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
Financial Management Work Group | Maturity Level: N/A | Standards Status: Informative | Compartments: Device, Encounter, Patient, Practitioner, RelatedPerson |
ShEx statement for claim
PREFIX fhir: <http://hl7.org/fhir/> PREFIX fhirvs: <http://hl7.org/fhir/ValueSet/> PREFIX xsd: <http://www.w3.org/2001/XMLSchema#> PREFIX rdf: <http://www.w3.org/1999/02/22-rdf-syntax-ns#> IMPORT <code.shex> IMPORT <date.shex> IMPORT <Money.shex> IMPORT <Period.shex> IMPORT <string.shex> IMPORT <Device.shex> IMPORT <Patient.shex> IMPORT <boolean.shex> IMPORT <Address.shex> IMPORT <decimal.shex> IMPORT <dateTime.shex> IMPORT <Location.shex> IMPORT <Coverage.shex> IMPORT <Quantity.shex> IMPORT <Resource.shex> IMPORT <Reference.shex> IMPORT <Condition.shex> IMPORT <Procedure.shex> IMPORT <Encounter.shex> IMPORT <Identifier.shex> IMPORT <Attachment.shex> IMPORT <positiveInt.shex> IMPORT <Practitioner.shex> IMPORT <Organization.shex> IMPORT <RelatedPerson.shex> IMPORT <DeviceRequest.shex> IMPORT <SupplyRequest.shex> IMPORT <DomainResource.shex> IMPORT <ServiceRequest.shex> IMPORT <NutritionOrder.shex> IMPORT <CodeableConcept.shex> IMPORT <BackboneElement.shex> IMPORT <PractitionerRole.shex> IMPORT <MedicationRequest.shex> IMPORT <CodeableReference.shex> IMPORT <VisionPrescription.shex> start=@<Claim> AND {fhir:nodeRole [fhir:treeRoot]} # Claim, Pre-determination or Pre-authorization <Claim> EXTENDS @<DomainResource> CLOSED { a [fhir:Claim]?; fhir:nodeRole [fhir:treeRoot]?; fhir:identifier @<OneOrMore_Identifier>?; # Business Identifier for claim fhir:traceNumber @<OneOrMore_Identifier>?; # Number for tracking fhir:status @<code> AND {fhir:v @fhirvs:fm-status}; # active | cancelled | draft | # entered-in-error fhir:type @<CodeableConcept>; # Category or discipline fhir:subType @<CodeableConcept>?; # More granular claim type fhir:use @<code> AND {fhir:v @fhirvs:claim-use}; # claim | preauthorization | # predetermination fhir:patient @<Reference> AND {fhir:link @<Patient> ? }; # The recipient of the products and # services fhir:billablePeriod @<Period>?; # Relevant time frame for the claim fhir:created @<dateTime>; # Resource creation date fhir:enterer @<Reference> AND {fhir:link @<Patient> OR @<Practitioner> OR @<PractitionerRole> OR @<RelatedPerson> ? }?; # Author of the claim fhir:insurer @<Reference> AND {fhir:link @<Organization> ? }?; # Target fhir:provider @<Reference> AND {fhir:link @<Organization> OR @<Practitioner> OR @<PractitionerRole> ? }?; # Party responsible for the claim fhir:priority @<CodeableConcept>?; # Desired processing urgency fhir:fundsReserve @<CodeableConcept>?; # For whom to reserve funds fhir:related @<OneOrMore_Claim.related>?; # Prior or corollary claims fhir:prescription @<Reference> AND {fhir:link @<DeviceRequest> OR @<MedicationRequest> OR @<VisionPrescription> ? }?; # Prescription authorizing services # and products fhir:originalPrescription @<Reference> AND {fhir:link @<DeviceRequest> OR @<MedicationRequest> OR @<VisionPrescription> ? }?; # Original prescription if # superseded by fulfiller fhir:payee @<Claim.payee>?; # Recipient of benefits payable fhir:referral @<Reference> AND {fhir:link @<ServiceRequest> ? }?; # Treatment referral fhir:encounter @<OneOrMore_Reference_Encounter>?; # Encounters associated with the # listed treatments fhir:facility @<Reference> AND {fhir:link @<Location> OR @<Organization> ? }?; # Servicing facility fhir:diagnosisRelatedGroup @<CodeableConcept>?; # Package billing code fhir:event @<OneOrMore_Claim.event>?; # Event information fhir:careTeam @<OneOrMore_Claim.careTeam>?; # Members of the care team fhir:supportingInfo @<OneOrMore_Claim.supportingInfo>?; # Supporting information fhir:diagnosis @<OneOrMore_Claim.diagnosis>?; # Pertinent diagnosis information fhir:procedure @<OneOrMore_Claim.procedure>?; # Clinical procedures performed fhir:insurance @<OneOrMore_Claim.insurance>?; # Patient insurance information fhir:accident @<Claim.accident>?; # Details of the event fhir:patientPaid @<Money>?; # Paid by the patient fhir:item @<OneOrMore_Claim.item>?; # Product or service provided fhir:total @<Money>?; # Total claim cost } # Prior or corollary claims <Claim.related> EXTENDS @<BackboneElement> CLOSED { fhir:claim @<Reference> AND {fhir:link @<Claim> ? }?; # Reference to the related claim fhir:relationship @<CodeableConcept>?; # How the reference claim is related fhir:reference @<Identifier>?; # File or case reference } # Event information <Claim.event> EXTENDS @<BackboneElement> CLOSED { fhir:type @<CodeableConcept>; # Specific event fhir:when @<dateTime> OR @<Period> ; # Occurance date or period } # Recipient of benefits payable <Claim.payee> EXTENDS @<BackboneElement> CLOSED { fhir:type @<CodeableConcept>; # Category of recipient fhir:party @<Reference> AND {fhir:link @<Organization> OR @<Patient> OR @<Practitioner> OR @<PractitionerRole> OR @<RelatedPerson> ? }?; # Recipient reference } # Patient insurance information <Claim.insurance> EXTENDS @<BackboneElement> CLOSED { fhir:sequence @<positiveInt>; # Insurance instance identifier fhir:focal @<boolean>; # Coverage to be used for # adjudication fhir:identifier @<Identifier>?; # Pre-assigned Claim number fhir:coverage @<Reference> AND {fhir:link @<Coverage> ? }; # Insurance information fhir:businessArrangement @<string>?; # Additional provider contract number fhir:preAuthRef @<OneOrMore_string>?; # Prior authorization reference # number fhir:claimResponse @<Reference> AND {fhir:link @<ClaimResponse> ? }?; # Adjudication results } # Product or service provided <Claim.item> EXTENDS @<BackboneElement> CLOSED { fhir:sequence @<positiveInt>; # Item instance identifier fhir:traceNumber @<OneOrMore_Identifier>?; # Number for tracking fhir:careTeamSequence @<OneOrMore_positiveInt>?; # Applicable careTeam members fhir:diagnosisSequence @<OneOrMore_positiveInt>?; # Applicable diagnoses fhir:procedureSequence @<OneOrMore_positiveInt>?; # Applicable procedures fhir:informationSequence @<OneOrMore_positiveInt>?; # Applicable exception and # supporting information fhir:revenue @<CodeableConcept>?; # Revenue or cost center code fhir:category @<CodeableConcept>?; # Benefit classification fhir:productOrService @<CodeableConcept>?; # Billing, service, product, or drug # code fhir:productOrServiceEnd @<CodeableConcept>?; # End of a range of codes fhir:request @<OneOrMore_Reference_DeviceRequest_OR_MedicationRequest_OR_NutritionOrder_OR_ServiceRequest_OR_SupplyRequest_OR_VisionPrescription>?; # Request or Referral for Service fhir:modifier @<OneOrMore_CodeableConcept>?; # Product or service billing # modifiers fhir:programCode @<OneOrMore_CodeableConcept>?; # Program the product or service is # provided under fhir:serviced @<date> OR @<Period> ?; # Date or dates of service or # product delivery fhir:location @<CodeableConcept> OR @<Address> OR (@<Reference> AND {fhir:link @<Location> }) ?; # Place of service or where product # was supplied fhir:patientPaid @<Money>?; # Paid by the patient fhir:quantity @<Quantity>?; # Count of products or services fhir:unitPrice @<Money>?; # Fee, charge or cost per item fhir:factor @<decimal>?; # Price scaling factor fhir:tax @<Money>?; # Total tax fhir:net @<Money>?; # Total item cost fhir:udi @<OneOrMore_Reference_Device>?; # Unique device identifier fhir:bodySite @<OneOrMore_Claim.item.bodySite>?; # Anatomical location fhir:encounter @<OneOrMore_Reference_Encounter>?; # Encounters associated with the # listed treatments fhir:detail @<OneOrMore_Claim.item.detail>?; # Product or service provided } # Product or service provided <Claim.item.detail.subDetail> EXTENDS @<BackboneElement> CLOSED { fhir:sequence @<positiveInt>; # Item instance identifier fhir:traceNumber @<OneOrMore_Identifier>?; # Number for tracking fhir:revenue @<CodeableConcept>?; # Revenue or cost center code fhir:category @<CodeableConcept>?; # Benefit classification fhir:productOrService @<CodeableConcept>?; # Billing, service, product, or drug # code fhir:productOrServiceEnd @<CodeableConcept>?; # End of a range of codes fhir:modifier @<OneOrMore_CodeableConcept>?; # Service/Product billing modifiers fhir:programCode @<OneOrMore_CodeableConcept>?; # Program the product or service is # provided under fhir:patientPaid @<Money>?; # Paid by the patient fhir:quantity @<Quantity>?; # Count of products or services fhir:unitPrice @<Money>?; # Fee, charge or cost per item fhir:factor @<decimal>?; # Price scaling factor fhir:tax @<Money>?; # Total tax fhir:net @<Money>?; # Total item cost fhir:udi @<OneOrMore_Reference_Device>?; # Unique device identifier } # Supporting information <Claim.supportingInfo> EXTENDS @<BackboneElement> CLOSED { fhir:sequence @<positiveInt>; # Information instance identifier fhir:category @<CodeableConcept>; # Classification of the supplied # information fhir:code @<CodeableConcept>?; # Type of information fhir:timing @<date> OR @<Period> ?; # When it occurred fhir:value @<boolean> OR @<string> OR @<Quantity> OR @<Attachment> OR (@<Reference> AND {fhir:link @<Resource> }) OR @<Identifier> ?; # Data to be provided fhir:reason @<CodeableConcept>?; # Explanation for the information } # Anatomical location <Claim.item.bodySite> EXTENDS @<BackboneElement> CLOSED { fhir:site @<OneOrMore_CodeableReference>; # Location fhir:subSite @<OneOrMore_CodeableConcept>?; # Sub-location } # Product or service provided <Claim.item.detail> EXTENDS @<BackboneElement> CLOSED { fhir:sequence @<positiveInt>; # Item instance identifier fhir:traceNumber @<OneOrMore_Identifier>?; # Number for tracking fhir:revenue @<CodeableConcept>?; # Revenue or cost center code fhir:category @<CodeableConcept>?; # Benefit classification fhir:productOrService @<CodeableConcept>?; # Billing, service, product, or drug # code fhir:productOrServiceEnd @<CodeableConcept>?; # End of a range of codes fhir:modifier @<OneOrMore_CodeableConcept>?; # Service/Product billing modifiers fhir:programCode @<OneOrMore_CodeableConcept>?; # Program the product or service is # provided under fhir:patientPaid @<Money>?; # Paid by the patient fhir:quantity @<Quantity>?; # Count of products or services fhir:unitPrice @<Money>?; # Fee, charge or cost per item fhir:factor @<decimal>?; # Price scaling factor fhir:tax @<Money>?; # Total tax fhir:net @<Money>?; # Total item cost fhir:udi @<OneOrMore_Reference_Device>?; # Unique device identifier fhir:subDetail @<OneOrMore_Claim.item.detail.subDetail>?; # Product or service provided } # Pertinent diagnosis information <Claim.diagnosis> EXTENDS @<BackboneElement> CLOSED { fhir:sequence @<positiveInt>; # Diagnosis instance identifier fhir:diagnosis @<CodeableConcept> OR (@<Reference> AND {fhir:link @<Condition> }) ; # Nature of illness or problem fhir:type @<OneOrMore_CodeableConcept>?; # Timing or nature of the diagnosis fhir:onAdmission @<CodeableConcept>?; # Present on admission } # Members of the care team <Claim.careTeam> EXTENDS @<BackboneElement> CLOSED { fhir:sequence @<positiveInt>; # Order of care team fhir:provider @<Reference> AND {fhir:link @<Organization> OR @<Practitioner> OR @<PractitionerRole> ? }; # Practitioner or organization fhir:responsible @<boolean>?; # Indicator of the lead practitioner fhir:role @<CodeableConcept>?; # Function within the team fhir:specialty @<CodeableConcept>?; # Practitioner or provider # specialization } # Details of the event <Claim.accident> EXTENDS @<BackboneElement> CLOSED { fhir:date @<date>; # When the incident occurred fhir:type @<CodeableConcept>?; # The nature of the accident fhir:location @<Address> OR (@<Reference> AND {fhir:link @<Location> }) ?; # Where the event occurred } # Clinical procedures performed <Claim.procedure> EXTENDS @<BackboneElement> CLOSED { fhir:sequence @<positiveInt>; # Procedure instance identifier fhir:type @<OneOrMore_CodeableConcept>?; # Category of Procedure fhir:date @<dateTime>?; # When the procedure was performed fhir:procedure @<CodeableConcept> OR (@<Reference> AND {fhir:link @<Procedure> }) ; # Specific clinical procedure fhir:udi @<OneOrMore_Reference_Device>?; # Unique device identifier } #---------------------- Cardinality Types (OneOrMore) ------------------- <OneOrMore_Identifier> CLOSED { rdf:first @<Identifier> ; rdf:rest [rdf:nil] OR @<OneOrMore_Identifier> } <OneOrMore_Claim.related> CLOSED { rdf:first @<Claim.related> ; rdf:rest [rdf:nil] OR @<OneOrMore_Claim.related> } <OneOrMore_Reference_Encounter> CLOSED { rdf:first @<Reference> AND {fhir:link @<Encounter> } ; rdf:rest [rdf:nil] OR @<OneOrMore_Reference_Encounter> } <OneOrMore_Claim.event> CLOSED { rdf:first @<Claim.event> ; rdf:rest [rdf:nil] OR @<OneOrMore_Claim.event> } <OneOrMore_Claim.careTeam> CLOSED { rdf:first @<Claim.careTeam> ; rdf:rest [rdf:nil] OR @<OneOrMore_Claim.careTeam> } <OneOrMore_Claim.supportingInfo> CLOSED { rdf:first @<Claim.supportingInfo> ; rdf:rest [rdf:nil] OR @<OneOrMore_Claim.supportingInfo> } <OneOrMore_Claim.diagnosis> CLOSED { rdf:first @<Claim.diagnosis> ; rdf:rest [rdf:nil] OR @<OneOrMore_Claim.diagnosis> } <OneOrMore_Claim.procedure> CLOSED { rdf:first @<Claim.procedure> ; rdf:rest [rdf:nil] OR @<OneOrMore_Claim.procedure> } <OneOrMore_Claim.insurance> CLOSED { rdf:first @<Claim.insurance> ; rdf:rest [rdf:nil] OR @<OneOrMore_Claim.insurance> } <OneOrMore_Claim.item> CLOSED { rdf:first @<Claim.item> ; rdf:rest [rdf:nil] OR @<OneOrMore_Claim.item> } <OneOrMore_string> CLOSED { rdf:first @<string> ; rdf:rest [rdf:nil] OR @<OneOrMore_string> } <OneOrMore_positiveInt> CLOSED { rdf:first @<positiveInt> ; rdf:rest [rdf:nil] OR @<OneOrMore_positiveInt> } <OneOrMore_Reference_DeviceRequest_OR_MedicationRequest_OR_NutritionOrder_OR_ServiceRequest_OR_SupplyRequest_OR_VisionPrescription> CLOSED { rdf:first @<Reference> AND {fhir:link @<DeviceRequest> OR @<MedicationRequest> OR @<NutritionOrder> OR @<ServiceRequest> OR @<SupplyRequest> OR @<VisionPrescription> } ; rdf:rest [rdf:nil] OR @<OneOrMore_Reference_DeviceRequest_OR_MedicationRequest_OR_NutritionOrder_OR_ServiceRequest_OR_SupplyRequest_OR_VisionPrescription> } <OneOrMore_CodeableConcept> CLOSED { rdf:first @<CodeableConcept> ; rdf:rest [rdf:nil] OR @<OneOrMore_CodeableConcept> } <OneOrMore_Reference_Device> CLOSED { rdf:first @<Reference> AND {fhir:link @<Device> } ; rdf:rest [rdf:nil] OR @<OneOrMore_Reference_Device> } <OneOrMore_Claim.item.bodySite> CLOSED { rdf:first @<Claim.item.bodySite> ; rdf:rest [rdf:nil] OR @<OneOrMore_Claim.item.bodySite> } <OneOrMore_Claim.item.detail> CLOSED { rdf:first @<Claim.item.detail> ; rdf:rest [rdf:nil] OR @<OneOrMore_Claim.item.detail> } <OneOrMore_CodeableReference> CLOSED { rdf:first @<CodeableReference> ; rdf:rest [rdf:nil] OR @<OneOrMore_CodeableReference> } <OneOrMore_Claim.item.detail.subDetail> CLOSED { rdf:first @<Claim.item.detail.subDetail> ; rdf:rest [rdf:nil] OR @<OneOrMore_Claim.item.detail.subDetail> } #---------------------- Value Sets ------------------------ # The purpose of the Claim: predetermination, preauthorization, claim. fhirvs:claim-use ["claim" "preauthorization" "predetermination"] # This value set includes Status codes. fhirvs:fm-status ["active" "cancelled" "draft" "entered-in-error"]
Usage note: every effort has been made to ensure that the ShEx files are correct and useful, but they are not a normative part of the specification.
FHIR ®© HL7.org 2011+. FHIR R6 hl7.fhir.core#6.0.0-ballot1 generated on Mon, Dec 18, 2023 15:16+1100.
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