Profile_R3_Claim_R4B - Definitions - Extensions for Using Data Elements from FHIR STU3 in FHIR R4B v0.1.0

Is Modifier false

Must Support false

Summary true

4. 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.

Short Metadata about the resource

Control 0..1

Meta

Is Modifier false

Must Support false

Summary true

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

6. Claim.meta.id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

8. Claim.meta.extension

Definition

An Extension

Short Extension

Control 0..*

Is Modifier false

Summary false

Invariants 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())

This element introduces a set of slices on Claim.meta.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

10. Claim.meta.extension:meta

Slice Name meta

Definition

STU3: Claim.meta additional types (Meta) additional types from child elements (lastUpdated, profile, security, tag, versionId)

Short STU3: meta additional types

Comments

Element Claim.meta is mapped to FHIR R4B element Claim.meta as SourceIsBroaderThanTarget. The mappings for Claim.meta do not cover the following types: Meta. The mappings for Claim.meta do not cover the following types based on type expansion: lastUpdated, profile, security, tag, versionId.

Control 0..1

Type Extension(STU3: meta additional types) (Complex Extension)

Is Modifier false

12. Claim.meta.versionId

Definition

The version specific identifier, as it appears in the version portion of the URL. This value changes when the resource is created, updated, or deleted.

Short Version specific identifier

Comments

The server assigns this value, and ignores what the client specifies, except in the case that the server is imposing version integrity on updates/deletes.

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

14. Claim.meta.lastUpdated

Definition

When the resource last changed - e.g. when the version changed.

Short When the resource version last changed

Comments

This value is always populated except when the resource is first being created. The server / resource manager sets this value; what a client provides is irrelevant. This is equivalent to the HTTP Last-Modified and SHOULD have the same value on a read interaction.

Control 0..1

instant

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

16. Claim.meta.source

Definition

A uri that identifies the source system of the resource. This provides a minimal amount of Provenance information that can be used to track or differentiate the source of information in the resource. The source may identify another FHIR server, document, message, database, etc.

Short Identifies where the resource comes from

Comments

In the provenance resource, this corresponds to Provenance.entity.what[x]. The exact use of the source (and the implied Provenance.entity.role) is left to implementer discretion. Only one nominated source is allowed; for additional provenance details, a full Provenance resource should be used.

This element can be used to indicate where the current master source of a resource that has a canonical URL if the resource is no longer hosted at the canonical URL.

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

18. Claim.meta.profile

Definition

A list of profiles (references to StructureDefinition resources) that this resource claims to conform to. The URL is a reference to StructureDefinition.url.

Short Profiles this resource claims to conform to

Comments

It is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set.

Control 0..*

Type canonical(StructureDefinition)

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

20. Claim.meta.security

Definition

Security labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure.

Short Security Labels applied to this resource

Comments

The security labels can be updated without changing the stated version of the resource. The list of security labels is a set. Uniqueness is based the system/code, and version and display are ignored.

Control 0..*

Binding Unless not suitable, these codes SHALL be taken from All Security Labels
(extensible to http://hl7.org/fhir/ValueSet/security-labels|4.3.0)

Is Modifier false

Summary true

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

22. Claim.meta.tag

Definition

Tags applied to this resource. Tags are intended to be used to identify and relate resources to process and workflow, and applications are not required to consider the tags when interpreting the meaning of a resource.

Short Tags applied to this resource

Comments

The tags can be updated without changing the stated version of the resource. The list of tags is a set. Uniqueness is based the system/code, and version and display are ignored.

Control 0..*

Binding For example codes, see CommonTags
(example to http://hl7.org/fhir/ValueSet/common-tags|4.3.0)

Is Modifier false

Summary true

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

24. 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.

Short A set of rules under which this content was created

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.

Control 0..1

Is Modifier true because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary true

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

26. Claim.language

Definition

The base language in which the resource is written.

Short Language of the resource content

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).

Control 0..1

The codes SHOULD be taken from CommonLanguages
(preferred to http://hl7.org/fhir/ValueSet/languages|4.3.0)

IETF language tag

Additional Bindings

Purpose

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

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

28. 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.

Short Text summary of the resource, for human interpretation

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.

Control 0..1

Narrative

Is Modifier false

Must Support false

Summary false

Alternate Names narrative, html, xhtml, display

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

30. Claim.text.id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

32. Claim.text.extension

Definition

An Extension

Short Extension

Control 0..*

Is Modifier false

Summary false

This element introduces a set of slices on Claim.text.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

34. Claim.text.extension:text

Slice Name text

Definition

STU3: Claim.text additional types (Narrative) additional types from child elements (div, status)

Short STU3: text additional types

Comments

Element Claim.text is mapped to FHIR R4B element Claim.text as SourceIsBroaderThanTarget. The mappings for Claim.text do not cover the following types: Narrative. The mappings for Claim.text do not cover the following types based on type expansion: div, status. 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 in formation is added later.

Control 0..1

Type Extension(STU3: text additional types) (Complex Extension)

Is Modifier false

36. Claim.text.status

Definition

The status of the narrative - whether it's entirely generated (from just the defined data or the extensions too), or whether a human authored it and it may contain additional data.

Short generated | extensions | additional | empty

Control 1..1

Binding The codes SHALL be taken from NarrativeStatus
(required to http://hl7.org/fhir/ValueSet/narrative-status|4.3.0)

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary false

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

38. Claim.text.div

Definition

The actual narrative content, a stripped down version of XHTML.

Short Limited xhtml content

Comments

The contents of the html element are an XHTML fragment containing only the basic html formatting elements described in chapters 7-11 and 15 of the HTML 4.0 standard, <a> elements (either name or href), images and internally contained stylesheets. The XHTML content SHALL NOT contain a head, a body, external stylesheet references, scripts, forms, base/link/xlink, frames, iframes and objects.

Control 1..1

xhtml

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary false

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
txt-1: The narrative SHALL contain only the basic html formatting elements and attributes described in chapters 7-11 (except section 4 of chapter 9) and 15 of the HTML 4.0 standard, <a> elements (either name or href), images and internally contained style attributes (htmlChecks())
txt-2: The narrative SHALL have some non-whitespace content (htmlChecks())

40. 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.

Short Contained, inline 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.

Control 0..*

Resource

Is Modifier false

Must Support false

Summary false

Alternate Names inline resources, anonymous resources, contained resources

Invariants dom-r4b: Containing new R4B resources within R4 resources may cause interoperability issues if instances are shared with R4 systems (($this is Citation or $this is Evidence or $this is EvidenceReport or $this is EvidenceVariable or $this is MedicinalProductDefinition or $this is PackagedProductDefinition or $this is AdministrableProductDefinition or $this is Ingredient or $this is ClinicalUseDefinition or $this is RegulatedAuthorization or $this is SubstanceDefinition or $this is SubscriptionStatus or $this is SubscriptionTopic) implies (%resource is Citation or %resource is Evidence or %resource is EvidenceReport or %resource is EvidenceVariable or %resource is MedicinalProductDefinition or %resource is PackagedProductDefinition or %resource is AdministrableProductDefinition or %resource is Ingredient or %resource is ClinicalUseDefinition or %resource is RegulatedAuthorization or %resource is SubstanceDefinition or %resource is SubscriptionStatus or %resource is SubscriptionTopic))

42. Claim.extension

Definition

An Extension

Short Extension

Control 0..*

Is Modifier false

Must Support false

Summary false

This element introduces a set of slices on Claim.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

44. Claim.extension:organization

Slice Name organization

Definition

STU3: Claim.organization (new:Reference(Organization))

Short STU3: Responsible organization (new)

Comments

Element Claim.organization has a context of Claim based on following the parent source element upwards and mapping to Claim. Element Claim.organization has no mapping targets in FHIR R4B. Typically, this is because the element has been added (is a new element).

Control 0..1
This element is affected by the following invariants: ele-1

Type Extension(STU3: Responsible organization (new)) (Extension Type: Reference(Cross-version Profile for STU3.Organization for use in FHIR R4B, Organization))

Is Modifier false

Must Support false

Summary false

Invariants ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource (hasValue() or (children().count() > id.count()) or $this is Parameters)
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())

46. Claim.extension:employmentImpacted

Slice Name employmentImpacted

Definition

STU3: Claim.employmentImpacted (new:Period)

Short STU3: Period unable to work (new)

Comments

Element Claim.employmentImpacted has a context of Claim based on following the parent source element upwards and mapping to Claim. Element Claim.employmentImpacted has no mapping targets in FHIR R4B. Typically, this is because the element has been added (is a new element).

Control 0..1
This element is affected by the following invariants: ele-1

Type Extension(STU3: Period unable to work (new)) (Extension Type: Period)

Is Modifier false

Must Support false

Summary false

48. Claim.extension:hospitalization

Slice Name hospitalization

Definition

STU3: Claim.hospitalization (new:Period)

Short STU3: Period in hospital (new)

Comments

Element Claim.hospitalization has a context of Claim based on following the parent source element upwards and mapping to Claim. Element Claim.hospitalization has no mapping targets in FHIR R4B. Typically, this is because the element has been added (is a new element).

Control 0..1
This element is affected by the following invariants: ele-1

Type Extension(STU3: Period in hospital (new)) (Extension Type: Period)

Is Modifier false

Must Support false

Summary false

50. 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).

Short Extensions that cannot be ignored

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.

Control 0..*

Is Modifier true because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them

Must Support false

Summary false

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 Names extensions, user content

52. Claim.identifier

Definition

A unique identifier assigned to this claim.

Short Business Identifier for claim

Note This is a business identifier, not a resource identifier (see discussion)

Control 0..*

Is Modifier false

Must Support false

Summary false

Requirements

Allows claims to be distinguished and referenced.

Alternate Names Claim Number

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

54. Claim.identifier.id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

56. Claim.identifier.extension

Definition

An Extension

Short Extension

Control 0..*

Is Modifier false

Summary false

This element introduces a set of slices on Claim.identifier.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

58. Claim.identifier.extension:identifier

Slice Name identifier

Definition

STU3: Claim.identifier additional types (Identifier) additional types from child elements (assigner, period, system, type, use, value)

Short STU3: Claim number additional types

Comments

Element Claim.identifier is mapped to FHIR R4B element Claim.identifier as SourceIsBroaderThanTarget. The mappings for Claim.identifier do not cover the following types: Identifier. The mappings for Claim.identifier do not cover the following types based on type expansion: assigner, period, system, type, use, value.

Control 0..*

Type Extension(STU3: Claim number additional types) (Extension Type: Identifier)

Is Modifier false

Summary false

60. Claim.identifier.use

Definition

The purpose of this identifier.

Short usual | official | temp | secondary | old (If known)

Comments

Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.

Control 0..1

Binding The codes SHALL be taken from IdentifierUse
(required to http://hl7.org/fhir/ValueSet/identifier-use|4.3.0)

Is Modifier true because This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one.

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

Requirements

Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.

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

62. Claim.identifier.type

Definition

A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.

Short Description of identifier

Comments

This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type.

Control 0..1

Binding Unless not suitable, these codes SHALL be taken from Identifier Type Codes
(extensible to http://hl7.org/fhir/ValueSet/identifier-type|4.3.0)

Is Modifier false

Summary true

Requirements

Allows users to make use of identifiers when the identifier system is not known.

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

64. Claim.identifier.system

Definition

Establishes the namespace for the value - that is, a URL that describes a set values that are unique.

Short The namespace for the identifier value

Comments

Identifier.system is always case sensitive.

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

Requirements

There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.

Example General: http://www.acme.com/identifiers/patient

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

66. Claim.identifier.value

Definition

The portion of the identifier typically relevant to the user and which is unique within the context of the system.

Short The value that is unique

Comments

If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

Example General: 123456

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

68. Claim.identifier.period

Definition

Time period during which identifier is/was valid for use.

Short Time period when id is/was valid for use

Control 0..1

Period

Is Modifier false

Summary true

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

70. Claim.identifier.assigner

Definition

Organization that issued/manages the identifier.

Short Organization that issued id (may be just text)

Comments

The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.

Control 0..1

Type Reference(Organization)

Is Modifier false

Summary true

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

72. Claim.status

Definition

The status of the resource instance.

Short active | cancelled | draft | entered-in-error

Comments

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

Control 1..1

The codes SHALL be taken from FinancialResourceStatusCodes
(required to http://hl7.org/fhir/ValueSet/fm-status|4.3.0)

A code specifying the state of the resource instance.

Is Modifier true because This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary true

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'.

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

74. Claim.type

Definition

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

Short Category or discipline

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.

Control 1..1

Unless not suitable, these codes SHALL be taken from ClaimTypeCodes
(extensible to http://hl7.org/fhir/ValueSet/claim-type|4.3.0)

The type or discipline-style of the claim.

Is Modifier false

Must Support false

Summary true

Requirements

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

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

76. Claim.type.id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

78. Claim.type.extension

Definition

An Extension

Short Extension

Control 0..*

Is Modifier false

Summary false

This element introduces a set of slices on Claim.type.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

80. Claim.type.extension:type

Slice Name type

Definition

STU3: Claim.type

Short STU3: Type or discipline

Comments

Element Claim.type is mapped to FHIR R4B element Claim.type as Equivalent. Affects which fields and value sets are used.

Control 0..1

Type Extension(STU3: Type or discipline) (Extension Type: CodeableConcept)

Is Modifier false

Summary false

82. Claim.type.coding

Definition

A reference to a code defined by a terminology system.

Short Code defined by a terminology system

Comments

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

Control 0..*

Is Modifier false

Summary true

Requirements

Allows for alternative encodings within a code system, and translations to other code systems.

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

84. Claim.type.text

Definition

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

Short Plain text representation of the concept

Comments

Very often the text is the same as a displayName of one of the codings.

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

Requirements

The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.

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

86. 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.

Short More granular claim type

Comments

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

Control 0..1

For example codes, see ExampleClaimSubTypeCodes
(example to http://hl7.org/fhir/ValueSet/claim-subtype|4.3.0)

A more granular claim typecode.

Is Modifier false

Must Support false

Summary false

Requirements

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

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

88. 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.

Short claim | preauthorization | predetermination

Control 1..1

The codes SHALL be taken from Use
(required to http://hl7.org/fhir/ValueSet/claim-use|4.3.0)

The purpose of the Claim: predetermination, preauthorization, claim.

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary true

Requirements

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

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

90. Claim.use.id

Definition

unique id for the element within a resource (for internal references)

Short xml:id (or equivalent in JSON)

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

92. Claim.use.extension

Definition

An Extension

Short Extension

Control 0..*

Is Modifier false

Summary false

This element introduces a set of slices on Claim.use.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

94. Claim.use.extension:use

Slice Name use

Definition

STU3: Claim.use

Short STU3: complete | proposed | exploratory | other

Comments

Element Claim.use is mapped to FHIR R4B element Claim.use as SourceIsBroaderThanTarget.

Control 0..1
This element is affected by the following invariants: ele-1

Type Extension(STU3: complete | proposed | exploratory | other) (Extension Type: code)

Is Modifier false

Summary false

96. Claim.use.value

Definition

Primitive value for code

Short Primitive value for code

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

98. 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.

Short The recipient of the products and services

Control 1..1

Type Reference(Patient)

Is Modifier false

Must Support false

Summary true

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.

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

100. Claim.patient.id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

102. Claim.patient.extension

Definition

An Extension

Short Extension

Control 0..*

Is Modifier false

Summary false

This element introduces a set of slices on Claim.patient.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

104. Claim.patient.extension:patient

Slice Name patient

Definition

STU3: Claim.patient additional types from child elements (display, identifier, reference)

Short STU3: The subject of the Products and Services additional types

Comments

Element Claim.patient is mapped to FHIR R4B element Claim.patient as SourceIsBroaderThanTarget. The mappings for Claim.patient do not cover the following types based on type expansion: display, identifier, reference. The standard extension alternate-reference has been mapped as the representation of FHIR STU3 element Claim.patient with unmapped reference targets: Patient.

Control 0..1

Type Extension(Alternate Reference) (Extension Type: Reference(Resource))

Is Modifier false

Summary false

106. Claim.patient.reference

Definition

A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.

Short Literal reference, Relative, internal or absolute URL

Comments

Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.

Control 0..1
This element is affected by the following invariants: ref-1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

108. Claim.patient.type

Definition

The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.

The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources).

Short Type the reference refers to (e.g. "Patient")

Comments

This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified.

Control 0..1

Binding Unless not suitable, these codes SHALL be taken from ResourceType
(extensible to http://hl7.org/fhir/ValueSet/resource-types|4.3.0)

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

110. Claim.patient.identifier

Definition

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

Short Logical reference, when literal reference is not known

Comments

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy.

When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference

Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).

Note This is a business identifier, not a resource identifier (see discussion)

Control 0..1

Is Modifier false

Summary true

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

112. Claim.patient.display

Definition

Plain text narrative that identifies the resource in addition to the resource reference.

Short Text alternative for the resource

Comments

This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

114. Claim.billablePeriod

Definition

The period for which charges are being submitted.

Short Relevant time frame for the claim

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.

Control 0..1

Period

Is Modifier false

Must Support false

Summary true

Requirements

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

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

116. Claim.billablePeriod.id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

118. Claim.billablePeriod.extension

Definition

An Extension

Short Extension

Control 0..*

Is Modifier false

Summary false

This element introduces a set of slices on Claim.billablePeriod.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

120. Claim.billablePeriod.extension:billablePeriod

Slice Name billablePeriod

Definition

STU3: Claim.billablePeriod additional types (Period) additional types from child elements (end, start)

Short STU3: Period for charge submission additional types

Comments

Element Claim.billablePeriod is mapped to FHIR R4B element Claim.billablePeriod as SourceIsBroaderThanTarget. The mappings for Claim.billablePeriod do not cover the following types: Period. The mappings for Claim.billablePeriod do not cover the following types based on type expansion: end, start.

Control 0..1

Type Extension(STU3: Period for charge submission additional types) (Extension Type: Period)

Is Modifier false

Summary false

122. Claim.billablePeriod.start

Definition

The start of the period. The boundary is inclusive.

Short Starting time with inclusive boundary

Comments

If the low element is missing, the meaning is that the low boundary is not known.

Control 0..1
This element is affected by the following invariants: per-1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

124. Claim.billablePeriod.end

Definition

The end of the period. If the end of the period is missing, it means no end was known or planned at the time the instance was created. The start may be in the past, and the end date in the future, which means that period is expected/planned to end at that time.

Short End time with inclusive boundary, if not ongoing

Comments

The high value includes any matching date/time. i.e. 2012-02-03T10:00:00 is in a period that has an end value of 2012-02-03.

Control 0..1
This element is affected by the following invariants: per-1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

Meaning if Missing If the end of the period is missing, it means that the period is ongoing

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

126. Claim.created

Definition

The date this resource was created.

Short Resource creation date

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.

Control 1..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary true

Requirements

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

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

128. Claim.enterer

Definition

Individual who created the claim, predetermination or preauthorization.

Short Author of the claim

Control 0..1

Type Reference(Practitioner, PractitionerRole)

Is Modifier false

Must Support false

Summary false

Requirements

Some jurisdictions require the contact information for personnel completing claims.

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

130. Claim.enterer.id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

132. Claim.enterer.extension

Definition

An Extension

Short Extension

Control 0..*

Is Modifier false

Summary false

This element introduces a set of slices on Claim.enterer.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

134. Claim.enterer.extension:enterer

Slice Name enterer

Definition

STU3: Claim.enterer additional types from child elements (display, identifier, reference)

Short STU3: Author additional types

Comments

Element Claim.enterer is mapped to FHIR R4B element Claim.enterer as SourceIsBroaderThanTarget. The mappings for Claim.enterer do not cover the following types based on type expansion: display, identifier, reference. The standard extension alternate-reference has been mapped as the representation of FHIR STU3 element Claim.enterer with unmapped reference targets: Practitioner.

Control 0..1

Type Extension(Alternate Reference) (Extension Type: Reference(Resource))

Is Modifier false

Summary false

136. Claim.enterer.reference

Definition

Short Literal reference, Relative, internal or absolute URL

Comments

Control 0..1
This element is affected by the following invariants: ref-1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

138. Claim.enterer.type

Definition

The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.

Short Type the reference refers to (e.g. "Patient")

Comments

Control 0..1

Binding Unless not suitable, these codes SHALL be taken from ResourceType
(extensible to http://hl7.org/fhir/ValueSet/resource-types|4.3.0)

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

140. Claim.enterer.identifier

Definition

Short Logical reference, when literal reference is not known

Comments

Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

Note This is a business identifier, not a resource identifier (see discussion)

Control 0..1

Is Modifier false

Summary true

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

142. Claim.enterer.display

Definition

Plain text narrative that identifies the resource in addition to the resource reference.

Short Text alternative for the resource

Comments

This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

144. Claim.insurer

Definition

The Insurer who is target of the request.

Short Target

Control 0..1

Type Reference(Organization)

Is Modifier false

Must Support false

Summary true

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

146. Claim.insurer.id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

148. Claim.insurer.extension

Definition

An Extension

Short Extension

Control 0..*

Is Modifier false

Summary false

This element introduces a set of slices on Claim.insurer.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

150. Claim.insurer.extension:insurer

Slice Name insurer

Definition

STU3: Claim.insurer additional types from child elements (display, identifier, reference)

Short STU3: insurer additional types

Comments

Element Claim.insurer is mapped to FHIR R4B element Claim.insurer as SourceIsBroaderThanTarget. The mappings for Claim.insurer do not cover the following types based on type expansion: display, identifier, reference. The standard extension alternate-reference has been mapped as the representation of FHIR STU3 element Claim.insurer with unmapped reference targets: Organization.

Control 0..1

Type Extension(Alternate Reference) (Extension Type: Reference(Resource))

Is Modifier false

Summary false

152. Claim.insurer.reference

Definition

Short Literal reference, Relative, internal or absolute URL

Comments

Control 0..1
This element is affected by the following invariants: ref-1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

154. Claim.insurer.type

Definition

The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.

Short Type the reference refers to (e.g. "Patient")

Comments

Control 0..1

Binding Unless not suitable, these codes SHALL be taken from ResourceType
(extensible to http://hl7.org/fhir/ValueSet/resource-types|4.3.0)

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

156. Claim.insurer.identifier

Definition

Short Logical reference, when literal reference is not known

Comments

Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

Note This is a business identifier, not a resource identifier (see discussion)

Control 0..1

Is Modifier false

Summary true

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

158. Claim.insurer.display

Definition

Plain text narrative that identifies the resource in addition to the resource reference.

Short Text alternative for the resource

Comments

This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

160. Claim.provider

Definition

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

Short Party responsible for the claim

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.

Control 1..1

Type Reference(Practitioner, PractitionerRole, Organization)

Is Modifier false

Must Support false

Summary true

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

162. Claim.provider.id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

164. Claim.provider.extension

Definition

An Extension

Short Extension

Control 0..*

Is Modifier false

Summary false

This element introduces a set of slices on Claim.provider.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

166. Claim.provider.extension:provider

Slice Name provider

Definition

STU3: Claim.provider additional types from child elements (display, identifier, reference)

Short STU3: Responsible provider additional types

Comments

Element Claim.provider is mapped to FHIR R4B element Claim.provider as SourceIsBroaderThanTarget. The mappings for Claim.provider do not cover the following types based on type expansion: display, identifier, reference. The standard extension alternate-reference has been mapped as the representation of FHIR STU3 element Claim.provider with unmapped reference targets: Practitioner.

Control 0..1

Type Extension(Alternate Reference) (Extension Type: Reference(Resource))

Is Modifier false

Summary false

168. Claim.provider.reference

Definition

Short Literal reference, Relative, internal or absolute URL

Comments

Control 0..1
This element is affected by the following invariants: ref-1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

170. Claim.provider.type

Definition

The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.

Short Type the reference refers to (e.g. "Patient")

Comments

Control 0..1

Binding Unless not suitable, these codes SHALL be taken from ResourceType
(extensible to http://hl7.org/fhir/ValueSet/resource-types|4.3.0)

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

172. Claim.provider.identifier

Definition

Short Logical reference, when literal reference is not known

Comments

Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

Note This is a business identifier, not a resource identifier (see discussion)

Control 0..1

Is Modifier false

Summary true

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

174. Claim.provider.display

Definition

Plain text narrative that identifies the resource in addition to the resource reference.

Short Text alternative for the resource

Comments

This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

176. Claim.priority

Definition

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

Short Desired processing ugency

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.

Control 1..1

For example codes, see ProcessPriorityCodes
(example to http://hl7.org/fhir/ValueSet/process-priority|4.3.0)

The timeliness with which processing is required: stat, normal, deferred.

Is Modifier false

Must Support false

Summary true

Requirements

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

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

178. Claim.fundsReserve

Definition

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

Short For whom to reserve funds

Comments

This field is only used for preauthorizations.

Control 0..1

For example codes, see Funds Reservation Codes
(example to http://hl7.org/fhir/ValueSet/fundsreserve|4.3.0)

For whom funds are to be reserved: (Patient, Provider, None).

Is Modifier false

Must Support false

Summary false

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 Names Fund pre-allocation

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

180. 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.

Short Prior or corollary claims

Comments

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

Control 0..*

Is Modifier false

Must Support false

Summary false

Requirements

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

Invariants ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource (hasValue() or (children().count() > id.count()) or $this is Parameters)

182. 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.

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

184. 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.

Short Additional content defined by implementations

Comments

Control 0..*

Is Modifier false

Summary false

Alternate Names extensions, user content

186. 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).

Short Extensions that cannot be ignored even if unrecognized

Comments

Control 0..*

Is Modifier true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them

Summary true

Requirements

Alternate Names extensions, user content, modifiers

188. Claim.related.claim

Definition

Reference to a related claim.

Short Reference to the related claim

Control 0..1

Type Reference(Claim)

Is Modifier false

Must Support false

Summary false

Requirements

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

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

190. Claim.related.claim.id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

192. Claim.related.claim.extension

Definition

An Extension

Short Extension

Control 0..*

Is Modifier false

Summary false

This element introduces a set of slices on Claim.related.claim.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

194. Claim.related.claim.extension:claim

Slice Name claim

Definition

STU3: Claim.related.claim additional types from child elements (display, identifier, reference)

Short STU3: claim additional types

Comments

Element Claim.related.claim is mapped to FHIR R4B element Claim.related.claim as SourceIsBroaderThanTarget. The mappings for Claim.related.claim do not cover the following types based on type expansion: display, identifier, reference. The standard extension alternate-reference has been mapped as the representation of FHIR STU3 element Claim.related.claim with unmapped reference targets: Claim. Do we need a relationship code?

Control 0..1

Type Extension(Alternate Reference) (Extension Type: Reference(Resource))

Is Modifier false

Summary false

196. Claim.related.claim.reference

Definition

Short Literal reference, Relative, internal or absolute URL

Comments

Control 0..1
This element is affected by the following invariants: ref-1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

198. Claim.related.claim.type

Definition

The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.

Short Type the reference refers to (e.g. "Patient")

Comments

Control 0..1

Binding Unless not suitable, these codes SHALL be taken from ResourceType
(extensible to http://hl7.org/fhir/ValueSet/resource-types|4.3.0)

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

200. Claim.related.claim.identifier

Definition

Short Logical reference, when literal reference is not known

Comments

Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

Note This is a business identifier, not a resource identifier (see discussion)

Control 0..1

Is Modifier false

Summary true

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

202. Claim.related.claim.display

Definition

Plain text narrative that identifies the resource in addition to the resource reference.

Short Text alternative for the resource

Comments

This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

204. Claim.related.relationship

Definition

A code to convey how the claims are related.

Short How the reference claim is related

Comments

For example, prior claim or umbrella.

Control 0..1

For example codes, see ExampleRelatedClaimRelationshipCodes
(example to http://hl7.org/fhir/ValueSet/related-claim-relationship|4.3.0)

Relationship of this claim to a related Claim.

Is Modifier false

Must Support false

Summary false

Requirements

Some insurers need a declaration of the type of relationship.

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

206. Claim.related.reference

Definition

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

Short File or case reference

Comments

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

Control 0..1

Is Modifier false

Must Support false

Summary false

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.

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

208. Claim.related.reference.id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

210. Claim.related.reference.extension

Definition

An Extension

Short Extension

Control 0..*

Is Modifier false

Summary false

This element introduces a set of slices on Claim.related.reference.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

212. Claim.related.reference.extension:reference

Slice Name reference

Definition

STU3: Claim.related.reference additional types (Identifier) additional types from child elements (assigner, period, system, type, use, value)

Short STU3: Related file or case reference additional types

Comments

Element Claim.related.reference is mapped to FHIR R4B element Claim.related.reference as SourceIsBroaderThanTarget. The mappings for Claim.related.reference do not cover the following types: Identifier. The mappings for Claim.related.reference do not cover the following types based on type expansion: assigner, period, system, type, use, value.

Control 0..1

Type Extension(STU3: Related file or case reference additional types) (Extension Type: Identifier)

Is Modifier false

Summary false

214. Claim.related.reference.use

Definition

The purpose of this identifier.

Short usual | official | temp | secondary | old (If known)

Comments

Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.

Control 0..1

Binding The codes SHALL be taken from IdentifierUse
(required to http://hl7.org/fhir/ValueSet/identifier-use|4.3.0)

Is Modifier true because This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one.

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

Requirements

Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.

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

216. Claim.related.reference.type

Definition

A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.

Short Description of identifier

Comments

Control 0..1

Binding Unless not suitable, these codes SHALL be taken from Identifier Type Codes
(extensible to http://hl7.org/fhir/ValueSet/identifier-type|4.3.0)

Is Modifier false

Summary true

Requirements

Allows users to make use of identifiers when the identifier system is not known.

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

218. Claim.related.reference.system

Definition

Establishes the namespace for the value - that is, a URL that describes a set values that are unique.

Short The namespace for the identifier value

Comments

Identifier.system is always case sensitive.

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

Requirements

There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.

Example General: http://www.acme.com/identifiers/patient

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

220. Claim.related.reference.value

Definition

The portion of the identifier typically relevant to the user and which is unique within the context of the system.

Short The value that is unique

Comments

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

Example General: 123456

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

222. Claim.related.reference.period

Definition

Time period during which identifier is/was valid for use.

Short Time period when id is/was valid for use

Control 0..1

Period

Is Modifier false

Summary true

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

224. Claim.related.reference.assigner

Definition

Organization that issued/manages the identifier.

Short Organization that issued id (may be just text)

Comments

The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.

Control 0..1

Type Reference(Organization)

Is Modifier false

Summary true

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

226. Claim.prescription

Definition

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

Short Prescription authorizing services and products

Control 0..1

Type Reference(DeviceRequest, MedicationRequest, VisionPrescription)

Is Modifier false

Must Support false

Summary false

Requirements

Required to authorize the dispensing of controlled substances and devices.

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

228. Claim.prescription.id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

230. Claim.prescription.extension

Definition

An Extension

Short Extension

Control 0..*

Is Modifier false

Summary false

This element introduces a set of slices on Claim.prescription.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

232. Claim.prescription.extension:prescription

Slice Name prescription

Definition

STU3: Claim.prescription additional types from child elements (display, identifier, reference)

Short STU3: Prescription authorizing services or products additional types

Comments

Element Claim.prescription is mapped to FHIR R4B element Claim.prescription as SourceIsBroaderThanTarget. The mappings for Claim.prescription do not cover the following types based on type expansion: display, identifier, reference. The standard extension alternate-reference has been mapped as the representation of FHIR STU3 element Claim.prescription with unmapped reference targets: MedicationRequest, VisionPrescription. Should we create a group to hold multiple prescriptions and add a sequence number and on the line items a link to the sequence.

Control 0..1

Type Extension(Alternate Reference) (Extension Type: Reference(Resource))

Is Modifier false

Summary false

234. Claim.prescription.reference

Definition

Short Literal reference, Relative, internal or absolute URL

Comments

Control 0..1
This element is affected by the following invariants: ref-1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

236. Claim.prescription.type

Definition

The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.

Short Type the reference refers to (e.g. "Patient")

Comments

Control 0..1

Binding Unless not suitable, these codes SHALL be taken from ResourceType
(extensible to http://hl7.org/fhir/ValueSet/resource-types|4.3.0)

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

238. Claim.prescription.identifier

Definition

Short Logical reference, when literal reference is not known

Comments

Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

Note This is a business identifier, not a resource identifier (see discussion)

Control 0..1

Is Modifier false

Summary true

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

240. Claim.prescription.display

Definition

Plain text narrative that identifies the resource in addition to the resource reference.

Short Text alternative for the resource

Comments

This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

242. Claim.originalPrescription

Definition

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

Short Original prescription if superseded by fulfiller

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'.

Control 0..1

Type Reference(DeviceRequest, MedicationRequest, VisionPrescription)

Is Modifier false

Must Support false

Summary false

Requirements

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

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

244. Claim.originalPrescription.id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

246. Claim.originalPrescription.extension

Definition

An Extension

Short Extension

Control 0..*

Is Modifier false

Summary false

This element introduces a set of slices on Claim.originalPrescription.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

248. Claim.originalPrescription.extension:originalPrescription

Slice Name originalPrescription

Definition

STU3: Claim.originalPrescription additional types from child elements (display, identifier, reference)

Short STU3: Original prescription if superceded by fulfiller additional types

Comments

Element Claim.originalPrescription is mapped to FHIR R4B element Claim.originalPrescription as SourceIsBroaderThanTarget. The mappings for Claim.originalPrescription do not cover the following types based on type expansion: display, identifier, reference. The standard extension alternate-reference has been mapped as the representation of FHIR STU3 element Claim.originalPrescription with unmapped reference targets: MedicationRequest. as above.

Control 0..1

Type Extension(Alternate Reference) (Extension Type: Reference(Resource))

Is Modifier false

Summary false

250. Claim.originalPrescription.reference

Definition

Short Literal reference, Relative, internal or absolute URL

Comments

Control 0..1
This element is affected by the following invariants: ref-1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

252. Claim.originalPrescription.type

Definition

The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.

Short Type the reference refers to (e.g. "Patient")

Comments

Control 0..1

Binding Unless not suitable, these codes SHALL be taken from ResourceType
(extensible to http://hl7.org/fhir/ValueSet/resource-types|4.3.0)

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

254. Claim.originalPrescription.identifier

Definition

Short Logical reference, when literal reference is not known

Comments

Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

Note This is a business identifier, not a resource identifier (see discussion)

Control 0..1

Is Modifier false

Summary true

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

256. Claim.originalPrescription.display

Definition

Plain text narrative that identifies the resource in addition to the resource reference.

Short Text alternative for the resource

Comments

This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

258. Claim.payee

Definition

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

Short Recipient of benefits payable

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.

Control 0..1

Is Modifier false

Must Support false

Summary false

Requirements

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

Invariants ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource (hasValue() or (children().count() > id.count()) or $this is Parameters)

260. 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.

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

262. Claim.payee.extension

Definition

Short Additional content defined by implementations

Comments

Control 0..*

Is Modifier false

Summary false

Alternate Names extensions, user content

264. Claim.payee.modifierExtension

Definition

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

Short Extensions that cannot be ignored even if unrecognized

Comments

Control 0..*

Is Modifier true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them

Summary true

Requirements

Alternate Names extensions, user content, modifiers

266. Claim.payee.type

Definition

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

Short Category of recipient

Control 1..1

For example codes, see Claim Payee Type Codes
(example to http://hl7.org/fhir/ValueSet/payeetype|4.3.0)

A code for the party to be reimbursed.

Is Modifier false

Must Support false

Summary false

Requirements

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

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

268. Claim.payee.party

Definition

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

Short Recipient reference

Comments

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

Control 0..1

Type Reference(Practitioner, PractitionerRole, Organization, Patient, RelatedPerson)

Is Modifier false

Must Support false

Summary false

Requirements

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

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

270. Claim.payee.party.id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

272. Claim.payee.party.extension

Definition

An Extension

Short Extension

Control 0..*

Is Modifier false

Summary false

This element introduces a set of slices on Claim.payee.party.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

274. Claim.payee.party.extension:resourceType

Slice Name resourceType

Definition

STU3: Claim.payee.resourceType additional types (Coding) additional types from child elements (code, display, system, userSelected, version)

Short STU3: organization | patient | practitioner | relatedperson additional types

Comments

Element Claim.payee.resourceType is mapped to FHIR R4B element Claim.payee.party as SourceIsBroaderThanTarget. The mappings for Claim.payee.resourceType do not cover the following types: Coding. The mappings for Claim.payee.resourceType do not cover the following types based on type expansion: code, display, system, userSelected, version.

Control 0..1

Type Extension(STU3: organization | patient | practitioner | relatedperson additional types) (Extension Type: Coding)

Is Modifier false

Summary false

276. Claim.payee.party.extension:party

Slice Name party

Definition

STU3: Claim.payee.party

Short STU3: Party to receive the payable

Comments

Element Claim.payee.party is mapped to FHIR R4B element Claim.payee.party as SourceIsBroaderThanTarget. The standard extension alternate-reference has been mapped as the representation of FHIR STU3 element Claim.payee.party with unmapped reference targets: Organization, Patient, Practitioner, RelatedPerson.

Control 0..1

Type Extension(Alternate Reference) (Extension Type: Reference(Resource))

Is Modifier false

Summary false

278. Claim.payee.party.reference

Definition

Short Literal reference, Relative, internal or absolute URL

Comments

Control 0..1
This element is affected by the following invariants: ref-1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

280. Claim.payee.party.type

Definition

The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.

Short Type the reference refers to (e.g. "Patient")

Comments

Control 0..1

Binding Unless not suitable, these codes SHALL be taken from ResourceType
(extensible to http://hl7.org/fhir/ValueSet/resource-types|4.3.0)

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

282. Claim.payee.party.identifier

Definition

Short Logical reference, when literal reference is not known

Comments

Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

Note This is a business identifier, not a resource identifier (see discussion)

Control 0..1

Is Modifier false

Summary true

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

284. Claim.payee.party.display

Definition

Plain text narrative that identifies the resource in addition to the resource reference.

Short Text alternative for the resource

Comments

This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

286. Claim.referral

Definition

A reference to a referral resource.

Short Treatment referral

Comments

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

Control 0..1

Type Reference(ServiceRequest)

Is Modifier false

Must Support false

Summary false

Requirements

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

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

288. Claim.referral.id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

290. Claim.referral.extension

Definition

An Extension

Short Extension

Control 0..*

Is Modifier false

Summary false

This element introduces a set of slices on Claim.referral.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

292. Claim.referral.extension:referral

Slice Name referral

Definition

STU3: Claim.referral additional types from child elements (display, identifier, reference)

Short STU3: Treatment Referral additional types

Comments

Element Claim.referral is mapped to FHIR R4B element Claim.referral as RelatedTo. The mappings for Claim.referral do not cover the following types based on type expansion: display, identifier, reference. The standard extension alternate-reference has been mapped as the representation of FHIR STU3 element Claim.referral with unmapped reference targets: ReferralRequest.

Control 0..1

Type Extension(Alternate Reference) (Extension Type: Reference(Resource))

Is Modifier false

Summary false

294. Claim.referral.reference

Definition

Short Literal reference, Relative, internal or absolute URL

Comments

Control 0..1
This element is affected by the following invariants: ref-1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

296. Claim.referral.type

Definition

The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.

Short Type the reference refers to (e.g. "Patient")

Comments

Control 0..1

Binding Unless not suitable, these codes SHALL be taken from ResourceType
(extensible to http://hl7.org/fhir/ValueSet/resource-types|4.3.0)

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

298. Claim.referral.identifier

Definition

Short Logical reference, when literal reference is not known

Comments

Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

Note This is a business identifier, not a resource identifier (see discussion)

Control 0..1

Is Modifier false

Summary true

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

300. Claim.referral.display

Definition

Plain text narrative that identifies the resource in addition to the resource reference.

Short Text alternative for the resource

Comments

This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

302. Claim.facility

Definition

Facility where the services were provided.

Short Servicing facility

Control 0..1

Type Reference(Location)

Is Modifier false

Must Support false

Summary false

Requirements

Insurance adjudication can be dependant on where services were delivered.

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

304. Claim.facility.id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

306. Claim.facility.extension

Definition

An Extension

Short Extension

Control 0..*

Is Modifier false

Summary false

This element introduces a set of slices on Claim.facility.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

308. Claim.facility.extension:facility

Slice Name facility

Definition

STU3: Claim.facility additional types from child elements (display, identifier, reference)

Short STU3: Servicing Facility additional types

Comments

Element Claim.facility is mapped to FHIR R4B element Claim.facility as SourceIsBroaderThanTarget. The mappings for Claim.facility do not cover the following types based on type expansion: display, identifier, reference. The standard extension alternate-reference has been mapped as the representation of FHIR STU3 element Claim.facility with unmapped reference targets: Location.

Control 0..1

Type Extension(Alternate Reference) (Extension Type: Reference(Resource))

Is Modifier false

Summary false

310. Claim.facility.reference

Definition

Short Literal reference, Relative, internal or absolute URL

Comments

Control 0..1
This element is affected by the following invariants: ref-1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

312. Claim.facility.type

Definition

The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.

Short Type the reference refers to (e.g. "Patient")

Comments

Control 0..1

Binding Unless not suitable, these codes SHALL be taken from ResourceType
(extensible to http://hl7.org/fhir/ValueSet/resource-types|4.3.0)

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

314. Claim.facility.identifier

Definition

Short Logical reference, when literal reference is not known

Comments

Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

Note This is a business identifier, not a resource identifier (see discussion)

Control 0..1

Is Modifier false

Summary true

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

316. Claim.facility.display

Definition

Plain text narrative that identifies the resource in addition to the resource reference.

Short Text alternative for the resource

Comments

This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

318. Claim.careTeam

Definition

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

Short Members of the care team

Control 0..*

Is Modifier false

Must Support false

Summary false

Requirements

Common to identify the responsible and supporting practitioners.

Invariants ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource (hasValue() or (children().count() > id.count()) or $this is Parameters)

320. 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.

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

322. Claim.careTeam.extension

Definition

Short Additional content defined by implementations

Comments

Control 0..*

Is Modifier false

Summary false

Alternate Names extensions, user content

324. Claim.careTeam.modifierExtension

Definition

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

Short Extensions that cannot be ignored even if unrecognized

Comments

Control 0..*

Is Modifier true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them

Summary true

Requirements

Alternate Names extensions, user content, modifiers

326. Claim.careTeam.sequence

Definition

A number to uniquely identify care team entries.

Short Order of care team

Control 1..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

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

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

328. Claim.careTeam.provider

Definition

Member of the team who provided the product or service.

Short Practitioner or organization

Control 1..1

Type Reference(Practitioner, PractitionerRole, Organization)

Is Modifier false

Must Support false

Summary false

Requirements

Often a regulatory requirement to specify the responsible provider.

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

330. Claim.careTeam.provider.id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

332. Claim.careTeam.provider.extension

Definition

An Extension

Short Extension

Control 0..*

Is Modifier false

Summary false

This element introduces a set of slices on Claim.careTeam.provider.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

334. Claim.careTeam.provider.extension:provider

Slice Name provider

Definition

STU3: Claim.careTeam.provider additional types from child elements (display, identifier, reference)

Short STU3: Provider individual or organization additional types

Comments

Element Claim.careTeam.provider is mapped to FHIR R4B element Claim.careTeam.provider as SourceIsBroaderThanTarget. The mappings for Claim.careTeam.provider do not cover the following types based on type expansion: display, identifier, reference. The standard extension alternate-reference has been mapped as the representation of FHIR STU3 element Claim.careTeam.provider with unmapped reference targets: Organization, Practitioner.

Control 0..1

Type Extension(Alternate Reference) (Extension Type: Reference(Resource))

Is Modifier false

Summary false

336. Claim.careTeam.provider.reference

Definition

Short Literal reference, Relative, internal or absolute URL

Comments

Control 0..1
This element is affected by the following invariants: ref-1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

338. Claim.careTeam.provider.type

Definition

The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.

Short Type the reference refers to (e.g. "Patient")

Comments

Control 0..1

Binding Unless not suitable, these codes SHALL be taken from ResourceType
(extensible to http://hl7.org/fhir/ValueSet/resource-types|4.3.0)

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

340. Claim.careTeam.provider.identifier

Definition

Short Logical reference, when literal reference is not known

Comments

Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

Note This is a business identifier, not a resource identifier (see discussion)

Control 0..1

Is Modifier false

Summary true

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

342. Claim.careTeam.provider.display

Definition

Plain text narrative that identifies the resource in addition to the resource reference.

Short Text alternative for the resource

Comments

This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

344. Claim.careTeam.responsible

Definition

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

Short Indicator of the lead practitioner

Comments

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

Control 0..1

boolean

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

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

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

346. Claim.careTeam.role

Definition

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

Short Function within the team

Comments

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

Control 0..1

For example codes, see ClaimCareTeamRoleCodes
(example to http://hl7.org/fhir/ValueSet/claim-careteamrole|4.3.0)

The role codes for the care team members.

Is Modifier false

Must Support false

Summary false

Requirements

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

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

348. Claim.careTeam.qualification

Definition

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

Short Practitioner credential or specialization

Control 0..1

For example codes, see ExampleProviderQualificationCodes
(example to http://hl7.org/fhir/ValueSet/provider-qualification|4.3.0)

Provider professional qualifications.

Is Modifier false

Must Support false

Summary false

Requirements

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

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

350. Claim.supportingInfo

Definition

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

Short Supporting information

Comments

Often there are multiple jurisdiction specific valuesets which are required.

Control 0..*

Is Modifier false

Must Support false

Summary false

Requirements

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

Alternate Names Attachments Exception Codes Occurrence Codes Value codes

Invariants ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource (hasValue() or (children().count() > id.count()) or $this is Parameters)

352. 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.

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

354. Claim.supportingInfo.extension

Definition

An Extension

Short Extension

Control 0..*

Is Modifier false

Summary false

This element introduces a set of slices on Claim.supportingInfo.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

356. Claim.supportingInfo.extension:timing

Slice Name timing

Definition

STU3: Claim.information.timing[x] additional types (Period) additional types from child elements (end, start)

Short STU3: timing additional types

Comments

Element Claim.information.timing[x] is mapped to FHIR R4B element Claim.supportingInfo.timing[x] as SourceIsBroaderThanTarget. The mappings for Claim.information.timing[x] do not cover the following types: Period. The mappings for Claim.information.timing[x] do not cover the following types based on type expansion: end, start. The target context Claim.supportingInfo.timing[x] is a choice-type element and cannot directly hold extensions. The context is moved up to parent element Claim.supportingInfo.

Control 0..1
This element is affected by the following invariants: ele-1

Type Extension(STU3: timing additional types) (Extension Type: Period)

Is Modifier false

Summary false

358. Claim.supportingInfo.extension:value

Slice Name value

Definition

STU3: Claim.information.value[x] additional types (Attachment)

Short STU3: Additional Data or supporting information additional types

Comments

Element Claim.information.value[x] is mapped to FHIR R4B element Claim.supportingInfo.value[x] as SourceIsBroaderThanTarget. The mappings for Claim.information.value[x] do not cover the following types: Attachment. The target context Claim.supportingInfo.value[x] is a choice-type element and cannot directly hold extensions. The context is moved up to parent element Claim.supportingInfo. The standard extension alternate-reference has been mapped as PART of the representation of FHIR STU3 element Claim.information.value[x] with unmapped reference targets: Resource. Source element Claim.information.value[x] has unmapped reference types. While the target element Claim.supportingInfo.value[x] is a choice type and does not allow extensions, the alternate-reference extension can be applied to Reference values within it.

Control 0..1
This element is affected by the following invariants: ele-1

Type Extension(STU3: Additional Data or supporting information additional types) (Extension Type: Attachment)

Is Modifier false

Summary false

360. Claim.supportingInfo.modifierExtension

Definition

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

Short Extensions that cannot be ignored even if unrecognized

Comments

Control 0..*

Is Modifier true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them

Summary true

Requirements

Alternate Names extensions, user content, modifiers

362. Claim.supportingInfo.sequence

Definition

A number to uniquely identify supporting information entries.

Short Information instance identifier

Control 1..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

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

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

364. Claim.supportingInfo.category

Definition

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

Short Classification of the supplied information

Comments

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

Control 1..1

For example codes, see ClaimInformationCategoryCodes
(example to http://hl7.org/fhir/ValueSet/claim-informationcategory|4.3.0)

The valuset used for additional information category codes.

Is Modifier false

Must Support false

Summary false

Requirements

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

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

366. 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.

Short Type of information

Control 0..1

For example codes, see ExceptionCodes
(example to http://hl7.org/fhir/ValueSet/claim-exception|4.3.0)

The valuset used for additional information codes.

Is Modifier false

Must Support false

Summary false

Requirements

Required to identify the kind of additional information.

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

368. Claim.supportingInfo.timing[x]

Definition

The date when or period to which this information refers.

Short When it occurred

Control 0..1

Type Choice of: date, Period

[x] Note SeeChoice of Data Typesfor further information about how to use [x]

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

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

370. 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.

Short Data to be provided

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.

Control 0..1

Type Choice of: boolean, string, Quantity, Attachment, Reference(Resource)

[x] Note SeeChoice of Data Typesfor further information about how to use [x]

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

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

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

372. Claim.supportingInfo.value[x].id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

374. Claim.supportingInfo.value[x].extension

Definition

Short Additional content defined by implementations

Comments

Control 0..*

Is Modifier false

Summary false

Alternate Names extensions, user content

This element introduces a set of slices on Claim.supportingInfo.value[x].extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

376. Claim.supportingInfo.value[x].extension:alternateReference

Slice Name alternateReference

Definition

STU3: Claim.information.value[x] additional types (Attachment)

Short STU3: Additional Data or supporting information additional types

Comments

Control 0..1

Type Extension(Alternate Reference) (Extension Type: Reference(Resource))

Is Modifier false

Summary false

378. Claim.supportingInfo.reason

Definition

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

Short Explanation for the information

Comments

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

Control 0..1

For example codes, see MissingToothReasonCodes
(example to http://hl7.org/fhir/ValueSet/missing-tooth-reason|4.3.0)

Reason codes for the missing teeth.

Is Modifier false

Must Support false

Summary false

Requirements

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

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

380. Claim.diagnosis

Definition

Information about diagnoses relevant to the claim items.

Short Pertinent diagnosis information

Control 0..*

Is Modifier false

Must Support false

Summary false

Requirements

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

Invariants ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource (hasValue() or (children().count() > id.count()) or $this is Parameters)

382. 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.

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

384. Claim.diagnosis.extension

Definition

Short Additional content defined by implementations

Comments

Control 0..*

Is Modifier false

Summary false

Alternate Names extensions, user content

386. Claim.diagnosis.modifierExtension

Definition

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

Short Extensions that cannot be ignored even if unrecognized

Comments

Control 0..*

Is Modifier true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them

Summary true

Requirements

Alternate Names extensions, user content, modifiers

388. Claim.diagnosis.sequence

Definition

A number to uniquely identify diagnosis entries.

Short Diagnosis instance identifier

Comments

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

Control 1..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

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

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

390. Claim.diagnosis.diagnosis[x]

Definition

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

Short Nature of illness or problem

Control 1..1

For example codes, see ICD-10Codes
(example to http://hl7.org/fhir/ValueSet/icd-10|4.3.0)

Example ICD10 Diagnostic codes.

Type Choice of: CodeableConcept, Reference(Condition)

[x] Note SeeChoice of Data Typesfor further information about how to use [x]

Is Modifier false

Must Support false

Summary false

Requirements

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

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

392. Claim.diagnosis.diagnosis[x].id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

394. Claim.diagnosis.diagnosis[x].extension

Definition

An Extension

Short Extension

Control 0..*

Is Modifier false

Summary false

This element introduces a set of slices on Claim.diagnosis.diagnosis[x].extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

396. Claim.diagnosis.diagnosis[x].extension:alternateReference

Slice Name alternateReference

Definition

STU3: Claim.diagnosis.diagnosis[x] additional types from child elements (display, identifier, reference)

Short STU3: Patient's diagnosis additional types

Comments

Element Claim.diagnosis.diagnosis[x] is mapped to FHIR R4B element Claim.diagnosis.diagnosis[x] as SourceIsBroaderThanTarget. The mappings for Claim.diagnosis.diagnosis[x] do not cover the following types based on type expansion: display, identifier, reference. The standard extension alternate-reference has been mapped as the representation of FHIR STU3 element Claim.diagnosis.diagnosis[x] with unmapped reference targets: Condition. Source element Claim.diagnosis.diagnosis[x] has unmapped reference types. While the target element Claim.diagnosis.diagnosis[x] is a choice type and does not allow extensions, the alternate-reference extension can be applied to Reference values within it.

Control 0..1

Type Extension(Alternate Reference) (Extension Type: Reference(Resource))

Is Modifier false

Summary false

398. Claim.diagnosis.type

Definition

When the condition was observed or the relative ranking.

Short Timing or nature of the diagnosis

Comments

For example: admitting, primary, secondary, discharge.

Control 0..*

For example codes, see ExampleDiagnosisTypeCodes
(example to http://hl7.org/fhir/ValueSet/ex-diagnosistype|4.3.0)

The type of the diagnosis: admitting, principal, discharge.

Is Modifier false

Must Support false

Summary false

Requirements

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

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

400. Claim.diagnosis.onAdmission

Definition

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

Short Present on admission

Control 0..1

For example codes, see ExampleDiagnosisOnAdmissionCodes
(example to http://hl7.org/fhir/ValueSet/ex-diagnosis-on-admission|4.3.0)

Present on admission.

Is Modifier false

Must Support false

Summary false

Requirements

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

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

402. 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.

Short Package billing 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.

Control 0..1

For example codes, see ExampleDiagnosisRelatedGroupCodes
(example to http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup|4.3.0)

The DRG codes associated with the diagnosis.

Is Modifier false

Must Support false

Summary false

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.

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

404. Claim.procedure

Definition

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

Short Clinical procedures performed

Control 0..*

Is Modifier false

Must Support false

Summary false

Requirements

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

Invariants ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource (hasValue() or (children().count() > id.count()) or $this is Parameters)

406. 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.

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

408. Claim.procedure.extension

Definition

Short Additional content defined by implementations

Comments

Control 0..*

Is Modifier false

Summary false

Alternate Names extensions, user content

410. Claim.procedure.modifierExtension

Definition

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

Short Extensions that cannot be ignored even if unrecognized

Comments

Control 0..*

Is Modifier true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them

Summary true

Requirements

Alternate Names extensions, user content, modifiers

412. Claim.procedure.sequence

Definition

A number to uniquely identify procedure entries.

Short Procedure instance identifier

Control 1..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

Necessary to provide a mechanism to link to claim details.

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

414. Claim.procedure.type

Definition

When the condition was observed or the relative ranking.

Short Category of Procedure

Comments

For example: primary, secondary.

Control 0..*

For example codes, see ExampleProcedureTypeCodes
(example to http://hl7.org/fhir/ValueSet/ex-procedure-type|4.3.0)

Example procedure type codes.

Is Modifier false

Must Support false

Summary false

Requirements

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

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

416. Claim.procedure.date

Definition

Date and optionally time the procedure was performed.

Short When the procedure was performed

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

Required for auditing purposes.

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

418. Claim.procedure.procedure[x]

Definition

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

Short Specific clinical procedure

Control 1..1

For example codes, see ICD-10ProcedureCodes
(example to http://hl7.org/fhir/ValueSet/icd-10-procedures|4.3.0)

Example ICD10 Procedure codes.

Type Choice of: CodeableConcept, Reference(Procedure)

[x] Note SeeChoice of Data Typesfor further information about how to use [x]

Is Modifier false

Must Support false

Summary false

Requirements

This identifies the actual clinical procedure.

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

420. Claim.procedure.procedure[x].id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

422. Claim.procedure.procedure[x].extension

Definition

An Extension

Short Extension

Control 0..*

Is Modifier false

Summary false

This element introduces a set of slices on Claim.procedure.procedure[x].extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

424. Claim.procedure.procedure[x].extension:alternateReference

Slice Name alternateReference

Definition

STU3: Claim.procedure.procedure[x] additional types from child elements (display, identifier, reference)

Short STU3: Patient's list of procedures performed additional types

Comments

Element Claim.procedure.procedure[x] is mapped to FHIR R4B element Claim.procedure.procedure[x] as SourceIsBroaderThanTarget. The mappings for Claim.procedure.procedure[x] do not cover the following types based on type expansion: display, identifier, reference. The standard extension alternate-reference has been mapped as the representation of FHIR STU3 element Claim.procedure.procedure[x] with unmapped reference targets: Procedure. Source element Claim.procedure.procedure[x] has unmapped reference types. While the target element Claim.procedure.procedure[x] is a choice type and does not allow extensions, the alternate-reference extension can be applied to Reference values within it.

Control 0..1

Type Extension(Alternate Reference) (Extension Type: Reference(Resource))

Is Modifier false

Summary false

426. Claim.procedure.udi

Definition

Unique Device Identifiers associated with this line item.

Short Unique device identifier

Control 0..*

Type Reference(Device)

Is Modifier false

Must Support false

Summary false

Requirements

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

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

428. Claim.insurance

Definition

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

Short Patient insurance information

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.

Control 1..*

Is Modifier false

Must Support false

Summary true

Requirements

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

Invariants ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource (hasValue() or (children().count() > id.count()) or $this is Parameters)

430. 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.

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

432. Claim.insurance.extension

Definition

Short Additional content defined by implementations

Comments

Control 0..*

Is Modifier false

Summary false

Alternate Names extensions, user content

434. Claim.insurance.modifierExtension

Definition

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

Short Extensions that cannot be ignored even if unrecognized

Comments

Control 0..*

Is Modifier true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them

Summary true

Requirements

Alternate Names extensions, user content, modifiers

436. Claim.insurance.sequence

Definition

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

Short Insurance instance identifier

Control 1..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary true

Requirements

To maintain order of the coverages.

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

438. Claim.insurance.focal

Definition

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

Short Coverage to be used for adjudication

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.

Control 1..1

boolean

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary true

Requirements

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

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

440. Claim.insurance.identifier

Definition

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

Short Pre-assigned Claim number

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'.

Note This is a business identifier, not a resource identifier (see discussion)

Control 0..1

Is Modifier false

Must Support false

Summary false

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.

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

442. 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.

Short Insurance information

Control 1..1

Type Reference(Coverage)

Is Modifier false

Must Support false

Summary true

Requirements

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

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

444. Claim.insurance.coverage.id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

446. Claim.insurance.coverage.extension

Definition

An Extension

Short Extension

Control 0..*

Is Modifier false

Summary false

This element introduces a set of slices on Claim.insurance.coverage.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

448. Claim.insurance.coverage.extension:coverage

Slice Name coverage

Definition

STU3: Claim.insurance.coverage additional types from child elements (display, identifier, reference)

Short STU3: coverage additional types

Comments

Element Claim.insurance.coverage is mapped to FHIR R4B element Claim.insurance.coverage as SourceIsBroaderThanTarget. The mappings for Claim.insurance.coverage do not cover the following types based on type expansion: display, identifier, reference. The standard extension alternate-reference has been mapped as the representation of FHIR STU3 element Claim.insurance.coverage with unmapped reference targets: Coverage.

Control 0..1

Type Extension(Alternate Reference) (Extension Type: Reference(Resource))

Is Modifier false

Summary false

450. Claim.insurance.coverage.reference

Definition

Short Literal reference, Relative, internal or absolute URL

Comments

Control 0..1
This element is affected by the following invariants: ref-1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

452. Claim.insurance.coverage.type

Definition

The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.

Short Type the reference refers to (e.g. "Patient")

Comments

Control 0..1

Binding Unless not suitable, these codes SHALL be taken from ResourceType
(extensible to http://hl7.org/fhir/ValueSet/resource-types|4.3.0)

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

454. Claim.insurance.coverage.identifier

Definition

Short Logical reference, when literal reference is not known

Comments

Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

Note This is a business identifier, not a resource identifier (see discussion)

Control 0..1

Is Modifier false

Summary true

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

456. Claim.insurance.coverage.display

Definition

Plain text narrative that identifies the resource in addition to the resource reference.

Short Text alternative for the resource

Comments

This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

458. Claim.insurance.businessArrangement

Definition

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

Short Additional provider contract number

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

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

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

460. 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.

Short Prior authorization reference number

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.

Control 0..*

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

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

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

462. Claim.insurance.claimResponse

Definition

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

Short Adjudication results

Comments

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

Control 0..1

Type Reference(ClaimResponse)

Is Modifier false

Must Support false

Summary false

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.

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

464. Claim.insurance.claimResponse.id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

466. Claim.insurance.claimResponse.extension

Definition

An Extension

Short Extension

Control 0..*

Is Modifier false

Summary false

This element introduces a set of slices on Claim.insurance.claimResponse.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

468. Claim.insurance.claimResponse.extension:claimResponse

Slice Name claimResponse

Definition

STU3: Claim.insurance.claimResponse additional types from child elements (display, identifier, reference)

Short STU3: claimResponse additional types

Comments

Element Claim.insurance.claimResponse is mapped to FHIR R4B element Claim.insurance.claimResponse as SourceIsBroaderThanTarget. The mappings for Claim.insurance.claimResponse do not cover the following types based on type expansion: display, identifier, reference. The standard extension alternate-reference has been mapped as the representation of FHIR STU3 element Claim.insurance.claimResponse with unmapped reference targets: ClaimResponse.

Control 0..1

Type Extension(Alternate Reference) (Extension Type: Reference(Resource))

Is Modifier false

Summary false

470. Claim.insurance.claimResponse.reference

Definition

Short Literal reference, Relative, internal or absolute URL

Comments

Control 0..1
This element is affected by the following invariants: ref-1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

472. Claim.insurance.claimResponse.type

Definition

The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.

Short Type the reference refers to (e.g. "Patient")

Comments

Control 0..1

Binding Unless not suitable, these codes SHALL be taken from ResourceType
(extensible to http://hl7.org/fhir/ValueSet/resource-types|4.3.0)

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

474. Claim.insurance.claimResponse.identifier

Definition

Short Logical reference, when literal reference is not known

Comments

Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

Note This is a business identifier, not a resource identifier (see discussion)

Control 0..1

Is Modifier false

Summary true

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

476. Claim.insurance.claimResponse.display

Definition

Plain text narrative that identifies the resource in addition to the resource reference.

Short Text alternative for the resource

Comments

This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

478. Claim.accident

Definition

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

Short Details of the event

Control 0..1

Is Modifier false

Must Support false

Summary false

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.

Invariants ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource (hasValue() or (children().count() > id.count()) or $this is Parameters)

480. 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.

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

482. Claim.accident.extension

Definition

An Extension

Short Extension

Control 0..*

Is Modifier false

Summary false

This element introduces a set of slices on Claim.accident.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

484. Claim.accident.extension:location

Slice Name location

Definition

STU3: Claim.accident.location[x] additional types (Address) additional types from child elements (city, country, district, line, period, postalCode, state, text, type, use, display, identifier, reference)

Short STU3: Accident Place additional types

Comments

Element Claim.accident.location[x] is mapped to FHIR R4B element Claim.accident.location[x] as SourceIsBroaderThanTarget. The mappings for Claim.accident.location[x] do not cover the following types: Address. The mappings for Claim.accident.location[x] do not cover the following types based on type expansion: city, country, display, district, identifier, line, period, postalCode, reference, state, text, type, use. The target context Claim.accident.location[x] is a choice-type element and cannot directly hold extensions. The context is moved up to parent element Claim.accident. The standard extension alternate-reference has been mapped as PART of the representation of FHIR STU3 element Claim.accident.location[x] with unmapped reference targets: Location. Source element Claim.accident.location[x] has unmapped reference types. While the target element Claim.accident.location[x] is a choice type and does not allow extensions, the alternate-reference extension can be applied to Reference values within it.

Control 0..1
This element is affected by the following invariants: ele-1

Type Extension(STU3: Accident Place additional types) (Extension Type: Address)

Is Modifier false

Summary false

486. Claim.accident.modifierExtension

Definition

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

Short Extensions that cannot be ignored even if unrecognized

Comments

Control 0..*

Is Modifier true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them

Summary true

Requirements

Alternate Names extensions, user content, modifiers

488. Claim.accident.date

Definition

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

Short When the incident occurred

Comments

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

Control 1..1

date

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

Required for audit purposes and adjudication.

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

490. 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.

Short The nature of the accident

Control 0..1

Unless not suitable, these codes SHALL be taken from ActIncidentCode (3.0.0)
(extensible to http://terminology.hl7.org/ValueSet/v3-ActIncidentCode|3.0.0)

Type of accident: work place, auto, etc.

Is Modifier false

Must Support false

Summary false

Requirements

Coverage may be dependant on the type of accident.

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

492. Claim.accident.type.id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

494. Claim.accident.type.extension

Definition

An Extension

Short Extension

Control 0..*

Is Modifier false

Summary false

This element introduces a set of slices on Claim.accident.type.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

496. Claim.accident.type.extension:type

Slice Name type

Definition

STU3: Claim.accident.type

Short STU3: type

Comments

Element Claim.accident.type is mapped to FHIR R4B element Claim.accident.type as Equivalent.

Control 0..1

Type Extension(STU3: type) (Extension Type: CodeableConcept)

Is Modifier false

Summary false

498. Claim.accident.type.coding

Definition

A reference to a code defined by a terminology system.

Short Code defined by a terminology system

Comments

Control 0..*

Is Modifier false

Summary true

Requirements

Allows for alternative encodings within a code system, and translations to other code systems.

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

500. Claim.accident.type.text

Definition

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

Short Plain text representation of the concept

Comments

Very often the text is the same as a displayName of one of the codings.

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

Requirements

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

502. Claim.accident.location[x]

Definition

The physical location of the accident event.

Short Where the event occurred

Control 0..1

Type Choice of: Address, Reference(Location)

[x] Note SeeChoice of Data Typesfor further information about how to use [x]

Is Modifier false

Must Support false

Summary false

Requirements

Required for audit purposes and determination of applicable insurance liability.

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

504. Claim.accident.location[x].id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

506. Claim.accident.location[x].extension

Definition

Short Additional content defined by implementations

Comments

Control 0..*

Is Modifier false

Summary false

Alternate Names extensions, user content

This element introduces a set of slices on Claim.accident.location[x].extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

508. Claim.accident.location[x].extension:alternateReference

Slice Name alternateReference

Definition

Short STU3: Accident Place additional types

Comments

Control 0..1

Type Extension(Alternate Reference) (Extension Type: Reference(Resource))

Is Modifier false

Summary false

510. 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.

Short Product or service provided

Control 0..*

Is Modifier false

Must Support false

Summary false

Requirements

The items to be processed for adjudication.

Invariants ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource (hasValue() or (children().count() > id.count()) or $this is Parameters)

512. 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.

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

514. Claim.item.extension

Definition

An Extension

Short Extension

Control 0..*

Is Modifier false

Summary false

This element introduces a set of slices on Claim.item.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

516. Claim.item.extension:serviced

Slice Name serviced

Definition

STU3: Claim.item.serviced[x] additional types (Period) additional types from child elements (end, start)

Short STU3: Date or dates of Service additional types

Comments

Element Claim.item.serviced[x] is mapped to FHIR R4B element Claim.item.serviced[x] as SourceIsBroaderThanTarget. The mappings for Claim.item.serviced[x] do not cover the following types: Period. The mappings for Claim.item.serviced[x] do not cover the following types based on type expansion: end, start. The target context Claim.item.serviced[x] is a choice-type element and cannot directly hold extensions. The context is moved up to parent element Claim.item.

Control 0..1
This element is affected by the following invariants: ele-1

Type Extension(STU3: Date or dates of Service additional types) (Extension Type: Period)

Is Modifier false

Summary false

518. Claim.item.extension:location

Slice Name location

Definition

STU3: Claim.item.location[x] additional types (Address)

Short STU3: Place of service additional types

Comments

Element Claim.item.location[x] is mapped to FHIR R4B element Claim.item.location[x] as SourceIsBroaderThanTarget. The mappings for Claim.item.location[x] do not cover the following types: Address. The target context Claim.item.location[x] is a choice-type element and cannot directly hold extensions. The context is moved up to parent element Claim.item. The standard extension alternate-reference has been mapped as PART of the representation of FHIR STU3 element Claim.item.location[x] with unmapped reference targets: Location. Source element Claim.item.location[x] has unmapped reference types. While the target element Claim.item.location[x] is a choice type and does not allow extensions, the alternate-reference extension can be applied to Reference values within it.

Control 0..1
This element is affected by the following invariants: ele-1

Type Extension(STU3: Place of service additional types) (Extension Type: Address)

Is Modifier false

Summary false

520. Claim.item.modifierExtension

Definition

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

Short Extensions that cannot be ignored even if unrecognized

Comments

Control 0..*

Is Modifier true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them

Summary true

Requirements

Alternate Names extensions, user content, modifiers

522. Claim.item.sequence

Definition

A number to uniquely identify item entries.

Short Item instance identifier

Control 1..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

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

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

524. Claim.item.careTeamSequence

Definition

CareTeam members related to this service or product.

Short Applicable careTeam members

Control 0..*

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

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

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

526. Claim.item.diagnosisSequence

Definition

Diagnosis applicable for this service or product.

Short Applicable diagnoses

Control 0..*

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

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

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

528. Claim.item.procedureSequence

Definition

Procedures applicable for this service or product.

Short Applicable procedures

Control 0..*

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

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

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

530. Claim.item.informationSequence

Definition

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

Short Applicable exception and supporting information

Control 0..*

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

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

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

532. Claim.item.revenue

Definition

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

Short Revenue or cost center code

Control 0..1

For example codes, see ExampleRevenueCenterCodes
(example to http://hl7.org/fhir/ValueSet/ex-revenue-center|4.3.0)

Codes for the revenue or cost centers supplying the service and/or products.

Is Modifier false

Must Support false

Summary false

Requirements

Needed in the processing of institutional claims.

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

534. Claim.item.category

Definition

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

Short Benefit classification

Comments

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

Control 0..1

For example codes, see BenefitCategoryCodes
(example to http://hl7.org/fhir/ValueSet/ex-benefitcategory|4.3.0)

Benefit categories such as: oral-basic, major, glasses.

Is Modifier false

Must Support false

Summary false

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.

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

536. 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.

Short Billing, service, product, or drug 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'.

Control 1..1

For example codes, see USCLSCodes
(example to http://hl7.org/fhir/ValueSet/service-uscls|4.3.0)

Allowable service and product codes.

Is Modifier false

Must Support false

Summary false

Requirements

Necessary to state what was provided or done.

Alternate Names Drug Code, Bill Code, Service Code

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

538. Claim.item.modifier

Definition

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

Short Product or service billing modifiers

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.

Control 0..*

For example codes, see ModifierTypeCodes
(example to http://hl7.org/fhir/ValueSet/claim-modifiers|4.3.0)

Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.

Is Modifier false

Must Support false

Summary false

Requirements

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

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

540. Claim.item.programCode

Definition

Identifies the program under which this may be recovered.

Short Program the product or service is provided under

Comments

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

Control 0..*

For example codes, see ExampleProgramReasonCodes
(example to http://hl7.org/fhir/ValueSet/ex-program-code|4.3.0)

Program specific reason codes.

Is Modifier false

Must Support false

Summary false

Requirements

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

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

542. Claim.item.serviced[x]

Definition

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

Short Date or dates of service or product delivery

Control 0..1

Type Choice of: date, Period

[x] Note SeeChoice of Data Typesfor further information about how to use [x]

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

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

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

544. Claim.item.location[x]

Definition

Where the product or service was provided.

Short Place of service or where product was supplied

Control 0..1

For example codes, see ExampleServicePlaceCodes
(example to http://hl7.org/fhir/ValueSet/service-place|4.3.0)

Place of service: pharmacy, school, prison, etc.

Type Choice of: CodeableConcept, Address, Reference(Location)

[x] Note SeeChoice of Data Typesfor further information about how to use [x]

Is Modifier false

Must Support false

Summary false

Requirements

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

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

546. Claim.item.location[x].id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

548. Claim.item.location[x].extension

Definition

Short Additional content defined by implementations

Comments

Control 0..*

Is Modifier false

Summary false

Alternate Names extensions, user content

This element introduces a set of slices on Claim.item.location[x].extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

550. Claim.item.location[x].extension:alternateReference

Slice Name alternateReference

Definition

STU3: Claim.item.location[x] additional types (Address)

Short STU3: Place of service additional types

Comments

Control 0..1

Type Extension(Alternate Reference) (Extension Type: Reference(Resource))

Is Modifier false

Summary false

552. Claim.item.quantity

Definition

The number of repetitions of a service or product.

Short Count of products or services

Control 0..1

Type Quantity(SimpleQuantity)

Is Modifier false

Must Support false

Summary false

Requirements

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

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

554. 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.

Short Fee, charge or cost per item

Control 0..1

Is Modifier false

Must Support false

Summary false

Requirements

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

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

556. 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.

Short Price scaling factor

Comments

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

Control 0..1

decimal

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

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

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

558. Claim.item.net

Definition

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

Short Total item cost

Comments

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

Control 0..1

Is Modifier false

Must Support false

Summary false

Requirements

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

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

560. Claim.item.udi

Definition

Unique Device Identifiers associated with this line item.

Short Unique device identifier

Control 0..*

Type Reference(Device)

Is Modifier false

Must Support false

Summary false

Requirements

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

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

562. Claim.item.udi.id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

564. Claim.item.udi.extension

Definition

An Extension

Short Extension

Control 0..*

Is Modifier false

Summary false

This element introduces a set of slices on Claim.item.udi.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

566. Claim.item.udi.extension:udi

Slice Name udi

Definition

STU3: Claim.item.udi additional types from child elements (display, identifier, reference)

Short STU3: Unique Device Identifier additional types

Comments

Element Claim.item.udi is mapped to FHIR R4B element Claim.item.udi as SourceIsBroaderThanTarget. The mappings for Claim.item.udi do not cover the following types based on type expansion: display, identifier, reference. The standard extension alternate-reference has been mapped as the representation of FHIR STU3 element Claim.item.udi with unmapped reference targets: Device.

Control 0..1

Type Extension(Alternate Reference) (Extension Type: Reference(Resource))

Is Modifier false

Summary false

568. Claim.item.udi.reference

Definition

Short Literal reference, Relative, internal or absolute URL

Comments

Control 0..1
This element is affected by the following invariants: ref-1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

570. Claim.item.udi.type

Definition

The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.

Short Type the reference refers to (e.g. "Patient")

Comments

Control 0..1

Binding Unless not suitable, these codes SHALL be taken from ResourceType
(extensible to http://hl7.org/fhir/ValueSet/resource-types|4.3.0)

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

572. Claim.item.udi.identifier

Definition

Short Logical reference, when literal reference is not known

Comments

Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

Note This is a business identifier, not a resource identifier (see discussion)

Control 0..1

Is Modifier false

Summary true

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

574. Claim.item.udi.display

Definition

Plain text narrative that identifies the resource in addition to the resource reference.

Short Text alternative for the resource

Comments

This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

576. Claim.item.bodySite

Definition

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

Short Anatomical location

Comments

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

Control 0..1

For example codes, see OralSiteCodes
(example to http://hl7.org/fhir/ValueSet/tooth|4.3.0)

The code for the teeth, quadrant, sextant and arch.

Is Modifier false

Must Support false

Summary false

Requirements

Allows insurer to validate specific procedures.

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

578. Claim.item.subSite

Definition

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

Short Anatomical sub-location

Control 0..*

For example codes, see SurfaceCodes
(example to http://hl7.org/fhir/ValueSet/surface|4.3.0)

The code for the tooth surface and surface combinations.

Is Modifier false

Must Support false

Summary false

Requirements

Allows insurer to validate specific procedures.

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

580. Claim.item.encounter

Definition

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

Short Encounters related to this billed item

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.

Control 0..*

Type Reference(Encounter)

Is Modifier false

Must Support false

Summary false

Requirements

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

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

582. Claim.item.encounter.id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

584. Claim.item.encounter.extension

Definition

An Extension

Short Extension

Control 0..*

Is Modifier false

Summary false

This element introduces a set of slices on Claim.item.encounter.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

586. Claim.item.encounter.extension:encounter

Slice Name encounter

Definition

STU3: Claim.item.encounter additional types from child elements (display, identifier, reference)

Short STU3: encounter additional types

Comments

Element Claim.item.encounter is mapped to FHIR R4B element Claim.item.encounter as SourceIsBroaderThanTarget. The mappings for Claim.item.encounter do not cover the following types based on type expansion: display, identifier, reference. The standard extension alternate-reference has been mapped as the representation of FHIR STU3 element Claim.item.encounter with unmapped reference targets: Encounter.

Control 0..1

Type Extension(Alternate Reference) (Extension Type: Reference(Resource))

Is Modifier false

Summary false

588. Claim.item.encounter.reference

Definition

Short Literal reference, Relative, internal or absolute URL

Comments

Control 0..1
This element is affected by the following invariants: ref-1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

590. Claim.item.encounter.type

Definition

The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.

Short Type the reference refers to (e.g. "Patient")

Comments

Control 0..1

Binding Unless not suitable, these codes SHALL be taken from ResourceType
(extensible to http://hl7.org/fhir/ValueSet/resource-types|4.3.0)

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

592. Claim.item.encounter.identifier

Definition

Short Logical reference, when literal reference is not known

Comments

Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

Note This is a business identifier, not a resource identifier (see discussion)

Control 0..1

Is Modifier false

Summary true

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

594. Claim.item.encounter.display

Definition

Plain text narrative that identifies the resource in addition to the resource reference.

Short Text alternative for the resource

Comments

This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

596. 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.

Short Product or service provided

Control 0..*

Is Modifier false

Must Support false

Summary false

Requirements

The items to be processed for adjudication.

Invariants ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource (hasValue() or (children().count() > id.count()) or $this is Parameters)

598. 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.

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

600. Claim.item.detail.extension

Definition

Short Additional content defined by implementations

Comments

Control 0..*

Is Modifier false

Summary false

Alternate Names extensions, user content

602. Claim.item.detail.modifierExtension

Definition

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

Short Extensions that cannot be ignored even if unrecognized

Comments

Control 0..*

Is Modifier true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them

Summary true

Requirements

Alternate Names extensions, user content, modifiers

604. Claim.item.detail.sequence

Definition

A number to uniquely identify item entries.

Short Item instance identifier

Control 1..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

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

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

606. Claim.item.detail.revenue

Definition

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

Short Revenue or cost center code

Control 0..1

For example codes, see ExampleRevenueCenterCodes
(example to http://hl7.org/fhir/ValueSet/ex-revenue-center|4.3.0)

Codes for the revenue or cost centers supplying the service and/or products.

Is Modifier false

Must Support false

Summary false

Requirements

Needed in the processing of institutional claims.

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

608. Claim.item.detail.category

Definition

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

Short Benefit classification

Comments

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

Control 0..1

For example codes, see BenefitCategoryCodes
(example to http://hl7.org/fhir/ValueSet/ex-benefitcategory|4.3.0)

Benefit categories such as: oral-basic, major, glasses.

Is Modifier false

Must Support false

Summary false

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.

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

610. 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.

Short Billing, service, product, or drug code

Comments

Control 1..1

For example codes, see USCLSCodes
(example to http://hl7.org/fhir/ValueSet/service-uscls|4.3.0)

Allowable service and product codes.

Is Modifier false

Must Support false

Summary false

Requirements

Necessary to state what was provided or done.

Alternate Names Drug Code, Bill Code, Service Code

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

612. Claim.item.detail.modifier

Definition

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

Short Service/Product billing modifiers

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.

Control 0..*

For example codes, see ModifierTypeCodes
(example to http://hl7.org/fhir/ValueSet/claim-modifiers|4.3.0)

Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.

Is Modifier false

Must Support false

Summary false

Requirements

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

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

614. Claim.item.detail.programCode

Definition

Identifies the program under which this may be recovered.

Short Program the product or service is provided under

Comments

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

Control 0..*

For example codes, see ExampleProgramReasonCodes
(example to http://hl7.org/fhir/ValueSet/ex-program-code|4.3.0)

Program specific reason codes.

Is Modifier false

Must Support false

Summary false

Requirements

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

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

616. Claim.item.detail.quantity

Definition

The number of repetitions of a service or product.

Short Count of products or services

Control 0..1

Type Quantity(SimpleQuantity)

Is Modifier false

Must Support false

Summary false

Requirements

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

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

618. 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.

Short Fee, charge or cost per item

Control 0..1

Is Modifier false

Must Support false

Summary false

Requirements

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

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

620. Claim.item.detail.factor

Definition

Short Price scaling factor

Comments

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

Control 0..1

decimal

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

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

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

622. Claim.item.detail.net

Definition

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

Short Total item cost

Comments

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

Control 0..1

Is Modifier false

Must Support false

Summary false

Requirements

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

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

624. Claim.item.detail.udi

Definition

Unique Device Identifiers associated with this line item.

Short Unique device identifier

Control 0..*

Type Reference(Device)

Is Modifier false

Must Support false

Summary false

Requirements

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

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

626. Claim.item.detail.udi.id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

628. Claim.item.detail.udi.extension

Definition

An Extension

Short Extension

Control 0..*

Is Modifier false

Summary false

This element introduces a set of slices on Claim.item.detail.udi.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

630. Claim.item.detail.udi.extension:udi

Slice Name udi

Definition

STU3: Claim.item.detail.udi additional types from child elements (display, identifier, reference)

Short STU3: Unique Device Identifier additional types

Comments

Element Claim.item.detail.udi is mapped to FHIR R4B element Claim.item.detail.udi as SourceIsBroaderThanTarget. The mappings for Claim.item.detail.udi do not cover the following types based on type expansion: display, identifier, reference. The standard extension alternate-reference has been mapped as the representation of FHIR STU3 element Claim.item.detail.udi with unmapped reference targets: Device.

Control 0..1

Type Extension(Alternate Reference) (Extension Type: Reference(Resource))

Is Modifier false

Summary false

632. Claim.item.detail.udi.reference

Definition

Short Literal reference, Relative, internal or absolute URL

Comments

Control 0..1
This element is affected by the following invariants: ref-1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

634. Claim.item.detail.udi.type

Definition

The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.

Short Type the reference refers to (e.g. "Patient")

Comments

Control 0..1

Binding Unless not suitable, these codes SHALL be taken from ResourceType
(extensible to http://hl7.org/fhir/ValueSet/resource-types|4.3.0)

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

636. Claim.item.detail.udi.identifier

Definition

Short Logical reference, when literal reference is not known

Comments

Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

Note This is a business identifier, not a resource identifier (see discussion)

Control 0..1

Is Modifier false

Summary true

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

638. Claim.item.detail.udi.display

Definition

Plain text narrative that identifies the resource in addition to the resource reference.

Short Text alternative for the resource

Comments

This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

640. 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.

Short Product or service provided

Control 0..*

Is Modifier false

Must Support false

Summary false

Requirements

The items to be processed for adjudication.

Invariants ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource (hasValue() or (children().count() > id.count()) or $this is Parameters)

642. 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.

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

644. Claim.item.detail.subDetail.extension

Definition

Short Additional content defined by implementations

Comments

Control 0..*

Is Modifier false

Summary false

Alternate Names extensions, user content

646. Claim.item.detail.subDetail.modifierExtension

Definition

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

Short Extensions that cannot be ignored even if unrecognized

Comments

Control 0..*

Is Modifier true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them

Summary true

Requirements

Alternate Names extensions, user content, modifiers

648. Claim.item.detail.subDetail.sequence

Definition

A number to uniquely identify item entries.

Short Item instance identifier

Control 1..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

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

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

650. Claim.item.detail.subDetail.revenue

Definition

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

Short Revenue or cost center code

Control 0..1

For example codes, see ExampleRevenueCenterCodes
(example to http://hl7.org/fhir/ValueSet/ex-revenue-center|4.3.0)

Codes for the revenue or cost centers supplying the service and/or products.

Is Modifier false

Must Support false

Summary false

Requirements

Needed in the processing of institutional claims.

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

652. Claim.item.detail.subDetail.category

Definition

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

Short Benefit classification

Comments

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

Control 0..1

For example codes, see BenefitCategoryCodes
(example to http://hl7.org/fhir/ValueSet/ex-benefitcategory|4.3.0)

Benefit categories such as: oral-basic, major, glasses.

Is Modifier false

Must Support false

Summary false

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.

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

654. 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.

Short Billing, service, product, or drug code

Comments

Control 1..1

For example codes, see USCLSCodes
(example to http://hl7.org/fhir/ValueSet/service-uscls|4.3.0)

Allowable service and product codes.

Is Modifier false

Must Support false

Summary false

Requirements

Necessary to state what was provided or done.

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

656. Claim.item.detail.subDetail.modifier

Definition

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

Short Service/Product billing modifiers

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.

Control 0..*

For example codes, see ModifierTypeCodes
(example to http://hl7.org/fhir/ValueSet/claim-modifiers|4.3.0)

Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.

Is Modifier false

Must Support false

Summary false

Requirements

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

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

658. Claim.item.detail.subDetail.programCode

Definition

Identifies the program under which this may be recovered.

Short Program the product or service is provided under

Comments

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

Control 0..*

For example codes, see ExampleProgramReasonCodes
(example to http://hl7.org/fhir/ValueSet/ex-program-code|4.3.0)

Program specific reason codes.

Is Modifier false

Must Support false

Summary false

Requirements

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

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

660. Claim.item.detail.subDetail.quantity

Definition

The number of repetitions of a service or product.

Short Count of products or services

Control 0..1

Type Quantity(SimpleQuantity)

Is Modifier false

Must Support false

Summary false

Requirements

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

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

662. 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.

Short Fee, charge or cost per item

Control 0..1

Is Modifier false

Must Support false

Summary false

Requirements

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

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

664. Claim.item.detail.subDetail.factor

Definition

Short Price scaling factor

Comments

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

Control 0..1

decimal

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

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

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

666. Claim.item.detail.subDetail.net

Definition

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

Short Total item cost

Comments

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

Control 0..1

Is Modifier false

Must Support false

Summary false

Requirements

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

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

668. Claim.item.detail.subDetail.udi

Definition

Unique Device Identifiers associated with this line item.

Short Unique device identifier

Control 0..*

Type Reference(Device)

Is Modifier false

Must Support false

Summary false

Requirements

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

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

670. Claim.item.detail.subDetail.udi.id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

672. Claim.item.detail.subDetail.udi.extension

Definition

An Extension

Short Extension

Control 0..*

Is Modifier false

Summary false

This element introduces a set of slices on Claim.item.detail.subDetail.udi.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

674. Claim.item.detail.subDetail.udi.extension:udi

Slice Name udi

Definition

STU3: Claim.item.detail.subDetail.udi additional types from child elements (display, identifier, reference)

Short STU3: Unique Device Identifier additional types

Comments

Element Claim.item.detail.subDetail.udi is mapped to FHIR R4B element Claim.item.detail.subDetail.udi as SourceIsBroaderThanTarget. The mappings for Claim.item.detail.subDetail.udi do not cover the following types based on type expansion: display, identifier, reference. The standard extension alternate-reference has been mapped as the representation of FHIR STU3 element Claim.item.detail.subDetail.udi with unmapped reference targets: Device.

Control 0..1

Type Extension(Alternate Reference) (Extension Type: Reference(Resource))

Is Modifier false

Summary false

676. Claim.item.detail.subDetail.udi.reference

Definition

Short Literal reference, Relative, internal or absolute URL

Comments

Control 0..1
This element is affected by the following invariants: ref-1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

678. Claim.item.detail.subDetail.udi.type

Definition

The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.

Short Type the reference refers to (e.g. "Patient")

Comments

Control 0..1

Binding Unless not suitable, these codes SHALL be taken from ResourceType
(extensible to http://hl7.org/fhir/ValueSet/resource-types|4.3.0)

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

680. Claim.item.detail.subDetail.udi.identifier

Definition

Short Logical reference, when literal reference is not known

Comments

Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

Note This is a business identifier, not a resource identifier (see discussion)

Control 0..1

Is Modifier false

Summary true

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

682. Claim.item.detail.subDetail.udi.display

Definition

Plain text narrative that identifies the resource in addition to the resource reference.

Short Text alternative for the resource

Comments

This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.

Control 0..1