Electronic Long-Term Services and Supports (eLTSS) Release 1 - US Realm
2.0.0-ballot - ballot United States of America flag

This page is part of the electronic Long-Term Services and Supports Implementation Guide (v2.0.0-ballot: STU2 Ballot 1) based on FHIR (HL7® FHIR® Standard) R4. The current version which supersedes this version is 1.0.0. For a full list of available versions, see the Directory of published versions

Resource Profile: eLTSS Claim Profile

Official URL: http://hl7.org/fhir/us/eltss/StructureDefinition/Claim-eltss Version: 2.0.0-ballot
Standards status: Trial-use Maturity Level: 2 Computable Name: Claim_eltss

Claim Resource profile for eLTSS

Implementer mapping guidance

The following aids in finding the location of eLTSS data elements. See R4 FHIR Mapping page for complete guidance, here we are providing a subset of fields for convenience.

eLTSS Grouping eLTSS Data Element Name Data Element Definition (includes examples, expected list of values and usage note where applicable) FHIR R4 Resource Element(s) FHIR R4 Resource Element Cardinality (with US Core Constraints) Additional Mapping Details Important change
Service Information Service Rate per Unit The rate of one unit for a service. CarePlan → activity
→ reference(ServiceRequest)

ServiceRequest → supportingInfo(Claim)

Claim → item → unitPrice		 CarePlan
...activity 0..*
......reference(ServiceRequest) 0..1
.........supportingInfo(Claim) 0..*
............item 0..*
...............unitPrice 0..1		 1) Will use CarePlan → activity → reference to reference a ServiceRequest, and supportingInfo to reference a Claim.
2) item maps to a service.
3) unitPrice contains the charge or cost per point, which maps to the cost per one unit of the service.
4) unitPrice is of type Money, which is a descendant of the Quantity complex type and inherits value, unit, system, code, and comparator.
5) Workgroup in charge of ServiceRequest wants to work with the Claim workgroup to determine best approach. One potential approach is to update the scope of ClaimResponse since that reflects what has been approved rather than what is being asked for.
Service Information Total Cost of Service The total cost of a service for the plan. CarePlan → activity
→ reference(ServiceRequest)

ServiceRequest → supportingInfo(Claim)

Claim → item → net		 CarePlan
...activity 0..*
......reference(ServiceRequest) 0..1
.........supportingInfo(Claim) 0..*
............item 0..*
...............net 0..1		 1) Will use CarePlan → activity → reference to reference a ServiceRequest, and supportingInfo to reference a Claim.
2) item maps to a service.
3) net is the total cost of an item, which in this case is the total cost for the service.
4) net is of type Money, which is a descendant of the Quantity complex type and inherits value, unit, system, code, and comparator.
5) See above.
Data Requirements Not Specific to eLTSS Dataset Data Elements
This section documents data elements that are mandatory per FHIR XML schemas or US Core requirements, but that do not align with individual eLTSS Dataset data elements.
FHIR Data Element Name
Requirement Source		 Data Element Definition FHIR R4 Resource Element(s) FHIR R4 Resource Element Cardinality (with US Core Constraints) Additional Mapping Details
Claim Created
FHIR		 The date this resource was created. Claim → created Claim
...created 1		 1) created is required by FHIR. Could use date signers signed or agency authorized. Suggest using date/time that signers signed.
Claim Insurance
FHIR		 Financial instruments for reimbursement for the health care products and services specified on the claim. Claim → insurance Claim
...insurance 1		 1) insurance is required by FHIR.
Claim Insurance Sequence
FHIR		 A number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order. Claim → insurance → sequence Claim
...insurance 1
......sequence 1		 1) sequence is required by FHIR and is a positiveInt. Suggest using "1".
Claim Insurance Focal
FHIR		 A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true. Claim → insurance → focal Claim
...insurance 1
......focal 1		 1) focal is required by FHIR and is a boolean. Suggest using "true".
Claim Insurance Coverage
FHIR		 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 system. Claim → insurance → coverage Claim
...insurance 1
......coverage 1		 1) coverage is required by FHIR and references Coverage.
Claim Item ProductOrService
FHIR		 When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item. Claim → item → productOrService Claim
...item 0..*
......productOrService 1		 1) productOrService is required by FHIR and must use the USCLS Codes value set (http://hl7.org/fhir/valueset-service-uscls.html). Suggest using the value "99555" for expense.
Claim Patient
FHIR		 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 sought. Claim → patient Claim
...patient 1		 1) patient is required by FHIR and references Patient.
Claim Priority
FHIR		 The provider-required urgency of processing the request. Claim → priority Claim
...priority 1		 1) priority is required by FHIR and must use the Process Priority Codes value set (http://hl7.org/fhir/valueset-process-priority.html). Possible values are: stat, normal, deferred. Suggest using "normal".
Claim Provider
FHIR		 The provider which is responsible for the claim, predetermination or preauthorization. Claim → provider Claim
...provider 1		 1) provider is required by FHIR and references Practitioner, PractitionerRole, Organization. Suggest using Practitioner or Organization.
Claim Status
FHIR		 The status of the resource instance. Claim → status Claim
...status 1		 1) status is required by FHIR, and must use the Financial Resource Status Codes value set (http://hl7.org/fhir/valueset-fm-status.html). Possible values are: active, cancelled, draft, entered-in-error. Suggest using "active".
Claim Type
FHIR		 The category of claim, e.g. oral, pharmacy, vision, institutional, professional. Claim → type Claim
...type 1		 1) type is required by FHIR, and contains the extensible Claim Type Codes value set (http://hl7.org/fhir/valueset-claim-type.html). Possible values are: institutional, oral, pharmacy, professional, vision. Could use "professional", could extend code list, or could use text data element that is part of codeable concept.
Claim Use
FHIR		 A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future. Claim → use Claim
...use 1		 1) use is required by FHIR, and must use the Use value set (http://hl7.org/fhir/valueset-claim-use.html). Possible values are: claim, preauthorization, predetermination. Suggest using "preauthorization"
Claim Item Sequence
FHIR		 A number to uniquely identify item entries Claim → item → sequence Claim
...item 0..*
......sequence 1		 1) sequence is required by FHIR, and is a positive integer.

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from Claim

NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim 0..*ClaimClaim, Pre-determination or Pre-authorization
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... resource-pertainsToGoal S0..*Reference(Goal)The resource-pertainsToGoal relates the resource to the goal(s) that pertain to it. Whenever there is a goal associated with a health concern or problem, this extension should be present and populated in activity (event or intent) resources.
URL: http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal
... patient 1..1Reference(Patient_eltss)The recipient of the products and services
... provider 1..1Reference(Practitioner_eltss | eLTSS PractitionerRole Profile | US Core Organization Profile)Party responsible for the claim
... related
.... claim 0..1Reference(Claim_eltss)Reference to the related claim
... payee
.... party 0..1Reference(Practitioner_eltss | eLTSS PractitionerRole Profile | US Core Organization Profile | Patient_eltss | eLTSS RelatedPerson Profile)Recipient reference
... referral 0..1Reference(ServiceRequest_eltss)Treatment referral
... facility 0..1Reference(Location_eltss)Servicing facility
... careTeam
.... provider 1..1Reference(Practitioner_eltss | eLTSS PractitionerRole Profile | US Core Organization Profile)Practitioner or organization
... diagnosis
.... Slices for diagnosis[x] 1..1CodeableConcept, Reference(Condition)Nature of illness or problem
Slice: Unordered, Open by type:$this
..... diagnosis[x]:diagnosisReference 0..1Reference(Condition_eltss)Nature of illness or problem
... accident
.... Slices for location[x] 0..1Address, Reference(Location)Where the event occurred
Slice: Unordered, Open by type:$this
..... location[x]:locationReference 0..1Reference(Location_eltss)Where the event occurred
... item S0..*BackboneElementProduct or service provided
.... unitPrice S0..1MoneyService Rate per Unit name
.... net S0..1MoneyTotal Cost of Service

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim 0..*ClaimClaim, Pre-determination or Pre-authorization
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... resource-pertainsToGoal S0..*Reference(Goal)The resource-pertainsToGoal relates the resource to the goal(s) that pertain to it. Whenever there is a goal associated with a health concern or problem, this extension should be present and populated in activity (event or intent) resources.
URL: http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... type Σ1..1CodeableConceptCategory or discipline
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.

... use Σ1..1codeclaim | preauthorization | predetermination
Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim.

... patient Σ1..1Reference(Patient_eltss)The recipient of the products and services
... created Σ1..1dateTimeResource creation date
... enterer 0..1Reference(Practitioner_eltss | eLTSS PractitionerRole Profile)Author of the claim
... provider Σ1..1Reference(Practitioner_eltss | eLTSS PractitionerRole Profile | US Core Organization Profile)Party responsible for the claim
... priority Σ1..1CodeableConceptDesired processing ugency
Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.

... referral 0..1Reference(ServiceRequest_eltss)Treatment referral
... facility 0..1Reference(Location_eltss)Servicing facility
... insurance Σ1..*BackboneElementPatient insurance information
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence Σ1..1positiveIntInsurance instance identifier
.... focal Σ1..1booleanCoverage to be used for adjudication
.... coverage Σ1..1Reference(Coverage)Insurance information
... item S0..*BackboneElementProduct or service provided
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntItem instance identifier
.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

.... unitPrice S0..1MoneyService Rate per Unit name
.... net S0..1MoneyTotal Cost of Service

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Claim.statusrequiredFinancialResourceStatusCodes
Claim.typeextensibleClaimTypeCodes
Claim.userequiredUse
Claim.priorityexampleProcessPriorityCodes
Claim.item.productOrServiceexampleUSCLSCodes

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorClaimIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorClaimIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorClaimIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorClaimIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceClaimA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim 0..*ClaimClaim, Pre-determination or Pre-authorization
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... resource-pertainsToGoal S0..*Reference(Goal)The resource-pertainsToGoal relates the resource to the goal(s) that pertain to it. Whenever there is a goal associated with a health concern or problem, this extension should be present and populated in activity (event or intent) resources.
URL: http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier 0..*IdentifierBusiness Identifier for claim
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... type Σ1..1CodeableConceptCategory or discipline
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.

... subType 0..1CodeableConceptMore granular claim type
Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.

... use Σ1..1codeclaim | preauthorization | predetermination
Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim.

... patient Σ1..1Reference(Patient_eltss)The recipient of the products and services
... billablePeriod Σ0..1PeriodRelevant time frame for the claim
... created Σ1..1dateTimeResource creation date
... enterer 0..1Reference(Practitioner_eltss | eLTSS PractitionerRole Profile)Author of the claim
... insurer Σ0..1Reference(Organization)Target
... provider Σ1..1Reference(Practitioner_eltss | eLTSS PractitionerRole Profile | US Core Organization Profile)Party responsible for the claim
... priority Σ1..1CodeableConceptDesired processing ugency
Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.

... fundsReserve 0..1CodeableConceptFor whom to reserve funds
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).

... related 0..*BackboneElementPrior or corollary claims
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... claim 0..1Reference(Claim_eltss)Reference to the related claim
.... relationship 0..1CodeableConceptHow the reference claim is related
Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim.

.... 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
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type 1..1CodeableConceptCategory of recipient
Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.

.... party 0..1Reference(Practitioner_eltss | eLTSS PractitionerRole Profile | US Core Organization Profile | Patient_eltss | eLTSS RelatedPerson Profile)Recipient reference
... referral 0..1Reference(ServiceRequest_eltss)Treatment referral
... facility 0..1Reference(Location_eltss)Servicing facility
... careTeam 0..*BackboneElementMembers of the care team
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntOrder of care team
.... provider 1..1Reference(Practitioner_eltss | eLTSS PractitionerRole Profile | US Core Organization Profile)Practitioner or organization
.... responsible 0..1booleanIndicator of the lead practitioner
.... role 0..1CodeableConceptFunction within the team
Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members.

.... qualification 0..1CodeableConceptPractitioner credential or specialization
Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.

... supportingInfo 0..*BackboneElementSupporting information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntInformation instance identifier
.... category 1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes.

.... code 0..1CodeableConceptType of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

.... timing[x] 0..1When it occurred
..... timingDatedate
..... timingPeriodPeriod
.... value[x] 0..1Data to be provided
..... valueBooleanboolean
..... valueStringstring
..... valueQuantityQuantity
..... valueAttachmentAttachment
..... valueReferenceReference(Resource)
.... reason 0..1CodeableConceptExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

... diagnosis 0..*BackboneElementPertinent diagnosis information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntDiagnosis instance identifier
.... Slices for diagnosis[x] 1..1Nature of illness or problem
Slice: Unordered, Open by type:$this
Binding: ICD-10Codes (example): Example ICD10 Diagnostic codes.

..... diagnosisCodeableConceptCodeableConcept
..... diagnosisReferenceReference(Condition)
..... diagnosis[x]:diagnosisReference 0..1Reference(Condition_eltss)Nature of illness or problem
.... type 0..*CodeableConceptTiming or nature of the diagnosis
Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge.


.... onAdmission 0..1CodeableConceptPresent on admission
Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.

.... packageCode 0..1CodeableConceptPackage billing code
Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.

... procedure 0..*BackboneElementClinical procedures performed
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntProcedure instance identifier
.... type 0..*CodeableConceptCategory of Procedure
Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.


.... date 0..1dateTimeWhen the procedure was performed
.... procedure[x] 1..1Specific clinical procedure
Binding: ICD-10ProcedureCodes (example): Example ICD10 Procedure codes.

..... procedureCodeableConceptCodeableConcept
..... procedureReferenceReference(Procedure)
.... udi 0..*Reference(Device)Unique device identifier
... insurance Σ1..*BackboneElementPatient insurance information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... 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
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... date 1..1dateWhen the incident occurred
.... type 0..1CodeableConceptThe nature of the accident
Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc.

.... Slices for location[x] 0..1Where the event occurred
Slice: Unordered, Open by type:$this
..... locationAddressAddress
..... locationReferenceReference(Location)
..... location[x]:locationReference 0..1Reference(Location_eltss)Where the event occurred
... item S0..*BackboneElementProduct or service provided
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntItem instance identifier
.... careTeamSequence 0..*positiveIntApplicable careTeam members
.... diagnosisSequence 0..*positiveIntApplicable diagnoses
.... procedureSequence 0..*positiveIntApplicable procedures
.... informationSequence 0..*positiveIntApplicable exception and supporting information
.... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

.... category 0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.

.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

.... modifier 0..*CodeableConceptProduct or service billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


.... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


.... 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: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.

..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice S0..1MoneyService Rate per Unit name
.... factor 0..1decimalPrice scaling factor
.... net S0..1MoneyTotal Cost of Service
.... udi 0..*Reference(Device)Unique device identifier
.... bodySite 0..1CodeableConceptAnatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.

.... subSite 0..*CodeableConceptAnatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.


.... encounter 0..*Reference(Encounter)Encounters related to this billed item
.... detail 0..*BackboneElementProduct or service provided
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntItem instance identifier
..... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

..... category 0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.

..... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

..... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


..... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


..... quantity 0..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal item cost
..... udi 0..*Reference(Device)Unique device identifier
..... subDetail 0..*BackboneElementProduct or service provided
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... sequence 1..1positiveIntItem instance identifier
...... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

...... category 0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.

...... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

...... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


...... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


...... quantity 0..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyTotal item cost
...... udi 0..*Reference(Device)Unique device identifier
... total 0..1MoneyTotal claim cost

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Claim.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Claim.statusrequiredFinancialResourceStatusCodes
Claim.typeextensibleClaimTypeCodes
Claim.subTypeexampleExampleClaimSubTypeCodes
Claim.userequiredUse
Claim.priorityexampleProcessPriorityCodes
Claim.fundsReserveexampleFunds Reservation Codes
Claim.related.relationshipexampleExampleRelatedClaimRelationshipCodes
Claim.payee.typeexampleClaim Payee Type Codes
Claim.careTeam.roleexampleClaimCareTeamRoleCodes
Claim.careTeam.qualificationexampleExampleProviderQualificationCodes
Claim.supportingInfo.categoryexampleClaimInformationCategoryCodes
Claim.supportingInfo.codeexampleExceptionCodes
Claim.supportingInfo.reasonexampleMissingToothReasonCodes
Claim.diagnosis.diagnosis[x]exampleICD-10Codes
Claim.diagnosis.typeexampleExampleDiagnosisTypeCodes
Claim.diagnosis.onAdmissionexampleExampleDiagnosisOnAdmissionCodes
Claim.diagnosis.packageCodeexampleExampleDiagnosisRelatedGroupCodes
Claim.procedure.typeexampleExampleProcedureTypeCodes
Claim.procedure.procedure[x]exampleICD-10ProcedureCodes
Claim.accident.typeextensibleActIncidentCode
Claim.item.revenueexampleExampleRevenueCenterCodes
Claim.item.categoryexampleBenefitCategoryCodes
Claim.item.productOrServiceexampleUSCLSCodes
Claim.item.modifierexampleModifierTypeCodes
Claim.item.programCodeexampleExampleProgramReasonCodes
Claim.item.location[x]exampleExampleServicePlaceCodes
Claim.item.bodySiteexampleOralSiteCodes
Claim.item.subSiteexampleSurfaceCodes
Claim.item.detail.revenueexampleExampleRevenueCenterCodes
Claim.item.detail.categoryexampleBenefitCategoryCodes
Claim.item.detail.productOrServiceexampleUSCLSCodes
Claim.item.detail.modifierexampleModifierTypeCodes
Claim.item.detail.programCodeexampleExampleProgramReasonCodes
Claim.item.detail.subDetail.revenueexampleExampleRevenueCenterCodes
Claim.item.detail.subDetail.categoryexampleBenefitCategoryCodes
Claim.item.detail.subDetail.productOrServiceexampleUSCLSCodes
Claim.item.detail.subDetail.modifierexampleModifierTypeCodes
Claim.item.detail.subDetail.programCodeexampleExampleProgramReasonCodes

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorClaimIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorClaimIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorClaimIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorClaimIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceClaimA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

Differential View

This structure is derived from Claim

NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim 0..*ClaimClaim, Pre-determination or Pre-authorization
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... resource-pertainsToGoal S0..*Reference(Goal)The resource-pertainsToGoal relates the resource to the goal(s) that pertain to it. Whenever there is a goal associated with a health concern or problem, this extension should be present and populated in activity (event or intent) resources.
URL: http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal
... patient 1..1Reference(Patient_eltss)The recipient of the products and services
... provider 1..1Reference(Practitioner_eltss | eLTSS PractitionerRole Profile | US Core Organization Profile)Party responsible for the claim
... related
.... claim 0..1Reference(Claim_eltss)Reference to the related claim
... payee
.... party 0..1Reference(Practitioner_eltss | eLTSS PractitionerRole Profile | US Core Organization Profile | Patient_eltss | eLTSS RelatedPerson Profile)Recipient reference
... referral 0..1Reference(ServiceRequest_eltss)Treatment referral
... facility 0..1Reference(Location_eltss)Servicing facility
... careTeam
.... provider 1..1Reference(Practitioner_eltss | eLTSS PractitionerRole Profile | US Core Organization Profile)Practitioner or organization
... diagnosis
.... Slices for diagnosis[x] 1..1CodeableConcept, Reference(Condition)Nature of illness or problem
Slice: Unordered, Open by type:$this
..... diagnosis[x]:diagnosisReference 0..1Reference(Condition_eltss)Nature of illness or problem
... accident
.... Slices for location[x] 0..1Address, Reference(Location)Where the event occurred
Slice: Unordered, Open by type:$this
..... location[x]:locationReference 0..1Reference(Location_eltss)Where the event occurred
... item S0..*BackboneElementProduct or service provided
.... unitPrice S0..1MoneyService Rate per Unit name
.... net S0..1MoneyTotal Cost of Service

doco Documentation for this format

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim 0..*ClaimClaim, Pre-determination or Pre-authorization
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... resource-pertainsToGoal S0..*Reference(Goal)The resource-pertainsToGoal relates the resource to the goal(s) that pertain to it. Whenever there is a goal associated with a health concern or problem, this extension should be present and populated in activity (event or intent) resources.
URL: http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... type Σ1..1CodeableConceptCategory or discipline
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.

... use Σ1..1codeclaim | preauthorization | predetermination
Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim.

... patient Σ1..1Reference(Patient_eltss)The recipient of the products and services
... created Σ1..1dateTimeResource creation date
... enterer 0..1Reference(Practitioner_eltss | eLTSS PractitionerRole Profile)Author of the claim
... provider Σ1..1Reference(Practitioner_eltss | eLTSS PractitionerRole Profile | US Core Organization Profile)Party responsible for the claim
... priority Σ1..1CodeableConceptDesired processing ugency
Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.

... referral 0..1Reference(ServiceRequest_eltss)Treatment referral
... facility 0..1Reference(Location_eltss)Servicing facility
... insurance Σ1..*BackboneElementPatient insurance information
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence Σ1..1positiveIntInsurance instance identifier
.... focal Σ1..1booleanCoverage to be used for adjudication
.... coverage Σ1..1Reference(Coverage)Insurance information
... item S0..*BackboneElementProduct or service provided
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntItem instance identifier
.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

.... unitPrice S0..1MoneyService Rate per Unit name
.... net S0..1MoneyTotal Cost of Service

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Claim.statusrequiredFinancialResourceStatusCodes
Claim.typeextensibleClaimTypeCodes
Claim.userequiredUse
Claim.priorityexampleProcessPriorityCodes
Claim.item.productOrServiceexampleUSCLSCodes

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorClaimIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorClaimIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorClaimIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorClaimIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceClaimA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim 0..*ClaimClaim, Pre-determination or Pre-authorization
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... resource-pertainsToGoal S0..*Reference(Goal)The resource-pertainsToGoal relates the resource to the goal(s) that pertain to it. Whenever there is a goal associated with a health concern or problem, this extension should be present and populated in activity (event or intent) resources.
URL: http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier 0..*IdentifierBusiness Identifier for claim
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... type Σ1..1CodeableConceptCategory or discipline
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.

... subType 0..1CodeableConceptMore granular claim type
Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.

... use Σ1..1codeclaim | preauthorization | predetermination
Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim.

... patient Σ1..1Reference(Patient_eltss)The recipient of the products and services
... billablePeriod Σ0..1PeriodRelevant time frame for the claim
... created Σ1..1dateTimeResource creation date
... enterer 0..1Reference(Practitioner_eltss | eLTSS PractitionerRole Profile)Author of the claim
... insurer Σ0..1Reference(Organization)Target
... provider Σ1..1Reference(Practitioner_eltss | eLTSS PractitionerRole Profile | US Core Organization Profile)Party responsible for the claim
... priority Σ1..1CodeableConceptDesired processing ugency
Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.

... fundsReserve 0..1CodeableConceptFor whom to reserve funds
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).

... related 0..*BackboneElementPrior or corollary claims
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... claim 0..1Reference(Claim_eltss)Reference to the related claim
.... relationship 0..1CodeableConceptHow the reference claim is related
Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim.

.... 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
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type 1..1CodeableConceptCategory of recipient
Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.

.... party 0..1Reference(Practitioner_eltss | eLTSS PractitionerRole Profile | US Core Organization Profile | Patient_eltss | eLTSS RelatedPerson Profile)Recipient reference
... referral 0..1Reference(ServiceRequest_eltss)Treatment referral
... facility 0..1Reference(Location_eltss)Servicing facility
... careTeam 0..*BackboneElementMembers of the care team
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntOrder of care team
.... provider 1..1Reference(Practitioner_eltss | eLTSS PractitionerRole Profile | US Core Organization Profile)Practitioner or organization
.... responsible 0..1booleanIndicator of the lead practitioner
.... role 0..1CodeableConceptFunction within the team
Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members.

.... qualification 0..1CodeableConceptPractitioner credential or specialization
Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.

... supportingInfo 0..*BackboneElementSupporting information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntInformation instance identifier
.... category 1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes.

.... code 0..1CodeableConceptType of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

.... timing[x] 0..1When it occurred
..... timingDatedate
..... timingPeriodPeriod
.... value[x] 0..1Data to be provided
..... valueBooleanboolean
..... valueStringstring
..... valueQuantityQuantity
..... valueAttachmentAttachment
..... valueReferenceReference(Resource)
.... reason 0..1CodeableConceptExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

... diagnosis 0..*BackboneElementPertinent diagnosis information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntDiagnosis instance identifier
.... Slices for diagnosis[x] 1..1Nature of illness or problem
Slice: Unordered, Open by type:$this
Binding: ICD-10Codes (example): Example ICD10 Diagnostic codes.

..... diagnosisCodeableConceptCodeableConcept
..... diagnosisReferenceReference(Condition)
..... diagnosis[x]:diagnosisReference 0..1Reference(Condition_eltss)Nature of illness or problem
.... type 0..*CodeableConceptTiming or nature of the diagnosis
Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge.


.... onAdmission 0..1CodeableConceptPresent on admission
Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.

.... packageCode 0..1CodeableConceptPackage billing code
Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.

... procedure 0..*BackboneElementClinical procedures performed
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntProcedure instance identifier
.... type 0..*CodeableConceptCategory of Procedure
Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.


.... date 0..1dateTimeWhen the procedure was performed
.... procedure[x] 1..1Specific clinical procedure
Binding: ICD-10ProcedureCodes (example): Example ICD10 Procedure codes.

..... procedureCodeableConceptCodeableConcept
..... procedureReferenceReference(Procedure)
.... udi 0..*Reference(Device)Unique device identifier
... insurance Σ1..*BackboneElementPatient insurance information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... 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
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... date 1..1dateWhen the incident occurred
.... type 0..1CodeableConceptThe nature of the accident
Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc.

.... Slices for location[x] 0..1Where the event occurred
Slice: Unordered, Open by type:$this
..... locationAddressAddress
..... locationReferenceReference(Location)
..... location[x]:locationReference 0..1Reference(Location_eltss)Where the event occurred
... item S0..*BackboneElementProduct or service provided
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntItem instance identifier
.... careTeamSequence 0..*positiveIntApplicable careTeam members
.... diagnosisSequence 0..*positiveIntApplicable diagnoses
.... procedureSequence 0..*positiveIntApplicable procedures
.... informationSequence 0..*positiveIntApplicable exception and supporting information
.... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

.... category 0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.

.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

.... modifier 0..*CodeableConceptProduct or service billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


.... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


.... 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: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.

..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice S0..1MoneyService Rate per Unit name
.... factor 0..1decimalPrice scaling factor
.... net S0..1MoneyTotal Cost of Service
.... udi 0..*Reference(Device)Unique device identifier
.... bodySite 0..1CodeableConceptAnatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.

.... subSite 0..*CodeableConceptAnatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.


.... encounter 0..*Reference(Encounter)Encounters related to this billed item
.... detail 0..*BackboneElementProduct or service provided
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntItem instance identifier
..... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

..... category 0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.

..... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

..... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


..... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


..... quantity 0..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal item cost
..... udi 0..*Reference(Device)Unique device identifier
..... subDetail 0..*BackboneElementProduct or service provided
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... sequence 1..1positiveIntItem instance identifier
...... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

...... category 0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.

...... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

...... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


...... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


...... quantity 0..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyTotal item cost
...... udi 0..*Reference(Device)Unique device identifier
... total 0..1MoneyTotal claim cost

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Claim.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Claim.statusrequiredFinancialResourceStatusCodes
Claim.typeextensibleClaimTypeCodes
Claim.subTypeexampleExampleClaimSubTypeCodes
Claim.userequiredUse
Claim.priorityexampleProcessPriorityCodes
Claim.fundsReserveexampleFunds Reservation Codes
Claim.related.relationshipexampleExampleRelatedClaimRelationshipCodes
Claim.payee.typeexampleClaim Payee Type Codes
Claim.careTeam.roleexampleClaimCareTeamRoleCodes
Claim.careTeam.qualificationexampleExampleProviderQualificationCodes
Claim.supportingInfo.categoryexampleClaimInformationCategoryCodes
Claim.supportingInfo.codeexampleExceptionCodes
Claim.supportingInfo.reasonexampleMissingToothReasonCodes
Claim.diagnosis.diagnosis[x]exampleICD-10Codes
Claim.diagnosis.typeexampleExampleDiagnosisTypeCodes
Claim.diagnosis.onAdmissionexampleExampleDiagnosisOnAdmissionCodes
Claim.diagnosis.packageCodeexampleExampleDiagnosisRelatedGroupCodes
Claim.procedure.typeexampleExampleProcedureTypeCodes
Claim.procedure.procedure[x]exampleICD-10ProcedureCodes
Claim.accident.typeextensibleActIncidentCode
Claim.item.revenueexampleExampleRevenueCenterCodes
Claim.item.categoryexampleBenefitCategoryCodes
Claim.item.productOrServiceexampleUSCLSCodes
Claim.item.modifierexampleModifierTypeCodes
Claim.item.programCodeexampleExampleProgramReasonCodes
Claim.item.location[x]exampleExampleServicePlaceCodes
Claim.item.bodySiteexampleOralSiteCodes
Claim.item.subSiteexampleSurfaceCodes
Claim.item.detail.revenueexampleExampleRevenueCenterCodes
Claim.item.detail.categoryexampleBenefitCategoryCodes
Claim.item.detail.productOrServiceexampleUSCLSCodes
Claim.item.detail.modifierexampleModifierTypeCodes
Claim.item.detail.programCodeexampleExampleProgramReasonCodes
Claim.item.detail.subDetail.revenueexampleExampleRevenueCenterCodes
Claim.item.detail.subDetail.categoryexampleBenefitCategoryCodes
Claim.item.detail.subDetail.productOrServiceexampleUSCLSCodes
Claim.item.detail.subDetail.modifierexampleModifierTypeCodes
Claim.item.detail.subDetail.programCodeexampleExampleProgramReasonCodes

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorClaimIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorClaimIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorClaimIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorClaimIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceClaimA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

 

Other representations of profile: CSV, Excel, Schematron