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Key: = Must support, = QICore-defined extension, = Is-Modifier
Field Card. Type and Description 
accident 0..1AccidentAn accident which resulted in the need for healthcare services.billablePeriod 0..1interval<DateTime>The billable period for which charges are being submitted.coverage 0..*List<Coverage>Financial instrument by which payment information for health care.created 0..1DateTimeThe date when the enclosed suite of services were performed or completed.diagnosis 0..*List<Diagnosis>Ordered list of patient diagnosis for which care is sought.employmentImpacted 0..1interval<DateTime>The start and optional end dates of when the patient was precluded from working due to the treatable condition(s).enterer[x] 0..1Identifier | PractitionerPerson who created the invoice/claim/pre-determination or pre-authorization.facility[x] 0..1Identifier | LocationFacility where the services were provided.fundsReserve 0..1CodeIn the case of a Pre-Determination/Pre-Authorization the provider may request that funds in the amount of the expected Benefit be reserved ('Patient' or 'Provider') to pay for the Benefits determined on the subsequent claim(s). 'None' explicitly indicates no funds reserving is requested.Binding: Funds Reservation Codes (Example)
hospitalization 0..1interval<DateTime>The start and optional end dates of when the patient was confined to a treatment center.identifier 0..*List<Identifier>The business identifier for the instance: claim number, pre-determination or pre-authorization number.information 0..*List<Information>Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. Often there are mutiple jurisdiction specific valuesets which are required.insurer[x] 0..1Identifier | OrganizationThe Insurer who is target of the request.item 0..*List<Item>First tier of goods and services.missingTeeth 0..*List<MissingTeeth>A list of teeth which would be expected but are not found due to having been previously extracted or for other reasons.organization[x] 0..1Identifier | OrganizationThe organization which is responsible for the bill, claim pre-determination, pre-authorization.originalPrescription[x] 0..1Identifier | MedicationOrderOriginal prescription which has been superceded by this prescription to support the dispensing of pharmacy services, medications or products.originalRuleset 0..1CodeThe version of the specification from which the original instance was created.Binding: Ruleset Codes (Example)
patient[x] 1..1Identifier | PatientPatient Resource.payee 0..1PayeeThe party to be reimbursed for the services.prescription[x] 0..1Identifier | MedicationOrder | VisionPrescriptionPrescription to support the dispensing of Pharmacy or Vision products.priority 0..1CodeImmediate (STAT), best effort (NORMAL), deferred (DEFER).Binding: Priority Codes (Example)
procedure 0..*List<Procedure>Ordered list of patient procedures performed to support the adjudication.provider[x] 0..1Identifier | PractitionerThe provider which is responsible for the bill, claim pre-determination, pre-authorization.referralReference 0..1ReferralRequestThe referral resource which lists the date, practitioner, reason and other supporting information.related 0..*List<Related>Other claims which are related to this claim such as prior claim versions or for related services.ruleset 0..1CodeThe version of the specification on which this instance relies.Binding: Ruleset Codes (Example)
status 1..1codeThe status of the resource instance.Binding: ClaimStatus (Required)
subType 0..*List<Code>A finer grained suite of claim subtype codes which may convey Inpatient vs Outpatient and/or a specialty service. In the US the BillType.Binding: Example Claim SubType Codes (Example)
total 0..1MoneyThe total value of the claim.type 1..1CodeThe category of claim, eg, oral, pharmacy, vision, insitutional, professional.Binding: Example Claim Type Codes (Required)
use 0..1codeComplete (Bill or Claim), Proposed (Pre-Authorization), Exploratory (Pre-determination).Binding: Use (Required)
Key: = Must support, = QICore-defined extension, = Is-Modifier
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