Electronic Long-Term Services and Supports (eLTSS) Release 1 - US Realm
2.0.0 - STU2
Electronic Long-Term Services and Supports (eLTSS) Release 1 - US Realm
2.0.0 - STU2
This page is part of the electronic Long-Term Services and Supports Implementation Guide (v2.0.0: STU2) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions
| Official URL: http://hl7.org/fhir/us/eltss/StructureDefinition/Claim-eltss | Version: 2.0.0 | |||
| Standards status: Trial-use | Maturity Level: 2 | Computable Name: Claim_eltss | ||
Claim Resource profile for eLTSS
An important step in eLTSS is payment for services. The following highlights basic CORE FHIR associations that can be used, should business requirements request it.
A Claim FHIR Resource provides costing information, this can be a “claim” or “preauthorization” or “predetermination” (indicated with Claim.use). The claim should be connected to the ServiceRequest with the Claim.referral referencing the ServiceRequest instance. As mentioned, the Procedure Resource can be used to communicate work performed if the business requirements need it. The Procedure can be connected to a Claim using Claim.procedure.procedureReference. Any Task records can be included by referencing using Claim.supportingInfo.
If business rules require it, the FHIR ClaimResponse Resource can be used “to provide the results of the adjudication and/or authorization of a set of healthcare-related products and services for a patient against the patient’s insurance coverages, or to respond with what the adjudication would be for a supplied set of products or services should they be actually supplied to the patient.” see FHIR R4 ClaimResponse Resource In other words, the ClaimResponse Resource is used to respond to a FHIR Claim data instance. The ClaimResponse would detail the actual monies that could or would be paid.
A final consideration is the use of ClaimResponse.net and Claim.net. They both detail the total cost. Using the total cost and the FHIR ServiceRequest (or FHIR Procedure) frequency and quantity information a system could theoretically calculate the hourly rate for a service requested or approved. This might be less ambiguous and more convenient than requesting entry of the cost per unit.
The following aids in finding the location of eLTSS data elements. See R4 FHIR Mapping page for complete guidance, here we are providing a subset of fields for convenience.
| eLTSS Grouping | eLTSS Data Element Name | Data Element Definition (includes examples, expected list of values and usage note where applicable) | FHIR R4 Resource Element(s) | FHIR R4 Resource Element Cardinality (with US Core Constraints) | Additional Mapping Details |
|---|---|---|---|---|---|
| Service Information | Service Rate per Unit | The rate of one unit for a service. | CarePlan → activity → reference(ServiceRequest) ServiceRequest → supportingInfo(Claim) Claim → item → unitPrice |
CarePlan ...activity 0..* ......reference(ServiceRequest) 0..1 .........supportingInfo(Claim) 0..* ............item 0..* ...............unitPrice 0..1 |
1) Will use CarePlan → activity → reference to reference a ServiceRequest, and supportingInfo to reference a Claim. 2) item maps to a service. 3) unitPrice contains the charge or cost per point, which maps to the cost per one unit of the service. 4) unitPrice is of type Money, which is a descendant of the Quantity complex type and inherits value, unit, system, code, and comparator. 5) Workgroup in charge of ServiceRequest wants to work with the Claim workgroup to determine best approach. One potential approach is to update the scope of ClaimResponse since that reflects what has been approved rather than what is being asked for. |
| Service Information | Total Cost of Service | The total cost of a service for the plan. | CarePlan → activity → reference(ServiceRequest) ServiceRequest → supportingInfo(Claim) Claim → item → net |
CarePlan ...activity 0..* ......reference(ServiceRequest) 0..1 .........supportingInfo(Claim) 0..* ............item 0..* ...............net 0..1 |
1) Will use CarePlan → activity → reference to reference a ServiceRequest, and supportingInfo to reference a Claim. 2) item maps to a service. 3) net is the total cost of an item, which in this case is the total cost for the service. 4) net is of type Money, which is a descendant of the Quantity complex type and inherits value, unit, system, code, and comparator. 5) See above. |
| Data Requirements Not Specific to eLTSS Dataset Data Elements This section documents data elements that are mandatory per FHIR XML schemas or US Core requirements, but that do not align with individual eLTSS Dataset data elements. |
||||
|---|---|---|---|---|
| FHIR Data Element Name Requirement Source |
Data Element Definition | FHIR R4 Resource Element(s) | FHIR R4 Resource Element Cardinality (with US Core Constraints) | Additional Mapping Details |
| Claim Created FHIR |
The date this resource was created. | Claim → created | Claim ...created 1 |
1) created is required by FHIR. Could use date signers signed or agency authorized. Suggest using date/time that signers signed. |
| Claim Insurance FHIR |
Financial instruments for reimbursement for the health care products and services specified on the claim. | Claim → insurance | Claim ...insurance 1 |
1) insurance is required by FHIR. |
| Claim Insurance Sequence FHIR |
A number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order. | Claim → insurance → sequence | Claim ...insurance 1 ......sequence 1 |
1) sequence is required by FHIR and is a positiveInt. Suggest using "1". |
| Claim Insurance Focal FHIR |
A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true. | Claim → insurance → focal | Claim ...insurance 1 ......focal 1 |
1) focal is required by FHIR and is a boolean. Suggest using "true". |
| Claim Insurance Coverage FHIR |
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. | Claim → insurance → coverage | Claim ...insurance 1 ......coverage 1 |
1) coverage is required by FHIR and references Coverage. |
| Claim Item ProductOrService FHIR |
When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item. | Claim → item → productOrService | Claim ...item 0..* ......productOrService 1 |
1) productOrService is required by FHIR and must use the USCLS Codes value set (http://hl7.org/fhir/valueset-service-uscls.html). Suggest using the value "99555" for expense. |
| Claim Patient FHIR |
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. | Claim → patient | Claim ...patient 1 |
1) patient is required by FHIR and references Patient. |
| Claim Priority FHIR |
The provider-required urgency of processing the request. | Claim → priority | Claim ...priority 1 |
1) priority is required by FHIR and must use the Process Priority Codes value set (http://hl7.org/fhir/valueset-process-priority.html). Possible values are: stat, normal, deferred. Suggest using "normal". |
| Claim Provider FHIR |
The provider which is responsible for the claim, predetermination or preauthorization. | Claim → provider | Claim ...provider 1 |
1) provider is required by FHIR and references Practitioner, PractitionerRole, Organization. Suggest using Practitioner or Organization. |
| Claim Status FHIR |
The status of the resource instance. | Claim → status | Claim ...status 1 |
1) status is required by FHIR, and must use the Financial Resource Status Codes value set (http://hl7.org/fhir/valueset-fm-status.html). Possible values are: active, cancelled, draft, entered-in-error. Suggest using "active". |
| Claim Type FHIR |
The category of claim, e.g. oral, pharmacy, vision, institutional, professional. | Claim → type | Claim ...type 1 |
1) type is required by FHIR, and contains the extensible Claim Type Codes value set (http://hl7.org/fhir/valueset-claim-type.html). Possible values are: institutional, oral, pharmacy, professional, vision. Could use "professional", could extend code list, or could use text data element that is part of codeable concept. |
| Claim Use FHIR |
A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future. | Claim → use | Claim ...use 1 |
1) use is required by FHIR, and must use the Use value set (http://hl7.org/fhir/valueset-claim-use.html). Possible values are: claim, preauthorization, predetermination. Suggest using "preauthorization" |
| Claim Item Sequence FHIR |
A number to uniquely identify item entries | Claim → item → sequence | Claim ...item 0..* ......sequence 1 |
1) sequence is required by FHIR, and is a positive integer. |
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Claim
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Claim |
0..* | Claim | Claim, Pre-determination or Pre-authorization | |
  Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
   resource-pertainsToGoal |
S | 0..* | Reference(Goal) | The resource-pertainsToGoal relates the resource to the goal(s) that pertain to it. Whenever there is a goal associated with a health concern or problem, this extension should be present and populated in activity (event or intent) resources. URL: http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal |
  patient |
1..1 | Reference(Patient_eltss) | The recipient of the products and services | |
| enterer |
0..1 | Reference(Practitioner_eltss | eLTSS PractitionerRole Profile) | Author of the claim | |
| provider |
1..1 | Reference(Practitioner_eltss | eLTSS PractitionerRole Profile | US Core Organization Profile) | Party responsible for the claim | |
 related |
||||
 claim |
0..1 | Reference(Claim_eltss) | Reference to the related claim | |
| payee |
||||
| party |
0..1 | Reference(Practitioner_eltss | eLTSS PractitionerRole Profile | US Core Organization Profile | Patient_eltss | eLTSS RelatedPerson Profile) | Recipient reference | |
| referral |
0..1 | Reference(ServiceRequest_eltss) | Treatment referral | |
| facility |
0..1 | Reference(Location_eltss) | Servicing facility | |
| careTeam |
||||
| provider |
1..1 | Reference(Practitioner_eltss | eLTSS PractitionerRole Profile | US Core Organization Profile) | Practitioner or organization | |
| diagnosis |
||||
  Slices for diagnosis[x] |
1..1 | CodeableConcept, Reference(Condition) | Nature of illness or problem Slice: Unordered, Open by type:$this | |
 diagnosis[x]:diagnosisReference |
0..1 | Reference(Condition_eltss) | Nature of illness or problem | |
| accident |
||||
| Slices for location[x] |
0..1 | Address, Reference(Location) | Where the event occurred Slice: Unordered, Open by type:$this | |
| location[x]:locationReference |
0..1 | Reference(Location_eltss) | Where the event occurred | |
| item |
S | 0..* | BackboneElement | Product or service provided |
| unitPrice |
S | 0..1 | Money | Service Rate per Unit name |
| net |
S | 0..1 | Money | Total Cost of Service |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Claim |
0..* | Claim | Claim, Pre-determination or Pre-authorization | |
 implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| resource-pertainsToGoal |
S | 0..* | Reference(Goal) | The resource-pertainsToGoal relates the resource to the goal(s) that pertain to it. Whenever there is a goal associated with a health concern or problem, this extension should be present and populated in activity (event or intent) resources. URL: http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal |
 modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored |
| status |
?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. |
 type |
Σ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. |
| use |
Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim. |
| patient |
Σ | 1..1 | Reference(Patient_eltss) | The recipient of the products and services |
| created |
Σ | 1..1 | dateTime | Resource creation date |
| enterer |
0..1 | Reference(Practitioner_eltss | eLTSS PractitionerRole Profile) | Author of the claim | |
| provider |
Σ | 1..1 | Reference(Practitioner_eltss | eLTSS PractitionerRole Profile | US Core Organization Profile) | Party responsible for the claim |
| priority |
Σ | 1..1 | CodeableConcept | Desired processing ugency Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred. |
| referral |
0..1 | Reference(ServiceRequest_eltss) | Treatment referral | |
| facility |
0..1 | Reference(Location_eltss) | Servicing facility | |
| insurance |
Σ | 1..* | BackboneElement | Patient insurance information |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence |
Σ | 1..1 | positiveInt | Insurance instance identifier |
| focal |
Σ | 1..1 | boolean | Coverage to be used for adjudication |
| coverage |
Σ | 1..1 | Reference(Coverage) | Insurance information |
| item |
S | 0..* | BackboneElement | Product or service provided |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence |
1..1 | positiveInt | Item instance identifier | |
| productOrService |
1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |
| unitPrice |
S | 0..1 | Money | Service Rate per Unit name |
| net |
S | 0..1 | Money | Total Cost of Service |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Claim.status | required | FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|4.0.1from the FHIR Standard | |
| Claim.type | extensible | ClaimTypeCodeshttp://hl7.org/fhir/ValueSet/claim-typefrom the FHIR Standard | |
| Claim.use | required | Usehttp://hl7.org/fhir/ValueSet/claim-use|4.0.1from the FHIR Standard | |
| Claim.priority | example | ProcessPriorityCodeshttp://hl7.org/fhir/ValueSet/process-priorityfrom the FHIR Standard | |
| Claim.item.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-usclsfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Claim | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Claim | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Claim | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Claim | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Claim | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Claim |
0..* | Claim | Claim, Pre-determination or Pre-authorization | |||||
| id |
Σ | 0..1 | id | Logical id of this artifact | ||||
| meta |
Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| resource-pertainsToGoal |
S | 0..* | Reference(Goal) | The resource-pertainsToGoal relates the resource to the goal(s) that pertain to it. Whenever there is a goal associated with a health concern or problem, this extension should be present and populated in activity (event or intent) resources. URL: http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal | ||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier |
0..* | Identifier | Business Identifier for claim | |||||
| status |
?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. | ||||
| type |
Σ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. | ||||
| subType |
0..1 | CodeableConcept | More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode. | |||||
| use |
Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim. | ||||
| patient |
Σ | 1..1 | Reference(Patient_eltss) | 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_eltss | eLTSS PractitionerRole Profile) | Author of the claim | |||||
| insurer |
Σ | 0..1 | Reference(Organization) | Target | ||||
| provider |
Σ | 1..1 | Reference(Practitioner_eltss | eLTSS PractitionerRole Profile | US Core Organization Profile) | Party responsible for the claim | ||||
| priority |
Σ | 1..1 | CodeableConcept | Desired processing ugency Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred. | ||||
| fundsReserve |
0..1 | CodeableConcept | For whom to reserve funds Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None). | |||||
| related |
0..* | BackboneElement | Prior or corollary claims | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| claim |
0..1 | Reference(Claim_eltss) | Reference to the related claim | |||||
| relationship |
0..1 | CodeableConcept | How the reference claim is related Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim. | |||||
| 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 | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| type |
1..1 | CodeableConcept | Category of recipient Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed. | |||||
| party |
0..1 | Reference(Practitioner_eltss | eLTSS PractitionerRole Profile | US Core Organization Profile | Patient_eltss | eLTSS RelatedPerson Profile) | Recipient reference | |||||
| referral |
0..1 | Reference(ServiceRequest_eltss) | Treatment referral | |||||
| facility |
0..1 | Reference(Location_eltss) | Servicing facility | |||||
| careTeam |
0..* | BackboneElement | Members of the care team | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| sequence |
1..1 | positiveInt | Order of care team | |||||
| provider |
1..1 | Reference(Practitioner_eltss | eLTSS PractitionerRole Profile | US Core Organization Profile) | Practitioner or organization | |||||
| responsible |
0..1 | boolean | Indicator of the lead practitioner | |||||
| role |
0..1 | CodeableConcept | Function within the team Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members. | |||||
| qualification |
0..1 | CodeableConcept | Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications. | |||||
| supportingInfo |
0..* | BackboneElement | Supporting information | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| sequence |
1..1 | positiveInt | Information instance identifier | |||||
| category |
1..1 | CodeableConcept | Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. | |||||
| code |
0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes. | |||||
 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(Resource) | |||||||
| reason |
0..1 | CodeableConcept | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth. | |||||
| diagnosis |
0..* | BackboneElement | Pertinent diagnosis information | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| sequence |
1..1 | positiveInt | Diagnosis instance identifier | |||||
| Slices for diagnosis[x] |
1..1 | Nature of illness or problem Slice: Unordered, Open by type:$this Binding: ICD-10Codes (example): Example ICD10 Diagnostic codes. | ||||||
 diagnosisCodeableConcept |
CodeableConcept | |||||||
| diagnosisReference |
Reference(Condition) | |||||||
| diagnosis[x]:diagnosisReference |
0..1 | Reference(Condition_eltss) | Nature of illness or problem | |||||
| type |
0..* | CodeableConcept | Timing or nature of the diagnosis Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge. | |||||
| onAdmission |
0..1 | CodeableConcept | Present on admission Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission. | |||||
| packageCode |
0..1 | CodeableConcept | Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis. | |||||
| procedure |
0..* | BackboneElement | Clinical procedures performed | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| sequence |
1..1 | positiveInt | Procedure instance identifier | |||||
| type |
0..* | CodeableConcept | Category of Procedure Binding: ExampleProcedureTypeCodes (example): Example procedure type codes. | |||||
| date |
0..1 | dateTime | When the procedure was performed | |||||
| procedure[x] |
1..1 | Specific clinical procedure Binding: ICD-10ProcedureCodes (example): Example ICD10 Procedure codes. | ||||||
| procedureCodeableConcept |
CodeableConcept | |||||||
| procedureReference |
Reference(Procedure) | |||||||
| udi |
0..* | Reference(Device) | Unique device identifier | |||||
| insurance |
Σ | 1..* | BackboneElement | Patient insurance information | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| 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 | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| date |
1..1 | date | When the incident occurred | |||||
| type |
0..1 | CodeableConcept | The nature of the accident Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc. | |||||
| Slices for location[x] |
0..1 | Where the event occurred Slice: Unordered, Open by type:$this | ||||||
| locationAddress |
Address | |||||||
| locationReference |
Reference(Location) | |||||||
| location[x]:locationReference |
0..1 | Reference(Location_eltss) | Where the event occurred | |||||
| item |
S | 0..* | BackboneElement | Product or service provided | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| 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 Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |||||
| category |
0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses. | |||||
| productOrService |
1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
| modifier |
0..* | CodeableConcept | Product or service billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
| programCode |
0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||
| 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: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc. | ||||||
| locationCodeableConcept |
CodeableConcept | |||||||
| locationAddress |
Address | |||||||
| locationReference |
Reference(Location) | |||||||
| quantity |
0..1 | SimpleQuantity | Count of products or services | |||||
| unitPrice |
S | 0..1 | Money | Service Rate per Unit name | ||||
| factor |
0..1 | decimal | Price scaling factor | |||||
| net |
S | 0..1 | Money | Total Cost of Service | ||||
| udi |
0..* | Reference(Device) | Unique device identifier | |||||
| bodySite |
0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch. | |||||
| subSite |
0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations. | |||||
| encounter |
0..* | Reference(Encounter) | Encounters related to this billed item | |||||
| detail |
0..* | BackboneElement | Product or service provided | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| sequence |
1..1 | positiveInt | Item instance identifier | |||||
| revenue |
0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |||||
| category |
0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses. | |||||
| productOrService |
1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
| modifier |
0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
| programCode |
0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||
| 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 | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| sequence |
1..1 | positiveInt | Item instance identifier | |||||
| revenue |
0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |||||
| category |
0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses. | |||||
| productOrService |
1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
| modifier |
0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
| programCode |
0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||
| 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 | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | URI | |||
| Claim.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| Claim.status | required | FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|4.0.1from the FHIR Standard | ||||
| Claim.type | extensible | ClaimTypeCodeshttp://hl7.org/fhir/ValueSet/claim-typefrom the FHIR Standard | ||||
| Claim.subType | example | ExampleClaimSubTypeCodeshttp://hl7.org/fhir/ValueSet/claim-subtypefrom the FHIR Standard | ||||
| Claim.use | required | Usehttp://hl7.org/fhir/ValueSet/claim-use|4.0.1from the FHIR Standard | ||||
| Claim.priority | example | ProcessPriorityCodeshttp://hl7.org/fhir/ValueSet/process-priorityfrom the FHIR Standard | ||||
| Claim.fundsReserve | example | Funds Reservation Codeshttp://hl7.org/fhir/ValueSet/fundsreservefrom the FHIR Standard | ||||
| Claim.related.relationship | example | ExampleRelatedClaimRelationshipCodeshttp://hl7.org/fhir/ValueSet/related-claim-relationshipfrom the FHIR Standard | ||||
| Claim.payee.type | example | Claim Payee Type Codeshttp://hl7.org/fhir/ValueSet/payeetypefrom the FHIR Standard | ||||
| Claim.careTeam.role | example | ClaimCareTeamRoleCodeshttp://hl7.org/fhir/ValueSet/claim-careteamrolefrom the FHIR Standard | ||||
| Claim.careTeam.qualification | example | ExampleProviderQualificationCodeshttp://hl7.org/fhir/ValueSet/provider-qualificationfrom the FHIR Standard | ||||
| Claim.supportingInfo.category | example | ClaimInformationCategoryCodeshttp://hl7.org/fhir/ValueSet/claim-informationcategoryfrom the FHIR Standard | ||||
| Claim.supportingInfo.code | example | ExceptionCodeshttp://hl7.org/fhir/ValueSet/claim-exceptionfrom the FHIR Standard | ||||
| Claim.supportingInfo.reason | example | MissingToothReasonCodeshttp://hl7.org/fhir/ValueSet/missing-tooth-reasonfrom the FHIR Standard | ||||
| Claim.diagnosis.diagnosis[x] | example | ICD-10Codeshttp://hl7.org/fhir/ValueSet/icd-10from the FHIR Standard | ||||
| Claim.diagnosis.type | example | ExampleDiagnosisTypeCodeshttp://hl7.org/fhir/ValueSet/ex-diagnosistypefrom the FHIR Standard | ||||
| Claim.diagnosis.onAdmission | example | ExampleDiagnosisOnAdmissionCodeshttp://hl7.org/fhir/ValueSet/ex-diagnosis-on-admissionfrom the FHIR Standard | ||||
| Claim.diagnosis.packageCode | example | ExampleDiagnosisRelatedGroupCodeshttp://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroupfrom the FHIR Standard | ||||
| Claim.procedure.type | example | ExampleProcedureTypeCodeshttp://hl7.org/fhir/ValueSet/ex-procedure-typefrom the FHIR Standard | ||||
| Claim.procedure.procedure[x] | example | ICD-10ProcedureCodeshttp://hl7.org/fhir/ValueSet/icd-10-proceduresfrom the FHIR Standard | ||||
| Claim.accident.type | extensible | ActIncidentCodehttp://terminology.hl7.org/ValueSet/v3-ActIncidentCode | ||||
| Claim.item.revenue | example | ExampleRevenueCenterCodeshttp://hl7.org/fhir/ValueSet/ex-revenue-centerfrom the FHIR Standard | ||||
| Claim.item.category | example | BenefitCategoryCodeshttp://hl7.org/fhir/ValueSet/ex-benefitcategoryfrom the FHIR Standard | ||||
| Claim.item.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-usclsfrom the FHIR Standard | ||||
| Claim.item.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiersfrom the FHIR Standard | ||||
| Claim.item.programCode | example | ExampleProgramReasonCodeshttp://hl7.org/fhir/ValueSet/ex-program-codefrom the FHIR Standard | ||||
| Claim.item.location[x] | example | ExampleServicePlaceCodeshttp://hl7.org/fhir/ValueSet/service-placefrom the FHIR Standard | ||||
| Claim.item.bodySite | example | OralSiteCodeshttp://hl7.org/fhir/ValueSet/toothfrom the FHIR Standard | ||||
| Claim.item.subSite | example | SurfaceCodeshttp://hl7.org/fhir/ValueSet/surfacefrom the FHIR Standard | ||||
| Claim.item.detail.revenue | example | ExampleRevenueCenterCodeshttp://hl7.org/fhir/ValueSet/ex-revenue-centerfrom the FHIR Standard | ||||
| Claim.item.detail.category | example | BenefitCategoryCodeshttp://hl7.org/fhir/ValueSet/ex-benefitcategoryfrom the FHIR Standard | ||||
| Claim.item.detail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-usclsfrom the FHIR Standard | ||||
| Claim.item.detail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiersfrom the FHIR Standard | ||||
| Claim.item.detail.programCode | example | ExampleProgramReasonCodeshttp://hl7.org/fhir/ValueSet/ex-program-codefrom the FHIR Standard | ||||
| Claim.item.detail.subDetail.revenue | example | ExampleRevenueCenterCodeshttp://hl7.org/fhir/ValueSet/ex-revenue-centerfrom the FHIR Standard | ||||
| Claim.item.detail.subDetail.category | example | BenefitCategoryCodeshttp://hl7.org/fhir/ValueSet/ex-benefitcategoryfrom the FHIR Standard | ||||
| Claim.item.detail.subDetail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-usclsfrom the FHIR Standard | ||||
| Claim.item.detail.subDetail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiersfrom the FHIR Standard | ||||
| Claim.item.detail.subDetail.programCode | example | ExampleProgramReasonCodeshttp://hl7.org/fhir/ValueSet/ex-program-codefrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Claim | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Claim | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Claim | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Claim | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Claim | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from Claim
Summary
Must-Support: 4 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Maturity: 2
Differential View
This structure is derived from Claim
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Claim |
0..* | Claim | Claim, Pre-determination or Pre-authorization | |
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| resource-pertainsToGoal |
S | 0..* | Reference(Goal) | The resource-pertainsToGoal relates the resource to the goal(s) that pertain to it. Whenever there is a goal associated with a health concern or problem, this extension should be present and populated in activity (event or intent) resources. URL: http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal |
| patient |
1..1 | Reference(Patient_eltss) | The recipient of the products and services | |
| enterer |
0..1 | Reference(Practitioner_eltss | eLTSS PractitionerRole Profile) | Author of the claim | |
| provider |
1..1 | Reference(Practitioner_eltss | eLTSS PractitionerRole Profile | US Core Organization Profile) | Party responsible for the claim | |
| related |
||||
| claim |
0..1 | Reference(Claim_eltss) | Reference to the related claim | |
| payee |
||||
| party |
0..1 | Reference(Practitioner_eltss | eLTSS PractitionerRole Profile | US Core Organization Profile | Patient_eltss | eLTSS RelatedPerson Profile) | Recipient reference | |
| referral |
0..1 | Reference(ServiceRequest_eltss) | Treatment referral | |
| facility |
0..1 | Reference(Location_eltss) | Servicing facility | |
| careTeam |
||||
| provider |
1..1 | Reference(Practitioner_eltss | eLTSS PractitionerRole Profile | US Core Organization Profile) | Practitioner or organization | |
| diagnosis |
||||
| Slices for diagnosis[x] |
1..1 | CodeableConcept, Reference(Condition) | Nature of illness or problem Slice: Unordered, Open by type:$this | |
| diagnosis[x]:diagnosisReference |
0..1 | Reference(Condition_eltss) | Nature of illness or problem | |
| accident |
||||
| Slices for location[x] |
0..1 | Address, Reference(Location) | Where the event occurred Slice: Unordered, Open by type:$this | |
| location[x]:locationReference |
0..1 | Reference(Location_eltss) | Where the event occurred | |
| item |
S | 0..* | BackboneElement | Product or service provided |
| unitPrice |
S | 0..1 | Money | Service Rate per Unit name |
| net |
S | 0..1 | Money | Total Cost of Service |
| Documentation for this format | ||||
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Claim |
0..* | Claim | Claim, Pre-determination or Pre-authorization | |
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| resource-pertainsToGoal |
S | 0..* | Reference(Goal) | The resource-pertainsToGoal relates the resource to the goal(s) that pertain to it. Whenever there is a goal associated with a health concern or problem, this extension should be present and populated in activity (event or intent) resources. URL: http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal |
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored |
| status |
?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. |
| type |
Σ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. |
| use |
Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim. |
| patient |
Σ | 1..1 | Reference(Patient_eltss) | The recipient of the products and services |
| created |
Σ | 1..1 | dateTime | Resource creation date |
| enterer |
0..1 | Reference(Practitioner_eltss | eLTSS PractitionerRole Profile) | Author of the claim | |
| provider |
Σ | 1..1 | Reference(Practitioner_eltss | eLTSS PractitionerRole Profile | US Core Organization Profile) | Party responsible for the claim |
| priority |
Σ | 1..1 | CodeableConcept | Desired processing ugency Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred. |
| referral |
0..1 | Reference(ServiceRequest_eltss) | Treatment referral | |
| facility |
0..1 | Reference(Location_eltss) | Servicing facility | |
| insurance |
Σ | 1..* | BackboneElement | Patient insurance information |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence |
Σ | 1..1 | positiveInt | Insurance instance identifier |
| focal |
Σ | 1..1 | boolean | Coverage to be used for adjudication |
| coverage |
Σ | 1..1 | Reference(Coverage) | Insurance information |
| item |
S | 0..* | BackboneElement | Product or service provided |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence |
1..1 | positiveInt | Item instance identifier | |
| productOrService |
1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |
| unitPrice |
S | 0..1 | Money | Service Rate per Unit name |
| net |
S | 0..1 | Money | Total Cost of Service |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Claim.status | required | FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|4.0.1from the FHIR Standard | |
| Claim.type | extensible | ClaimTypeCodeshttp://hl7.org/fhir/ValueSet/claim-typefrom the FHIR Standard | |
| Claim.use | required | Usehttp://hl7.org/fhir/ValueSet/claim-use|4.0.1from the FHIR Standard | |
| Claim.priority | example | ProcessPriorityCodeshttp://hl7.org/fhir/ValueSet/process-priorityfrom the FHIR Standard | |
| Claim.item.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-usclsfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Claim | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Claim | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Claim | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Claim | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Claim | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Claim |
0..* | Claim | Claim, Pre-determination or Pre-authorization | |||||
| id |
Σ | 0..1 | id | Logical id of this artifact | ||||
| meta |
Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| resource-pertainsToGoal |
S | 0..* | Reference(Goal) | The resource-pertainsToGoal relates the resource to the goal(s) that pertain to it. Whenever there is a goal associated with a health concern or problem, this extension should be present and populated in activity (event or intent) resources. URL: http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal | ||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier |
0..* | Identifier | Business Identifier for claim | |||||
| status |
?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. | ||||
| type |
Σ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. | ||||
| subType |
0..1 | CodeableConcept | More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode. | |||||
| use |
Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim. | ||||
| patient |
Σ | 1..1 | Reference(Patient_eltss) | 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_eltss | eLTSS PractitionerRole Profile) | Author of the claim | |||||
| insurer |
Σ | 0..1 | Reference(Organization) | Target | ||||
| provider |
Σ | 1..1 | Reference(Practitioner_eltss | eLTSS PractitionerRole Profile | US Core Organization Profile) | Party responsible for the claim | ||||
| priority |
Σ | 1..1 | CodeableConcept | Desired processing ugency Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred. | ||||
| fundsReserve |
0..1 | CodeableConcept | For whom to reserve funds Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None). | |||||
| related |
0..* | BackboneElement | Prior or corollary claims | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| claim |
0..1 | Reference(Claim_eltss) | Reference to the related claim | |||||
| relationship |
0..1 | CodeableConcept | How the reference claim is related Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim. | |||||
| 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 | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| type |
1..1 | CodeableConcept | Category of recipient Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed. | |||||
| party |
0..1 | Reference(Practitioner_eltss | eLTSS PractitionerRole Profile | US Core Organization Profile | Patient_eltss | eLTSS RelatedPerson Profile) | Recipient reference | |||||
| referral |
0..1 | Reference(ServiceRequest_eltss) | Treatment referral | |||||
| facility |
0..1 | Reference(Location_eltss) | Servicing facility | |||||
| careTeam |
0..* | BackboneElement | Members of the care team | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| sequence |
1..1 | positiveInt | Order of care team | |||||
| provider |
1..1 | Reference(Practitioner_eltss | eLTSS PractitionerRole Profile | US Core Organization Profile) | Practitioner or organization | |||||
| responsible |
0..1 | boolean | Indicator of the lead practitioner | |||||
| role |
0..1 | CodeableConcept | Function within the team Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members. | |||||
| qualification |
0..1 | CodeableConcept | Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications. | |||||
| supportingInfo |
0..* | BackboneElement | Supporting information | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| sequence |
1..1 | positiveInt | Information instance identifier | |||||
| category |
1..1 | CodeableConcept | Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. | |||||
| code |
0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes. | |||||
| 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(Resource) | |||||||
| reason |
0..1 | CodeableConcept | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth. | |||||
| diagnosis |
0..* | BackboneElement | Pertinent diagnosis information | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| sequence |
1..1 | positiveInt | Diagnosis instance identifier | |||||
| Slices for diagnosis[x] |
1..1 | Nature of illness or problem Slice: Unordered, Open by type:$this Binding: ICD-10Codes (example): Example ICD10 Diagnostic codes. | ||||||
| diagnosisCodeableConcept |
CodeableConcept | |||||||
| diagnosisReference |
Reference(Condition) | |||||||
| diagnosis[x]:diagnosisReference |
0..1 | Reference(Condition_eltss) | Nature of illness or problem | |||||
| type |
0..* | CodeableConcept | Timing or nature of the diagnosis Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge. | |||||
| onAdmission |
0..1 | CodeableConcept | Present on admission Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission. | |||||
| packageCode |
0..1 | CodeableConcept | Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis. | |||||
| procedure |
0..* | BackboneElement | Clinical procedures performed | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| sequence |
1..1 | positiveInt | Procedure instance identifier | |||||
| type |
0..* | CodeableConcept | Category of Procedure Binding: ExampleProcedureTypeCodes (example): Example procedure type codes. | |||||
| date |
0..1 | dateTime | When the procedure was performed | |||||
| procedure[x] |
1..1 | Specific clinical procedure Binding: ICD-10ProcedureCodes (example): Example ICD10 Procedure codes. | ||||||
| procedureCodeableConcept |
CodeableConcept | |||||||
| procedureReference |
Reference(Procedure) | |||||||
| udi |
0..* | Reference(Device) | Unique device identifier | |||||
| insurance |
Σ | 1..* | BackboneElement | Patient insurance information | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| 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 | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| date |
1..1 | date | When the incident occurred | |||||
| type |
0..1 | CodeableConcept | The nature of the accident Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc. | |||||
| Slices for location[x] |
0..1 | Where the event occurred Slice: Unordered, Open by type:$this | ||||||
| locationAddress |
Address | |||||||
| locationReference |
Reference(Location) | |||||||
| location[x]:locationReference |
0..1 | Reference(Location_eltss) | Where the event occurred | |||||
| item |
S | 0..* | BackboneElement | Product or service provided | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| 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 Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |||||
| category |
0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses. | |||||
| productOrService |
1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
| modifier |
0..* | CodeableConcept | Product or service billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
| programCode |
0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||
| 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: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc. | ||||||
| locationCodeableConcept |
CodeableConcept | |||||||
| locationAddress |
Address | |||||||
| locationReference |
Reference(Location) | |||||||
| quantity |
0..1 | SimpleQuantity | Count of products or services | |||||
| unitPrice |
S | 0..1 | Money | Service Rate per Unit name | ||||
| factor |
0..1 | decimal | Price scaling factor | |||||
| net |
S | 0..1 | Money | Total Cost of Service | ||||
| udi |
0..* | Reference(Device) | Unique device identifier | |||||
| bodySite |
0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch. | |||||
| subSite |
0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations. | |||||
| encounter |
0..* | Reference(Encounter) | Encounters related to this billed item | |||||
| detail |
0..* | BackboneElement | Product or service provided | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| sequence |
1..1 | positiveInt | Item instance identifier | |||||
| revenue |
0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |||||
| category |
0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses. | |||||
| productOrService |
1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
| modifier |
0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
| programCode |
0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||
| 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 | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| sequence |
1..1 | positiveInt | Item instance identifier | |||||
| revenue |
0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |||||
| category |
0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses. | |||||
| productOrService |
1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
| modifier |
0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
| programCode |
0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||
| 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 | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | URI | |||
| Claim.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| Claim.status | required | FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|4.0.1from the FHIR Standard | ||||
| Claim.type | extensible | ClaimTypeCodeshttp://hl7.org/fhir/ValueSet/claim-typefrom the FHIR Standard | ||||
| Claim.subType | example | ExampleClaimSubTypeCodeshttp://hl7.org/fhir/ValueSet/claim-subtypefrom the FHIR Standard | ||||
| Claim.use | required | Usehttp://hl7.org/fhir/ValueSet/claim-use|4.0.1from the FHIR Standard | ||||
| Claim.priority | example | ProcessPriorityCodeshttp://hl7.org/fhir/ValueSet/process-priorityfrom the FHIR Standard | ||||
| Claim.fundsReserve | example | Funds Reservation Codeshttp://hl7.org/fhir/ValueSet/fundsreservefrom the FHIR Standard | ||||
| Claim.related.relationship | example | ExampleRelatedClaimRelationshipCodeshttp://hl7.org/fhir/ValueSet/related-claim-relationshipfrom the FHIR Standard | ||||
| Claim.payee.type | example | Claim Payee Type Codeshttp://hl7.org/fhir/ValueSet/payeetypefrom the FHIR Standard | ||||
| Claim.careTeam.role | example | ClaimCareTeamRoleCodeshttp://hl7.org/fhir/ValueSet/claim-careteamrolefrom the FHIR Standard | ||||
| Claim.careTeam.qualification | example | ExampleProviderQualificationCodeshttp://hl7.org/fhir/ValueSet/provider-qualificationfrom the FHIR Standard | ||||
| Claim.supportingInfo.category | example | ClaimInformationCategoryCodeshttp://hl7.org/fhir/ValueSet/claim-informationcategoryfrom the FHIR Standard | ||||
| Claim.supportingInfo.code | example | ExceptionCodeshttp://hl7.org/fhir/ValueSet/claim-exceptionfrom the FHIR Standard | ||||
| Claim.supportingInfo.reason | example | MissingToothReasonCodeshttp://hl7.org/fhir/ValueSet/missing-tooth-reasonfrom the FHIR Standard | ||||
| Claim.diagnosis.diagnosis[x] | example | ICD-10Codeshttp://hl7.org/fhir/ValueSet/icd-10from the FHIR Standard | ||||
| Claim.diagnosis.type | example | ExampleDiagnosisTypeCodeshttp://hl7.org/fhir/ValueSet/ex-diagnosistypefrom the FHIR Standard | ||||
| Claim.diagnosis.onAdmission | example | ExampleDiagnosisOnAdmissionCodeshttp://hl7.org/fhir/ValueSet/ex-diagnosis-on-admissionfrom the FHIR Standard | ||||
| Claim.diagnosis.packageCode | example | ExampleDiagnosisRelatedGroupCodeshttp://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroupfrom the FHIR Standard | ||||
| Claim.procedure.type | example | ExampleProcedureTypeCodeshttp://hl7.org/fhir/ValueSet/ex-procedure-typefrom the FHIR Standard | ||||
| Claim.procedure.procedure[x] | example | ICD-10ProcedureCodeshttp://hl7.org/fhir/ValueSet/icd-10-proceduresfrom the FHIR Standard | ||||
| Claim.accident.type | extensible | ActIncidentCodehttp://terminology.hl7.org/ValueSet/v3-ActIncidentCode | ||||
| Claim.item.revenue | example | ExampleRevenueCenterCodeshttp://hl7.org/fhir/ValueSet/ex-revenue-centerfrom the FHIR Standard | ||||
| Claim.item.category | example | BenefitCategoryCodeshttp://hl7.org/fhir/ValueSet/ex-benefitcategoryfrom the FHIR Standard | ||||
| Claim.item.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-usclsfrom the FHIR Standard | ||||
| Claim.item.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiersfrom the FHIR Standard | ||||
| Claim.item.programCode | example | ExampleProgramReasonCodeshttp://hl7.org/fhir/ValueSet/ex-program-codefrom the FHIR Standard | ||||
| Claim.item.location[x] | example | ExampleServicePlaceCodeshttp://hl7.org/fhir/ValueSet/service-placefrom the FHIR Standard | ||||
| Claim.item.bodySite | example | OralSiteCodeshttp://hl7.org/fhir/ValueSet/toothfrom the FHIR Standard | ||||
| Claim.item.subSite | example | SurfaceCodeshttp://hl7.org/fhir/ValueSet/surfacefrom the FHIR Standard | ||||
| Claim.item.detail.revenue | example | ExampleRevenueCenterCodeshttp://hl7.org/fhir/ValueSet/ex-revenue-centerfrom the FHIR Standard | ||||
| Claim.item.detail.category | example | BenefitCategoryCodeshttp://hl7.org/fhir/ValueSet/ex-benefitcategoryfrom the FHIR Standard | ||||
| Claim.item.detail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-usclsfrom the FHIR Standard | ||||
| Claim.item.detail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiersfrom the FHIR Standard | ||||
| Claim.item.detail.programCode | example | ExampleProgramReasonCodeshttp://hl7.org/fhir/ValueSet/ex-program-codefrom the FHIR Standard | ||||
| Claim.item.detail.subDetail.revenue | example | ExampleRevenueCenterCodeshttp://hl7.org/fhir/ValueSet/ex-revenue-centerfrom the FHIR Standard | ||||
| Claim.item.detail.subDetail.category | example | BenefitCategoryCodeshttp://hl7.org/fhir/ValueSet/ex-benefitcategoryfrom the FHIR Standard | ||||
| Claim.item.detail.subDetail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-usclsfrom the FHIR Standard | ||||
| Claim.item.detail.subDetail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiersfrom the FHIR Standard | ||||
| Claim.item.detail.subDetail.programCode | example | ExampleProgramReasonCodeshttp://hl7.org/fhir/ValueSet/ex-program-codefrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Claim | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Claim | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Claim | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Claim | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Claim | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from Claim
Summary
Must-Support: 4 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Maturity: 2
Other representations of profile: CSV, Excel, Schematron
IG © 2020+ HL7 International / Human and Social Services. Package hl7.fhir.us.eltss#2.0.0 based on FHIR 4.0.1. Generated 2024-05-27
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