifier
    // diagnosis[x]: Nature of illness or problem. One of these 2:
    "diagnosisCodeableConcept" : { CodeableConcept },
    "diagnosisReference" : { Reference(Condition) },
    "type" : [{ CodeableConcept }], // Timing or nature of the diagnosis
    "onAdmission" : { CodeableConcept }, // Present on admission
    "packageCode" : { CodeableConcept } // Package billing code
  }],
  "procedure" : [{ // Clinical procedures performed
    "sequence" : "<positiveInt>", // R!  Procedure instance identifier
    "type" : [{ CodeableConcept }], // Category of Procedure
    "date" : "<dateTime>", // When the procedure was performed
    // procedure[x]: Specific clinical procedure. One of these 2:
    "procedureCodeableConcept" : { CodeableConcept },
    "procedureReference" : { Reference(Procedure) },
    "udi" : [{ Reference(Device) }] // Unique device identifier
  }],
  "insurance" : [{ // R!  Patient insurance information
    "sequence" : "<positiveInt>", // R!  Insurance instance identifier
    "focal" : <boolean>, // R!  Coverage to be used for adjudication
    "identifier" : { Identifier }, // Pre-assigned Claim number
    "coverage" : { Reference(Coverage) }, // R!  Insurance information
    "businessArrangement" : "<string>", // Additional provider contract number
    "preAuthRef" : ["<string>"], // Prior authorization reference number
    "claimResponse" : { Reference(ClaimResponse) } // Adjudication results
  }],
  "accident" : { // Details of the event
    "date" : "<date>", // R!  When the incident occurred
    "type" : { CodeableConcept }, // The nature of the accident 
    // location[x]: Where the event occurred. One of these 2:
    "locationAddress" : { Address }
    "locationReference" : { Reference(Location) }
  },
  "item" : [{ // Product or service provided
    "sequence" : "<positiveInt>", // R!  Item instance identifier
    "careTeamSequence" : ["<positiveInt>"], // Applicable careTeam members
    "diagnosisSequence" : ["<positiveInt>"], // Applicable diagnoses
    "procedureSequence" : ["<positiveInt>"], // Applicable procedures
    "informationSequence" : ["<positiveInt>"], // Applicable exception and supporting information
    "revenue" : { CodeableConcept }, // Revenue or cost center code
    "category" : { CodeableConcept }, // Benefit classification
    "productOrService" : { CodeableConcept }, // R!  Billing, service, product, or drug code
    "modifier" : [{ CodeableConcept }], // Product or service billing modifiers
    "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
    // serviced[x]: Date or dates of service or product delivery. One of these 2:
    "servicedDate" : "<date>",
    "servicedPeriod" : { Period },
    // location[x]: Place of service or where product was supplied. One of these 3:
    "locationCodeableConcept" : { CodeableConcept },
    "locationAddress" : { Address },
    "locationReference" : { Reference(Location) },
    "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
    "unitPrice" : { Money }, // Fee, charge or cost per item
    "factor" : <decimal>, // Price scaling factor
    "net" : { Money }, // Total item cost
    "udi" : [{ Reference(Device) }], // Unique device identifier
    "bodySite" : { CodeableConcept }, // Anatomical location
    "subSite" : [{ CodeableConcept }], // Anatomical sub-location
    "encounter" : [{ Reference(Encounter) }], // Encounters related to this billed item
    "detail" : [{ // Product or service provided
      "sequence" : "<positiveInt>", // R!  Item instance identifier
      "revenue" : { CodeableConcept }, // Revenue or cost center code
      "category" : { CodeableConcept }, // Benefit classification
      "productOrService" : { CodeableConcept }, // R!  Billing, service, product, or drug code
      "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
      "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
      "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
      "unitPrice" : { Money }, // Fee, charge or cost per item
      "factor" : <decimal>, // Price scaling factor
      "net" : { Money }, // Total item cost
      "udi" : [{ Reference(Device) }], // Unique device identifier
      "subDetail" : [{ // Product or service provided
        "sequence" : "<positiveInt>", // R!  Item instance identifier
        "revenue" : { CodeableConcept }, // Revenue or cost center code
        "category" : { CodeableConcept }, // Benefit classification
        "productOrService" : { CodeableConcept }, // R!  Billing, service, product, or drug code
        "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
        "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
        "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
        "unitPrice" : { Money }, // Fee, charge or cost per item
        "factor" : <decimal>, // Price scaling factor
        "net" : { Money }, // Total item cost
        "udi" : [{ Reference(Device) }] // Unique device identifier
      }]
    }]
  }],
  "total" : { Money } // Total claim cost
}

Turtle Template

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


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

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:Claim.identifier [ Identifier ], ... ; # 0..* Business Identifier for claim
  fhir:Claim.status [ code ]; # 1..1 active | cancelled | draft | entered-in-error
  fhir:Claim.type [ CodeableConcept ]; # 1..1 Category or discipline
  fhir:Claim.subType [ CodeableConcept ]; # 0..1 More granular claim type
  fhir:Claim.use [ code ]; # 1..1 claim | preauthorization | predetermination
  fhir:Claim.patient [ Reference(Patient) ]; # 1..1 The recipient of the products and services
  fhir:Claim.billablePeriod [ Period ]; # 0..1 Relevant time frame for the claim
  fhir:Claim.created [ dateTime ]; # 1..1 Resource creation date
  fhir:Claim.enterer [ Reference(Practitioner|PractitionerRole) ]; # 0..1 Author of the claim
  fhir:Claim.insurer [ Reference(Organization) ]; # 0..1 Target
  fhir:Claim.provider [ Reference(Organization|Practitioner|PractitionerRole) ]; # 1..1 Party responsible for the claim
  fhir:Claim.priority [ CodeableConcept ]; # 1..1 Desired processing ugency
  fhir:Claim.fundsReserve [ CodeableConcept ]; # 0..1 For whom to reserve funds
  fhir:Claim.related [ # 0..* Prior or corollary claims
    fhir:Claim.related.claim [ Reference(Claim) ]; # 0..1 Reference to the related claim
    fhir:Claim.related.relationship [ CodeableConcept ]; # 0..1 How the reference claim is related
    fhir:Claim.related.reference [ Identifier ]; # 0..1 File or case reference
  ], ...;
  fhir:Claim.prescription [ Reference(DeviceRequest|MedicationRequest|VisionPrescription) ]; # 0..1 Prescription authorizing services and products
  fhir:Claim.originalPrescription [ Reference(DeviceRequest|MedicationRequest|VisionPrescription) ]; # 0..1 Original prescription if superseded by fulfiller
  fhir:Claim.payee [ # 0..1 Recipient of benefits payable
    fhir:Claim.payee.type [ CodeableConcept ]; # 1..1 Category of recipient
    fhir:Claim.payee.party [ Reference(Organization|Patient|Practitioner|PractitionerRole|RelatedPerson) ]; # 0..1 Recipient reference
  ];
  fhir:Claim.referral [ Reference(ServiceRequest) ]; # 0..1 Treatment referral
  fhir:Claim.facility [ Reference(Location) ]; # 0..1 Servicing facility
  fhir:Claim.careTeam [ # 0..* Members of the care team
    fhir:Claim.careTeam.sequence [ positiveInt ]; # 1..1 Order of care team
    fhir:Claim.careTeam.provider [ Reference(Organization|Practitioner|PractitionerRole) ]; # 1..1 Practitioner or organization
    fhir:Claim.careTeam.responsible [ boolean ]; # 0..1 Indicator of the lead practitioner
    fhir:Claim.careTeam.role [ CodeableConcept ]; # 0..1 Function within the team
    fhir:Claim.careTeam.qualification [ CodeableConcept ]; # 0..1 Practitioner credential or specialization
  ], ...;
  fhir:Claim.supportingInfo [ # 0..* Supporting information
    fhir:Claim.supportingInfo.sequence [ positiveInt ]; # 1..1 Information instance identifier
    fhir:Claim.supportingInfo.category [ CodeableConcept ]; # 1..1 Classification of the supplied information
    fhir:Claim.supportingInfo.code [ CodeableConcept ]; # 0..1 Type of information
    # Claim.supportingInfo.timing[x] : 0..1 When it occurred. One of these 2
      fhir:Claim.supportingInfo.timingDate [ date ]
      fhir:Claim.supportingInfo.timingPeriod [ Period ]
    # Claim.supportingInfo.value[x] : 0..1 Data to be provided. One of these 5
      fhir:Claim.supportingInfo.valueBoolean [ boolean ]
      fhir:Claim.supportingInfo.valueString [ string ]
      fhir:Claim.supportingInfo.valueQuantity [ Quantity ]
      fhir:Claim.supportingInfo.valueAttachment [ Attachment ]
      fhir:Claim.supportingInfo.valueReference [ Reference(Any) ]
    fhir:Claim.supportingInfo.reason [ CodeableConcept ]; # 0..1 Explanation for the information
  ], ...;
  fhir:Claim.diagnosis [ # 0..* Pertinent diagnosis information
    fhir:Claim.diagnosis.sequence [ positiveInt ]; # 1..1 Diagnosis instance identifier
    # Claim.diagnosis.diagnosis[x] : 1..1 Nature of illness or problem. One of these 2
      fhir:Claim.diagnosis.diagnosisCodeableConcept [ CodeableConcept ]
      fhir:Claim.diagnosis.diagnosisReference [ Reference(Condition) ]
    fhir:Claim.diagnosis.type [ CodeableConcept ], ... ; # 0..* Timing or nature of the diagnosis
    fhir:Claim.diagnosis.onAdmission [ CodeableConcept ]; # 0..1 Present on admission
    fhir:Claim.diagnosis.packageCode [ CodeableConcept ]; # 0..1 Package billing code
  ], ...;
  fhir:Claim.procedure [ # 0..* Clinical procedures performed
    fhir:Claim.procedure.sequence [ positiveInt ]; # 1..1 Procedure instance identifier
    fhir:Claim.procedure.type [ CodeableConcept ], ... ; # 0..* Category of Procedure
    fhir:Claim.procedure.date [ dateTime ]; # 0..1 When the procedure was performed
    # Claim.procedure.procedure[x] : 1..1 Specific clinical procedure. One of these 2
      fhir:Claim.procedure.procedureCodeableConcept [ CodeableConcept ]
      fhir:Claim.procedure.procedureReference [ Reference(Procedure) ]
    fhir:Claim.procedure.udi [ Reference(Device) ], ... ; # 0..* Unique device identifier
  ], ...;
  fhir:Claim.insurance [ # 1..* Patient insurance information
    fhir:Claim.insurance.sequence [ positiveInt ]; # 1..1 Insurance instance identifier
    fhir:Claim.insurance.focal [ boolean ]; # 1..1 Coverage to be used for adjudication
    fhir:Claim.insurance.identifier [ Identifier ]; # 0..1 Pre-assigned Claim number
    fhir:Claim.insurance.coverage [ Reference(Coverage) ]; # 1..1 Insurance information
    fhir:Claim.insurance.businessArrangement [ string ]; # 0..1 Additional provider contract number
    fhir:Claim.insurance.preAuthRef [ string ], ... ; # 0..* Prior authorization reference number
    fhir:Claim.insurance.claimResponse [ Reference(ClaimResponse) ]; # 0..1 Adjudication results
  ], ...;
  fhir:Claim.accident [ # 0..1 Details of the event
    fhir:Claim.accident.date [ date ]; # 1..1 When the incident occurred
    fhir:Claim.accident.type [ CodeableConcept ]; # 0..1 The nature of the accident
    # Claim.accident.location[x] : 0..1 Where the event occurred. One of these 2
      fhir:Claim.accident.locationAddress [ Address ]
      fhir:Claim.accident.locationReference [ Reference(Location) ]
  ];
  fhir:Claim.item [ # 0..* Product or service provided
    fhir:Claim.item.sequence [ positiveInt ]; # 1..1 Item instance identifier
    fhir:Claim.item.careTeamSequence [ positiveInt ], ... ; # 0..* Applicable careTeam members
    fhir:Claim.item.diagnosisSequence [ positiveInt ], ... ; # 0..* Applicable diagnoses
    fhir:Claim.item.procedureSequence [ positiveInt ], ... ; # 0..* Applicable procedures
    fhir:Claim.item.informationSequence [ positiveInt ], ... ; # 0..* Applicable exception and supporting information
    fhir:Claim.item.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
    fhir:Claim.item.category [ CodeableConcept ]; # 0..1 Benefit classification
    fhir:Claim.item.productOrService [ CodeableConcept ]; # 1..1 Billing, service, product, or drug code
    fhir:Claim.item.modifier [ CodeableConcept ], ... ; # 0..* Product or service billing modifiers
    fhir:Claim.item.programCode [ CodeableConcept ], ... ; # 0..* Program the product or service is provided under
    # Claim.item.serviced[x] : 0..1 Date or dates of service or product delivery. One of these 2
      fhir:Claim.item.servicedDate [ date ]
      fhir:Claim.item.servicedPeriod [ Period ]
    # Claim.item.location[x] : 0..1 Place of service or where product was supplied. One of these 3
      fhir:Claim.item.locationCodeableConcept [ CodeableConcept ]
      fhir:Claim.item.locationAddress [ Address ]
      fhir:Claim.item.locationReference [ Reference(Location) ]
    fhir:Claim.item.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of products or services
    fhir:Claim.item.unitPrice [ Money ]; # 0..1 Fee, charge or cost per item
    fhir:Claim.item.factor [ decimal ]; # 0..1 Price scaling factor
    fhir:Claim.item.net [ Money ]; # 0..1 Total item cost
    fhir:Claim.item.udi [ Reference(Device) ], ... ; # 0..* Unique device identifier
    fhir:Claim.item.bodySite [ CodeableConcept ]; # 0..1 Anatomical location
    fhir:Claim.item.subSite [ CodeableConcept ], ... ; # 0..* Anatomical sub-location
    fhir:Claim.item.encounter [ Reference(Encounter) ], ... ; # 0..* Encounters related to this billed item
    fhir:Claim.item.detail [ # 0..* Product or service provided
      fhir:Claim.item.detail.sequence [ positiveInt ]; # 1..1 Item instance identifier
      fhir:Claim.item.detail.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
      fhir:Claim.item.detail.category [ CodeableConcept ]; # 0..1 Benefit classification
      fhir:Claim.item.detail.productOrService [ CodeableConcept ]; # 1..1 Billing, service, product, or drug code
      fhir:Claim.item.detail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
      fhir:Claim.item.detail.programCode [ CodeableConcept ], ... ; # 0..* Program the product or service is provided under
      fhir:Claim.item.detail.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of products or services
      fhir:Claim.item.detail.unitPrice [ Money ]; # 0..1 Fee, charge or cost per item
      fhir:Claim.item.detail.factor [ decimal ]; # 0..1 Price scaling factor
      fhir:Claim.item.detail.net [ Money ]; # 0..1 Total item cost
      fhir:Claim.item.detail.udi [ Reference(Device) ], ... ; # 0..* Unique device identifier
      fhir:Claim.item.detail.subDetail [ # 0..* Product or service provided
        fhir:Claim.item.detail.subDetail.sequence [ positiveInt ]; # 1..1 Item instance identifier
        fhir:Claim.item.detail.subDetail.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
        fhir:Claim.item.detail.subDetail.category [ CodeableConcept ]; # 0..1 Benefit classification
        fhir:Claim.item.detail.subDetail.productOrService [ CodeableConcept ]; # 1..1 Billing, service, product, or drug code
        fhir:Claim.item.detail.subDetail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
        fhir:Claim.item.detail.subDetail.programCode [ CodeableConcept ], ... ; # 0..* Program the product or service is provided under
        fhir:Claim.item.detail.subDetail.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of products or services
        fhir:Claim.item.detail.subDetail.unitPrice [ Money ]; # 0..1 Fee, charge or cost per item
        fhir:Claim.item.detail.subDetail.factor [ decimal ]; # 0..1 Price scaling factor
        fhir:Claim.item.detail.subDetail.net [ Money ]; # 0..1 Total item cost
        fhir:Claim.item.detail.subDetail.udi [ Reference(Device) ], ... ; # 0..* Unique device identifier
      ], ...;
    ], ...;
  ], ...;
  fhir:Claim.total [ Money ]; # 0..1 Total claim cost
]

Changes since Release 3

Claim
Claim.status
  • Change value set from http://hl7.org/fhir/ValueSet/fm-status|4.0.0 to http://hl7.org/fhir/ValueSet/fm-status|4.5.0
Claim.use
  • Change value set from http://hl7.org/fhir/ValueSet/claim-use|4.0.0 to http://hl7.org/fhir/ValueSet/claim-use|4.5.0

See the Full Difference for further information

This analysis is available as XML or JSON.

See R3 <--> R4 Conversion Maps (status = 16 tests of which 3 fail to execute. 13 fail round-trip testing and 3 r3 resources are invalid (0 errors).)

 

See the Profiles & Extensions and the alternate definitions: Master Definition XML + JSON, XML Schema/Schematron + JSON Schema, ShEx (for Turtle) + see the extensions, the spreadsheet version & the dependency analysis a

13.6.4.1 Terminology Bindings

PathDefinitionTypeReference
Claim.status A code specifying the state of the resource instance.RequiredFinancialResourceStatusCodes
Claim.type The type or discipline-style of the claim.ExtensibleClaimTypeCodes
Claim.subType A more granular claim typecode.ExampleExampleClaimSubTypeCodes
Claim.use The purpose of the Claim: predetermination, preauthorization, claim.RequiredUse
Claim.priority The timeliness with which processing is required: stat, normal, deferred.ExampleProcessPriorityCodes
Claim.fundsReserve For whom funds are to be reserved: (Patient, Provider, None).ExampleFunds Reservation Codes
Claim.related.relationship Relationship of this claim to a related Claim.ExampleExampleRelatedClaimRelationshipCodes
Claim.payee.type A code for the party to be reimbursed.ExampleClaim Payee Type Codes
Claim.careTeam.role The role codes for the care team members.ExampleClaimCareTeamRoleCodes
Claim.careTeam.qualification Provider professional qualifications.ExampleExampleProviderQualificationCodes
Claim.supportingInfo.category The valuset used for additional information category codes.ExampleClaimInformationCategoryCodes
Claim.supportingInfo.code The valuset used for additional information codes.ExampleExceptionCodes
Claim.supportingInfo.reason Reason codes for the missing teeth.ExampleMissingToothReasonCodes
Claim.diagnosis.diagnosis[x] Example ICD10 Diagnostic codes.ExampleICD-10Codes
Claim.diagnosis.type The type of the diagnosis: admitting, principal, discharge.ExampleExampleDiagnosisTypeCodes
Claim.diagnosis.onAdmission Present on admission.ExampleExampleDiagnosisOnAdmissionCodes
Claim.diagnosis.packageCode The DRG codes associated with the diagnosis.ExampleExampleDiagnosisRelatedGroupCodes
Claim.procedure.type Example procedure type codes.ExampleExampleProcedureTypeCodes
Claim.procedure.procedure[x] Example ICD10 Procedure codes.ExampleICD-10ProcedureCodes
Claim.accident.type Type of accident: work place, auto, etc.ExtensibleActIncidentCode
Claim.item.revenue
Claim.item.detail.revenue
Claim.item.detail.subDetail.revenue 		Codes for the revenue or cost centers supplying the service and/or products.ExampleExampleRevenueCenterCodes
Claim.item.category
Claim.item.detail.category
Claim.item.detail.subDetail.category 		Benefit categories such as: oral-basic, major, glasses.ExampleBenefitCategoryCodes
Claim.item.productOrService
Claim.item.detail.productOrService
Claim.item.detail.subDetail.productOrService 		Allowable service and product codes.ExampleUSCLSCodes
Claim.item.modifier
Claim.item.detail.modifier
Claim.item.detail.subDetail.modifier 		Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.ExampleModifierTypeCodes
Claim.item.programCode
Claim.item.detail.programCode
Claim.item.detail.subDetail.programCode 		Program specific reason codes.ExampleExampleProgramReasonCodes
Claim.item.location[x] Place of service: pharmacy, school, prison, etc.ExampleExampleServicePlaceCodes
Claim.item.bodySite The code for the teeth, quadrant, sextant and arch.ExampleOralSiteCodes
Claim.item.subSite The code for the tooth surface and surface combinations.ExampleSurfaceCodes

13.6.5 Search Parameters

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

NameTypeDescriptionExpressionIn Common
care-teamreferenceMember of the CareTeamClaim.careTeam.provider
(Practitioner, Organization, PractitionerRole)
created NdateThe creation date for the ClaimClaim.created
detail-udireferenceUDI associated with a line item, detail product or serviceClaim.item.detail.udi
(Device)
encounterreferenceEncounters associated with a billed line itemClaim.item.encounter
(Encounter)
entererreferenceThe party responsible for the entry of the ClaimClaim.enterer
(Practitioner, PractitionerRole)
facilityreferenceFacility where the products or services have been or will be providedClaim.facility
(Location)
identifiertokenThe primary identifier of the financial resourceClaim.identifier
insurerreferenceThe target payor/insurer for the ClaimClaim.insurer
(Organization)
item-udireferenceUDI associated with a line item product or serviceClaim.item.udi
(Device)
patientreferencePatient receiving the products or servicesClaim.patient
(Patient)
payeereferenceThe party receiving any payment for the ClaimClaim.payee.party
(Practitioner, Organization, Patient, PractitionerRole, RelatedPerson)
prioritytokenProcessing priority requestedClaim.priority
procedure-udireferenceUDI associated with a procedureClaim.procedure.udi
(Device)
providerreferenceProvider responsible for the ClaimClaim.provider
(Practitioner, Organization, PractitionerRole)
status NtokenThe status of the Claim instance.Claim.status
subdetail-udireferenceUDI associated with a line item, detail, subdetail product or serviceClaim.item.detail.subDetail.udi
(Device)
use NtokenThe kind of financial resourceClaim.use