Name Flags Card. Type Description & Constraints doco
. . Claim TU DomainResource Claim, Pre-determination or Pre-authorization
Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
. . . identifier 0..* Identifier Business Identifier for claim
. . . status ?! Σ 1..1 code active | cancelled | draft | entered-in-error
Financial Resource Status Codes ( Required)
. . . type Σ 1..1 CodeableConcept Category or discipline
Claim Type Codes ( Extensible)
. . . subType 0..1 CodeableConcept More granular claim type
Example Claim SubType Codes ( Example)
. . . use Σ 1..1 code claim | preauthorization | predetermination
Use ( Required)
. . . patient Σ 1..1 Reference( Patient) The recipient of the products and services
. . . billablePeriod Σ 0..1 Period Relevant time frame for the claim
. . . created Σ 1..1 dateTime Resource creation date
. . . enterer 0..1 Reference( Practitioner | PractitionerRole) Author of the claim
. . . insurer Σ 0..1 Reference( Organization) Target
. . . provider Σ 1..1 Reference( Practitioner | PractitionerRole | Organization) Party responsible for the claim
. . . priority Σ 1..1 CodeableConcept Desired processing ugency
Process Priority Codes ( Example)
. . . fundsReserve 0..1 CodeableConcept For whom to reserve funds
FundsReserve ( Example)
. . . related 0..* BackboneElement Prior or corollary claims
. . . . claim 0..1 Reference( Claim) Reference to the related claim
. . . . relationship 0..1 CodeableConcept How the reference claim is related
Example Related Claim Relationship Codes ( Example)
. . . . reference 0..1 Identifier File or case reference
. . . prescription 0..1 Reference( DeviceRequest | MedicationRequest | VisionPrescription) Prescription authorizing services and products
. . . originalPrescription 0..1 Reference( DeviceRequest | MedicationRequest | VisionPrescription) Original prescription if superseded by fulfiller
. . . payee 0..1 BackboneElement Recipient of benefits payable
. . . . type 1..1 CodeableConcept Category of recipient
PayeeType ( Example)
. . . . party 0..1 Reference( Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) Recipient reference
. . . referral 0..1 Reference( ServiceRequest) Treatment referral
. . . facility 0..1 Reference( Location) Servicing facility
. . . careTeam 0..* BackboneElement Members of the care team
. . . . sequence 1..1 positiveInt Order of care team
. . . . provider 1..1 Reference( Practitioner | PractitionerRole | Organization) Practitioner or organization
. . . . responsible 0..1 boolean Indicator of the lead practitioner
. . . . role 0..1 CodeableConcept Function within the team
Claim Care Team Role Codes ( Example)
. . . . qualification 0..1 CodeableConcept Practitioner credential or specialization
Example Provider Qualification Codes ( Example)
. . . supportingInfo 0..* BackboneElement Supporting information
. . . . sequence 1..1 positiveInt Information instance identifier
. . . . category 1..1 CodeableConcept Classification of the supplied information
Claim Information Category Codes ( Example)
. . . . code 0..1 CodeableConcept Type of information
Exception Codes ( Example)
. . . . timing[x] 0..1 When it occurred
. . . . . timingDate date
. . . . . timingPeriod Period
. . . . value[x] 0..1 Data to be provided
. . . . . valueBoolean boolean
. . . . . valueString string
. . . . . valueQuantity Quantity
. . . . . valueAttachment Attachment
. . . . . valueReference Reference( Any)
. . . . reason 0..1 CodeableConcept Explanation for the information
Missing Tooth Reason Codes ( Example)
. . . diagnosis 0..* BackboneElement Pertinent diagnosis information
. . . . sequence 1..1 positiveInt Diagnosis instance identifier
. . . . diagnosis[x] 1..1 Nature of illness or problem
ICD-10 Codes ( Example)
. . . . . diagnosisCodeableConcept CodeableConcept
. . . . . diagnosisReference Reference( Condition)
. . . . type 0..* CodeableConcept Timing or nature of the diagnosis
Example Diagnosis Type Codes ( Example)
. . . . onAdmission 0..1 CodeableConcept Present on admission
Example Diagnosis on Admission Codes ( Example)
. . . . packageCode 0..1 CodeableConcept Package billing code
Example Diagnosis Related Group Codes ( Example)
. . . procedure 0..* BackboneElement Clinical procedures performed
. . . . sequence 1..1 positiveInt Procedure instance identifier
. . . . type 0..* CodeableConcept Category of Procedure
Example Procedure Type Codes ( Example)
. . . . date 0..1 dateTime When the procedure was performed
. . . . procedure[x] 1..1 Specific clinical procedure
ICD-10 Procedure Codes ( Example)
. . . . . procedureCodeableConcept CodeableConcept
. . . . . procedureReference Reference( Procedure)
. . . . udi 0..* Reference( Device) Unique device identifier
. . . insurance Σ 1..* BackboneElement Patient insurance information
. . . . sequence Σ 1..1 positiveInt Insurance instance identifier
. . . . focal Σ 1..1 boolean Coverage to be used for adjudication
. . . . identifier 0..1 Identifier Pre-assigned Claim number
. . . . coverage Σ 1..1 Reference( Coverage) Insurance information
. . . . businessArrangement 0..1 string Additional provider contract number
. . . . preAuthRef 0..* string Prior authorization reference number
. . . . claimResponse 0..1 Reference( ClaimResponse) Adjudication results
. . . accident 0..1 BackboneElement Details of the event
. . . . date 1..1 date When the incident occurred
. . . . type 0..1 CodeableConcept The nature of the accident
V3 Value SetActIncidentCode ( Extensible)
. . . . location[x] 0..1 Where the event occurred
. . . . . locationAddress Address
. . . . . locationReference Reference( Location)
. . . item 0..* BackboneElement Product or service provided
. . . . sequence 1..1 positiveInt Item instance identifier
. . . . careTeamSequence 0..* positiveInt Applicable careTeam members
. . . . diagnosisSequence 0..* positiveInt Applicable diagnoses
. . . . procedureSequence 0..* positiveInt Applicable procedures
. . . . informationSequence 0..* positiveInt Applicable exception and supporting information
. . . . revenue 0..1 CodeableConcept Revenue or cost center code
Example Revenue Center Codes ( Example)
. . . . category 0..1 CodeableConcept Benefit classification
Benefit Category Codes ( Example)
. . . . productOrService 1..1 CodeableConcept Billing, service, product, or drug code
USCLS Codes ( Example)
. . . . modifier 0..* CodeableConcept Product or service billing modifiers
Modifier type Codes ( Example)
. . . . programCode 0..* CodeableConcept Program the product or service is provided under
Example Program Reason Codes ( Example)
. . . . serviced[x] 0..1 Date or dates of service or product delivery
. . . . . servicedDate date
. . . . . servicedPeriod Period
. . . . location[x] 0..1 Place of service or where product was supplied
Example Service Place Codes ( Example)
. . . . . locationCodeableConcept CodeableConcept
. . . . . locationAddress Address
. . . . . locationReference Reference( Location)
. . . . quantity 0..1 SimpleQuantity Count of products or services
. . . . unitPrice 0..1 Money Fee, charge or cost per item
. . . . factor 0..1 decimal Price scaling factor
. . . . net 0..1 Money Total item cost
. . . . udi 0..* Reference( Device) Unique device identifier
. . . . bodySite 0..1 CodeableConcept Anatomical location
Oral Site Codes ( Example)
. . . . subSite 0..* CodeableConcept Anatomical sub-location
Surface Codes ( Example)
. . . . encounter 0..* Reference( Encounter) Encounters related to this billed item
. . . . detail 0..* BackboneElement Product or service provided
. . . . . sequence 1..1 positiveInt Item instance identifier
. . . . . revenue 0..1 CodeableConcept Revenue or cost center code
Example Revenue Center Codes ( Example)
. . . . . category 0..1 CodeableConcept Benefit classification
Benefit Category Codes ( Example)
. . . . . productOrService 1..1 CodeableConcept Billing, service, product, or drug code
USCLS Codes ( Example)
. . . . . modifier 0..* CodeableConcept Service/Product billing modifiers
Modifier type Codes ( Example)
. . . . . programCode 0..* CodeableConcept Program the product or service is provided under
Example Program Reason Codes ( Example)
. . . . . quantity 0..1 SimpleQuantity Count of products or services
. . . . . unitPrice 0..1 Money Fee, charge or cost per item
. . . . . factor 0..1 decimal Price scaling factor
. . . . . net 0..1 Money Total item cost
. . . . . udi 0..* Reference( Device) Unique device identifier
. . . . . subDetail 0..* BackboneElement Product or service provided
. . . . . . sequence 1..1 positiveInt Item instance identifier
. . . . . . revenue 0..1 CodeableConcept Revenue or cost center code
Example Revenue Center Codes ( Example)
. . . . . . category 0..1 CodeableConcept Benefit classification
Benefit Category Codes ( Example)
. . . . . . productOrService 1..1 CodeableConcept Billing, service, product, or drug code
USCLS Codes ( Example)
. . . . . . modifier 0..* CodeableConcept Service/Product billing modifiers
Modifier type Codes ( Example)
. . . . . . programCode 0..* CodeableConcept Program the product or service is provided under
Example Program Reason Codes ( Example)
. . . . . . quantity 0..1 SimpleQuantity Count of products or services
. . . . . . unitPrice 0..1 Money Fee, charge or cost per item
. . . . . . factor 0..1 decimal Price scaling factor
. . . . . . net 0..1 Money Total item cost
. . . . . . udi 0..* Reference( Device) Unique device identifier
. . . total 0..1 Money Total claim cost

doco Documentation for this format