Generated Narrative: StructureDefinition profile-Claim Name Flags Card. Type Description & Constraints Claim 0..* Claim(5.0.0) Claim, Pre-determination or Pre-authorization #xD; meta #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:meta 0..1 Meta STU3: meta additional types URL: http://hl7.org/fhir/3.0/StructureDefinition/extension-Claim.meta #xD; text #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:text 0..1 (Complex) STU3: text additional types URL: http://hl7.org/fhir/3.0/StructureDefinition/extension-Claim.text #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:organization 0..1 Reference(Cross-version Profile for STU3.Organization for use in FHIR R5(0.1.0) | Organization) STU3: Responsible organization (new) URL: http://hl7.org/fhir/3.0/StructureDefinition/extension-Claim.organization #xD; extension:employmentImpacted 0..1 Period STU3: Period unable to work (new) URL: http://hl7.org/fhir/3.0/StructureDefinition/extension-Claim.employmentImpacted #xD; extension:hospitalization 0..1 Period STU3: Period in hospital (new) URL: http://hl7.org/fhir/3.0/StructureDefinition/extension-Claim.hospitalization #xD; identifier #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:identifier 0..* Identifier STU3: Claim number additional types URL: http://hl7.org/fhir/3.0/StructureDefinition/extension-Claim.identifier #xD; type #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:type 0..1 CodeableConcept STU3: Type or discipline URL: http://hl7.org/fhir/3.0/StructureDefinition/extension-Claim.type Binding: ClaimTypeCodes (required): The type or discipline-style of the claim #xD; use #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:use 0..1 code STU3: complete | proposed | exploratory | other URL: http://hl7.org/fhir/3.0/StructureDefinition/extension-Claim.use Binding: R3ClaimUseForR5 (0.1.0) (required): Complete, proposed, exploratory, other #xD; patient #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:patient 0..1 Reference(Resource) STU3: The subject of the Products and Services additional types URL: http://hl7.org/fhir/StructureDefinition/alternate-reference #xD; billablePeriod #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:billablePeriod 0..1 Period STU3: Period for charge submission additional types URL: http://hl7.org/fhir/3.0/StructureDefinition/extension-Claim.billablePeriod #xD; enterer #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:enterer 0..1 Reference(Resource) STU3: Author additional types URL: http://hl7.org/fhir/StructureDefinition/alternate-reference #xD; insurer #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:insurer 0..1 Reference(Resource) STU3: insurer additional types URL: http://hl7.org/fhir/StructureDefinition/alternate-reference #xD; provider #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:provider 0..1 Reference(Resource) STU3: Responsible provider additional types URL: http://hl7.org/fhir/StructureDefinition/alternate-reference #xD; related #xD; claim #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:claim 0..1 Reference(Resource) STU3: claim additional types URL: http://hl7.org/fhir/StructureDefinition/alternate-reference #xD; reference #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:reference 0..1 Identifier STU3: Related file or case reference additional types URL: http://hl7.org/fhir/3.0/StructureDefinition/extension-Claim.related.reference #xD; prescription #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:prescription 0..1 Reference(Resource) STU3: Prescription authorizing services or products additional types URL: http://hl7.org/fhir/StructureDefinition/alternate-reference #xD; originalPrescription #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:originalPrescription 0..1 Reference(Resource) STU3: Original prescription if superceded by fulfiller additional types URL: http://hl7.org/fhir/StructureDefinition/alternate-reference #xD; payee #xD; party #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:resourceType 0..1 Coding STU3: organization | patient | practitioner | relatedperson additional types URL: http://hl7.org/fhir/3.0/StructureDefinition/extension-Claim.payee.resourceType Binding: R3ExPayeeResourceTypeForR5 (0.1.0) (example): The type of Claim payee Resource #xD; extension:party 0..1 Reference(Resource) STU3: Party to receive the payable URL: http://hl7.org/fhir/StructureDefinition/alternate-reference #xD; referral #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:referral 0..1 Reference(Resource) STU3: Treatment Referral additional types URL: http://hl7.org/fhir/StructureDefinition/alternate-reference #xD; facility #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:facility 0..1 Reference(Resource) STU3: Servicing Facility additional types URL: http://hl7.org/fhir/StructureDefinition/alternate-reference #xD; careTeam #xD; provider #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:provider 0..1 Reference(Resource) STU3: Provider individual or organization additional types URL: http://hl7.org/fhir/StructureDefinition/alternate-reference #xD; supportingInfo #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:timing 0..1 Period STU3: timing additional types URL: http://hl7.org/fhir/3.0/StructureDefinition/extension-Claim.information.timing #xD; extension:value 0..1 Attachment STU3: Additional Data or supporting information additional types URL: http://hl7.org/fhir/3.0/StructureDefinition/extension-Claim.information.value #xD; valueReference #xD; Slices for extension Content/Rules for all slices #xD; extension:alternateReference 0..1 Reference(Resource) STU3: Additional Data or supporting information additional types URL: http://hl7.org/fhir/StructureDefinition/alternate-reference #xD; diagnosis #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:packageCode 0..1 CodeableConcept STU3: Package billing code (new) URL: http://hl7.org/fhir/3.0/StructureDefinition/extension-Claim.diagnosis.packageCode Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis #xD; diagnosisReference #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:alternateReference 0..1 Reference(Resource) STU3: Patient's diagnosis additional types URL: http://hl7.org/fhir/StructureDefinition/alternate-reference #xD; procedure #xD; procedureReference #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:alternateReference 0..1 Reference(Resource) STU3: Patient's list of procedures performed additional types URL: http://hl7.org/fhir/StructureDefinition/alternate-reference #xD; insurance #xD; coverage #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:coverage 0..1 Reference(Resource) STU3: coverage additional types URL: http://hl7.org/fhir/StructureDefinition/alternate-reference #xD; claimResponse #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:claimResponse 0..1 Reference(Resource) STU3: claimResponse additional types URL: http://hl7.org/fhir/StructureDefinition/alternate-reference #xD; accident #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:location 0..1 Address STU3: Accident Place additional types URL: http://hl7.org/fhir/3.0/StructureDefinition/extension-Claim.accident.location #xD; type #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:type 0..1 CodeableConcept STU3: type URL: http://hl7.org/fhir/3.0/StructureDefinition/extension-Claim.accident.type Binding: http://terminology.hl7.org/ValueSet/v3-ActIncidentCode|2.0.0 (required): Type of accident: work place, auto, etc. #xD; locationReference #xD; Slices for extension Content/Rules for all slices #xD; extension:alternateReference 0..1 Reference(Resource) STU3: Accident Place additional types URL: http://hl7.org/fhir/StructureDefinition/alternate-reference #xD; item #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:serviced 0..1 Period STU3: Date or dates of Service additional types URL: http://hl7.org/fhir/3.0/StructureDefinition/extension-Claim.item.serviced #xD; extension:location 0..1 Address STU3: Place of service additional types URL: http://hl7.org/fhir/3.0/StructureDefinition/extension-Claim.item.location #xD; extension:subSite 0..* CodeableConcept STU3: Service Sub-location (new) URL: http://hl7.org/fhir/3.0/StructureDefinition/extension-Claim.item.subSite Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations #xD; locationReference #xD; Slices for extension Content/Rules for all slices #xD; extension:alternateReference 0..1 Reference(Resource) STU3: Place of service additional types URL: http://hl7.org/fhir/StructureDefinition/alternate-reference #xD; udi #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:udi 0..* Reference(Resource) STU3: Unique Device Identifier additional types URL: http://hl7.org/fhir/StructureDefinition/alternate-reference #xD; encounter #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:encounter 0..* Reference(Resource) STU3: Encounters related to this billed item additional types URL: http://hl7.org/fhir/StructureDefinition/alternate-reference #xD; detail #xD; udi #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:udi 0..* Reference(Resource) STU3: Unique Device Identifier additional types URL: http://hl7.org/fhir/StructureDefinition/alternate-reference #xD; subDetail #xD; udi #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:udi 0..* Reference(Resource) STU3: Unique Device Identifier additional types URL: http://hl7.org/fhir/StructureDefinition/alternate-reference #xD; Documentation for this format
Cross-version Profile for STU3.Claim for use in FHIR R5
This cross-version profile allows STU3 Claim content to be represented via FHIR R5 Claim resources.
Claim, Pre-determination or Pre-authorization
A provider issued list of professional services and products which have been provided, or are to be provided, to a patient which is sent to an insurer for reimbursement.
The Claim resource fulfills three information request requirements: Claim - a request for adjudication for reimbursement for products and/or services provided; Preauthorization - a request to authorize the future provision of products and/or services including an anticipated adjudication; and, Predetermination - a request for a non-bind adjudication of possible future products and/or services.
If the resource is contained in another resource, it SHALL NOT contain nested Resources
If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().ofType(canonical) | %resource.descendants().ofType(uri) | %resource.descendants().ofType(url))) or descendants().where(reference = '#').exists() or descendants().where(ofType(canonical) = '#').exists() or descendants().where(ofType(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
If a resource is contained in another resource, it SHALL NOT have a security label
When a resource has no narrative, only systems that fully understand the data can display the resource to a human safely. Including a human readable representation in the resource makes for a much more robust eco-system and cheaper handling of resources by intermediary systems. Some ecosystems restrict distribution of resources to only those systems that do fully understand the resources, and as a consequence implementers may believe that the narrative is superfluous. However experience shows that such eco-systems often open up to new participants over time.
A resource should have narrative for robust management
The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
Within the context of the FHIR RESTful interactions, the resource has an id except for cases like the create and conditional update. Otherwise, the use of the resouce id depends on the given use case.
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.
All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Extensions are always sliced by (at least) url
Must have either extensions or value[x], not both
STU3: `Claim.meta` additional types (Meta) additional types from child elements (lastUpdated, profile, security, tag, versionId)
Element `Claim.meta` is mapped to FHIR R5 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.
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.
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.
When the resource last changed - e.g. when the version changed.
This element is generally omitted in instances submitted in a PUT or POST. Instead, it is populated in the response instance and when retrieving information using a GET. 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](http://hl7.org/fhir/R5/http.html#read) interaction.
Identifies where the resource comes from
A uri that identifies the source system of the resource. This provides a minimal amount of [Provenance](http://hl7.org/fhir/R5/provenance.html#) 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.
The exact use of the source (and the possible implied Provenance.entity.role and agent.role) is left to implementer discretion. Only one nominated source is allowed; for additional provenance details, a full Provenance resource should be used. The source may correspond to Provenance.entity.what[x] or Provenance.agent.who[x], though it may be a more general or abstract reference. 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.
Profiles this resource claims to conform to
A list of profiles (references to [StructureDefinition](http://hl7.org/fhir/R5/structuredefinition.html#) resources) that this resource claims to conform to. The URL is a reference to [StructureDefinition.url](http://hl7.org/fhir/R5/structuredefinition-definitions.html#StructureDefinition.url).
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.
Security Labels applied to this resource
Security labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure.
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.
Security Labels from the Healthcare Privacy and Security Classification System.
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.
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.
Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
A set of rules under which this content was created
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.
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 its narrative along with other profiles, value sets, etc.
This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies its meaning or interpretation
The base language in which the resource is written.
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).
Text summary of the resource, for human interpretation
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.
Contained resources do not have a 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.
STU3: `Claim.text` additional types (Narrative) additional types from child elements (div, status)
Element `Claim.text` is mapped to FHIR R5 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.
generated | extensions | additional | empty
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.
The actual narrative content, a stripped down version of XHTML.
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, 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.
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, elements (either name or href), images and internally contained style attributes
The narrative SHALL have some non-whitespace content
These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, nor can they have their own independent transaction scope. This is allowed to be a Parameters resource if and only if it is referenced by a resource that provides context/meaning.
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.
STU3: `Claim.organization` (new:Reference(Organization))
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 R5. Typically, this is because the element has been added (is a new element).
STU3: `Claim.employmentImpacted` (new:Period)
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 R5. Typically, this is because the element has been added (is a new element).
STU3: `Claim.hospitalization` (new:Period)
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 R5. Typically, this is because the element has been added (is a new element).
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 managable, 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).
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.
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](http://hl7.org/fhir/R5/extensibility.html#modifierExtension).
Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
A unique identifier assigned to this claim.
Allows claims to be distinguished and referenced.
STU3: `Claim.identifier` additional types (Identifier) additional types from child elements (assigner, period, system, type, use, value)
Element `Claim.identifier` is mapped to FHIR R5 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.
usual | official | temp | secondary | old (If known)
Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.
Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.
This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one.
Identifies the purpose for this identifier, if known .
A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.
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.
Allows users to make use of identifiers when the identifier system is not known.
A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
Establishes the namespace for the value - that is, an absolute URL that describes a set values that are unique.
Identifier.system is always case sensitive.
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.
The portion of the identifier typically relevant to the user and which is unique within the context of the system.
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 [http://hl7.org/fhir/StructureDefinition/rendered-value](http://hl7.org/fhir/extensions/StructureDefinition-rendered-value.html)). 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.
II.extension or II.root if system indicates OID or GUID (Or Role.id.extension or root)
Time period when id is/was valid for use
Time period during which identifier is/was valid for use.
Role.effectiveTime or implied by context
Organization that issued id (may be just text)
Organization that issued/manages the identifier.
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.
II.assigningAuthorityName but note that this is an improper use by the definition of the field. Also Role.scoper
Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners.
Allows partners to uniquely identify components for tracking.
active | cancelled | draft | entered-in-error
This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.
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'.
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
A code specifying the state of the resource instance.
The category of claim, e.g. oral, pharmacy, vision, institutional, professional.
The code system provides oral, pharmacy, vision, professional and institutional claim types. Those supported depends on the requirements of the jurisdiction. The valueset is extensible to accommodate other types of claims as required by the jurisdiction.
Claim type determine the general sets of business rules applied for information requirements and adjudication.
The type or discipline-style of the claim.
Element `Claim.type` is mapped to FHIR R5 element `Claim.type` as `Equivalent`. Affects which fields and value sets are used.
A reference to a code defined by a terminology system.
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.
Allows for alternative encodings within a code system, and translations to other code systems.
fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
Plain text representation of the concept
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.
Very often the text is the same as a displayName of one of the codings.
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.
C*E.9. But note many systems use C*E.2 for this
fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.
This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.
Some jurisdictions need a finer grained claim type for routing and adjudication.
claim | preauthorization | predetermination
A code to indicate whether the nature of the request is: Claim - A request to an Insurer to adjudicate the supplied charges for health care goods and services under the identified policy and to pay the determined Benefit amount, if any; Preauthorization - A request to an Insurer to adjudicate the supplied proposed future charges for health care goods and services under the identified policy and to approve the services and provide the expected benefit amounts and potentially to reserve funds to pay the benefits when Claims for the indicated services are later submitted; or, Pre-determination - A request to an Insurer to adjudicate the supplied 'what if' charges for health care goods and services under the identified policy and report back what the Benefit payable would be had the services actually been provided.
This element is required to understand the nature of the request for adjudication.
The purpose of the Claim: predetermination, preauthorization, claim.
unique id for the element within a resource (for internal references)
STU3: complete | proposed | exploratory | other
Element `Claim.use` is mapped to FHIR R5 element `Claim.use` as `SourceIsBroaderThanTarget`.
The recipient of the products and services
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.
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.
STU3: The subject of the Products and Services additional types
STU3: `Claim.patient` additional types from child elements (display, identifier, reference)
Element `Claim.patient` is mapped to FHIR R5 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.
Literal reference, Relative, internal or absolute URL
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.
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.
Type the reference refers to (e.g. "Patient") - must be a resource in resources
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).
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 known RESTful URL) or by resolving the target of the reference.
Aa resource (or, for logical models, the URI of the logical model).
Logical reference, when literal reference is not known
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.
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). This element only allows for a single identifier. In the case where additional identifers are required, use the [http://hl7.org/fhir/StructureDefinition/additionalIdentifier](http://hl7.org/fhir/extensions/StructureDefinition-additionalIdentifier.html) extension.
Plain text narrative that identifies the resource in addition to the resource reference.
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.
The period for which charges are being submitted.
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.
A number jurisdictions required the submission of the billing period when submitting claims for example for hospital stays or long-term care.
STU3: Period for charge submission additional types
STU3: `Claim.billablePeriod` additional types (Period) additional types from child elements (end, start)
Element `Claim.billablePeriod` is mapped to FHIR R5 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.
The start of the period. The boundary is inclusive.
If the low element is missing, the meaning is that the low boundary is not known.
End time with inclusive boundary, if not ongoing
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.
The end 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.
If the end of the period is missing, it means that the period is ongoing
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.
Need to record a timestamp for use by both the recipient and the issuer.
Individual who created the claim, predetermination or preauthorization.
Some jurisdictions require the contact information for personnel completing claims.
STU3: `Claim.enterer` additional types from child elements (display, identifier, reference)
Element `Claim.enterer` is mapped to FHIR R5 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.
The Insurer who is target of the request.
STU3: `Claim.insurer` additional types from child elements (display, identifier, reference)
Element `Claim.insurer` is mapped to FHIR R5 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.
The provider which is responsible for the claim, predetermination or preauthorization.
Typically this field would be 1..1 where this party is accountable for the data content within the claim but is not necessarily the facility, provider group or practitioner who provided the products and services listed within this claim resource. This field is the Billing Provider, for example, a facility, provider group, lab or practitioner.
STU3: Responsible provider additional types
STU3: `Claim.provider` additional types from child elements (display, identifier, reference)
Element `Claim.provider` is mapped to FHIR R5 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.
The provider-required urgency of processing the request. Typical values include: stat, normal, deferred.
If a claim processor is unable to complete the processing as per the priority then they should generate an error and not process the request.
The provider may need to indicate their processing requirements so that the processor can indicate if they are unable to comply.
The timeliness with which processing is required: stat, normal, deferred.
A code to indicate whether and for whom funds are to be reserved for future claims.
This field is only used for preauthorizations.
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.
For whom funds are to be reserved: (Patient, Provider, None).
Other claims which are related to this claim such as prior submissions or claims for related services or for the same event.
For example, for the original treatment and follow-up exams.
For workplace or other accidents it is common to relate separate claims arising from the same event.
Additional content defined by implementations
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 managable, 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.
Extensions that cannot be ignored even if unrecognized
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 managable, 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).
Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
STU3: `Claim.related.claim` additional types from child elements (display, identifier, reference)
Element `Claim.related.claim` is mapped to FHIR R5 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?
A code to convey how the claims are related.
Some insurers need a declaration of the type of relationship.
Relationship of this claim to a related Claim.
An alternate organizational reference to the case or file to which this particular claim pertains.
For example, Property/Casualty insurer claim # or Workers Compensation case # .
In cases where an event-triggered claim is being submitted to an insurer which requires a reference number to be specified on all exchanges.
STU3: Related file or case reference additional types
STU3: `Claim.related.reference` additional types (Identifier) additional types from child elements (assigner, period, system, type, use, value)
Element `Claim.related.reference` is mapped to FHIR R5 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.
Prescription authorizing services and products
Prescription is the document/authorization given to the claim author for them to provide products and services for which consideration (reimbursement) is sought. Could be a RX for medications, an 'order' for oxygen or wheelchair or physiotherapy treatments.
Required to authorize the dispensing of controlled substances and devices.
STU3: Prescription authorizing services or products additional types
STU3: `Claim.prescription` additional types from child elements (display, identifier, reference)
Element `Claim.prescription` is mapped to FHIR R5 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.
Original prescription if superseded by fulfiller
Original prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or products.
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'.
Often required when a fulfiller varies what is fulfilled from that authorized on the original prescription.
STU3: Original prescription if superceded by fulfiller additional types
STU3: `Claim.originalPrescription` additional types from child elements (display, identifier, reference)
Element `Claim.originalPrescription` is mapped to FHIR R5 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.
The party to be reimbursed for cost of the products and services according to the terms of the policy.
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.
The provider needs to specify who they wish to be reimbursed and the claims processor needs express who they will reimburse.
Type of Party to be reimbursed: subscriber, provider, other.
Need to know who should receive payment with the most common situations being the Provider (assignment of benefits) or the Subscriber.
Reference to the individual or organization to whom any payment will be made.
Not required if the payee is 'subscriber' or 'provider'.
Need to provide demographics if the payee is not 'subscriber' nor 'provider'.
STU3: organization | patient | practitioner | relatedperson additional types
STU3: `Claim.payee.resourceType` additional types (Coding) additional types from child elements (code, display, system, userSelected, version)
Element `Claim.payee.resourceType` is mapped to FHIR R5 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.
Element `Claim.payee.party` is mapped to FHIR R5 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.
The referral information received by the claim author, it is not to be used when the author generates a referral for a patient. A copy of that referral may be provided as supporting information. Some insurers require proof of referral to pay for services or to pay specialist rates for services.
The referral resource which lists the date, practitioner, reason and other supporting information.
Some insurers require proof of referral to pay for services or to pay specialist rates for services.
STU3: Treatment Referral additional types
STU3: `Claim.referral` additional types from child elements (display, identifier, reference)
Element `Claim.referral` is mapped to FHIR R5 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.
Encounters associated with the listed treatments
Healthcare encounters related to this claim.
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.
Used in some jurisdictions to link clinical events to claim items.
Facility where the services were provided.
Insurance adjudication can be dependant on where services were delivered.
STU3: Servicing Facility additional types
STU3: `Claim.facility` additional types from child elements (display, identifier, reference)
Element `Claim.facility` is mapped to FHIR R5 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.
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.
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.
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.
Information code for an event with a corresponding date or period.
A coded event such as when a service is expected or a card printed.
A date or period in the past or future indicating when the event occurred or is expectd to occur.
The members of the team who provided the products and services.
Common to identify the responsible and supporting practitioners.
A number to uniquely identify care team entries.
Necessary to maintain the order of the care team and provide a mechanism to link individuals to claim details.
Member of the team who provided the product or service.
Often a regulatory requirement to specify the responsible provider.
STU3: Provider individual or organization additional types
STU3: `Claim.careTeam.provider` additional types from child elements (display, identifier, reference)
Element `Claim.careTeam.provider` is mapped to FHIR R5 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.
The party who is billing and/or responsible for the claimed products or services.
Responsible might not be required when there is only a single provider listed.
When multiple parties are present it is required to distinguish the lead or responsible individual.
The lead, assisting or supervising practitioner and their discipline if a multidisciplinary team.
Role might not be required when there is only a single provider listed.
When multiple parties are present it is required to distinguish the roles performed by each member.
The role codes for the care team members.
The specialization of the practitioner or provider which is applicable for this service.
Need to specify which specialization a practitioner or provider acting under when delivering the product or service.
Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.
Often there are multiple jurisdiction specific valuesets which are required.
Typically these information codes are required to support the services rendered or the adjudication of the services rendered.
Attachments Exception Codes Occurrence Codes Value codes
STU3: `Claim.information.timing[x]` additional types (Period) additional types from child elements (end, start)
Element `Claim.information.timing[x]` is mapped to FHIR R5 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`.
STU3: Additional Data or supporting information additional types
STU3: `Claim.information.value[x]` additional types (Attachment)
Element `Claim.information.value[x]` is mapped to FHIR R5 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.
A number to uniquely identify supporting information entries.
Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details.
Classification of the supplied information
The general class of the information supplied: information; exception; accident, employment; onset, etc.
This may contain a category for the local bill type codes.
Required to group or associate information items with common characteristics. For example: admission information or prior treatments.
The valuset used for additional information category codes.
System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought.
Required to identify the kind of additional information.
The valuset used for additional information codes.
The date when or period to which this information refers.
Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.
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.
To convey the data content to be provided when the information is more than a simple code or period.
Provides the reason in the situation where a reason code is required in addition to the content.
For example: the reason for the additional stay, or why a tooth is missing.
Needed when the supporting information has both a date and amount/value and requires explanation.
Information about diagnoses relevant to the claim items.
Required for the adjudication by provided context for the services and product listed.
STU3: `Claim.diagnosis.packageCode` (new:CodeableConcept)
Element `Claim.diagnosis.packageCode` has a context of Claim.diagnosis based on following the parent source element upwards and mapping to `Claim`. Element `Claim.diagnosis.packageCode` has no mapping targets in FHIR R5. Typically, this is because the element has been added (is a new element).
A number to uniquely identify diagnosis entries.
Diagnosis are presented in list order to their expected importance: primary, secondary, etc.
Necessary to maintain the order of the diagnosis items and provide a mechanism to link to claim details.
The nature of illness or problem in a coded form or as a reference to an external defined Condition.
Provides health context for the evaluation of the products and/or services.
STU3: Patient's diagnosis additional types
STU3: `Claim.diagnosis.diagnosis[x]` additional types from child elements (display, identifier, reference)
Element `Claim.diagnosis.diagnosis[x]` is mapped to FHIR R5 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.
When the condition was observed or the relative ranking.
For example: admitting, primary, secondary, discharge.
Often required to capture a particular diagnosis, for example: primary or discharge.
The type of the diagnosis: admitting, principal, discharge.
Indication of whether the diagnosis was present on admission to a facility.
Many systems need to understand for adjudication if the diagnosis was present a time of admission.
Procedures performed on the patient relevant to the billing items with the claim.
The specific clinical invention are sometimes required to be provided to justify billing a greater than customary amount for a service.
A number to uniquely identify procedure entries.
Necessary to provide a mechanism to link to claim details.
Date and optionally time the procedure was performed.
The code or reference to a Procedure resource which identifies the clinical intervention performed.
This identifies the actual clinical procedure.
STU3: Patient's list of procedures performed additional types
STU3: `Claim.procedure.procedure[x]` additional types from child elements (display, identifier, reference)
Element `Claim.procedure.procedure[x]` is mapped to FHIR R5 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.
Unique Device Identifiers associated with this line item.
The UDI code allows the insurer to obtain device level information on the product supplied.
Financial instruments for reimbursement for the health care products and services specified on the claim.
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.
At least one insurer is required for a claim to be a claim.
A number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order.
A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.
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.
To identify which coverage in the list is being used to adjudicate this claim.
The business identifier to be used when the claim is sent for adjudication against this insurance policy.
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'.
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.
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.
Required to allow the adjudicator to locate the correct policy and history within their information system.
STU3: `Claim.insurance.coverage` additional types from child elements (display, identifier, reference)
Element `Claim.insurance.coverage` is mapped to FHIR R5 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.
A business agreement number established between the provider and the insurer for special business processing purposes.
Providers may have multiple business arrangements with a given insurer and must supply the specific contract number for adjudication.
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.
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.
Providers must quote previously issued authorization reference numbers in order to obtain adjudication as previously advised on the Preauthorization.
The result of the adjudication of the line items for the Coverage specified in this insurance.
Must not be specified when 'focal=true' for this insurance.
An insurer need the adjudication results from prior insurers to determine the outstanding balance remaining by item for the items in the curent claim.
STU3: `Claim.insurance.claimResponse` additional types from child elements (display, identifier, reference)
Element `Claim.insurance.claimResponse` is mapped to FHIR R5 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.
Details of an accident which resulted in injuries which required the products and services listed in the claim.
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.
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)
Element `Claim.accident.location[x]` is mapped to FHIR R5 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.
Date of an accident event related to the products and services contained in the claim.
The date of the accident has to precede the dates of the products and services but within a reasonable timeframe.
Required for audit purposes and adjudication.
The type or context of the accident event for the purposes of selection of potential insurance coverages and determination of coordination between insurers.
Coverage may be dependant on the type of accident.
Type of accident: work place, auto, etc.
Element `Claim.accident.type` is mapped to FHIR R5 element `Claim.accident.type` as `Equivalent`.
The physical location of the accident event.
Required for audit purposes and determination of applicable insurance liability.
The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services.
Necessary to demonstrate that copayments, co-insurance and similar patient payments have been made or accounted for.
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.
The items to be processed for adjudication.
STU3: Date or dates of Service additional types
STU3: `Claim.item.serviced[x]` additional types (Period) additional types from child elements (end, start)
Element `Claim.item.serviced[x]` is mapped to FHIR R5 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`.
STU3: `Claim.item.location[x]` additional types (Address)
Element `Claim.item.location[x]` is mapped to FHIR R5 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.
STU3: `Claim.item.subSite` (new:CodeableConcept)
Element `Claim.item.subSite` has a context of Claim.item based on following the parent source element upwards and mapping to `Claim`. Element `Claim.item.subSite` has no mapping targets in FHIR R5. Typically, this is because the element has been added (is a new element).
A number to uniquely identify item entries.
Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse.
CareTeam members related to this service or product.
Need to identify the individuals and their roles in the provision of the product or service.
Diagnosis applicable for this service or product.
Need to related the product or service to the associated diagnoses.
Procedures applicable for this service or product.
Need to provide any listed specific procedures to support the product or service being claimed.
Applicable exception and supporting information
Exceptions, special conditions and supporting information applicable for this service or product.
Need to reference the supporting information items that relate directly to this product or service.
The type of revenue or cost center providing the product and/or service.
Needed in the processing of institutional claims.
Codes for the revenue or cost centers supplying the service and/or products.
Code to identify the general type of benefits under which products and services are provided.
Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.
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.
Benefit categories such as: oral-basic, major, glasses.
When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used.
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'.
Necessary to state what was provided or done.
This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claims.
End of a range of Drug Code; Bill Code; Service Cod
Request or Referral for Goods or Service to be rendered.
May identify the service to be provided or provider authorization for the service.
Item typification or modifiers codes to convey additional context for the product or service.
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.
To support inclusion of the item for adjudication or to charge an elevated fee.
Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
Program the product or service is provided under
Identifies the program under which this may be recovered.
For example: Neonatal program, child dental program or drug users recovery program.
Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.
Date or dates of service or product delivery
The date or dates when the service or product was supplied, performed or completed.
Needed to determine whether the service or product was provided during the term of the insurance coverage.
Place of service or where product was supplied
Where the product or service was provided.
The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount.
Place of service: pharmacy, school, prison, etc.
The number of repetitions of a service or product.
Required when the product or service code does not convey the quantity provided.
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.
The amount charged to the patient by the provider for a single unit.
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.
To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.
The total of taxes applicable for this product or service.
Required when taxes are not embedded in the unit price or provided as a separate service.
The total amount claimed for the group (if a grouper) or the line item. Net = unit price * quantity * factor.
For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
Provides the total amount claimed for the group (if a grouper) or the line item.
STU3: Unique Device Identifier additional types
STU3: `Claim.item.udi` additional types from child elements (display, identifier, reference)
Element `Claim.item.udi` is mapped to FHIR R5 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.
Physical location where the service is performed or applies.
Physical service site on the patient (limb, tooth, etc.).
For example: Providing a tooth code, allows an insurer to identify a provider performing a filling on a tooth that was previously removed.
Allows insurer to validate specific procedures.
A region or surface of the bodySite, e.g. limb region or tooth surface(s).
STU3: Encounters related to this billed item additional types
STU3: `Claim.item.encounter` additional types from child elements (display, identifier, reference)
Element `Claim.item.encounter` is mapped to FHIR R5 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.
A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.
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.
The total amount claimed for the group (if a grouper) or the line item.detail. Net = unit price * quantity * factor.
STU3: `Claim.item.detail.udi` additional types from child elements (display, identifier, reference)
Element `Claim.item.detail.udi` is mapped to FHIR R5 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.
The total amount claimed for line item.detail.subDetail. Net = unit price * quantity * factor.
STU3: `Claim.item.detail.subDetail.udi` additional types from child elements (display, identifier, reference)
Element `Claim.item.detail.subDetail.udi` is mapped to FHIR R5 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.
The total value of the all the items in the claim.