QI-Core Implementation Guide
4.1.1 - STU 4.1.1 US

This page is part of the Quality Improvement Core Framework (v4.1.1: STU 4) based on FHIR R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

Resource Profile: QICoreClaim - Detailed Descriptions

Draft as of 2018-08-22

Definitions for the qicore-claim resource profile.

1. Claim
Definition

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.

Control0..*
Alternate NamesAdjudication Request, Preauthorization Request, Predetermination Request
Comments

The Claim resource fulfills three information request requirements: Claim - a request for adjudication for reimbursement for products and/or services provided; Preauthorization - a request to authorize the future provision of products and/or services including an anticipated adjudication; and, Predetermination - a request for a non-bind adjudication of possible future products and/or services.

InvariantsDefined on this element
dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (: contained.contained.empty())
dom-3: If 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-4: If 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-5: If a resource is contained in another resource, it SHALL NOT have a security label (: contained.meta.security.empty())
dom-6: A resource should have narrative for robust management (: text.`div`.exists())
2. Claim.id
Definition

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

Control0..1
Typestring
Comments

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

3. Claim.meta
Definition

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

Control0..1
TypeMeta
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
4. Claim.implicitRules
Definition

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

Control0..1
Typeuri
Is Modifiertrue
Comments

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
5. Claim.language
Definition

The base language in which the resource is written.

Control0..1
BindingThe codes SHOULD be taken from CommonLanguages
Max Binding: AllLanguages A human language.

Typecode
Comments

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
6. Claim.text
Definition

A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

Control0..1
TypeNarrative
Alternate Namesnarrative, html, xhtml, display
Comments

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
7. Claim.contained
Definition

These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

Control0..*
TypeResource
Alternate Namesinline resources, anonymous resources, contained resources
Comments

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.

8. Claim.extension
Definition

May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
9. Claim.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
10. Claim.identifier
Definition

A unique identifier assigned to this claim.

NoteThis is a business identifier, not a resource identifier (see discussion)
Control0..*
TypeIdentifier
Requirements

Allows claims to be distinguished and referenced.

Alternate NamesClaim Number
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
11. Claim.status
Definition

The status of the resource instance.

Control1..1
BindingThe codes SHALL be taken from FinancialResourceStatusCodes A code specifying the state of the resource instance.

Typecode
Is Modifiertrue
Requirements

Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.

Comments

This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
12. Claim.type
Definition

The category of claim, e.g. oral, pharmacy, vision, institutional, professional.

Control1..1
BindingThe codes SHALL be taken from ClaimTypeCodes; other codes may be used where these codes are not suitable The type or discipline-style of the claim.

TypeCodeableConcept
Requirements

Claim type determine the general sets of business rules applied for information requirements and adjudication.

Comments

The majority of jurisdictions use: oral, pharmacy, vision, professional and institutional, or variants on those terms, as the general styles of claims. The valueset is extensible to accommodate other jurisdictional requirements.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
13. Claim.subType
Definition

A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.

Control0..1
BindingFor example codes, see ExampleClaimSubTypeCodes A more granular claim typecode.

TypeCodeableConcept
Requirements

Some jurisdictions need a finer grained claim type for routing and adjudication.

Comments

This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
14. Claim.use
Definition

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.

Control1..1
BindingThe codes SHALL be taken from Use The purpose of the Claim: predetermination, preauthorization, claim.

Typecode
Requirements

This element is required to understand the nature of the request for adjudication.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
15. Claim.patient
Definition

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.

Control1..1
TypeReference(QICorePatient)
Must Supporttrue
Requirements

The patient must be supplied to the insurer so that confirmation of coverage and service history may be considered as part of the authorization and/or adjudiction.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
16. Claim.billablePeriod
Definition

The period for which charges are being submitted.

Control0..1
TypePeriod
Must Supporttrue
Requirements

A number jurisdictions required the submission of the billing period when submitting claims for example for hospital stays or long-term care.

Comments

Typically this would be today or in the past for a claim, and today or in the future for preauthorizations and predeterminations. Typically line item dates of service should fall within the billing period if one is specified.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
17. Claim.created
Definition

The date this resource was created.

Control1..1
TypedateTime
Must Supporttrue
Requirements

Need to record a timestamp for use by both the recipient and the issuer.

Comments

This field is independent of the date of creation of the resource as it may reflect the creation date of a source document prior to digitization. Typically for claims all services must be completed as of this date.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
18. Claim.enterer
Definition

Individual who created the claim, predetermination or preauthorization.

Control0..1
TypeReference(Practitioner | PractitionerRole)
Requirements

Some jurisdictions require the contact information for personnel completing claims.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
19. Claim.insurer
Definition

The Insurer who is target of the request.

Control0..1
TypeReference(Organization)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
20. Claim.provider
Definition

The provider which is responsible for the claim, predetermination or preauthorization.

Control1..1
TypeReference(QICorePractitioner | QICorePractitionerRole | QICoreOrganization)
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
Comments

Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
21. Claim.priority
Definition

The provider-required urgency of processing the request. Typical values include: stat, routine deferred.

Control1..1
BindingFor example codes, see ProcessPriorityCodes The timeliness with which processing is required: stat, normal, deferred.

TypeCodeableConcept
Requirements

The provider may need to indicate their processing requirements so that the processor can indicate if they are unable to comply.

Comments

If a claim processor is unable to complete the processing as per the priority then they should generate and error and not process the request.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
22. Claim.fundsReserve
Definition

A code to indicate whether and for whom funds are to be reserved for future claims.

Control0..1
BindingFor example codes, see Funds Reservation Codes For whom funds are to be reserved: (Patient, Provider, None).

TypeCodeableConcept
Requirements

In 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.

Alternate NamesFund pre-allocation
Comments

This field is only used for preauthorizations.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
23. Claim.related
Definition

Other claims which are related to this claim such as prior submissions or claims for related services or for the same event.

Control0..*
TypeBackboneElement
Requirements

For workplace or other accidents it is common to relate separate claims arising from the same event.

Comments

For example, for the original treatment and follow-up exams.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
24. Claim.related.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
25. Claim.related.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
26. Claim.related.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
27. Claim.related.claim
Definition

Reference to a related claim.

Control0..1
TypeReference(Claim)
Requirements

For workplace or other accidents it is common to relate separate claims arising from the same event.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
28. Claim.related.relationship
Definition

A code to convey how the claims are related.

Control0..1
BindingFor example codes, see ExampleRelatedClaimRelationshipCodes Relationship of this claim to a related Claim.

TypeCodeableConcept
Requirements

Some insurers need a declaration of the type of relationship.

Comments

For example, prior claim or umbrella.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
29. Claim.related.reference
Definition

An alternate organizational reference to the case or file to which this particular claim pertains.

Control0..1
TypeIdentifier
Requirements

In cases where an event-triggered claim is being submitted to an insurer which requires a reference number to be specified on all exchanges.

Comments

For example, Property/Casualty insurer claim # or Workers Compensation case # .

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
30. Claim.prescription
Definition

Prescription to support the dispensing of pharmacy, device or vision products.

Control0..1
TypeReference(QICoreDeviceRequest | QICoreMedicationRequest | VisionPrescription)
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
Requirements

Required to authorize the dispensing of controlled substances and devices.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
31. Claim.originalPrescription
Definition

Original prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or products.

Control0..1
TypeReference(DeviceRequest | MedicationRequest | VisionPrescription)
Requirements

Often required when a fulfiller varies what is fulfilled from that authorized on the original prescription.

Comments

For example, a physician may prescribe a medication which the pharmacy determines is contraindicated, or for which the patient has an intolerance, and therefore issues a new prescription for an alternate medication which has the same therapeutic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription'.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
32. Claim.payee
Definition

The party to be reimbursed for cost of the products and services according to the terms of the policy.

Control0..1
TypeBackboneElement
Requirements

The provider needs to specify who they wish to be reimbursed and the claims processor needs express who they will reimburse.

Comments

Often providers agree to receive the benefits payable to reduce the near-term costs to the patient. The insurer may decline to pay the provider and choose to pay the subscriber instead.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
33. Claim.payee.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
34. Claim.payee.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
35. Claim.payee.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
36. Claim.payee.type
Definition

Type of Party to be reimbursed: subscriber, provider, other.

Control1..1
BindingFor example codes, see Claim Payee Type Codes A code for the party to be reimbursed.

TypeCodeableConcept
Requirements

Need to know who should receive payment with the most common situations being the Provider (assignment of benefits) or the Subscriber.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
37. Claim.payee.party
Definition

Reference to the individual or organization to whom any payment will be made.

Control0..1
TypeReference(QICorePractitioner | QICorePractitionerRole | QICoreOrganization | QICorePatient | QICoreRelatedPerson)
Requirements

Need to provide demographics if the payee is not 'subscriber' nor 'provider'.

Comments

Not required if the payee is 'subscriber' or 'provider'.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
38. Claim.referral
Definition

A reference to a referral resource.

Control0..1
TypeReference(QICoreServiceRequest)
Requirements

Some insurers require proof of referral to pay for services or to pay specialist rates for services.

Comments

The referral resource which lists the date, practitioner, reason and other supporting information.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
39. Claim.facility
Definition

Facility where the services were provided.

Control0..1
TypeReference(QICoreLocation)
Requirements

Insurance adjudication can be dependant on where services were delivered.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
40. Claim.careTeam
Definition

The members of the team who provided the products and services.

Control0..*
TypeBackboneElement
Requirements

Common to identify the responsible and supporting practitioners.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
41. Claim.careTeam.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
42. Claim.careTeam.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
43. Claim.careTeam.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
44. Claim.careTeam.sequence
Definition

A number to uniquely identify care team entries.

Control1..1
TypepositiveInt
Requirements

Necessary to maintain the order of the care team and provide a mechanism to link individuals to claim details.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
45. Claim.careTeam.provider
Definition

Member of the team who provided the product or service.

Control1..1
TypeReference(QICorePractitioner | QICorePractitionerRole | QICoreOrganization)
Requirements

Often a regulatory requirement to specify the responsible provider.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
46. Claim.careTeam.responsible
Definition

The party who is billing and/or responsible for the claimed products or services.

Control0..1
Typeboolean
Requirements

When multiple parties are present it is required to distinguish the lead or responsible individual.

Comments

Responsible might not be required when there is only a single provider listed.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
47. Claim.careTeam.role
Definition

The lead, assisting or supervising practitioner and their discipline if a multidisciplinary team.

Control0..1
BindingFor example codes, see ClaimCareTeamRoleCodes The role codes for the care team members.

TypeCodeableConcept
Requirements

When multiple parties are present it is required to distinguish the roles performed by each member.

Comments

Role might not be required when there is only a single provider listed.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
48. Claim.careTeam.qualification
Definition

The qualification of the practitioner which is applicable for this service.

Control0..1
BindingFor example codes, see ExampleProviderQualificationCodes Provider professional qualifications.

TypeCodeableConcept
Requirements

Need to specify which qualification a provider is delivering the product or service under.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
49. Claim.supportingInfo
Definition

Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.

Control0..*
TypeBackboneElement
Requirements

Typically these information codes are required to support the services rendered or the adjudication of the services rendered.

Alternate NamesAttachments Exception Codes Occurrence Codes Value codes
Comments

Often there are multiple jurisdiction specific valuesets which are required.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
50. Claim.supportingInfo.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
51. Claim.supportingInfo.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
52. Claim.supportingInfo.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
53. Claim.supportingInfo.sequence
Definition

A number to uniquely identify supporting information entries.

Control1..1
TypepositiveInt
Requirements

Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
54. Claim.supportingInfo.category
Definition

The general class of the information supplied: information; exception; accident, employment; onset, etc.

Control1..1
BindingFor example codes, see ClaimInformationCategoryCodes The valuset used for additional information category codes.

TypeCodeableConcept
Requirements

Required to group or associate information items with common characteristics. For example: admission information or prior treatments.

Comments

This may contain a category for the local bill type codes.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
55. Claim.supportingInfo.code
Definition

System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought.

Control0..1
BindingFor example codes, see ExceptionCodes The valuset used for additional information codes.

TypeCodeableConcept
Requirements

Required to identify the kind of additional information.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
56. Claim.supportingInfo.timing[x]
Definition

The date when or period to which this information refers.

Control0..1
TypeChoice of: date, Period
[x] NoteSee Choice of Data Types for further information about how to use [x]
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
57. Claim.supportingInfo.value[x]
Definition

Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.

Control0..1
TypeChoice of: boolean, string, Quantity, Attachment, Reference(Resource)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

To convey the data content to be provided when the information is more than a simple code or period.

Comments

Could be used to provide references to other resources, document. For example could contain a PDF in an Attachment of the Police Report for an Accident.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
58. Claim.supportingInfo.reason
Definition

Provides the reason in the situation where a reason code is required in addition to the content.

Control0..1
BindingFor example codes, see MissingToothReasonCodes Reason codes for the missing teeth.

TypeCodeableConcept
Requirements

Needed when the supporting information has both a date and amount/value and requires explanation.

Comments

For example: the reason for the additional stay, or why a tooth is missing.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
59. Claim.diagnosis
Definition

Information about diagnoses relevant to the claim items.

Control0..*
TypeBackboneElement
Requirements

Required for the adjudication by provided context for the services and product listed.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
60. Claim.diagnosis.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
61. Claim.diagnosis.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
62. Claim.diagnosis.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
63. Claim.diagnosis.sequence
Definition

A number to uniquely identify diagnosis entries.

Control1..1
TypepositiveInt
Requirements

Necessary to maintain the order of the diagnosis items and provide a mechanism to link to claim details.

Comments

Diagnosis are presented in list order to their expected importance: primary, secondary, etc.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
64. Claim.diagnosis.diagnosis[x]
Definition

The nature of illness or problem in a coded form or as a reference to an external defined Condition.

Control1..1
BindingFor example codes, see ICD-10Codes Example ICD10 Diagnostic codes.

TypeChoice of: CodeableConcept, Reference(Condition)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

Provides health context for the evaluation of the products and/or services.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
65. Claim.diagnosis.type
Definition

When the condition was observed or the relative ranking.

Control0..*
BindingFor example codes, see ExampleDiagnosisTypeCodes The type of the diagnosis: admitting, principal, discharge.

TypeCodeableConcept
Requirements

Often required to capture a particular diagnosis, for example: primary or discharge.

Comments

For example: admitting, primary, secondary, discharge.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
66. Claim.diagnosis.onAdmission
Definition

Indication of whether the diagnosis was present on admission to a facility.

Control0..1
BindingFor example codes, see ExampleDiagnosisOnAdmissionCodes Present on admission.

TypeCodeableConcept
Requirements

Many systems need to understand for adjudication if the diagnosis was present a time of admission.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
67. Claim.diagnosis.packageCode
Definition

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 system.

Control0..1
BindingFor example codes, see ExampleDiagnosisRelatedGroupCodes The DRG codes associated with the diagnosis.

TypeCodeableConcept
Requirements

Required to relate the current diagnosis to a package billing code that is then referenced on the individual claim items which are specific to the health condition covered by the package code.

Comments

For example DRG (Diagnosis Related Group) or a bundled billing code. A patient may have a diagnosis of a Myocardial Infarction and a DRG for HeartAttack would be assigned. The Claim item (and possible subsequent claims) would refer to the DRG for those line items that were for services related to the heart attack event.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
68. Claim.procedure
Definition

Procedures performed on the patient relevant to the billing items with the claim.

Control0..*
TypeBackboneElement
Requirements

The specific clinical invention are sometimes required to be provided to justify billing a greater than customary amount for a service.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
69. Claim.procedure.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
70. Claim.procedure.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
71. Claim.procedure.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
72. Claim.procedure.sequence
Definition

A number to uniquely identify procedure entries.

Control1..1
TypepositiveInt
Requirements

Necessary to provide a mechanism to link to claim details.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
73. Claim.procedure.type
Definition

When the condition was observed or the relative ranking.

Control0..*
BindingFor example codes, see ExampleProcedureTypeCodes Example procedure type codes.

TypeCodeableConcept
Requirements

Often required to capture a particular diagnosis, for example: primary or discharge.

Comments

For example: primary, secondary.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
74. Claim.procedure.date
Definition

Date and optionally time the procedure was performed.

Control0..1
TypedateTime
Requirements

Required for auditing purposes.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
75. Claim.procedure.procedure[x]
Definition

The code or reference to a Procedure resource which identifies the clinical intervention performed.

Control1..1
BindingFor example codes, see ICD-10ProcedureCodes Example ICD10 Procedure codes.

TypeChoice of: CodeableConcept, Reference(Procedure)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

This identifies the actual clinical procedure.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
76. Claim.procedure.udi
Definition

Unique Device Identifiers associated with this line item.

Control0..*
TypeReference(Device)
Requirements

The UDI code allows the insurer to obtain device level information on the product supplied.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
77. Claim.insurance
Definition

Financial instruments for reimbursement for the health care products and services specified on the claim.

Control1..*
TypeBackboneElement
Requirements

At least one insurer is required for a claim to be a claim.

Comments

All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. Coverages appearing before the focal Coverage in the list, and where 'Coverage.subrogation=false', should provide a reference to the ClaimResponse containing the adjudication results of the prior claim.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
78. Claim.insurance.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
79. Claim.insurance.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
80. Claim.insurance.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
81. Claim.insurance.sequence
Definition

A number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order.

Control1..1
TypepositiveInt
Requirements

To maintain order of the coverages.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
82. Claim.insurance.focal
Definition

A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.

Control1..1
Typeboolean
Requirements

To identify which coverage in the list is being used to adjudicate this claim.

Comments

A patient may (will) have multiple insurance policies which provide reimbursement for healthcare services and products. For example a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for adjudicating this claim. Other claims would be created to request adjudication against the other listed policies.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
83. Claim.insurance.identifier
Definition

The business identifier to be used when the claim is sent for adjudication against this insurance policy.

NoteThis is a business identifier, not a resource identifier (see discussion)
Control0..1
TypeIdentifier
Requirements

This will be the claim number should it be necessary to create this claim in the future. This is provided so that payors may forward claims to other payors in the Coordination of Benefit for adjudication rather than the provider being required to initiate each adjudication.

Comments

Only required in jurisdictions where insurers, rather than the provider, are required to send claims to insurers that appear after them in the list. This element is not required when 'subrogation=true'.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
84. Claim.insurance.coverage
Definition

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.

Control1..1
TypeReference(Coverage)
Requirements

Required to allow the adjudicator to locate the correct policy and history within their information system.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
85. Claim.insurance.businessArrangement
Definition

A business agreement number established between the provider and the insurer for special business processing purposes.

Control0..1
Typestring
Requirements

Providers may have multiple business arrangements with a given insurer and must supply the specific contract number for adjudication.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
86. Claim.insurance.preAuthRef
Definition

Reference numbers previously provided by the insurer to the provider to be quoted on subsequent claims containing services or products related to the prior authorization.

Control0..*
Typestring
Requirements

Providers must quote previously issued authorization reference numbers in order to obtain adjudication as previously advised on the Preauthorization.

Comments

This value is an alphanumeric string that may be provided over the phone, via text, via paper, or within a ClaimResponse resource and is not a FHIR Identifier.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
87. Claim.insurance.claimResponse
Definition

The result of the adjudication of the line items for the Coverage specified in this insurance.

Control0..1
TypeReference(ClaimResponse)
Requirements

An insurer need the adjudication results from prior insurers to determine the outstanding balance remaining by item for the items in the curent claim.

Comments

Must not be specified when 'focal=true' for this insurance.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
88. Claim.accident
Definition

Details of an accident which resulted in injuries which required the products and services listed in the claim.

Control0..1
TypeBackboneElement
Requirements

When healthcare products and services are accident related, benefits may be payable under accident provisions of policies, such as automotive, etc before they are payable under normal health insurance.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
89. Claim.accident.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
90. Claim.accident.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
91. Claim.accident.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
92. Claim.accident.date
Definition

Date of an accident event related to the products and services contained in the claim.

Control1..1
Typedate
Requirements

Required for audit purposes and adjudication.

Comments

The date of the accident has to precede the dates of the products and services but within a reasonable timeframe.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
93. Claim.accident.type
Definition

The type or context of the accident event for the purposes of selection of potential insurance coverages and determination of coordination between insurers.

Control0..1
BindingThe codes SHALL be taken from ActIncidentCode; other codes may be used where these codes are not suitable Type of accident: work place, auto, etc.

TypeCodeableConcept
Requirements

Coverage may be dependant on the type of accident.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
94. Claim.accident.location[x]
Definition

The physical location of the accident event.

Control0..1
TypeChoice of: Address, Reference(Location)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

Required for audit purposes and determination of applicable insurance liability.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
95. Claim.item
Definition

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-details.

Control0..*
TypeBackboneElement
Requirements

The items to be processed for adjudication.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
96. Claim.item.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
97. Claim.item.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
98. Claim.item.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
99. Claim.item.sequence
Definition

A number to uniquely identify item entries.

Control1..1
TypepositiveInt
Requirements

Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
100. Claim.item.careTeamSequence
Definition

CareTeam members related to this service or product.

Control0..*
TypepositiveInt
Requirements

Need to identify the individuals and their roles in the provision of the product or service.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
101. Claim.item.diagnosisSequence
Definition

Diagnosis applicable for this service or product.

Control0..*
TypepositiveInt
Requirements

Need to related the product or service to the associated diagnoses.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
102. Claim.item.procedureSequence
Definition

Procedures applicable for this service or product.

Control0..*
TypepositiveInt
Requirements

Need to provide any listed specific procedures to support the product or service being claimed.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
103. Claim.item.informationSequence
Definition

Exceptions, special conditions and supporting information applicable for this service or product.

Control0..*
TypepositiveInt
Requirements

Need to reference the supporting information items that relate directly to this product or service.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
104. Claim.item.revenue
Definition

The type of revenue or cost center providing the product and/or service.

Control0..1
BindingFor example codes, see ExampleRevenueCenterCodes Codes for the revenue or cost centers supplying the service and/or products.

TypeCodeableConcept
Requirements

Needed in the processing of institutional claims.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
105. Claim.item.category
Definition

Code to identify the general type of benefits under which products and services are provided.

Control0..1
BindingFor example codes, see BenefitCategoryCodes Benefit categories such as: oral-basic, major, glasses.

TypeCodeableConcept
Requirements

Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.

Comments

Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
106. Claim.item.productOrService
Definition

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.

Control1..1
BindingFor example codes, see USCLSCodes Allowable service and product codes.

TypeCodeableConcept
Requirements

Necessary to state what was provided or done.

Alternate NamesDrug Code, Bill Code, Service Code
Comments

If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
107. Claim.item.modifier
Definition

Item typification or modifiers codes to convey additional context for the product or service.

Control0..*
BindingFor example codes, see ModifierTypeCodes Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.

TypeCodeableConcept
Requirements

To support inclusion of the item for adjudication or to charge an elevated fee.

Comments

For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
108. Claim.item.programCode
Definition

Identifies the program under which this may be recovered.

Control0..*
BindingFor example codes, see ExampleProgramReasonCodes Program specific reason codes.

TypeCodeableConcept
Requirements

Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.

Comments

For example: Neonatal program, child dental program or drug users recovery program.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
109. Claim.item.serviced[x]
Definition

The date or dates when the service or product was supplied, performed or completed.

Control0..1
TypeChoice of: date, Period
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

Needed to determine whether the service or product was provided during the term of the insurance coverage.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
110. Claim.item.location[x]
Definition

Where the product or service was provided.

Control0..1
BindingFor example codes, see ExampleServicePlaceCodes Place of service: pharmacy, school, prison, etc.

TypeChoice of: CodeableConcept, Address, Reference(Location)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
111. Claim.item.quantity
Definition

The number of repetitions of a service or product.

Control0..1
TypeQuantity(SimpleQuantity)
Requirements

Required when the product or service code does not convey the quantity provided.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
112. Claim.item.unitPrice
Definition

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 group.

Control0..1
TypeMoney
Requirements

The amount charged to the patient by the provider for a single unit.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
113. Claim.item.factor
Definition

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 amount.

Control0..1
Typedecimal
Requirements

When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

Comments

To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
114. Claim.item.net
Definition

The quantity times the unit price for an additional service or product or charge.

Control0..1
TypeMoney
Requirements

Provides the total amount claimed for the group (if a grouper) or the line item.

Comments

For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
115. Claim.item.udi
Definition

Unique Device Identifiers associated with this line item.

Control0..*
TypeReference(Device)
Requirements

The UDI code allows the insurer to obtain device level information on the product supplied.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
116. Claim.item.bodySite
Definition

Physical service site on the patient (limb, tooth, etc.).

Control0..1
BindingFor example codes, see OralSiteCodes The code for the teeth, quadrant, sextant and arch.

TypeCodeableConcept
Requirements

Allows insurer to validate specific procedures.

Comments

For example: Providing a tooth code, allows an insurer to identify a provider performing a filling on a tooth that was previously removed.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
117. Claim.item.subSite
Definition

A region or surface of the bodySite, e.g. limb region or tooth surface(s).

Control0..*
BindingFor example codes, see SurfaceCodes The code for the tooth surface and surface combinations.

TypeCodeableConcept
Requirements

Allows insurer to validate specific procedures.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
118. Claim.item.encounter
Definition

The Encounters during which this Claim was created or to which the creation of this record is tightly associated.

Control0..*
TypeReference(Encounter)
Requirements

Used in some jurisdictions to link clinical events to claim items.

Comments

This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
119. Claim.item.detail
Definition

A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.

Control0..*
TypeBackboneElement
Requirements

The items to be processed for adjudication.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
120. Claim.item.detail.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
121. Claim.item.detail.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
122. Claim.item.detail.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
123. Claim.item.detail.sequence
Definition

A number to uniquely identify item entries.

Control1..1
TypepositiveInt
Requirements

Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
124. Claim.item.detail.revenue
Definition

The type of revenue or cost center providing the product and/or service.

Control0..1
BindingFor example codes, see ExampleRevenueCenterCodes Codes for the revenue or cost centers supplying the service and/or products.

TypeCodeableConcept
Requirements

Needed in the processing of institutional claims.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
125. Claim.item.detail.category
Definition

Code to identify the general type of benefits under which products and services are provided.

Control0..1
BindingFor example codes, see BenefitCategoryCodes Benefit categories such as: oral-basic, major, glasses.

TypeCodeableConcept
Requirements

Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.

Comments

Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
126. Claim.item.detail.productOrService
Definition

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.

Control1..1
BindingFor example codes, see USCLSCodes Allowable service and product codes.

TypeCodeableConcept
Requirements

Necessary to state what was provided or done.

Alternate NamesDrug Code, Bill Code, Service Code
Comments

If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
127. Claim.item.detail.modifier
Definition

Item typification or modifiers codes to convey additional context for the product or service.

Control0..*
BindingFor example codes, see ModifierTypeCodes Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.

TypeCodeableConcept
Requirements

To support inclusion of the item for adjudication or to charge an elevated fee.

Comments

For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
128. Claim.item.detail.programCode
Definition

Identifies the program under which this may be recovered.

Control0..*
BindingFor example codes, see ExampleProgramReasonCodes Program specific reason codes.

TypeCodeableConcept
Requirements

Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.

Comments

For example: Neonatal program, child dental program or drug users recovery program.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
129. Claim.item.detail.quantity
Definition

The number of repetitions of a service or product.

Control0..1
TypeQuantity(SimpleQuantity)
Requirements

Required when the product or service code does not convey the quantity provided.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
130. Claim.item.detail.unitPrice
Definition

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 group.

Control0..1
TypeMoney
Requirements

The amount charged to the patient by the provider for a single unit.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
131. Claim.item.detail.factor
Definition

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 amount.

Control0..1
Typedecimal
Requirements

When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

Comments

To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
132. Claim.item.detail.net
Definition

The quantity times the unit price for an additional service or product or charge.

Control0..1
TypeMoney
Requirements

Provides the total amount claimed for the group (if a grouper) or the line item.

Comments

For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
133. Claim.item.detail.udi
Definition

Unique Device Identifiers associated with this line item.

Control0..*
TypeReference(Device)
Requirements

The UDI code allows the insurer to obtain device level information on the product supplied.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
134. Claim.item.detail.subDetail
Definition

A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.

Control0..*
TypeBackboneElement
Requirements

The items to be processed for adjudication.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
135. Claim.item.detail.subDetail.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
136. Claim.item.detail.subDetail.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
137. Claim.item.detail.subDetail.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Control0..*
TypeExtension
Is Modifiertrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
138. Claim.item.detail.subDetail.sequence
Definition

A number to uniquely identify item entries.

Control1..1
TypepositiveInt
Requirements

Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
139. Claim.item.detail.subDetail.revenue
Definition

The type of revenue or cost center providing the product and/or service.

Control0..1
BindingFor example codes, see ExampleRevenueCenterCodes Codes for the revenue or cost centers supplying the service and/or products.

TypeCodeableConcept
Requirements

Needed in the processing of institutional claims.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
140. Claim.item.detail.subDetail.category
Definition

Code to identify the general type of benefits under which products and services are provided.

Control0..1
BindingFor example codes, see BenefitCategoryCodes Benefit categories such as: oral-basic, major, glasses.

TypeCodeableConcept
Requirements

Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.

Comments

Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
141. Claim.item.detail.subDetail.productOrService
Definition

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.

Control1..1
BindingFor example codes, see USCLSCodes Allowable service and product codes.

TypeCodeableConcept
Requirements

Necessary to state what was provided or done.

Comments

If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
142. Claim.item.detail.subDetail.modifier
Definition

Item typification or modifiers codes to convey additional context for the product or service.

Control0..*
BindingFor example codes, see ModifierTypeCodes Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.

TypeCodeableConcept
Requirements

To support inclusion of the item for adjudication or to charge an elevated fee.

Comments

For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
143. Claim.item.detail.subDetail.programCode
Definition

Identifies the program under which this may be recovered.

Control0..*
BindingFor example codes, see ExampleProgramReasonCodes Program specific reason codes.

TypeCodeableConcept
Requirements

Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.

Comments

For example: Neonatal program, child dental program or drug users recovery program.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
144. Claim.item.detail.subDetail.quantity
Definition

The number of repetitions of a service or product.

Control0..1
TypeQuantity(SimpleQuantity)
Requirements

Required when the product or service code does not convey the quantity provided.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
145. Claim.item.detail.subDetail.unitPrice
Definition

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 group.

Control0..1
TypeMoney
Requirements

The amount charged to the patient by the provider for a single unit.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
146. Claim.item.detail.subDetail.factor
Definition

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 amount.

Control0..1
Typedecimal
Requirements

When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

Comments

To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
147. Claim.item.detail.subDetail.net
Definition

The quantity times the unit price for an additional service or product or charge.

Control0..1
TypeMoney
Requirements

Provides the total amount claimed for the group (if a grouper) or the line item.

Comments

For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
148. Claim.item.detail.subDetail.udi
Definition

Unique Device Identifiers associated with this line item.

Control0..*
TypeReference(Device)
Requirements

The UDI code allows the insurer to obtain device level information on the product supplied.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
149. Claim.total
Definition

The total value of the all the items in the claim.

Control0..1
TypeMoney
Requirements

Used for control total purposes.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))