R6 Ballot (1st Draft)

This page is part of the FHIR Specification v6.0.0-ballot1: Release 6 Ballot (1st Draft) (see Ballot Notes). The current version is 5.0.0. For a full list of available versions, see the Directory of published versions

13.6 Resource Claim - Content

Financial Management icon 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.type code system provides oral, pharmacy, vision, professional and institutional claim types. Claim types supported are influenced by the requirements of the implementing jurisdiction. The valueset is extensible to accommodate other types of claims as required by the jurisdiction.

The Claim also supports:

  • Up to a 3-tier hierarchy of Goods, products, and Services, to support simple to complex billing, see 3-Tier Line Item Hierarchy.
  • 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 icon. 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.
  • 3-Tier Line Item Hierarchy: 3-tier hierarchy of Goods, products, and Services, to support simple to complex billing.
  • Tax: Tax handling of Goods, products, and Services.

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 Personal 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 to this Resource

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

... traceNumber 0..*IdentifierNumber for tracking

... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: Financial Resource Status Codes (Required)
... type Σ1..1CodeableConceptCategory or discipline
Binding: Claim Type Codes (Extensible)
... subType 0..1CodeableConceptMore granular claim type
Binding: Example Claim SubType Codes (Example)
... use Σ1..1codeclaim | preauthorization | predetermination
Binding: 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 | Patient | RelatedPerson)Author of the claim
... insurer Σ0..1Reference(Organization)Target
... provider Σ0..1Reference(Practitioner | PractitionerRole | Organization)Party responsible for the claim
... priority Σ0..1CodeableConceptDesired processing urgency
Binding: Process Priority Codes (Example)
... fundsReserve 0..1CodeableConceptFor whom to reserve funds
Binding: Funds Reservation Codes (Example)
... related 0..*BackboneElementPrior or corollary claims

.... claim 0..1Reference(Claim)Reference to the related claim
.... relationship 0..1CodeableConceptHow the reference claim is related
Binding: 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
Binding: Claim Payee Type Codes (Example)
.... party 0..1Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson)Recipient reference
... referral 0..1Reference(ServiceRequest)Treatment referral
... encounter 0..*Reference(Encounter)Encounters associated with the listed treatments

... facility 0..1Reference(Location | Organization)Servicing facility
... diagnosisRelatedGroup 0..1CodeableConceptPackage billing code
Binding: Example Diagnosis Related Group Codes (Example)
... event 0..*BackboneElementEvent information

.... type 1..1CodeableConceptSpecific event
Binding: Dates Type Codes (Example)
.... when[x] 1..1Occurance date or period
..... whenDateTimedateTime
..... whenPeriodPeriod
... 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
Binding: Claim Care Team Role Codes (Example)
.... specialty 0..1CodeableConceptPractitioner or provider specialization
Binding: Example Provider Qualification Codes (Example)
... supportingInfo 0..*BackboneElementSupporting information

.... sequence 1..1positiveIntInformation instance identifier
.... category 1..1CodeableConceptClassification of the supplied information
Binding: Claim Information Category Codes (Example)
.... code 0..1CodeableConceptType of information
Binding: Exception Codes (Example)
.... timing[x] 0..1When it occurred
..... timingDatedate
..... timingPeriodPeriod
.... value[x] 0..1Data to be provided
..... valueBooleanboolean
..... valueStringstring
..... valueQuantityQuantity
..... valueAttachmentAttachment
..... valueReferenceReference(Any)
..... valueIdentifierIdentifier
.... reason 0..1CodeableConceptExplanation for the information
Binding: Missing Tooth Reason Codes (Example)
... diagnosis 0..*BackboneElementPertinent diagnosis information

.... sequence 1..1positiveIntDiagnosis instance identifier
.... diagnosis[x] 1..1Nature of illness or problem
Binding: ICD-10 Codes (Example)
..... diagnosisCodeableConceptCodeableConcept
..... diagnosisReferenceReference(Condition)
.... type 0..*CodeableConceptTiming or nature of the diagnosis
Binding: Example Diagnosis Type Codes (Example)

.... onAdmission 0..1CodeableConceptPresent on admission
Binding: Example Diagnosis on Admission Codes (Example)
... procedure 0..*BackboneElementClinical procedures performed

.... sequence 1..1positiveIntProcedure instance identifier
.... type 0..*CodeableConceptCategory of Procedure
Binding: Example Procedure Type Codes (Example)

.... date 0..1dateTimeWhen the procedure was performed
.... procedure[x] 1..1Specific clinical procedure
Binding: ICD-10 Procedure Codes (Example)
..... procedureCodeableConceptCodeableConcept
..... procedureReferenceReference(Procedure)
.... udi 0..*Reference(Device)Unique device identifier

... insurance Σ0..*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
Binding: ActIncidentCode icon (Extensible)
.... location[x] 0..1Where the event occurred
..... locationAddressAddress
..... locationReferenceReference(Location)
... patientPaid 0..1MoneyPaid by the patient
... item 0..*BackboneElementProduct or service provided

.... sequence 1..1positiveIntItem instance identifier
.... traceNumber 0..*IdentifierNumber for tracking

.... 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
Binding: Example Revenue Center Codes (Example)
.... category 0..1CodeableConceptBenefit classification
Binding: Benefit Category Codes (Example)
.... productOrService 0..1CodeableConceptBilling, service, product, or drug code
Binding: USCLS Codes (Example)
.... productOrServiceEnd 0..1CodeableConceptEnd of a range of codes
Binding: USCLS Codes (Example)
.... request 0..*Reference(DeviceRequest | MedicationRequest | NutritionOrder | ServiceRequest | SupplyRequest | VisionPrescription)Request or Referral for Service

.... modifier 0..*CodeableConceptProduct or service billing modifiers
Binding: Modifier type Codes (Example)

.... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: 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
Binding: Example Service Place Codes (Example)
..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... patientPaid 0..1MoneyPaid by the patient
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... tax 0..1MoneyTotal tax
.... net 0..1MoneyTotal item cost
.... udi 0..*Reference(Device)Unique device identifier

.... bodySite 0..*BackboneElementAnatomical location

..... site 1..*CodeableReference(BodyStructure)Location
Binding: Oral Site Codes (Example)

..... subSite 0..*CodeableConceptSub-location
Binding: Surface Codes (Example)

.... encounter 0..*Reference(Encounter)Encounters associated with the listed treatments

.... detail 0..*BackboneElementProduct or service provided

..... sequence 1..1positiveIntItem instance identifier
..... traceNumber 0..*IdentifierNumber for tracking

..... revenue 0..1CodeableConceptRevenue or cost center code
Binding: Example Revenue Center Codes (Example)
..... category 0..1CodeableConceptBenefit classification
Binding: Benefit Category Codes (Example)
..... productOrService 0..1CodeableConceptBilling, service, product, or drug code
Binding: USCLS Codes (Example)
..... productOrServiceEnd 0..1CodeableConceptEnd of a range of codes
Binding: USCLS Codes (Example)
..... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: Modifier type Codes (Example)

..... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: Example Program Reason Codes (Example)

..... patientPaid 0..1MoneyPaid by the patient
..... quantity 0..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... tax 0..1MoneyTotal tax
..... net 0..1MoneyTotal item cost
..... udi 0..*Reference(Device)Unique device identifier

..... subDetail 0..*BackboneElementProduct or service provided

...... sequence 1..1positiveIntItem instance identifier
...... traceNumber 0..*IdentifierNumber for tracking

...... revenue 0..1CodeableConceptRevenue or cost center code
Binding: Example Revenue Center Codes (Example)
...... category 0..1CodeableConceptBenefit classification
Binding: Benefit Category Codes (Example)
...... productOrService 0..1CodeableConceptBilling, service, product, or drug code
Binding: USCLS Codes (Example)
...... productOrServiceEnd 0..1CodeableConceptEnd of a range of codes
Binding: USCLS Codes (Example)
...... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: Modifier type Codes (Example)

...... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: Example Program Reason Codes (Example)

...... patientPaid 0..1MoneyPaid by the patient
...... quantity 0..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... tax 0..1MoneyTotal tax
...... net 0..1MoneyTotal item cost
...... udi 0..*Reference(Device)Unique device identifier

... total 0..1MoneyTotal claim cost

doco Documentation for this format icon

See the Extensions for this resource

UML Diagram (Legend)

Claim (DomainResource)A unique identifier assigned to this claimidentifier : Identifier [0..*]Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partnerstraceNumber : Identifier [0..*]The status of the resource instance (this element modifies the meaning of other elements)status : code [1..1] « null (Strength=Required)FinancialResourceStatusCodes! »The category of claim, e.g. oral, pharmacy, vision, institutional, professionaltype : CodeableConcept [1..1] « null (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] « null (Strength=Example)ExampleClaimSubTypeCodes?? »A code to indicate whether the nature of the request is: Claim - A request to an Insurer to adjudicate the supplied charges for health care goods and services under the identified policy and to pay the determined Benefit amount, if any; Preauthorization - A request to an Insurer to adjudicate the supplied proposed future charges for health care goods and services under the identified policy and to approve the services and provide the expected benefit amounts and potentially to reserve funds to pay the benefits when Claims for the indicated services are later submitted; or, Pre-determination - A request to an Insurer to adjudicate the supplied 'what if' charges for health care goods and services under the identified policy and report back what the Benefit payable would be had the services actually been provideduse : code [1..1] « null (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|Patient| RelatedPerson »The Insurer who is target of the requestinsurer : Reference [0..1] « Organization »The provider which is responsible for the claim, predetermination or preauthorizationprovider : Reference [0..1] « Practitioner|PractitionerRole| Organization »The provider-required urgency of processing the request. Typical values include: stat, normal, deferredpriority : CodeableConcept [0..1] « null (Strength=Example)ProcessPriorityCodes?? »A code to indicate whether and for whom funds are to be reserved for future claimsfundsReserve : CodeableConcept [0..1] « null (Strength=Example)FundsReservationCodes?? »Prescription is the document/authorization given to the claim author for them to provide products and services for which consideration (reimbursement) is sought. Could be a RX for medications, an 'order' for oxygen or wheelchair or physiotherapy treatmentsprescription : 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 »The referral information received by the claim author, it is not to be used when the author generates a referral for a patient. A copy of that referral may be provided as supporting information. Some insurers require proof of referral to pay for services or to pay specialist rates for servicesreferral : Reference [0..1] « ServiceRequest »Healthcare encounters related to this claimencounter : Reference [0..*] « Encounter »Facility where the services were providedfacility : Reference [0..1] « Location|Organization »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 systemdiagnosisRelatedGroup : CodeableConcept [0..1] « null (Strength=Example) ExampleDiagnosisRelatedGroupC...?? »The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and servicespatientPaid : Money [0..1]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] « null (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] « null (Strength=Example)ClaimPayeeTypeCodes?? »Reference to the individual or organization to whom any payment will be madeparty : Reference [0..1] « Practitioner|PractitionerRole| Organization|Patient|RelatedPerson »EventA coded event such as when a service is expected or a card printedtype : CodeableConcept [1..1] « null (Strength=Example)DatesTypeCodes?? »A date or period in the past or future indicating when the event occurred or is expectd to occurwhen[x] : DataType [1..1] « dateTime|Period »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] « null (Strength=Example)ClaimCareTeamRoleCodes?? »The specialization of the practitioner or provider which is applicable for this servicespecialty : CodeableConcept [0..1] « null (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] « null (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] « null (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)|Identifier »Provides the reason in the situation where a reason code is required in addition to the contentreason : CodeableConcept [0..1] « null (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); null (Strength=Example) ICD10Codes?? »When the condition was observed or the relative rankingtype : CodeableConcept [0..*] « null (Strength=Example)ExampleDiagnosisTypeCodes?? »Indication of whether the diagnosis was present on admission to a facilityonAdmission : CodeableConcept [0..1] « null (Strength=Example) ExampleDiagnosisOnAdmissionCo...?? »ProcedureA number to uniquely identify procedure entriessequence : positiveInt [1..1]When the condition was observed or the relative rankingtype : CodeableConcept [0..*] « null (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); null (Strength=Example) ICD10ProcedureCodes?? »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] « null (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]Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partnerstraceNumber : Identifier [0..*]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] « null (Strength=Example)ExampleRevenueCenterCodes?? »Code to identify the general type of benefits under which products and services are providedcategory : CodeableConcept [0..1] « null (Strength=Example)BenefitCategoryCodes?? »When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not usedproductOrService : CodeableConcept [0..1] « null (Strength=Example)USCLSCodes?? »This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claimsproductOrServiceEnd : CodeableConcept [0..1] « null (Strength=Example)USCLSCodes?? »Request or Referral for Goods or Service to be renderedrequest : Reference [0..*] « DeviceRequest|MedicationRequest| NutritionOrder|ServiceRequest|SupplyRequest|VisionPrescription »Item typification or modifiers codes to convey additional context for the product or servicemodifier : CodeableConcept [0..*] « null (Strength=Example)ModifierTypeCodes?? »Identifies the program under which this may be recoveredprogramCode : CodeableConcept [0..*] « null (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); null (Strength=Example)ExampleServicePlaceCodes?? »The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and servicespatientPaid : Money [0..1]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 total of taxes applicable for this product or servicetax : Money [0..1]The total amount claimed for the group (if a grouper) or the line item. Net = unit price * quantity * factornet : Money [0..1]Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »Healthcare encounters related to this claimencounter : Reference [0..*] « Encounter »BodySitePhysical service site on the patient (limb, tooth, etc.)site : CodeableReference [1..*] « BodyStructure; null (Strength=Example)OralSiteCodes?? »A region or surface of the bodySite, e.g. limb region or tooth surface(s)subSite : CodeableConcept [0..*] « null (Strength=Example)SurfaceCodes?? »DetailA number to uniquely identify item entriessequence : positiveInt [1..1]Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partnerstraceNumber : Identifier [0..*]The type of revenue or cost center providing the product and/or servicerevenue : CodeableConcept [0..1] « null (Strength=Example)ExampleRevenueCenterCodes?? »Code to identify the general type of benefits under which products and services are providedcategory : CodeableConcept [0..1] « null (Strength=Example)BenefitCategoryCodes?? »When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not usedproductOrService : CodeableConcept [0..1] « null (Strength=Example)USCLSCodes?? »This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claimsproductOrServiceEnd : CodeableConcept [0..1] « null (Strength=Example)USCLSCodes?? »Item typification or modifiers codes to convey additional context for the product or servicemodifier : CodeableConcept [0..*] « null (Strength=Example)ModifierTypeCodes?? »Identifies the program under which this may be recoveredprogramCode : CodeableConcept [0..*] « null (Strength=Example)ExampleProgramReasonCodes?? »The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and servicespatientPaid : Money [0..1]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 total of taxes applicable for this product or servicetax : Money [0..1]The total amount claimed for the group (if a grouper) or the line item.detail. Net = unit price * quantity * factornet : Money [0..1]Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »SubDetailA number to uniquely identify item entriessequence : positiveInt [1..1]Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partnerstraceNumber : Identifier [0..*]The type of revenue or cost center providing the product and/or servicerevenue : CodeableConcept [0..1] « null (Strength=Example)ExampleRevenueCenterCodes?? »Code to identify the general type of benefits under which products and services are providedcategory : CodeableConcept [0..1] « null (Strength=Example)BenefitCategoryCodes?? »When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not usedproductOrService : CodeableConcept [0..1] « null (Strength=Example)USCLSCodes?? »This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claimsproductOrServiceEnd : CodeableConcept [0..1] « null (Strength=Example)USCLSCodes?? »Item typification or modifiers codes to convey additional context for the product or servicemodifier : CodeableConcept [0..*] « null (Strength=Example)ModifierTypeCodes?? »Identifies the program under which this may be recoveredprogramCode : CodeableConcept [0..*] « null (Strength=Example)ExampleProgramReasonCodes?? »The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and servicespatientPaid : Money [0..1]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 total of taxes applicable for this product or servicetax : Money [0..1]The total amount claimed for line item.detail.subDetail. Net = unit price * quantity * factornet : 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]Information code for an event with a corresponding date or periodevent[0..*]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[0..*]Details of an accident which resulted in injuries which required the products and services listed in the claimaccident[0..1]Physical location where the service is performed or appliesbodySite[0..*]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>
 <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>
 <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(Patient|Practitioner|PractitionerRole|RelatedPerson) Author of the claim --></enterer>
 <insurer><!-- 0..1 Reference(Organization) Target --></insurer>
 <provider><!-- 0..1 Reference(Organization|Practitioner|PractitionerRole) Party responsible for the claim --></provider>
 <priority><!-- 0..1 CodeableConcept Desired processing urgency --></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>
 <encounter><!-- 0..* Reference(Encounter) Encounters associated with the listed treatments --></encounter>
 <facility><!-- 0..1 Reference(Location|Organization) Servicing facility --></facility>
 <diagnosisRelatedGroup><!-- 0..1 CodeableConcept Package billing code --></diagnosisRelatedGroup>
 <event>  <!-- 0..* Event information -->
  <type><!-- 1..1 CodeableConcept Specific event --></type>
  <when[x]><!-- 1..1 dateTime|Period Occurance date or period --></when[x]>
 </event>
 <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>
  <specialty><!-- 0..1 CodeableConcept Practitioner or provider specialization --></specialty>
 </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)|
    Identifier 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>
 </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>  <!-- 0..* 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 icon --></type>
  <location[x]><!-- 0..1 Address|Reference(Location) Where the event occurred --></location[x]>
 </accident>
 <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid>
 <item>  <!-- 0..* Product or service provided -->
  <sequence value="[positiveInt]"/><!-- 1..1 Item instance identifier -->
  <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>
  <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><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
  <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd>
  <request><!-- 0..* Reference(DeviceRequest|MedicationRequest|NutritionOrder|
    ServiceRequest|SupplyRequest|VisionPrescription) Request or Referral for Service --></request>
  <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]>
  <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid>
  <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 -->
  <tax><!-- 0..1 Money Total tax --></tax>
  <net><!-- 0..1 Money Total item cost --></net>
  <udi><!-- 0..* Reference(Device) Unique device identifier --></udi>
  <bodySite>  <!-- 0..* Anatomical location -->
   <site><!-- 1..* CodeableReference(BodyStructure) Location --></site>
   <subSite><!-- 0..* CodeableConcept Sub-location --></subSite>
  </bodySite>
  <encounter><!-- 0..* Reference(Encounter) Encounters associated with the listed treatments --></encounter>
  <detail>  <!-- 0..* Product or service provided -->
   <sequence value="[positiveInt]"/><!-- 1..1 Item instance identifier -->
   <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>
   <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
   <category><!-- 0..1 CodeableConcept Benefit classification --></category>
   <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
   <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd>
   <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
   <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode>
   <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid>
   <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 -->
   <tax><!-- 0..1 Money Total tax --></tax>
   <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 -->
    <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>
    <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
    <category><!-- 0..1 CodeableConcept Benefit classification --></category>
    <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
    <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd>
    <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
    <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode>
    <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid>
    <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 -->
    <tax><!-- 0..1 Money Total tax --></tax>
    <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
  "traceNumber" : [{ Identifier }], // Number for tracking
  "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(Patient|Practitioner|PractitionerRole|RelatedPerson) }, // Author of the claim
  "insurer" : { Reference(Organization) }, // Target
  "provider" : { Reference(Organization|Practitioner|PractitionerRole) }, // Party responsible for the claim
  "priority" : { CodeableConcept }, // Desired processing urgency
  "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
  "encounter" : [{ Reference(Encounter) }], // Encounters associated with the listed treatments
  "facility" : { Reference(Location|Organization) }, // Servicing facility
  "diagnosisRelatedGroup" : { CodeableConcept }, // Package billing code
  "event" : [{ // Event information
    "type" : { CodeableConcept }, // R!  Specific event
    // when[x]: Occurance date or period. One of these 2:
    "whenDateTime" : "<dateTime>",
    "whenPeriod" : { Period }
  }],
  "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
    "specialty" : { CodeableConcept } // Practitioner or provider 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 6:
    "valueBoolean" : <boolean>,
    "valueString" : "<string>",
    "valueQuantity" : { Quantity },
    "valueAttachment" : { Attachment },
    "valueReference" : { Reference(Any) },
    "valueIdentifier" : { Identifier },
    "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
  }],
  "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" : [{ // 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 icon
    // location[x]: Where the event occurred. One of these 2:
    "locationAddress" : { Address },
    "locationReference" : { Reference(Location) }
  },
  "patientPaid" : { Money }, // Paid by the patient
  "item" : [{ // Product or service provided
    "sequence" : "<positiveInt>", // R!  Item instance identifier
    "traceNumber" : [{ Identifier }], // Number for tracking
    "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 }, // Billing, service, product, or drug code
    "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes
    "request" : [{ Reference(DeviceRequest|MedicationRequest|NutritionOrder|
    ServiceRequest|SupplyRequest|VisionPrescription) }], // Request or Referral for Service
    "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) },
    "patientPaid" : { Money }, // Paid by the patient
    "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
    "unitPrice" : { Money }, // Fee, charge or cost per item
    "factor" : <decimal>, // Price scaling factor
    "tax" : { Money }, // Total tax
    "net" : { Money }, // Total item cost
    "udi" : [{ Reference(Device) }], // Unique device identifier
    "bodySite" : [{ // Anatomical location
      "site" : [{ CodeableReference(BodyStructure) }], // R!  Location
      "subSite" : [{ CodeableConcept }] // Sub-location
    }],
    "encounter" : [{ Reference(Encounter) }], // Encounters associated with the listed treatments
    "detail" : [{ // Product or service provided
      "sequence" : "<positiveInt>", // R!  Item instance identifier
      "traceNumber" : [{ Identifier }], // Number for tracking
      "revenue" : { CodeableConcept }, // Revenue or cost center code
      "category" : { CodeableConcept }, // Benefit classification
      "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
      "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes
      "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
      "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
      "patientPaid" : { Money }, // Paid by the patient
      "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
      "unitPrice" : { Money }, // Fee, charge or cost per item
      "factor" : <decimal>, // Price scaling factor
      "tax" : { Money }, // Total tax
      "net" : { Money }, // Total item cost
      "udi" : [{ Reference(Device) }], // Unique device identifier
      "subDetail" : [{ // Product or service provided
        "sequence" : "<positiveInt>", // R!  Item instance identifier
        "traceNumber" : [{ Identifier }], // Number for tracking
        "revenue" : { CodeableConcept }, // Revenue or cost center code
        "category" : { CodeableConcept }, // Benefit classification
        "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
        "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes
        "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
        "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
        "patientPaid" : { Money }, // Paid by the patient
        "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
        "unitPrice" : { Money }, // Fee, charge or cost per item
        "factor" : <decimal>, // Price scaling factor
        "tax" : { Money }, // Total tax
        "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:identifier  ( [ Identifier ] ... ) ; # 0..* Business Identifier for claim
  fhir:traceNumber  ( [ Identifier ] ... ) ; # 0..* Number for tracking
  fhir:status [ code ] ; # 1..1 active | cancelled | draft | entered-in-error
  fhir:type [ CodeableConcept ] ; # 1..1 Category or discipline
  fhir:subType [ CodeableConcept ] ; # 0..1 More granular claim type
  fhir:use [ code ] ; # 1..1 claim | preauthorization | predetermination
  fhir:patient [ Reference(Patient) ] ; # 1..1 The recipient of the products and services
  fhir:billablePeriod [ Period ] ; # 0..1 Relevant time frame for the claim
  fhir:created [ dateTime ] ; # 1..1 Resource creation date
  fhir:enterer [ Reference(Patient|Practitioner|PractitionerRole|RelatedPerson) ] ; # 0..1 Author of the claim
  fhir:insurer [ Reference(Organization) ] ; # 0..1 Target
  fhir:provider [ Reference(Organization|Practitioner|PractitionerRole) ] ; # 0..1 Party responsible for the claim
  fhir:priority [ CodeableConcept ] ; # 0..1 Desired processing urgency
  fhir:fundsReserve [ CodeableConcept ] ; # 0..1 For whom to reserve funds
  fhir:related ( [ # 0..* Prior or corollary claims
    fhir:claim [ Reference(Claim) ] ; # 0..1 Reference to the related claim
    fhir:relationship [ CodeableConcept ] ; # 0..1 How the reference claim is related
    fhir:reference [ Identifier ] ; # 0..1 File or case reference
  ] ... ) ;
  fhir:prescription [ Reference(DeviceRequest|MedicationRequest|VisionPrescription) ] ; # 0..1 Prescription authorizing services and products
  fhir:originalPrescription [ Reference(DeviceRequest|MedicationRequest|VisionPrescription) ] ; # 0..1 Original prescription if superseded by fulfiller
  fhir:payee [ # 0..1 Recipient of benefits payable
    fhir:type [ CodeableConcept ] ; # 1..1 Category of recipient
    fhir:party [ Reference(Organization|Patient|Practitioner|PractitionerRole|RelatedPerson) ] ; # 0..1 Recipient reference
  ] ;
  fhir:referral [ Reference(ServiceRequest) ] ; # 0..1 Treatment referral
  fhir:encounter  ( [ Reference(Encounter) ] ... ) ; # 0..* Encounters associated with the listed treatments
  fhir:facility [ Reference(Location|Organization) ] ; # 0..1 Servicing facility
  fhir:diagnosisRelatedGroup [ CodeableConcept ] ; # 0..1 Package billing code
  fhir:event ( [ # 0..* Event information
    fhir:type [ CodeableConcept ] ; # 1..1 Specific event
    # when[x] : 1..1 Occurance date or period. One of these 2
      fhir:when [  a fhir:dateTime ; dateTime ]
      fhir:when [  a fhir:Period ; Period ]
  ] ... ) ;
  fhir:careTeam ( [ # 0..* Members of the care team
    fhir:sequence [ positiveInt ] ; # 1..1 Order of care team
    fhir:provider [ Reference(Organization|Practitioner|PractitionerRole) ] ; # 1..1 Practitioner or organization
    fhir:responsible [ boolean ] ; # 0..1 Indicator of the lead practitioner
    fhir:role [ CodeableConcept ] ; # 0..1 Function within the team
    fhir:specialty [ CodeableConcept ] ; # 0..1 Practitioner or provider specialization
  ] ... ) ;
  fhir:supportingInfo ( [ # 0..* Supporting information
    fhir:sequence [ positiveInt ] ; # 1..1 Information instance identifier
    fhir:category [ CodeableConcept ] ; # 1..1 Classification of the supplied information
    fhir:code [ CodeableConcept ] ; # 0..1 Type of information
    # timing[x] : 0..1 When it occurred. One of these 2
      fhir:timing [  a fhir:date ; date ]
      fhir:timing [  a fhir:Period ; Period ]
    # value[x] : 0..1 Data to be provided. One of these 6
      fhir:value [  a fhir:boolean ; boolean ]
      fhir:value [  a fhir:string ; string ]
      fhir:value [  a fhir:Quantity ; Quantity ]
      fhir:value [  a fhir:Attachment ; Attachment ]
      fhir:value [  a fhir:Reference ; Reference(Any) ]
      fhir:value [  a fhir:Identifier ; Identifier ]
    fhir:reason [ CodeableConcept ] ; # 0..1 Explanation for the information
  ] ... ) ;
  fhir:diagnosis ( [ # 0..* Pertinent diagnosis information
    fhir:sequence [ positiveInt ] ; # 1..1 Diagnosis instance identifier
    # diagnosis[x] : 1..1 Nature of illness or problem. One of these 2
      fhir:diagnosis [  a fhir:CodeableConcept ; CodeableConcept ]
      fhir:diagnosis [  a fhir:Reference ; Reference(Condition) ]
    fhir:type  ( [ CodeableConcept ] ... ) ; # 0..* Timing or nature of the diagnosis
    fhir:onAdmission [ CodeableConcept ] ; # 0..1 Present on admission
  ] ... ) ;
  fhir:procedure ( [ # 0..* Clinical procedures performed
    fhir:sequence [ positiveInt ] ; # 1..1 Procedure instance identifier
    fhir:type  ( [ CodeableConcept ] ... ) ; # 0..* Category of Procedure
    fhir:date [ dateTime ] ; # 0..1 When the procedure was performed
    # procedure[x] : 1..1 Specific clinical procedure. One of these 2
      fhir:procedure [  a fhir:CodeableConcept ; CodeableConcept ]
      fhir:procedure [  a fhir:Reference ; Reference(Procedure) ]
    fhir:udi  ( [ Reference(Device) ] ... ) ; # 0..* Unique device identifier
  ] ... ) ;
  fhir:insurance ( [ # 0..* Patient insurance information
    fhir:sequence [ positiveInt ] ; # 1..1 Insurance instance identifier
    fhir:focal [ boolean ] ; # 1..1 Coverage to be used for adjudication
    fhir:identifier [ Identifier ] ; # 0..1 Pre-assigned Claim number
    fhir:coverage [ Reference(Coverage) ] ; # 1..1 Insurance information
    fhir:businessArrangement [ string ] ; # 0..1 Additional provider contract number
    fhir:preAuthRef  ( [ string ] ... ) ; # 0..* Prior authorization reference number
    fhir:claimResponse [ Reference(ClaimResponse) ] ; # 0..1 Adjudication results
  ] ... ) ;
  fhir:accident [ # 0..1 Details of the event
    fhir:date [ date ] ; # 1..1 When the incident occurred
    fhir:type [ CodeableConcept ] ; # 0..1 The nature of the accident
    # location[x] : 0..1 Where the event occurred. One of these 2
      fhir:location [  a fhir:Address ; Address ]
      fhir:location [  a fhir:Reference ; Reference(Location) ]
  ] ;
  fhir:patientPaid [ Money ] ; # 0..1 Paid by the patient
  fhir:item ( [ # 0..* Product or service provided
    fhir:sequence [ positiveInt ] ; # 1..1 Item instance identifier
    fhir:traceNumber  ( [ Identifier ] ... ) ; # 0..* Number for tracking
    fhir:careTeamSequence  ( [ positiveInt ] ... ) ; # 0..* Applicable careTeam members
    fhir:diagnosisSequence  ( [ positiveInt ] ... ) ; # 0..* Applicable diagnoses
    fhir:procedureSequence  ( [ positiveInt ] ... ) ; # 0..* Applicable procedures
    fhir:informationSequence  ( [ positiveInt ] ... ) ; # 0..* Applicable exception and supporting information
    fhir:revenue [ CodeableConcept ] ; # 0..1 Revenue or cost center code
    fhir:category [ CodeableConcept ] ; # 0..1 Benefit classification
    fhir:productOrService [ CodeableConcept ] ; # 0..1 Billing, service, product, or drug code
    fhir:productOrServiceEnd [ CodeableConcept ] ; # 0..1 End of a range of codes
    fhir:request  ( [ Reference(DeviceRequest|MedicationRequest|NutritionOrder|ServiceRequest|SupplyRequest|
  VisionPrescription) ] ... ) ; # 0..* Request or Referral for Service
    fhir:modifier  ( [ CodeableConcept ] ... ) ; # 0..* Product or service billing modifiers
    fhir:programCode  ( [ CodeableConcept ] ... ) ; # 0..* Program the product or service is provided under
    # serviced[x] : 0..1 Date or dates of service or product delivery. One of these 2
      fhir:serviced [  a fhir:date ; date ]
      fhir:serviced [  a fhir:Period ; Period ]
    # location[x] : 0..1 Place of service or where product was supplied. One of these 3
      fhir:location [  a fhir:CodeableConcept ; CodeableConcept ]
      fhir:location [  a fhir:Address ; Address ]
      fhir:location [  a fhir:Reference ; Reference(Location) ]
    fhir:patientPaid [ Money ] ; # 0..1 Paid by the patient
    fhir:quantity [ Quantity(SimpleQuantity) ] ; # 0..1 Count of products or services
    fhir:unitPrice [ Money ] ; # 0..1 Fee, charge or cost per item
    fhir:factor [ decimal ] ; # 0..1 Price scaling factor
    fhir:tax [ Money ] ; # 0..1 Total tax
    fhir:net [ Money ] ; # 0..1 Total item cost
    fhir:udi  ( [ Reference(Device) ] ... ) ; # 0..* Unique device identifier
    fhir:bodySite ( [ # 0..* Anatomical location
      fhir:site  ( [ CodeableReference(BodyStructure) ] ... ) ; # 1..* Location
      fhir:subSite  ( [ CodeableConcept ] ... ) ; # 0..* Sub-location
    ] ... ) ;
    fhir:encounter  ( [ Reference(Encounter) ] ... ) ; # 0..* Encounters associated with the listed treatments
    fhir:detail ( [ # 0..* Product or service provided
      fhir:sequence [ positiveInt ] ; # 1..1 Item instance identifier
      fhir:traceNumber  ( [ Identifier ] ... ) ; # 0..* Number for tracking
      fhir:revenue [ CodeableConcept ] ; # 0..1 Revenue or cost center code
      fhir:category [ CodeableConcept ] ; # 0..1 Benefit classification
      fhir:productOrService [ CodeableConcept ] ; # 0..1 Billing, service, product, or drug code
      fhir:productOrServiceEnd [ CodeableConcept ] ; # 0..1 End of a range of codes
      fhir:modifier  ( [ CodeableConcept ] ... ) ; # 0..* Service/Product billing modifiers
      fhir:programCode  ( [ CodeableConcept ] ... ) ; # 0..* Program the product or service is provided under
      fhir:patientPaid [ Money ] ; # 0..1 Paid by the patient
      fhir:quantity [ Quantity(SimpleQuantity) ] ; # 0..1 Count of products or services
      fhir:unitPrice [ Money ] ; # 0..1 Fee, charge or cost per item
      fhir:factor [ decimal ] ; # 0..1 Price scaling factor
      fhir:tax [ Money ] ; # 0..1 Total tax
      fhir:net [ Money ] ; # 0..1 Total item cost
      fhir:udi  ( [ Reference(Device) ] ... ) ; # 0..* Unique device identifier
      fhir:subDetail ( [ # 0..* Product or service provided
        fhir:sequence [ positiveInt ] ; # 1..1 Item instance identifier
        fhir:traceNumber  ( [ Identifier ] ... ) ; # 0..* Number for tracking
        fhir:revenue [ CodeableConcept ] ; # 0..1 Revenue or cost center code
        fhir:category [ CodeableConcept ] ; # 0..1 Benefit classification
        fhir:productOrService [ CodeableConcept ] ; # 0..1 Billing, service, product, or drug code
        fhir:productOrServiceEnd [ CodeableConcept ] ; # 0..1 End of a range of codes
        fhir:modifier  ( [ CodeableConcept ] ... ) ; # 0..* Service/Product billing modifiers
        fhir:programCode  ( [ CodeableConcept ] ... ) ; # 0..* Program the product or service is provided under
        fhir:patientPaid [ Money ] ; # 0..1 Paid by the patient
        fhir:quantity [ Quantity(SimpleQuantity) ] ; # 0..1 Count of products or services
        fhir:unitPrice [ Money ] ; # 0..1 Fee, charge or cost per item
        fhir:factor [ decimal ] ; # 0..1 Price scaling factor
        fhir:tax [ Money ] ; # 0..1 Total tax
        fhir:net [ Money ] ; # 0..1 Total item cost
        fhir:udi  ( [ Reference(Device) ] ... ) ; # 0..* Unique device identifier
      ] ... ) ;
    ] ... ) ;
  ] ... ) ;
  fhir:total [ Money ] ; # 0..1 Total claim cost
]

Changes from both R4 and R4B

Claim
Claim.traceNumber
  • Added Element
Claim.enterer
  • Type Reference: Added Target Types Patient, RelatedPerson
Claim.provider
  • Min Cardinality changed from 1 to 0
Claim.priority
  • Min Cardinality changed from 1 to 0
Claim.encounter
  • Added Element
Claim.facility
  • Type Reference: Added Target Type Organization
Claim.diagnosisRelatedGroup
  • Added Element
Claim.event
  • Added Element
Claim.event.type
  • Added Mandatory Element
Claim.event.when[x]
  • Added Mandatory Element
Claim.careTeam.specialty
  • Added Element
Claim.supportingInfo.value[x]
  • Add Type Identifier
Claim.insurance
  • Min Cardinality changed from 1 to 0
Claim.patientPaid
  • Added Element
Claim.item.traceNumber
  • Added Element
Claim.item.productOrService
  • Min Cardinality changed from 1 to 0
Claim.item.productOrServiceEnd
  • Added Element
Claim.item.request
  • Added Element
Claim.item.patientPaid
  • Added Element
Claim.item.tax
  • Added Element
Claim.item.bodySite
  • Max Cardinality changed from 1 to *
  • Type changed from CodeableConcept to BackboneElement
Claim.item.bodySite.site
  • Added Mandatory Element
Claim.item.bodySite.subSite
  • Added Element
Claim.item.detail.traceNumber
  • Added Element
Claim.item.detail.productOrService
  • Min Cardinality changed from 1 to 0
Claim.item.detail.productOrServiceEnd
  • Added Element
Claim.item.detail.patientPaid
  • Added Element
Claim.item.detail.tax
  • Added Element
Claim.item.detail.subDetail.traceNumber
  • Added Element
Claim.item.detail.subDetail.productOrService
  • Min Cardinality changed from 1 to 0
Claim.item.detail.subDetail.productOrServiceEnd
  • Added Element
Claim.item.detail.subDetail.patientPaid
  • Added Element
Claim.item.detail.subDetail.tax
  • Added Element
Claim.careTeam.qualification
  • Deleted
Claim.diagnosis.packageCode
  • Deleted
Claim.item.subSite
  • Deleted

See the Full Difference for further information

This analysis is available for R4 as XML or JSON and for R4B as XML or JSON.

See R4 <--> R5 Conversion Maps (status = See Conversions Summary.)

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

... traceNumber 0..*IdentifierNumber for tracking

... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: Financial Resource Status Codes (Required)
... type Σ1..1CodeableConceptCategory or discipline
Binding: Claim Type Codes (Extensible)
... subType 0..1CodeableConceptMore granular claim type
Binding: Example Claim SubType Codes (Example)
... use Σ1..1codeclaim | preauthorization | predetermination
Binding: 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 | Patient | RelatedPerson)Author of the claim
... insurer Σ0..1Reference(Organization)Target
... provider Σ0..1Reference(Practitioner | PractitionerRole | Organization)Party responsible for the claim
... priority Σ0..1CodeableConceptDesired processing urgency
Binding: Process Priority Codes (Example)
... fundsReserve 0..1CodeableConceptFor whom to reserve funds
Binding: Funds Reservation Codes (Example)
... related 0..*BackboneElementPrior or corollary claims

.... claim 0..1Reference(Claim)Reference to the related claim
.... relationship 0..1CodeableConceptHow the reference claim is related
Binding: 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
Binding: Claim Payee Type Codes (Example)
.... party 0..1Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson)Recipient reference
... referral 0..1Reference(ServiceRequest)Treatment referral
... encounter 0..*Reference(Encounter)Encounters associated with the listed treatments

... facility 0..1Reference(Location | Organization)Servicing facility
... diagnosisRelatedGroup 0..1CodeableConceptPackage billing code
Binding: Example Diagnosis Related Group Codes (Example)
... event 0..*BackboneElementEvent information

.... type 1..1CodeableConceptSpecific event
Binding: Dates Type Codes (Example)
.... when[x] 1..1Occurance date or period
..... whenDateTimedateTime
..... whenPeriodPeriod
... 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
Binding: Claim Care Team Role Codes (Example)
.... specialty 0..1CodeableConceptPractitioner or provider specialization
Binding: Example Provider Qualification Codes (Example)
... supportingInfo 0..*BackboneElementSupporting information

.... sequence 1..1positiveIntInformation instance identifier
.... category 1..1CodeableConceptClassification of the supplied information
Binding: Claim Information Category Codes (Example)
.... code 0..1CodeableConceptType of information
Binding: Exception Codes (Example)
.... timing[x] 0..1When it occurred
..... timingDatedate
..... timingPeriodPeriod
.... value[x] 0..1Data to be provided
..... valueBooleanboolean
..... valueStringstring
..... valueQuantityQuantity
..... valueAttachmentAttachment
..... valueReferenceReference(Any)
..... valueIdentifierIdentifier
.... reason 0..1CodeableConceptExplanation for the information
Binding: Missing Tooth Reason Codes (Example)
... diagnosis 0..*BackboneElementPertinent diagnosis information

.... sequence 1..1positiveIntDiagnosis instance identifier
.... diagnosis[x] 1..1Nature of illness or problem
Binding: ICD-10 Codes (Example)
..... diagnosisCodeableConceptCodeableConcept
..... diagnosisReferenceReference(Condition)
.... type 0..*CodeableConceptTiming or nature of the diagnosis
Binding: Example Diagnosis Type Codes (Example)

.... onAdmission 0..1CodeableConceptPresent on admission
Binding: Example Diagnosis on Admission Codes (Example)
... procedure 0..*BackboneElementClinical procedures performed

.... sequence 1..1positiveIntProcedure instance identifier
.... type 0..*CodeableConceptCategory of Procedure
Binding: Example Procedure Type Codes (Example)

.... date 0..1dateTimeWhen the procedure was performed
.... procedure[x] 1..1Specific clinical procedure
Binding: ICD-10 Procedure Codes (Example)
..... procedureCodeableConceptCodeableConcept
..... procedureReferenceReference(Procedure)
.... udi 0..*Reference(Device)Unique device identifier

... insurance Σ0..*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
Binding: ActIncidentCode icon (Extensible)
.... location[x] 0..1Where the event occurred
..... locationAddressAddress
..... locationReferenceReference(Location)
... patientPaid 0..1MoneyPaid by the patient
... item 0..*BackboneElementProduct or service provided

.... sequence 1..1positiveIntItem instance identifier
.... traceNumber 0..*IdentifierNumber for tracking

.... 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
Binding: Example Revenue Center Codes (Example)
.... category 0..1CodeableConceptBenefit classification
Binding: Benefit Category Codes (Example)
.... productOrService 0..1CodeableConceptBilling, service, product, or drug code
Binding: USCLS Codes (Example)
.... productOrServiceEnd 0..1CodeableConceptEnd of a range of codes
Binding: USCLS Codes (Example)
.... request 0..*Reference(DeviceRequest | MedicationRequest | NutritionOrder | ServiceRequest | SupplyRequest | VisionPrescription)Request or Referral for Service

.... modifier 0..*CodeableConceptProduct or service billing modifiers
Binding: Modifier type Codes (Example)

.... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: 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
Binding: Example Service Place Codes (Example)
..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... patientPaid 0..1MoneyPaid by the patient
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... tax 0..1MoneyTotal tax
.... net 0..1MoneyTotal item cost
.... udi 0..*Reference(Device)Unique device identifier

.... bodySite 0..*BackboneElementAnatomical location

..... site 1..*CodeableReference(BodyStructure)Location
Binding: Oral Site Codes (Example)

..... subSite 0..*CodeableConceptSub-location
Binding: Surface Codes (Example)

.... encounter 0..*Reference(Encounter)Encounters associated with the listed treatments

.... detail 0..*BackboneElementProduct or service provided

..... sequence 1..1positiveIntItem instance identifier
..... traceNumber 0..*IdentifierNumber for tracking

..... revenue 0..1CodeableConceptRevenue or cost center code
Binding: Example Revenue Center Codes (Example)
..... category 0..1CodeableConceptBenefit classification
Binding: Benefit Category Codes (Example)
..... productOrService 0..1CodeableConceptBilling, service, product, or drug code
Binding: USCLS Codes (Example)
..... productOrServiceEnd 0..1CodeableConceptEnd of a range of codes
Binding: USCLS Codes (Example)
..... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: Modifier type Codes (Example)

..... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: Example Program Reason Codes (Example)

..... patientPaid 0..1MoneyPaid by the patient
..... quantity 0..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... tax 0..1MoneyTotal tax
..... net 0..1MoneyTotal item cost
..... udi 0..*Reference(Device)Unique device identifier

..... subDetail 0..*BackboneElementProduct or service provided

...... sequence 1..1positiveIntItem instance identifier
...... traceNumber 0..*IdentifierNumber for tracking

...... revenue 0..1CodeableConceptRevenue or cost center code
Binding: Example Revenue Center Codes (Example)
...... category 0..1CodeableConceptBenefit classification
Binding: Benefit Category Codes (Example)
...... productOrService 0..1CodeableConceptBilling, service, product, or drug code
Binding: USCLS Codes (Example)
...... productOrServiceEnd 0..1CodeableConceptEnd of a range of codes
Binding: USCLS Codes (Example)
...... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: Modifier type Codes (Example)

...... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: Example Program Reason Codes (Example)

...... patientPaid 0..1MoneyPaid by the patient
...... quantity 0..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... tax 0..1MoneyTotal tax
...... net 0..1MoneyTotal item cost
...... udi 0..*Reference(Device)Unique device identifier

... total 0..1MoneyTotal claim cost

doco Documentation for this format icon

See the Extensions for this resource

UML Diagram (Legend)

Claim (DomainResource)A unique identifier assigned to this claimidentifier : Identifier [0..*]Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partnerstraceNumber : Identifier [0..*]The status of the resource instance (this element modifies the meaning of other elements)status : code [1..1] « null (Strength=Required)FinancialResourceStatusCodes! »The category of claim, e.g. oral, pharmacy, vision, institutional, professionaltype : CodeableConcept [1..1] « null (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] « null (Strength=Example)ExampleClaimSubTypeCodes?? »A code to indicate whether the nature of the request is: Claim - A request to an Insurer to adjudicate the supplied charges for health care goods and services under the identified policy and to pay the determined Benefit amount, if any; Preauthorization - A request to an Insurer to adjudicate the supplied proposed future charges for health care goods and services under the identified policy and to approve the services and provide the expected benefit amounts and potentially to reserve funds to pay the benefits when Claims for the indicated services are later submitted; or, Pre-determination - A request to an Insurer to adjudicate the supplied 'what if' charges for health care goods and services under the identified policy and report back what the Benefit payable would be had the services actually been provideduse : code [1..1] « null (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|Patient| RelatedPerson »The Insurer who is target of the requestinsurer : Reference [0..1] « Organization »The provider which is responsible for the claim, predetermination or preauthorizationprovider : Reference [0..1] « Practitioner|PractitionerRole| Organization »The provider-required urgency of processing the request. Typical values include: stat, normal, deferredpriority : CodeableConcept [0..1] « null (Strength=Example)ProcessPriorityCodes?? »A code to indicate whether and for whom funds are to be reserved for future claimsfundsReserve : CodeableConcept [0..1] « null (Strength=Example)FundsReservationCodes?? »Prescription is the document/authorization given to the claim author for them to provide products and services for which consideration (reimbursement) is sought. Could be a RX for medications, an 'order' for oxygen or wheelchair or physiotherapy treatmentsprescription : 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 »The referral information received by the claim author, it is not to be used when the author generates a referral for a patient. A copy of that referral may be provided as supporting information. Some insurers require proof of referral to pay for services or to pay specialist rates for servicesreferral : Reference [0..1] « ServiceRequest »Healthcare encounters related to this claimencounter : Reference [0..*] « Encounter »Facility where the services were providedfacility : Reference [0..1] « Location|Organization »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 systemdiagnosisRelatedGroup : CodeableConcept [0..1] « null (Strength=Example) ExampleDiagnosisRelatedGroupC...?? »The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and servicespatientPaid : Money [0..1]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] « null (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] « null (Strength=Example)ClaimPayeeTypeCodes?? »Reference to the individual or organization to whom any payment will be madeparty : Reference [0..1] « Practitioner|PractitionerRole| Organization|Patient|RelatedPerson »EventA coded event such as when a service is expected or a card printedtype : CodeableConcept [1..1] « null (Strength=Example)DatesTypeCodes?? »A date or period in the past or future indicating when the event occurred or is expectd to occurwhen[x] : DataType [1..1] « dateTime|Period »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] « null (Strength=Example)ClaimCareTeamRoleCodes?? »The specialization of the practitioner or provider which is applicable for this servicespecialty : CodeableConcept [0..1] « null (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] « null (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] « null (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)|Identifier »Provides the reason in the situation where a reason code is required in addition to the contentreason : CodeableConcept [0..1] « null (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); null (Strength=Example) ICD10Codes?? »When the condition was observed or the relative rankingtype : CodeableConcept [0..*] « null (Strength=Example)ExampleDiagnosisTypeCodes?? »Indication of whether the diagnosis was present on admission to a facilityonAdmission : CodeableConcept [0..1] « null (Strength=Example) ExampleDiagnosisOnAdmissionCo...?? »ProcedureA number to uniquely identify procedure entriessequence : positiveInt [1..1]When the condition was observed or the relative rankingtype : CodeableConcept [0..*] « null (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); null (Strength=Example) ICD10ProcedureCodes?? »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] « null (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]Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partnerstraceNumber : Identifier [0..*]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] « null (Strength=Example)ExampleRevenueCenterCodes?? »Code to identify the general type of benefits under which products and services are providedcategory : CodeableConcept [0..1] « null (Strength=Example)BenefitCategoryCodes?? »When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not usedproductOrService : CodeableConcept [0..1] « null (Strength=Example)USCLSCodes?? »This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claimsproductOrServiceEnd : CodeableConcept [0..1] « null (Strength=Example)USCLSCodes?? »Request or Referral for Goods or Service to be renderedrequest : Reference [0..*] « DeviceRequest|MedicationRequest| NutritionOrder|ServiceRequest|SupplyRequest|VisionPrescription »Item typification or modifiers codes to convey additional context for the product or servicemodifier : CodeableConcept [0..*] « null (Strength=Example)ModifierTypeCodes?? »Identifies the program under which this may be recoveredprogramCode : CodeableConcept [0..*] « null (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); null (Strength=Example)ExampleServicePlaceCodes?? »The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and servicespatientPaid : Money [0..1]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 total of taxes applicable for this product or servicetax : Money [0..1]The total amount claimed for the group (if a grouper) or the line item. Net = unit price * quantity * factornet : Money [0..1]Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »Healthcare encounters related to this claimencounter : Reference [0..*] « Encounter »BodySitePhysical service site on the patient (limb, tooth, etc.)site : CodeableReference [1..*] « BodyStructure; null (Strength=Example)OralSiteCodes?? »A region or surface of the bodySite, e.g. limb region or tooth surface(s)subSite : CodeableConcept [0..*] « null (Strength=Example)SurfaceCodes?? »DetailA number to uniquely identify item entriessequence : positiveInt [1..1]Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partnerstraceNumber : Identifier [0..*]The type of revenue or cost center providing the product and/or servicerevenue : CodeableConcept [0..1] « null (Strength=Example)ExampleRevenueCenterCodes?? »Code to identify the general type of benefits under which products and services are providedcategory : CodeableConcept [0..1] « null (Strength=Example)BenefitCategoryCodes?? »When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not usedproductOrService : CodeableConcept [0..1] « null (Strength=Example)USCLSCodes?? »This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claimsproductOrServiceEnd : CodeableConcept [0..1] « null (Strength=Example)USCLSCodes?? »Item typification or modifiers codes to convey additional context for the product or servicemodifier : CodeableConcept [0..*] « null (Strength=Example)ModifierTypeCodes?? »Identifies the program under which this may be recoveredprogramCode : CodeableConcept [0..*] « null (Strength=Example)ExampleProgramReasonCodes?? »The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and servicespatientPaid : Money [0..1]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 total of taxes applicable for this product or servicetax : Money [0..1]The total amount claimed for the group (if a grouper) or the line item.detail. Net = unit price * quantity * factornet : Money [0..1]Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »SubDetailA number to uniquely identify item entriessequence : positiveInt [1..1]Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partnerstraceNumber : Identifier [0..*]The type of revenue or cost center providing the product and/or servicerevenue : CodeableConcept [0..1] « null (Strength=Example)ExampleRevenueCenterCodes?? »Code to identify the general type of benefits under which products and services are providedcategory : CodeableConcept [0..1] « null (Strength=Example)BenefitCategoryCodes?? »When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not usedproductOrService : CodeableConcept [0..1] « null (Strength=Example)USCLSCodes?? »This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claimsproductOrServiceEnd : CodeableConcept [0..1] « null (Strength=Example)USCLSCodes?? »Item typification or modifiers codes to convey additional context for the product or servicemodifier : CodeableConcept [0..*] « null (Strength=Example)ModifierTypeCodes?? »Identifies the program under which this may be recoveredprogramCode : CodeableConcept [0..*] « null (Strength=Example)ExampleProgramReasonCodes?? »The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and servicespatientPaid : Money [0..1]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 total of taxes applicable for this product or servicetax : Money [0..1]The total amount claimed for line item.detail.subDetail. Net = unit price * quantity * factornet : 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]Information code for an event with a corresponding date or periodevent[0..*]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[0..*]Details of an accident which resulted in injuries which required the products and services listed in the claimaccident[0..1]Physical location where the service is performed or appliesbodySite[0..*]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>
 <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>
 <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(Patient|Practitioner|PractitionerRole|RelatedPerson) Author of the claim --></enterer>
 <insurer><!-- 0..1 Reference(Organization) Target --></insurer>
 <provider><!-- 0..1 Reference(Organization|Practitioner|PractitionerRole) Party responsible for the claim --></provider>
 <priority><!-- 0..1 CodeableConcept Desired processing urgency --></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>
 <encounter><!-- 0..* Reference(Encounter) Encounters associated with the listed treatments --></encounter>
 <facility><!-- 0..1 Reference(Location|Organization) Servicing facility --></facility>
 <diagnosisRelatedGroup><!-- 0..1 CodeableConcept Package billing code --></diagnosisRelatedGroup>
 <event>  <!-- 0..* Event information -->
  <type><!-- 1..1 CodeableConcept Specific event --></type>
  <when[x]><!-- 1..1 dateTime|Period Occurance date or period --></when[x]>
 </event>
 <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>
  <specialty><!-- 0..1 CodeableConcept Practitioner or provider specialization --></specialty>
 </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)|
    Identifier 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>
 </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>  <!-- 0..* 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 icon --></type>
  <location[x]><!-- 0..1 Address|Reference(Location) Where the event occurred --></location[x]>
 </accident>
 <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid>
 <item>  <!-- 0..* Product or service provided -->
  <sequence value="[positiveInt]"/><!-- 1..1 Item instance identifier -->
  <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>
  <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><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
  <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd>
  <request><!-- 0..* Reference(DeviceRequest|MedicationRequest|NutritionOrder|
    ServiceRequest|SupplyRequest|VisionPrescription) Request or Referral for Service --></request>
  <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]>
  <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid>
  <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 -->
  <tax><!-- 0..1 Money Total tax --></tax>
  <net><!-- 0..1 Money Total item cost --></net>
  <udi><!-- 0..* Reference(Device) Unique device identifier --></udi>
  <bodySite>  <!-- 0..* Anatomical location -->
   <site><!-- 1..* CodeableReference(BodyStructure) Location --></site>
   <subSite><!-- 0..* CodeableConcept Sub-location --></subSite>
  </bodySite>
  <encounter><!-- 0..* Reference(Encounter) Encounters associated with the listed treatments --></encounter>
  <detail>  <!-- 0..* Product or service provided -->
   <sequence value="[positiveInt]"/><!-- 1..1 Item instance identifier -->
   <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>
   <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
   <category><!-- 0..1 CodeableConcept Benefit classification --></category>
   <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
   <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd>
   <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
   <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode>
   <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid>
   <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 -->
   <tax><!-- 0..1 Money Total tax --></tax>
   <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 -->
    <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>
    <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
    <category><!-- 0..1 CodeableConcept Benefit classification --></category>
    <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
    <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd>
    <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
    <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode>
    <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid>
    <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 -->
    <tax><!-- 0..1 Money Total tax --></tax>
    <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
  "traceNumber" : [{ Identifier }], // Number for tracking
  "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(Patient|Practitioner|PractitionerRole|RelatedPerson) }, // Author of the claim
  "insurer" : { Reference(Organization) }, // Target
  "provider" : { Reference(Organization|Practitioner|PractitionerRole) }, // Party responsible for the claim
  "priority" : { CodeableConcept }, // Desired processing urgency
  "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
  "encounter" : [{ Reference(Encounter) }], // Encounters associated with the listed treatments
  "facility" : { Reference(Location|Organization) }, // Servicing facility
  "diagnosisRelatedGroup" : { CodeableConcept }, // Package billing code
  "event" : [{ // Event information
    "type" : { CodeableConcept }, // R!  Specific event
    // when[x]: Occurance date or period. One of these 2:
    "whenDateTime" : "<dateTime>",
    "whenPeriod" : { Period }
  }],
  "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
    "specialty" : { CodeableConcept } // Practitioner or provider 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 6:
    "valueBoolean" : <boolean>,
    "valueString" : "<string>",
    "valueQuantity" : { Quantity },
    "valueAttachment" : { Attachment },
    "valueReference" : { Reference(Any) },
    "valueIdentifier" : { Identifier },
    "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
  }],
  "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" : [{ // 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 icon
    // location[x]: Where the event occurred. One of these 2:
    "locationAddress" : { Address },
    "locationReference" : { Reference(Location) }
  },
  "patientPaid" : { Money }, // Paid by the patient
  "item" : [{ // Product or service provided
    "sequence" : "<positiveInt>", // R!  Item instance identifier
    "traceNumber" : [{ Identifier }], // Number for tracking
    "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 }, // Billing, service, product, or drug code
    "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes
    "request" : [{ Reference(DeviceRequest|MedicationRequest|NutritionOrder|
    ServiceRequest|SupplyRequest|VisionPrescription) }], // Request or Referral for Service
    "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) },
    "patientPaid" : { Money }, // Paid by the patient
    "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
    "unitPrice" : { Money }, // Fee, charge or cost per item
    "factor" : <decimal>, // Price scaling factor
    "tax" : { Money }, // Total tax
    "net" : { Money }, // Total item cost
    "udi" : [{ Reference(Device) }], // Unique device identifier
    "bodySite" : [{ // Anatomical location
      "site" : [{ CodeableReference(BodyStructure) }], // R!  Location
      "subSite" : [{ CodeableConcept }] // Sub-location
    }],
    "encounter" : [{ Reference(Encounter) }], // Encounters associated with the listed treatments
    "detail" : [{ // Product or service provided
      "sequence" : "<positiveInt>", // R!  Item instance identifier
      "traceNumber" : [{ Identifier }], // Number for tracking
      "revenue" : { CodeableConcept }, // Revenue or cost center code
      "category" : { CodeableConcept }, // Benefit classification
      "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
      "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes
      "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
      "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
      "patientPaid" : { Money }, // Paid by the patient
      "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
      "unitPrice" : { Money }, // Fee, charge or cost per item
      "factor" : <decimal>, // Price scaling factor
      "tax" : { Money }, // Total tax
      "net" : { Money }, // Total item cost
      "udi" : [{ Reference(Device) }], // Unique device identifier
      "subDetail" : [{ // Product or service provided
        "sequence" : "<positiveInt>", // R!  Item instance identifier
        "traceNumber" : [{ Identifier }], // Number for tracking
        "revenue" : { CodeableConcept }, // Revenue or cost center code
        "category" : { CodeableConcept }, // Benefit classification
        "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
        "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes
        "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
        "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
        "patientPaid" : { Money }, // Paid by the patient
        "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
        "unitPrice" : { Money }, // Fee, charge or cost per item
        "factor" : <decimal>, // Price scaling factor
        "tax" : { Money }, // Total tax
        "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:identifier  ( [ Identifier ] ... ) ; # 0..* Business Identifier for claim
  fhir:traceNumber  ( [ Identifier ] ... ) ; # 0..* Number for tracking
  fhir:status [ code ] ; # 1..1 active | cancelled | draft | entered-in-error
  fhir:type [ CodeableConcept ] ; # 1..1 Category or discipline
  fhir:subType [ CodeableConcept ] ; # 0..1 More granular claim type
  fhir:use [ code ] ; # 1..1 claim | preauthorization | predetermination
  fhir:patient [ Reference(Patient) ] ; # 1..1 The recipient of the products and services
  fhir:billablePeriod [ Period ] ; # 0..1 Relevant time frame for the claim
  fhir:created [ dateTime ] ; # 1..1 Resource creation date
  fhir:enterer [ Reference(Patient|Practitioner|PractitionerRole|RelatedPerson) ] ; # 0..1 Author of the claim
  fhir:insurer [ Reference(Organization) ] ; # 0..1 Target
  fhir:provider [ Reference(Organization|Practitioner|PractitionerRole) ] ; # 0..1 Party responsible for the claim
  fhir:priority [ CodeableConcept ] ; # 0..1 Desired processing urgency
  fhir:fundsReserve [ CodeableConcept ] ; # 0..1 For whom to reserve funds
  fhir:related ( [ # 0..* Prior or corollary claims
    fhir:claim [ Reference(Claim) ] ; # 0..1 Reference to the related claim
    fhir:relationship [ CodeableConcept ] ; # 0..1 How the reference claim is related
    fhir:reference [ Identifier ] ; # 0..1 File or case reference
  ] ... ) ;
  fhir:prescription [ Reference(DeviceRequest|MedicationRequest|VisionPrescription) ] ; # 0..1 Prescription authorizing services and products
  fhir:originalPrescription [ Reference(DeviceRequest|MedicationRequest|VisionPrescription) ] ; # 0..1 Original prescription if superseded by fulfiller
  fhir:payee [ # 0..1 Recipient of benefits payable
    fhir:type [ CodeableConcept ] ; # 1..1 Category of recipient
    fhir:party [ Reference(Organization|Patient|Practitioner|PractitionerRole|RelatedPerson) ] ; # 0..1 Recipient reference
  ] ;
  fhir:referral [ Reference(ServiceRequest) ] ; # 0..1 Treatment referral
  fhir:encounter  ( [ Reference(Encounter) ] ... ) ; # 0..* Encounters associated with the listed treatments
  fhir:facility [ Reference(Location|Organization) ] ; # 0..1 Servicing facility
  fhir:diagnosisRelatedGroup [ CodeableConcept ] ; # 0..1 Package billing code
  fhir:event ( [ # 0..* Event information
    fhir:type [ CodeableConcept ] ; # 1..1 Specific event
    # when[x] : 1..1 Occurance date or period. One of these 2
      fhir:when [  a fhir:dateTime ; dateTime ]
      fhir:when [  a fhir:Period ; Period ]
  ] ... ) ;
  fhir:careTeam ( [ # 0..* Members of the care team
    fhir:sequence [ positiveInt ] ; # 1..1 Order of care team
    fhir:provider [ Reference(Organization|Practitioner|PractitionerRole) ] ; # 1..1 Practitioner or organization
    fhir:responsible [ boolean ] ; # 0..1 Indicator of the lead practitioner
    fhir:role [ CodeableConcept ] ; # 0..1 Function within the team
    fhir:specialty [ CodeableConcept ] ; # 0..1 Practitioner or provider specialization
  ] ... ) ;
  fhir:supportingInfo ( [ # 0..* Supporting information
    fhir:sequence [ positiveInt ] ; # 1..1 Information instance identifier
    fhir:category [ CodeableConcept ] ; # 1..1 Classification of the supplied information
    fhir:code [ CodeableConcept ] ; # 0..1 Type of information
    # timing[x] : 0..1 When it occurred. One of these 2
      fhir:timing [  a fhir:date ; date ]
      fhir:timing [  a fhir:Period ; Period ]
    # value[x] : 0..1 Data to be provided. One of these 6
      fhir:value [  a fhir:boolean ; boolean ]
      fhir:value [  a fhir:string ; string ]
      fhir:value [  a fhir:Quantity ; Quantity ]
      fhir:value [  a fhir:Attachment ; Attachment ]
      fhir:value [  a fhir:Reference ; Reference(Any) ]
      fhir:value [  a fhir:Identifier ; Identifier ]
    fhir:reason [ CodeableConcept ] ; # 0..1 Explanation for the information
  ] ... ) ;
  fhir:diagnosis ( [ # 0..* Pertinent diagnosis information
    fhir:sequence [ positiveInt ] ; # 1..1 Diagnosis instance identifier
    # diagnosis[x] : 1..1 Nature of illness or problem. One of these 2
      fhir:diagnosis [  a fhir:CodeableConcept ; CodeableConcept ]
      fhir:diagnosis [  a fhir:Reference ; Reference(Condition) ]
    fhir:type  ( [ CodeableConcept ] ... ) ; # 0..* Timing or nature of the diagnosis
    fhir:onAdmission [ CodeableConcept ] ; # 0..1 Present on admission
  ] ... ) ;
  fhir:procedure ( [ # 0..* Clinical procedures performed
    fhir:sequence [ positiveInt ] ; # 1..1 Procedure instance identifier
    fhir:type  ( [ CodeableConcept ] ... ) ; # 0..* Category of Procedure
    fhir:date [ dateTime ] ; # 0..1 When the procedure was performed
    # procedure[x] : 1..1 Specific clinical procedure. One of these 2
      fhir:procedure [  a fhir:CodeableConcept ; CodeableConcept ]
      fhir:procedure [  a fhir:Reference ; Reference(Procedure) ]
    fhir:udi  ( [ Reference(Device) ] ... ) ; # 0..* Unique device identifier
  ] ... ) ;
  fhir:insurance ( [ # 0..* Patient insurance information
    fhir:sequence [ positiveInt ] ; # 1..1 Insurance instance identifier
    fhir:focal [ boolean ] ; # 1..1 Coverage to be used for adjudication
    fhir:identifier [ Identifier ] ; # 0..1 Pre-assigned Claim number
    fhir:coverage [ Reference(Coverage) ] ; # 1..1 Insurance information
    fhir:businessArrangement [ string ] ; # 0..1 Additional provider contract number
    fhir:preAuthRef  ( [ string ] ... ) ; # 0..* Prior authorization reference number
    fhir:claimResponse [ Reference(ClaimResponse) ] ; # 0..1 Adjudication results
  ] ... ) ;
  fhir:accident [ # 0..1 Details of the event
    fhir:date [ date ] ; # 1..1 When the incident occurred
    fhir:type [ CodeableConcept ] ; # 0..1 The nature of the accident
    # location[x] : 0..1 Where the event occurred. One of these 2
      fhir:location [  a fhir:Address ; Address ]
      fhir:location [  a fhir:Reference ; Reference(Location) ]
  ] ;
  fhir:patientPaid [ Money ] ; # 0..1 Paid by the patient
  fhir:item ( [ # 0..* Product or service provided
    fhir:sequence [ positiveInt ] ; # 1..1 Item instance identifier
    fhir:traceNumber  ( [ Identifier ] ... ) ; # 0..* Number for tracking
    fhir:careTeamSequence  ( [ positiveInt ] ... ) ; # 0..* Applicable careTeam members
    fhir:diagnosisSequence  ( [ positiveInt ] ... ) ; # 0..* Applicable diagnoses
    fhir:procedureSequence  ( [ positiveInt ] ... ) ; # 0..* Applicable procedures
    fhir:informationSequence  ( [ positiveInt ] ... ) ; # 0..* Applicable exception and supporting information
    fhir:revenue [ CodeableConcept ] ; # 0..1 Revenue or cost center code
    fhir:category [ CodeableConcept ] ; # 0..1 Benefit classification
    fhir:productOrService [ CodeableConcept ] ; # 0..1 Billing, service, product, or drug code
    fhir:productOrServiceEnd [ CodeableConcept ] ; # 0..1 End of a range of codes
    fhir:request  ( [ Reference(DeviceRequest|MedicationRequest|NutritionOrder|ServiceRequest|SupplyRequest|
  VisionPrescription) ] ... ) ; # 0..* Request or Referral for Service
    fhir:modifier  ( [ CodeableConcept ] ... ) ; # 0..* Product or service billing modifiers
    fhir:programCode  ( [ CodeableConcept ] ... ) ; # 0..* Program the product or service is provided under
    # serviced[x] : 0..1 Date or dates of service or product delivery. One of these 2
      fhir:serviced [  a fhir:date ; date ]
      fhir:serviced [  a fhir:Period ; Period ]
    # location[x] : 0..1 Place of service or where product was supplied. One of these 3
      fhir:location [  a fhir:CodeableConcept ; CodeableConcept ]
      fhir:location [  a fhir:Address ; Address ]
      fhir:location [  a fhir:Reference ; Reference(Location) ]
    fhir:patientPaid [ Money ] ; # 0..1 Paid by the patient
    fhir:quantity [ Quantity(SimpleQuantity) ] ; # 0..1 Count of products or services
    fhir:unitPrice [ Money ] ; # 0..1 Fee, charge or cost per item
    fhir:factor [ decimal ] ; # 0..1 Price scaling factor
    fhir:tax [ Money ] ; # 0..1 Total tax
    fhir:net [ Money ] ; # 0..1 Total item cost
    fhir:udi  ( [ Reference(Device) ] ... ) ; # 0..* Unique device identifier
    fhir:bodySite ( [ # 0..* Anatomical location
      fhir:site  ( [ CodeableReference(BodyStructure) ] ... ) ; # 1..* Location
      fhir:subSite  ( [ CodeableConcept ] ... ) ; # 0..* Sub-location
    ] ... ) ;
    fhir:encounter  ( [ Reference(Encounter) ] ... ) ; # 0..* Encounters associated with the listed treatments
    fhir:detail ( [ # 0..* Product or service provided
      fhir:sequence [ positiveInt ] ; # 1..1 Item instance identifier
      fhir:traceNumber  ( [ Identifier ] ... ) ; # 0..* Number for tracking
      fhir:revenue [ CodeableConcept ] ; # 0..1 Revenue or cost center code
      fhir:category [ CodeableConcept ] ; # 0..1 Benefit classification
      fhir:productOrService [ CodeableConcept ] ; # 0..1 Billing, service, product, or drug code
      fhir:productOrServiceEnd [ CodeableConcept ] ; # 0..1 End of a range of codes
      fhir:modifier  ( [ CodeableConcept ] ... ) ; # 0..* Service/Product billing modifiers
      fhir:programCode  ( [ CodeableConcept ] ... ) ; # 0..* Program the product or service is provided under
      fhir:patientPaid [ Money ] ; # 0..1 Paid by the patient
      fhir:quantity [ Quantity(SimpleQuantity) ] ; # 0..1 Count of products or services
      fhir:unitPrice [ Money ] ; # 0..1 Fee, charge or cost per item
      fhir:factor [ decimal ] ; # 0..1 Price scaling factor
      fhir:tax [ Money ] ; # 0..1 Total tax
      fhir:net [ Money ] ; # 0..1 Total item cost
      fhir:udi  ( [ Reference(Device) ] ... ) ; # 0..* Unique device identifier
      fhir:subDetail ( [ # 0..* Product or service provided
        fhir:sequence [ positiveInt ] ; # 1..1 Item instance identifier
        fhir:traceNumber  ( [ Identifier ] ... ) ; # 0..* Number for tracking
        fhir:revenue [ CodeableConcept ] ; # 0..1 Revenue or cost center code
        fhir:category [ CodeableConcept ] ; # 0..1 Benefit classification
        fhir:productOrService [ CodeableConcept ] ; # 0..1 Billing, service, product, or drug code
        fhir:productOrServiceEnd [ CodeableConcept ] ; # 0..1 End of a range of codes
        fhir:modifier  ( [ CodeableConcept ] ... ) ; # 0..* Service/Product billing modifiers
        fhir:programCode  ( [ CodeableConcept ] ... ) ; # 0..* Program the product or service is provided under
        fhir:patientPaid [ Money ] ; # 0..1 Paid by the patient
        fhir:quantity [ Quantity(SimpleQuantity) ] ; # 0..1 Count of products or services
        fhir:unitPrice [ Money ] ; # 0..1 Fee, charge or cost per item
        fhir:factor [ decimal ] ; # 0..1 Price scaling factor
        fhir:tax [ Money ] ; # 0..1 Total tax
        fhir:net [ Money ] ; # 0..1 Total item cost
        fhir:udi  ( [ Reference(Device) ] ... ) ; # 0..* Unique device identifier
      ] ... ) ;
    ] ... ) ;
  ] ... ) ;
  fhir:total [ Money ] ; # 0..1 Total claim cost
]

Changes from both R4 and R4B

Claim
Claim.traceNumber
  • Added Element
Claim.enterer
  • Type Reference: Added Target Types Patient, RelatedPerson
Claim.provider
  • Min Cardinality changed from 1 to 0
Claim.priority
  • Min Cardinality changed from 1 to 0
Claim.encounter
  • Added Element
Claim.facility
  • Type Reference: Added Target Type Organization
Claim.diagnosisRelatedGroup
  • Added Element
Claim.event
  • Added Element
Claim.event.type
  • Added Mandatory Element
Claim.event.when[x]
  • Added Mandatory Element
Claim.careTeam.specialty
  • Added Element
Claim.supportingInfo.value[x]
  • Add Type Identifier
Claim.insurance
  • Min Cardinality changed from 1 to 0
Claim.patientPaid
  • Added Element
Claim.item.traceNumber
  • Added Element
Claim.item.productOrService
  • Min Cardinality changed from 1 to 0
Claim.item.productOrServiceEnd
  • Added Element
Claim.item.request
  • Added Element
Claim.item.patientPaid
  • Added Element
Claim.item.tax
  • Added Element
Claim.item.bodySite
  • Max Cardinality changed from 1 to *
  • Type changed from CodeableConcept to BackboneElement
Claim.item.bodySite.site
  • Added Mandatory Element
Claim.item.bodySite.subSite
  • Added Element
Claim.item.detail.traceNumber
  • Added Element
Claim.item.detail.productOrService
  • Min Cardinality changed from 1 to 0
Claim.item.detail.productOrServiceEnd
  • Added Element
Claim.item.detail.patientPaid
  • Added Element
Claim.item.detail.tax
  • Added Element
Claim.item.detail.subDetail.traceNumber
  • Added Element
Claim.item.detail.subDetail.productOrService
  • Min Cardinality changed from 1 to 0
Claim.item.detail.subDetail.productOrServiceEnd
  • Added Element
Claim.item.detail.subDetail.patientPaid
  • Added Element
Claim.item.detail.subDetail.tax
  • Added Element
Claim.careTeam.qualification
  • Deleted
Claim.diagnosis.packageCode
  • Deleted
Claim.item.subSite
  • Deleted

See the Full Difference for further information

This analysis is available for R4 as XML or JSON and for R4B as XML or JSON.

See R4 <--> R5 Conversion Maps (status = See Conversions Summary.)

 

Additional definitions: Master Definition XML + JSON, XML Schema/Schematron + JSON Schema, ShEx (for Turtle) + see the extensions, the spreadsheet version & the dependency analysis

13.6.4.1 Terminology Bindings

PathValueSetTypeDocumentation
Claim.status FinancialResourceStatusCodes Required

This value set includes Status codes.
Claim.type ClaimTypeCodes Extensible

This value set includes Claim Type codes.
Claim.subType ExampleClaimSubTypeCodes Example

This value set includes sample Claim SubType codes which are used to distinguish the claim types for example within type institutional there may be subtypes for emergency services, bed stay and transportation.
Claim.use Use Required

The purpose of the Claim: predetermination, preauthorization, claim.
Claim.priority ProcessPriorityCodes Example

This value set includes the financial processing priority codes.
Claim.fundsReserve FundsReservationCodes Example

This value set includes sample funds reservation type codes.
Claim.related.relationship ExampleRelatedClaimRelationshipCodes Example

This value set includes sample Related Claim Relationship codes.
Claim.payee.type ClaimPayeeTypeCodes (a valid code from Payee Type Codes icon)Example

This value set includes sample Payee Type codes.
Claim.diagnosisRelatedGroup ExampleDiagnosisRelatedGroupCodes Example

This value set includes example Diagnosis Related Group codes.
Claim.event.type DatesTypeCodes (a valid code from Dates Event Type Codes)Example

This value set includes sample Dates Type codes.
Claim.careTeam.role ClaimCareTeamRoleCodes Example

This value set includes sample Claim Care Team Role codes.
Claim.careTeam.specialty ExampleProviderQualificationCodes Example

This value set includes sample Provider Qualification codes.
Claim.supportingInfo.category ClaimInformationCategoryCodes Example

This value set includes sample Information Category codes.
Claim.supportingInfo.code ExceptionCodes Example

This value set includes sample Exception codes.
Claim.supportingInfo.reason MissingToothReasonCodes Example

This value set includes sample Missing Tooth Reason codes.
Claim.diagnosis.diagnosis[x] ICD10Codes (a valid code from ICD-10 icon)Example

This value set includes sample ICD-10 codes.
Claim.diagnosis.type ExampleDiagnosisTypeCodes Example

This value set includes example Diagnosis Type codes.
Claim.diagnosis.onAdmission ExampleDiagnosisOnAdmissionCodes Example

This value set includes example Diagnosis on Admission codes.
Claim.procedure.type ExampleProcedureTypeCodes Example

This value set includes example Procedure Type codes.
Claim.procedure.procedure[x] ICD10ProcedureCodes (a valid code from ICD-10 Procedure Codes)Example

This value set includes sample ICD-10 Procedure codes.
Claim.accident.type ActIncidentCode icon Extensible

Set of codes indicating the type of incident or accident.
Claim.item.revenue ExampleRevenueCenterCodes Example

This value set includes sample Revenue Center codes.
Claim.item.category BenefitCategoryCodes Example

This value set includes examples of Benefit Category codes.
Claim.item.productOrService USCLSCodes Example

This value set includes a smattering of USCLS codes.
Claim.item.productOrServiceEnd USCLSCodes Example

This value set includes a smattering of USCLS codes.
Claim.item.modifier ModifierTypeCodes Example

This value set includes sample Modifier type codes.
Claim.item.programCode ExampleProgramReasonCodes Example

This value set includes sample Program Reason Span codes.
Claim.item.location[x] ExampleServicePlaceCodes Example

This value set includes a smattering of Service Place codes.
Claim.item.bodySite.site OralSiteCodes Example

This value set includes a smattering of FDI oral site codes.
Claim.item.bodySite.subSite SurfaceCodes Example

This value set includes a smattering of FDI tooth surface codes.
Claim.item.detail.revenue ExampleRevenueCenterCodes Example

This value set includes sample Revenue Center codes.
Claim.item.detail.category BenefitCategoryCodes Example

This value set includes examples of Benefit Category codes.
Claim.item.detail.productOrService USCLSCodes Example

This value set includes a smattering of USCLS codes.
Claim.item.detail.productOrServiceEnd USCLSCodes Example

This value set includes a smattering of USCLS codes.
Claim.item.detail.modifier ModifierTypeCodes Example

This value set includes sample Modifier type codes.
Claim.item.detail.programCode ExampleProgramReasonCodes Example

This value set includes sample Program Reason Span codes.
Claim.item.detail.subDetail.revenue ExampleRevenueCenterCodes Example

This value set includes sample Revenue Center codes.
Claim.item.detail.subDetail.category BenefitCategoryCodes Example

This value set includes examples of Benefit Category codes.
Claim.item.detail.subDetail.productOrService USCLSCodes Example

This value set includes a smattering of USCLS codes.
Claim.item.detail.subDetail.productOrServiceEnd USCLSCodes Example

This value set includes a smattering of USCLS codes.
Claim.item.detail.subDetail.modifier ModifierTypeCodes Example

This value set includes sample Modifier type codes.
Claim.item.detail.subDetail.programCode ExampleProgramReasonCodes Example

This value set includes sample Program Reason Span codes.

13.6.5 Additional Information

The information presented in different backbone elements, such as .supportingInfo or .adjudication, has a different context based on the .category code presented in each, for example, adjudication occurrence may represent an amount paid by the patient while another may represent the amount paid to the provider.

Additionally, there are several places in the resource which point to other sections of the resource via the use of a .sequence number in the referred-to element and an .elementSequence in the referring element. Sequence numbers appear in such element as .careTeam referred to by .careTeamSequence, .diagnosis referred to by .diagnosisSequence, .procedure referred to by .procedureSequence, .supportingInfo referred to by .informationSequence and .item referred to by .itemSequence.

13.6.6 Search Parameters

Search parameters for this resource. See also the full list of search parameters for this resource, and check the Extensions registry for search parameters on extensions related to 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)
createddateThe 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)		29 Resources
entererreferenceThe party responsible for the entry of the ClaimClaim.enterer
(Practitioner, Patient, PractitionerRole, RelatedPerson)
facilityreferenceFacility where the products or services have been or will be providedClaim.facility
(Organization, Location)
identifiertokenThe primary identifier of the financial resourceClaim.identifier65 Resources
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)		66 Resources
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)
statustokenThe status of the Claim instance.Claim.status
subdetail-udireferenceUDI associated with a line item, detail, subdetail product or serviceClaim.item.detail.subDetail.udi
(Device)
usetokenThe kind of financial resourceClaim.use