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

Pharmacyclaim.questionnaire

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

Pharmacyclaim.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

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

Metadata about the resource

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

Text summary of the resource, for human interpretation

PharmacyClaim.text
PharmacyClaim.text 1

Contained, inline Resources

PharmacyClaim.contained
PharmacyClaim.contained 1

Claim number

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

Payee

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

Diagnosis

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

Insurance or medical plan

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

Goods and Services

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

Count of Products or Services

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

Fee, charge or cost per point

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

Total item cost

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

Additional items

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

Count of Products or Services

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

Fee, charge or cost per point

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

Total additional item cost

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

Additional items

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

Count of Products or Services

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

Fee, charge or cost per point

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

Net additional item cost

PharmacyClaim.item.detail.subDetail.net
PharmacyClaim.item.detail.subDetail.net.value value:
PharmacyClaim.item.detail.subDetail.net.currency currency:
PharmacyClaim.item.detail.subDetail.net 1
PharmacyClaim.item.detail.subDetail.udi
PharmacyClaim.item.detail.subDetail.udi.value Unique Device Identifier
PharmacyClaim.item.detail.subDetail.udi 1
PharmacyClaim.item.detail.subDetail 1
PharmacyClaim.item.detail 1
PharmacyClaim.item 1
PharmacyClaim.additionalMaterials
PharmacyClaim.additionalMaterials.value Additional materials, documents, etc.
PharmacyClaim.additionalMaterials 1
PharmacyClaim 1