2nd DSTU Draft For Comment

This page is part of the FHIR Specification (v0.4.0: DSTU 2 Draft). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions

Oralhealthclaim.questionnaire

This is an example form generated from the questionnaire. See also the XML or JSON format.

Oralhealthclaim.questionnaire - FHIR v0.4.0 Form
2nd DSTU Draft For Comment

This is an example form generated from the questionnaire. See also the XML or JSON format

Claim, Pre-determination or Pre-authorization

OralHealthClaim
OralHealthClaim.id
OralHealthClaim.id.value Logical id of this artefact
OralHealthClaim.id 1

Metadata about the resource

OralHealthClaim.meta
OralHealthClaim.meta 1
OralHealthClaim.implicitRules
OralHealthClaim.implicitRules.value A set of rules under which this content was created
OralHealthClaim.implicitRules 1
OralHealthClaim.language
OralHealthClaim.language.value language
OralHealthClaim.language 1

Text summary of the resource, for human interpretation

OralHealthClaim.text
OralHealthClaim.text 1

Contained, inline Resources

OralHealthClaim.contained
OralHealthClaim.contained 1

Claim number

OralHealthClaim.identifier
OralHealthClaim.identifier.label label:
OralHealthClaim.identifier.system system:
OralHealthClaim.identifier.value value:
OralHealthClaim.identifier 1
OralHealthClaim.ruleset
OralHealthClaim.ruleset.value Current specification followed
OralHealthClaim.ruleset 1
OralHealthClaim.originalRuleset
OralHealthClaim.originalRuleset.value Original specification followed
OralHealthClaim.originalRuleset 1
OralHealthClaim.created
OralHealthClaim.created.value Creation date
OralHealthClaim.created 1
OralHealthClaim.target
OralHealthClaim.target.value Insurer
OralHealthClaim.target 1
OralHealthClaim.provider
OralHealthClaim.provider.value Responsible provider
OralHealthClaim.provider 1
OralHealthClaim.organization
OralHealthClaim.organization.value Responsible organization
OralHealthClaim.organization 1
OralHealthClaim.use
OralHealthClaim.use.value use
OralHealthClaim.use 1
OralHealthClaim.priority
OralHealthClaim.priority.value Desired processing priority
OralHealthClaim.priority 1
OralHealthClaim.fundsReserve
OralHealthClaim.fundsReserve.value Funds requested to be reserved
OralHealthClaim.fundsReserve 1
OralHealthClaim.enterer
OralHealthClaim.enterer.value Author
OralHealthClaim.enterer 1
OralHealthClaim.facility
OralHealthClaim.facility.value Servicing Facility
OralHealthClaim.facility 1

Payee

OralHealthClaim.payee
OralHealthClaim.payee.id
OralHealthClaim.payee.id.value xml:id (or equivalent in JSON)
OralHealthClaim.payee.id 1
OralHealthClaim.payee.type
OralHealthClaim.payee.type.value Party to be paid any benefits payable
OralHealthClaim.payee.type 1
OralHealthClaim.payee.provider
OralHealthClaim.payee.provider.value Provider who is the payee
OralHealthClaim.payee.provider 1
OralHealthClaim.payee.organization
OralHealthClaim.payee.organization.value Organization who is the payee
OralHealthClaim.payee.organization 1
OralHealthClaim.payee.person
OralHealthClaim.payee.person.value Other person who is the payee
OralHealthClaim.payee.person 1
OralHealthClaim.payee 1
OralHealthClaim.referral
OralHealthClaim.referral.value Treatment Referral
OralHealthClaim.referral 1

Diagnosis

OralHealthClaim.diagnosis
OralHealthClaim.diagnosis.id
OralHealthClaim.diagnosis.id.value xml:id (or equivalent in JSON)
OralHealthClaim.diagnosis.id 1
OralHealthClaim.diagnosis.sequence
OralHealthClaim.diagnosis.sequence.value Sequence of diagnosis
OralHealthClaim.diagnosis.sequence 1
OralHealthClaim.diagnosis.diagnosis
OralHealthClaim.diagnosis.diagnosis.value Patient's list of diagnosis
OralHealthClaim.diagnosis.diagnosis 1
OralHealthClaim.diagnosis 1
OralHealthClaim.condition
OralHealthClaim.condition.value List of presenting Conditions
OralHealthClaim.condition 1
OralHealthClaim.patient
OralHealthClaim.patient.value The subject of the Products and Services
OralHealthClaim.patient 1

Insurance or medical plan

OralHealthClaim.coverage
OralHealthClaim.coverage.id
OralHealthClaim.coverage.id.value xml:id (or equivalent in JSON)
OralHealthClaim.coverage.id 1
OralHealthClaim.coverage.sequence
OralHealthClaim.coverage.sequence.value Service instance identifier
OralHealthClaim.coverage.sequence 1
OralHealthClaim.coverage.focal
OralHealthClaim.coverage.focal.value Is the focal Coverage
OralHealthClaim.coverage.focal 1
OralHealthClaim.coverage.coverage
OralHealthClaim.coverage.coverage.value Insurance information
OralHealthClaim.coverage.coverage 1
OralHealthClaim.coverage.businessArrangement
OralHealthClaim.coverage.businessArrangement.value Business agreement
OralHealthClaim.coverage.businessArrangement 1
OralHealthClaim.coverage.relationship
OralHealthClaim.coverage.relationship.value Patient relationship to subscriber
OralHealthClaim.coverage.relationship 1
OralHealthClaim.coverage.preauthref
OralHealthClaim.coverage.preauthref.value Pre-Authorization/Determination Reference
OralHealthClaim.coverage.preauthref 1
OralHealthClaim.coverage.claimResponse
OralHealthClaim.coverage.claimResponse.value Adjudication results
OralHealthClaim.coverage.claimResponse 1
OralHealthClaim.coverage.originalRuleset
OralHealthClaim.coverage.originalRuleset.value Original version
OralHealthClaim.coverage.originalRuleset 1
OralHealthClaim.coverage 1
OralHealthClaim.exception
OralHealthClaim.exception.value Eligibility exceptions
OralHealthClaim.exception 1
OralHealthClaim.school
OralHealthClaim.school.value Name of School
OralHealthClaim.school 1
OralHealthClaim.accident
OralHealthClaim.accident.value Accident Date
OralHealthClaim.accident 1
OralHealthClaim.accidentType
OralHealthClaim.accidentType.value Accident Type
OralHealthClaim.accidentType 1
OralHealthClaim.interventionException
OralHealthClaim.interventionException.value Intervention and exception code (Pharma)
OralHealthClaim.interventionException 1

Missing Teeth

OralHealthClaim.missingteeth
OralHealthClaim.missingteeth.id
OralHealthClaim.missingteeth.id.value xml:id (or equivalent in JSON)
OralHealthClaim.missingteeth.id 1
OralHealthClaim.missingteeth.tooth
OralHealthClaim.missingteeth.tooth.value Tooth Code
OralHealthClaim.missingteeth.tooth 1
OralHealthClaim.missingteeth.reason
OralHealthClaim.missingteeth.reason.value Reason for missing
OralHealthClaim.missingteeth.reason 1
OralHealthClaim.missingteeth.extractiondate
OralHealthClaim.missingteeth.extractiondate.value Date of Extraction
OralHealthClaim.missingteeth.extractiondate 1
OralHealthClaim.missingteeth 1

Orthodontic Treatment Plan

OralHealthClaim.orthoPlan
OralHealthClaim.orthoPlan.id
OralHealthClaim.orthoPlan.id.value xml:id (or equivalent in JSON)
OralHealthClaim.orthoPlan.id 1
OralHealthClaim.orthoPlan.start
OralHealthClaim.orthoPlan.start.value Start date
OralHealthClaim.orthoPlan.start 1

First exam fee

OralHealthClaim.orthoPlan.examFee
OralHealthClaim.orthoPlan.examFee.value value:
OralHealthClaim.orthoPlan.examFee.currency currency:
OralHealthClaim.orthoPlan.examFee 1

Diagnostic phase fee

OralHealthClaim.orthoPlan.diagnosticFee
OralHealthClaim.orthoPlan.diagnosticFee.value value:
OralHealthClaim.orthoPlan.diagnosticFee.currency currency:
OralHealthClaim.orthoPlan.diagnosticFee 1

Initial payment

OralHealthClaim.orthoPlan.initialPayment
OralHealthClaim.orthoPlan.initialPayment.value value:
OralHealthClaim.orthoPlan.initialPayment.currency currency:
OralHealthClaim.orthoPlan.initialPayment 1
OralHealthClaim.orthoPlan.durationMonths
OralHealthClaim.orthoPlan.durationMonths.value Duration in months
OralHealthClaim.orthoPlan.durationMonths 1
OralHealthClaim.orthoPlan.paymentCount
OralHealthClaim.orthoPlan.paymentCount.value Anticipated number of payments
OralHealthClaim.orthoPlan.paymentCount 1

Anticipated payment

OralHealthClaim.orthoPlan.periodicPayment
OralHealthClaim.orthoPlan.periodicPayment.value value:
OralHealthClaim.orthoPlan.periodicPayment.currency currency:
OralHealthClaim.orthoPlan.periodicPayment 1
OralHealthClaim.orthoPlan 1

Goods and Services

OralHealthClaim.item
OralHealthClaim.item.id
OralHealthClaim.item.id.value xml:id (or equivalent in JSON)
OralHealthClaim.item.id 1
OralHealthClaim.item.sequence
OralHealthClaim.item.sequence.value Service instance
OralHealthClaim.item.sequence 1
OralHealthClaim.item.type
OralHealthClaim.item.type.value Group or type of product or service
OralHealthClaim.item.type 1
OralHealthClaim.item.provider
OralHealthClaim.item.provider.value Responsible practitioner
OralHealthClaim.item.provider 1
OralHealthClaim.item.diagnosisLinkId
OralHealthClaim.item.diagnosisLinkId.value Diagnosis Link
OralHealthClaim.item.diagnosisLinkId 1
OralHealthClaim.item.service
OralHealthClaim.item.service.value Item Code
OralHealthClaim.item.service 1
OralHealthClaim.item.serviceDate
OralHealthClaim.item.serviceDate.value Date of Service
OralHealthClaim.item.serviceDate 1

Count of Products or Services

OralHealthClaim.item.quantity
OralHealthClaim.item.quantity.comparator comp:
OralHealthClaim.item.quantity.value value:
OralHealthClaim.item.quantity.units units:
OralHealthClaim.item.quantity.code coded units:
OralHealthClaim.item.quantity.system units system:
OralHealthClaim.item.quantity 1

Fee, charge or cost per point

OralHealthClaim.item.unitPrice
OralHealthClaim.item.unitPrice.value value:
OralHealthClaim.item.unitPrice.currency currency:
OralHealthClaim.item.unitPrice 1
OralHealthClaim.item.factor
OralHealthClaim.item.factor.value Price scaling factor
OralHealthClaim.item.factor 1
OralHealthClaim.item.points
OralHealthClaim.item.points.value Difficulty scaling factor
OralHealthClaim.item.points 1

Total item cost

OralHealthClaim.item.net
OralHealthClaim.item.net.value value:
OralHealthClaim.item.net.currency currency:
OralHealthClaim.item.net 1
OralHealthClaim.item.udi
OralHealthClaim.item.udi.value Unique Device Identifier
OralHealthClaim.item.udi 1
OralHealthClaim.item.bodySite
OralHealthClaim.item.bodySite.value Service Location
OralHealthClaim.item.bodySite 1
OralHealthClaim.item.subsite
OralHealthClaim.item.subsite.value Service Sub-location
OralHealthClaim.item.subsite 1
OralHealthClaim.item.modifier
OralHealthClaim.item.modifier.value Service/Product billing modifiers
OralHealthClaim.item.modifier 1

Additional items

OralHealthClaim.item.detail
OralHealthClaim.item.detail.id
OralHealthClaim.item.detail.id.value xml:id (or equivalent in JSON)
OralHealthClaim.item.detail.id 1
OralHealthClaim.item.detail.sequence
OralHealthClaim.item.detail.sequence.value Service instance
OralHealthClaim.item.detail.sequence 1
OralHealthClaim.item.detail.type
OralHealthClaim.item.detail.type.value Group or type of product or service
OralHealthClaim.item.detail.type 1
OralHealthClaim.item.detail.service
OralHealthClaim.item.detail.service.value Additional item codes
OralHealthClaim.item.detail.service 1

Count of Products or Services

OralHealthClaim.item.detail.quantity
OralHealthClaim.item.detail.quantity.comparator comp:
OralHealthClaim.item.detail.quantity.value value:
OralHealthClaim.item.detail.quantity.units units:
OralHealthClaim.item.detail.quantity.code coded units:
OralHealthClaim.item.detail.quantity.system units system:
OralHealthClaim.item.detail.quantity 1

Fee, charge or cost per point

OralHealthClaim.item.detail.unitPrice
OralHealthClaim.item.detail.unitPrice.value value:
OralHealthClaim.item.detail.unitPrice.currency currency:
OralHealthClaim.item.detail.unitPrice 1
OralHealthClaim.item.detail.factor
OralHealthClaim.item.detail.factor.value Price scaling factor
OralHealthClaim.item.detail.factor 1
OralHealthClaim.item.detail.points
OralHealthClaim.item.detail.points.value Difficulty scaling factor
OralHealthClaim.item.detail.points 1

Total additional item cost

OralHealthClaim.item.detail.net
OralHealthClaim.item.detail.net.value value:
OralHealthClaim.item.detail.net.currency currency:
OralHealthClaim.item.detail.net 1
OralHealthClaim.item.detail.udi
OralHealthClaim.item.detail.udi.value Unique Device Identifier
OralHealthClaim.item.detail.udi 1

Additional items

OralHealthClaim.item.detail.subDetail
OralHealthClaim.item.detail.subDetail.id
OralHealthClaim.item.detail.subDetail.id.value xml:id (or equivalent in JSON)
OralHealthClaim.item.detail.subDetail.id 1
OralHealthClaim.item.detail.subDetail.sequence
OralHealthClaim.item.detail.subDetail.sequence.value Service instance
OralHealthClaim.item.detail.subDetail.sequence 1
OralHealthClaim.item.detail.subDetail.type
OralHealthClaim.item.detail.subDetail.type.value Type of product or service
OralHealthClaim.item.detail.subDetail.type 1
OralHealthClaim.item.detail.subDetail.service
OralHealthClaim.item.detail.subDetail.service.value Additional item codes
OralHealthClaim.item.detail.subDetail.service 1

Count of Products or Services

OralHealthClaim.item.detail.subDetail.quantity
OralHealthClaim.item.detail.subDetail.quantity.comparator comp:
OralHealthClaim.item.detail.subDetail.quantity.value value:
OralHealthClaim.item.detail.subDetail.quantity.units units:
OralHealthClaim.item.detail.subDetail.quantity.code coded units:
OralHealthClaim.item.detail.subDetail.quantity.system units system:
OralHealthClaim.item.detail.subDetail.quantity 1

Fee, charge or cost per point

OralHealthClaim.item.detail.subDetail.unitPrice
OralHealthClaim.item.detail.subDetail.unitPrice.value value:
OralHealthClaim.item.detail.subDetail.unitPrice.currency currency:
OralHealthClaim.item.detail.subDetail.unitPrice 1
OralHealthClaim.item.detail.subDetail.factor
OralHealthClaim.item.detail.subDetail.factor.value Price scaling factor
OralHealthClaim.item.detail.subDetail.factor 1
OralHealthClaim.item.detail.subDetail.points
OralHealthClaim.item.detail.subDetail.points.value Difficulty scaling factor
OralHealthClaim.item.detail.subDetail.points 1

Net additional item cost

OralHealthClaim.item.detail.subDetail.net
OralHealthClaim.item.detail.subDetail.net.value value:
OralHealthClaim.item.detail.subDetail.net.currency currency:
OralHealthClaim.item.detail.subDetail.net 1
OralHealthClaim.item.detail.subDetail.udi
OralHealthClaim.item.detail.subDetail.udi.value Unique Device Identifier
OralHealthClaim.item.detail.subDetail.udi 1
OralHealthClaim.item.detail.subDetail 1
OralHealthClaim.item.detail 1

Prosthetic details

OralHealthClaim.item.prosthesis
OralHealthClaim.item.prosthesis.id
OralHealthClaim.item.prosthesis.id.value xml:id (or equivalent in JSON)
OralHealthClaim.item.prosthesis.id 1
OralHealthClaim.item.prosthesis.initial
OralHealthClaim.item.prosthesis.initial.value Is this the initial service
OralHealthClaim.item.prosthesis.initial 1
OralHealthClaim.item.prosthesis.priorDate
OralHealthClaim.item.prosthesis.priorDate.value Initial service Date
OralHealthClaim.item.prosthesis.priorDate 1
OralHealthClaim.item.prosthesis.priorMaterial
OralHealthClaim.item.prosthesis.priorMaterial.value Prosthetic Material
OralHealthClaim.item.prosthesis.priorMaterial 1
OralHealthClaim.item.prosthesis 1
OralHealthClaim.item 1
OralHealthClaim.additionalMaterials
OralHealthClaim.additionalMaterials.value Additional materials, documents, etc.
OralHealthClaim.additionalMaterials 1
OralHealthClaim 1