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

Visionclaim.questionnaire

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

Visionclaim.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 Preauthorization

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

Metadata about the resource

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

Text summary of the resource, for human interpretation

VisionClaim.text
VisionClaim.text 1

Contained, inline Resources

VisionClaim.contained
VisionClaim.contained 1

Claim number

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

Payee

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

Diagnosis

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

Insurance or medical plan

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

Goods and Services

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

Count of Products or Services

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

Fee, charge or cost per point

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

Total item cost

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

Additional items

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

Count of Products or Services

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

Fee, charge or cost per point

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

Total additional item cost

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

Additional items

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

Count of Products or Services

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

Fee, charge or cost per point

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

Net additional item cost

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