{
"description": "Profile of Claim for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.",
"_filename": "StructureDefinition-qicore-claim.json",
"package_name": "hl7.fhir.us.qicore",
"date": "2018-08-22T00:00:00+10:00",
"derivation": "constraint",
"publisher": "Health Level Seven, Inc. - CQI WG",
"fhirVersion": "3.0.1",
"name": "QICore-Claim",
"mapping": [ {
"uri": "http://hl7.org/fhir/workflow",
"name": "Workflow Mapping",
"identity": "workflow"
}, {
"uri": "http://hl7.org/fhir/w5",
"name": "W5 Mapping",
"identity": "w5"
}, {
"uri": "http://hl7.org/v3",
"name": "RIM Mapping",
"identity": "rim"
} ],
"abstract": false,
"type": "Claim",
"experimental": null,
"resourceType": "StructureDefinition",
"title": null,
"package_version": "3.1.0",
"snapshot": {
"element": [ {
"constraint": [ {
"key": "dom-2",
"human": "If the resource is contained in another resource, it SHALL NOT contain nested Resources",
"xpath": "not(parent::f:contained and f:contained)",
"source": "DomainResource",
"severity": "error",
"expression": "contained.contained.empty()"
}, {
"key": "dom-1",
"human": "If the resource is contained in another resource, it SHALL NOT contain any narrative",
"xpath": "not(parent::f:contained and f:text)",
"source": "DomainResource",
"severity": "error",
"expression": "contained.text.empty()"
}, {
"key": "dom-4",
"human": "If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated",
"xpath": "not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))",
"source": "DomainResource",
"severity": "error",
"expression": "contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()"
}, {
"key": "dom-3",
"human": "If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource",
"xpath": "not(exists(for $id in f:contained/*/@id return $id[not(ancestor::f:contained/parent::*/descendant::f:reference/@value=concat('#', $id))]))",
"source": "DomainResource",
"severity": "error",
"expression": "contained.where(('#'+id in %resource.descendants().reference).not()).empty()"
} ],
"path": "Claim",
"min": 0,
"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.",
"short": "Claim, Pre-determination or Pre-authorization",
"mapping": [ {
"map": "Entity. Role, or Act",
"identity": "rim"
}, {
"map": "Request",
"identity": "workflow"
}, {
"map": "financial.billing",
"identity": "w5"
} ],
"mustSupport": false,
"max": "*",
"id": "Claim",
"base": {
"max": "*",
"min": 0,
"path": "Claim"
}
}, {
"path": "Claim.id",
"min": 0,
"definition": "The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.",
"short": "Logical id of this artifact",
"type": [ {
"code": "id"
} ],
"max": "1",
"id": "Claim.id",
"comment": "The only time that a resource does not have an id is when it is being submitted to the server using a create operation.",
"base": {
"max": "1",
"min": 0,
"path": "Resource.id"
},
"isSummary": true
}, {
"path": "Claim.meta",
"min": 0,
"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.",
"short": "Metadata about the resource",
"type": [ {
"code": "Meta"
} ],
"max": "1",
"id": "Claim.meta",
"base": {
"max": "1",
"min": 0,
"path": "Resource.meta"
},
"isSummary": true
}, {
"path": "Claim.implicitRules",
"min": 0,
"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.",
"isModifier": true,
"short": "A set of rules under which this content was created",
"type": [ {
"code": "uri"
} ],
"max": "1",
"id": "Claim.implicitRules",
"comment": "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. \n\nThis element is labelled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation.",
"base": {
"max": "1",
"min": 0,
"path": "Resource.implicitRules"
},
"isSummary": true
}, {
"path": "Claim.language",
"min": 0,
"definition": "The base language in which the resource is written.",
"short": "Language of the resource content",
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "extensible",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-maxValueSet",
"valueReference": {
"reference": "http://hl7.org/fhir/ValueSet/all-languages"
}
}, {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Language"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
} ],
"description": "A human language.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/languages"
}
},
"max": "1",
"id": "Claim.language",
"comment": "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).",
"base": {
"max": "1",
"min": 0,
"path": "Resource.language"
}
}, {
"path": "Claim.text",
"min": 0,
"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.",
"short": "Text summary of the resource, for human interpretation",
"mapping": [ {
"map": "Act.text?",
"identity": "rim"
} ],
"type": [ {
"code": "Narrative"
} ],
"alias": [ "narrative", "html", "xhtml", "display" ],
"max": "1",
"id": "Claim.text",
"condition": [ "dom-1" ],
"comment": "Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a \"text blob\" or where text is additionally entered raw or narrated and encoded in formation is added later.",
"base": {
"max": "1",
"min": 0,
"path": "DomainResource.text"
}
}, {
"path": "Claim.contained",
"min": 0,
"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.",
"short": "Contained, inline Resources",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Resource"
} ],
"alias": [ "inline resources", "anonymous resources", "contained resources" ],
"max": "*",
"id": "Claim.contained",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "DomainResource.contained"
}
}, {
"path": "Claim.extension",
"min": 0,
"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.",
"short": "Additional Content defined by implementations",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Claim.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "DomainResource.extension"
}
}, {
"path": "Claim.modifierExtension",
"min": 0,
"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.",
"isModifier": true,
"short": "Extensions that cannot be ignored",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Claim.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "DomainResource.modifierExtension"
}
}, {
"path": "Claim.identifier",
"min": 0,
"definition": "The business identifier for the instance: claim number, pre-determination or pre-authorization number.",
"short": "Claim number",
"mapping": [ {
"map": "Request.identifier",
"identity": "workflow"
}, {
"map": "id",
"identity": "w5"
} ],
"type": [ {
"code": "Identifier"
} ],
"max": "*",
"id": "Claim.identifier",
"base": {
"max": "*",
"min": 0,
"path": "Claim.identifier"
}
}, {
"path": "Claim.status",
"min": 0,
"definition": "The status of the resource instance.",
"isModifier": true,
"short": "active | cancelled | draft | entered-in-error",
"mapping": [ {
"map": "Request.status",
"identity": "workflow"
}, {
"map": "status",
"identity": "w5"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ClaimStatus"
} ],
"description": "A code specifying the state of the resource instance.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/fm-status"
}
},
"max": "1",
"id": "Claim.status",
"comment": "This element is labeled as a modifier because the status contains the code entered-in-error that marks the claim as not currently valid.",
"base": {
"max": "1",
"min": 0,
"path": "Claim.status"
},
"isSummary": true
}, {
"path": "Claim.type",
"min": 0,
"definition": "The category of claim, eg, oral, pharmacy, vision, insitutional, professional.",
"short": "Type or discipline",
"mapping": [ {
"map": "class",
"identity": "w5"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "required",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ClaimType"
} ],
"description": "The type or discipline-style of the claim",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-type"
}
},
"max": "1",
"id": "Claim.type",
"comment": "Affects which fields and value sets are used.",
"base": {
"max": "1",
"min": 0,
"path": "Claim.type"
}
}, {
"path": "Claim.subType",
"min": 0,
"definition": "A finer grained suite of claim subtype codes which may convey Inpatient vs Outpatient and/or a specialty service. In the US the BillType.",
"short": "Finer grained claim type information",
"mapping": [ {
"map": "class",
"identity": "w5"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ClaimSubType"
} ],
"description": "A more granular claim typecode",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-subtype"
}
},
"max": "*",
"id": "Claim.subType",
"comment": "This may contain the local bill type codes such as the US UB-04 bill type code.",
"base": {
"max": "*",
"min": 0,
"path": "Claim.subType"
}
}, {
"path": "Claim.use",
"min": 0,
"definition": "Complete (Bill or Claim), Proposed (Pre-Authorization), Exploratory (Pre-determination).",
"short": "complete | proposed | exploratory | other",
"mapping": [ {
"map": "class",
"identity": "w5"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Use"
} ],
"description": "Complete, proposed, exploratory, other",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-use"
}
},
"max": "1",
"id": "Claim.use",
"base": {
"max": "1",
"min": 0,
"path": "Claim.use"
}
}, {
"path": "Claim.patient",
"min": 1,
"definition": "Patient Resource.",
"short": "The subject of the Products and Services",
"mapping": [ {
"map": "Request.subject",
"identity": "workflow"
}, {
"map": "who.focus",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-patient"
} ],
"mustSupport": true,
"max": "1",
"id": "Claim.patient",
"base": {
"max": "1",
"min": 0,
"path": "Claim.patient"
}
}, {
"path": "Claim.billablePeriod",
"min": 0,
"definition": "The billable period for which charges are being submitted.",
"short": "Period for charge submission",
"mapping": [ {
"map": "when.done",
"identity": "w5"
} ],
"type": [ {
"code": "Period"
} ],
"max": "1",
"id": "Claim.billablePeriod",
"base": {
"max": "1",
"min": 0,
"path": "Claim.billablePeriod"
}
}, {
"path": "Claim.created",
"min": 1,
"definition": "The date when the enclosed suite of services were performed or completed.",
"short": "Creation date",
"mapping": [ {
"map": "Request.authoredOn",
"identity": "workflow"
}, {
"map": "when.recorded",
"identity": "w5"
} ],
"type": [ {
"code": "dateTime"
} ],
"mustSupport": true,
"max": "1",
"id": "Claim.created",
"base": {
"max": "1",
"min": 0,
"path": "Claim.created"
}
}, {
"path": "Claim.enterer",
"min": 0,
"definition": "Person who created the invoice/claim/pre-determination or pre-authorization.",
"short": "Author",
"mapping": [ {
"map": "who.author",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Practitioner"
} ],
"max": "1",
"id": "Claim.enterer",
"base": {
"max": "1",
"min": 0,
"path": "Claim.enterer"
}
}, {
"path": "Claim.insurer",
"min": 0,
"definition": "The Insurer who is target of the request.",
"short": "Target",
"mapping": [ {
"map": "Request.performer",
"identity": "workflow"
} ],
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization"
} ],
"max": "1",
"id": "Claim.insurer",
"base": {
"max": "1",
"min": 0,
"path": "Claim.insurer"
}
}, {
"path": "Claim.provider",
"min": 1,
"definition": "The provider which is responsible for the bill, claim pre-determination, pre-authorization.",
"short": "Responsible provider",
"mapping": [ {
"map": "Request.requester.agent",
"identity": "workflow"
}, {
"map": "who.source",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-practitioner"
} ],
"mustSupport": true,
"max": "1",
"id": "Claim.provider",
"base": {
"max": "1",
"min": 0,
"path": "Claim.provider"
}
}, {
"path": "Claim.organization",
"min": 0,
"definition": "The organization which is responsible for the bill, claim pre-determination, pre-authorization.",
"short": "Responsible organization",
"mapping": [ {
"map": "Request.requester.onBehalfOf",
"identity": "workflow"
}, {
"map": "who.source",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization"
} ],
"max": "1",
"id": "Claim.organization",
"base": {
"max": "1",
"min": 0,
"path": "Claim.organization"
}
}, {
"path": "Claim.priority",
"min": 0,
"definition": "Immediate (STAT), best effort (NORMAL), deferred (DEFER).",
"short": "Desired processing priority",
"mapping": [ {
"map": "Request.priority",
"identity": "workflow"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProcessPriority"
} ],
"description": "The timeliness with which processing is required: STAT, normal, Deferred",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/process-priority"
}
},
"max": "1",
"id": "Claim.priority",
"base": {
"max": "1",
"min": 0,
"path": "Claim.priority"
}
}, {
"path": "Claim.fundsReserve",
"min": 0,
"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.",
"short": "Funds requested to be reserved",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "FundsReserve"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
} ],
"description": "For whom funds are to be reserved: (Patient, Provider, None).",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/fundsreserve"
}
},
"max": "1",
"id": "Claim.fundsReserve",
"base": {
"max": "1",
"min": 0,
"path": "Claim.fundsReserve"
}
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "Element",
"severity": "error",
"expression": "hasValue() | (children().count() > id.count())"
} ],
"path": "Claim.related",
"min": 0,
"definition": "Other claims which are related to this claim such as prior claim versions or for related services.",
"short": "Related Claims which may be revelant to processing this claimn",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "RelatedClaim"
} ],
"max": "*",
"id": "Claim.related",
"base": {
"max": "*",
"min": 0,
"path": "Claim.related"
}
}, {
"path": "Claim.related.id",
"min": 0,
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "string"
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Claim.related.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
}
}, {
"path": "Claim.related.extension",
"min": 0,
"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.",
"short": "Additional Content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Claim.related.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
}
}, {
"path": "Claim.related.modifierExtension",
"min": 0,
"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.",
"isModifier": true,
"short": "Extensions that cannot be ignored",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Claim.related.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isSummary": true
}, {
"path": "Claim.related.claim",
"min": 0,
"definition": "Other claims which are related to this claim such as prior claim versions or for related services.",
"short": "Reference to the related claim",
"mapping": [ {
"map": "Request.replaces",
"identity": "workflow"
} ],
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Claim"
} ],
"max": "1",
"id": "Claim.related.claim",
"comment": "Do we need a relationship code?",
"base": {
"max": "1",
"min": 0,
"path": "Claim.related.claim"
}
}, {
"path": "Claim.related.relationship",
"min": 0,
"definition": "For example prior or umbrella.",
"short": "How the reference claim is related",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "RelatedClaimRelationship"
} ],
"description": "Relationship of this claim to a related Claim",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/related-claim-relationship"
}
},
"max": "1",
"id": "Claim.related.relationship",
"base": {
"max": "1",
"min": 0,
"path": "Claim.related.relationship"
}
}, {
"id": "Claim.related.reference",
"max": "1",
"min": 0,
"base": {
"max": "1",
"min": 0,
"path": "Claim.related.reference"
},
"path": "Claim.related.reference",
"type": [ {
"code": "Identifier"
} ],
"short": "Related file or case reference",
"definition": "An alternate organizational reference to the case or file to which this particular claim pertains - eg Property/Casualy insurer claim # or Workers Compensation case # ."
}, {
"path": "Claim.prescription",
"requirements": "For type=Pharmacy and Vision only.",
"min": 1,
"definition": "Prescription to support the dispensing of Pharmacy or Vision products.",
"short": "Prescription authorizing services or products",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-medicationrequest"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/VisionPrescription"
} ],
"mustSupport": true,
"max": "1",
"id": "Claim.prescription",
"comment": "Should we create a group to hold multiple prescriptions and add a sequence number and on the line items a link to the sequence.",
"base": {
"max": "1",
"min": 0,
"path": "Claim.prescription"
}
}, {
"path": "Claim.originalPrescription",
"min": 0,
"definition": "Original prescription which has been superceded by this prescription to support the dispensing of pharmacy services, medications or products. For example, a physician may prescribe a medication which the pharmacy determines is contraindicated, or for which the patient has an intolerance, and therefor issues a new precription for an alternate medication which has the same theraputic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription'.",
"short": "Original prescription if superceded by fulfiller",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/MedicationRequest"
} ],
"max": "1",
"id": "Claim.originalPrescription",
"comment": "as above.",
"base": {
"max": "1",
"min": 0,
"path": "Claim.originalPrescription"
}
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "Element",
"severity": "error",
"expression": "hasValue() | (children().count() > id.count())"
} ],
"path": "Claim.payee",
"min": 0,
"definition": "The party to be reimbursed for the services.",
"short": "Party to be paid any benefits payable",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Payee"
} ],
"max": "1",
"id": "Claim.payee",
"base": {
"max": "1",
"min": 0,
"path": "Claim.payee"
}
}, {
"path": "Claim.payee.id",
"min": 0,
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "string"
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Claim.payee.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
}
}, {
"path": "Claim.payee.extension",
"min": 0,
"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.",
"short": "Additional Content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Claim.payee.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
}
}, {
"path": "Claim.payee.modifierExtension",
"min": 0,
"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.",
"isModifier": true,
"short": "Extensions that cannot be ignored",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Claim.payee.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isSummary": true
}, {
"path": "Claim.payee.type",
"min": 1,
"definition": "Type of Party to be reimbursed: Subscriber, provider, other.",
"short": "Type of party: Subscriber, Provider, other",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "PayeeType"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
} ],
"description": "A code for the party to be reimbursed.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/payeetype"
}
},
"max": "1",
"id": "Claim.payee.type",
"base": {
"max": "1",
"min": 1,
"path": "Claim.payee.type"
}
}, {
"path": "Claim.payee.resourceType",
"min": 0,
"definition": "organization | patient | practitioner | relatedperson.",
"short": "organization | patient | practitioner | relatedperson",
"type": [ {
"code": "Coding"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ClaimPayeeResourceType"
} ],
"description": "The type of Claim payee Resource",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-payee-resource-type"
}
},
"max": "1",
"id": "Claim.payee.resourceType",
"base": {
"max": "1",
"min": 0,
"path": "Claim.payee.resourceType"
}
}, {
"path": "Claim.payee.party",
"min": 0,
"definition": "Party to be reimbursed: Subscriber, provider, other.",
"short": "Party to receive the payable",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-practitioner"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-organization"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-patient"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-relatedperson"
} ],
"mustSupport": false,
"max": "1",
"id": "Claim.payee.party",
"base": {
"max": "1",
"min": 0,
"path": "Claim.payee.party"
}
}, {
"path": "Claim.referral",
"min": 0,
"definition": "The referral resource which lists the date, practitioner, reason and other supporting information.",
"short": "Treatment Referral",
"mapping": [ {
"map": "who.cause",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-referralrequest"
} ],
"mustSupport": false,
"max": "1",
"id": "Claim.referral",
"base": {
"max": "1",
"min": 0,
"path": "Claim.referral"
}
}, {
"path": "Claim.facility",
"min": 0,
"definition": "Facility where the services were provided.",
"short": "Servicing Facility",
"mapping": [ {
"map": "where",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Location"
} ],
"max": "1",
"id": "Claim.facility",
"base": {
"max": "1",
"min": 0,
"path": "Claim.facility"
}
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "Element",
"severity": "error",
"expression": "hasValue() | (children().count() > id.count())"
} ],
"path": "Claim.careTeam",
"requirements": "Role and Responsible may not be required when there is only a single provider listed.",
"min": 0,
"definition": "The members of the team who provided the overall service as well as their role and whether responsible and qualifications.",
"short": "Members of the care team",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "CareTeam"
} ],
"max": "*",
"id": "Claim.careTeam",
"base": {
"max": "*",
"min": 0,
"path": "Claim.careTeam"
}
}, {
"path": "Claim.careTeam.id",
"min": 0,
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "string"
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Claim.careTeam.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
}
}, {
"path": "Claim.careTeam.extension",
"min": 0,
"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.",
"short": "Additional Content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Claim.careTeam.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
}
}, {
"path": "Claim.careTeam.modifierExtension",
"min": 0,
"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.",
"isModifier": true,
"short": "Extensions that cannot be ignored",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Claim.careTeam.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isSummary": true
}, {
"path": "Claim.careTeam.sequence",
"requirements": "Required to maintain order of the careTeam.",
"min": 1,
"definition": "Sequence of the careTeam which serves to order and provide a link.",
"short": "Number to covey order of careTeam",
"type": [ {
"code": "positiveInt"
} ],
"max": "1",
"id": "Claim.careTeam.sequence",
"base": {
"max": "1",
"min": 1,
"path": "Claim.careTeam.sequence"
}
}, {
"path": "Claim.careTeam.provider",
"min": 1,
"definition": "Member of the team who provided the overall service.",
"short": "Provider individual or organization",
"mapping": [ {
"map": "who.actor",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-practitioner"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-organization"
} ],
"mustSupport": false,
"max": "1",
"id": "Claim.careTeam.provider",
"base": {
"max": "1",
"min": 1,
"path": "Claim.careTeam.provider"
}
}, {
"id": "Claim.careTeam.responsible",
"max": "1",
"min": 0,
"base": {
"max": "1",
"min": 0,
"path": "Claim.careTeam.responsible"
},
"path": "Claim.careTeam.responsible",
"type": [ {
"code": "boolean"
} ],
"short": "Billing provider",
"definition": "The party who is billing and responsible for the claimed good or service rendered to the patient."
}, {
"path": "Claim.careTeam.role",
"min": 0,
"definition": "The lead, assisting or supervising practitioner and their discipline if a multidisiplinary team.",
"short": "Role on the team",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CareTeamRole"
} ],
"description": "The role codes for the care team members.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-careteamrole"
}
},
"max": "1",
"id": "Claim.careTeam.role",
"base": {
"max": "1",
"min": 0,
"path": "Claim.careTeam.role"
}
}, {
"path": "Claim.careTeam.qualification",
"min": 0,
"definition": "The qualification which is applicable for this service.",
"short": "Type, classification or Specialization",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProviderQualification"
} ],
"description": "Provider professional qualifications",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/provider-qualification"
}
},
"max": "1",
"id": "Claim.careTeam.qualification",
"base": {
"max": "1",
"min": 0,
"path": "Claim.careTeam.qualification"
}
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "Element",
"severity": "error",
"expression": "hasValue() | (children().count() > id.count())"
} ],
"path": "Claim.information",
"requirements": "Typically these information codes are required to support the services rendered or the adjudication of the services rendered.",
"min": 0,
"definition": "Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. Often there are mutiple jurisdiction specific valuesets which are required.",
"short": "Exceptions, special considerations, the condition, situation, prior or concurrent issues",
"mapping": [ {
"map": "Request.supportingInfo",
"identity": "workflow"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "SpecialCondition"
} ],
"max": "*",
"id": "Claim.information",
"base": {
"max": "*",
"min": 0,
"path": "Claim.information"
}
}, {
"path": "Claim.information.id",
"min": 0,
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "string"
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Claim.information.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
}
}, {
"path": "Claim.information.extension",
"min": 0,
"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.",
"short": "Additional Content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Claim.information.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
}
}, {
"path": "Claim.information.modifierExtension",
"min": 0,
"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.",
"isModifier": true,
"short": "Extensions that cannot be ignored",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Claim.information.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isSummary": true
}, {
"path": "Claim.information.sequence",
"requirements": "To provide a reference link.",
"min": 1,
"definition": "Sequence of the information element which serves to provide a link.",
"short": "Information instance identifier",
"type": [ {
"code": "positiveInt"
} ],
"max": "1",
"id": "Claim.information.sequence",
"base": {
"max": "1",
"min": 1,
"path": "Claim.information.sequence"
}
}, {
"path": "Claim.information.category",
"min": 1,
"definition": "The general class of the information supplied: information; exception; accident, employment; onset, etc.",
"short": "General class of information",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": true,
"binding": {
"strength": "example",
"description": "This value set includes sample Information Category codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-informationcategory"
}
},
"max": "1",
"id": "Claim.information.category",
"comment": "This may contain the local bill type codes such as the US UB-04 bill type code.",
"base": {
"max": "1",
"min": 1,
"path": "Claim.information.category"
}
}, {
"path": "Claim.information.code",
"min": 0,
"definition": "System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought which may influence the adjudication.",
"short": "Type of information",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": true,
"binding": {
"strength": "example",
"description": "This value set includes sample Exception codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-exception"
}
},
"max": "1",
"id": "Claim.information.code",
"comment": "This may contain the local bill type codes such as the US UB-04 bill type code.",
"base": {
"max": "1",
"min": 0,
"path": "Claim.information.code"
}
}, {
"id": "Claim.information.timing[x]",
"max": "1",
"min": 0,
"base": {
"max": "1",
"min": 0,
"path": "Claim.information.timing[x]"
},
"path": "Claim.information.timing[x]",
"type": [ {
"code": "date"
}, {
"code": "Period"
} ],
"short": "When it occurred",
"definition": "The date when or period to which this information refers."
}, {
"id": "Claim.information.value[x]",
"max": "1",
"min": 0,
"base": {
"max": "1",
"min": 0,
"path": "Claim.information.value[x]"
},
"path": "Claim.information.value[x]",
"type": [ {
"code": "string"
}, {
"code": "Quantity"
}, {
"code": "Attachment"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Resource"
} ],
"short": "Additional Data or supporting information",
"definition": "Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data."
}, {
"path": "Claim.information.reason",
"min": 0,
"definition": "For example, provides the reason for: the additional stay, or missing tooth or any other situation where a reason code is required in addition to the content.",
"short": "Reason associated with the information",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "MissingReason"
} ],
"description": "Reason codes for the missing teeth",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/missing-tooth-reason"
}
},
"max": "1",
"id": "Claim.information.reason",
"base": {
"max": "1",
"min": 0,
"path": "Claim.information.reason"
}
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "Element",
"severity": "error",
"expression": "hasValue() | (children().count() > id.count())"
} ],
"path": "Claim.diagnosis",
"min": 0,
"definition": "List of patient diagnosis for which care is sought.",
"short": "List of Diagnosis",
"mapping": [ {
"map": "Request.reasonReference",
"identity": "workflow"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Diagnosis"
} ],
"max": "*",
"id": "Claim.diagnosis",
"base": {
"max": "*",
"min": 0,
"path": "Claim.diagnosis"
}
}, {
"path": "Claim.diagnosis.id",
"min": 0,
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "string"
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Claim.diagnosis.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
}
}, {
"path": "Claim.diagnosis.extension",
"min": 0,
"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.",
"short": "Additional Content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Claim.diagnosis.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
}
}, {
"path": "Claim.diagnosis.modifierExtension",
"min": 0,
"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.",
"isModifier": true,
"short": "Extensions that cannot be ignored",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Claim.diagnosis.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isSummary": true
}, {
"path": "Claim.diagnosis.sequence",
"requirements": "Required to allow line items to reference the diagnoses.",
"min": 1,
"definition": "Sequence of diagnosis which serves to provide a link.",
"short": "Number to covey order of diagnosis",
"type": [ {
"code": "positiveInt"
} ],
"max": "1",
"id": "Claim.diagnosis.sequence",
"base": {
"max": "1",
"min": 1,
"path": "Claim.diagnosis.sequence"
}
}, {
"path": "Claim.diagnosis.diagnosis[x]",
"requirements": "Required to adjudicate services rendered to condition presented.",
"min": 1,
"definition": "The diagnosis.",
"short": "Patient's diagnosis",
"type": [ {
"code": "CodeableConcept"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Condition"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ICD10"
} ],
"description": "ICD10 Diagnostic codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/icd-10"
}
},
"max": "1",
"id": "Claim.diagnosis.diagnosis[x]",
"base": {
"max": "1",
"min": 1,
"path": "Claim.diagnosis.diagnosis[x]"
}
}, {
"path": "Claim.diagnosis.type",
"requirements": "May be required to adjudicate services rendered.",
"min": 0,
"definition": "The type of the Diagnosis, for example: admitting, primary, secondary, discharge.",
"short": "Timing or nature of the diagnosis",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "This value set includes example Diagnosis Type codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-diagnosistype"
}
},
"max": "*",
"id": "Claim.diagnosis.type",
"comment": "Diagnosis are presented in list order to their expected importance: primary, secondary, etc.",
"base": {
"max": "*",
"min": 0,
"path": "Claim.diagnosis.type"
}
}, {
"path": "Claim.diagnosis.packageCode",
"requirements": "May be required to adjudicate services rendered to the mandated grouping system.",
"min": 0,
"definition": "The package billing code, for example DRG, based on the assigned grouping code system.",
"short": "Package billing code",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "DiagnosisRelatedGroup"
} ],
"description": "The DRG codes associated with the diagnosis",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup"
}
},
"max": "1",
"id": "Claim.diagnosis.packageCode",
"base": {
"max": "1",
"min": 0,
"path": "Claim.diagnosis.packageCode"
}
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "Element",
"severity": "error",
"expression": "hasValue() | (children().count() > id.count())"
} ],
"path": "Claim.procedure",
"min": 0,
"definition": "Procedures performed.",
"short": "Procedures performed",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Procedure"
} ],
"max": "*",
"id": "Claim.procedure",
"base": {
"max": "*",
"min": 0,
"path": "Claim.procedure"
}
}, {
"path": "Claim.procedure.id",
"min": 0,
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "string"
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Claim.procedure.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
}
}, {
"path": "Claim.procedure.extension",
"min": 0,
"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.",
"short": "Additional Content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Claim.procedure.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
}
}, {
"path": "Claim.procedure.modifierExtension",
"min": 0,
"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.",
"isModifier": true,
"short": "Extensions that cannot be ignored",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Claim.procedure.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isSummary": true
}, {
"path": "Claim.procedure.sequence",
"requirements": "Required to maintain order of the procudures.",
"min": 1,
"definition": "Procedure sequence for reference.",
"short": "Procedure sequence for reference",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": true,
"max": "1",
"id": "Claim.procedure.sequence",
"base": {
"max": "1",
"min": 1,
"path": "Claim.procedure.sequence"
}
}, {
"path": "Claim.procedure.date",
"requirements": "Required to adjudicate services rendered.",
"min": 0,
"definition": "When the procedure was performed.",
"short": "When the procedure was performed",
"type": [ {
"code": "dateTime"
} ],
"mustSupport": true,
"max": "1",
"id": "Claim.procedure.date",
"comment": "SB DateTime??",
"base": {
"max": "1",
"min": 0,
"path": "Claim.procedure.date"
}
}, {
"path": "Claim.procedure.procedure[x]",
"requirements": "Required to adjudicate services rendered.",
"min": 1,
"definition": "When the procedure was performed.",
"short": "Patient's list of procedures performed",
"type": [ {
"code": "CodeableConcept"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Procedure"
} ],
"mustSupport": true,
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ICD10_Procedures"
} ],
"description": "ICD10 Procedure codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/icd-10-procedures"
}
},
"max": "1",
"id": "Claim.procedure.procedure[x]",
"base": {
"max": "1",
"min": 1,
"path": "Claim.procedure.procedure[x]"
}
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "Element",
"severity": "error",
"expression": "hasValue() | (children().count() > id.count())"
} ],
"path": "Claim.insurance",
"requirements": "Health care programs and insurers are significant payors of health service costs.",
"min": 0,
"definition": "Financial instrument by which payment information for health care.",
"short": "Insurance or medical plan",
"mapping": [ {
"map": "Coverage",
"identity": "rim"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Insurance"
} ],
"max": "*",
"id": "Claim.insurance",
"base": {
"max": "*",
"min": 0,
"path": "Claim.insurance"
}
}, {
"path": "Claim.insurance.id",
"min": 0,
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "string"
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Claim.insurance.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
}
}, {
"path": "Claim.insurance.extension",
"min": 0,
"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.",
"short": "Additional Content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Claim.insurance.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
}
}, {
"path": "Claim.insurance.modifierExtension",
"min": 0,
"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.",
"isModifier": true,
"short": "Extensions that cannot be ignored",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Claim.insurance.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isSummary": true
}, {
"path": "Claim.insurance.sequence",
"requirements": "To maintain order of the coverages.",
"min": 1,
"definition": "Sequence of coverage which serves to provide a link and convey coordination of benefit order.",
"short": "Service instance identifier",
"type": [ {
"code": "positiveInt"
} ],
"max": "1",
"id": "Claim.insurance.sequence",
"base": {
"max": "1",
"min": 1,
"path": "Claim.insurance.sequence"
}
}, {
"path": "Claim.insurance.focal",
"requirements": "To identify which coverage is being adjudicated.",
"min": 1,
"definition": "A flag to indicate that this Coverage is the focus for adjudication. The Coverage against which the claim is to be adjudicated.",
"short": "Is the focal Coverage",
"type": [ {
"code": "boolean"
} ],
"max": "1",
"id": "Claim.insurance.focal",
"base": {
"max": "1",
"min": 1,
"path": "Claim.insurance.focal"
}
}, {
"path": "Claim.insurance.coverage",
"requirements": "Need to identify the issuer to target for processing and for coordination of benefit processing.",
"min": 1,
"definition": "Reference to the program or plan identification, underwriter or payor.",
"short": "Insurance information",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Coverage"
} ],
"max": "1",
"id": "Claim.insurance.coverage",
"base": {
"max": "1",
"min": 1,
"path": "Claim.insurance.coverage"
}
}, {
"id": "Claim.insurance.businessArrangement",
"max": "1",
"min": 0,
"base": {
"max": "1",
"min": 0,
"path": "Claim.insurance.businessArrangement"
},
"path": "Claim.insurance.businessArrangement",
"type": [ {
"code": "string"
} ],
"short": "Business agreement",
"definition": "The contract number of a business agreement which describes the terms and conditions."
}, {
"path": "Claim.insurance.preAuthRef",
"requirements": "To provide any pre=determination or prior authorization reference.",
"min": 0,
"definition": "A list of references from the Insurer to which these services pertain.",
"short": "Pre-Authorization/Determination Reference",
"type": [ {
"code": "string"
} ],
"max": "*",
"id": "Claim.insurance.preAuthRef",
"base": {
"max": "*",
"min": 0,
"path": "Claim.insurance.preAuthRef"
}
}, {
"path": "Claim.insurance.claimResponse",
"requirements": "Used by downstream payers to determine what balance remains and the net payable.",
"min": 0,
"definition": "The Coverages adjudication details.",
"short": "Adjudication results",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/ClaimResponse"
} ],
"max": "1",
"id": "Claim.insurance.claimResponse",
"base": {
"max": "1",
"min": 0,
"path": "Claim.insurance.claimResponse"
}
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "Element",
"severity": "error",
"expression": "hasValue() | (children().count() > id.count())"
} ],
"path": "Claim.accident",
"min": 0,
"definition": "An accident which resulted in the need for healthcare services.",
"short": "Details about an accident",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Accident"
} ],
"max": "1",
"id": "Claim.accident",
"base": {
"max": "1",
"min": 0,
"path": "Claim.accident"
}
}, {
"path": "Claim.accident.id",
"min": 0,
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "string"
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Claim.accident.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
}
}, {
"path": "Claim.accident.extension",
"min": 0,
"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.",
"short": "Additional Content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Claim.accident.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
}
}, {
"path": "Claim.accident.modifierExtension",
"min": 0,
"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.",
"isModifier": true,
"short": "Extensions that cannot be ignored",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Claim.accident.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isSummary": true
}, {
"path": "Claim.accident.date",
"requirements": "Coverage may be dependant on accidents.",
"min": 1,
"definition": "Date of an accident which these services are addressing.",
"short": "When the accident occurred\nsee information codes\nsee information codes",
"type": [ {
"code": "date"
} ],
"max": "1",
"id": "Claim.accident.date",
"base": {
"max": "1",
"min": 1,
"path": "Claim.accident.date"
}
}, {
"path": "Claim.accident.type",
"requirements": "Coverage may be dependant on the type of accident.",
"min": 0,
"definition": "Type of accident: work, auto, etc.",
"short": "The nature of the accident",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "required",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "AccidentType"
} ],
"description": "Type of accident: work place, auto, etc.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/v3-ActIncidentCode"
}
},
"max": "1",
"id": "Claim.accident.type",
"base": {
"max": "1",
"min": 0,
"path": "Claim.accident.type"
}
}, {
"id": "Claim.accident.location[x]",
"max": "1",
"min": 0,
"base": {
"max": "1",
"min": 0,
"path": "Claim.accident.location[x]"
},
"path": "Claim.accident.location[x]",
"type": [ {
"code": "Address"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Location"
} ],
"short": "Accident Place",
"definition": "Accident Place."
}, {
"id": "Claim.employmentImpacted",
"max": "1",
"min": 0,
"base": {
"max": "1",
"min": 0,
"path": "Claim.employmentImpacted"
},
"path": "Claim.employmentImpacted",
"type": [ {
"code": "Period"
} ],
"short": "Period unable to work",
"definition": "The start and optional end dates of when the patient was precluded from working due to the treatable condition(s)."
}, {
"path": "Claim.hospitalization",
"min": 0,
"definition": "Period in hospital.",
"short": "Period in hospital",
"type": [ {
"code": "Period"
} ],
"mustSupport": true,
"max": "1",
"id": "Claim.hospitalization",
"base": {
"max": "1",
"min": 0,
"path": "Claim.hospitalization"
}
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "Element",
"severity": "error",
"expression": "hasValue() | (children().count() > id.count())"
} ],
"path": "Claim.item",
"min": 1,
"definition": "First tier of goods and services.",
"short": "Goods and Services",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Item"
} ],
"max": "*",
"id": "Claim.item",
"base": {
"max": "*",
"min": 0,
"path": "Claim.item"
}
}, {
"path": "Claim.item.id",
"min": 0,
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "string"
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Claim.item.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
}
}, {
"path": "Claim.item.extension",
"min": 0,
"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.",
"short": "Additional Content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Claim.item.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
}
}, {
"path": "Claim.item.modifierExtension",
"min": 0,
"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.",
"isModifier": true,
"short": "Extensions that cannot be ignored",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Claim.item.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isSummary": true
}, {
"id": "Claim.item.sequence",
"max": "1",
"min": 1,
"base": {
"max": "1",
"min": 1,
"path": "Claim.item.sequence"
},
"path": "Claim.item.sequence",
"type": [ {
"code": "positiveInt"
} ],
"short": "Service instance",
"definition": "A service line number."
}, {
"id": "Claim.item.careTeamLinkId",
"max": "*",
"min": 0,
"base": {
"max": "*",
"min": 0,
"path": "Claim.item.careTeamLinkId"
},
"path": "Claim.item.careTeamLinkId",
"type": [ {
"code": "positiveInt"
} ],
"short": "Applicable careTeam members",
"definition": "CareTeam applicable for this service or product line."
}, {
"id": "Claim.item.diagnosisLinkId",
"max": "*",
"min": 0,
"base": {
"max": "*",
"min": 0,
"path": "Claim.item.diagnosisLinkId"
},
"path": "Claim.item.diagnosisLinkId",
"type": [ {
"code": "positiveInt"
} ],
"short": "Applicable diagnoses",
"definition": "Diagnosis applicable for this service or product line."
}, {
"id": "Claim.item.procedureLinkId",
"max": "*",
"min": 0,
"base": {
"max": "*",
"min": 0,
"path": "Claim.item.procedureLinkId"
},
"path": "Claim.item.procedureLinkId",
"type": [ {
"code": "positiveInt"
} ],
"short": "Applicable procedures",
"definition": "Procedures applicable for this service or product line."
}, {
"id": "Claim.item.informationLinkId",
"max": "*",
"min": 0,
"base": {
"max": "*",
"min": 0,
"path": "Claim.item.informationLinkId"
},
"path": "Claim.item.informationLinkId",
"type": [ {
"code": "positiveInt"
} ],
"short": "Applicable exception and supporting information",
"definition": "Exceptions, special conditions and supporting information pplicable for this service or product line."
}, {
"path": "Claim.item.revenue",
"min": 0,
"definition": "The type of reveneu or cost center providing the product and/or service.",
"short": "Revenue or cost center code",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "RevenueCenter"
} ],
"description": "Codes for the revenue or cost centers supplying the service and/or products.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-revenue-center"
}
},
"max": "1",
"id": "Claim.item.revenue",
"base": {
"max": "1",
"min": 0,
"path": "Claim.item.revenue"
}
}, {
"path": "Claim.item.category",
"min": 0,
"definition": "Health Care Service Type Codes to identify the classification of service or benefits.",
"short": "Type of service or product",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitSubCategory"
} ],
"description": "Benefit subcategories such as: oral-basic, major, glasses",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-subcategory"
}
},
"max": "1",
"id": "Claim.item.category",
"base": {
"max": "1",
"min": 0,
"path": "Claim.item.category"
}
}, {
"path": "Claim.item.service",
"min": 1,
"definition": "If this is an actual service or product line, ie. not a Group, then use code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RXNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. \"glasses\" or \"compound\".",
"short": "Billing Code",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": true,
"binding": {
"strength": "example",
"description": "This value set includes a smattering of USCLS codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
},
"max": "1",
"id": "Claim.item.service",
"base": {
"max": "1",
"min": 0,
"path": "Claim.item.service"
}
}, {
"path": "Claim.item.modifier",
"requirements": "May impact on adjudication.",
"min": 0,
"definition": "Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.",
"short": "Service/Product billing modifiers",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Modifiers"
} ],
"description": "Item type or modifiers codes, eg 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"
}
},
"max": "*",
"id": "Claim.item.modifier",
"base": {
"max": "*",
"min": 0,
"path": "Claim.item.modifier"
}
}, {
"path": "Claim.item.programCode",
"min": 0,
"definition": "For programs which require reason codes for the inclusion or covering of this billed item under the program or sub-program.",
"short": "Program specific reason for item inclusion",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProgramCode"
} ],
"description": "Program specific reason codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-program-code"
}
},
"max": "*",
"id": "Claim.item.programCode",
"base": {
"max": "*",
"min": 0,
"path": "Claim.item.programCode"
}
}, {
"path": "Claim.item.serviced[x]",
"min": 1,
"definition": "The date or dates when the enclosed suite of services were performed or completed.",
"short": "Date or dates of Service",
"mapping": [ {
"map": "when.done",
"identity": "w5"
} ],
"type": [ {
"code": "date"
}, {
"code": "Period"
} ],
"mustSupport": true,
"max": "1",
"id": "Claim.item.serviced[x]",
"base": {
"max": "1",
"min": 0,
"path": "Claim.item.serviced[x]"
}
}, {
"path": "Claim.item.locationReference",
"min": 0,
"definition": "Where the service was provided.",
"short": "Place of service",
"mapping": [ {
"map": "where",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-location"
} ],
"mustSupport": false,
"max": "1",
"id": "Claim.item.locationReference",
"base": {
"max": "1",
"min": 0,
"path": "Claim.item.location[x]"
}
}, {
"id": "Claim.item.quantity",
"max": "1",
"min": 0,
"base": {
"max": "1",
"min": 0,
"path": "Claim.item.quantity"
},
"path": "Claim.item.quantity",
"type": [ {
"code": "Quantity",
"profile": "http://hl7.org/fhir/StructureDefinition/SimpleQuantity"
} ],
"short": "Count of Products or Services",
"definition": "The number of repetitions of a service or product."
}, {
"id": "Claim.item.unitPrice",
"max": "1",
"min": 0,
"base": {
"max": "1",
"min": 0,
"path": "Claim.item.unitPrice"
},
"path": "Claim.item.unitPrice",
"type": [ {
"code": "Money"
} ],
"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."
}, {
"path": "Claim.item.factor",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"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.",
"short": "Price scaling factor",
"type": [ {
"code": "decimal"
} ],
"max": "1",
"id": "Claim.item.factor",
"base": {
"max": "1",
"min": 0,
"path": "Claim.item.factor"
}
}, {
"path": "Claim.item.net",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"definition": "The quantity times the unit price for an addittional 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.",
"short": "Total item cost",
"type": [ {
"code": "Money"
} ],
"max": "1",
"id": "Claim.item.net",
"base": {
"max": "1",
"min": 0,
"path": "Claim.item.net"
}
}, {
"path": "Claim.item.udi",
"requirements": "The UDI code and issuer if applicable for the supplied product.",
"min": 0,
"definition": "List of Unique Device Identifiers associated with this line item.",
"short": "Unique Device Identifier",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-device"
} ],
"mustSupport": false,
"max": "*",
"id": "Claim.item.udi",
"base": {
"max": "*",
"min": 0,
"path": "Claim.item.udi"
}
}, {
"path": "Claim.item.bodySite",
"min": 0,
"definition": "Physical service site on the patient (limb, tooth, etc).",
"short": "Service Location",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "OralSites"
} ],
"description": "The code for the teeth, quadrant, sextant and arch",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/tooth"
}
},
"max": "1",
"id": "Claim.item.bodySite",
"base": {
"max": "1",
"min": 0,
"path": "Claim.item.bodySite"
}
}, {
"path": "Claim.item.subSite",
"min": 0,
"definition": "A region or surface of the site, eg. limb region or tooth surface(s).",
"short": "Service Sub-location",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Surface"
} ],
"description": "The code for the tooth surface and surface combinations",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/surface"
}
},
"max": "*",
"id": "Claim.item.subSite",
"base": {
"max": "*",
"min": 0,
"path": "Claim.item.subSite"
}
}, {
"path": "Claim.item.encounter",
"min": 0,
"definition": "Encounters related to this billed item.",
"short": "Encounters related to this billed item",
"mapping": [ {
"map": "Request.context",
"identity": "workflow"
} ],
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-encounter"
} ],
"mustSupport": true,
"max": "*",
"id": "Claim.item.encounter",
"base": {
"max": "*",
"min": 0,
"path": "Claim.item.encounter"
}
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "Element",
"severity": "error",
"expression": "hasValue() | (children().count() > id.count())"
} ],
"path": "Claim.item.detail",
"min": 0,
"definition": "Second tier of goods and services.",
"short": "Additional items",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Detail"
} ],
"max": "*",
"id": "Claim.item.detail",
"base": {
"max": "*",
"min": 0,
"path": "Claim.item.detail"
}
}, {
"path": "Claim.item.detail.id",
"min": 0,
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "string"
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Claim.item.detail.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
}
}, {
"path": "Claim.item.detail.extension",
"min": 0,
"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.",
"short": "Additional Content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Claim.item.detail.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
}
}, {
"path": "Claim.item.detail.modifierExtension",
"min": 0,
"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.",
"isModifier": true,
"short": "Extensions that cannot be ignored",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Claim.item.detail.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isSummary": true
}, {
"id": "Claim.item.detail.sequence",
"max": "1",
"min": 1,
"base": {
"max": "1",
"min": 1,
"path": "Claim.item.detail.sequence"
},
"path": "Claim.item.detail.sequence",
"type": [ {
"code": "positiveInt"
} ],
"short": "Service instance",
"definition": "A service line number."
}, {
"path": "Claim.item.detail.revenue",
"min": 0,
"definition": "The type of reveneu or cost center providing the product and/or service.",
"short": "Revenue or cost center code",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "RevenueCenter"
} ],
"description": "Codes for the revenue or cost centers supplying the service and/or products.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-revenue-center"
}
},
"max": "1",
"id": "Claim.item.detail.revenue",
"base": {
"max": "1",
"min": 0,
"path": "Claim.item.detail.revenue"
}
}, {
"path": "Claim.item.detail.category",
"min": 0,
"definition": "Health Care Service Type Codes to identify the classification of service or benefits.",
"short": "Type of service or product",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitSubCategory"
} ],
"description": "Benefit subcategories such as: oral-basic, major, glasses",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-subcategory"
}
},
"max": "1",
"id": "Claim.item.detail.category",
"base": {
"max": "1",
"min": 0,
"path": "Claim.item.detail.category"
}
}, {
"path": "Claim.item.detail.service",
"min": 0,
"definition": "If this is an actual service or product line, ie. not a Group, then use code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'.",
"short": "Billing Code",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
} ],
"description": "Allowable service and product codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
},
"max": "1",
"id": "Claim.item.detail.service",
"base": {
"max": "1",
"min": 0,
"path": "Claim.item.detail.service"
}
}, {
"path": "Claim.item.detail.modifier",
"requirements": "May impact on adjudication.",
"min": 0,
"definition": "Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.",
"short": "Service/Product billing modifiers",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Modifiers"
} ],
"description": "Item type or modifiers codes, eg 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"
}
},
"max": "*",
"id": "Claim.item.detail.modifier",
"base": {
"max": "*",
"min": 0,
"path": "Claim.item.detail.modifier"
}
}, {
"path": "Claim.item.detail.programCode",
"min": 0,
"definition": "For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program.",
"short": "Program specific reason for item inclusion",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProgramCode"
} ],
"description": "Program specific reason codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-program-code"
}
},
"max": "*",
"id": "Claim.item.detail.programCode",
"base": {
"max": "*",
"min": 0,
"path": "Claim.item.detail.programCode"
}
}, {
"id": "Claim.item.detail.quantity",
"max": "1",
"min": 0,
"base": {
"max": "1",
"min": 0,
"path": "Claim.item.detail.quantity"
},
"path": "Claim.item.detail.quantity",
"type": [ {
"code": "Quantity",
"profile": "http://hl7.org/fhir/StructureDefinition/SimpleQuantity"
} ],
"short": "Count of Products or Services",
"definition": "The number of repetitions of a service or product."
}, {
"path": "Claim.item.detail.unitPrice",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"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.",
"short": "Fee, charge or cost per point",
"type": [ {
"code": "Money"
} ],
"max": "1",
"id": "Claim.item.detail.unitPrice",
"base": {
"max": "1",
"min": 0,
"path": "Claim.item.detail.unitPrice"
}
}, {
"path": "Claim.item.detail.factor",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"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.",
"short": "Price scaling factor",
"type": [ {
"code": "decimal"
} ],
"max": "1",
"id": "Claim.item.detail.factor",
"base": {
"max": "1",
"min": 0,
"path": "Claim.item.detail.factor"
}
}, {
"path": "Claim.item.detail.net",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"definition": "The quantity times the unit price for an addittional 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.",
"short": "Total additional item cost",
"type": [ {
"code": "Money"
} ],
"max": "1",
"id": "Claim.item.detail.net",
"base": {
"max": "1",
"min": 0,
"path": "Claim.item.detail.net"
}
}, {
"path": "Claim.item.detail.udi",
"requirements": "The UDI code and issuer if applicable for the supplied product.",
"min": 0,
"definition": "List of Unique Device Identifiers associated with this line item.",
"short": "Unique Device Identifier",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-device"
} ],
"mustSupport": false,
"max": "*",
"id": "Claim.item.detail.udi",
"base": {
"max": "*",
"min": 0,
"path": "Claim.item.detail.udi"
}
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "Element",
"severity": "error",
"expression": "hasValue() | (children().count() > id.count())"
} ],
"path": "Claim.item.detail.subDetail",
"min": 0,
"definition": "Third tier of goods and services.",
"short": "Additional items",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "SubDetail"
} ],
"max": "*",
"id": "Claim.item.detail.subDetail",
"base": {
"max": "*",
"min": 0,
"path": "Claim.item.detail.subDetail"
}
}, {
"path": "Claim.item.detail.subDetail.id",
"min": 0,
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "string"
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Claim.item.detail.subDetail.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
}
}, {
"path": "Claim.item.detail.subDetail.extension",
"min": 0,
"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.",
"short": "Additional Content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Claim.item.detail.subDetail.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
}
}, {
"path": "Claim.item.detail.subDetail.modifierExtension",
"min": 0,
"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.",
"isModifier": true,
"short": "Extensions that cannot be ignored",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Claim.item.detail.subDetail.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isSummary": true
}, {
"id": "Claim.item.detail.subDetail.sequence",
"max": "1",
"min": 1,
"base": {
"max": "1",
"min": 1,
"path": "Claim.item.detail.subDetail.sequence"
},
"path": "Claim.item.detail.subDetail.sequence",
"type": [ {
"code": "positiveInt"
} ],
"short": "Service instance",
"definition": "A service line number."
}, {
"path": "Claim.item.detail.subDetail.revenue",
"min": 0,
"definition": "The type of reveneu or cost center providing the product and/or service.",
"short": "Revenue or cost center code",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "RevenueCenter"
} ],
"description": "Codes for the revenue or cost centers supplying the service and/or products.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-revenue-center"
}
},
"max": "1",
"id": "Claim.item.detail.subDetail.revenue",
"base": {
"max": "1",
"min": 0,
"path": "Claim.item.detail.subDetail.revenue"
}
}, {
"path": "Claim.item.detail.subDetail.category",
"min": 0,
"definition": "Health Care Service Type Codes to identify the classification of service or benefits.",
"short": "Type of service or product",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitSubCategory"
} ],
"description": "Benefit subcategories such as: oral-basic, major, glasses",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-subcategory"
}
},
"max": "1",
"id": "Claim.item.detail.subDetail.category",
"base": {
"max": "1",
"min": 0,
"path": "Claim.item.detail.subDetail.category"
}
}, {
"path": "Claim.item.detail.subDetail.service",
"min": 0,
"definition": "A code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI).",
"short": "Billing Code",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
} ],
"description": "Allowable service and product codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
},
"max": "1",
"id": "Claim.item.detail.subDetail.service",
"base": {
"max": "1",
"min": 0,
"path": "Claim.item.detail.subDetail.service"
}
}, {
"path": "Claim.item.detail.subDetail.modifier",
"requirements": "May impact on adjudication.",
"min": 0,
"definition": "Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.",
"short": "Service/Product billing modifiers",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Modifiers"
} ],
"description": "Item type or modifiers codes, eg 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"
}
},
"max": "*",
"id": "Claim.item.detail.subDetail.modifier",
"base": {
"max": "*",
"min": 0,
"path": "Claim.item.detail.subDetail.modifier"
}
}, {
"path": "Claim.item.detail.subDetail.programCode",
"min": 0,
"definition": "For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program.",
"short": "Program specific reason for item inclusion",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProgramCode"
} ],
"description": "Program specific reason codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-program-code"
}
},
"max": "*",
"id": "Claim.item.detail.subDetail.programCode",
"base": {
"max": "*",
"min": 0,
"path": "Claim.item.detail.subDetail.programCode"
}
}, {
"id": "Claim.item.detail.subDetail.quantity",
"max": "1",
"min": 0,
"base": {
"max": "1",
"min": 0,
"path": "Claim.item.detail.subDetail.quantity"
},
"path": "Claim.item.detail.subDetail.quantity",
"type": [ {
"code": "Quantity",
"profile": "http://hl7.org/fhir/StructureDefinition/SimpleQuantity"
} ],
"short": "Count of Products or Services",
"definition": "The number of repetitions of a service or product."
}, {
"path": "Claim.item.detail.subDetail.unitPrice",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"definition": "The fee for an addittional service or product or charge.",
"short": "Fee, charge or cost per point",
"type": [ {
"code": "Money"
} ],
"max": "1",
"id": "Claim.item.detail.subDetail.unitPrice",
"base": {
"max": "1",
"min": 0,
"path": "Claim.item.detail.subDetail.unitPrice"
}
}, {
"path": "Claim.item.detail.subDetail.factor",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"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.",
"short": "Price scaling factor",
"type": [ {
"code": "decimal"
} ],
"max": "1",
"id": "Claim.item.detail.subDetail.factor",
"base": {
"max": "1",
"min": 0,
"path": "Claim.item.detail.subDetail.factor"
}
}, {
"path": "Claim.item.detail.subDetail.net",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"definition": "The quantity times the unit price for an addittional 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.",
"short": "Net additional item cost",
"type": [ {
"code": "Money"
} ],
"max": "1",
"id": "Claim.item.detail.subDetail.net",
"base": {
"max": "1",
"min": 0,
"path": "Claim.item.detail.subDetail.net"
}
}, {
"path": "Claim.item.detail.subDetail.udi",
"requirements": "The UDI code and issuer if applicable for the supplied product.",
"min": 0,
"definition": "List of Unique Device Identifiers associated with this line item.",
"short": "Unique Device Identifier",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-device"
} ],
"mustSupport": false,
"max": "1",
"id": "Claim.item.detail.subDetail.udi",
"base": {
"max": "*",
"min": 0,
"path": "Claim.item.detail.subDetail.udi"
}
}, {
"id": "Claim.total",
"max": "1",
"min": 0,
"base": {
"max": "1",
"min": 0,
"path": "Claim.total"
},
"path": "Claim.total",
"type": [ {
"code": "Money"
} ],
"short": "Total claim cost",
"definition": "The total value of the claim."
} ]
},
"status": "draft",
"id": "13eac1f0-3bd7-4113-958f-c4761f11f0f3",
"kind": "resource",
"url": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-claim",
"version": "3.1.0",
"differential": {
"element": [ {
"id": "Claim",
"path": "Claim",
"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.",
"isModifier": false,
"mustSupport": false
}, {
"id": "Claim.patient",
"max": "1",
"min": 1,
"path": "Claim.patient",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-patient"
} ],
"definition": "Patient Resource.",
"isModifier": false,
"mustSupport": true
}, {
"id": "Claim.created",
"max": "1",
"min": 1,
"path": "Claim.created",
"type": [ {
"code": "dateTime"
} ],
"definition": "The date when the enclosed suite of services were performed or completed.",
"isModifier": false,
"mustSupport": true
}, {
"id": "Claim.provider",
"max": "1",
"min": 1,
"path": "Claim.provider",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-practitioner"
} ],
"definition": "The provider which is responsible for the bill, claim pre-determination, pre-authorization.",
"isModifier": false,
"mustSupport": true
}, {
"id": "Claim.prescription",
"max": "1",
"min": 1,
"path": "Claim.prescription",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-medicationrequest"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/VisionPrescription"
} ],
"definition": "Prescription to support the dispensing of Pharmacy or Vision products.",
"isModifier": false,
"mustSupport": true
}, {
"id": "Claim.payee",
"max": "1",
"min": 0,
"path": "Claim.payee",
"type": [ {
"code": "BackboneElement"
} ],
"definition": "The party to be reimbursed for the services.",
"isModifier": false,
"mustSupport": false
}, {
"id": "Claim.payee.party",
"max": "1",
"min": 0,
"path": "Claim.payee.party",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-practitioner"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-organization"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-patient"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-relatedperson"
} ],
"definition": "Party to be reimbursed: Subscriber, provider, other.",
"isModifier": false,
"mustSupport": false
}, {
"id": "Claim.referral",
"max": "1",
"min": 0,
"path": "Claim.referral",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-referralrequest"
} ],
"definition": "The referral resource which lists the date, practitioner, reason and other supporting information.",
"isModifier": false,
"mustSupport": false
}, {
"id": "Claim.careTeam",
"max": "*",
"min": 0,
"path": "Claim.careTeam",
"type": [ {
"code": "BackboneElement"
} ],
"definition": "The members of the team who provided the overall service as well as their role and whether responsible and qualifications.",
"isModifier": false,
"mustSupport": false
}, {
"id": "Claim.careTeam.provider",
"max": "1",
"min": 1,
"path": "Claim.careTeam.provider",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-practitioner"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-organization"
} ],
"definition": "Member of the team who provided the overall service.",
"isModifier": false,
"mustSupport": false
}, {
"id": "Claim.information",
"max": "*",
"min": 0,
"path": "Claim.information",
"type": [ {
"code": "BackboneElement"
} ],
"definition": "Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. Often there are mutiple jurisdiction specific valuesets which are required.",
"isModifier": false,
"mustSupport": false
}, {
"path": "Claim.information.category",
"min": 1,
"definition": "The general class of the information supplied: information; exception; accident, employment; onset, etc.",
"isModifier": false,
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": true,
"binding": {
"strength": "example",
"description": "This value set includes sample Information Category codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-informationcategory"
}
},
"max": "1",
"id": "Claim.information.category"
}, {
"path": "Claim.information.code",
"min": 0,
"definition": "System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought which may influence the adjudication.",
"isModifier": false,
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": true,
"binding": {
"strength": "example",
"description": "This value set includes sample Exception codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-exception"
}
},
"max": "1",
"id": "Claim.information.code"
}, {
"id": "Claim.diagnosis",
"max": "*",
"min": 0,
"path": "Claim.diagnosis",
"type": [ {
"code": "BackboneElement"
} ],
"definition": "List of patient diagnosis for which care is sought.",
"isModifier": false,
"mustSupport": false
}, {
"path": "Claim.diagnosis.type",
"min": 0,
"definition": "The type of the Diagnosis, for example: admitting, primary, secondary, discharge.",
"isModifier": false,
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"description": "This value set includes example Diagnosis Type codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-diagnosistype"
}
},
"max": "*",
"id": "Claim.diagnosis.type"
}, {
"id": "Claim.procedure",
"max": "*",
"min": 0,
"path": "Claim.procedure",
"type": [ {
"code": "BackboneElement"
} ],
"definition": "Procedures performed.",
"isModifier": false,
"mustSupport": true
}, {
"id": "Claim.procedure.sequence",
"max": "1",
"min": 1,
"path": "Claim.procedure.sequence",
"type": [ {
"code": "positiveInt"
} ],
"definition": "Procedure sequence for reference.",
"isModifier": false,
"mustSupport": true
}, {
"id": "Claim.procedure.date",
"max": "1",
"min": 0,
"path": "Claim.procedure.date",
"type": [ {
"code": "dateTime"
} ],
"definition": "When the procedure was performed.",
"isModifier": false,
"mustSupport": true
}, {
"id": "Claim.procedure.procedure[x]",
"max": "1",
"min": 1,
"path": "Claim.procedure.procedure[x]",
"definition": "When the procedure was performed.",
"isModifier": false,
"mustSupport": true
}, {
"id": "Claim.hospitalization",
"max": "1",
"min": 0,
"path": "Claim.hospitalization",
"type": [ {
"code": "Period"
} ],
"definition": "Period in hospital.",
"isModifier": false,
"mustSupport": true
}, {
"id": "Claim.item",
"max": "*",
"min": 1,
"path": "Claim.item",
"type": [ {
"code": "BackboneElement"
} ],
"definition": "First tier of goods and services.",
"isModifier": false,
"mustSupport": true
}, {
"path": "Claim.item.service",
"min": 1,
"definition": "If this is an actual service or product line, ie. not a Group, then use code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RXNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. \"glasses\" or \"compound\".",
"isModifier": false,
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": true,
"binding": {
"strength": "example",
"description": "This value set includes a smattering of USCLS codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
},
"max": "1",
"id": "Claim.item.service"
}, {
"id": "Claim.item.serviced[x]",
"max": "1",
"min": 1,
"path": "Claim.item.serviced[x]",
"definition": "The date or dates when the enclosed suite of services were performed or completed.",
"isModifier": false,
"mustSupport": true
}, {
"id": "Claim.item.locationReference",
"max": "1",
"min": 0,
"path": "Claim.item.locationReference",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-location"
} ],
"definition": "Where the service was provided.",
"isModifier": false,
"mustSupport": false
}, {
"id": "Claim.item.udi",
"max": "*",
"min": 0,
"path": "Claim.item.udi",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-device"
} ],
"definition": "List of Unique Device Identifiers associated with this line item.",
"isModifier": false,
"mustSupport": false
}, {
"id": "Claim.item.encounter",
"max": "*",
"min": 0,
"path": "Claim.item.encounter",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-encounter"
} ],
"definition": "Encounters related to this billed item.",
"isModifier": false,
"mustSupport": true
}, {
"id": "Claim.item.detail",
"max": "*",
"min": 0,
"path": "Claim.item.detail",
"type": [ {
"code": "BackboneElement"
} ],
"definition": "Second tier of goods and services.",
"isModifier": false,
"mustSupport": false
}, {
"id": "Claim.item.detail.udi",
"max": "*",
"min": 0,
"path": "Claim.item.detail.udi",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-device"
} ],
"definition": "List of Unique Device Identifiers associated with this line item.",
"isModifier": false,
"mustSupport": false
}, {
"id": "Claim.item.detail.subDetail",
"max": "*",
"min": 0,
"path": "Claim.item.detail.subDetail",
"type": [ {
"code": "BackboneElement"
} ],
"definition": "Third tier of goods and services.",
"isModifier": false,
"mustSupport": false
}, {
"id": "Claim.item.detail.subDetail.udi",
"max": "1",
"min": 0,
"path": "Claim.item.detail.subDetail.udi",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-device"
} ],
"definition": "List of Unique Device Identifiers associated with this line item.",
"isModifier": false,
"mustSupport": false
} ]
},
"contact": [ {
"telecom": [ {
"value": "http://hl7.org/special/committees/CQI",
"system": "url"
} ]
} ],
"baseDefinition": "http://hl7.org/fhir/StructureDefinition/Claim"
}