description: A provider issued list of professional services and products which have been provided, or are to be provided, to a patient which is sent to an insurer for reimbursement.
package_name: hl7.fhir.r4.examples
derivation: specialization
name: Claim
type: Claim
elements:
  patient:
    short: The recipient of the products and services
    refers: ['http://hl7.org/fhir/StructureDefinition/Patient']
    type: Reference
    isSummary: true
    index: 5
  insurance:
    min: 1
    short: Patient insurance information
    index: 64
    type: BackboneElement
    array: true
    elements:
      sequence: {short: Insurance instance identifier, type: positiveInt, isSummary: true, index: 65}
      focal: {short: Coverage to be used for adjudication, type: boolean, isSummary: true, index: 66}
      identifier: {short: Pre-assigned Claim number, type: Identifier, index: 67}
      coverage:
        short: Insurance information
        refers: ['http://hl7.org/fhir/StructureDefinition/Coverage']
        type: Reference
        isSummary: true
        index: 68
      businessArrangement: {type: string, short: Additional provider contract number, index: 69}
      preAuthRef: {short: Prior authorization reference number, type: string, array: true, index: 70}
      claimResponse:
        short: Adjudication results
        refers: ['http://hl7.org/fhir/StructureDefinition/ClaimResponse']
        type: Reference
        index: 71
    required: [coverage, focal, sequence]
    isSummary: true
  facility:
    short: Servicing facility
    refers: ['http://hl7.org/fhir/StructureDefinition/Location']
    type: Reference
    index: 23
  diagnosis:
    short: Pertinent diagnosis information
    type: BackboneElement
    array: true
    index: 46
    elements:
      sequence: {short: Diagnosis instance identifier, type: positiveInt, index: 47}
      diagnosis:
        short: Nature of illness or problem
        choices: [diagnosisCodeableConcept, diagnosisReference]
        index: 49
      diagnosisCodeableConcept: {short: Nature of illness or problem, type: CodeableConcept, choiceOf: diagnosis, index: 50}
      diagnosisReference:
        short: Nature of illness or problem
        refers: ['http://hl7.org/fhir/StructureDefinition/Condition']
        type: Reference
        choiceOf: diagnosis
        index: 51
      type:
        short: Timing or nature of the diagnosis
        type: CodeableConcept
        array: true
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-diagnosistype'}
        index: 52
      onAdmission:
        short: Present on admission
        type: CodeableConcept
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-diagnosis-on-admission'}
        index: 53
      packageCode:
        short: Package billing code
        type: CodeableConcept
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup'}
        index: 54
    required: [diagnosisReference, diagnosis, diagnosisCodeableConcept, sequence]
  enterer:
    short: Author of the claim
    refers: ['http://hl7.org/fhir/StructureDefinition/Practitioner', 'http://hl7.org/fhir/StructureDefinition/PractitionerRole']
    type: Reference
    index: 8
  supportingInfo:
    short: Supporting information
    type: BackboneElement
    array: true
    index: 30
    elements:
      category:
        short: Classification of the supplied information
        type: CodeableConcept
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-informationcategory'}
        index: 32
      valueReference:
        short: Data to be provided
        refers: ['http://hl7.org/fhir/StructureDefinition/Resource']
        type: Reference
        choiceOf: value
        index: 44
      valueQuantity: {short: Data to be provided, type: Quantity, choiceOf: value, index: 42}
      timingPeriod: {type: Period, short: When it occurred, choiceOf: timing, index: 37}
      value:
        short: Data to be provided
        choices: [valueBoolean, valueString, valueQuantity, valueAttachment, valueReference]
        index: 39
      valueString: {short: Data to be provided, type: string, choiceOf: value, index: 41}
      valueBoolean: {short: Data to be provided, type: boolean, choiceOf: value, index: 40}
      reason:
        short: Explanation for the information
        type: CodeableConcept
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/missing-tooth-reason'}
        index: 45
      timing:
        short: When it occurred
        choices: [timingDate, timingPeriod]
        index: 35
      sequence: {type: positiveInt, short: Information instance identifier, index: 31}
      code:
        short: Type of information
        type: CodeableConcept
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-exception'}
        index: 33
      timingDate: {type: date, short: When it occurred, choiceOf: timing, index: 36}
      valueAttachment: {short: Data to be provided, type: Attachment, choiceOf: value, index: 43}
    required: [sequence, category]
  use:
    short: claim | preauthorization | predetermination
    type: code
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/claim-use|4.0.1'}
    isSummary: true
    index: 4
  item:
    short: Product or service provided
    type: BackboneElement
    array: true
    index: 79
    elements:
      category:
        short: Benefit classification
        type: CodeableConcept
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-benefitcategory'}
        index: 86
      diagnosisSequence: {type: positiveInt, short: Applicable diagnoses, array: true, index: 82}
      procedureSequence: {type: positiveInt, short: Applicable procedures, array: true, index: 83}
      locationAddress: {short: Place of service or where product was supplied, type: Address, choiceOf: location, index: 97}
      modifier:
        short: Product or service billing modifiers
        type: CodeableConcept
        array: true
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-modifiers'}
        index: 88
      revenue:
        short: Revenue or cost center code
        type: CodeableConcept
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-revenue-center'}
        index: 85
      encounter:
        short: Encounters related to this billed item
        refers: ['http://hl7.org/fhir/StructureDefinition/Encounter']
        type: Reference
        array: true
        index: 106
      locationCodeableConcept: {short: Place of service or where product was supplied, type: CodeableConcept, choiceOf: location, index: 96}
      net: {short: Total item cost, type: Money, index: 102}
      serviced:
        short: Date or dates of service or product delivery
        choices: [servicedDate, servicedPeriod]
        index: 91
      subSite:
        short: Anatomical sub-location
        type: CodeableConcept
        array: true
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/surface'}
        index: 105
      careTeamSequence: {type: positiveInt, short: Applicable careTeam members, array: true, index: 81}
      productOrService:
        short: Billing, service, product, or drug code
        type: CodeableConcept
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
        index: 87
      locationReference:
        short: Place of service or where product was supplied
        refers: ['http://hl7.org/fhir/StructureDefinition/Location']
        type: Reference
        choiceOf: location
        index: 98
      udi:
        short: Unique device identifier
        refers: ['http://hl7.org/fhir/StructureDefinition/Device']
        type: Reference
        array: true
        index: 103
      informationSequence: {type: positiveInt, short: Applicable exception and supporting information, array: true, index: 84}
      programCode:
        short: Program the product or service is provided under
        type: CodeableConcept
        array: true
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-program-code'}
        index: 89
      factor: {short: Price scaling factor, type: decimal, index: 101}
      servicedDate: {short: Date or dates of service or product delivery, type: date, choiceOf: serviced, index: 92}
      sequence: {type: positiveInt, short: Item instance identifier, index: 80}
      bodySite:
        short: Anatomical location
        type: CodeableConcept
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/tooth'}
        index: 104
      quantity: {type: Quantity, short: Count of products or services, index: 99}
      location:
        short: Place of service or where product was supplied
        choices: [locationCodeableConcept, locationAddress, locationReference]
        index: 95
      unitPrice: {type: Money, short: 'Fee, charge or cost per item', index: 100}
      servicedPeriod: {short: Date or dates of service or product delivery, type: Period, choiceOf: serviced, index: 93}
      detail:
        short: Product or service provided
        type: BackboneElement
        array: true
        index: 107
        elements:
          category:
            short: Benefit classification
            type: CodeableConcept
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-benefitcategory'}
            index: 110
          modifier:
            short: Service/Product billing modifiers
            type: CodeableConcept
            array: true
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-modifiers'}
            index: 112
          revenue:
            short: Revenue or cost center code
            type: CodeableConcept
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-revenue-center'}
            index: 109
          net: {short: Total item cost, type: Money, index: 117}
          productOrService:
            short: Billing, service, product, or drug code
            type: CodeableConcept
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
            index: 111
          udi:
            short: Unique device identifier
            refers: ['http://hl7.org/fhir/StructureDefinition/Device']
            type: Reference
            array: true
            index: 118
          programCode:
            short: Program the product or service is provided under
            type: CodeableConcept
            array: true
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-program-code'}
            index: 113
          factor: {short: Price scaling factor, type: decimal, index: 116}
          sequence: {type: positiveInt, short: Item instance identifier, index: 108}
          subDetail:
            short: Product or service provided
            type: BackboneElement
            array: true
            index: 119
            elements:
              category:
                short: Benefit classification
                type: CodeableConcept
                binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-benefitcategory'}
                index: 122
              modifier:
                short: Service/Product billing modifiers
                type: CodeableConcept
                array: true
                binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-modifiers'}
                index: 124
              revenue:
                short: Revenue or cost center code
                type: CodeableConcept
                binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-revenue-center'}
                index: 121
              net: {short: Total item cost, type: Money, index: 129}
              productOrService:
                short: Billing, service, product, or drug code
                type: CodeableConcept
                binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
                index: 123
              udi:
                short: Unique device identifier
                refers: ['http://hl7.org/fhir/StructureDefinition/Device']
                type: Reference
                array: true
                index: 130
              programCode:
                short: Program the product or service is provided under
                type: CodeableConcept
                array: true
                binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-program-code'}
                index: 125
              factor: {short: Price scaling factor, type: decimal, index: 128}
              sequence: {type: positiveInt, short: Item instance identifier, index: 120}
              quantity: {type: Quantity, short: Count of products or services, index: 126}
              unitPrice: {type: Money, short: 'Fee, charge or cost per item', index: 127}
            required: [sequence, productOrService]
          quantity: {type: Quantity, short: Count of products or services, index: 114}
          unitPrice: {type: Money, short: 'Fee, charge or cost per item', index: 115}
        required: [sequence, productOrService]
    required: [sequence, productOrService]
  type:
    short: Category or discipline
    type: CodeableConcept
    binding: {strength: extensible, valueSet: 'http://hl7.org/fhir/ValueSet/claim-type'}
    isSummary: true
    index: 2
  created: {short: Resource creation date, type: dateTime, isSummary: true, index: 7}
  procedure:
    short: Clinical procedures performed
    type: BackboneElement
    array: true
    index: 55
    elements:
      sequence: {type: positiveInt, short: Procedure instance identifier, index: 56}
      type:
        short: Category of Procedure
        type: CodeableConcept
        array: true
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-procedure-type'}
        index: 57
      date: {type: dateTime, short: When the procedure was performed, index: 58}
      procedure:
        short: Specific clinical procedure
        choices: [procedureCodeableConcept, procedureReference]
        index: 60
      procedureCodeableConcept: {short: Specific clinical procedure, type: CodeableConcept, choiceOf: procedure, index: 61}
      procedureReference:
        short: Specific clinical procedure
        refers: ['http://hl7.org/fhir/StructureDefinition/Procedure']
        type: Reference
        choiceOf: procedure
        index: 62
      udi:
        short: Unique device identifier
        refers: ['http://hl7.org/fhir/StructureDefinition/Device']
        type: Reference
        array: true
        index: 63
    required: [procedureReference, sequence, procedure, procedureCodeableConcept]
  related:
    short: Prior or corollary claims
    type: BackboneElement
    array: true
    index: 13
    elements:
      claim:
        short: Reference to the related claim
        refers: ['http://hl7.org/fhir/StructureDefinition/Claim']
        type: Reference
        index: 14
      relationship:
        short: How the reference claim is related
        type: CodeableConcept
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/related-claim-relationship'}
        index: 15
      reference: {short: File or case reference, type: Identifier, index: 16}
  referral:
    short: Treatment referral
    refers: ['http://hl7.org/fhir/StructureDefinition/ServiceRequest']
    type: Reference
    index: 22
  total: {type: Money, short: Total claim cost, index: 131}
  insurer:
    short: Target
    refers: ['http://hl7.org/fhir/StructureDefinition/Organization']
    type: Reference
    isSummary: true
    index: 9
  fundsReserve:
    short: For whom to reserve funds
    type: CodeableConcept
    binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/fundsreserve'}
    index: 12
  priority:
    short: Desired processing ugency
    type: CodeableConcept
    binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/process-priority'}
    isSummary: true
    index: 11
  accident:
    short: Details of the event
    type: BackboneElement
    index: 72
    elements:
      date: {short: When the incident occurred, type: date, index: 73}
      type:
        short: The nature of the accident
        type: CodeableConcept
        binding: {strength: extensible, valueSet: 'http://terminology.hl7.org/ValueSet/v3-ActIncidentCode'}
        index: 74
      location:
        short: Where the event occurred
        choices: [locationAddress, locationReference]
        index: 76
      locationAddress: {short: Where the event occurred, type: Address, choiceOf: location, index: 77}
      locationReference:
        short: Where the event occurred
        refers: ['http://hl7.org/fhir/StructureDefinition/Location']
        type: Reference
        choiceOf: location
        index: 78
    required: [date]
  status:
    isModifier: true
    short: active | cancelled | draft | entered-in-error
    type: code
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/fm-status|4.0.1'}
    isModifierReason: This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
    isSummary: true
    index: 1
  payee:
    short: Recipient of benefits payable
    type: BackboneElement
    index: 19
    elements:
      type:
        short: Category of recipient
        type: CodeableConcept
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/payeetype'}
        index: 20
      party:
        short: Recipient reference
        refers: ['http://hl7.org/fhir/StructureDefinition/Organization', 'http://hl7.org/fhir/StructureDefinition/Patient', 'http://hl7.org/fhir/StructureDefinition/Practitioner', 'http://hl7.org/fhir/StructureDefinition/PractitionerRole', 'http://hl7.org/fhir/StructureDefinition/RelatedPerson']
        type: Reference
        index: 21
    required: [type]
  prescription:
    short: Prescription authorizing services and products
    refers: ['http://hl7.org/fhir/StructureDefinition/DeviceRequest', 'http://hl7.org/fhir/StructureDefinition/MedicationRequest', 'http://hl7.org/fhir/StructureDefinition/VisionPrescription']
    type: Reference
    index: 17
  billablePeriod: {short: Relevant time frame for the claim, type: Period, isSummary: true, index: 6}
  identifier: {short: Business Identifier for claim, type: Identifier, array: true, index: 0}
  subType:
    short: More granular claim type
    type: CodeableConcept
    binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-subtype'}
    index: 3
  provider:
    short: Party responsible for the claim
    refers: ['http://hl7.org/fhir/StructureDefinition/Organization', 'http://hl7.org/fhir/StructureDefinition/Practitioner', 'http://hl7.org/fhir/StructureDefinition/PractitionerRole']
    type: Reference
    isSummary: true
    index: 10
  originalPrescription:
    short: Original prescription if superseded by fulfiller
    refers: ['http://hl7.org/fhir/StructureDefinition/DeviceRequest', 'http://hl7.org/fhir/StructureDefinition/MedicationRequest', 'http://hl7.org/fhir/StructureDefinition/VisionPrescription']
    type: Reference
    index: 18
  careTeam:
    short: Members of the care team
    type: BackboneElement
    array: true
    index: 24
    elements:
      sequence: {type: positiveInt, short: Order of care team, index: 25}
      provider:
        short: Practitioner or organization
        refers: ['http://hl7.org/fhir/StructureDefinition/Organization', 'http://hl7.org/fhir/StructureDefinition/Practitioner', 'http://hl7.org/fhir/StructureDefinition/PractitionerRole']
        type: Reference
        index: 26
      responsible: {short: Indicator of the lead practitioner, type: boolean, index: 27}
      role:
        short: Function within the team
        type: CodeableConcept
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-careteamrole'}
        index: 28
      qualification:
        short: Practitioner credential or specialization
        type: CodeableConcept
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/provider-qualification'}
        index: 29
    required: [provider, sequence]
package_version: 4.0.1
class: resource
kind: resource
url: http://hl7.org/fhir/StructureDefinition/Claim
base: http://hl7.org/fhir/StructureDefinition/DomainResource
version: 4.0.1
required: [created, priority, provider, status, insurance, type, patient, use]