This page is part of the FHIR Specification (v5.0.0: R5 - STU). This is the current published version in it's permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2
Financial Management Work Group | Maturity Level: 2 | Trial Use | Security Category: Patient | Compartments: Device, Encounter, Patient, Practitioner, RelatedPerson |
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 is used by providers and payors, insurers, to exchange the financial information, and supporting clinical information, regarding the provision of health care services with payors and for reporting to regulatory bodies and firms which provide data analytics. The primary uses of this resource is to support eClaims, the exchange of information relating to the proposed or actual provision of healthcare-related goods and services for patients to their benefit payors, insurers and national health programs, for treatment payment planning and reimbursement.
The Claim resource is a "request" resource from a FHIR workflow perspective - see Workflow Request.
The Claim resource may be interpreted differently depending on its intended use (and the Claim.use element contains the code to indicate):
The Claim.type code system provides oral, pharmacy, vision, professional and institutional claim types. Claim types supported are influenced by the requirements of the implementing jurisdiction. The valueset is extensible to accommodate other types of claims as required by the jurisdiction.
The Claim also supports:
Mapping to other Claim specifications: Mappings are currently maintained by the Financial Management Work Group to UB04 and CMS1500 and are available at https://confluence.hl7.org/display/FM/FHIR+Resource+Development . Mappings to other specifications may be made available where IP restrictions permit.
Additional information regarding electronic claims content and usage may be found at:
The Claim resource is used to request the adjudication and/or authorization of a set of healthcare-related goods and services for a patient against the patient's insurance coverages, or to request what the adjudication would be for a supplied set of goods or services should they be actually supplied to the patient.
When requesting whether the patient's coverage is inforce, whether it is valid at this or a specified date, or requesting the benefit details or preauthorization requirements associated with a coverage, then CoverageEligibilityRequest should be used instead.
When using the resources for reporting and transferring claims data, which may have originated in some standard other than FHIR, the Claim resource is useful if only the request side of the information exchange is of interest. If, however, both the request and the adjudication information is to be reported then the ExplanationOfBenefit should be used instead.
For reporting out to patients or transferring data to patient centered applications, such as Personal Health Record (PHR) application, the ExplanationOfBenefit should be used instead of the Claim and ClaimResponse resources as those resources may contain provider and payer specific information which is not appropriate for sharing with the patient.
The eClaim domain includes a number of related resources
Claim | A suite of goods and services and insurances coverages under which adjudication or authorization is requested. |
CoverageEligibilityRequest | A request to a payor to: ascertain whether a coverage is in-force at the current or at a specified time; list the table of benefits; determine whether coverage is provided for specified categories or specific services; and whether preauthorization is required, and if so what supporting information would be required. |
ClaimResponse | A payor's adjudication and/or authorization response to the suite of services provided in a Claim. Typically the ClaimResponse references the Claim but does not duplicate the clinical or financial information provided in the claim. |
ExplanationOfBenefit | This resource combines the information from the Claim and the ClaimResponse, stripping out any provider or payor proprietary information, into a unified information model suitable for use for: patient reporting; transferring information to a Patient Health Record system; and, supporting complete claim and adjudication information exchange with regulatory and analytics organizations and other parts of the provider's organization. |
Structure
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
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 | |
traceNumber | 0..* | Identifier | Number for tracking | |
status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: Financial Resource Status Codes (Required) |
type | Σ | 1..1 | CodeableConcept | Category or discipline Binding: Claim Type Codes (Extensible) |
subType | 0..1 | CodeableConcept | More granular claim type Binding: Example Claim SubType Codes (Example) | |
use | Σ | 1..1 | code | claim | preauthorization | predetermination Binding: 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 | Patient | RelatedPerson) | Author of the claim | |
insurer | Σ | 0..1 | Reference(Organization) | Target |
provider | Σ | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim |
priority | Σ | 0..1 | CodeableConcept | Desired processing urgency Binding: Process Priority Codes (Example) |
fundsReserve | 0..1 | CodeableConcept | For whom to reserve funds Binding: Funds Reservation Codes (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 Binding: 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 Binding: Claim Payee Type Codes (Example) | |
party | 0..1 | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) | Recipient reference | |
referral | 0..1 | Reference(ServiceRequest) | Treatment referral | |
encounter | 0..* | Reference(Encounter) | Encounters associated with the listed treatments | |
facility | 0..1 | Reference(Location | Organization) | Servicing facility | |
diagnosisRelatedGroup | 0..1 | CodeableConcept | Package billing code Binding: Example Diagnosis Related Group Codes (Example) | |
event | 0..* | BackboneElement | Event information | |
type | 1..1 | CodeableConcept | Specific event Binding: Dates Type Codes (Example) | |
when[x] | 1..1 | Occurance date or period | ||
whenDateTime | dateTime | |||
whenPeriod | Period | |||
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 Binding: Claim Care Team Role Codes (Example) | |
specialty | 0..1 | CodeableConcept | Practitioner or provider specialization Binding: 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 Binding: Claim Information Category Codes (Example) | |
code | 0..1 | CodeableConcept | Type of information Binding: 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) | |||
valueIdentifier | Identifier | |||
reason | 0..1 | CodeableConcept | Explanation for the information Binding: 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 Binding: ICD-10 Codes (Example) | ||
diagnosisCodeableConcept | CodeableConcept | |||
diagnosisReference | Reference(Condition) | |||
type | 0..* | CodeableConcept | Timing or nature of the diagnosis Binding: Example Diagnosis Type Codes (Example) | |
onAdmission | 0..1 | CodeableConcept | Present on admission Binding: Example Diagnosis on Admission Codes (Example) | |
procedure | 0..* | BackboneElement | Clinical procedures performed | |
sequence | 1..1 | positiveInt | Procedure instance identifier | |
type | 0..* | CodeableConcept | Category of Procedure Binding: Example Procedure Type Codes (Example) | |
date | 0..1 | dateTime | When the procedure was performed | |
procedure[x] | 1..1 | Specific clinical procedure Binding: ICD-10 Procedure Codes (Example) | ||
procedureCodeableConcept | CodeableConcept | |||
procedureReference | Reference(Procedure) | |||
udi | 0..* | Reference(Device) | Unique device identifier | |
insurance | Σ | 0..* | 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 Binding: ActIncidentCode (Extensible) | |
location[x] | 0..1 | Where the event occurred | ||
locationAddress | Address | |||
locationReference | Reference(Location) | |||
patientPaid | 0..1 | Money | Paid by the patient | |
item | 0..* | BackboneElement | Product or service provided | |
sequence | 1..1 | positiveInt | Item instance identifier | |
traceNumber | 0..* | Identifier | Number for tracking | |
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 Binding: Example Revenue Center Codes (Example) | |
category | 0..1 | CodeableConcept | Benefit classification Binding: Benefit Category Codes (Example) | |
productOrService | 0..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLS Codes (Example) | |
productOrServiceEnd | 0..1 | CodeableConcept | End of a range of codes Binding: USCLS Codes (Example) | |
request | 0..* | Reference(DeviceRequest | MedicationRequest | NutritionOrder | ServiceRequest | SupplyRequest | VisionPrescription) | Request or Referral for Service | |
modifier | 0..* | CodeableConcept | Product or service billing modifiers Binding: Modifier type Codes (Example) | |
programCode | 0..* | CodeableConcept | Program the product or service is provided under Binding: 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 Binding: Example Service Place Codes (Example) | ||
locationCodeableConcept | CodeableConcept | |||
locationAddress | Address | |||
locationReference | Reference(Location) | |||
patientPaid | 0..1 | Money | Paid by the patient | |
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 | |
tax | 0..1 | Money | Total tax | |
net | 0..1 | Money | Total item cost | |
udi | 0..* | Reference(Device) | Unique device identifier | |
bodySite | 0..* | BackboneElement | Anatomical location | |
site | 1..* | CodeableReference(BodyStructure) | Location Binding: Oral Site Codes (Example) | |
subSite | 0..* | CodeableConcept | Sub-location Binding: Surface Codes (Example) | |
encounter | 0..* | Reference(Encounter) | Encounters associated with the listed treatments | |
detail | 0..* | BackboneElement | Product or service provided | |
sequence | 1..1 | positiveInt | Item instance identifier | |
traceNumber | 0..* | Identifier | Number for tracking | |
revenue | 0..1 | CodeableConcept | Revenue or cost center code Binding: Example Revenue Center Codes (Example) | |
category | 0..1 | CodeableConcept | Benefit classification Binding: Benefit Category Codes (Example) | |
productOrService | 0..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLS Codes (Example) | |
productOrServiceEnd | 0..1 | CodeableConcept | End of a range of codes Binding: USCLS Codes (Example) | |
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: Modifier type Codes (Example) | |
programCode | 0..* | CodeableConcept | Program the product or service is provided under Binding: Example Program Reason Codes (Example) | |
patientPaid | 0..1 | Money | Paid by the patient | |
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 | |
tax | 0..1 | Money | Total tax | |
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 | |
traceNumber | 0..* | Identifier | Number for tracking | |
revenue | 0..1 | CodeableConcept | Revenue or cost center code Binding: Example Revenue Center Codes (Example) | |
category | 0..1 | CodeableConcept | Benefit classification Binding: Benefit Category Codes (Example) | |
productOrService | 0..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLS Codes (Example) | |
productOrServiceEnd | 0..1 | CodeableConcept | End of a range of codes Binding: USCLS Codes (Example) | |
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: Modifier type Codes (Example) | |
programCode | 0..* | CodeableConcept | Program the product or service is provided under Binding: Example Program Reason Codes (Example) | |
patientPaid | 0..1 | Money | Paid by the patient | |
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 | |
tax | 0..1 | Money | Total tax | |
net | 0..1 | Money | Total item cost | |
udi | 0..* | Reference(Device) | Unique device identifier | |
total | 0..1 | Money | Total claim cost | |
Documentation for this format |
See the Extensions for this resource
UML Diagram (Legend)
XML Template
<Claim xmlns="http://hl7.org/fhir"> <!-- from Resource: id, meta, implicitRules, and language --> <!-- from DomainResource: text, contained, extension, and modifierExtension --> <identifier><!-- 0..* Identifier Business Identifier for claim --></identifier> <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber> <status value="[code]"/><!-- 1..1 active | cancelled | draft | entered-in-error --> <type><!-- 1..1 CodeableConcept Category or discipline --></type> <subType><!-- 0..1 CodeableConcept More granular claim type --></subType> <use value="[code]"/><!-- 1..1 claim | preauthorization | predetermination --> <patient><!-- 1..1 Reference(Patient) The recipient of the products and services --></patient> <billablePeriod><!-- 0..1 Period Relevant time frame for the claim --></billablePeriod> <created value="[dateTime]"/><!-- 1..1 Resource creation date --> <enterer><!-- 0..1 Reference(Patient|Practitioner|PractitionerRole|RelatedPerson) Author of the claim --></enterer> <insurer><!-- 0..1 Reference(Organization) Target --></insurer> <provider><!-- 0..1 Reference(Organization|Practitioner|PractitionerRole) Party responsible for the claim --></provider> <priority><!-- 0..1 CodeableConcept Desired processing urgency --></priority> <fundsReserve><!-- 0..1 CodeableConcept For whom to reserve funds --></fundsReserve> <related> <!-- 0..* Prior or corollary claims --> <claim><!-- 0..1 Reference(Claim) Reference to the related claim --></claim> <relationship><!-- 0..1 CodeableConcept How the reference claim is related --></relationship> <reference><!-- 0..1 Identifier File or case reference --></reference> </related> <prescription><!-- 0..1 Reference(DeviceRequest|MedicationRequest| VisionPrescription) Prescription authorizing services and products --></prescription> <originalPrescription><!-- 0..1 Reference(DeviceRequest|MedicationRequest| VisionPrescription) Original prescription if superseded by fulfiller --></originalPrescription> <payee> <!-- 0..1 Recipient of benefits payable --> <type><!-- 1..1 CodeableConcept Category of recipient --></type> <party><!-- 0..1 Reference(Organization|Patient|Practitioner|PractitionerRole| RelatedPerson) Recipient reference --></party> </payee> <referral><!-- 0..1 Reference(ServiceRequest) Treatment referral --></referral> <encounter><!-- 0..* Reference(Encounter) Encounters associated with the listed treatments --></encounter> <facility><!-- 0..1 Reference(Location|Organization) Servicing facility --></facility> <diagnosisRelatedGroup><!-- 0..1 CodeableConcept Package billing code --></diagnosisRelatedGroup> <event> <!-- 0..* Event information --> <type><!-- 1..1 CodeableConcept Specific event --></type> <when[x]><!-- 1..1 dateTime|Period Occurance date or period --></when[x]> </event> <careTeam> <!-- 0..* Members of the care team --> <sequence value="[positiveInt]"/><!-- 1..1 Order of care team --> <provider><!-- 1..1 Reference(Organization|Practitioner|PractitionerRole) Practitioner or organization --></provider> <responsible value="[boolean]"/><!-- 0..1 Indicator of the lead practitioner --> <role><!-- 0..1 CodeableConcept Function within the team --></role> <specialty><!-- 0..1 CodeableConcept Practitioner or provider specialization --></specialty> </careTeam> <supportingInfo> <!-- 0..* Supporting information --> <sequence value="[positiveInt]"/><!-- 1..1 Information instance identifier --> <category><!-- 1..1 CodeableConcept Classification of the supplied information --></category> <code><!-- 0..1 CodeableConcept Type of information --></code> <timing[x]><!-- 0..1 date|Period When it occurred --></timing[x]> <value[x]><!-- 0..1 boolean|string|Quantity|Attachment|Reference(Any)| Identifier Data to be provided --></value[x]> <reason><!-- 0..1 CodeableConcept Explanation for the information --></reason> </supportingInfo> <diagnosis> <!-- 0..* Pertinent diagnosis information --> <sequence value="[positiveInt]"/><!-- 1..1 Diagnosis instance identifier --> <diagnosis[x]><!-- 1..1 CodeableConcept|Reference(Condition) Nature of illness or problem --></diagnosis[x]> <type><!-- 0..* CodeableConcept Timing or nature of the diagnosis --></type> <onAdmission><!-- 0..1 CodeableConcept Present on admission --></onAdmission> </diagnosis> <procedure> <!-- 0..* Clinical procedures performed --> <sequence value="[positiveInt]"/><!-- 1..1 Procedure instance identifier --> <type><!-- 0..* CodeableConcept Category of Procedure --></type> <date value="[dateTime]"/><!-- 0..1 When the procedure was performed --> <procedure[x]><!-- 1..1 CodeableConcept|Reference(Procedure) Specific clinical procedure --></procedure[x]> <udi><!-- 0..* Reference(Device) Unique device identifier --></udi> </procedure> <insurance> <!-- 0..* Patient insurance information --> <sequence value="[positiveInt]"/><!-- 1..1 Insurance instance identifier --> <focal value="[boolean]"/><!-- 1..1 Coverage to be used for adjudication --> <identifier><!-- 0..1 Identifier Pre-assigned Claim number --></identifier> <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage> <businessArrangement value="[string]"/><!-- 0..1 Additional provider contract number --> <preAuthRef value="[string]"/><!-- 0..* Prior authorization reference number --> <claimResponse><!-- 0..1 Reference(ClaimResponse) Adjudication results --></claimResponse> </insurance> <accident> <!-- 0..1 Details of the event --> <date value="[date]"/><!-- 1..1 When the incident occurred --> <type><!-- 0..1 CodeableConcept The nature of the accident --></type> <location[x]><!-- 0..1 Address|Reference(Location) Where the event occurred --></location[x]> </accident> <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid> <item> <!-- 0..* Product or service provided --> <sequence value="[positiveInt]"/><!-- 1..1 Item instance identifier --> <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber> <careTeamSequence value="[positiveInt]"/><!-- 0..* Applicable careTeam members --> <diagnosisSequence value="[positiveInt]"/><!-- 0..* Applicable diagnoses --> <procedureSequence value="[positiveInt]"/><!-- 0..* Applicable procedures --> <informationSequence value="[positiveInt]"/><!-- 0..* Applicable exception and supporting information --> <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue> <category><!-- 0..1 CodeableConcept Benefit classification --></category> <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService> <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd> <request><!-- 0..* Reference(DeviceRequest|MedicationRequest|NutritionOrder| ServiceRequest|SupplyRequest|VisionPrescription) Request or Referral for Service --></request> <modifier><!-- 0..* CodeableConcept Product or service billing modifiers --></modifier> <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode> <serviced[x]><!-- 0..1 date|Period Date or dates of service or product delivery --></serviced[x]> <location[x]><!-- 0..1 CodeableConcept|Address|Reference(Location) Place of service or where product was supplied --></location[x]> <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid> <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity> <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice> <factor value="[decimal]"/><!-- 0..1 Price scaling factor --> <tax><!-- 0..1 Money Total tax --></tax> <net><!-- 0..1 Money Total item cost --></net> <udi><!-- 0..* Reference(Device) Unique device identifier --></udi> <bodySite> <!-- 0..* Anatomical location --> <site><!-- 1..* CodeableReference(BodyStructure) Location --></site> <subSite><!-- 0..* CodeableConcept Sub-location --></subSite> </bodySite> <encounter><!-- 0..* Reference(Encounter) Encounters associated with the listed treatments --></encounter> <detail> <!-- 0..* Product or service provided --> <sequence value="[positiveInt]"/><!-- 1..1 Item instance identifier --> <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber> <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue> <category><!-- 0..1 CodeableConcept Benefit classification --></category> <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService> <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd> <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier> <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode> <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid> <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity> <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice> <factor value="[decimal]"/><!-- 0..1 Price scaling factor --> <tax><!-- 0..1 Money Total tax --></tax> <net><!-- 0..1 Money Total item cost --></net> <udi><!-- 0..* Reference(Device) Unique device identifier --></udi> <subDetail> <!-- 0..* Product or service provided --> <sequence value="[positiveInt]"/><!-- 1..1 Item instance identifier --> <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber> <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue> <category><!-- 0..1 CodeableConcept Benefit classification --></category> <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService> <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd> <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier> <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode> <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid> <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity> <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice> <factor value="[decimal]"/><!-- 0..1 Price scaling factor --> <tax><!-- 0..1 Money Total tax --></tax> <net><!-- 0..1 Money Total item cost --></net> <udi><!-- 0..* Reference(Device) Unique device identifier --></udi> </subDetail> </detail> </item> <total><!-- 0..1 Money Total claim cost --></total> </Claim>
JSON Template
{ "resourceType" : "Claim", // from Resource: id, meta, implicitRules, and language // from DomainResource: text, contained, extension, and modifierExtension "identifier" : [{ Identifier }], // Business Identifier for claim "traceNumber" : [{ Identifier }], // Number for tracking "status" : "<code>", // R! active | cancelled | draft | entered-in-error "type" : { CodeableConcept }, // R! Category or discipline "subType" : { CodeableConcept }, // More granular claim type "use" : "<code>", // R! claim | preauthorization | predetermination "patient" : { Reference(Patient) }, // R! The recipient of the products and services "billablePeriod" : { Period }, // Relevant time frame for the claim "created" : "<dateTime>", // R! Resource creation date "enterer" : { Reference(Patient|Practitioner|PractitionerRole|RelatedPerson) }, // Author of the claim "insurer" : { Reference(Organization) }, // Target "provider" : { Reference(Organization|Practitioner|PractitionerRole) }, // Party responsible for the claim "priority" : { CodeableConcept }, // Desired processing urgency "fundsReserve" : { CodeableConcept }, // For whom to reserve funds "related" : [{ // Prior or corollary claims "claim" : { Reference(Claim) }, // Reference to the related claim "relationship" : { CodeableConcept }, // How the reference claim is related "reference" : { Identifier } // File or case reference }], "prescription" : { Reference(DeviceRequest|MedicationRequest| VisionPrescription) }, // Prescription authorizing services and products "originalPrescription" : { Reference(DeviceRequest|MedicationRequest| VisionPrescription) }, // Original prescription if superseded by fulfiller "payee" : { // Recipient of benefits payable "type" : { CodeableConcept }, // R! Category of recipient "party" : { Reference(Organization|Patient|Practitioner|PractitionerRole| RelatedPerson) } // Recipient reference }, "referral" : { Reference(ServiceRequest) }, // Treatment referral "encounter" : [{ Reference(Encounter) }], // Encounters associated with the listed treatments "facility" : { Reference(Location|Organization) }, // Servicing facility "diagnosisRelatedGroup" : { CodeableConcept }, // Package billing code "event" : [{ // Event information "type" : { CodeableConcept }, // R! Specific event // when[x]: Occurance date or period. One of these 2: "whenDateTime" : "<dateTime>", "whenPeriod" : { Period } }], "careTeam" : [{ // Members of the care team "sequence" : "<positiveInt>", // R! Order of care team "provider" : { Reference(Organization|Practitioner|PractitionerRole) }, // R! Practitioner or organization "responsible" : <boolean>, // Indicator of the lead practitioner "role" : { CodeableConcept }, // Function within the team "specialty" : { CodeableConcept } // Practitioner or provider specialization }], "supportingInfo" : [{ // Supporting information "sequence" : "<positiveInt>", // R! Information instance identifier "category" : { CodeableConcept }, // R! Classification of the supplied information "code" : { CodeableConcept }, // Type of information // timing[x]: When it occurred. One of these 2: "timingDate" : "<date>", "timingPeriod" : { Period }, // value[x]: Data to be provided. One of these 6: "valueBoolean" : <boolean>, "valueString" : "<string>", "valueQuantity" : { Quantity }, "valueAttachment" : { Attachment }, "valueReference" : { Reference(Any) }, "valueIdentifier" : { Identifier }, "reason" : { CodeableConcept } // Explanation for the information }], "diagnosis" : [{ // Pertinent diagnosis information "sequence" : "<positiveInt>", // R! Diagnosis instance identifier // diagnosis[x]: Nature of illness or problem. One of these 2: "diagnosisCodeableConcept" : { CodeableConcept }, "diagnosisReference" : { Reference(Condition) }, "type" : [{ CodeableConcept }], // Timing or nature of the diagnosis "onAdmission" : { CodeableConcept } // Present on admission }], "procedure" : [{ // Clinical procedures performed "sequence" : "<positiveInt>", // R! Procedure instance identifier "type" : [{ CodeableConcept }], // Category of Procedure "date" : "<dateTime>", // When the procedure was performed // procedure[x]: Specific clinical procedure. One of these 2: "procedureCodeableConcept" : { CodeableConcept }, "procedureReference" : { Reference(Procedure) }, "udi" : [{ Reference(Device) }] // Unique device identifier }], "insurance" : [{ // Patient insurance information "sequence" : "<positiveInt>", // R! Insurance instance identifier "focal" : <boolean>, // R! Coverage to be used for adjudication "identifier" : { Identifier }, // Pre-assigned Claim number "coverage" : { Reference(Coverage) }, // R! Insurance information "businessArrangement" : "<string>", // Additional provider contract number "preAuthRef" : ["<string>"], // Prior authorization reference number "claimResponse" : { Reference(ClaimResponse) } // Adjudication results }], "accident" : { // Details of the event "date" : "<date>", // R! When the incident occurred "type" : { CodeableConcept }, // The nature of the accident // location[x]: Where the event occurred. One of these 2: "locationAddress" : { Address }, "locationReference" : { Reference(Location) } }, "patientPaid" : { Money }, // Paid by the patient "item" : [{ // Product or service provided "sequence" : "<positiveInt>", // R! Item instance identifier "traceNumber" : [{ Identifier }], // Number for tracking "careTeamSequence" : ["<positiveInt>"], // Applicable careTeam members "diagnosisSequence" : ["<positiveInt>"], // Applicable diagnoses "procedureSequence" : ["<positiveInt>"], // Applicable procedures "informationSequence" : ["<positiveInt>"], // Applicable exception and supporting information "revenue" : { CodeableConcept }, // Revenue or cost center code "category" : { CodeableConcept }, // Benefit classification "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes "request" : [{ Reference(DeviceRequest|MedicationRequest|NutritionOrder| ServiceRequest|SupplyRequest|VisionPrescription) }], // Request or Referral for Service "modifier" : [{ CodeableConcept }], // Product or service billing modifiers "programCode" : [{ CodeableConcept }], // Program the product or service is provided under // serviced[x]: Date or dates of service or product delivery. One of these 2: "servicedDate" : "<date>", "servicedPeriod" : { Period }, // location[x]: Place of service or where product was supplied. One of these 3: "locationCodeableConcept" : { CodeableConcept }, "locationAddress" : { Address }, "locationReference" : { Reference(Location) }, "patientPaid" : { Money }, // Paid by the patient "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services "unitPrice" : { Money }, // Fee, charge or cost per item "factor" : <decimal>, // Price scaling factor "tax" : { Money }, // Total tax "net" : { Money }, // Total item cost "udi" : [{ Reference(Device) }], // Unique device identifier "bodySite" : [{ // Anatomical location "site" : [{ CodeableReference(BodyStructure) }], // R! Location "subSite" : [{ CodeableConcept }] // Sub-location }], "encounter" : [{ Reference(Encounter) }], // Encounters associated with the listed treatments "detail" : [{ // Product or service provided "sequence" : "<positiveInt>", // R! Item instance identifier "traceNumber" : [{ Identifier }], // Number for tracking "revenue" : { CodeableConcept }, // Revenue or cost center code "category" : { CodeableConcept }, // Benefit classification "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers "programCode" : [{ CodeableConcept }], // Program the product or service is provided under "patientPaid" : { Money }, // Paid by the patient "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services "unitPrice" : { Money }, // Fee, charge or cost per item "factor" : <decimal>, // Price scaling factor "tax" : { Money }, // Total tax "net" : { Money }, // Total item cost "udi" : [{ Reference(Device) }], // Unique device identifier "subDetail" : [{ // Product or service provided "sequence" : "<positiveInt>", // R! Item instance identifier "traceNumber" : [{ Identifier }], // Number for tracking "revenue" : { CodeableConcept }, // Revenue or cost center code "category" : { CodeableConcept }, // Benefit classification "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers "programCode" : [{ CodeableConcept }], // Program the product or service is provided under "patientPaid" : { Money }, // Paid by the patient "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services "unitPrice" : { Money }, // Fee, charge or cost per item "factor" : <decimal>, // Price scaling factor "tax" : { Money }, // Total tax "net" : { Money }, // Total item cost "udi" : [{ Reference(Device) }] // Unique device identifier }] }] }], "total" : { Money } // Total claim cost }
Turtle Template
@prefix fhir: <http://hl7.org/fhir/> . [ a fhir:Claim; fhir:nodeRole fhir:treeRoot; # if this is the parser root # from Resource: .id, .meta, .implicitRules, and .language # from DomainResource: .text, .contained, .extension, and .modifierExtension fhir:identifier ( [ Identifier ] ... ) ; # 0..* Business Identifier for claim fhir:traceNumber ( [ Identifier ] ... ) ; # 0..* Number for tracking fhir:status [ code ] ; # 1..1 active | cancelled | draft | entered-in-error fhir:type [ CodeableConcept ] ; # 1..1 Category or discipline fhir:subType [ CodeableConcept ] ; # 0..1 More granular claim type fhir:use [ code ] ; # 1..1 claim | preauthorization | predetermination fhir:patient [ Reference(Patient) ] ; # 1..1 The recipient of the products and services fhir:billablePeriod [ Period ] ; # 0..1 Relevant time frame for the claim fhir:created [ dateTime ] ; # 1..1 Resource creation date fhir:enterer [ Reference(Patient|Practitioner|PractitionerRole|RelatedPerson) ] ; # 0..1 Author of the claim fhir:insurer [ Reference(Organization) ] ; # 0..1 Target fhir:provider [ Reference(Organization|Practitioner|PractitionerRole) ] ; # 0..1 Party responsible for the claim fhir:priority [ CodeableConcept ] ; # 0..1 Desired processing urgency fhir:fundsReserve [ CodeableConcept ] ; # 0..1 For whom to reserve funds fhir:related ( [ # 0..* Prior or corollary claims fhir:claim [ Reference(Claim) ] ; # 0..1 Reference to the related claim fhir:relationship [ CodeableConcept ] ; # 0..1 How the reference claim is related fhir:reference [ Identifier ] ; # 0..1 File or case reference ] ... ) ; fhir:prescription [ Reference(DeviceRequest|MedicationRequest|VisionPrescription) ] ; # 0..1 Prescription authorizing services and products fhir:originalPrescription [ Reference(DeviceRequest|MedicationRequest|VisionPrescription) ] ; # 0..1 Original prescription if superseded by fulfiller fhir:payee [ # 0..1 Recipient of benefits payable fhir:type [ CodeableConcept ] ; # 1..1 Category of recipient fhir:party [ Reference(Organization|Patient|Practitioner|PractitionerRole|RelatedPerson) ] ; # 0..1 Recipient reference ] ; fhir:referral [ Reference(ServiceRequest) ] ; # 0..1 Treatment referral fhir:encounter ( [ Reference(Encounter) ] ... ) ; # 0..* Encounters associated with the listed treatments fhir:facility [ Reference(Location|Organization) ] ; # 0..1 Servicing facility fhir:diagnosisRelatedGroup [ CodeableConcept ] ; # 0..1 Package billing code fhir:event ( [ # 0..* Event information fhir:type [ CodeableConcept ] ; # 1..1 Specific event # when[x] : 1..1 Occurance date or period. One of these 2 fhir:when [ a fhir:dateTime ; dateTime ] fhir:when [ a fhir:Period ; Period ] ] ... ) ; fhir:careTeam ( [ # 0..* Members of the care team fhir:sequence [ positiveInt ] ; # 1..1 Order of care team fhir:provider [ Reference(Organization|Practitioner|PractitionerRole) ] ; # 1..1 Practitioner or organization fhir:responsible [ boolean ] ; # 0..1 Indicator of the lead practitioner fhir:role [ CodeableConcept ] ; # 0..1 Function within the team fhir:specialty [ CodeableConcept ] ; # 0..1 Practitioner or provider specialization ] ... ) ; fhir:supportingInfo ( [ # 0..* Supporting information fhir:sequence [ positiveInt ] ; # 1..1 Information instance identifier fhir:category [ CodeableConcept ] ; # 1..1 Classification of the supplied information fhir:code [ CodeableConcept ] ; # 0..1 Type of information # timing[x] : 0..1 When it occurred. One of these 2 fhir:timing [ a fhir:date ; date ] fhir:timing [ a fhir:Period ; Period ] # value[x] : 0..1 Data to be provided. One of these 6 fhir:value [ a fhir:boolean ; boolean ] fhir:value [ a fhir:string ; string ] fhir:value [ a fhir:Quantity ; Quantity ] fhir:value [ a fhir:Attachment ; Attachment ] fhir:value [ a fhir:Reference ; Reference(Any) ] fhir:value [ a fhir:Identifier ; Identifier ] fhir:reason [ CodeableConcept ] ; # 0..1 Explanation for the information ] ... ) ; fhir:diagnosis ( [ # 0..* Pertinent diagnosis information fhir:sequence [ positiveInt ] ; # 1..1 Diagnosis instance identifier # diagnosis[x] : 1..1 Nature of illness or problem. One of these 2 fhir:diagnosis [ a fhir:CodeableConcept ; CodeableConcept ] fhir:diagnosis [ a fhir:Reference ; Reference(Condition) ] fhir:type ( [ CodeableConcept ] ... ) ; # 0..* Timing or nature of the diagnosis fhir:onAdmission [ CodeableConcept ] ; # 0..1 Present on admission ] ... ) ; fhir:procedure ( [ # 0..* Clinical procedures performed fhir:sequence [ positiveInt ] ; # 1..1 Procedure instance identifier fhir:type ( [ CodeableConcept ] ... ) ; # 0..* Category of Procedure fhir:date [ dateTime ] ; # 0..1 When the procedure was performed # procedure[x] : 1..1 Specific clinical procedure. One of these 2 fhir:procedure [ a fhir:CodeableConcept ; CodeableConcept ] fhir:procedure [ a fhir:Reference ; Reference(Procedure) ] fhir:udi ( [ Reference(Device) ] ... ) ; # 0..* Unique device identifier ] ... ) ; fhir:insurance ( [ # 0..* Patient insurance information fhir:sequence [ positiveInt ] ; # 1..1 Insurance instance identifier fhir:focal [ boolean ] ; # 1..1 Coverage to be used for adjudication fhir:identifier [ Identifier ] ; # 0..1 Pre-assigned Claim number fhir:coverage [ Reference(Coverage) ] ; # 1..1 Insurance information fhir:businessArrangement [ string ] ; # 0..1 Additional provider contract number fhir:preAuthRef ( [ string ] ... ) ; # 0..* Prior authorization reference number fhir:claimResponse [ Reference(ClaimResponse) ] ; # 0..1 Adjudication results ] ... ) ; fhir:accident [ # 0..1 Details of the event fhir:date [ date ] ; # 1..1 When the incident occurred fhir:type [ CodeableConcept ] ; # 0..1 The nature of the accident # location[x] : 0..1 Where the event occurred. One of these 2 fhir:location [ a fhir:Address ; Address ] fhir:location [ a fhir:Reference ; Reference(Location) ] ] ; fhir:patientPaid [ Money ] ; # 0..1 Paid by the patient fhir:item ( [ # 0..* Product or service provided fhir:sequence [ positiveInt ] ; # 1..1 Item instance identifier fhir:traceNumber ( [ Identifier ] ... ) ; # 0..* Number for tracking fhir:careTeamSequence ( [ positiveInt ] ... ) ; # 0..* Applicable careTeam members fhir:diagnosisSequence ( [ positiveInt ] ... ) ; # 0..* Applicable diagnoses fhir:procedureSequence ( [ positiveInt ] ... ) ; # 0..* Applicable procedures fhir:informationSequence ( [ positiveInt ] ... ) ; # 0..* Applicable exception and supporting information fhir:revenue [ CodeableConcept ] ; # 0..1 Revenue or cost center code fhir:category [ CodeableConcept ] ; # 0..1 Benefit classification fhir:productOrService [ CodeableConcept ] ; # 0..1 Billing, service, product, or drug code fhir:productOrServiceEnd [ CodeableConcept ] ; # 0..1 End of a range of codes fhir:request ( [ Reference(DeviceRequest|MedicationRequest|NutritionOrder|ServiceRequest|SupplyRequest| VisionPrescription) ] ... ) ; # 0..* Request or Referral for Service fhir:modifier ( [ CodeableConcept ] ... ) ; # 0..* Product or service billing modifiers fhir:programCode ( [ CodeableConcept ] ... ) ; # 0..* Program the product or service is provided under # serviced[x] : 0..1 Date or dates of service or product delivery. One of these 2 fhir:serviced [ a fhir:date ; date ] fhir:serviced [ a fhir:Period ; Period ] # location[x] : 0..1 Place of service or where product was supplied. One of these 3 fhir:location [ a fhir:CodeableConcept ; CodeableConcept ] fhir:location [ a fhir:Address ; Address ] fhir:location [ a fhir:Reference ; Reference(Location) ] fhir:patientPaid [ Money ] ; # 0..1 Paid by the patient fhir:quantity [ Quantity(SimpleQuantity) ] ; # 0..1 Count of products or services fhir:unitPrice [ Money ] ; # 0..1 Fee, charge or cost per item fhir:factor [ decimal ] ; # 0..1 Price scaling factor fhir:tax [ Money ] ; # 0..1 Total tax fhir:net [ Money ] ; # 0..1 Total item cost fhir:udi ( [ Reference(Device) ] ... ) ; # 0..* Unique device identifier fhir:bodySite ( [ # 0..* Anatomical location fhir:site ( [ CodeableReference(BodyStructure) ] ... ) ; # 1..* Location fhir:subSite ( [ CodeableConcept ] ... ) ; # 0..* Sub-location ] ... ) ; fhir:encounter ( [ Reference(Encounter) ] ... ) ; # 0..* Encounters associated with the listed treatments fhir:detail ( [ # 0..* Product or service provided fhir:sequence [ positiveInt ] ; # 1..1 Item instance identifier fhir:traceNumber ( [ Identifier ] ... ) ; # 0..* Number for tracking fhir:revenue [ CodeableConcept ] ; # 0..1 Revenue or cost center code fhir:category [ CodeableConcept ] ; # 0..1 Benefit classification fhir:productOrService [ CodeableConcept ] ; # 0..1 Billing, service, product, or drug code fhir:productOrServiceEnd [ CodeableConcept ] ; # 0..1 End of a range of codes fhir:modifier ( [ CodeableConcept ] ... ) ; # 0..* Service/Product billing modifiers fhir:programCode ( [ CodeableConcept ] ... ) ; # 0..* Program the product or service is provided under fhir:patientPaid [ Money ] ; # 0..1 Paid by the patient fhir:quantity [ Quantity(SimpleQuantity) ] ; # 0..1 Count of products or services fhir:unitPrice [ Money ] ; # 0..1 Fee, charge or cost per item fhir:factor [ decimal ] ; # 0..1 Price scaling factor fhir:tax [ Money ] ; # 0..1 Total tax fhir:net [ Money ] ; # 0..1 Total item cost fhir:udi ( [ Reference(Device) ] ... ) ; # 0..* Unique device identifier fhir:subDetail ( [ # 0..* Product or service provided fhir:sequence [ positiveInt ] ; # 1..1 Item instance identifier fhir:traceNumber ( [ Identifier ] ... ) ; # 0..* Number for tracking fhir:revenue [ CodeableConcept ] ; # 0..1 Revenue or cost center code fhir:category [ CodeableConcept ] ; # 0..1 Benefit classification fhir:productOrService [ CodeableConcept ] ; # 0..1 Billing, service, product, or drug code fhir:productOrServiceEnd [ CodeableConcept ] ; # 0..1 End of a range of codes fhir:modifier ( [ CodeableConcept ] ... ) ; # 0..* Service/Product billing modifiers fhir:programCode ( [ CodeableConcept ] ... ) ; # 0..* Program the product or service is provided under fhir:patientPaid [ Money ] ; # 0..1 Paid by the patient fhir:quantity [ Quantity(SimpleQuantity) ] ; # 0..1 Count of products or services fhir:unitPrice [ Money ] ; # 0..1 Fee, charge or cost per item fhir:factor [ decimal ] ; # 0..1 Price scaling factor fhir:tax [ Money ] ; # 0..1 Total tax fhir:net [ Money ] ; # 0..1 Total item cost fhir:udi ( [ Reference(Device) ] ... ) ; # 0..* Unique device identifier ] ... ) ; ] ... ) ; ] ... ) ; fhir:total [ Money ] ; # 0..1 Total claim cost ]
Changes from both R4 and R4B
Claim | |
Claim.traceNumber |
|
Claim.enterer |
|
Claim.provider |
|
Claim.priority |
|
Claim.encounter |
|
Claim.facility |
|
Claim.diagnosisRelatedGroup |
|
Claim.event |
|
Claim.event.type |
|
Claim.event.when[x] |
|
Claim.careTeam.specialty |
|
Claim.supportingInfo.value[x] |
|
Claim.insurance |
|
Claim.patientPaid |
|
Claim.item.traceNumber |
|
Claim.item.productOrService |
|
Claim.item.productOrServiceEnd |
|
Claim.item.request |
|
Claim.item.patientPaid |
|
Claim.item.tax |
|
Claim.item.bodySite |
|
Claim.item.bodySite.site |
|
Claim.item.bodySite.subSite |
|
Claim.item.detail.traceNumber |
|
Claim.item.detail.productOrService |
|
Claim.item.detail.productOrServiceEnd |
|
Claim.item.detail.patientPaid |
|
Claim.item.detail.tax |
|
Claim.item.detail.subDetail.traceNumber |
|
Claim.item.detail.subDetail.productOrService |
|
Claim.item.detail.subDetail.productOrServiceEnd |
|
Claim.item.detail.subDetail.patientPaid |
|
Claim.item.detail.subDetail.tax |
|
Claim.careTeam.qualification |
|
Claim.diagnosis.packageCode |
|
Claim.item.subSite |
|
See the Full Difference for further information
This analysis is available for R4 as XML or JSON and for R4B as XML or JSON.
See R4 <--> R5 Conversion Maps (status = See Conversions Summary.)
Structure
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
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 | |
traceNumber | 0..* | Identifier | Number for tracking | |
status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: Financial Resource Status Codes (Required) |
type | Σ | 1..1 | CodeableConcept | Category or discipline Binding: Claim Type Codes (Extensible) |
subType | 0..1 | CodeableConcept | More granular claim type Binding: Example Claim SubType Codes (Example) | |
use | Σ | 1..1 | code | claim | preauthorization | predetermination Binding: 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 | Patient | RelatedPerson) | Author of the claim | |
insurer | Σ | 0..1 | Reference(Organization) | Target |
provider | Σ | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim |
priority | Σ | 0..1 | CodeableConcept | Desired processing urgency Binding: Process Priority Codes (Example) |
fundsReserve | 0..1 | CodeableConcept | For whom to reserve funds Binding: Funds Reservation Codes (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 Binding: 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 Binding: Claim Payee Type Codes (Example) | |
party | 0..1 | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) | Recipient reference | |
referral | 0..1 | Reference(ServiceRequest) | Treatment referral | |
encounter | 0..* | Reference(Encounter) | Encounters associated with the listed treatments | |
facility | 0..1 | Reference(Location | Organization) | Servicing facility | |
diagnosisRelatedGroup | 0..1 | CodeableConcept | Package billing code Binding: Example Diagnosis Related Group Codes (Example) | |
event | 0..* | BackboneElement | Event information | |
type | 1..1 | CodeableConcept | Specific event Binding: Dates Type Codes (Example) | |
when[x] | 1..1 | Occurance date or period | ||
whenDateTime | dateTime | |||
whenPeriod | Period | |||
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 Binding: Claim Care Team Role Codes (Example) | |
specialty | 0..1 | CodeableConcept | Practitioner or provider specialization Binding: 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 Binding: Claim Information Category Codes (Example) | |
code | 0..1 | CodeableConcept | Type of information Binding: 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) | |||
valueIdentifier | Identifier | |||
reason | 0..1 | CodeableConcept | Explanation for the information Binding: 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 Binding: ICD-10 Codes (Example) | ||
diagnosisCodeableConcept | CodeableConcept | |||
diagnosisReference | Reference(Condition) | |||
type | 0..* | CodeableConcept | Timing or nature of the diagnosis Binding: Example Diagnosis Type Codes (Example) | |
onAdmission | 0..1 | CodeableConcept | Present on admission Binding: Example Diagnosis on Admission Codes (Example) | |
procedure | 0..* | BackboneElement | Clinical procedures performed | |
sequence | 1..1 | positiveInt | Procedure instance identifier | |
type | 0..* | CodeableConcept | Category of Procedure Binding: Example Procedure Type Codes (Example) | |
date | 0..1 | dateTime | When the procedure was performed | |
procedure[x] | 1..1 | Specific clinical procedure Binding: ICD-10 Procedure Codes (Example) | ||
procedureCodeableConcept | CodeableConcept | |||
procedureReference | Reference(Procedure) | |||
udi | 0..* | Reference(Device) | Unique device identifier | |
insurance | Σ | 0..* | 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 Binding: ActIncidentCode (Extensible) | |
location[x] | 0..1 | Where the event occurred | ||
locationAddress | Address | |||
locationReference | Reference(Location) | |||
patientPaid | 0..1 | Money | Paid by the patient | |
item | 0..* | BackboneElement | Product or service provided | |
sequence | 1..1 | positiveInt | Item instance identifier | |
traceNumber | 0..* | Identifier | Number for tracking | |
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 Binding: Example Revenue Center Codes (Example) | |
category | 0..1 | CodeableConcept | Benefit classification Binding: Benefit Category Codes (Example) | |
productOrService | 0..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLS Codes (Example) | |
productOrServiceEnd | 0..1 | CodeableConcept | End of a range of codes Binding: USCLS Codes (Example) | |
request | 0..* | Reference(DeviceRequest | MedicationRequest | NutritionOrder | ServiceRequest | SupplyRequest | VisionPrescription) | Request or Referral for Service | |
modifier | 0..* | CodeableConcept | Product or service billing modifiers Binding: Modifier type Codes (Example) | |
programCode | 0..* | CodeableConcept | Program the product or service is provided under Binding: 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 Binding: Example Service Place Codes (Example) | ||
locationCodeableConcept | CodeableConcept | |||
locationAddress | Address | |||
locationReference | Reference(Location) | |||
patientPaid | 0..1 | Money | Paid by the patient | |
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 | |
tax | 0..1 | Money | Total tax | |
net | 0..1 | Money | Total item cost | |
udi | 0..* | Reference(Device) | Unique device identifier | |
bodySite | 0..* | BackboneElement | Anatomical location | |
site | 1..* | CodeableReference(BodyStructure) | Location Binding: Oral Site Codes (Example) | |
subSite | 0..* | CodeableConcept | Sub-location Binding: Surface Codes (Example) | |
encounter | 0..* | Reference(Encounter) | Encounters associated with the listed treatments | |
detail | 0..* | BackboneElement | Product or service provided | |
sequence | 1..1 | positiveInt | Item instance identifier | |
traceNumber | 0..* | Identifier | Number for tracking | |
revenue | 0..1 | CodeableConcept | Revenue or cost center code Binding: Example Revenue Center Codes (Example) | |
category | 0..1 | CodeableConcept | Benefit classification Binding: Benefit Category Codes (Example) | |
productOrService | 0..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLS Codes (Example) | |
productOrServiceEnd | 0..1 | CodeableConcept | End of a range of codes Binding: USCLS Codes (Example) | |
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: Modifier type Codes (Example) | |
programCode | 0..* | CodeableConcept | Program the product or service is provided under Binding: Example Program Reason Codes (Example) | |
patientPaid | 0..1 | Money | Paid by the patient | |
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 | |
tax | 0..1 | Money | Total tax | |
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 | |
traceNumber | 0..* | Identifier | Number for tracking | |
revenue | 0..1 | CodeableConcept | Revenue or cost center code Binding: Example Revenue Center Codes (Example) | |
category | 0..1 | CodeableConcept | Benefit classification Binding: Benefit Category Codes (Example) | |
productOrService | 0..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLS Codes (Example) | |
productOrServiceEnd | 0..1 | CodeableConcept | End of a range of codes Binding: USCLS Codes (Example) | |
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: Modifier type Codes (Example) | |
programCode | 0..* | CodeableConcept | Program the product or service is provided under Binding: Example Program Reason Codes (Example) | |
patientPaid | 0..1 | Money | Paid by the patient | |
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 | |
tax | 0..1 | Money | Total tax | |
net | 0..1 | Money | Total item cost | |
udi | 0..* | Reference(Device) | Unique device identifier | |
total | 0..1 | Money | Total claim cost | |
Documentation for this format |
See the Extensions for this resource
XML Template
<Claim xmlns="http://hl7.org/fhir"> <!-- from Resource: id, meta, implicitRules, and language --> <!-- from DomainResource: text, contained, extension, and modifierExtension --> <identifier><!-- 0..* Identifier Business Identifier for claim --></identifier> <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber> <status value="[code]"/><!-- 1..1 active | cancelled | draft | entered-in-error --> <type><!-- 1..1 CodeableConcept Category or discipline --></type> <subType><!-- 0..1 CodeableConcept More granular claim type --></subType> <use value="[code]"/><!-- 1..1 claim | preauthorization | predetermination --> <patient><!-- 1..1 Reference(Patient) The recipient of the products and services --></patient> <billablePeriod><!-- 0..1 Period Relevant time frame for the claim --></billablePeriod> <created value="[dateTime]"/><!-- 1..1 Resource creation date --> <enterer><!-- 0..1 Reference(Patient|Practitioner|PractitionerRole|RelatedPerson) Author of the claim --></enterer> <insurer><!-- 0..1 Reference(Organization) Target --></insurer> <provider><!-- 0..1 Reference(Organization|Practitioner|PractitionerRole) Party responsible for the claim --></provider> <priority><!-- 0..1 CodeableConcept Desired processing urgency --></priority> <fundsReserve><!-- 0..1 CodeableConcept For whom to reserve funds --></fundsReserve> <related> <!-- 0..* Prior or corollary claims --> <claim><!-- 0..1 Reference(Claim) Reference to the related claim --></claim> <relationship><!-- 0..1 CodeableConcept How the reference claim is related --></relationship> <reference><!-- 0..1 Identifier File or case reference --></reference> </related> <prescription><!-- 0..1 Reference(DeviceRequest|MedicationRequest| VisionPrescription) Prescription authorizing services and products --></prescription> <originalPrescription><!-- 0..1 Reference(DeviceRequest|MedicationRequest| VisionPrescription) Original prescription if superseded by fulfiller --></originalPrescription> <payee> <!-- 0..1 Recipient of benefits payable --> <type><!-- 1..1 CodeableConcept Category of recipient --></type> <party><!-- 0..1 Reference(Organization|Patient|Practitioner|PractitionerRole| RelatedPerson) Recipient reference --></party> </payee> <referral><!-- 0..1 Reference(ServiceRequest) Treatment referral --></referral> <encounter><!-- 0..* Reference(Encounter) Encounters associated with the listed treatments --></encounter> <facility><!-- 0..1 Reference(Location|Organization) Servicing facility --></facility> <diagnosisRelatedGroup><!-- 0..1 CodeableConcept Package billing code --></diagnosisRelatedGroup> <event> <!-- 0..* Event information --> <type><!-- 1..1 CodeableConcept Specific event --></type> <when[x]><!-- 1..1 dateTime|Period Occurance date or period --></when[x]> </event> <careTeam> <!-- 0..* Members of the care team --> <sequence value="[positiveInt]"/><!-- 1..1 Order of care team --> <provider><!-- 1..1 Reference(Organization|Practitioner|PractitionerRole) Practitioner or organization --></provider> <responsible value="[boolean]"/><!-- 0..1 Indicator of the lead practitioner --> <role><!-- 0..1 CodeableConcept Function within the team --></role> <specialty><!-- 0..1 CodeableConcept Practitioner or provider specialization --></specialty> </careTeam> <supportingInfo> <!-- 0..* Supporting information --> <sequence value="[positiveInt]"/><!-- 1..1 Information instance identifier --> <category><!-- 1..1 CodeableConcept Classification of the supplied information --></category> <code><!-- 0..1 CodeableConcept Type of information --></code> <timing[x]><!-- 0..1 date|Period When it occurred --></timing[x]> <value[x]><!-- 0..1 boolean|string|Quantity|Attachment|Reference(Any)| Identifier Data to be provided --></value[x]> <reason><!-- 0..1 CodeableConcept Explanation for the information --></reason> </supportingInfo> <diagnosis> <!-- 0..* Pertinent diagnosis information --> <sequence value="[positiveInt]"/><!-- 1..1 Diagnosis instance identifier --> <diagnosis[x]><!-- 1..1 CodeableConcept|Reference(Condition) Nature of illness or problem --></diagnosis[x]> <type><!-- 0..* CodeableConcept Timing or nature of the diagnosis --></type> <onAdmission><!-- 0..1 CodeableConcept Present on admission --></onAdmission> </diagnosis> <procedure> <!-- 0..* Clinical procedures performed --> <sequence value="[positiveInt]"/><!-- 1..1 Procedure instance identifier --> <type><!-- 0..* CodeableConcept Category of Procedure --></type> <date value="[dateTime]"/><!-- 0..1 When the procedure was performed --> <procedure[x]><!-- 1..1 CodeableConcept|Reference(Procedure) Specific clinical procedure --></procedure[x]> <udi><!-- 0..* Reference(Device) Unique device identifier --></udi> </procedure> <insurance> <!-- 0..* Patient insurance information --> <sequence value="[positiveInt]"/><!-- 1..1 Insurance instance identifier --> <focal value="[boolean]"/><!-- 1..1 Coverage to be used for adjudication --> <identifier><!-- 0..1 Identifier Pre-assigned Claim number --></identifier> <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage> <businessArrangement value="[string]"/><!-- 0..1 Additional provider contract number --> <preAuthRef value="[string]"/><!-- 0..* Prior authorization reference number --> <claimResponse><!-- 0..1 Reference(ClaimResponse) Adjudication results --></claimResponse> </insurance> <accident> <!-- 0..1 Details of the event --> <date value="[date]"/><!-- 1..1 When the incident occurred --> <type><!-- 0..1 CodeableConcept The nature of the accident --></type> <location[x]><!-- 0..1 Address|Reference(Location) Where the event occurred --></location[x]> </accident> <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid> <item> <!-- 0..* Product or service provided --> <sequence value="[positiveInt]"/><!-- 1..1 Item instance identifier --> <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber> <careTeamSequence value="[positiveInt]"/><!-- 0..* Applicable careTeam members --> <diagnosisSequence value="[positiveInt]"/><!-- 0..* Applicable diagnoses --> <procedureSequence value="[positiveInt]"/><!-- 0..* Applicable procedures --> <informationSequence value="[positiveInt]"/><!-- 0..* Applicable exception and supporting information --> <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue> <category><!-- 0..1 CodeableConcept Benefit classification --></category> <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService> <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd> <request><!-- 0..* Reference(DeviceRequest|MedicationRequest|NutritionOrder| ServiceRequest|SupplyRequest|VisionPrescription) Request or Referral for Service --></request> <modifier><!-- 0..* CodeableConcept Product or service billing modifiers --></modifier> <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode> <serviced[x]><!-- 0..1 date|Period Date or dates of service or product delivery --></serviced[x]> <location[x]><!-- 0..1 CodeableConcept|Address|Reference(Location) Place of service or where product was supplied --></location[x]> <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid> <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity> <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice> <factor value="[decimal]"/><!-- 0..1 Price scaling factor --> <tax><!-- 0..1 Money Total tax --></tax> <net><!-- 0..1 Money Total item cost --></net> <udi><!-- 0..* Reference(Device) Unique device identifier --></udi> <bodySite> <!-- 0..* Anatomical location --> <site><!-- 1..* CodeableReference(BodyStructure) Location --></site> <subSite><!-- 0..* CodeableConcept Sub-location --></subSite> </bodySite> <encounter><!-- 0..* Reference(Encounter) Encounters associated with the listed treatments --></encounter> <detail> <!-- 0..* Product or service provided --> <sequence value="[positiveInt]"/><!-- 1..1 Item instance identifier --> <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber> <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue> <category><!-- 0..1 CodeableConcept Benefit classification --></category> <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService> <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd> <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier> <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode> <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid> <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity> <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice> <factor value="[decimal]"/><!-- 0..1 Price scaling factor --> <tax><!-- 0..1 Money Total tax --></tax> <net><!-- 0..1 Money Total item cost --></net> <udi><!-- 0..* Reference(Device) Unique device identifier --></udi> <subDetail> <!-- 0..* Product or service provided --> <sequence value="[positiveInt]"/><!-- 1..1 Item instance identifier --> <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber> <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue> <category><!-- 0..1 CodeableConcept Benefit classification --></category> <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService> <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd> <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier> <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode> <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid> <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity> <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice> <factor value="[decimal]"/><!-- 0..1 Price scaling factor --> <tax><!-- 0..1 Money Total tax --></tax> <net><!-- 0..1 Money Total item cost --></net> <udi><!-- 0..* Reference(Device) Unique device identifier --></udi> </subDetail> </detail> </item> <total><!-- 0..1 Money Total claim cost --></total> </Claim>
JSON Template
{ "resourceType" : "Claim", // from Resource: id, meta, implicitRules, and language // from DomainResource: text, contained, extension, and modifierExtension "identifier" : [{ Identifier }], // Business Identifier for claim "traceNumber" : [{ Identifier }], // Number for tracking "status" : "<code>", // R! active | cancelled | draft | entered-in-error "type" : { CodeableConcept }, // R! Category or discipline "subType" : { CodeableConcept }, // More granular claim type "use" : "<code>", // R! claim | preauthorization | predetermination "patient" : { Reference(Patient) }, // R! The recipient of the products and services "billablePeriod" : { Period }, // Relevant time frame for the claim "created" : "<dateTime>", // R! Resource creation date "enterer" : { Reference(Patient|Practitioner|PractitionerRole|RelatedPerson) }, // Author of the claim "insurer" : { Reference(Organization) }, // Target "provider" : { Reference(Organization|Practitioner|PractitionerRole) }, // Party responsible for the claim "priority" : { CodeableConcept }, // Desired processing urgency "fundsReserve" : { CodeableConcept }, // For whom to reserve funds "related" : [{ // Prior or corollary claims "claim" : { Reference(Claim) }, // Reference to the related claim "relationship" : { CodeableConcept }, // How the reference claim is related "reference" : { Identifier } // File or case reference }], "prescription" : { Reference(DeviceRequest|MedicationRequest| VisionPrescription) }, // Prescription authorizing services and products "originalPrescription" : { Reference(DeviceRequest|MedicationRequest| VisionPrescription) }, // Original prescription if superseded by fulfiller "payee" : { // Recipient of benefits payable "type" : { CodeableConcept }, // R! Category of recipient "party" : { Reference(Organization|Patient|Practitioner|PractitionerRole| RelatedPerson) } // Recipient reference }, "referral" : { Reference(ServiceRequest) }, // Treatment referral "encounter" : [{ Reference(Encounter) }], // Encounters associated with the listed treatments "facility" : { Reference(Location|Organization) }, // Servicing facility "diagnosisRelatedGroup" : { CodeableConcept }, // Package billing code "event" : [{ // Event information "type" : { CodeableConcept }, // R! Specific event // when[x]: Occurance date or period. One of these 2: "whenDateTime" : "<dateTime>", "whenPeriod" : { Period } }], "careTeam" : [{ // Members of the care team "sequence" : "<positiveInt>", // R! Order of care team "provider" : { Reference(Organization|Practitioner|PractitionerRole) }, // R! Practitioner or organization "responsible" : <boolean>, // Indicator of the lead practitioner "role" : { CodeableConcept }, // Function within the team "specialty" : { CodeableConcept } // Practitioner or provider specialization }], "supportingInfo" : [{ // Supporting information "sequence" : "<positiveInt>", // R! Information instance identifier "category" : { CodeableConcept }, // R! Classification of the supplied information "code" : { CodeableConcept }, // Type of information // timing[x]: When it occurred. One of these 2: "timingDate" : "<date>", "timingPeriod" : { Period }, // value[x]: Data to be provided. One of these 6: "valueBoolean" : <boolean>, "valueString" : "<string>", "valueQuantity" : { Quantity }, "valueAttachment" : { Attachment }, "valueReference" : { Reference(Any) }, "valueIdentifier" : { Identifier }, "reason" : { CodeableConcept } // Explanation for the information }], "diagnosis" : [{ // Pertinent diagnosis information "sequence" : "<positiveInt>", // R! Diagnosis instance identifier // diagnosis[x]: Nature of illness or problem. One of these 2: "diagnosisCodeableConcept" : { CodeableConcept }, "diagnosisReference" : { Reference(Condition) }, "type" : [{ CodeableConcept }], // Timing or nature of the diagnosis "onAdmission" : { CodeableConcept } // Present on admission }], "procedure" : [{ // Clinical procedures performed "sequence" : "<positiveInt>", // R! Procedure instance identifier "type" : [{ CodeableConcept }], // Category of Procedure "date" : "<dateTime>", // When the procedure was performed // procedure[x]: Specific clinical procedure. One of these 2: "procedureCodeableConcept" : { CodeableConcept }, "procedureReference" : { Reference(Procedure) }, "udi" : [{ Reference(Device) }] // Unique device identifier }], "insurance" : [{ // Patient insurance information "sequence" : "<positiveInt>", // R! Insurance instance identifier "focal" : <boolean>, // R! Coverage to be used for adjudication "identifier" : { Identifier }, // Pre-assigned Claim number "coverage" : { Reference(Coverage) }, // R! Insurance information "businessArrangement" : "<string>", // Additional provider contract number "preAuthRef" : ["<string>"], // Prior authorization reference number "