A provider issued list of professional services and products which have been provided, or are to be provided, to a patient which is provided sent to an insurer for payment recovery. reimbursement.

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.

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.

The business A unique identifier assigned to this claim.

Allows claims to be distinguished and referenced.

Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners.

Allows partners to uniquely identify components for tracking.

The status of the resource instance.

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'.

This element is labeled as a modifier because the status contains the code entered-in-error codes that marks mark the claim resource as not currently valid.

Used to indicate why the status has changed.

This is used to implement conformance on other elements.

Implementation guides may consider adding invariants such that if status = cancelled, statusReason SHALL be supplied.

The category of claim, eg, e.g. oral, pharmacy, vision, insitutional, institutional, professional.

Claim type determine the general sets of business rules applied for information requirements and adjudication.

Affects which fields The code system provides oral, pharmacy, vision, professional and value sets are used. institutional claim types. Those supported depends on the requirements of the jurisdiction. The valueset is extensible to accommodate other types of claims as required by the jurisdiction.

A finer grained suite of claim subtype type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service. In the US the BillType.

Some jurisdictions need a finer grained claim type for routing and adjudication.

This may contain the local bill type codes such as codes, for example the US UB-04 bill type code. code or the CMS bill type.

Complete (Bill or Claim), Proposed (Pre-Authorization), Exploratory (Pre-determination). A code to indicate whether the nature of the request is: Claim - A request to an Insurer to adjudicate the supplied charges for health care goods and services under the identified policy and to pay the determined Benefit amount, if any; Preauthorization - A request to an Insurer to adjudicate the supplied proposed future charges for health care goods and services under the identified policy and to approve the services and provide the expected benefit amounts and potentially to reserve funds to pay the benefits when Claims for the indicated services are later submitted; or, Pre-determination - A request to an Insurer to adjudicate the supplied 'what if' charges for health care goods and services under the identified policy and report back what the Benefit payable would be had the services actually been provided.

This element is required to understand the nature of the request for adjudication.

Patient Resource. The party/group to whom the professional services and/or products have been supplied or are being considered and for whom actual or forecast reimbursement is sought.

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.

The billable period for which charges are being submitted.

A number jurisdictions required the submission of the billing period when submitting claims for example for hospital stays or long-term care.

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.

The date when the enclosed suite of services were performed or completed. this resource was created.

Need to record a timestamp for use by both the recipient and the issuer.

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.

Person Individual who created the invoice/claim/pre-determination claim, predetermination or pre-authorization. preauthorization.

Some jurisdictions require the contact information for personnel completing claims.

The Insurer who is target of the request.

The provider which is responsible for the bill, claim pre-determination, pre-authorization. claim, predetermination or preauthorization.

Typically this field would be 1..1 where this party is accountable for the data content within the claim but is not necessarily the facility, provider group or practitioner who provided the products and services listed within this claim resource. This field is the Billing Provider, for example, a facility, provider group, lab or practitioner.

The organization which is responsible for provider-required urgency of processing the bill, claim pre-determination, pre-authorization. request. Typical values include: stat, normal, deferred.

The provider may need to indicate their processing requirements so that the processor can indicate if they are unable to comply.

If a claim processor is unable to complete the processing as per the priority then they should generate an error and not process the request.

Immediate (STAT), best effort (NORMAL), deferred (DEFER). A code to indicate whether and for whom funds are to be reserved for future claims.

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.

This field is only used for preauthorizations.

Other claims which are related to this claim such as prior claim versions submissions or claims for related services. services or for the same event.

For workplace or other accidents it is common to relate separate claims arising from the same event.

For example, for the original treatment and follow-up exams.

Other claims which are related Reference to this claim such as prior claim versions or for a related services. claim.

Do we need a relationship code? For workplace or other accidents it is common to relate separate claims arising from the same event.

For example prior or umbrella. A code to convey how the claims are related.

Some insurers need a declaration of the type of relationship.

For example, prior claim or umbrella.

An alternate organizational reference to the case or file to which this particular claim pertains - eg Property/Casualy insurer claim # pertains.

In cases where an event-triggered claim is being submitted to an insurer which requires a reference number to be specified on all exchanges.

For example, Property/Casualty insurer claim # or Workers Compensation case # .

Prescription is the document/authorization given to support the dispensing of Pharmacy claim author for them to provide products and services for which consideration (reimbursement) is sought. Could be a RX for medications, an 'order' for oxygen or Vision products. wheelchair or physiotherapy treatments.

For type=Pharmacy Required to authorize the dispensing of controlled substances and Vision only. devices.

Original prescription which has been superceded superseded by this prescription to support the dispensing of pharmacy services, medications or products.

Often required when a fulfiller varies what is fulfilled from that authorized on the original prescription.

For example, a physician may prescribe a medication which the pharmacy determines is contraindicated, or for which the patient has an intolerance, and therefor therefore issues a new precription prescription for an alternate medication which has the same theraputic therapeutic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription'.

as above. The party to be reimbursed for cost of the products and services according to the terms of the policy.

The party billing provider needs to specify who they wish to be reimbursed for and the services. claims processor needs express who they will reimburse.

Often billing 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.

Type of Party to be reimbursed: Subscriber, subscriber, provider, other.

Need to know who should receive payment with the most common situations being the billing Provider (assignment of benefits) or the Subscriber.

Reference to the individual or organization | patient | practitioner | relatedperson. to whom any payment will be made.

Need to provide demographics if the payee is not 'subscriber' nor 'provider'.

Not required if the payee is 'subscriber' or 'provider'.

Party The referral information received by the claim author, it is not to be reimbursed: Subscriber, provider, other. used when the author generates a referral for a patient. A copy of that referral may be provided as supporting information. Some insurers require proof of referral to pay for services or to pay specialist rates for services.

Some insurers require proof of referral to pay for services or to pay specialist rates for services.

The referral resource which lists the date, practitioner, reason and other supporting information.

Healthcare encounters related to this claim.

Used in some jurisdictions to link clinical events to claim items.

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.

Facility where the services were provided.

Insurance adjudication can be dependant on where services were delivered.

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.

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.

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.

Information code for an event with a corresponding date or period.

A coded event such as when a service is expected or a card printed.

A date or period in the past or future indicating when the event occurred or is expectd to occur.

The members of the team who provided the overall service as well as their role and whether responsible products and qualifications. services.

Role Common to identify the responsible and Responsible may not be required when there is only a single provider listed. supporting practitioners.

Sequence of the careTeam which serves A number to order and provide a link. uniquely identify care team entries.

Required Necessary to maintain the order of the careTeam. care team and provide a mechanism to link individuals to claim details.

Member of the team who provided the overall product or service.

The party who is billing and responsible for the claimed good or service rendered Often a regulatory requirement to specify the patient. responsible provider.

The lead, assisting or supervising practitioner and their discipline if a multidisiplinary multidisciplinary team.

When multiple parties are present it is required to distinguish the roles performed by each member.

Role might not be required when there is only a single provider listed.

The qualification specialization of the practitioner or provider which is applicable for this service.

Need to specify which specialization a practitioner or provider acting under when delivering the product or service.

Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. Often there are mutiple jurisdiction specific valuesets which are required.

Typically these information codes are required to support the services rendered or the adjudication of the services rendered.

Often there are multiple jurisdiction specific valuesets which are required.

Sequence of the information element which serves A number to provide a link. uniquely identify supporting information entries.

To Necessary to maintain the order of the supporting information items and provide a reference link. mechanism to link to claim details.

The general class of the information supplied: information; exception; accident, employment; onset, etc.

Required to group or associate information items with common characteristics. For example: admission information or prior treatments.

This may contain a category for the local bill type codes such as the US UB-04 bill type code. codes.

A finer classification within the more general category.

Required to provide more detailed categorization, for example lab-test grouping: blood, tissue etc.

System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought which may influence the adjudication. sought.

This may contain the local bill type codes such as Required to identify the US UB-04 bill type code. kind of additional information.

The date when or period to which this information refers.

Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.

To convey the data content to be provided when the information is more than a simple code or period.

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.

For example, provides Provides the reason for: in the additional stay, or missing tooth or any other situation where a reason code is required in addition to the content.

Needed when the supporting information has both a date and amount/value and requires explanation.

For example: the reason for the additional stay, or why a tooth is missing.

List of patient Information about diagnoses relevant to the claim items.

Required for which care is sought. the adjudication by provided context for the services and product listed.

Sequence of diagnosis which serves A number to provide a link. uniquely identify diagnosis entries.

Required Necessary to allow line maintain the order of the diagnosis items and provide a mechanism to reference the diagnoses. link to claim details.

Diagnosis are presented in list order to their expected importance: primary, secondary, etc.

The diagnosis. nature of illness or problem in a coded form or as a reference to an external defined Condition.

Required to adjudicate services rendered to condition presented. Provides health context for the evaluation of the products and/or services.

The type of When the Diagnosis, for example: admitting, primary, secondary, discharge. condition was observed or the relative ranking.

May be Often required to adjudicate services rendered. capture a particular diagnosis, for example: primary or discharge.

Diagnosis are presented in list order to their expected importance: For example: admitting, primary, secondary, etc. discharge.

The package billing code, for example DRG, based on Indication of whether the assigned grouping code system. diagnosis was present on admission to a facility.

May be required to adjudicate services rendered Many systems need to understand for adjudication if the mandated grouping system. diagnosis was present a time of admission.

Ordered list of patient procedures Procedures performed on the patient relevant to support the adjudication. billing items with the claim.

The specific clinical invention are sometimes required to be provided to justify billing a greater than customary amount for a service.

Sequence of procedures which serves A number to order and provide a link. uniquely identify procedure entries.

Required Necessary to maintain order of provide a mechanism to link to claim details.

When the procudures. condition was observed or the relative ranking.

Often required to capture a particular diagnosis, for example: primary or discharge.

For example: primary, secondary.

Date and optionally time the procedure was performed . performed.

Required to adjudicate services rendered. for auditing purposes.

The procedure code. code or reference to a Procedure resource which identifies the clinical intervention performed.

This identifies the actual clinical procedure.

Required Unique Device Identifiers associated with this line item.

The UDI code allows the insurer to adjudicate services rendered. obtain device level information on the product supplied.

Financial instrument by which payment information instruments for reimbursement for the health care. care products and services specified on the claim.

At least one insurer is required for a claim to be a claim.

Health care programs All insurance coverages for the patient which may be applicable for reimbursement, of the products and insurers services listed in the claim, are significant payors typically provided in the claim to allow insurers to confirm the ordering of health service costs. 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.

Sequence of coverage which serves A number to uniquely identify insurance entries and provide a link and sequence of coverages to convey coordination of benefit order.

To maintain order of the coverages.

A flag to indicate that this Coverage is the focus to be used for adjudication. The Coverage against which the adjudication of this claim is when set to be adjudicated. true.

To identify which coverage in the list is being adjudicated. used to adjudicate this claim.

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.

The business identifier to be used when the claim is sent for adjudication against this insurance policy.

This will be the claim number should it be necessary to create this claim in the future. This is provided so that payers may forward claims to other payers in the Coordination of Benefit for adjudication rather than the provider being required to initiate each adjudication.

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'.

Reference to the program or plan identification, underwriter or payor. 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.

Need Required to identify allow the issuer adjudicator to target for processing locate the correct policy and for coordination of benefit processing. history within their information system.

The contract number of a A business agreement which describes number established between the terms provider and conditions. the insurer for special business processing purposes.

Providers may have multiple business arrangements with a given insurer and must supply the specific contract number for adjudication.

A list of references from Reference numbers previously provided by the Insurer insurer to which these the provider to be quoted on subsequent claims containing services pertain. or products related to the prior authorization.

Providers must quote previously issued authorization reference numbers in order to obtain adjudication as previously advised on the Preauthorization.

To provide any pre=determination This value is an alphanumeric string that may be provided over the phone, via text, via paper, or prior authorization reference. within a ClaimResponse resource and is not a FHIR Identifier.

The Coverages result of the adjudication details. of the line items for the Coverage specified in this insurance.

Used by downstream payers An insurer need the adjudication results from prior insurers to determine what the outstanding balance remains and remaining by item for the net payable. items in the curent claim.

Must not be specified when 'focal=true' for this insurance.

An Details of an accident which resulted in injuries which required the need for healthcare services. products and services listed in the claim.

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.

Date of an accident which these event related to the products and services are addressing. contained in the claim.

Required for audit purposes and adjudication.

Coverage may be dependant on accidents. The date of the accident has to precede the dates of the products and services but within a reasonable timeframe.

Type The type or context of accident: work, auto, etc. the accident event for the purposes of selection of potential insurance coverages and determination of coordination between insurers.

Coverage may be dependant on the type of accident.

Accident Place. The physical location of the accident event.

Required for audit purposes and determination of applicable insurance liability.

The start and optional end dates of when amount paid by the patient was precluded from working due patient, in total at the claim claim level or specifically for the item and detail level, to the treatable condition(s). provider for goods and services.

Necessary to demonstrate that copayments, co-insurance and similar patient payments have been made or accounted for.

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.

The start and optional end dates of when the patient was confined items to a treatment center. be processed for adjudication.

A number to uniquely identify item entries.

Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse.

First tier of goods and services. Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners.

Allows partners to uniquely identify components for tracking.

A service line number. The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for facast reimbursement is sought.

Profilers should consider making this element required when the backbone .subject is a group.

CareTeam applicable for members related to this service or product line. product.

Need to identify the individuals and their roles in the provision of the product or service.

Diagnosis applicable for this service or product line. product.

Need to related the product or service to the associated diagnoses.

Procedures applicable for this service or product line. product.

Need to provide any listed specific procedures to support the product or service being claimed.

Exceptions, special conditions and supporting information pplicable applicable for this service or product line. product.

Need to reference the supporting information items that relate directly to this product or service.

The type of reveneu revenue or cost center providing the product and/or service.

Needed in the processing of institutional claims.

Health Care Service Type Codes Code to identify the classification general type of service or benefits. benefits under which products and services are provided.

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.

Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used.

Necessary to state what was provided or done.

If this is an actual service or product line, ie. i.e. not a Group, then use code to indicate the Professional Service or Product supplied (eg. (e.g. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,RXNorm,ACHI,CCI). HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. e.g. 'glasses' or 'compound'.

This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claims.

Request or Referral for Goods or Service to be rendered.

May identify the service to be provided or provider authorization for the service.

Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or codes to convey additional context for medical whether the treatment was outside the clinic product or out of office hours. service.

To support inclusion of the item for adjudication or to charge an elevated fee.

May impact on adjudication. 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.

For programs which require reason codes for Identifies the inclusion or covering of this billed item program under which this may be recovered.

Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.

For example: Neonatal program, child dental program or drug users recovery program.

The date or dates when the enclosed suite of services were service or product was supplied, performed or completed.

Needed to determine whether the service or product was provided during the term of the insurance coverage.

Where the product or service was provided.

The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount.

The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services.

Necessary to demonstrate that copayments, co-insurance and similar patient payments have been made or accounted for.

The number of repetitions of a service or product.

Required when the product or service code does not convey the quantity provided.

If the item is not a node group then this is the fee for the product or service, otherwise this is the total of the fees for the children details of the group.

The amount charged to the patient by the provider for a single unit.

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.

If When discounts are provided to a fee is present the associated product/service code patient (example: Senior's discount) then this must be present. documented for adjudication.

To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

The quantity times total of taxes applicable for this product or service.

Required when taxes are not embedded in the unit price for an addittional service or product provided as a separate service.

The total amount claimed for the group (if a grouper) or charge. For example, the formula: unit Quantity * line item. Net = unit Price (Cost per Point) price * factor Number quantity * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied. factor.

If Provides the total amount claimed for the group (if a fee is present grouper) or the associated product/service code must line item.

For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be present. 1 if not supplied.

List of Unique Device Identifiers associated with this line item.

The UDI code and issuer if applicable for allows the supplied product. insurer to obtain device level information on the product supplied.

Physical location where the service is performed or applies.

Physical service site on the patient (limb, tooth, etc). etc.).

Allows insurer to validate specific procedures.

For example: Providing a tooth code, allows an insurer to identify a provider performing a filling on a tooth that was previously removed.

A region or surface of the site, eg. bodySite, e.g. limb region or tooth surface(s).

Allows insurer to validate specific procedures.

A billed item may include goods or services provided in multiple encounters. Healthcare encounters related to this claim.

Used in some jurisdictions to link clinical events to claim items.

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.

Second tier A claim detail line. Either a simple (a product or service) or a 'group' of goods and services. sub-details which are simple items.

The items to be processed for adjudication.

A service line number. number to uniquely identify item entries.

Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse.

Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners.

Allows partners to uniquely identify components for tracking.

The type of reveneu revenue or cost center providing the product and/or service.

Needed in the processing of institutional claims.

Health Care Service Type Codes Code to identify the classification general type of service or benefits. benefits under which products and services are provided.

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.

Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used.

Necessary to state what was provided or done.

If this is an actual service or product line, ie. i.e. not a Group, then use code to indicate the Professional Service or Product supplied (eg. (e.g. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. e.g. 'glasses' or 'compound'.

This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claims.

Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or codes to convey additional context for medical whether the treatment was outside the clinic product or out of office hours. service.

To support inclusion of the item for adjudication or to charge an elevated fee.

May impact on adjudication. 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.

For programs which require reson codes for Identifies the inclusion, covering, of this billed item program under which this may be recovered.

Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.

For example: Neonatal program, child dental program or drug users recovery program.

The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services.

Necessary to demonstrate that copayments, co-insurance and similar patient payments have been made or accounted for.

The number of repetitions of a service or product.

Required when the product or service code does not convey the quantity provided.

If the item is not a node group then this is the fee for the product or service, otherwise this is the total of the fees for the children details of the group.

If a fee is present The amount charged to the associated product/service code must be present. patient by the provider for a single unit.

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.

If When discounts are provided to a fee is present the associated product/service code patient (example: Senior's discount) then this must be present. documented for adjudication.

To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

The quantity times total of taxes applicable for this product or service.

Required when taxes are not embedded in the unit price for an addittional service or product provided as a separate service.

The total amount claimed for the group (if a grouper) or charge. For example, the formula: unit Quantity * line item.detail. Net = unit Price (Cost per Point) price * factor Number quantity * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied. factor.

If Provides the total amount claimed for the group (if a fee is present grouper) or the associated product/service code must line item.

For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be present. 1 if not supplied.

List of Unique Device Identifiers associated with this line item.

The UDI code and issuer if applicable for allows the supplied product. insurer to obtain device level information on the product supplied.

Third tier A claim detail line. Either a simple (a product or service) or a 'group' of goods and services. sub-details which are simple items.

The items to be processed for adjudication.

A service line number. number to uniquely identify item entries.

Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse.

Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners.

Allows partners to uniquely identify components for tracking.

The type of reveneu revenue or cost center providing the product and/or service.

Needed in the processing of institutional claims.

Health Care Service Type Codes Code to identify the classification general type of service or benefits. benefits under which products and services are provided.

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.

Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used.

A Necessary to state what was provided or done.

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 (eg. (e.g. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). 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'.

This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claims.

Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or codes to convey additional context for medical whether the treatment was outside the clinic product or out of office hours. service.

To support inclusion of the item for adjudication or to charge an elevated fee.

May impact on adjudication. 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.

For programs which require reson codes for Identifies the inclusion, covering, of this billed item program under which this may be recovered.

Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.

For example: Neonatal program, child dental program or drug users recovery program.

The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services.

Necessary to demonstrate that copayments, co-insurance and similar patient payments have been made or accounted for.

The number of repetitions of a service or product.

Required when the product or service code does not convey the quantity provided.

The If the item is not a group then this is the fee for an addittional service or the product or charge. service, otherwise this is the total of the fees for the details of the group.

If a fee is present The amount charged to the associated product/service code must be present. patient by the provider for a single unit.

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.

If When discounts are provided to a fee is present the associated product/service code patient (example: Senior's discount) then this must be present. documented for adjudication.

To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

The quantity times the unit price total of taxes applicable for an addittional service or this product or charge. For example, service.

Required when taxes are not embedded in the formula: unit Quantity * price or provided as a separate service.

The total amount claimed for line item.detail.subDetail. Net = unit Price (Cost per Point) price * factor Number quantity * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied. factor.

If Provides the total amount claimed for the group (if a fee is present grouper) or the associated product/service code must line item.

For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be present. 1 if not supplied.

List of Unique Device Identifiers associated with this line item.

The UDI code and issuer if applicable for allows the supplied product. insurer to obtain device level information on the product supplied.

The total value of the all the items in the claim.

Used for control total purposes.