{
"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.",
"_filename": "MyClaim.json",
"package_name": "PharmacyClaimProfile.test",
"date": "2018-12-27T22:37:54+11:00",
"derivation": "specialization",
"meta": {
"lastUpdated": "2018-12-27T22:37:54.724+11:00"
},
"publisher": "Health Level Seven International (Financial Management)",
"fhirVersion": "4.0.0",
"purpose": "The Claim resource is used by providers to exchange services and products rendered to patients or planned to be rendered with insurers for reimbuserment. It is also used by insurers to exchange claims information with statutory reporting and data analytics firms.",
"name": "Claim",
"mapping": [ {
"uri": "http://hl7.org/fhir/workflow",
"name": "Workflow Pattern",
"identity": "workflow"
}, {
"uri": "http://hl7.org/fhir/fivews",
"name": "FiveWs Pattern 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": "1.0.1-beta",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-category",
"valueString": "Financial.Billing"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status",
"valueCode": "trial-use"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm",
"valueInteger": 2
}, {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-security-category",
"valueCode": "patient"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
"valueCode": "fm"
} ],
"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-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 or SHALL refer to the containing resource",
"xpath": "not(exists(for $contained in f:contained return $contained[not(parent::*/descendant::f:reference/@va lue=concat('#', $contained/*/id/@value) or descendant::f:reference[@value='#'])]))",
"source": "DomainResource",
"severity": "error",
"expression": "contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonica l) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(refer ence = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(c anonical) = '#').exists()).not()).trace('unmatched', id).empty()"
}, {
"key": "dom-6",
"human": "A resource should have narrative for robust management",
"xpath": "exists(f:text/h:div)",
"source": "DomainResource",
"severity": "warning",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bestpractice",
"valueBoolean": true
}, {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bestpractice-explanation",
"valueMarkdown": "When a resource has no narrative, only systems that fully understand the data can display the resource to a human safely. Including a human readable representation in the resource makes for a much more robust eco-system and cheaper handling of resources by intermediary systems. Some ecosystems restrict distribution of resources to only those systems that do fully understand the resources, and as a consequence implementers may believe that the narrative is superfluous. However experience shows that such eco-systems often open up to new participants over time."
} ],
"expression": "text.div.exists()"
}, {
"key": "dom-5",
"human": "If a resource is contained in another resource, it SHALL NOT have a security label",
"xpath": "not(exists(f:contained/*/f:meta/f:security))",
"source": "DomainResource",
"severity": "error",
"expression": "contained.meta.security.empty()"
} ],
"path": "Claim",
"min": 0,
"definition": "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.",
"isModifier": false,
"short": "Claim, Pre-determination or Pre-authorization",
"mapping": [ {
"map": "Entity. Role, or Act",
"identity": "rim"
}, {
"map": "Request",
"identity": "workflow"
} ],
"alias": [ "Adjudication Request", "Preauthorization Request", "Predetermination Request" ],
"max": "*",
"id": "Claim",
"comment": "The Claim resource fulfills three information request requirements: Claim - a request for adjudication for reimbursement for products and/or services provided; Preauthorization - a request to authorize the future provision of products and/or services including an anticipated adjudication; and, Predetermination - a request for a non-bind adjudication of possible future products and/or services.",
"base": {
"max": "*",
"min": 0,
"path": "Claim"
},
"isSummary": false
}, {
"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.",
"isModifier": false,
"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 might not always be associated with version changes to the resource.",
"isModifier": false,
"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. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.",
"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. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.",
"base": {
"max": "1",
"min": 0,
"path": "Resource.implicitRules"
},
"isModifierReason": "This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation",
"isSummary": true
}, {
"path": "Claim.language",
"min": 0,
"definition": "The base language in which the resource is written.",
"isModifier": false,
"short": "Language of the resource content",
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/languages",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-maxValueSet",
"valueCanonical": "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."
},
"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"
},
"isSummary": false
}, {
"path": "Claim.text",
"min": 0,
"definition": "A human-readable narrative that contains a summary of the resource and can 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.",
"isModifier": false,
"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",
"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 information is added later.",
"base": {
"max": "1",
"min": 0,
"path": "DomainResource.text"
},
"isSummary": false
}, {
"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.",
"isModifier": false,
"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. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.",
"base": {
"max": "*",
"min": 0,
"path": "DomainResource.contained"
},
"isSummary": false
}, {
"path": "Claim.extension",
"min": 0,
"definition": "May be used to represent additional information that is not part of the basic definition of the resource. 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 can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"isModifier": false,
"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"
},
"isSummary": false
}, {
"path": "Claim.modifierExtension",
"requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.ht ml#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 and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"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"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them",
"isSummary": false
}, {
"path": "Claim.identifier",
"requirements": "Allows claims to be distinguished and referenced.",
"min": 0,
"definition": "A unique identifier assigned to this claim.",
"isModifier": false,
"short": "Business Identifier for claim",
"mapping": [ {
"map": "Request.identifier",
"identity": "workflow"
}, {
"map": "FiveWs.identifier",
"identity": "w5"
} ],
"type": [ {
"code": "Identifier"
} ],
"alias": [ "Claim Number" ],
"max": "*",
"id": "Claim.identifier",
"base": {
"max": "*",
"min": 0,
"path": "Claim.identifier"
},
"isSummary": false
}, {
"path": "Claim.status",
"requirements": "Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.",
"min": 1,
"definition": "The status of the resource instance.",
"isModifier": true,
"short": "active | cancelled | draft | entered-in-error",
"mapping": [ {
"map": "Request.status",
"identity": "workflow"
}, {
"map": "FiveWs.status",
"identity": "w5"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/fm-status|4.0.0",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ClaimStatus"
} ],
"description": "A code specifying the state of the resource instance."
},
"max": "1",
"id": "Claim.status",
"comment": "This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.",
"base": {
"max": "1",
"min": 1,
"path": "Claim.status"
},
"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
}, {
"path": "Claim.type",
"requirements": "Claim type determine the general sets of business rules applied for information requirements and adjudication.",
"min": 1,
"definition": "The category of claim, e.g. oral, pharmacy, vision, institutional, professional.",
"isModifier": false,
"short": "Category or discipline",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "extensible",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-type",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ClaimType"
} ],
"description": "The type or discipline-style of the claim."
},
"max": "1",
"id": "Claim.type",
"comment": "The majority of jurisdictions use: oral, pharmacy, vision, professional and institutional, or variants on those terms, as the general styles of claims. The valueset is extensible to accommodate other jurisdictional requirements.",
"base": {
"max": "1",
"min": 1,
"path": "Claim.type"
},
"isSummary": true
}, {
"path": "Claim.subType",
"requirements": "Some jurisdictions need a finer grained claim type for routing and adjudication.",
"min": 0,
"definition": "A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.",
"isModifier": false,
"short": "More granular claim type",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-subtype",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ClaimSubType"
} ],
"description": "A more granular claim typecode."
},
"max": "1",
"id": "Claim.subType",
"comment": "This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.",
"base": {
"max": "1",
"min": 0,
"path": "Claim.subType"
},
"isSummary": false
}, {
"path": "Claim.use",
"requirements": "This element is required to understand the nature of the request for adjudication.",
"min": 1,
"definition": "A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future.",
"isModifier": false,
"short": "claim | preauthorization | predetermination",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-use|4.0.0",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Use"
} ],
"description": "The purpose of the Claim: predetermination, preauthorization, claim."
},
"max": "1",
"id": "Claim.use",
"base": {
"max": "1",
"min": 1,
"path": "Claim.use"
},
"isSummary": true
}, {
"path": "Claim.patient",
"requirements": "The patient must be supplied to the insurer so that confirmation of coverage and service history may be considered as part of the authorization and/or adjudiction.",
"min": 1,
"definition": "The party to whom the professional services and/or products have been supplied or are being considered and for whom actual or forecast reimbursement is sought.",
"isModifier": false,
"short": "The recipient of the products and services",
"mapping": [ {
"map": "Request.subject",
"identity": "workflow"
}, {
"map": "FiveWs.subject[x]",
"identity": "w5"
}, {
"map": "FiveWs.subject",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Patient" ]
} ],
"max": "1",
"id": "Claim.patient",
"base": {
"max": "1",
"min": 1,
"path": "Claim.patient"
},
"isSummary": true
}, {
"path": "Claim.billablePeriod",
"requirements": "A number jurisdictions required the submission of the billing period when submitting claims for example for hospital stays or long-term care.",
"min": 0,
"definition": "The period for which charges are being submitted.",
"isModifier": false,
"short": "Relevant time frame for the claim",
"mapping": [ {
"map": "FiveWs.done[x]",
"identity": "w5"
} ],
"type": [ {
"code": "Period"
} ],
"max": "1",
"id": "Claim.billablePeriod",
"comment": "Typically this would be today or in the past for a claim, and today or in the future for preauthorizations and predeterminations. Typically line item dates of service should fall within the billing period if one is specified.",
"base": {
"max": "1",
"min": 0,
"path": "Claim.billablePeriod"
},
"isSummary": true
}, {
"path": "Claim.created",
"requirements": "Need to record a timestamp for use by both the recipient and the issuer.",
"min": 1,
"definition": "The date this resource was created.",
"isModifier": false,
"short": "Resource creation date",
"mapping": [ {
"map": "Request.authoredOn",
"identity": "workflow"
}, {
"map": "FiveWs.recorded",
"identity": "w5"
} ],
"type": [ {
"code": "dateTime"
} ],
"max": "1",
"id": "Claim.created",
"comment": "This field is independent of the date of creation of the resource as it may reflect the creation date of a source document prior to digitization. Typically for claims all services must be completed as of this date.",
"base": {
"max": "1",
"min": 1,
"path": "Claim.created"
},
"isSummary": true
}, {
"path": "Claim.enterer",
"requirements": "Some jurisdictions require the contact information for personnel completing claims.",
"min": 0,
"definition": "Individual who created the claim, predetermination or preauthorization.",
"isModifier": false,
"short": "Author of the claim",
"mapping": [ {
"map": "FiveWs.author",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole" ]
} ],
"max": "1",
"id": "Claim.enterer",
"base": {
"max": "1",
"min": 0,
"path": "Claim.enterer"
},
"isSummary": false
}, {
"path": "Claim.insurer",
"min": 0,
"definition": "The Insurer who is target of the request.",
"isModifier": false,
"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"
},
"isSummary": true
}, {
"path": "Claim.provider",
"min": 1,
"definition": "The provider which is responsible for the claim, predetermination or preauthorization.",
"isModifier": false,
"short": "Party responsible for the claim",
"mapping": [ {
"map": "Request.requester",
"identity": "workflow"
}, {
"map": "FiveWs.source",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"max": "1",
"id": "Claim.provider",
"comment": "Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below.",
"base": {
"max": "1",
"min": 1,
"path": "Claim.provider"
},
"isSummary": true
}, {
"path": "Claim.priority",
"requirements": "The provider may need to indicate their processing requirements so that the processor can indicate if they are unable to comply.",
"min": 1,
"definition": "The provider-required urgency of processing the request. Typical values include: stat, routine deferred.",
"isModifier": false,
"short": "Desired processing ugency",
"mapping": [ {
"map": "Request.priority",
"identity": "workflow"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/process-priority",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProcessPriority"
} ],
"description": "The timeliness with which processing is required: stat, normal, deferred."
},
"max": "1",
"id": "Claim.priority",
"comment": "If a claim processor is unable to complete the processing as per the priority then they should generate and error and not process the request.",
"base": {
"max": "1",
"min": 1,
"path": "Claim.priority"
},
"isSummary": true
}, {
"path": "Claim.fundsReserve",
"requirements": "In the case of a Pre-Determination/Pre-Authorization the provider may request that funds in the amount of the expected Benefit be reserved ('Patient' or 'Provider') to pay for the Benefits determined on the subsequent claim(s). 'None' explicitly indicates no funds reserving is requested.",
"min": 0,
"definition": "A code to indicate whether and for whom funds are to be reserved for future claims.",
"isModifier": false,
"short": "For whom to reserve funds",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/fundsreserve",
"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)."
},
"alias": [ "Fund pre-allocation" ],
"max": "1",
"id": "Claim.fundsReserve",
"comment": "This field is only used for preauthorizations.",
"base": {
"max": "1",
"min": 0,
"path": "Claim.fundsReserve"
},
"isSummary": false
}, {
"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() or (children().count() > id.count())"
} ],
"path": "Claim.related",
"requirements": "For workplace or other accidents it is common to relate separate claims arising from the same event.",
"min": 0,
"definition": "Other claims which are related to this claim such as prior submissions or claims for related services or for the same event.",
"isModifier": false,
"short": "Prior or corollary claims",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "RelatedClaim"
} ],
"max": "*",
"id": "Claim.related",
"comment": "For example, for the original treatment and follow-up exams.",
"base": {
"max": "*",
"min": 0,
"path": "Claim.related"
},
"isSummary": false
}, {
"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.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"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"
},
"isSummary": false
}, {
"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. 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 can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"isModifier": false,
"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"
},
"isSummary": false
}, {
"path": "Claim.related.modifierExtension",
"requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.ht ml#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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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 can 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"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"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"path": "Claim.related.claim",
"requirements": "For workplace or other accidents it is common to relate separate claims arising from the same event.",
"min": 0,
"definition": "Reference to a related claim.",
"isModifier": false,
"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",
"base": {
"max": "1",
"min": 0,
"path": "Claim.related.claim"
},
"isSummary": false
}, {
"path": "Claim.related.relationship",
"requirements": "Some insurers need a declaration of the type of relationship.",
"min": 0,
"definition": "A code to convey how the claims are related.",
"isModifier": false,
"short": "How the reference claim is related",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/related-claim-relationship",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "RelatedClaimRelationship"
} ],
"description": "Relationship of this claim to a related Claim."
},
"max": "1",
"id": "Claim.related.relationship",
"comment": "For example, prior claim or umbrella.",
"base": {
"max": "1",
"min": 0,
"path": "Claim.related.relationship"
},
"isSummary": false
}, {
"path": "Claim.related.reference",
"requirements": "In cases where an event-triggered claim is being submitted to an insurer which requires a reference number to be specified on all exchanges.",
"min": 0,
"definition": "An alternate organizational reference to the case or file to which this particular claim pertains.",
"isModifier": false,
"short": "File or case reference",
"type": [ {
"code": "Identifier"
} ],
"max": "1",
"id": "Claim.related.reference",
"comment": "For example, Property/Casualty insurer claim # or Workers Compensation case # .",
"base": {
"max": "1",
"min": 0,
"path": "Claim.related.reference"
},
"isSummary": false
}, {
"path": "Claim.prescription",
"requirements": "Required to authorize the dispensing of controlled substances and devices.",
"min": 0,
"definition": "Prescription to support the dispensing of pharmacy, device or vision products.",
"isModifier": false,
"short": "Prescription authorizing services and products",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/DeviceRequest", "http://hl7.org/fhir/StructureDefinition/MedicationRequest", "http://hl7.org/fhir/StructureDefinition/VisionPrescription" ]
} ],
"max": "1",
"id": "Claim.prescription",
"base": {
"max": "1",
"min": 0,
"path": "Claim.prescription"
},
"isSummary": false
}, {
"path": "Claim.originalPrescription",
"requirements": "Often required when a fulfiller varies what is fulfilled from that authorized on the original prescription.",
"min": 0,
"definition": "Original prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or products.",
"isModifier": false,
"short": "Original prescription if superseded by fulfiller",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/DeviceRequest", "http://hl7.org/fhir/StructureDefinition/MedicationRequest", "http://hl7.org/fhir/StructureDefinition/VisionPrescription" ]
} ],
"max": "1",
"id": "Claim.originalPrescription",
"comment": "For example, a physician may prescribe a medication which the pharmacy determines is contraindicated , or for which the patient has an intolerance, and therefore issues a new prescription for an alternate medication which has the same therapeutic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription'.",
"base": {
"max": "1",
"min": 0,
"path": "Claim.originalPrescription"
},
"isSummary": false
}, {
"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() or (children().count() > id.count())"
} ],
"path": "Claim.payee",
"requirements": "The provider needs to specify who they wish to be reimbursed and the claims processor needs express who they will reimburse.",
"min": 0,
"definition": "The party to be reimbursed for cost of the products and services according to the terms of the policy.",
"isModifier": false,
"short": "Recipient of benefits payable",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Payee"
} ],
"max": "1",
"id": "Claim.payee",
"comment": "Often providers agree to receive the benefits payable to reduce the near-term costs to the patient. The insurer may decline to pay the provider and choose to pay the subscriber instead.",
"base": {
"max": "1",
"min": 0,
"path": "Claim.payee"
},
"isSummary": false
}, {
"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.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"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"
},
"isSummary": false
}, {
"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. 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 can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"isModifier": false,
"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"
},
"isSummary": false
}, {
"path": "Claim.payee.modifierExtension",
"requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.ht ml#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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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 can 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"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"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"path": "Claim.payee.type",
"requirements": "Need to know who should receive payment with the most common situations being the Provider (assignment of benefits) or the Subscriber.",
"min": 1,
"definition": "Type of Party to be reimbursed: subscriber, provider, other.",
"isModifier": false,
"short": "Category of recipient",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/payeetype",
"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."
},
"max": "1",
"id": "Claim.payee.type",
"base": {
"max": "1",
"min": 1,
"path": "Claim.payee.type"
},
"isSummary": false
}, {
"path": "Claim.payee.party",
"requirements": "Need to provide demographics if the payee is not 'subscriber' nor 'provider'.",
"min": 0,
"definition": "Reference to the individual or organization to whom any payment will be made.",
"isModifier": false,
"short": "Recipient reference",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Organization", "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/RelatedPerson" ]
} ],
"max": "1",
"id": "Claim.payee.party",
"comment": "Not required if the payee is 'subscriber' or 'provider'.",
"base": {
"max": "1",
"min": 0,
"path": "Claim.payee.party"
},
"isSummary": false
}, {
"path": "Claim.referral",
"requirements": "Some insurers require proof of referral to pay for services or to pay specialist rates for services.",
"min": 0,
"definition": "A reference to a referral resource.",
"isModifier": false,
"short": "Treatment referral",
"mapping": [ {
"map": "FiveWs.cause",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/ServiceRequest" ]
} ],
"max": "1",
"id": "Claim.referral",
"comment": "The referral resource which lists the date, practitioner, reason and other supporting information.",
"base": {
"max": "1",
"min": 0,
"path": "Claim.referral"
},
"isSummary": false
}, {
"path": "Claim.facility",
"requirements": "Insurance adjudication can be dependant on where services were delivered.",
"min": 0,
"definition": "Facility where the services were provided.",
"isModifier": false,
"short": "Servicing facility",
"mapping": [ {
"map": "FiveWs.where[x]",
"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"
},
"isSummary": false
}, {
"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() or (children().count() > id.count())"
} ],
"path": "Claim.careTeam",
"requirements": "Common to identify the responsible and supporting practitioners.",
"min": 0,
"definition": "The members of the team who provided the products and services.",
"isModifier": false,
"short": "Members of the care team",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "CareTeam"
} ],
"max": "*",
"id": "Claim.careTeam",
"base": {
"max": "*",
"min": 0,
"path": "Claim.careTeam"
},
"isSummary": false
}, {
"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.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"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"
},
"isSummary": false
}, {
"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. 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 can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"isModifier": false,
"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"
},
"isSummary": false
}, {
"path": "Claim.careTeam.modifierExtension",
"requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.ht ml#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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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 can 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"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"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"path": "Claim.careTeam.sequence",
"requirements": "Necessary to maintain the order of the care team and provide a mechanism to link individuals to claim details.",
"min": 1,
"definition": "A number to uniquely identify care team entries.",
"isModifier": false,
"short": "Order of care team",
"type": [ {
"code": "positiveInt"
} ],
"max": "1",
"id": "Claim.careTeam.sequence",
"base": {
"max": "1",
"min": 1,
"path": "Claim.careTeam.sequence"
},
"isSummary": false
}, {
"path": "Claim.careTeam.provider",
"requirements": "Often a regulatory requirement to specify the responsible provider.",
"min": 1,
"definition": "Member of the team who provided the product or service.",
"isModifier": false,
"short": "Practitioner or organization",
"mapping": [ {
"map": "FiveWs.actor",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"max": "1",
"id": "Claim.careTeam.provider",
"base": {
"max": "1",
"min": 1,
"path": "Claim.careTeam.provider"
},
"isSummary": false
}, {
"path": "Claim.careTeam.responsible",
"requirements": "When multiple parties are present it is required to distinguish the lead or responsible individual.",
"min": 0,
"definition": "The party who is billing and/or responsible for the claimed products or services.",
"isModifier": false,
"short": "Indicator of the lead practitioner",
"type": [ {
"code": "boolean"
} ],
"max": "1",
"id": "Claim.careTeam.responsible",
"comment": "Responsible might not be required when there is only a single provider listed.",
"base": {
"max": "1",
"min": 0,
"path": "Claim.careTeam.responsible"
},
"isSummary": false
}, {
"path": "Claim.careTeam.role",
"requirements": "When multiple parties are present it is required to distinguish the roles performed by each member.",
"min": 0,
"definition": "The lead, assisting or supervising practitioner and their discipline if a multidisciplinary team.",
"isModifier": false,
"short": "Function within the team",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-careteamrole",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CareTeamRole"
} ],
"description": "The role codes for the care team members."
},
"max": "1",
"id": "Claim.careTeam.role",
"comment": "Role might not be required when there is only a single provider listed.",
"base": {
"max": "1",
"min": 0,
"path": "Claim.careTeam.role"
},
"isSummary": false
}, {
"path": "Claim.careTeam.qualification",
"requirements": "Need to specify which qualification a provider is delivering the product or service under.",
"min": 0,
"definition": "The qualification of the practitioner which is applicable for this service.",
"isModifier": false,
"short": "Practitioner credential or specialization",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/provider-qualification",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProviderQualification"
} ],
"description": "Provider professional qualifications."
},
"max": "1",
"id": "Claim.careTeam.qualification",
"base": {
"max": "1",
"min": 0,
"path": "Claim.careTeam.qualification"
},
"isSummary": false
}, {
"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() or (children().count() > id.count())"
} ],
"path": "Claim.supportingInfo",
"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.",
"isModifier": false,
"short": "Supporting information",
"mapping": [ {
"map": "Request.supportingInfo",
"identity": "workflow"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "SupportingInformation"
} ],
"alias": [ "Attachments Exception Codes Occurrence Codes Value codes" ],
"max": "*",
"id": "Claim.supportingInfo",
"comment": "Often there are multiple jurisdiction specific valuesets which are required.",
"base": {
"max": "*",
"min": 0,
"path": "Claim.supportingInfo"
},
"isSummary": false
}, {
"path": "Claim.supportingInfo.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.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "string"
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Claim.supportingInfo.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"path": "Claim.supportingInfo.extension",
"min": 0,
"definition": "May be used to represent additional information that is not part of the basic definition of the element. 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 can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Claim.supportingInfo.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"
},
"isSummary": false
}, {
"path": "Claim.supportingInfo.modifierExtension",
"requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.ht ml#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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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 can 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Claim.supportingInfo.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"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"path": "Claim.supportingInfo.sequence",
"requirements": "Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details.",
"min": 1,
"definition": "A number to uniquely identify supporting information entries.",
"isModifier": false,
"short": "Information instance identifier",
"type": [ {
"code": "positiveInt"
} ],
"max": "1",
"id": "Claim.supportingInfo.sequence",
"base": {
"max": "1",
"min": 1,
"path": "Claim.supportingInfo.sequence"
},
"isSummary": false
}, {
"path": "Claim.supportingInfo.category",
"requirements": "Required to group or associate information items with common characteristics. For example: admission information or prior treatments.",
"min": 1,
"definition": "The general class of the information supplied: information; exception; accident, employment; onset, etc.",
"isModifier": false,
"short": "Classification of the supplied information",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-informationcategory",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "InformationCategory"
} ],
"description": "The valuset used for additional information category codes."
},
"max": "1",
"id": "Claim.supportingInfo.category",
"comment": "This may contain a category for the local bill type codes.",
"base": {
"max": "1",
"min": 1,
"path": "Claim.supportingInfo.category"
},
"isSummary": false
}, {
"path": "Claim.supportingInfo.code",
"requirements": "Required to identify the kind of additional information.",
"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.",
"isModifier": false,
"short": "Type of information",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-exception",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "InformationCode"
} ],
"description": "The valuset used for additional information codes."
},
"max": "1",
"id": "Claim.supportingInfo.code",
"base": {
"max": "1",
"min": 0,
"path": "Claim.supportingInfo.code"
},
"isSummary": false
}, {
"path": "Claim.supportingInfo.timing[x]",
"min": 0,
"definition": "The date when or period to which this information refers.",
"isModifier": false,
"short": "When it occurred",
"type": [ {
"code": "date"
}, {
"code": "Period"
} ],
"max": "1",
"id": "Claim.supportingInfo.timing[x]",
"base": {
"max": "1",
"min": 0,
"path": "Claim.supportingInfo.timing[x]"
},
"isSummary": false
}, {
"path": "Claim.supportingInfo.value[x]",
"requirements": "To convey the data content to be provided when the information is more than a simple code or period.",
"min": 0,
"definition": "Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.",
"isModifier": false,
"short": "Data to be provided",
"type": [ {
"code": "boolean"
}, {
"code": "string"
}, {
"code": "Quantity"
}, {
"code": "Attachment"
}, {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "1",
"id": "Claim.supportingInfo.value[x]",
"comment": "Could be used to provide references to other resources, document. For example could contain a PDF in an Attachment of the Police Report for an Accident.",
"base": {
"max": "1",
"min": 0,
"path": "Claim.supportingInfo.value[x]"
},
"isSummary": false
}, {
"path": "Claim.supportingInfo.reason",
"requirements": "Needed when the supporting information has both a date and amount/value and requires explanation.",
"min": 0,
"definition": "Provides the reason in the situation where a reason code is required in addition to the content.",
"isModifier": false,
"short": "Explanation for the information",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/missing-tooth-reason",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "MissingReason"
} ],
"description": "Reason codes for the missing teeth."
},
"max": "1",
"id": "Claim.supportingInfo.reason",
"comment": "For example: the reason for the additional stay, or why a tooth is missing.",
"base": {
"max": "1",
"min": 0,
"path": "Claim.supportingInfo.reason"
},
"isSummary": false
}, {
"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() or (children().count() > id.count())"
} ],
"path": "Claim.diagnosis",
"requirements": "Required for the adjudication by provided context for the services and product listed.",
"min": 0,
"definition": "Information about diagnoses relevant to the claim items.",
"isModifier": false,
"short": "Pertinent diagnosis information",
"mapping": [ {
"map": "Request.reasonReference",
"identity": "workflow"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Diagnosis"
} ],
"max": "*",
"id": "Claim.diagnosis",
"base": {
"max": "*",
"min": 0,
"path": "Claim.diagnosis"
},
"isSummary": false
}, {
"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.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"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"
},
"isSummary": false
}, {
"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. 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 can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"isModifier": false,
"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"
},
"isSummary": false
}, {
"path": "Claim.diagnosis.modifierExtension",
"requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.ht ml#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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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 can 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"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"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"path": "Claim.diagnosis.sequence",
"requirements": "Necessary to maintain the order of the diagnosis items and provide a mechanism to link to claim details.",
"min": 1,
"definition": "A number to uniquely identify diagnosis entries.",
"isModifier": false,
"short": "Diagnosis instance identifier",
"type": [ {
"code": "positiveInt"
} ],
"max": "1",
"id": "Claim.diagnosis.sequence",
"comment": "Diagnosis are presented in list order to their expected importance: primary, secondary, etc.",
"base": {
"max": "1",
"min": 1,
"path": "Claim.diagnosis.sequence"
},
"isSummary": false
}, {
"path": "Claim.diagnosis.diagnosis[x]",
"requirements": "Provides health context for the evaluation of the products and/or services.",
"min": 1,
"definition": "The nature of illness or problem in a coded form or as a reference to an external defined Condition.",
"isModifier": false,
"short": "Nature of illness or problem",
"type": [ {
"code": "CodeableConcept"
}, {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Condition" ]
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/icd-10",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ICD10"
} ],
"description": "Example ICD10 Diagnostic codes."
},
"max": "1",
"id": "Claim.diagnosis.diagnosis[x]",
"base": {
"max": "1",
"min": 1,
"path": "Claim.diagnosis.diagnosis[x]"
},
"isSummary": false
}, {
"path": "Claim.diagnosis.type",
"requirements": "Often required to capture a particular diagnosis, for example: primary or discharge.",
"min": 0,
"definition": "When the condition was observed or the relative ranking.",
"isModifier": false,
"short": "Timing or nature of the diagnosis",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-diagnosistype",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "DiagnosisType"
} ],
"description": "The type of the diagnosis: admitting, principal, discharge."
},
"max": "*",
"id": "Claim.diagnosis.type",
"comment": "For example: admitting, primary, secondary, discharge.",
"base": {
"max": "*",
"min": 0,
"path": "Claim.diagnosis.type"
},
"isSummary": false
}, {
"path": "Claim.diagnosis.onAdmission",
"requirements": "Many systems need to understand for adjudication if the diagnosis was present a time of admission.",
"min": 0,
"definition": "Indication of whether the diagnosis was present on admission to a facility.",
"isModifier": false,
"short": "Present on admission",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-diagnosis-on-admission",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "DiagnosisOnAdmission"
} ],
"description": "Present on admission."
},
"max": "1",
"id": "Claim.diagnosis.onAdmission",
"base": {
"max": "1",
"min": 0,
"path": "Claim.diagnosis.onAdmission"
},
"isSummary": false
}, {
"path": "Claim.diagnosis.packageCode",
"requirements": "Required to relate the current diagnosis to a package billing code that is then referenced on the individual claim items which are specific to the health condition covered by the package code.",
"min": 0,
"definition": "A package billing code or bundle code used to group products and services to a particular health condition (such as heart attack) which is based on a predetermined grouping code system.",
"isModifier": false,
"short": "Package billing code",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "DiagnosisRelatedGroup"
} ],
"description": "The DRG codes associated with the diagnosis."
},
"max": "1",
"id": "Claim.diagnosis.packageCode",
"comment": "For example DRG (Diagnosis Related Group) or a bundled billing code. A patient may have a diagnosis of a Myocardial Infarction and a DRG for HeartAttack would be assigned. The Claim item (and possible subsequent claims) would refer to the DRG for those line items that were for services related to the heart attack event.",
"base": {
"max": "1",
"min": 0,
"path": "Claim.diagnosis.packageCode"
},
"isSummary": false
}, {
"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() or (children().count() > id.count())"
} ],
"path": "Claim.procedure",
"requirements": "The specific clinical invention are sometimes required to be provided to justify billing a greater than customary amount for a service.",
"min": 0,
"definition": "Procedures performed on the patient relevant to the billing items with the claim.",
"isModifier": false,
"short": "Clinical procedures performed",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Procedure"
} ],
"max": "*",
"id": "Claim.procedure",
"base": {
"max": "*",
"min": 0,
"path": "Claim.procedure"
},
"isSummary": false
}, {
"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.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"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"
},
"isSummary": false
}, {
"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. 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 can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"isModifier": false,
"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"
},
"isSummary": false
}, {
"path": "Claim.procedure.modifierExtension",
"requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.ht ml#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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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 can 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"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"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"path": "Claim.procedure.sequence",
"requirements": "Necessary to provide a mechanism to link to claim details.",
"min": 1,
"definition": "A number to uniquely identify procedure entries.",
"isModifier": false,
"short": "Procedure instance identifier",
"type": [ {
"code": "positiveInt"
} ],
"max": "1",
"id": "Claim.procedure.sequence",
"base": {
"max": "1",
"min": 1,
"path": "Claim.procedure.sequence"
},
"isSummary": false
}, {
"path": "Claim.procedure.type",
"requirements": "Often required to capture a particular diagnosis, for example: primary or discharge.",
"min": 0,
"definition": "When the condition was observed or the relative ranking.",
"isModifier": false,
"short": "Category of Procedure",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-procedure-type",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProcedureType"
} ],
"description": "Example procedure type codes."
},
"max": "*",
"id": "Claim.procedure.type",
"comment": "For example: primary, secondary.",
"base": {
"max": "*",
"min": 0,
"path": "Claim.procedure.type"
},
"isSummary": false
}, {
"path": "Claim.procedure.date",
"requirements": "Required for auditing purposes.",
"min": 0,
"definition": "Date and optionally time the procedure was performed.",
"isModifier": false,
"short": "When the procedure was performed",
"type": [ {
"code": "dateTime"
} ],
"max": "1",
"id": "Claim.procedure.date",
"base": {
"max": "1",
"min": 0,
"path": "Claim.procedure.date"
},
"isSummary": false
}, {
"path": "Claim.procedure.procedure[x]",
"requirements": "This identifies the actual clinical procedure.",
"min": 1,
"definition": "The code or reference to a Procedure resource which identifies the clinical intervention performed.",
"isModifier": false,
"short": "Specific clinical procedure",
"type": [ {
"code": "CodeableConcept"
}, {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Procedure" ]
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/icd-10-procedures",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ICD10_Procedures"
} ],
"description": "Example ICD10 Procedure codes."
},
"max": "1",
"id": "Claim.procedure.procedure[x]",
"base": {
"max": "1",
"min": 1,
"path": "Claim.procedure.procedure[x]"
},
"isSummary": false
}, {
"path": "Claim.procedure.udi",
"requirements": "The UDI code allows the insurer to obtain device level information on the product supplied.",
"min": 0,
"definition": "Unique Device Identifiers associated with this line item.",
"isModifier": false,
"short": "Unique device identifier",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Device" ]
} ],
"max": "*",
"id": "Claim.procedure.udi",
"base": {
"max": "*",
"min": 0,
"path": "Claim.procedure.udi"
},
"isSummary": false
}, {
"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() or (children().count() > id.count())"
} ],
"path": "Claim.insurance",
"requirements": "At least one insurer is required for a claim to be a claim.",
"min": 1,
"definition": "Financial instruments for reimbursement for the health care products and services specified on the claim.",
"isModifier": false,
"short": "Patient insurance information",
"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",
"comment": "All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. Coverages appearing before the focal Coverage in the list, and where 'Coverage.subrogation=false', should provide a reference to the ClaimResponse containing the adjudication results of the prior claim.",
"base": {
"max": "*",
"min": 1,
"path": "Claim.insurance"
},
"isSummary": true
}, {
"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.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"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"
},
"isSummary": false
}, {
"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. 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 can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"isModifier": false,
"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"
},
"isSummary": false
}, {
"path": "Claim.insurance.modifierExtension",
"requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.ht ml#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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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 can 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"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"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"path": "Claim.insurance.sequence",
"requirements": "To maintain order of the coverages.",
"min": 1,
"definition": "A number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order.",
"isModifier": false,
"short": "Insurance instance identifier",
"type": [ {
"code": "positiveInt"
} ],
"max": "1",
"id": "Claim.insurance.sequence",
"base": {
"max": "1",
"min": 1,
"path": "Claim.insurance.sequence"
},
"isSummary": true
}, {
"path": "Claim.insurance.focal",
"requirements": "To identify which coverage in the list is being used to adjudicate this claim.",
"min": 1,
"definition": "A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.",
"isModifier": false,
"short": "Coverage to be used for adjudication",
"type": [ {
"code": "boolean"
} ],
"max": "1",
"id": "Claim.insurance.focal",
"comment": "A patient may (will) have multiple insurance policies which provide reimbursement for healthcare services and products. For example a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for adjudicating this claim. Other claims would be created to request adjudication against the other listed policies.",
"base": {
"max": "1",
"min": 1,
"path": "Claim.insurance.focal"
},
"isSummary": true
}, {
"path": "Claim.insurance.identifier",
"requirements": "This will be the claim number should it be necessary to create this claim in the future. This is provided so that payors may forward claims to other payors in the Coordination of Benefit for adjudication rather than the provider being required to initiate each adjudication.",
"min": 0,
"definition": "The business identifier to be used when the claim is sent for adjudication against this insurance policy.",
"isModifier": false,
"short": "Pre-assigned Claim number",
"mapping": [ {
"map": "Request.identifier",
"identity": "workflow"
}, {
"map": "FiveWs.identifier",
"identity": "w5"
} ],
"type": [ {
"code": "Identifier"
} ],
"max": "1",
"id": "Claim.insurance.identifier",
"comment": "Only required in jurisdictions where insurers, rather than the provider, are required to send claims to insurers that appear after them in the list. This element is not required when 'subrogation=true'.",
"base": {
"max": "1",
"min": 0,
"path": "Claim.insurance.identifier"
},
"isSummary": false
}, {
"path": "Claim.insurance.coverage",
"requirements": "Required to allow the adjudicator to locate the correct policy and history within their information system.",
"min": 1,
"definition": "Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.",
"isModifier": false,
"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"
},
"isSummary": true
}, {
"path": "Claim.insurance.businessArrangement",
"requirements": "Providers may have multiple business arrangements with a given insurer and must supply the specific contract number for adjudication.",
"min": 0,
"definition": "A business agreement number established between the provider and the insurer for special business processing purposes.",
"isModifier": false,
"short": "Additional provider contract number",
"type": [ {
"code": "string"
} ],
"max": "1",
"id": "Claim.insurance.businessArrangement",
"base": {
"max": "1",
"min": 0,
"path": "Claim.insurance.businessArrangement"
},
"isSummary": false
}, {
"path": "Claim.insurance.preAuthRef",
"requirements": "Providers must quote previously issued authorization reference numbers in order to obtain adjudication as previously advised on the Preauthorization.",
"min": 0,
"definition": "Reference numbers previously provided by the insurer to the provider to be quoted on subsequent claims containing services or products related to the prior authorization.",
"isModifier": false,
"short": "Prior authorization reference number",
"type": [ {
"code": "string"
} ],
"max": "*",
"id": "Claim.insurance.preAuthRef",
"comment": "This value is an alphanumeric string that may be provided over the phone, via text, via paper, or within a ClaimResponse resource and is not a FHIR Identifier.",
"base": {
"max": "*",
"min": 0,
"path": "Claim.insurance.preAuthRef"
},
"isSummary": false
}, {
"path": "Claim.insurance.claimResponse",
"requirements": "An insurer need the adjudication results from prior insurers to determine the outstanding balance remaining by item for the items in the curent claim.",
"min": 0,
"definition": "The result of the adjudication of the line items for the Coverage specified in this insurance.",
"isModifier": false,
"short": "Adjudication results",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/ClaimResponse" ]
} ],
"max": "1",
"id": "Claim.insurance.claimResponse",
"comment": "Must not be specified when 'focal=true' for this insurance.",
"base": {
"max": "1",
"min": 0,
"path": "Claim.insurance.claimResponse"
},
"isSummary": false
}, {
"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() or (children().count() > id.count())"
} ],
"path": "Claim.accident",
"requirements": "When healthcare products and services are accident related, benefits may be payable under accident provisions of policies, such as automotive, etc before they are payable under normal health insurance.",
"min": 0,
"definition": "Details of an accident which resulted in injuries which required the products and services listed in the claim.",
"isModifier": false,
"short": "Details of the event",
"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"
},
"isSummary": false
}, {
"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.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"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"
},
"isSummary": false
}, {
"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. 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 can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"isModifier": false,
"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"
},
"isSummary": false
}, {
"path": "Claim.accident.modifierExtension",
"requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.ht ml#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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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 can 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"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"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"path": "Claim.accident.date",
"requirements": "Required for audit purposes and adjudication.",
"min": 1,
"definition": "Date of an accident event related to the products and services contained in the claim.",
"isModifier": false,
"short": "When the incident occurred",
"type": [ {
"code": "date"
} ],
"max": "1",
"id": "Claim.accident.date",
"comment": "The date of the accident has to precede the dates of the products and services but within a reasonable timeframe.",
"base": {
"max": "1",
"min": 1,
"path": "Claim.accident.date"
},
"isSummary": false
}, {
"path": "Claim.accident.type",
"requirements": "Coverage may be dependant on the type of accident.",
"min": 0,
"definition": "The type or context of the accident event for the purposes of selection of potential insurance coverages and determination of coordination between insurers.",
"isModifier": false,
"short": "The nature of the accident",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "extensible",
"valueSet": "http://terminology.hl7.org/ValueSet/v3-ActIncidentCode",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "AccidentType"
} ],
"description": "Type of accident: work place, auto, etc."
},
"max": "1",
"id": "Claim.accident.type",
"base": {
"max": "1",
"min": 0,
"path": "Claim.accident.type"
},
"isSummary": false
}, {
"path": "Claim.accident.location[x]",
"requirements": "Required for audit purposes and determination of applicable insurance liability.",
"min": 0,
"definition": "The physical location of the accident event.",
"isModifier": false,
"short": "Where the event occurred",
"type": [ {
"code": "Address"
}, {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Location" ]
} ],
"max": "1",
"id": "Claim.accident.location[x]",
"base": {
"max": "1",
"min": 0,
"path": "Claim.accident.location[x]"
},
"isSummary": false
}, {
"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() or (children().count() > id.count())"
} ],
"path": "Claim.item",
"requirements": "The items to be processed for adjudication.",
"min": 0,
"definition": "A claim line. Either a simple product or service or a 'group' of details which can each be a simple items or groups of sub-details.",
"isModifier": false,
"short": "Product or service provided",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Item"
} ],
"max": "*",
"id": "Claim.item",
"base": {
"max": "*",
"min": 0,
"path": "Claim.item"
},
"isSummary": false
}, {
"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.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"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"
},
"isSummary": false
}, {
"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. 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 can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"isModifier": false,
"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"
},
"isSummary": false
}, {
"path": "Claim.item.modifierExtension",
"requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.ht ml#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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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 can 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"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"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"path": "Claim.item.sequence",
"requirements": "Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse.",
"min": 1,
"definition": "A number to uniquely identify item entries.",
"isModifier": false,
"short": "Item instance identifier",
"type": [ {
"code": "positiveInt"
} ],
"max": "1",
"id": "Claim.item.sequence",
"base": {
"max": "1",
"min": 1,
"path": "Claim.item.sequence"
},
"isSummary": false
}, {
"path": "Claim.item.careTeamSequence",
"requirements": "Need to identify the individuals and their roles in the provision of the product or service.",
"min": 0,
"definition": "CareTeam members related to this service or product.",
"isModifier": false,
"short": "Applicable careTeam members",
"type": [ {
"code": "positiveInt"
} ],
"max": "*",
"id": "Claim.item.careTeamSequence",
"base": {
"max": "*",
"min": 0,
"path": "Claim.item.careTeamSequence"
},
"isSummary": false
}, {
"path": "Claim.item.diagnosisSequence",
"requirements": "Need to related the product or service to the associated diagnoses.",
"min": 0,
"definition": "Diagnosis applicable for this service or product.",
"isModifier": false,
"short": "Applicable diagnoses",
"type": [ {
"code": "positiveInt"
} ],
"max": "*",
"id": "Claim.item.diagnosisSequence",
"base": {
"max": "*",
"min": 0,
"path": "Claim.item.diagnosisSequence"
},
"isSummary": false
}, {
"path": "Claim.item.procedureSequence",
"requirements": "Need to provide any listed specific procedures to support the product or service being claimed.",
"min": 0,
"definition": "Procedures applicable for this service or product.",
"isModifier": false,
"short": "Applicable procedures",
"type": [ {
"code": "positiveInt"
} ],
"max": "*",
"id": "Claim.item.procedureSequence",
"base": {
"max": "*",
"min": 0,
"path": "Claim.item.procedureSequence"
},
"isSummary": false
}, {
"path": "Claim.item.informationSequence",
"requirements": "Need to reference the supporting information items that relate directly to this product or service.",
"min": 0,
"definition": "Exceptions, special conditions and supporting information applicable for this service or product.",
"isModifier": false,
"short": "Applicable exception and supporting information",
"type": [ {
"code": "positiveInt"
} ],
"max": "*",
"id": "Claim.item.informationSequence",
"base": {
"max": "*",
"min": 0,
"path": "Claim.item.informationSequence"
},
"isSummary": false
}, {
"path": "Claim.item.revenue",
"requirements": "Needed in the processing of institutional claims.",
"min": 0,
"definition": "The type of revenue or cost center providing the product and/or service.",
"isModifier": false,
"short": "Revenue or cost center code",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-revenue-center",
"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."
},
"max": "1",
"id": "Claim.item.revenue",
"base": {
"max": "1",
"min": 0,
"path": "Claim.item.revenue"
},
"isSummary": false
}, {
"path": "Claim.item.category",
"requirements": "Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.",
"min": 0,
"definition": "Code to identify the general type of benefits under which products and services are provided.",
"isModifier": false,
"short": "Benefit classification",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-benefitcategory",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitCategory"
} ],
"description": "Benefit categories such as: oral-basic, major, glasses."
},
"max": "1",
"id": "Claim.item.category",
"comment": "Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.",
"base": {
"max": "1",
"min": 0,
"path": "Claim.item.category"
},
"isSummary": false
}, {
"path": "Claim.item.productOrService",
"requirements": "Necessary to state what was provided or done.",
"min": 1,
"definition": "When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.",
"isModifier": false,
"short": "Billing, service, product, or drug code",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/service-uscls",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
} ],
"description": "Allowable service and product codes."
},
"alias": [ "Drug Code", "Bill Code", "Service Code" ],
"max": "1",
"id": "Claim.item.productOrService",
"comment": "If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. 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 e.g. 'glasses' or 'compound'.",
"base": {
"max": "1",
"min": 1,
"path": "Claim.item.productOrService"
},
"isSummary": false
}, {
"path": "Claim.item.modifier",
"requirements": "To support inclusion of the item for adjudication or to charge an elevated fee.",
"min": 0,
"definition": "Item typification or modifiers codes to convey additional context for the product or service.",
"isModifier": false,
"short": "Product or service billing modifiers",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-modifiers",
"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."
},
"max": "*",
"id": "Claim.item.modifier",
"comment": "For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours.",
"base": {
"max": "*",
"min": 0,
"path": "Claim.item.modifier"
},
"isSummary": false
}, {
"path": "Claim.item.programCode",
"requirements": "Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.",
"min": 0,
"definition": "Identifies the program under which this may be recovered.",
"isModifier": false,
"short": "Program the product or service is provided under",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-program-code",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProgramCode"
} ],
"description": "Program specific reason codes."
},
"max": "*",
"id": "Claim.item.programCode",
"comment": "For example: Neonatal program, child dental program or drug users recovery program.",
"base": {
"max": "*",
"min": 0,
"path": "Claim.item.programCode"
},
"isSummary": false
}, {
"path": "Claim.item.serviced[x]",
"requirements": "Needed to determine whether the service or product was provided during the term of the insurance coverage.",
"min": 0,
"definition": "The date or dates when the service or product was supplied, performed or completed.",
"isModifier": false,
"short": "Date or dates of service or product delivery",
"mapping": [ {
"map": "FiveWs.done[x]",
"identity": "w5"
} ],
"type": [ {
"code": "date"
}, {
"code": "Period"
} ],
"max": "1",
"id": "Claim.item.serviced[x]",
"base": {
"max": "1",
"min": 0,
"path": "Claim.item.serviced[x]"
},
"isSummary": false
}, {
"path": "Claim.item.location[x]",
"requirements": "The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount.",
"min": 0,
"definition": "Where the product or service was provided.",
"isModifier": false,
"short": "Place of service or where product was supplied",
"mapping": [ {
"map": "FiveWs.where[x]",
"identity": "w5"
} ],
"type": [ {
"code": "CodeableConcept"
}, {
"code": "Address"
}, {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Location" ]
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/service-place",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServicePlace"
} ],
"description": "Place of service: pharmacy, school, prison, etc."
},
"max": "1",
"id": "Claim.item.location[x]",
"base": {
"max": "1",
"min": 0,
"path": "Claim.item.location[x]"
},
"isSummary": false
}, {
"path": "Claim.item.quantity",
"requirements": "Required when the product or service code does not convey the quantity provided.",
"min": 0,
"definition": "The number of repetitions of a service or product.",
"isModifier": false,
"short": "Count of products or services",
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" ]
} ],
"max": "1",
"id": "Claim.item.quantity",
"base": {
"max": "1",
"min": 0,
"path": "Claim.item.quantity"
},
"isSummary": false
}, {
"path": "Claim.item.unitPrice",
"requirements": "The amount charged to the patient by the provider for a single unit.",
"min": 0,
"definition": "If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.",
"isModifier": false,
"short": "Fee, charge or cost per item",
"type": [ {
"code": "Money"
} ],
"max": "1",
"id": "Claim.item.unitPrice",
"base": {
"max": "1",
"min": 0,
"path": "Claim.item.unitPrice"
},
"isSummary": false
}, {
"path": "Claim.item.factor",
"requirements": "When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.",
"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.",
"isModifier": false,
"short": "Price scaling factor",
"type": [ {
"code": "decimal"
} ],
"max": "1",
"id": "Claim.item.factor",
"comment": "To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).",
"base": {
"max": "1",
"min": 0,
"path": "Claim.item.factor"
},
"isSummary": false
}, {
"path": "Claim.item.net",
"requirements": "Provides the total amount claimed for the group (if a grouper) or the line item.",
"min": 0,
"definition": "The quantity times the unit price for an additional service or product or charge.",
"isModifier": false,
"short": "Total item cost",
"type": [ {
"code": "Money"
} ],
"max": "1",
"id": "Claim.item.net",
"comment": "For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.",
"base": {
"max": "1",
"min": 0,
"path": "Claim.item.net"
},
"isSummary": false
}, {
"path": "Claim.item.udi",
"requirements": "The UDI code allows the insurer to obtain device level information on the product supplied.",
"min": 0,
"definition": "Unique Device Identifiers associated with this line item.",
"isModifier": false,
"short": "Unique device identifier",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Device" ]
} ],
"max": "*",
"id": "Claim.item.udi",
"base": {
"max": "*",
"min": 0,
"path": "Claim.item.udi"
},
"isSummary": false
}, {
"path": "Claim.item.bodySite",
"requirements": "Allows insurer to validate specific procedures.",
"min": 0,
"definition": "Physical service site on the patient (limb, tooth, etc.).",
"isModifier": false,
"short": "Anatomical location",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/tooth",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "OralSites"
} ],
"description": "The code for the teeth, quadrant, sextant and arch."
},
"max": "1",
"id": "Claim.item.bodySite",
"comment": "For example: Providing a tooth code, allows an insurer to identify a provider performing a filling on a tooth that was previously removed.",
"base": {
"max": "1",
"min": 0,
"path": "Claim.item.bodySite"
},
"isSummary": false
}, {
"path": "Claim.item.subSite",
"requirements": "Allows insurer to validate specific procedures.",
"min": 0,
"definition": "A region or surface of the bodySite, e.g. limb region or tooth surface(s).",
"isModifier": false,
"short": "Anatomical sub-location",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/surface",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Surface"
} ],
"description": "The code for the tooth surface and surface combinations."
},
"max": "*",
"id": "Claim.item.subSite",
"base": {
"max": "*",
"min": 0,
"path": "Claim.item.subSite"
},
"isSummary": false
}, {
"path": "Claim.item.encounter",
"requirements": "Used in some jurisdictions to link clinical events to claim items.",
"min": 0,
"definition": "The Encounters during which this Claim was created or to which the creation of this record is tightly associated.",
"isModifier": false,
"short": "Encounters related to this billed item",
"mapping": [ {
"map": "Request.context",
"identity": "workflow"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Encounter" ]
} ],
"max": "*",
"id": "Claim.item.encounter",
"comment": "This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter.",
"base": {
"max": "*",
"min": 0,
"path": "Claim.item.encounter"
},
"isSummary": false
}, {
"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() or (children().count() > id.count())"
} ],
"path": "Claim.item.detail",
"requirements": "The items to be processed for adjudication.",
"min": 0,
"definition": "A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.",
"isModifier": false,
"short": "Product or service provided",
"type": [ {
"code": "BackboneElement"
} ],
"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"
},
"isSummary": false
}, {
"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.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"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"
},
"isSummary": false
}, {
"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. 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 can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"isModifier": false,
"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"
},
"isSummary": false
}, {
"path": "Claim.item.detail.modifierExtension",
"requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.ht ml#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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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 can 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"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"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"path": "Claim.item.detail.sequence",
"requirements": "Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse.",
"min": 1,
"definition": "A number to uniquely identify item entries.",
"isModifier": false,
"short": "Item instance identifier",
"type": [ {
"code": "positiveInt"
} ],
"max": "1",
"id": "Claim.item.detail.sequence",
"base": {
"max": "1",
"min": 1,
"path": "Claim.item.detail.sequence"
},
"isSummary": false
}, {
"path": "Claim.item.detail.revenue",
"requirements": "Needed in the processing of institutional claims.",
"min": 0,
"definition": "The type of revenue or cost center providing the product and/or service.",
"isModifier": false,
"short": "Revenue or cost center code",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-revenue-center",
"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."
},
"max": "1",
"id": "Claim.item.detail.revenue",
"base": {
"max": "1",
"min": 0,
"path": "Claim.item.detail.revenue"
},
"isSummary": false
}, {
"path": "Claim.item.detail.category",
"requirements": "Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.",
"min": 0,
"definition": "Code to identify the general type of benefits under which products and services are provided.",
"isModifier": false,
"short": "Benefit classification",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-benefitcategory",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitCategory"
} ],
"description": "Benefit categories such as: oral-basic, major, glasses."
},
"max": "1",
"id": "Claim.item.detail.category",
"comment": "Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.",
"base": {
"max": "1",
"min": 0,
"path": "Claim.item.detail.category"
},
"isSummary": false
}, {
"path": "Claim.item.detail.productOrService",
"requirements": "Necessary to state what was provided or done.",
"min": 1,
"definition": "When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.",
"isModifier": false,
"short": "Billing, service, product, or drug code",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/service-uscls",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
} ],
"description": "Allowable service and product codes."
},
"alias": [ "Drug Code", "Bill Code", "Service Code" ],
"max": "1",
"id": "Claim.item.detail.productOrService",
"comment": "If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. 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 e.g. 'glasses' or 'compound'.",
"base": {
"max": "1",
"min": 1,
"path": "Claim.item.detail.productOrService"
},
"isSummary": false
}, {
"path": "Claim.item.detail.modifier",
"requirements": "To support inclusion of the item for adjudication or to charge an elevated fee.",
"min": 0,
"definition": "Item typification or modifiers codes to convey additional context for the product or service.",
"isModifier": false,
"short": "Service/Product billing modifiers",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-modifiers",
"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."
},
"max": "*",
"id": "Claim.item.detail.modifier",
"comment": "For example in 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.",
"base": {
"max": "*",
"min": 0,
"path": "Claim.item.detail.modifier"
},
"isSummary": false
}, {
"path": "Claim.item.detail.programCode",
"requirements": "Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.",
"min": 0,
"definition": "Identifies the program under which this may be recovered.",
"isModifier": false,
"short": "Program the product or service is provided under",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-program-code",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProgramCode"
} ],
"description": "Program specific reason codes."
},
"max": "*",
"id": "Claim.item.detail.programCode",
"comment": "For example: Neonatal program, child dental program or drug users recovery program.",
"base": {
"max": "*",
"min": 0,
"path": "Claim.item.detail.programCode"
},
"isSummary": false
}, {
"path": "Claim.item.detail.quantity",
"requirements": "Required when the product or service code does not convey the quantity provided.",
"min": 0,
"definition": "The number of repetitions of a service or product.",
"isModifier": false,
"short": "Count of products or services",
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" ]
} ],
"max": "1",
"id": "Claim.item.detail.quantity",
"base": {
"max": "1",
"min": 0,
"path": "Claim.item.detail.quantity"
},
"isSummary": false
}, {
"path": "Claim.item.detail.unitPrice",
"requirements": "The amount charged to the patient by the provider for a single unit.",
"min": 0,
"definition": "If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.",
"isModifier": false,
"short": "Fee, charge or cost per item",
"type": [ {
"code": "Money"
} ],
"max": "1",
"id": "Claim.item.detail.unitPrice",
"base": {
"max": "1",
"min": 0,
"path": "Claim.item.detail.unitPrice"
},
"isSummary": false
}, {
"path": "Claim.item.detail.factor",
"requirements": "When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.",
"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.",
"isModifier": false,
"short": "Price scaling factor",
"type": [ {
"code": "decimal"
} ],
"max": "1",
"id": "Claim.item.detail.factor",
"comment": "To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).",
"base": {
"max": "1",
"min": 0,
"path": "Claim.item.detail.factor"
},
"isSummary": false
}, {
"path": "Claim.item.detail.net",
"requirements": "Provides the total amount claimed for the group (if a grouper) or the line item.",
"min": 0,
"definition": "The quantity times the unit price for an additional service or product or charge.",
"isModifier": false,
"short": "Total item cost",
"type": [ {
"code": "Money"
} ],
"max": "1",
"id": "Claim.item.detail.net",
"comment": "For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.",
"base": {
"max": "1",
"min": 0,
"path": "Claim.item.detail.net"
},
"isSummary": false
}, {
"path": "Claim.item.detail.udi",
"requirements": "The UDI code allows the insurer to obtain device level information on the product supplied.",
"min": 0,
"definition": "Unique Device Identifiers associated with this line item.",
"isModifier": false,
"short": "Unique device identifier",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Device" ]
} ],
"max": "*",
"id": "Claim.item.detail.udi",
"base": {
"max": "*",
"min": 0,
"path": "Claim.item.detail.udi"
},
"isSummary": false
}, {
"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() or (children().count() > id.count())"
} ],
"path": "Claim.item.detail.subDetail",
"requirements": "The items to be processed for adjudication.",
"min": 0,
"definition": "A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.",
"isModifier": false,
"short": "Product or service provided",
"type": [ {
"code": "BackboneElement"
} ],
"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"
},
"isSummary": false
}, {
"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.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"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"
},
"isSummary": false
}, {
"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. 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 can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"isModifier": false,
"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"
},
"isSummary": false
}, {
"path": "Claim.item.detail.subDetail.modifierExtension",
"requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.ht ml#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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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 can 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"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"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"path": "Claim.item.detail.subDetail.sequence",
"requirements": "Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse.",
"min": 1,
"definition": "A number to uniquely identify item entries.",
"isModifier": false,
"short": "Item instance identifier",
"type": [ {
"code": "positiveInt"
} ],
"max": "1",
"id": "Claim.item.detail.subDetail.sequence",
"base": {
"max": "1",
"min": 1,
"path": "Claim.item.detail.subDetail.sequence"
},
"isSummary": false
}, {
"path": "Claim.item.detail.subDetail.revenue",
"requirements": "Needed in the processing of institutional claims.",
"min": 0,
"definition": "The type of revenue or cost center providing the product and/or service.",
"isModifier": false,
"short": "Revenue or cost center code",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-revenue-center",
"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."
},
"max": "1",
"id": "Claim.item.detail.subDetail.revenue",
"base": {
"max": "1",
"min": 0,
"path": "Claim.item.detail.subDetail.revenue"
},
"isSummary": false
}, {
"path": "Claim.item.detail.subDetail.category",
"requirements": "Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.",
"min": 0,
"definition": "Code to identify the general type of benefits under which products and services are provided.",
"isModifier": false,
"short": "Benefit classification",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-benefitcategory",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitCategory"
} ],
"description": "Benefit categories such as: oral-basic, major, glasses."
},
"max": "1",
"id": "Claim.item.detail.subDetail.category",
"comment": "Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.",
"base": {
"max": "1",
"min": 0,
"path": "Claim.item.detail.subDetail.category"
},
"isSummary": false
}, {
"path": "Claim.item.detail.subDetail.productOrService",
"requirements": "Necessary to state what was provided or done.",
"min": 1,
"definition": "When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.",
"isModifier": false,
"short": "Billing, service, product, or drug code",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/service-uscls",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
} ],
"description": "Allowable service and product codes."
},
"max": "1",
"id": "Claim.item.detail.subDetail.productOrService",
"comment": "If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. 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 e.g. 'glasses' or 'compound'.",
"base": {
"max": "1",
"min": 1,
"path": "Claim.item.detail.subDetail.productOrService"
},
"isSummary": false
}, {
"path": "Claim.item.detail.subDetail.modifier",
"requirements": "To support inclusion of the item for adjudication or to charge an elevated fee.",
"min": 0,
"definition": "Item typification or modifiers codes to convey additional context for the product or service.",
"isModifier": false,
"short": "Service/Product billing modifiers",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-modifiers",
"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."
},
"max": "*",
"id": "Claim.item.detail.subDetail.modifier",
"comment": "For example in 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.",
"base": {
"max": "*",
"min": 0,
"path": "Claim.item.detail.subDetail.modifier"
},
"isSummary": false
}, {
"path": "Claim.item.detail.subDetail.programCode",
"requirements": "Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.",
"min": 0,
"definition": "Identifies the program under which this may be recovered.",
"isModifier": false,
"short": "Program the product or service is provided under",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-program-code",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProgramCode"
} ],
"description": "Program specific reason codes."
},
"max": "*",
"id": "Claim.item.detail.subDetail.programCode",
"comment": "For example: Neonatal program, child dental program or drug users recovery program.",
"base": {
"max": "*",
"min": 0,
"path": "Claim.item.detail.subDetail.programCode"
},
"isSummary": false
}, {
"path": "Claim.item.detail.subDetail.quantity",
"requirements": "Required when the product or service code does not convey the quantity provided.",
"min": 0,
"definition": "The number of repetitions of a service or product.",
"isModifier": false,
"short": "Count of products or services",
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" ]
} ],
"max": "1",
"id": "Claim.item.detail.subDetail.quantity",
"base": {
"max": "1",
"min": 0,
"path": "Claim.item.detail.subDetail.quantity"
},
"isSummary": false
}, {
"path": "Claim.item.detail.subDetail.unitPrice",
"requirements": "The amount charged to the patient by the provider for a single unit.",
"min": 0,
"definition": "If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.",
"isModifier": false,
"short": "Fee, charge or cost per item",
"type": [ {
"code": "Money"
} ],
"max": "1",
"id": "Claim.item.detail.subDetail.unitPrice",
"base": {
"max": "1",
"min": 0,
"path": "Claim.item.detail.subDetail.unitPrice"
},
"isSummary": false
}, {
"path": "Claim.item.detail.subDetail.factor",
"requirements": "When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.",
"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.",
"isModifier": false,
"short": "Price scaling factor",
"type": [ {
"code": "decimal"
} ],
"max": "1",
"id": "Claim.item.detail.subDetail.factor",
"comment": "To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).",
"base": {
"max": "1",
"min": 0,
"path": "Claim.item.detail.subDetail.factor"
},
"isSummary": false
}, {
"path": "Claim.item.detail.subDetail.net",
"requirements": "Provides the total amount claimed for the group (if a grouper) or the line item.",
"min": 0,
"definition": "The quantity times the unit price for an additional service or product or charge.",
"isModifier": false,
"short": "Total item cost",
"type": [ {
"code": "Money"
} ],
"max": "1",
"id": "Claim.item.detail.subDetail.net",
"comment": "For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.",
"base": {
"max": "1",
"min": 0,
"path": "Claim.item.detail.subDetail.net"
},
"isSummary": false
}, {
"path": "Claim.item.detail.subDetail.udi",
"requirements": "The UDI code allows the insurer to obtain device level information on the product supplied.",
"min": 0,
"definition": "Unique Device Identifiers associated with this line item.",
"isModifier": false,
"short": "Unique device identifier",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Device" ]
} ],
"max": "*",
"id": "Claim.item.detail.subDetail.udi",
"base": {
"max": "*",
"min": 0,
"path": "Claim.item.detail.subDetail.udi"
},
"isSummary": false
}, {
"path": "Claim.total",
"requirements": "Used for control total purposes.",
"min": 0,
"definition": "The total value of the all the items in the claim.",
"isModifier": false,
"short": "Total claim cost",
"type": [ {
"code": "Money"
} ],
"max": "1",
"id": "Claim.total",
"base": {
"max": "1",
"min": 0,
"path": "Claim.total"
},
"isSummary": false
} ]
},
"status": "draft",
"id": "cfbc079c-ba9f-48e7-8006-ec0b1e9f6ea0",
"kind": "resource",
"url": "http://hl7.org/fhir/StructureDefinition/Claim",
"version": "4.0.0",
"differential": {
"element": [ {
"path": "Claim",
"min": 0,
"definition": "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.",
"short": "Claim, Pre-determination or Pre-authorization",
"mapping": [ {
"map": "Request",
"identity": "workflow"
} ],
"alias": [ "Adjudication Request", "Preauthorization Request", "Predetermination Request" ],
"max": "*",
"id": "Claim",
"comment": "The Claim resource fulfills three information request requirements: Claim - a request for adjudication for reimbursement for products and/or services provided; Preauthorization - a request to authorize the future provision of products and/or services including an anticipated adjudication; and, Predetermination - a request for a non-bind adjudication of possible future products and/or services."
}, {
"path": "Claim.identifier",
"requirements": "Allows claims to be distinguished and referenced.",
"min": 0,
"definition": "A unique identifier assigned to this claim.",
"short": "Business Identifier for claim",
"mapping": [ {
"map": "Request.identifier",
"identity": "workflow"
}, {
"map": "FiveWs.identifier",
"identity": "w5"
} ],
"type": [ {
"code": "Identifier"
} ],
"alias": [ "Claim Number" ],
"max": "*",
"id": "Claim.identifier"
}, {
"path": "Claim.status",
"requirements": "Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.",
"min": 1,
"definition": "The status of the resource instance.",
"isModifier": true,
"short": "active | cancelled | draft | entered-in-error",
"mapping": [ {
"map": "Request.status",
"identity": "workflow"
}, {
"map": "FiveWs.status",
"identity": "w5"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/fm-status|4.0.0",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ClaimStatus"
} ],
"description": "A code specifying the state of the resource instance."
},
"max": "1",
"id": "Claim.status",
"comment": "This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.",
"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
}, {
"path": "Claim.type",
"requirements": "Claim type determine the general sets of business rules applied for information requirements and adjudication.",
"min": 1,
"definition": "The category of claim, e.g. oral, pharmacy, vision, institutional, professional.",
"short": "Category or discipline",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "extensible",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-type",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ClaimType"
} ],
"description": "The type or discipline-style of the claim."
},
"max": "1",
"id": "Claim.type",
"comment": "The majority of jurisdictions use: oral, pharmacy, vision, professional and institutional, or variants on those terms, as the general styles of claims. The valueset is extensible to accommodate other jurisdictional requirements.",
"isSummary": true
}, {
"path": "Claim.subType",
"requirements": "Some jurisdictions need a finer grained claim type for routing and adjudication.",
"min": 0,
"definition": "A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.",
"short": "More granular claim type",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-subtype",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ClaimSubType"
} ],
"description": "A more granular claim typecode."
},
"max": "1",
"id": "Claim.subType",
"comment": "This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type."
}, {
"path": "Claim.use",
"requirements": "This element is required to understand the nature of the request for adjudication.",
"min": 1,
"definition": "A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future.",
"short": "claim | preauthorization | predetermination",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-use|4.0.0",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Use"
} ],
"description": "The purpose of the Claim: predetermination, preauthorization, claim."
},
"max": "1",
"id": "Claim.use",
"isSummary": true
}, {
"path": "Claim.patient",
"requirements": "The patient must be supplied to the insurer so that confirmation of coverage and service history may be considered as part of the authorization and/or adjudiction.",
"min": 1,
"definition": "The party to whom the professional services and/or products have been supplied or are being considered and for whom actual or forecast reimbursement is sought.",
"short": "The recipient of the products and services",
"mapping": [ {
"map": "Request.subject",
"identity": "workflow"
}, {
"map": "FiveWs.subject[x]",
"identity": "w5"
}, {
"map": "FiveWs.subject",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Patient" ]
} ],
"max": "1",
"id": "Claim.patient",
"isSummary": true
}, {
"path": "Claim.billablePeriod",
"requirements": "A number jurisdictions required the submission of the billing period when submitting claims for example for hospital stays or long-term care.",
"min": 0,
"definition": "The period for which charges are being submitted.",
"short": "Relevant time frame for the claim",
"mapping": [ {
"map": "FiveWs.done[x]",
"identity": "w5"
} ],
"type": [ {
"code": "Period"
} ],
"max": "1",
"id": "Claim.billablePeriod",
"comment": "Typically this would be today or in the past for a claim, and today or in the future for preauthorizations and predeterminations. Typically line item dates of service should fall within the billing period if one is specified.",
"isSummary": true
}, {
"path": "Claim.created",
"requirements": "Need to record a timestamp for use by both the recipient and the issuer.",
"min": 1,
"definition": "The date this resource was created.",
"short": "Resource creation date",
"mapping": [ {
"map": "Request.authoredOn",
"identity": "workflow"
}, {
"map": "FiveWs.recorded",
"identity": "w5"
} ],
"type": [ {
"code": "dateTime"
} ],
"max": "1",
"id": "Claim.created",
"comment": "This field is independent of the date of creation of the resource as it may reflect the creation date of a source document prior to digitization. Typically for claims all services must be completed as of this date.",
"isSummary": true
}, {
"path": "Claim.enterer",
"requirements": "Some jurisdictions require the contact information for personnel completing claims.",
"min": 0,
"definition": "Individual who created the claim, predetermination or preauthorization.",
"short": "Author of the claim",
"mapping": [ {
"map": "FiveWs.author",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole" ]
} ],
"max": "1",
"id": "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",
"isSummary": true
}, {
"path": "Claim.provider",
"min": 1,
"definition": "The provider which is responsible for the claim, predetermination or preauthorization.",
"short": "Party responsible for the claim",
"mapping": [ {
"map": "Request.requester",
"identity": "workflow"
}, {
"map": "FiveWs.source",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"max": "1",
"id": "Claim.provider",
"comment": "Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below.",
"isSummary": true
}, {
"path": "Claim.priority",
"requirements": "The provider may need to indicate their processing requirements so that the processor can indicate if they are unable to comply.",
"min": 1,
"definition": "The provider-required urgency of processing the request. Typical values include: stat, routine deferred.",
"short": "Desired processing ugency",
"mapping": [ {
"map": "Request.priority",
"identity": "workflow"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/process-priority",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProcessPriority"
} ],
"description": "The timeliness with which processing is required: stat, normal, deferred."
},
"max": "1",
"id": "Claim.priority",
"comment": "If a claim processor is unable to complete the processing as per the priority then they should generate and error and not process the request.",
"isSummary": true
}, {
"path": "Claim.fundsReserve",
"requirements": "In the case of a Pre-Determination/Pre-Authorization the provider may request that funds in the amount of the expected Benefit be reserved ('Patient' or 'Provider') to pay for the Benefits determined on the subsequent claim(s). 'None' explicitly indicates no funds reserving is requested.",
"min": 0,
"definition": "A code to indicate whether and for whom funds are to be reserved for future claims.",
"short": "For whom to reserve funds",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/fundsreserve",
"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)."
},
"alias": [ "Fund pre-allocation" ],
"max": "1",
"id": "Claim.fundsReserve",
"comment": "This field is only used for preauthorizations."
}, {
"path": "Claim.related",
"requirements": "For workplace or other accidents it is common to relate separate claims arising from the same event.",
"min": 0,
"definition": "Other claims which are related to this claim such as prior submissions or claims for related services or for the same event.",
"short": "Prior or corollary claims",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "RelatedClaim"
} ],
"max": "*",
"id": "Claim.related",
"comment": "For example, for the original treatment and follow-up exams."
}, {
"path": "Claim.related.claim",
"requirements": "For workplace or other accidents it is common to relate separate claims arising from the same event.",
"min": 0,
"definition": "Reference to a related claim.",
"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"
}, {
"path": "Claim.related.relationship",
"requirements": "Some insurers need a declaration of the type of relationship.",
"min": 0,
"definition": "A code to convey how the claims are related.",
"short": "How the reference claim is related",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/related-claim-relationship",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "RelatedClaimRelationship"
} ],
"description": "Relationship of this claim to a related Claim."
},
"max": "1",
"id": "Claim.related.relationship",
"comment": "For example, prior claim or umbrella."
}, {
"path": "Claim.related.reference",
"requirements": "In cases where an event-triggered claim is being submitted to an insurer which requires a reference number to be specified on all exchanges.",
"min": 0,
"definition": "An alternate organizational reference to the case or file to which this particular claim pertains.",
"short": "File or case reference",
"type": [ {
"code": "Identifier"
} ],
"max": "1",
"id": "Claim.related.reference",
"comment": "For example, Property/Casualty insurer claim # or Workers Compensation case # ."
}, {
"id": "Claim.prescription",
"max": "1",
"min": 0,
"path": "Claim.prescription",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/DeviceRequest", "http://hl7.org/fhir/StructureDefinition/MedicationRequest", "http://hl7.org/fhir/StructureDefinition/VisionPrescription" ]
} ],
"short": "Prescription authorizing services and products",
"definition": "Prescription to support the dispensing of pharmacy, device or vision products.",
"requirements": "Required to authorize the dispensing of controlled substances and devices."
}, {
"path": "Claim.originalPrescription",
"requirements": "Often required when a fulfiller varies what is fulfilled from that authorized on the original prescription.",
"min": 0,
"definition": "Original prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or products.",
"short": "Original prescription if superseded by fulfiller",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/DeviceRequest", "http://hl7.org/fhir/StructureDefinition/MedicationRequest", "http://hl7.org/fhir/StructureDefinition/VisionPrescription" ]
} ],
"max": "1",
"id": "Claim.originalPrescription",
"comment": "For example, a physician may prescribe a medication which the pharmacy determines is contraindicated , or for which the patient has an intolerance, and therefore issues a new prescription for an alternate medication which has the same therapeutic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription'."
}, {
"path": "Claim.payee",
"requirements": "The provider needs to specify who they wish to be reimbursed and the claims processor needs express who they will reimburse.",
"min": 0,
"definition": "The party to be reimbursed for cost of the products and services according to the terms of the policy.",
"short": "Recipient of benefits payable",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Payee"
} ],
"max": "1",
"id": "Claim.payee",
"comment": "Often providers agree to receive the benefits payable to reduce the near-term costs to the patient. The insurer may decline to pay the provider and choose to pay the subscriber instead."
}, {
"path": "Claim.payee.type",
"requirements": "Need to know who should receive payment with the most common situations being the Provider (assignment of benefits) or the Subscriber.",
"min": 1,
"definition": "Type of Party to be reimbursed: subscriber, provider, other.",
"short": "Category of recipient",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/payeetype",
"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."
},
"max": "1",
"id": "Claim.payee.type"
}, {
"path": "Claim.payee.party",
"requirements": "Need to provide demographics if the payee is not 'subscriber' nor 'provider'.",
"min": 0,
"definition": "Reference to the individual or organization to whom any payment will be made.",
"short": "Recipient reference",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Organization", "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/RelatedPerson" ]
} ],
"max": "1",
"id": "Claim.payee.party",
"comment": "Not required if the payee is 'subscriber' or 'provider'."
}, {
"path": "Claim.referral",
"requirements": "Some insurers require proof of referral to pay for services or to pay specialist rates for services.",
"min": 0,
"definition": "A reference to a referral resource.",
"short": "Treatment referral",
"mapping": [ {
"map": "FiveWs.cause",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/ServiceRequest" ]
} ],
"max": "1",
"id": "Claim.referral",
"comment": "The referral resource which lists the date, practitioner, reason and other supporting information."
}, {
"path": "Claim.facility",
"requirements": "Insurance adjudication can be dependant on where services were delivered.",
"min": 0,
"definition": "Facility where the services were provided.",
"short": "Servicing facility",
"mapping": [ {
"map": "FiveWs.where[x]",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Location" ]
} ],
"max": "1",
"id": "Claim.facility"
}, {
"path": "Claim.careTeam",
"requirements": "Common to identify the responsible and supporting practitioners.",
"min": 0,
"definition": "The members of the team who provided the products and services.",
"short": "Members of the care team",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "CareTeam"
} ],
"max": "*",
"id": "Claim.careTeam"
}, {
"id": "Claim.careTeam.sequence",
"max": "1",
"min": 1,
"path": "Claim.careTeam.sequence",
"type": [ {
"code": "positiveInt"
} ],
"short": "Order of care team",
"definition": "A number to uniquely identify care team entries.",
"requirements": "Necessary to maintain the order of the care team and provide a mechanism to link individuals to claim details."
}, {
"path": "Claim.careTeam.provider",
"requirements": "Often a regulatory requirement to specify the responsible provider.",
"min": 1,
"definition": "Member of the team who provided the product or service.",
"short": "Practitioner or organization",
"mapping": [ {
"map": "FiveWs.actor",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"max": "1",
"id": "Claim.careTeam.provider"
}, {
"path": "Claim.careTeam.responsible",
"requirements": "When multiple parties are present it is required to distinguish the lead or responsible individual.",
"min": 0,
"definition": "The party who is billing and/or responsible for the claimed products or services.",
"short": "Indicator of the lead practitioner",
"type": [ {
"code": "boolean"
} ],
"max": "1",
"id": "Claim.careTeam.responsible",
"comment": "Responsible might not be required when there is only a single provider listed."
}, {
"path": "Claim.careTeam.role",
"requirements": "When multiple parties are present it is required to distinguish the roles performed by each member.",
"min": 0,
"definition": "The lead, assisting or supervising practitioner and their discipline if a multidisciplinary team.",
"short": "Function within the team",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-careteamrole",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CareTeamRole"
} ],
"description": "The role codes for the care team members."
},
"max": "1",
"id": "Claim.careTeam.role",
"comment": "Role might not be required when there is only a single provider listed."
}, {
"path": "Claim.careTeam.qualification",
"requirements": "Need to specify which qualification a provider is delivering the product or service under.",
"min": 0,
"definition": "The qualification of the practitioner which is applicable for this service.",
"short": "Practitioner credential or specialization",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/provider-qualification",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProviderQualification"
} ],
"description": "Provider professional qualifications."
},
"max": "1",
"id": "Claim.careTeam.qualification"
}, {
"path": "Claim.supportingInfo",
"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.",
"short": "Supporting information",
"mapping": [ {
"map": "Request.supportingInfo",
"identity": "workflow"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "SupportingInformation"
} ],
"alias": [ "Attachments Exception Codes Occurrence Codes Value codes" ],
"max": "*",
"id": "Claim.supportingInfo",
"comment": "Often there are multiple jurisdiction specific valuesets which are required."
}, {
"id": "Claim.supportingInfo.sequence",
"max": "1",
"min": 1,
"path": "Claim.supportingInfo.sequence",
"type": [ {
"code": "positiveInt"
} ],
"short": "Information instance identifier",
"definition": "A number to uniquely identify supporting information entries.",
"requirements": "Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details."
}, {
"path": "Claim.supportingInfo.category",
"requirements": "Required to group or associate information items with common characteristics. For example: admission information or prior treatments.",
"min": 1,
"definition": "The general class of the information supplied: information; exception; accident, employment; onset, etc.",
"short": "Classification of the supplied information",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-informationcategory",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "InformationCategory"
} ],
"description": "The valuset used for additional information category codes."
},
"max": "1",
"id": "Claim.supportingInfo.category",
"comment": "This may contain a category for the local bill type codes."
}, {
"path": "Claim.supportingInfo.code",
"requirements": "Required to identify the kind of additional information.",
"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.",
"short": "Type of information",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-exception",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "InformationCode"
} ],
"description": "The valuset used for additional information codes."
},
"max": "1",
"id": "Claim.supportingInfo.code"
}, {
"id": "Claim.supportingInfo.timing[x]",
"max": "1",
"min": 0,
"path": "Claim.supportingInfo.timing[x]",
"type": [ {
"code": "date"
}, {
"code": "Period"
} ],
"short": "When it occurred",
"definition": "The date when or period to which this information refers."
}, {
"path": "Claim.supportingInfo.value[x]",
"requirements": "To convey the data content to be provided when the information is more than a simple code or period.",
"min": 0,
"definition": "Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.",
"short": "Data to be provided",
"type": [ {
"code": "boolean"
}, {
"code": "string"
}, {
"code": "Quantity"
}, {
"code": "Attachment"
}, {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"max": "1",
"id": "Claim.supportingInfo.value[x]",
"comment": "Could be used to provide references to other resources, document. For example could contain a PDF in an Attachment of the Police Report for an Accident."
}, {
"path": "Claim.supportingInfo.reason",
"requirements": "Needed when the supporting information has both a date and amount/value and requires explanation.",
"min": 0,
"definition": "Provides the reason in the situation where a reason code is required in addition to the content.",
"short": "Explanation for the information",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/missing-tooth-reason",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "MissingReason"
} ],
"description": "Reason codes for the missing teeth."
},
"max": "1",
"id": "Claim.supportingInfo.reason",
"comment": "For example: the reason for the additional stay, or why a tooth is missing."
}, {
"path": "Claim.diagnosis",
"requirements": "Required for the adjudication by provided context for the services and product listed.",
"min": 0,
"definition": "Information about diagnoses relevant to the claim items.",
"short": "Pertinent diagnosis information",
"mapping": [ {
"map": "Request.reasonReference",
"identity": "workflow"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Diagnosis"
} ],
"max": "*",
"id": "Claim.diagnosis"
}, {
"path": "Claim.diagnosis.sequence",
"requirements": "Necessary to maintain the order of the diagnosis items and provide a mechanism to link to claim details.",
"min": 1,
"definition": "A number to uniquely identify diagnosis entries.",
"short": "Diagnosis instance identifier",
"type": [ {
"code": "positiveInt"
} ],
"max": "1",
"id": "Claim.diagnosis.sequence",
"comment": "Diagnosis are presented in list order to their expected importance: primary, secondary, etc."
}, {
"path": "Claim.diagnosis.diagnosis[x]",
"requirements": "Provides health context for the evaluation of the products and/or services.",
"min": 1,
"definition": "The nature of illness or problem in a coded form or as a reference to an external defined Condition.",
"short": "Nature of illness or problem",
"type": [ {
"code": "CodeableConcept"
}, {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Condition" ]
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/icd-10",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ICD10"
} ],
"description": "Example ICD10 Diagnostic codes."
},
"max": "1",
"id": "Claim.diagnosis.diagnosis[x]"
}, {
"path": "Claim.diagnosis.type",
"requirements": "Often required to capture a particular diagnosis, for example: primary or discharge.",
"min": 0,
"definition": "When the condition was observed or the relative ranking.",
"short": "Timing or nature of the diagnosis",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-diagnosistype",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "DiagnosisType"
} ],
"description": "The type of the diagnosis: admitting, principal, discharge."
},
"max": "*",
"id": "Claim.diagnosis.type",
"comment": "For example: admitting, primary, secondary, discharge."
}, {
"path": "Claim.diagnosis.onAdmission",
"requirements": "Many systems need to understand for adjudication if the diagnosis was present a time of admission.",
"min": 0,
"definition": "Indication of whether the diagnosis was present on admission to a facility.",
"short": "Present on admission",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-diagnosis-on-admission",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "DiagnosisOnAdmission"
} ],
"description": "Present on admission."
},
"max": "1",
"id": "Claim.diagnosis.onAdmission"
}, {
"path": "Claim.diagnosis.packageCode",
"requirements": "Required to relate the current diagnosis to a package billing code that is then referenced on the individual claim items which are specific to the health condition covered by the package code.",
"min": 0,
"definition": "A package billing code or bundle code used to group products and services to a particular health condition (such as heart attack) which is based on a predetermined grouping code system.",
"short": "Package billing code",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "DiagnosisRelatedGroup"
} ],
"description": "The DRG codes associated with the diagnosis."
},
"max": "1",
"id": "Claim.diagnosis.packageCode",
"comment": "For example DRG (Diagnosis Related Group) or a bundled billing code. A patient may have a diagnosis of a Myocardial Infarction and a DRG for HeartAttack would be assigned. The Claim item (and possible subsequent claims) would refer to the DRG for those line items that were for services related to the heart attack event."
}, {
"path": "Claim.procedure",
"requirements": "The specific clinical invention are sometimes required to be provided to justify billing a greater than customary amount for a service.",
"min": 0,
"definition": "Procedures performed on the patient relevant to the billing items with the claim.",
"short": "Clinical procedures performed",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Procedure"
} ],
"max": "*",
"id": "Claim.procedure"
}, {
"id": "Claim.procedure.sequence",
"max": "1",
"min": 1,
"path": "Claim.procedure.sequence",
"type": [ {
"code": "positiveInt"
} ],
"short": "Procedure instance identifier",
"definition": "A number to uniquely identify procedure entries.",
"requirements": "Necessary to provide a mechanism to link to claim details."
}, {
"path": "Claim.procedure.type",
"requirements": "Often required to capture a particular diagnosis, for example: primary or discharge.",
"min": 0,
"definition": "When the condition was observed or the relative ranking.",
"short": "Category of Procedure",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-procedure-type",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProcedureType"
} ],
"description": "Example procedure type codes."
},
"max": "*",
"id": "Claim.procedure.type",
"comment": "For example: primary, secondary."
}, {
"id": "Claim.procedure.date",
"max": "1",
"min": 0,
"path": "Claim.procedure.date",
"type": [ {
"code": "dateTime"
} ],
"short": "When the procedure was performed",
"definition": "Date and optionally time the procedure was performed.",
"requirements": "Required for auditing purposes."
}, {
"path": "Claim.procedure.procedure[x]",
"requirements": "This identifies the actual clinical procedure.",
"min": 1,
"definition": "The code or reference to a Procedure resource which identifies the clinical intervention performed.",
"short": "Specific clinical procedure",
"type": [ {
"code": "CodeableConcept"
}, {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Procedure" ]
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/icd-10-procedures",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ICD10_Procedures"
} ],
"description": "Example ICD10 Procedure codes."
},
"max": "1",
"id": "Claim.procedure.procedure[x]"
}, {
"id": "Claim.procedure.udi",
"max": "*",
"min": 0,
"path": "Claim.procedure.udi",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Device" ]
} ],
"short": "Unique device identifier",
"definition": "Unique Device Identifiers associated with this line item.",
"requirements": "The UDI code allows the insurer to obtain device level information on the product supplied."
}, {
"path": "Claim.insurance",
"requirements": "At least one insurer is required for a claim to be a claim.",
"min": 1,
"definition": "Financial instruments for reimbursement for the health care products and services specified on the claim.",
"short": "Patient insurance information",
"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",
"comment": "All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. Coverages appearing before the focal Coverage in the list, and where 'Coverage.subrogation=false', should provide a reference to the ClaimResponse containing the adjudication results of the prior claim.",
"isSummary": true
}, {
"path": "Claim.insurance.sequence",
"requirements": "To maintain order of the coverages.",
"min": 1,
"definition": "A number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order.",
"short": "Insurance instance identifier",
"type": [ {
"code": "positiveInt"
} ],
"max": "1",
"id": "Claim.insurance.sequence",
"isSummary": true
}, {
"path": "Claim.insurance.focal",
"requirements": "To identify which coverage in the list is being used to adjudicate this claim.",
"min": 1,
"definition": "A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.",
"short": "Coverage to be used for adjudication",
"type": [ {
"code": "boolean"
} ],
"max": "1",
"id": "Claim.insurance.focal",
"comment": "A patient may (will) have multiple insurance policies which provide reimbursement for healthcare services and products. For example a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for adjudicating this claim. Other claims would be created to request adjudication against the other listed policies.",
"isSummary": true
}, {
"path": "Claim.insurance.identifier",
"requirements": "This will be the claim number should it be necessary to create this claim in the future. This is provided so that payors may forward claims to other payors in the Coordination of Benefit for adjudication rather than the provider being required to initiate each adjudication.",
"min": 0,
"definition": "The business identifier to be used when the claim is sent for adjudication against this insurance policy.",
"short": "Pre-assigned Claim number",
"mapping": [ {
"map": "Request.identifier",
"identity": "workflow"
}, {
"map": "FiveWs.identifier",
"identity": "w5"
} ],
"type": [ {
"code": "Identifier"
} ],
"max": "1",
"id": "Claim.insurance.identifier",
"comment": "Only required in jurisdictions where insurers, rather than the provider, are required to send claims to insurers that appear after them in the list. This element is not required when 'subrogation=true'."
}, {
"path": "Claim.insurance.coverage",
"requirements": "Required to allow the adjudicator to locate the correct policy and history within their information system.",
"min": 1,
"definition": "Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.",
"short": "Insurance information",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Coverage" ]
} ],
"max": "1",
"id": "Claim.insurance.coverage",
"isSummary": true
}, {
"id": "Claim.insurance.businessArrangement",
"max": "1",
"min": 0,
"path": "Claim.insurance.businessArrangement",
"type": [ {
"code": "string"
} ],
"short": "Additional provider contract number",
"definition": "A business agreement number established between the provider and the insurer for special business processing purposes.",
"requirements": "Providers may have multiple business arrangements with a given insurer and must supply the specific contract number for adjudication."
}, {
"path": "Claim.insurance.preAuthRef",
"requirements": "Providers must quote previously issued authorization reference numbers in order to obtain adjudication as previously advised on the Preauthorization.",
"min": 0,
"definition": "Reference numbers previously provided by the insurer to the provider to be quoted on subsequent claims containing services or products related to the prior authorization.",
"short": "Prior authorization reference number",
"type": [ {
"code": "string"
} ],
"max": "*",
"id": "Claim.insurance.preAuthRef",
"comment": "This value is an alphanumeric string that may be provided over the phone, via text, via paper, or within a ClaimResponse resource and is not a FHIR Identifier."
}, {
"path": "Claim.insurance.claimResponse",
"requirements": "An insurer need the adjudication results from prior insurers to determine the outstanding balance remaining by item for the items in the curent claim.",
"min": 0,
"definition": "The result of the adjudication of the line items for the Coverage specified in this insurance.",
"short": "Adjudication results",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/ClaimResponse" ]
} ],
"max": "1",
"id": "Claim.insurance.claimResponse",
"comment": "Must not be specified when 'focal=true' for this insurance."
}, {
"path": "Claim.accident",
"requirements": "When healthcare products and services are accident related, benefits may be payable under accident provisions of policies, such as automotive, etc before they are payable under normal health insurance.",
"min": 0,
"definition": "Details of an accident which resulted in injuries which required the products and services listed in the claim.",
"short": "Details of the event",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Accident"
} ],
"max": "1",
"id": "Claim.accident"
}, {
"path": "Claim.accident.date",
"requirements": "Required for audit purposes and adjudication.",
"min": 1,
"definition": "Date of an accident event related to the products and services contained in the claim.",
"short": "When the incident occurred",
"type": [ {
"code": "date"
} ],
"max": "1",
"id": "Claim.accident.date",
"comment": "The date of the accident has to precede the dates of the products and services but within a reasonable timeframe."
}, {
"path": "Claim.accident.type",
"requirements": "Coverage may be dependant on the type of accident.",
"min": 0,
"definition": "The type or context of the accident event for the purposes of selection of potential insurance coverages and determination of coordination between insurers.",
"short": "The nature of the accident",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "extensible",
"valueSet": "http://terminology.hl7.org/ValueSet/v3-ActIncidentCode",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "AccidentType"
} ],
"description": "Type of accident: work place, auto, etc."
},
"max": "1",
"id": "Claim.accident.type"
}, {
"id": "Claim.accident.location[x]",
"max": "1",
"min": 0,
"path": "Claim.accident.location[x]",
"type": [ {
"code": "Address"
}, {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Location" ]
} ],
"short": "Where the event occurred",
"definition": "The physical location of the accident event.",
"requirements": "Required for audit purposes and determination of applicable insurance liability."
}, {
"path": "Claim.item",
"requirements": "The items to be processed for adjudication.",
"min": 0,
"definition": "A claim line. Either a simple product or service or a 'group' of details which can each be a simple items or groups of sub-details.",
"short": "Product or service provided",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Item"
} ],
"max": "*",
"id": "Claim.item"
}, {
"id": "Claim.item.sequence",
"max": "1",
"min": 1,
"path": "Claim.item.sequence",
"type": [ {
"code": "positiveInt"
} ],
"short": "Item instance identifier",
"definition": "A number to uniquely identify item entries.",
"requirements": "Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse."
}, {
"id": "Claim.item.careTeamSequence",
"max": "*",
"min": 0,
"path": "Claim.item.careTeamSequence",
"type": [ {
"code": "positiveInt"
} ],
"short": "Applicable careTeam members",
"definition": "CareTeam members related to this service or product.",
"requirements": "Need to identify the individuals and their roles in the provision of the product or service."
}, {
"id": "Claim.item.diagnosisSequence",
"max": "*",
"min": 0,
"path": "Claim.item.diagnosisSequence",
"type": [ {
"code": "positiveInt"
} ],
"short": "Applicable diagnoses",
"definition": "Diagnosis applicable for this service or product.",
"requirements": "Need to related the product or service to the associated diagnoses."
}, {
"id": "Claim.item.procedureSequence",
"max": "*",
"min": 0,
"path": "Claim.item.procedureSequence",
"type": [ {
"code": "positiveInt"
} ],
"short": "Applicable procedures",
"definition": "Procedures applicable for this service or product.",
"requirements": "Need to provide any listed specific procedures to support the product or service being claimed."
}, {
"id": "Claim.item.informationSequence",
"max": "*",
"min": 0,
"path": "Claim.item.informationSequence",
"type": [ {
"code": "positiveInt"
} ],
"short": "Applicable exception and supporting information",
"definition": "Exceptions, special conditions and supporting information applicable for this service or product.",
"requirements": "Need to reference the supporting information items that relate directly to this product or service."
}, {
"path": "Claim.item.revenue",
"requirements": "Needed in the processing of institutional claims.",
"min": 0,
"definition": "The type of revenue or cost center providing the product and/or service.",
"short": "Revenue or cost center code",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-revenue-center",
"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."
},
"max": "1",
"id": "Claim.item.revenue"
}, {
"path": "Claim.item.category",
"requirements": "Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.",
"min": 0,
"definition": "Code to identify the general type of benefits under which products and services are provided.",
"short": "Benefit classification",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-benefitcategory",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitCategory"
} ],
"description": "Benefit categories such as: oral-basic, major, glasses."
},
"max": "1",
"id": "Claim.item.category",
"comment": "Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage."
}, {
"path": "Claim.item.productOrService",
"requirements": "Necessary to state what was provided or done.",
"min": 1,
"definition": "When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.",
"short": "Billing, service, product, or drug code",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/service-uscls",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
} ],
"description": "Allowable service and product codes."
},
"alias": [ "Drug Code", "Bill Code", "Service Code" ],
"max": "1",
"id": "Claim.item.productOrService",
"comment": "If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. 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 e.g. 'glasses' or 'compound'."
}, {
"path": "Claim.item.modifier",
"requirements": "To support inclusion of the item for adjudication or to charge an elevated fee.",
"min": 0,
"definition": "Item typification or modifiers codes to convey additional context for the product or service.",
"short": "Product or service billing modifiers",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-modifiers",
"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."
},
"max": "*",
"id": "Claim.item.modifier",
"comment": "For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours."
}, {
"path": "Claim.item.programCode",
"requirements": "Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.",
"min": 0,
"definition": "Identifies the program under which this may be recovered.",
"short": "Program the product or service is provided under",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-program-code",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProgramCode"
} ],
"description": "Program specific reason codes."
},
"max": "*",
"id": "Claim.item.programCode",
"comment": "For example: Neonatal program, child dental program or drug users recovery program."
}, {
"path": "Claim.item.serviced[x]",
"requirements": "Needed to determine whether the service or product was provided during the term of the insurance coverage.",
"min": 0,
"definition": "The date or dates when the service or product was supplied, performed or completed.",
"short": "Date or dates of service or product delivery",
"mapping": [ {
"map": "FiveWs.done[x]",
"identity": "w5"
} ],
"type": [ {
"code": "date"
}, {
"code": "Period"
} ],
"max": "1",
"id": "Claim.item.serviced[x]"
}, {
"path": "Claim.item.location[x]",
"requirements": "The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount.",
"min": 0,
"definition": "Where the product or service was provided.",
"short": "Place of service or where product was supplied",
"mapping": [ {
"map": "FiveWs.where[x]",
"identity": "w5"
} ],
"type": [ {
"code": "CodeableConcept"
}, {
"code": "Address"
}, {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Location" ]
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/service-place",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServicePlace"
} ],
"description": "Place of service: pharmacy, school, prison, etc."
},
"max": "1",
"id": "Claim.item.location[x]"
}, {
"id": "Claim.item.quantity",
"max": "1",
"min": 0,
"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.",
"requirements": "Required when the product or service code does not convey the quantity provided."
}, {
"id": "Claim.item.unitPrice",
"max": "1",
"min": 0,
"path": "Claim.item.unitPrice",
"type": [ {
"code": "Money"
} ],
"short": "Fee, charge or cost per item",
"definition": "If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.",
"requirements": "The amount charged to the patient by the provider for a single unit."
}, {
"path": "Claim.item.factor",
"requirements": "When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.",
"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",
"comment": "To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10)."
}, {
"path": "Claim.item.net",
"requirements": "Provides the total amount claimed for the group (if a grouper) or the line item.",
"min": 0,
"definition": "The quantity times the unit price for an additional service or product or charge.",
"short": "Total item cost",
"type": [ {
"code": "Money"
} ],
"max": "1",
"id": "Claim.item.net",
"comment": "For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied."
}, {
"id": "Claim.item.udi",
"max": "*",
"min": 0,
"path": "Claim.item.udi",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Device" ]
} ],
"short": "Unique device identifier",
"definition": "Unique Device Identifiers associated with this line item.",
"requirements": "The UDI code allows the insurer to obtain device level information on the product supplied."
}, {
"path": "Claim.item.bodySite",
"requirements": "Allows insurer to validate specific procedures.",
"min": 0,
"definition": "Physical service site on the patient (limb, tooth, etc.).",
"short": "Anatomical location",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/tooth",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "OralSites"
} ],
"description": "The code for the teeth, quadrant, sextant and arch."
},
"max": "1",
"id": "Claim.item.bodySite",
"comment": "For example: Providing a tooth code, allows an insurer to identify a provider performing a filling on a tooth that was previously removed."
}, {
"path": "Claim.item.subSite",
"requirements": "Allows insurer to validate specific procedures.",
"min": 0,
"definition": "A region or surface of the bodySite, e.g. limb region or tooth surface(s).",
"short": "Anatomical sub-location",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/surface",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Surface"
} ],
"description": "The code for the tooth surface and surface combinations."
},
"max": "*",
"id": "Claim.item.subSite"
}, {
"path": "Claim.item.encounter",
"requirements": "Used in some jurisdictions to link clinical events to claim items.",
"min": 0,
"definition": "The Encounters during which this Claim was created or to which the creation of this record is tightly associated.",
"short": "Encounters related to this billed item",
"mapping": [ {
"map": "Request.context",
"identity": "workflow"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Encounter" ]
} ],
"max": "*",
"id": "Claim.item.encounter",
"comment": "This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter."
}, {
"path": "Claim.item.detail",
"requirements": "The items to be processed for adjudication.",
"min": 0,
"definition": "A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.",
"short": "Product or service provided",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Detail"
} ],
"max": "*",
"id": "Claim.item.detail"
}, {
"id": "Claim.item.detail.sequence",
"max": "1",
"min": 1,
"path": "Claim.item.detail.sequence",
"type": [ {
"code": "positiveInt"
} ],
"short": "Item instance identifier",
"definition": "A number to uniquely identify item entries.",
"requirements": "Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse."
}, {
"path": "Claim.item.detail.revenue",
"requirements": "Needed in the processing of institutional claims.",
"min": 0,
"definition": "The type of revenue or cost center providing the product and/or service.",
"short": "Revenue or cost center code",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-revenue-center",
"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."
},
"max": "1",
"id": "Claim.item.detail.revenue"
}, {
"path": "Claim.item.detail.category",
"requirements": "Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.",
"min": 0,
"definition": "Code to identify the general type of benefits under which products and services are provided.",
"short": "Benefit classification",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-benefitcategory",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitCategory"
} ],
"description": "Benefit categories such as: oral-basic, major, glasses."
},
"max": "1",
"id": "Claim.item.detail.category",
"comment": "Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage."
}, {
"path": "Claim.item.detail.productOrService",
"requirements": "Necessary to state what was provided or done.",
"min": 1,
"definition": "When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.",
"short": "Billing, service, product, or drug code",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/service-uscls",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
} ],
"description": "Allowable service and product codes."
},
"alias": [ "Drug Code", "Bill Code", "Service Code" ],
"max": "1",
"id": "Claim.item.detail.productOrService",
"comment": "If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. 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 e.g. 'glasses' or 'compound'."
}, {
"path": "Claim.item.detail.modifier",
"requirements": "To support inclusion of the item for adjudication or to charge an elevated fee.",
"min": 0,
"definition": "Item typification or modifiers codes to convey additional context for the product or service.",
"short": "Service/Product billing modifiers",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-modifiers",
"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."
},
"max": "*",
"id": "Claim.item.detail.modifier",
"comment": "For example in 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."
}, {
"path": "Claim.item.detail.programCode",
"requirements": "Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.",
"min": 0,
"definition": "Identifies the program under which this may be recovered.",
"short": "Program the product or service is provided under",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-program-code",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProgramCode"
} ],
"description": "Program specific reason codes."
},
"max": "*",
"id": "Claim.item.detail.programCode",
"comment": "For example: Neonatal program, child dental program or drug users recovery program."
}, {
"id": "Claim.item.detail.quantity",
"max": "1",
"min": 0,
"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.",
"requirements": "Required when the product or service code does not convey the quantity provided."
}, {
"id": "Claim.item.detail.unitPrice",
"max": "1",
"min": 0,
"path": "Claim.item.detail.unitPrice",
"type": [ {
"code": "Money"
} ],
"short": "Fee, charge or cost per item",
"definition": "If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.",
"requirements": "The amount charged to the patient by the provider for a single unit."
}, {
"path": "Claim.item.detail.factor",
"requirements": "When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.",
"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",
"comment": "To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10)."
}, {
"path": "Claim.item.detail.net",
"requirements": "Provides the total amount claimed for the group (if a grouper) or the line item.",
"min": 0,
"definition": "The quantity times the unit price for an additional service or product or charge.",
"short": "Total item cost",
"type": [ {
"code": "Money"
} ],
"max": "1",
"id": "Claim.item.detail.net",
"comment": "For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied."
}, {
"id": "Claim.item.detail.udi",
"max": "*",
"min": 0,
"path": "Claim.item.detail.udi",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Device" ]
} ],
"short": "Unique device identifier",
"definition": "Unique Device Identifiers associated with this line item.",
"requirements": "The UDI code allows the insurer to obtain device level information on the product supplied."
}, {
"path": "Claim.item.detail.subDetail",
"requirements": "The items to be processed for adjudication.",
"min": 0,
"definition": "A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.",
"short": "Product or service provided",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "SubDetail"
} ],
"max": "*",
"id": "Claim.item.detail.subDetail"
}, {
"id": "Claim.item.detail.subDetail.sequence",
"max": "1",
"min": 1,
"path": "Claim.item.detail.subDetail.sequence",
"type": [ {
"code": "positiveInt"
} ],
"short": "Item instance identifier",
"definition": "A number to uniquely identify item entries.",
"requirements": "Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse."
}, {
"path": "Claim.item.detail.subDetail.revenue",
"requirements": "Needed in the processing of institutional claims.",
"min": 0,
"definition": "The type of revenue or cost center providing the product and/or service.",
"short": "Revenue or cost center code",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-revenue-center",
"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."
},
"max": "1",
"id": "Claim.item.detail.subDetail.revenue"
}, {
"path": "Claim.item.detail.subDetail.category",
"requirements": "Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.",
"min": 0,
"definition": "Code to identify the general type of benefits under which products and services are provided.",
"short": "Benefit classification",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-benefitcategory",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitCategory"
} ],
"description": "Benefit categories such as: oral-basic, major, glasses."
},
"max": "1",
"id": "Claim.item.detail.subDetail.category",
"comment": "Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage."
}, {
"path": "Claim.item.detail.subDetail.productOrService",
"requirements": "Necessary to state what was provided or done.",
"min": 1,
"definition": "When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.",
"short": "Billing, service, product, or drug code",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/service-uscls",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
} ],
"description": "Allowable service and product codes."
},
"max": "1",
"id": "Claim.item.detail.subDetail.productOrService",
"comment": "If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. 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 e.g. 'glasses' or 'compound'."
}, {
"path": "Claim.item.detail.subDetail.modifier",
"requirements": "To support inclusion of the item for adjudication or to charge an elevated fee.",
"min": 0,
"definition": "Item typification or modifiers codes to convey additional context for the product or service.",
"short": "Service/Product billing modifiers",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-modifiers",
"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."
},
"max": "*",
"id": "Claim.item.detail.subDetail.modifier",
"comment": "For example in 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."
}, {
"path": "Claim.item.detail.subDetail.programCode",
"requirements": "Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.",
"min": 0,
"definition": "Identifies the program under which this may be recovered.",
"short": "Program the product or service is provided under",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-program-code",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProgramCode"
} ],
"description": "Program specific reason codes."
},
"max": "*",
"id": "Claim.item.detail.subDetail.programCode",
"comment": "For example: Neonatal program, child dental program or drug users recovery program."
}, {
"id": "Claim.item.detail.subDetail.quantity",
"max": "1",
"min": 0,
"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.",
"requirements": "Required when the product or service code does not convey the quantity provided."
}, {
"id": "Claim.item.detail.subDetail.unitPrice",
"max": "1",
"min": 0,
"path": "Claim.item.detail.subDetail.unitPrice",
"type": [ {
"code": "Money"
} ],
"short": "Fee, charge or cost per item",
"definition": "If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.",
"requirements": "The amount charged to the patient by the provider for a single unit."
}, {
"path": "Claim.item.detail.subDetail.factor",
"requirements": "When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.",
"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",
"comment": "To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10)."
}, {
"path": "Claim.item.detail.subDetail.net",
"requirements": "Provides the total amount claimed for the group (if a grouper) or the line item.",
"min": 0,
"definition": "The quantity times the unit price for an additional service or product or charge.",
"short": "Total item cost",
"type": [ {
"code": "Money"
} ],
"max": "1",
"id": "Claim.item.detail.subDetail.net",
"comment": "For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied."
}, {
"id": "Claim.item.detail.subDetail.udi",
"max": "*",
"min": 0,
"path": "Claim.item.detail.subDetail.udi",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Device" ]
} ],
"short": "Unique device identifier",
"definition": "Unique Device Identifiers associated with this line item.",
"requirements": "The UDI code allows the insurer to obtain device level information on the product supplied."
}, {
"id": "Claim.total",
"max": "1",
"min": 0,
"path": "Claim.total",
"type": [ {
"code": "Money"
} ],
"short": "Total claim cost",
"definition": "The total value of the all the items in the claim.",
"requirements": "Used for control total purposes."
} ]
},
"contact": [ {
"telecom": [ {
"value": "http://hl7.org/fhir",
"system": "url"
} ]
}, {
"telecom": [ {
"value": "http://www.hl7.org/Special/committees/fm/index.cfm",
"system": "url"
} ]
} ],
"baseDefinition": "http://hl7.org/fhir/StructureDefinition/DomainResource"
}