DSTU2
This page is part of the FHIR Specification (v1.0.2: DSTU 2). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions 
. Page versions: R5 R4B R4 R3 R2
StructureDefinition for claim
{
"resourceType": "StructureDefinition",
"id": "Claim",
"meta": {
"lastUpdated": "2015-10-24T07:41:03.495+11:00"
},
"text": {
"status": "generated",
"div": "<div>!-- Snipped for Brevity --></div>"
},
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm",
"valueInteger": 0
}
],
"url": "http://hl7.org/fhir/StructureDefinition/Claim",
"name": "Claim",
"status": "draft",
"publisher": "Health Level Seven International (Financial Management)",
"contact": [
{
"telecom": [
{
"system": "other",
"value": "http://hl7.org/fhir"
}
]
},
{
"telecom": [
{
"system": "other",
"value": "http://www.hl7.org/Special/committees/fm/index.cfm"
}
]
}
],
"date": "2015-10-24T07:41:03+11:00",
"description": "Base StructureDefinition for Claim Resource",
"fhirVersion": "1.0.2",
"mapping": [
{
"identity": "w5",
"uri": "http://hl7.org/fhir/w5",
"name": "W5 Mapping"
},
{
"identity": "rim",
"uri": "http://hl7.org/v3",
"name": "RIM"
}
],
"kind": "resource",
"abstract": false,
"base": "http://hl7.org/fhir/StructureDefinition/DomainResource",
"snapshot": {
"element": [
{
"path": "Claim",
"short": "Claim, Pre-determination or Pre-authorization",
"definition": "A provider issued list of services and products provided, or to be provided, to a patient which is provided to an insurer for payment recovery.",
"min": 0,
"max": "*",
"type": [
{
"code": "DomainResource"
}
],
"isSummary": true,
"mapping": [
{
"identity": "w5",
"map": "financial.billing"
}
]
},
{
"path": "Claim.id",
"short": "Logical id of this artifact",
"definition": "The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.",
"comments": "The only time that a resource does not have an id is when it is being submitted to the server using a create operation. Bundles always have an id, though it is usually a generated UUID.",
"min": 0,
"max": "1",
"type": [
{
"code": "id"
}
],
"isSummary": true
},
{
"path": "Claim.meta",
"short": "Metadata about the resource",
"definition": "The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content may not always be associated with version changes to the resource.",
"min": 0,
"max": "1",
"type": [
{
"code": "Meta"
}
],
"isSummary": true
},
{
"path": "Claim.implicitRules",
"short": "A set of rules under which this content was created",
"definition": "A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content.",
"comments": "Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element as much as possible.",
"min": 0,
"max": "1",
"type": [
{
"code": "uri"
}
],
"isModifier": true,
"isSummary": true
},
{
"path": "Claim.language",
"short": "Language of the resource content",
"definition": "The base language in which the resource is written.",
"comments": "Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).",
"min": 0,
"max": "1",
"type": [
{
"code": "code"
}
],
"binding": {
"strength": "required",
"description": "A human language.",
"valueSetUri": "http://tools.ietf.org/html/bcp47"
}
},
{
"path": "Claim.text",
"short": "Text summary of the resource, for human interpretation",
"definition": "A human-readable narrative that contains a summary of the resource, and may be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it \"clinically safe\" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.",
"comments": "Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative.",
"alias": [
"narrative",
"html",
"xhtml",
"display"
],
"min": 0,
"max": "1",
"type": [
{
"code": "Narrative"
}
],
"condition": [
"dom-1"
],
"mapping": [
{
"identity": "rim",
"map": "Act.text?"
}
]
},
{
"path": "Claim.contained",
"short": "Contained, inline Resources",
"definition": "These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.",
"comments": "This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again.",
"alias": [
"inline resources",
"anonymous resources",
"contained resources"
],
"min": 0,
"max": "*",
"type": [
{
"code": "Resource"
}
],
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"path": "Claim.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the resource. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"path": "Claim.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the resource, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"path": "Claim.type",
"short": "institutional | oral | pharmacy | professional | vision",
"definition": "The category of claim this is.",
"comments": "Affects which fields and value sets are used.",
"min": 1,
"max": "1",
"type": [
{
"code": "code"
}
],
"isSummary": true,
"binding": {
"strength": "required",
"description": "The type or discipline-style of the claim.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-type-link"
}
}
},
{
"path": "Claim.identifier",
"short": "Claim number",
"definition": "The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization number.",
"min": 0,
"max": "*",
"type": [
{
"code": "Identifier"
}
],
"isSummary": true
},
{
"path": "Claim.ruleset",
"short": "Current specification followed",
"definition": "The version of the specification on which this instance relies.",
"alias": [
"BusinessVersion"
],
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "The static and dynamic model to which contents conform, which may be business version or standard/version.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ruleset"
}
}
},
{
"path": "Claim.originalRuleset",
"short": "Original specification followed",
"definition": "The version of the specification from which the original instance was created.",
"alias": [
"OriginalBusinessVersion"
],
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "The static and dynamic model to which contents conform, which may be business version or standard/version.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ruleset"
}
}
},
{
"path": "Claim.created",
"short": "Creation date",
"definition": "The date when the enclosed suite of services were performed or completed.",
"min": 0,
"max": "1",
"type": [
{
"code": "dateTime"
}
],
"isSummary": true
},
{
"path": "Claim.target",
"short": "Insurer",
"definition": "Insurer Identifier, typical BIN number (6 digit).",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Organization"
]
}
],
"isSummary": true
},
{
"path": "Claim.provider",
"short": "Responsible provider",
"definition": "The provider which is responsible for the bill, claim pre-determination, pre-authorization.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Practitioner"
]
}
],
"isSummary": true
},
{
"path": "Claim.organization",
"short": "Responsible organization",
"definition": "The organization which is responsible for the bill, claim pre-determination, pre-authorization.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Organization"
]
}
],
"isSummary": true
},
{
"path": "Claim.use",
"short": "complete | proposed | exploratory | other",
"definition": "Complete (Bill or Claim), Proposed (Pre-Authorization), Exploratory (Pre-determination).",
"min": 0,
"max": "1",
"type": [
{
"code": "code"
}
],
"isSummary": true,
"binding": {
"strength": "required",
"description": "Complete, proposed, exploratory, other.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-use-link"
}
}
},
{
"path": "Claim.priority",
"short": "Desired processing priority",
"definition": "Immediate (stat), best effort (normal), deferred (deferred).",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "The timeliness with which processing is required: STAT, Normal, Deferred.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/process-priority"
}
}
},
{
"path": "Claim.fundsReserve",
"short": "Funds requested to be reserved",
"definition": "In the case of a Pre-Determination/Pre-Authorization the provider may request that funds in the amount of the expected Benefit be reserved ('Patient' or 'Provider') to pay for the Benefits determined on the subsequent claim(s). 'None' explicitly indicates no funds reserving is requested.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "For whom funds are to be reserved: (Patient, Provider, None).",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/fundsreserve"
}
}
},
{
"path": "Claim.enterer",
"short": "Author",
"definition": "Person who created the invoice/claim/pre-determination or pre-authorization.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Practitioner"
]
}
],
"isSummary": true
},
{
"path": "Claim.facility",
"short": "Servicing Facility",
"definition": "Facility where the services were provided.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Location"
]
}
],
"isSummary": true
},
{
"path": "Claim.prescription",
"short": "Prescription",
"definition": "Prescription to support the dispensing of Pharmacy or Vision products.",
"requirements": "For type=Pharmacy and Vision only.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/MedicationOrder"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/VisionPrescription"
]
}
],
"isSummary": true
},
{
"path": "Claim.originalPrescription",
"short": "Original Prescription",
"definition": "Original prescription to support the dispensing of pharmacy services, medications or products.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/MedicationOrder"
]
}
],
"isSummary": true
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Payee"
}
],
"path": "Claim.payee",
"short": "Payee",
"definition": "The party to be reimbursed for the services.",
"min": 0,
"max": "1",
"type": [
{
"code": "BackboneElement"
}
],
"isSummary": true
},
{
"path": "Claim.payee.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references).",
"min": 0,
"max": "1",
"type": [
{
"code": "id"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "Claim.payee.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "Claim.payee.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"path": "Claim.payee.type",
"short": "Party to be paid any benefits payable",
"definition": "Party to be reimbursed: Subscriber, provider, other.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "A code for the party to be reimbursed.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/payeetype"
}
}
},
{
"path": "Claim.payee.provider",
"short": "Provider who is the payee",
"definition": "The provider who is to be reimbursed for the claim (the party to whom any benefit is assigned).",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Practitioner"
]
}
],
"isSummary": true
},
{
"path": "Claim.payee.organization",
"short": "Organization who is the payee",
"definition": "The organization who is to be reimbursed for the claim (the party to whom any benefit is assigned).",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Organization"
]
}
],
"isSummary": true
},
{
"path": "Claim.payee.person",
"short": "Other person who is the payee",
"definition": "The person other than the subscriber who is to be reimbursed for the claim (the party to whom any benefit is assigned).",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Patient"
]
}
],
"isSummary": true
},
{
"path": "Claim.referral",
"short": "Treatment Referral",
"definition": "The referral resource which lists the date, practitioner, reason and other supporting information.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/ReferralRequest"
]
}
],
"isSummary": true
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Diagnosis"
}
],
"path": "Claim.diagnosis",
"short": "Diagnosis",
"definition": "Ordered list of patient diagnosis for which care is sought.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"isSummary": true
},
{
"path": "Claim.diagnosis.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references).",
"min": 0,
"max": "1",
"type": [
{
"code": "id"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "Claim.diagnosis.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "Claim.diagnosis.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"path": "Claim.diagnosis.sequence",
"short": "Sequence of diagnosis",
"definition": "Sequence of diagnosis which serves to order and provide a link.",
"requirements": "Required to maintain order of the diagnoses.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
],
"isSummary": true
},
{
"path": "Claim.diagnosis.diagnosis",
"short": "Patient's list of diagnosis",
"definition": "The diagnosis.",
"requirements": "Required to adjudicate services rendered to condition presented.",
"min": 1,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "ICD10 diagnostic codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/icd-10"
}
}
},
{
"path": "Claim.condition",
"short": "List of presenting Conditions",
"definition": "List of patient conditions for which care is sought.",
"min": 0,
"max": "*",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "Patient conditions and symptoms.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/fm-conditions"
}
}
},
{
"path": "Claim.patient",
"short": "The subject of the Products and Services",
"definition": "Patient Resource.",
"min": 1,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Patient"
]
}
],
"isSummary": true
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Coverage"
}
],
"path": "Claim.coverage",
"short": "Insurance or medical plan",
"definition": "Financial instrument by which payment information for health care.",
"requirements": "Health care programs and insurers are significant payors of health service costs.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "Coverage"
}
]
},
{
"path": "Claim.coverage.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references).",
"min": 0,
"max": "1",
"type": [
{
"code": "id"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "Claim.coverage.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "Claim.coverage.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"path": "Claim.coverage.sequence",
"short": "Service instance identifier",
"definition": "A service line item.",
"requirements": "To maintain order of the coverages.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
],
"isSummary": true
},
{
"path": "Claim.coverage.focal",
"short": "The focal Coverage",
"definition": "The instance number of the Coverage which is the focus for adjudication. The Coverage against which the claim is to be adjudicated.",
"requirements": "To identify which coverage is being adjudicated.",
"min": 1,
"max": "1",
"type": [
{
"code": "boolean"
}
],
"isSummary": true
},
{
"path": "Claim.coverage.coverage",
"short": "Insurance information",
"definition": "Reference to the program or plan identification, underwriter or payor.",
"requirements": "Need to identify the issuer to target for processing and for coordination of benefit processing.",
"min": 1,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Coverage"
]
}
],
"isSummary": true
},
{
"path": "Claim.coverage.businessArrangement",
"short": "Business agreement",
"definition": "The contract number of a business agreement which describes the terms and conditions.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"isSummary": true
},
{
"path": "Claim.coverage.relationship",
"short": "Patient relationship to subscriber",
"definition": "The relationship of the patient to the subscriber.",
"requirements": "To determine the relationship between the patient and the subscriber.",
"min": 1,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "The code for the relationship of the patient to the subscriber.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/relationship"
}
}
},
{
"path": "Claim.coverage.preAuthRef",
"short": "Pre-Authorization/Determination Reference",
"definition": "A list of references from the Insurer to which these services pertain.",
"requirements": "To provide any pre=determination or prior authorization reference.",
"min": 0,
"max": "*",
"type": [
{
"code": "string"
}
],
"isSummary": true
},
{
"path": "Claim.coverage.claimResponse",
"short": "Adjudication results",
"definition": "The Coverages adjudication details.",
"requirements": "Used by downstream payers to determine what balance remains and the net payable.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/ClaimResponse"
]
}
],
"isSummary": true
},
{
"path": "Claim.coverage.originalRuleset",
"short": "Original version",
"definition": "The style (standard) and version of the original material which was converted into this resource.",
"requirements": "Knowledge of the original version can inform the processing of this instance so that information which is processable by the originating system may be generated.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "The static and dynamic model to which contents conform, which may be business version or standard/version.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ruleset"
}
}
},
{
"path": "Claim.exception",
"short": "Eligibility exceptions",
"definition": "Factors which may influence the applicability of coverage.",
"requirements": "To determine extenuating circumstances for coverage.",
"min": 0,
"max": "*",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "The eligibility exception codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-exception"
}
}
},
{
"path": "Claim.school",
"short": "Name of School",
"definition": "Name of school for over-aged dependents.",
"requirements": "Often required for over-age dependents.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"isSummary": true
},
{
"path": "Claim.accident",
"short": "Accident Date",
"definition": "Date of an accident which these services are addressing.",
"requirements": "Coverage may be dependent on accidents.",
"min": 0,
"max": "1",
"type": [
{
"code": "date"
}
],
"isSummary": true
},
{
"path": "Claim.accidentType",
"short": "Accident Type",
"definition": "Type of accident: work, auto, etc.",
"requirements": "Coverage may be dependent on the type of accident.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "required",
"description": "Type of accident: work place, auto, etc.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/v3-ActIncidentCode"
}
}
},
{
"path": "Claim.interventionException",
"short": "Intervention and exception code (Pharma)",
"definition": "A list of intervention and exception codes which may influence the adjudication of the claim.",
"requirements": "Coverage may be modified based on exception information provided.",
"min": 0,
"max": "*",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "Intervention and exception codes (Pharm).",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/intervention"
}
}
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Items"
}
],
"path": "Claim.item",
"short": "Goods and Services",
"definition": "First tier of goods and services.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"isSummary": true
},
{
"path": "Claim.item.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references).",
"min": 0,
"max": "1",
"type": [
{
"code": "id"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "Claim.item.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "Claim.item.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"path": "Claim.item.sequence",
"short": "Service instance",
"definition": "A service line number.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
],
"isSummary": true
},
{
"path": "Claim.item.type",
"short": "Group or type of product or service",
"definition": "The type of product or service.",
"min": 1,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "required",
"description": "Service, Product, Rx Dispense, Rx Compound etc.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/v3-ActInvoiceGroupCode"
}
}
},
{
"path": "Claim.item.provider",
"short": "Responsible practitioner",
"definition": "The practitioner who is responsible for the services rendered to the patient.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Practitioner"
]
}
],
"isSummary": true
},
{
"path": "Claim.item.diagnosisLinkId",
"short": "Diagnosis Link",
"definition": "Diagnosis applicable for this service or product line.",
"min": 0,
"max": "*",
"type": [
{
"code": "positiveInt"
}
],
"isSummary": true
},
{
"path": "Claim.item.service",
"short": "Item Code",
"definition": "If a grouping item then 'GROUP' otherwise it is a node therefore a code to indicate the Professional Service or Product supplied.",
"min": 1,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "Allowable service and product codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
}
},
{
"path": "Claim.item.serviceDate",
"short": "Date of Service",
"definition": "The date when the enclosed suite of services were performed or completed.",
"min": 0,
"max": "1",
"type": [
{
"code": "date"
}
],
"isSummary": true
},
{
"path": "Claim.item.quantity",
"short": "Count of Products or Services",
"definition": "The number of repetitions of a service or product.",
"min": 0,
"max": "1",
"type": [
{
"code": "Quantity",
"profile": [
"http://hl7.org/fhir/StructureDefinition/SimpleQuantity"
]
}
],
"isSummary": true
},
{
"path": "Claim.item.unitPrice",
"short": "Fee, charge or cost per point",
"definition": "If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group.",
"min": 0,
"max": "1",
"type": [
{
"code": "Quantity",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Money"
]
}
],
"isSummary": true
},
{
"path": "Claim.item.factor",
"short": "Price scaling factor",
"definition": "A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "decimal"
}
],
"isSummary": true
},
{
"path": "Claim.item.points",
"short": "Difficulty scaling factor",
"definition": "An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each point.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "decimal"
}
],
"isSummary": true
},
{
"path": "Claim.item.net",
"short": "Total item cost",
"definition": "The quantity times the unit price for an additional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "Quantity",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Money"
]
}
],
"isSummary": true
},
{
"path": "Claim.item.udi",
"short": "Unique Device Identifier",
"definition": "List of Unique Device Identifiers associated with this line item.",
"requirements": "The UDI code and issuer if applicable for the supplied product.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "The FDA, or other, UDI repository.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/udi"
}
}
},
{
"path": "Claim.item.bodySite",
"short": "Service Location",
"definition": "Physical service site on the patient (limb, tooth, etc.).",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "The code for the teeth, quadrant, sextant and arch.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/tooth"
}
}
},
{
"path": "Claim.item.subSite",
"short": "Service Sub-location",
"definition": "A region or surface of the site, e.g. limb region or tooth surface(s).",
"min": 0,
"max": "*",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "The code for the tooth surface and surface combinations.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/surface"
}
}
},
{
"path": "Claim.item.modifier",
"short": "Service/Product billing modifiers",
"definition": "Item typification or modifiers codes, e.g. for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.",
"requirements": "May impact on adjudication.",
"min": 0,
"max": "*",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "Item type or modifiers codes, e.g. for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-modifiers"
}
}
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Detail"
}
],
"path": "Claim.item.detail",
"short": "Additional items",
"definition": "Second tier of goods and services.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"isSummary": true
},
{
"path": "Claim.item.detail.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references).",
"min": 0,
"max": "1",
"type": [
{
"code": "id"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "Claim.item.detail.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "Claim.item.detail.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"path": "Claim.item.detail.sequence",
"short": "Service instance",
"definition": "A service line number.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
],
"isSummary": true
},
{
"path": "Claim.item.detail.type",
"short": "Group or type of product or service",
"definition": "The type of product or service.",
"min": 1,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "required",
"description": "Service, Product, Rx Dispense, Rx Compound etc.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/v3-ActInvoiceGroupCode"
}
}
},
{
"path": "Claim.item.detail.service",
"short": "Additional item codes",
"definition": "If a grouping item then 'GROUP' otherwise it is a node therefore a code to indicate the Professional Service or Product supplied.",
"min": 1,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "Allowable service and product codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
}
},
{
"path": "Claim.item.detail.quantity",
"short": "Count of Products or Services",
"definition": "The number of repetitions of a service or product.",
"min": 0,
"max": "1",
"type": [
{
"code": "Quantity",
"profile": [
"http://hl7.org/fhir/StructureDefinition/SimpleQuantity"
]
}
],
"isSummary": true
},
{
"path": "Claim.item.detail.unitPrice",
"short": "Fee, charge or cost per point",
"definition": "If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "Quantity",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Money"
]
}
],
"isSummary": true
},
{
"path": "Claim.item.detail.factor",
"short": "Price scaling factor",
"definition": "A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "decimal"
}
],
"isSummary": true
},
{
"path": "Claim.item.detail.points",
"short": "Difficulty scaling factor",
"definition": "An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each point.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "decimal"
}
],
"isSummary": true
},
{
"path": "Claim.item.detail.net",
"short": "Total additional item cost",
"definition": "The quantity times the unit price for an additional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "Quantity",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Money"
]
}
],
"isSummary": true
},
{
"path": "Claim.item.detail.udi",
"short": "Unique Device Identifier",
"definition": "List of Unique Device Identifiers associated with this line item.",
"requirements": "The UDI code and issuer if applicable for the supplied product.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "The FDA, or other, UDI repository.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/udi"
}
}
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "SubDetail"
}
],
"path": "Claim.item.detail.subDetail",
"short": "Additional items",
"definition": "Third tier of goods and services.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"isSummary": true
},
{
"path": "Claim.item.detail.subDetail.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references).",
"min": 0,
"max": "1",
"type": [
{
"code": "id"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "Claim.item.detail.subDetail.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "Claim.item.detail.subDetail.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"path": "Claim.item.detail.subDetail.sequence",
"short": "Service instance",
"definition": "A service line number.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
],
"isSummary": true
},
{
"path": "Claim.item.detail.subDetail.type",
"short": "Type of product or service",
"definition": "The type of product or service.",
"min": 1,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "required",
"description": "Service, Product, Rx Dispense, Rx Compound etc.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/v3-ActInvoiceGroupCode"
}
}
},
{
"path": "Claim.item.detail.subDetail.service",
"short": "Additional item codes",
"definition": "The fee for an additional service or product or charge.",
"min": 1,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "Allowable service and product codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
}
},
{
"path": "Claim.item.detail.subDetail.quantity",
"short": "Count of Products or Services",
"definition": "The number of repetitions of a service or product.",
"min": 0,
"max": "1",
"type": [
{
"code": "Quantity",
"profile": [
"http://hl7.org/fhir/StructureDefinition/SimpleQuantity"
]
}
],
"isSummary": true
},
{
"path": "Claim.item.detail.subDetail.unitPrice",
"short": "Fee, charge or cost per point",
"definition": "The fee for an additional service or product or charge.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "Quantity",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Money"
]
}
],
"isSummary": true
},
{
"path": "Claim.item.detail.subDetail.factor",
"short": "Price scaling factor",
"definition": "A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "decimal"
}
],
"isSummary": true
},
{
"path": "Claim.item.detail.subDetail.points",
"short": "Difficulty scaling factor",
"definition": "An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each point.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "decimal"
}
],
"isSummary": true
},
{
"path": "Claim.item.detail.subDetail.net",
"short": "Net additional item cost",
"definition": "The quantity times the unit price for an additional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "Quantity",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Money"
]
}
],
"isSummary": true
},
{
"path": "Claim.item.detail.subDetail.udi",
"short": "Unique Device Identifier",
"definition": "List of Unique Device Identifiers associated with this line item.",
"requirements": "The UDI code and issuer if applicable for the supplied product.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "The FDA, or other, UDI repository.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/udi"
}
}
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Prosthesis"
}
],
"path": "Claim.item.prosthesis",
"short": "Prosthetic details",
"definition": "The materials and placement date of prior fixed prosthesis.",
"min": 0,
"max": "1",
"type": [
{
"code": "BackboneElement"
}
],
"isSummary": true
},
{
"path": "Claim.item.prosthesis.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references).",
"min": 0,
"max": "1",
"type": [
{
"code": "id"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "Claim.item.prosthesis.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "Claim.item.prosthesis.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"path": "Claim.item.prosthesis.initial",
"short": "Is this the initial service",
"definition": "Indicates whether this is the initial placement of a fixed prosthesis.",
"requirements": "May impact on adjudication.",
"min": 0,
"max": "1",
"type": [
{
"code": "boolean"
}
],
"isSummary": true
},
{
"path": "Claim.item.prosthesis.priorDate",
"short": "Initial service Date",
"definition": "Date of the initial placement.",
"requirements": "May impact on adjudication.",
"min": 0,
"max": "1",
"type": [
{
"code": "date"
}
],
"isSummary": true
},
{
"path": "Claim.item.prosthesis.priorMaterial",
"short": "Prosthetic Material",
"definition": "Material of the prior denture or bridge prosthesis. (Oral).",
"requirements": "May impact on adjudication.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "Material of the prior denture or bridge prosthesis. (Oral)",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/oral-prosthodontic-material"
}
}
},
{
"path": "Claim.additionalMaterials",
"short": "Additional materials, documents, etc.",
"definition": "Code to indicate that Xrays, images, emails, documents, models or attachments are being sent in support of this submission.",
"min": 0,
"max": "*",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "Code to indicate that Xrays, images, emails, documents, models or attachments are being sent in support of this submission.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/additionalmaterials"
}
}
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "MissingTeeth"
}
],
"path": "Claim.missingTeeth",
"short": "Only if type = oral",
"definition": "A list of teeth which would be expected but are not found due to having been previously extracted or for other reasons.",
"requirements": "The list of missing teeth may influence the adjudication of services for example with Bridges.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"isSummary": true
},
{
"path": "Claim.missingTeeth.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references).",
"min": 0,
"max": "1",
"type": [
{
"code": "id"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "Claim.missingTeeth.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "Claim.missingTeeth.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"path": "Claim.missingTeeth.tooth",
"short": "Tooth Code",
"definition": "The code identifying which tooth is missing.",
"requirements": "Provides the tooth number of the missing tooth.",
"min": 1,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "The codes for the teeth, subset of OralSites.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/teeth"
}
}
},
{
"path": "Claim.missingTeeth.reason",
"short": "Reason for missing",
"definition": "Missing reason may be: E-extraction, O-other.",
"requirements": "Provides the reason for the missing tooth.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "Reason codes for the missing teeth.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/missing-tooth-reason"
}
}
},
{
"path": "Claim.missingTeeth.extractionDate",
"short": "Date of Extraction",
"definition": "The date of the extraction either known from records or patient reported estimate.",
"requirements": "Some services and adjudications require this information.",
"min": 0,
"max": "1",
"type": [
{
"code": "date"
}
],
"isSummary": true
}
]
},
"differential": {
"element": [
{
"path": "Claim",
"short": "Claim, Pre-determination or Pre-authorization",
"definition": "A provider issued list of services and products provided, or to be provided, to a patient which is provided to an insurer for payment recovery.",
"min": 0,
"max": "*",
"type": [
{
"code": "DomainResource"
}
],
"isSummary": true,
"mapping": [
{
"identity": "w5",
"map": "financial.billing"
}
]
},
{
"path": "Claim.type",
"short": "institutional | oral | pharmacy | professional | vision",
"definition": "The category of claim this is.",
"comments": "Affects which fields and value sets are used.",
"min": 1,
"max": "1",
"type": [
{
"code": "code"
}
],
"isSummary": true,
"binding": {
"strength": "required",
"description": "The type or discipline-style of the claim.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-type-link"
}
}
},
{
"path": "Claim.identifier",
"short": "Claim number",
"definition": "The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization number.",
"min": 0,
"max": "*",
"type": [
{
"code": "Identifier"
}
],
"isSummary": true
},
{
"path": "Claim.ruleset",
"short": "Current specification followed",
"definition": "The version of the specification on which this instance relies.",
"alias": [
"BusinessVersion"
],
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "The static and dynamic model to which contents conform, which may be business version or standard/version.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ruleset"
}
}
},
{
"path": "Claim.originalRuleset",
"short": "Original specification followed",
"definition": "The version of the specification from which the original instance was created.",
"alias": [
"OriginalBusinessVersion"
],
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "The static and dynamic model to which contents conform, which may be business version or standard/version.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ruleset"
}
}
},
{
"path": "Claim.created",
"short": "Creation date",
"definition": "The date when the enclosed suite of services were performed or completed.",
"min": 0,
"max": "1",
"type": [
{
"code": "dateTime"
}
],
"isSummary": true
},
{
"path": "Claim.target",
"short": "Insurer",
"definition": "Insurer Identifier, typical BIN number (6 digit).",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Organization"
]
}
],
"isSummary": true
},
{
"path": "Claim.provider",
"short": "Responsible provider",
"definition": "The provider which is responsible for the bill, claim pre-determination, pre-authorization.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Practitioner"
]
}
],
"isSummary": true
},
{
"path": "Claim.organization",
"short": "Responsible organization",
"definition": "The organization which is responsible for the bill, claim pre-determination, pre-authorization.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Organization"
]
}
],
"isSummary": true
},
{
"path": "Claim.use",
"short": "complete | proposed | exploratory | other",
"definition": "Complete (Bill or Claim), Proposed (Pre-Authorization), Exploratory (Pre-determination).",
"min": 0,
"max": "1",
"type": [
{
"code": "code"
}
],
"isSummary": true,
"binding": {
"strength": "required",
"description": "Complete, proposed, exploratory, other.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-use-link"
}
}
},
{
"path": "Claim.priority",
"short": "Desired processing priority",
"definition": "Immediate (stat), best effort (normal), deferred (deferred).",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "The timeliness with which processing is required: STAT, Normal, Deferred.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/process-priority"
}
}
},
{
"path": "Claim.fundsReserve",
"short": "Funds requested to be reserved",
"definition": "In the case of a Pre-Determination/Pre-Authorization the provider may request that funds in the amount of the expected Benefit be reserved ('Patient' or 'Provider') to pay for the Benefits determined on the subsequent claim(s). 'None' explicitly indicates no funds reserving is requested.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "For whom funds are to be reserved: (Patient, Provider, None).",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/fundsreserve"
}
}
},
{
"path": "Claim.enterer",
"short": "Author",
"definition": "Person who created the invoice/claim/pre-determination or pre-authorization.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Practitioner"
]
}
],
"isSummary": true
},
{
"path": "Claim.facility",
"short": "Servicing Facility",
"definition": "Facility where the services were provided.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Location"
]
}
],
"isSummary": true
},
{
"path": "Claim.prescription",
"short": "Prescription",
"definition": "Prescription to support the dispensing of Pharmacy or Vision products.",
"requirements": "For type=Pharmacy and Vision only.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/MedicationOrder"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/VisionPrescription"
]
}
],
"isSummary": true
},
{
"path": "Claim.originalPrescription",
"short": "Original Prescription",
"definition": "Original prescription to support the dispensing of pharmacy services, medications or products.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/MedicationOrder"
]
}
],
"isSummary": true
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Payee"
}
],
"path": "Claim.payee",
"short": "Payee",
"definition": "The party to be reimbursed for the services.",
"min": 0,
"max": "1",
"type": [
{
"code": "BackboneElement"
}
],
"isSummary": true
},
{
"path": "Claim.payee.type",
"short": "Party to be paid any benefits payable",
"definition": "Party to be reimbursed: Subscriber, provider, other.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "A code for the party to be reimbursed.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/payeetype"
}
}
},
{
"path": "Claim.payee.provider",
"short": "Provider who is the payee",
"definition": "The provider who is to be reimbursed for the claim (the party to whom any benefit is assigned).",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Practitioner"
]
}
],
"isSummary": true
},
{
"path": "Claim.payee.organization",
"short": "Organization who is the payee",
"definition": "The organization who is to be reimbursed for the claim (the party to whom any benefit is assigned).",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Organization"
]
}
],
"isSummary": true
},
{
"path": "Claim.payee.person",
"short": "Other person who is the payee",
"definition": "The person other than the subscriber who is to be reimbursed for the claim (the party to whom any benefit is assigned).",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Patient"
]
}
],
"isSummary": true
},
{
"path": "Claim.referral",
"short": "Treatment Referral",
"definition": "The referral resource which lists the date, practitioner, reason and other supporting information.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/ReferralRequest"
]
}
],
"isSummary": true
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Diagnosis"
}
],
"path": "Claim.diagnosis",
"short": "Diagnosis",
"definition": "Ordered list of patient diagnosis for which care is sought.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"isSummary": true
},
{
"path": "Claim.diagnosis.sequence",
"short": "Sequence of diagnosis",
"definition": "Sequence of diagnosis which serves to order and provide a link.",
"requirements": "Required to maintain order of the diagnoses.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
],
"isSummary": true
},
{
"path": "Claim.diagnosis.diagnosis",
"short": "Patient's list of diagnosis",
"definition": "The diagnosis.",
"requirements": "Required to adjudicate services rendered to condition presented.",
"min": 1,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "ICD10 diagnostic codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/icd-10"
}
}
},
{
"path": "Claim.condition",
"short": "List of presenting Conditions",
"definition": "List of patient conditions for which care is sought.",
"min": 0,
"max": "*",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "Patient conditions and symptoms.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/fm-conditions"
}
}
},
{
"path": "Claim.patient",
"short": "The subject of the Products and Services",
"definition": "Patient Resource.",
"min": 1,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Patient"
]
}
],
"isSummary": true
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Coverage"
}
],
"path": "Claim.coverage",
"short": "Insurance or medical plan",
"definition": "Financial instrument by which payment information for health care.",
"requirements": "Health care programs and insurers are significant payors of health service costs.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "Coverage"
}
]
},
{
"path": "Claim.coverage.sequence",
"short": "Service instance identifier",
"definition": "A service line item.",
"requirements": "To maintain order of the coverages.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
],
"isSummary": true
},
{
"path": "Claim.coverage.focal",
"short": "The focal Coverage",
"definition": "The instance number of the Coverage which is the focus for adjudication. The Coverage against which the claim is to be adjudicated.",
"requirements": "To identify which coverage is being adjudicated.",
"min": 1,
"max": "1",
"type": [
{
"code": "boolean"
}
],
"isSummary": true
},
{
"path": "Claim.coverage.coverage",
"short": "Insurance information",
"definition": "Reference to the program or plan identification, underwriter or payor.",
"requirements": "Need to identify the issuer to target for processing and for coordination of benefit processing.",
"min": 1,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Coverage"
]
}
],
"isSummary": true
},
{
"path": "Claim.coverage.businessArrangement",
"short": "Business agreement",
"definition": "The contract number of a business agreement which describes the terms and conditions.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"isSummary": true
},
{
"path": "Claim.coverage.relationship",
"short": "Patient relationship to subscriber",
"definition": "The relationship of the patient to the subscriber.",
"requirements": "To determine the relationship between the patient and the subscriber.",
"min": 1,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "The code for the relationship of the patient to the subscriber.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/relationship"
}
}
},
{
"path": "Claim.coverage.preAuthRef",
"short": "Pre-Authorization/Determination Reference",
"definition": "A list of references from the Insurer to which these services pertain.",
"requirements": "To provide any pre=determination or prior authorization reference.",
"min": 0,
"max": "*",
"type": [
{
"code": "string"
}
],
"isSummary": true
},
{
"path": "Claim.coverage.claimResponse",
"short": "Adjudication results",
"definition": "The Coverages adjudication details.",
"requirements": "Used by downstream payers to determine what balance remains and the net payable.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/ClaimResponse"
]
}
],
"isSummary": true
},
{
"path": "Claim.coverage.originalRuleset",
"short": "Original version",
"definition": "The style (standard) and version of the original material which was converted into this resource.",
"requirements": "Knowledge of the original version can inform the processing of this instance so that information which is processable by the originating system may be generated.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "The static and dynamic model to which contents conform, which may be business version or standard/version.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ruleset"
}
}
},
{
"path": "Claim.exception",
"short": "Eligibility exceptions",
"definition": "Factors which may influence the applicability of coverage.",
"requirements": "To determine extenuating circumstances for coverage.",
"min": 0,
"max": "*",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "The eligibility exception codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-exception"
}
}
},
{
"path": "Claim.school",
"short": "Name of School",
"definition": "Name of school for over-aged dependents.",
"requirements": "Often required for over-age dependents.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"isSummary": true
},
{
"path": "Claim.accident",
"short": "Accident Date",
"definition": "Date of an accident which these services are addressing.",
"requirements": "Coverage may be dependent on accidents.",
"min": 0,
"max": "1",
"type": [
{
"code": "date"
}
],
"isSummary": true
},
{
"path": "Claim.accidentType",
"short": "Accident Type",
"definition": "Type of accident: work, auto, etc.",
"requirements": "Coverage may be dependent on the type of accident.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "required",
"description": "Type of accident: work place, auto, etc.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/v3-ActIncidentCode"
}
}
},
{
"path": "Claim.interventionException",
"short": "Intervention and exception code (Pharma)",
"definition": "A list of intervention and exception codes which may influence the adjudication of the claim.",
"requirements": "Coverage may be modified based on exception information provided.",
"min": 0,
"max": "*",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "Intervention and exception codes (Pharm).",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/intervention"
}
}
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Items"
}
],
"path": "Claim.item",
"short": "Goods and Services",
"definition": "First tier of goods and services.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"isSummary": true
},
{
"path": "Claim.item.sequence",
"short": "Service instance",
"definition": "A service line number.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
],
"isSummary": true
},
{
"path": "Claim.item.type",
"short": "Group or type of product or service",
"definition": "The type of product or service.",
"min": 1,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "required",
"description": "Service, Product, Rx Dispense, Rx Compound etc.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/v3-ActInvoiceGroupCode"
}
}
},
{
"path": "Claim.item.provider",
"short": "Responsible practitioner",
"definition": "The practitioner who is responsible for the services rendered to the patient.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Practitioner"
]
}
],
"isSummary": true
},
{
"path": "Claim.item.diagnosisLinkId",
"short": "Diagnosis Link",
"definition": "Diagnosis applicable for this service or product line.",
"min": 0,
"max": "*",
"type": [
{
"code": "positiveInt"
}
],
"isSummary": true
},
{
"path": "Claim.item.service",
"short": "Item Code",
"definition": "If a grouping item then 'GROUP' otherwise it is a node therefore a code to indicate the Professional Service or Product supplied.",
"min": 1,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "Allowable service and product codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
}
},
{
"path": "Claim.item.serviceDate",
"short": "Date of Service",
"definition": "The date when the enclosed suite of services were performed or completed.",
"min": 0,
"max": "1",
"type": [
{
"code": "date"
}
],
"isSummary": true
},
{
"path": "Claim.item.quantity",
"short": "Count of Products or Services",
"definition": "The number of repetitions of a service or product.",
"min": 0,
"max": "1",
"type": [
{
"code": "Quantity",
"profile": [
"http://hl7.org/fhir/StructureDefinition/SimpleQuantity"
]
}
],
"isSummary": true
},
{
"path": "Claim.item.unitPrice",
"short": "Fee, charge or cost per point",
"definition": "If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group.",
"min": 0,
"max": "1",
"type": [
{
"code": "Quantity",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Money"
]
}
],
"isSummary": true
},
{
"path": "Claim.item.factor",
"short": "Price scaling factor",
"definition": "A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "decimal"
}
],
"isSummary": true
},
{
"path": "Claim.item.points",
"short": "Difficulty scaling factor",
"definition": "An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each point.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "decimal"
}
],
"isSummary": true
},
{
"path": "Claim.item.net",
"short": "Total item cost",
"definition": "The quantity times the unit price for an additional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "Quantity",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Money"
]
}
],
"isSummary": true
},
{
"path": "Claim.item.udi",
"short": "Unique Device Identifier",
"definition": "List of Unique Device Identifiers associated with this line item.",
"requirements": "The UDI code and issuer if applicable for the supplied product.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "The FDA, or other, UDI repository.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/udi"
}
}
},
{
"path": "Claim.item.bodySite",
"short": "Service Location",
"definition": "Physical service site on the patient (limb, tooth, etc.).",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "The code for the teeth, quadrant, sextant and arch.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/tooth"
}
}
},
{
"path": "Claim.item.subSite",
"short": "Service Sub-location",
"definition": "A region or surface of the site, e.g. limb region or tooth surface(s).",
"min": 0,
"max": "*",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "The code for the tooth surface and surface combinations.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/surface"
}
}
},
{
"path": "Claim.item.modifier",
"short": "Service/Product billing modifiers",
"definition": "Item typification or modifiers codes, e.g. for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.",
"requirements": "May impact on adjudication.",
"min": 0,
"max": "*",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "Item type or modifiers codes, e.g. for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-modifiers"
}
}
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Detail"
}
],
"path": "Claim.item.detail",
"short": "Additional items",
"definition": "Second tier of goods and services.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"isSummary": true
},
{
"path": "Claim.item.detail.sequence",
"short": "Service instance",
"definition": "A service line number.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
],
"isSummary": true
},
{
"path": "Claim.item.detail.type",
"short": "Group or type of product or service",
"definition": "The type of product or service.",
"min": 1,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "required",
"description": "Service, Product, Rx Dispense, Rx Compound etc.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/v3-ActInvoiceGroupCode"
}
}
},
{
"path": "Claim.item.detail.service",
"short": "Additional item codes",
"definition": "If a grouping item then 'GROUP' otherwise it is a node therefore a code to indicate the Professional Service or Product supplied.",
"min": 1,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "Allowable service and product codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
}
},
{
"path": "Claim.item.detail.quantity",
"short": "Count of Products or Services",
"definition": "The number of repetitions of a service or product.",
"min": 0,
"max": "1",
"type": [
{
"code": "Quantity",
"profile": [
"http://hl7.org/fhir/StructureDefinition/SimpleQuantity"
]
}
],
"isSummary": true
},
{
"path": "Claim.item.detail.unitPrice",
"short": "Fee, charge or cost per point",
"definition": "If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "Quantity",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Money"
]
}
],
"isSummary": true
},
{
"path": "Claim.item.detail.factor",
"short": "Price scaling factor",
"definition": "A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "decimal"
}
],
"isSummary": true
},
{
"path": "Claim.item.detail.points",
"short": "Difficulty scaling factor",
"definition": "An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each point.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "decimal"
}
],
"isSummary": true
},
{
"path": "Claim.item.detail.net",
"short": "Total additional item cost",
"definition": "The quantity times the unit price for an additional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "Quantity",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Money"
]
}
],
"isSummary": true
},
{
"path": "Claim.item.detail.udi",
"short": "Unique Device Identifier",
"definition": "List of Unique Device Identifiers associated with this line item.",
"requirements": "The UDI code and issuer if applicable for the supplied product.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "The FDA, or other, UDI repository.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/udi"
}
}
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "SubDetail"
}
],
"path": "Claim.item.detail.subDetail",
"short": "Additional items",
"definition": "Third tier of goods and services.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"isSummary": true
},
{
"path": "Claim.item.detail.subDetail.sequence",
"short": "Service instance",
"definition": "A service line number.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
],
"isSummary": true
},
{
"path": "Claim.item.detail.subDetail.type",
"short": "Type of product or service",
"definition": "The type of product or service.",
"min": 1,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "required",
"description": "Service, Product, Rx Dispense, Rx Compound etc.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/v3-ActInvoiceGroupCode"
}
}
},
{
"path": "Claim.item.detail.subDetail.service",
"short": "Additional item codes",
"definition": "The fee for an additional service or product or charge.",
"min": 1,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "Allowable service and product codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
}
},
{
"path": "Claim.item.detail.subDetail.quantity",
"short": "Count of Products or Services",
"definition": "The number of repetitions of a service or product.",
"min": 0,
"max": "1",
"type": [
{
"code": "Quantity",
"profile": [
"http://hl7.org/fhir/StructureDefinition/SimpleQuantity"
]
}
],
"isSummary": true
},
{
"path": "Claim.item.detail.subDetail.unitPrice",
"short": "Fee, charge or cost per point",
"definition": "The fee for an additional service or product or charge.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "Quantity",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Money"
]
}
],
"isSummary": true
},
{
"path": "Claim.item.detail.subDetail.factor",
"short": "Price scaling factor",
"definition": "A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "decimal"
}
],
"isSummary": true
},
{
"path": "Claim.item.detail.subDetail.points",
"short": "Difficulty scaling factor",
"definition": "An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each point.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "decimal"
}
],
"isSummary": true
},
{
"path": "Claim.item.detail.subDetail.net",
"short": "Net additional item cost",
"definition": "The quantity times the unit price for an additional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "Quantity",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Money"
]
}
],
"isSummary": true
},
{
"path": "Claim.item.detail.subDetail.udi",
"short": "Unique Device Identifier",
"definition": "List of Unique Device Identifiers associated with this line item.",
"requirements": "The UDI code and issuer if applicable for the supplied product.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "The FDA, or other, UDI repository.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/udi"
}
}
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Prosthesis"
}
],
"path": "Claim.item.prosthesis",
"short": "Prosthetic details",
"definition": "The materials and placement date of prior fixed prosthesis.",
"min": 0,
"max": "1",
"type": [
{
"code": "BackboneElement"
}
],
"isSummary": true
},
{
"path": "Claim.item.prosthesis.initial",
"short": "Is this the initial service",
"definition": "Indicates whether this is the initial placement of a fixed prosthesis.",
"requirements": "May impact on adjudication.",
"min": 0,
"max": "1",
"type": [
{
"code": "boolean"
}
],
"isSummary": true
},
{
"path": "Claim.item.prosthesis.priorDate",
"short": "Initial service Date",
"definition": "Date of the initial placement.",
"requirements": "May impact on adjudication.",
"min": 0,
"max": "1",
"type": [
{
"code": "date"
}
],
"isSummary": true
},
{
"path": "Claim.item.prosthesis.priorMaterial",
"short": "Prosthetic Material",
"definition": "Material of the prior denture or bridge prosthesis. (Oral).",
"requirements": "May impact on adjudication.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "Material of the prior denture or bridge prosthesis. (Oral)",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/oral-prosthodontic-material"
}
}
},
{
"path": "Claim.additionalMaterials",
"short": "Additional materials, documents, etc.",
"definition": "Code to indicate that Xrays, images, emails, documents, models or attachments are being sent in support of this submission.",
"min": 0,
"max": "*",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "Code to indicate that Xrays, images, emails, documents, models or attachments are being sent in support of this submission.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/additionalmaterials"
}
}
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "MissingTeeth"
}
],
"path": "Claim.missingTeeth",
"short": "Only if type = oral",
"definition": "A list of teeth which would be expected but are not found due to having been previously extracted or for other reasons.",
"requirements": "The list of missing teeth may influence the adjudication of services for example with Bridges.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"isSummary": true
},
{
"path": "Claim.missingTeeth.tooth",
"short": "Tooth Code",
"definition": "The code identifying which tooth is missing.",
"requirements": "Provides the tooth number of the missing tooth.",
"min": 1,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "The codes for the teeth, subset of OralSites.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/teeth"
}
}
},
{
"path": "Claim.missingTeeth.reason",
"short": "Reason for missing",
"definition": "Missing reason may be: E-extraction, O-other.",
"requirements": "Provides the reason for the missing tooth.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "Reason codes for the missing teeth.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/missing-tooth-reason"
}
}
},
{
"path": "Claim.missingTeeth.extractionDate",
"short": "Date of Extraction",
"definition": "The date of the extraction either known from records or patient reported estimate.",
"requirements": "Some services and adjudications require this information.",
"min": 0,
"max": "1",
"type": [
{
"code": "date"
}
],
"isSummary": true
}
]
}
}
Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.
© HL7.org 2011+. FHIR DSTU2 (v1.0.2-7202) generated on Sat, Oct 24, 2015 07:43+1100.
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