This page is part of the FHIR Specification (v0.0.82: DSTU 1). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions

Claim.questionnaire

This is an example form generated from the questionnaire. See also the XML or JSON format.

Claim.questionnaire - FHIR v0.4.0 Form
Development Version

This is an example form generated from the questionnaire. See also the XML or JSON format

Claim, Pre-determination or Pre-authorization

Claim
Claim.id
Claim.id.value Logical id of this artefact
Claim.id 1

Metadata about the resource

Claim.meta
Claim.meta 1
Claim.implicitRules
Claim.implicitRules.value A set of rules under which this content was created
Claim.implicitRules 1
Claim.language
Claim.language.value language
Claim.language 1

Text summary of the resource, for human interpretation

Claim.text
Claim.text 1

Contained, inline Resources

Claim.contained
Claim.contained 1
Claim.type
Claim.type.value type
Claim.type 1

Claim number

Claim.identifier
Claim.identifier.label label:
Claim.identifier.system system:
Claim.identifier.value value:
Claim.identifier 1
Claim.ruleset
Claim.ruleset.value Current specification followed
Claim.ruleset 1
Claim.originalRuleset
Claim.originalRuleset.value Original specification followed
Claim.originalRuleset 1
Claim.created
Claim.created.value Creation date
Claim.created 1
Claim.target
Claim.target.value Insurer
Claim.target 1
Claim.provider
Claim.provider.value Responsible provider
Claim.provider 1
Claim.organization
Claim.organization.value Responsible organization
Claim.organization 1
Claim.use
Claim.use.value use
Claim.use 1
Claim.priority
Claim.priority.value Desired processing priority
Claim.priority 1
Claim.fundsReserve
Claim.fundsReserve.value Funds requested to be reserved
Claim.fundsReserve 1
Claim.enterer
Claim.enterer.value Author
Claim.enterer 1
Claim.facility
Claim.facility.value Servicing Facility
Claim.facility 1

Prescription

Claim.prescription
Claim.prescription._type type
Claim.prescription._MedicationPrescription
Claim.prescription._MedicationPrescription.value MedicationPrescription
Claim.prescription._MedicationPrescription 1
Claim.prescription._VisionPrescription
Claim.prescription._VisionPrescription.value VisionPrescription
Claim.prescription._VisionPrescription 1
Claim.prescription 1
Claim.originalPrescription
Claim.originalPrescription.value Original Prescription
Claim.originalPrescription 1

Payee

Claim.payee
Claim.payee.id
Claim.payee.id.value xml:id (or equivalent in JSON)
Claim.payee.id 1
Claim.payee.type
Claim.payee.type.value Party to be paid any benefits payable
Claim.payee.type 1
Claim.payee.provider
Claim.payee.provider.value Provider who is the payee
Claim.payee.provider 1
Claim.payee.organization
Claim.payee.organization.value Organization who is the payee
Claim.payee.organization 1
Claim.payee.person
Claim.payee.person.value Other person who is the payee
Claim.payee.person 1
Claim.payee 1
Claim.referral
Claim.referral.value Treatment Referral
Claim.referral 1

Diagnosis

Claim.diagnosis
Claim.diagnosis.id
Claim.diagnosis.id.value xml:id (or equivalent in JSON)
Claim.diagnosis.id 1
Claim.diagnosis.sequence
Claim.diagnosis.sequence.value Sequence of diagnosis
Claim.diagnosis.sequence 1
Claim.diagnosis.diagnosis
Claim.diagnosis.diagnosis.value Patient's list of diagnosis
Claim.diagnosis.diagnosis 1
Claim.diagnosis 1
Claim.condition
Claim.condition.value List of presenting Conditions
Claim.condition 1
Claim.patient
Claim.patient.value The subject of the Products and Services
Claim.patient 1

Insurance or medical plan

Claim.coverage
Claim.coverage.id
Claim.coverage.id.value xml:id (or equivalent in JSON)
Claim.coverage.id 1
Claim.coverage.sequence
Claim.coverage.sequence.value Service instance identifier
Claim.coverage.sequence 1
Claim.coverage.focal
Claim.coverage.focal.value Is the focal Coverage
Claim.coverage.focal 1
Claim.coverage.coverage
Claim.coverage.coverage.value Insurance information
Claim.coverage.coverage 1
Claim.coverage.businessArrangement
Claim.coverage.businessArrangement.value Business agreement
Claim.coverage.businessArrangement 1
Claim.coverage.relationship
Claim.coverage.relationship.value Patient relationship to subscriber
Claim.coverage.relationship 1
Claim.coverage.preAuthRef
Claim.coverage.preAuthRef.value Pre-Authorization/Determination Reference
Claim.coverage.preAuthRef 1
Claim.coverage.claimResponse
Claim.coverage.claimResponse.value Adjudication results
Claim.coverage.claimResponse 1
Claim.coverage.originalRuleset
Claim.coverage.originalRuleset.value Original version
Claim.coverage.originalRuleset 1
Claim.coverage 1
Claim.exception
Claim.exception.value Eligibility exceptions
Claim.exception 1
Claim.school
Claim.school.value Name of School
Claim.school 1
Claim.accident
Claim.accident.value Accident Date
Claim.accident 1
Claim.accidentType
Claim.accidentType.value Accident Type
Claim.accidentType 1
Claim.interventionException
Claim.interventionException.value Intervention and exception code (Pharma)
Claim.interventionException 1

Goods and Services

Claim.item
Claim.item.id
Claim.item.id.value xml:id (or equivalent in JSON)
Claim.item.id 1
Claim.item.sequence
Claim.item.sequence.value Service instance
Claim.item.sequence 1
Claim.item.type
Claim.item.type.value Group or type of product or service
Claim.item.type 1
Claim.item.provider
Claim.item.provider.value Responsible practitioner
Claim.item.provider 1
Claim.item.diagnosisLinkId
Claim.item.diagnosisLinkId.value Diagnosis Link
Claim.item.diagnosisLinkId 1
Claim.item.service
Claim.item.service.value Item Code
Claim.item.service 1
Claim.item.serviceDate
Claim.item.serviceDate.value Date of Service
Claim.item.serviceDate 1

Count of Products or Services

Claim.item.quantity
Claim.item.quantity.comparator comp:
Claim.item.quantity.value value:
Claim.item.quantity.units units:
Claim.item.quantity.code coded units:
Claim.item.quantity.system units system:
Claim.item.quantity 1

Fee, charge or cost per point

Claim.item.unitPrice
Claim.item.unitPrice.value value:
Claim.item.unitPrice.currency currency:
Claim.item.unitPrice 1
Claim.item.factor
Claim.item.factor.value Price scaling factor
Claim.item.factor 1
Claim.item.points
Claim.item.points.value Difficulty scaling factor
Claim.item.points 1

Total item cost

Claim.item.net
Claim.item.net.value value:
Claim.item.net.currency currency:
Claim.item.net 1
Claim.item.udi
Claim.item.udi.value Unique Device Identifier
Claim.item.udi 1
Claim.item.bodySite
Claim.item.bodySite.value Service Location
Claim.item.bodySite 1
Claim.item.subSite
Claim.item.subSite.value Service Sub-location
Claim.item.subSite 1
Claim.item.modifier
Claim.item.modifier.value Service/Product billing modifiers
Claim.item.modifier 1

Additional items

Claim.item.detail
Claim.item.detail.id
Claim.item.detail.id.value xml:id (or equivalent in JSON)
Claim.item.detail.id 1
Claim.item.detail.sequence
Claim.item.detail.sequence.value Service instance
Claim.item.detail.sequence 1
Claim.item.detail.type
Claim.item.detail.type.value Group or type of product or service
Claim.item.detail.type 1
Claim.item.detail.service
Claim.item.detail.service.value Additional item codes
Claim.item.detail.service 1

Count of Products or Services

Claim.item.detail.quantity
Claim.item.detail.quantity.comparator comp:
Claim.item.detail.quantity.value value:
Claim.item.detail.quantity.units units:
Claim.item.detail.quantity.code coded units:
Claim.item.detail.quantity.system units system:
Claim.item.detail.quantity 1

Fee, charge or cost per point

Claim.item.detail.unitPrice
Claim.item.detail.unitPrice.value value:
Claim.item.detail.unitPrice.currency currency:
Claim.item.detail.unitPrice 1
Claim.item.detail.factor
Claim.item.detail.factor.value Price scaling factor
Claim.item.detail.factor 1
Claim.item.detail.points
Claim.item.detail.points.value Difficulty scaling factor
Claim.item.detail.points 1

Total additional item cost

Claim.item.detail.net
Claim.item.detail.net.value value:
Claim.item.detail.net.currency currency:
Claim.item.detail.net 1
Claim.item.detail.udi
Claim.item.detail.udi.value Unique Device Identifier
Claim.item.detail.udi 1

Additional items

Claim.item.detail.subDetail
Claim.item.detail.subDetail.id
Claim.item.detail.subDetail.id.value xml:id (or equivalent in JSON)
Claim.item.detail.subDetail.id 1
Claim.item.detail.subDetail.sequence
Claim.item.detail.subDetail.sequence.value Service instance
Claim.item.detail.subDetail.sequence 1
Claim.item.detail.subDetail.type
Claim.item.detail.subDetail.type.value Type of product or service
Claim.item.detail.subDetail.type 1
Claim.item.detail.subDetail.service
Claim.item.detail.subDetail.service.value Additional item codes
Claim.item.detail.subDetail.service 1

Count of Products or Services

Claim.item.detail.subDetail.quantity
Claim.item.detail.subDetail.quantity.comparator comp:
Claim.item.detail.subDetail.quantity.value value:
Claim.item.detail.subDetail.quantity.units units:
Claim.item.detail.subDetail.quantity.code coded units:
Claim.item.detail.subDetail.quantity.system units system:
Claim.item.detail.subDetail.quantity 1

Fee, charge or cost per point

Claim.item.detail.subDetail.unitPrice
Claim.item.detail.subDetail.unitPrice.value value:
Claim.item.detail.subDetail.unitPrice.currency currency:
Claim.item.detail.subDetail.unitPrice 1
Claim.item.detail.subDetail.factor
Claim.item.detail.subDetail.factor.value Price scaling factor
Claim.item.detail.subDetail.factor 1
Claim.item.detail.subDetail.points
Claim.item.detail.subDetail.points.value Difficulty scaling factor
Claim.item.detail.subDetail.points 1

Net additional item cost

Claim.item.detail.subDetail.net
Claim.item.detail.subDetail.net.value value:
Claim.item.detail.subDetail.net.currency currency:
Claim.item.detail.subDetail.net 1
Claim.item.detail.subDetail.udi
Claim.item.detail.subDetail.udi.value Unique Device Identifier
Claim.item.detail.subDetail.udi 1
Claim.item.detail.subDetail 1
Claim.item.detail 1

Prosthetic details

Claim.item.prosthesis
Claim.item.prosthesis.id
Claim.item.prosthesis.id.value xml:id (or equivalent in JSON)
Claim.item.prosthesis.id 1
Claim.item.prosthesis.initial
Claim.item.prosthesis.initial.value Is this the initial service
Claim.item.prosthesis.initial 1
Claim.item.prosthesis.priorDate
Claim.item.prosthesis.priorDate.value Initial service Date
Claim.item.prosthesis.priorDate 1
Claim.item.prosthesis.priorMaterial
Claim.item.prosthesis.priorMaterial.value Prosthetic Material
Claim.item.prosthesis.priorMaterial 1
Claim.item.prosthesis 1
Claim.item 1
Claim.additionalMaterials
Claim.additionalMaterials.value Additional materials, documents, etc.
Claim.additionalMaterials 1

Only if type = oral

Claim.missingTeeth
Claim.missingTeeth.id
Claim.missingTeeth.id.value xml:id (or equivalent in JSON)
Claim.missingTeeth.id 1
Claim.missingTeeth.tooth
Claim.missingTeeth.tooth.value Tooth Code
Claim.missingTeeth.tooth 1
Claim.missingTeeth.reason
Claim.missingTeeth.reason.value Reason for missing
Claim.missingTeeth.reason 1
Claim.missingTeeth.extractionDate
Claim.missingTeeth.extractionDate.value Date of Extraction
Claim.missingTeeth.extractionDate 1
Claim.missingTeeth 1
Claim 1