DSTU2 STU 3 Candidate
This page is part of the FHIR Specification (v1.0.2: DSTU 2). The current version which supercedes this version is

This page is part of the FHIR Specification (v1.4.0: STU 3 Ballot 3). The current version which supercedes this version is 5.0.0 . For a full list of available versions, see the Directory of published versions . For a full list of available versions, see the Directory of published versions . Page versions: . Page versions: R5 R4B R4 R3 R2

7.1 Resource Claim - Content Resource Claim - Content

A provider issued list of services and products provided, or to be provided, to a patient which is provided to an insurer for payment recovery.
Financial Management Financial Management Work Group Work Group Maturity Level : 0 Maturity Level : 0 Compartments : : Patient , , Practitioner

A provider issued list of services and products provided, or to be provided, to a patient which is provided to an insurer for payment recovery.

7.1.1 Scope and Usage Scope and Usage The OralHealthClaim is one of a suite of similar resources (VisionClaim, PharmacyClaim, ProfessionalClaim, InstitutionalClaim) which are used by providers to exchange the financial information, and supporting clinical information, regarding the provision of healthcare services. The primary uses of this resource is to support eClaims, the exchange of proposed or actual services to benefit payors, insurers and national health programs, for treatment payment planning and reimbursement. The Claim is intended to support: Claims - where the provision of goods and services is

The OralHealthClaim is one of a suite of similar resources (VisionClaim, PharmacyClaim, ProfessionalClaim, InstitutionalClaim) which are used by providers to exchange the financial information, and supporting clinical information, regarding the provision of healthcare services. The primary uses of this resource is to support eClaims, the exchange of proposed or actual services to benefit payors, insurers and national health programs, for treatment payment planning and reimbursement.

The Claim is intended to support:

  • Claims - where the provision of goods and services is complete and reimbursement is sought. Pre-Authorization - where the provision of goods and services is and reimbursement is sought.
  • Pre-Authorization - where the provision of goods and services is proposed and either authorization and/or the reservation of funds is desired. Pre-Determination - where the provision of goods and services is and either authorization and/or the reservation of funds is desired.
  • Pre-Determination - where the provision of goods and services is explored to determine what services may be covered and to what amount. Essentially a 'what if' claim. The Claim also supports: Up to a 3 tier hierarchy of Goods, products, and Services, to support simple to complex billing. Multiple insurance programs arranged in a Coordination of Benefit sequence to enable exchange with primary, secondary, tertiary etc. insurance coverages. Assignment of benefit - the benefit may be requested to be directed to the subscriber, the provider or another party. Todo This resource is referenced by to determine what services may be covered and to what amount. Essentially a 'what if' claim.

The Claim also supports:

  • Up to a 3 tier hierarchy of Goods, products, and Services, to support simple to complex billing.
  • Multiple insurance programs arranged in a Coordination of Benefit sequence to enable exchange with primary, secondary, tertiary etc. insurance coverages.
  • Assignment of benefit - the benefit may be requested to be directed to the subscriber, the provider or another party.

Todo

This resource is referenced by ClaimResponse and and ExplanationOfBenefit

7.1.2 Resource Content Resource Content

Structure

Insurer Responsible provider Responsible organization Author Provider who is the payee The subject of the Products and Services Insurance information Surface Codes Intervention Codes Money UDI Codes Surface Codes
Name Flags Card. Type Description & Constraints Description & Constraints doco
. . Claim Σ DomainResource Claim, Pre-determination or Pre-authorization Claim, Pre-determination or Pre-authorization
. . . type Σ 1..1 code institutional | oral | pharmacy | professional | vision institutional | oral | pharmacy | professional | vision
ClaimType ( ( Required )
. . identifier . subType Σ 0..* Coding Finer grained claim type information
Example Claim SubType Codes ( Example )
... identifier Σ 0..* Identifier Claim number Claim number
. . . ruleset Σ 0..1 Coding Current specification followed Current specification followed
Ruleset Codes ( Ruleset Codes ( Example )
. . . originalRuleset Σ 0..1 Coding Original specification followed Original specification followed
Ruleset Codes ( Ruleset Codes ( Example )
. . . created Σ 0..1 dateTime Creation date Creation date
. . target . billablePeriod Σ 0..1 Period Period for charge submission
... target[x] Σ 0..1 Insurer
.... targetIdentifier Identifier
.... targetReference Reference ( Organization )
. . provider . provider[x] Σ 0..1 Responsible provider
.... providerIdentifier Identifier
.... providerReference Reference ( Practitioner )
. . organization . organization[x] Σ 0..1 Responsible organization
.... organizationIdentifier Identifier
.... organizationReference Reference ( Organization )
. . . use Σ 0..1 code complete | proposed | exploratory | other complete | proposed | exploratory | other
Use ( ( Required )
. . . priority Σ 0..1 Coding Desired processing priority Desired processing priority
Priority Codes ( Priority Codes ( Example )
. . . fundsReserve Σ 0..1 Coding Funds requested to be reserved Funds requested to be reserved
Funds Reservation Codes ( Funds Reservation Codes ( Example )
. . enterer . enterer[x] Σ 0..1 Author
.... entererIdentifier Identifier
.... entererReference Reference ( Practitioner )
. . facility . facility[x] Σ 0..1 Servicing Facility
.... facilityIdentifier Identifier
.... facilityReference Reference ( Location )
. . . related Servicing Facility Σ 0..* BackboneElement Related Claims which may be revelant to processing this claimn
. . . prescription . claim[x] Σ 0..1 Reference to the related claim
..... claimIdentifier Identifier
..... claimReference Reference ( MedicationOrder Claim | VisionPrescription )
.... relationship Σ 0..1 Coding How the reference claim is related
Example Related Claim Relationship Codes ( Example )
. . . . reference Prescription Σ 0..1 Identifier Related file or case reference
. . originalPrescription . prescription[x] Σ 0..1 Prescription
.... prescriptionIdentifier Identifier
.... prescriptionReference Reference ( MedicationOrder | VisionPrescription )
. . . originalPrescription[x] Original Prescription Σ 0..1 Original Prescription
.... originalPrescriptionIdentifier Identifier
.... originalPrescriptionReference Reference ( MedicationOrder )
. . . payee Σ 0..1 BackboneElement Payee Party to be paid any benefits payable
. . . . type Σ 0..1 1..1 Coding Party to be paid any benefits payable Type of party: Subscriber, Provider, other
Payee Type Codes ( Payee Type Codes ( Example )
. . . provider . party[x] Σ 0..1 Party to receive the payable
..... partyIdentifier Identifier
..... partyReference Reference ( Practitioner | Organization | Patient | RelatedPerson )
. . organization . referral[x] Σ 0..1 Treatment Referral
.... referralIdentifier Reference ( Organization ) Organization who is the payee Identifier
. . . person . referralReference Reference ( ReferralRequest )
. . . occurrenceCode Σ 0..1 0..* Reference ( Patient Coding ) Other person who is the payee Occurrence Codes
Example Occurrance Codes ( Example )
. . referral . occurenceSpanCode Σ 0..1 0..* Reference Coding ( ReferralRequest Occurrence Span Codes
Example Occurrance Span Codes ( Example )
. . . valueCode Treatment Referral Σ 0..* Coding Value Codes
Example Value Codes ( Example )
. . . diagnosis Σ 0..* BackboneElement Diagnosis
. . . . sequence Σ 1..1 positiveInt Sequence of diagnosis Number to covey order of diagnosis
. . . . diagnosis Σ 1..1 Coding Patient's list of diagnosis Patient's list of diagnosis
ICD-10 Codes ICD-10 Codes ( Example ( )
... procedure Σ 0..* BackboneElement Procedures performed
.... sequence Σ 1..1 positiveInt Procedure sequence for reference
.... date Σ 0..1 dateTime When the procedure was performed
.... procedure[x] Σ 1..1 Patient's list of procedures performed
ICD-10 Procedure Codes ( Example )
. . . . condition . procedureCoding Coding
. . . . . procedureReference Reference ( Procedure )
... specialCondition Σ 0..* Coding List of presenting Conditions List of special Conditions
Conditions Codes ( Conditions Codes ( Example )
. . patient . patient[x] Σ 1..1 The subject of the Products and Services
.... patientIdentifier Identifier
.... patientReference Reference ( Patient )
. . . coverage Σ 0..* BackboneElement Insurance or medical plan Insurance or medical plan
. . . . sequence Σ 1..1 positiveInt Service instance identifier Service instance identifier
. . . . focal Σ 1..1 boolean The focal Coverage Is the focal Coverage
. . . coverage . coverage[x] Σ 1..1 Insurance information
..... coverageIdentifier Identifier
..... coverageReference Reference ( Coverage )
. . . . businessArrangement Σ 0..1 string Business agreement Business agreement
. . . relationship . preAuthRef Σ 1..1 0..* Coding string Patient relationship to subscriber Pre-Authorization/Determination Reference
. . . . claimResponse Σ 0..1 Reference ( Example ClaimResponse ) Adjudication results
. . . preAuthRef . originalRuleset Σ 0..* 0..1 string Coding Pre-Authorization/Determination Reference Original version
Ruleset Codes ( Example )
. . claimResponse . accidentDate Σ 0..1 Reference ( ClaimResponse date ) Adjudication results When the accident occurred
. . originalRuleset . accidentType Σ 0..1 Coding Original version The nature of the accident
Ruleset Codes ActIncidentCode ( Required )
... accidentLocation[x] Σ 0..1 Accident Place
.... accidentLocationAddress Address
.... accidentLocationReference Reference ( Example Location )
. . exception . interventionException Σ 0..* Coding Eligibility exceptions Intervention and exception code (Pharma)
Exception Codes ( Intervention Codes ( Example )
. . school . onset Σ 0..1 0..* string BackboneElement Name of School Condition related Onset related dates and codes
. . . accident . time[x] Σ 0..1 Illness, injury or treatable condition date
..... timeDate date
. . . . . timePeriod Accident Date Period
. . accidentType . . type Σ 0..1 Coding Accident Type Onset of what
ActIncidentCode ( Required Example Onset Type (Reason) Codes ( Example )
. . interventionException . employmentImpacted Σ 0..* 0..1 Coding Period Intervention and exception code (Pharma) Period unable to work
. . . hospitalization ( Example Σ 0..1 Period ) Period in hospital
. . . item Σ 0..* BackboneElement Goods and Services Goods and Services
. . . . sequence Σ 1..1 positiveInt Service instance Service instance
. . . . type Σ 1..1 Coding Group or type of product or service Group or type of product or service
ActInvoiceGroupCode ( Exception Codes ( Required )
. . . provider . provider[x] Σ 0..1 Responsible practitioner
..... providerIdentifier Identifier
..... providerReference Reference ( Practitioner )
.... supervisor[x] Σ 0..1 Supervising Practitioner
..... supervisorIdentifier Identifier
..... supervisorReference Reference ( Practitioner )
. . . . providerQualification Responsible practitioner Σ 0..1 Coding Type, classification or Specialization
Example Provider Qualification Codes ( Example )
. . . . diagnosisLinkId Σ 0..* positiveInt Diagnosis Link Applicable diagnoses
. . . . service Σ 1..1 Coding Item Code Item Code
USCLS Codes ( USCLS Codes ( Example )
. . . serviceDate . serviceModifier Σ 0..1 0..* date Coding Date of Service Service/Product modifiers
Example Service Modifier Codes ( Example )
. . . quantity . modifier Σ 0..1 0..* SimpleQuantity Coding Count of Products or Services Service/Product billing modifiers
Modifier type Codes ( Example )
. . . unitPrice . programCode Σ 0..* Coding Program specific reason for item inclusion
Example Program Reason Codes ( Example )
.... serviced[x] Σ 0..1 Date or dates of Service
. . . . . servicedDate date
. . . . . servicedPeriod Fee, charge or cost per point Period
. . . factor . place Σ 0..1 decimal Coding Price scaling factor Place of service
Example Service Place Codes ( Example )
. . . points . quantity Σ 0..1 decimal SimpleQuantity Difficulty scaling factor Count of Products or Services
. . . net . unitPrice Σ 0..1 Money Total item cost Fee, charge or cost per point
. . . udi . factor Σ 0..1 Coding decimal Unique Device Identifier Price scaling factor
. . . . points ( Example Σ 0..1 decimal ) Difficulty scaling factor
. . . bodySite . net Σ 0..1 Coding Money Service Location Total item cost
. . . . udi Σ 0..* Reference ( Example Device ) Unique Device Identifier
. . . subSite . bodySite Σ 0..* 0..1 Coding Service Sub-location Service Location
Surface Codes ( Oral Site Codes ( Example )
. . . modifier . subSite Σ 0..* Coding Service/Product billing modifiers Service Sub-location
Modifier type Codes ( Surface Codes ( Example )
. . . . detail Σ 0..* BackboneElement Additional items Additional items
. . . . . sequence Σ 1..1 positiveInt Service instance Service instance
. . . . . type Σ 1..1 Coding Group or type of product or service Group or type of product or service
ActInvoiceGroupCode ( Exception Codes ( Required )
. . . . . service Σ 1..1 Coding Additional item codes Additional item codes
USCLS Codes USCLS Codes ( Example ( )
..... programCode Σ 0..* Coding Program specific reason for item inclusion
Example Program Reason Codes ( Example )
. . . . . quantity Σ 0..1 SimpleQuantity Count of Products or Services Count of Products or Services
. . . . . unitPrice Σ 0..1 Money Fee, charge or cost per point Fee, charge or cost per point
. . . . . factor Σ 0..1 decimal Price scaling factor Price scaling factor
. . . . . points Σ 0..1 decimal Difficulty scaling factor Difficulty scaling factor
. . . . . net Σ 0..1 Money Total additional item cost Total additional item cost
. . . . . udi Σ 0..1 Coding 0..* Unique Device Identifier UDI Codes Reference ( Example Device ) Unique Device Identifier
. . . . . subDetail Σ 0..* BackboneElement Additional items Additional items
. . . . . . sequence Σ 1..1 positiveInt Service instance Service instance
. . . . . . type Σ 1..1 Coding Type of product or service Type of product or service
ActInvoiceGroupCode ( Exception Codes ( Required )
. . . . . . service Σ 1..1 Coding Additional item codes Additional item codes
USCLS Codes USCLS Codes ( Example ( )
...... programCode Σ 0..* Coding Program specific reason for item inclusion
Example Program Reason Codes ( Example )
. . . . . . quantity Σ 0..1 SimpleQuantity Count of Products or Services Count of Products or Services
. . . . . . unitPrice Σ 0..1 Money Fee, charge or cost per point Fee, charge or cost per point
. . . . . . factor Σ 0..1 decimal Price scaling factor Price scaling factor
. . . . . . points Σ 0..1 decimal Difficulty scaling factor Difficulty scaling factor
. . . . . . net Σ 0..1 Money Net additional item cost Net additional item cost
. . . . . . udi Σ 0..1 Coding 0..* Unique Device Identifier UDI Codes Reference ( Example Device ) Unique Device Identifier
. . . . prosthesis Σ 0..1 BackboneElement Prosthetic details Prosthetic details
. . . . . initial Σ 0..1 boolean Is this the initial service Is this the initial service
. . . . . priorDate Σ 0..1 date Initial service Date Initial service Date
. . . . . priorMaterial Σ 0..1 Coding Prosthetic Material Prosthetic Material
Oral Prostho Material type Codes ( Oral Prostho Material type Codes ( Example )
. . additionalMaterials . total Σ 0..1 Money Total claim cost
... additionalMaterial Σ 0..* Coding Additional materials, documents, etc. Additional supporting materials and documents
Additional Material Codes ( Additional Material Codes ( Example )
. . . missingTeeth Σ 0..* BackboneElement Only if type = oral Only if type = oral
. . . . tooth Σ 1..1 Coding Tooth Code Tooth Code
Teeth Codes ( Teeth Codes ( Example )
. . . . reason Σ 0..1 Coding Reason for missing Indicates whether it was extracted or other reason
Missing Tooth Reason Codes ( Missing Tooth Reason Codes ( Example )
. . . . extractionDate Σ 0..1 date Date of Extraction Date tooth was extracted if known

Documentation for this format doco Documentation for this format

UML Diagram UML Diagram

Claim ( ( DomainResource ) The category of claim this is The category of claim type : : code [1..1] « [1..1] « The type or discipline-style of the claim. (Strength=Required) The type or discipline-style of the claim (Strength=Required) ClaimType ! » ! » A finer grained suite of claim subtype codes which may convey Inpatient vs Outpatient and/or a specialty service. In the US the BillType subType : Coding [0..*] « A more granulat claim typecode (Strength=Example) Example Claim SubType ?? » The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization number The business identifier for the instance: claim number, pre-determination or pre-authorization number identifier : : Identifier [0..*] [0..*] The version of the specification on which this instance relies The version of the specification on which this instance relies ruleset : : Coding [0..1] « [0..1] « The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example) The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example) Ruleset ?? » Ruleset ?? » The version of the specification from which the original instance was created The version of the specification from which the original instance was created originalRuleset : : Coding [0..1] « [0..1] « The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example) The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example) Ruleset ?? » Ruleset ?? » The date when the enclosed suite of services were performed or completed The date when the enclosed suite of services were performed or completed created : : dateTime [0..1] [0..1] Insurer Identifier, typical BIN number (6 digit) The billable period for which charges are being submitted target billablePeriod : Period [0..1] Insurer Identifier, typical BIN number (6 digit) target[x] : Type [0..1] « Identifier : | Reference [0..1] « ( Organization » ) » The provider which is responsible for the bill, claim pre-determination, pre-authorization The provider which is responsible for the bill, claim pre-determination, pre-authorization provider provider[x] : Type [0..1] « Identifier : | Reference [0..1] « ( Practitioner » ) » The organization which is responsible for the bill, claim pre-determination, pre-authorization The organization which is responsible for the bill, claim pre-determination, pre-authorization organization organization[x] : Type [0..1] « Identifier : | Reference [0..1] « ( Organization » ) » Complete (Bill or Claim), Proposed (Pre-Authorization), Exploratory (Pre-determination) Complete (Bill or Claim), Proposed (Pre-Authorization), Exploratory (Pre-determination) use : : code [0..1] « [0..1] « Complete, proposed, exploratory, other. (Strength=Required) Complete, proposed, exploratory, other (Strength=Required) Use ! » ! » Immediate (stat), best effort (normal), deferred (deferred) Immediate (STAT), best effort (NORMAL), deferred (DEFER) priority : : Coding [0..1] « [0..1] « The timeliness with which processing is required: STAT, Normal, Deferred. (Strength=Example) The timeliness with which processing is required: STAT, normal, Deferred (Strength=Example) Priority ?? » Priority ?? » 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 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 fundsReserve : : Coding [0..1] « [0..1] « For whom funds are to be reserved: (Patient, Provider, None). (Strength=Example) For whom funds are to be reserved: (Patient, Provider, None). (Strength=Example) Funds Reservation ?? » Funds Reservation ?? » Person who created the invoice/claim/pre-determination or pre-authorization Person who created the invoice/claim/pre-determination or pre-authorization enterer enterer[x] : Type [0..1] « Identifier : | Reference [0..1] « ( Practitioner » ) » Facility where the services were provided Facility where the services were provided facility facility[x] : Type [0..1] « Identifier : | Reference [0..1] « ( Location » ) » Prescription to support the dispensing of Pharmacy or Vision products Prescription to support the dispensing of Pharmacy or Vision products prescription prescription[x] : Type [0..1] « Identifier : | Reference [0..1] « ( MedicationOrder | VisionPrescription » ) » Original prescription to support the dispensing of pharmacy services, medications or products Original prescription which has been superceded by this prescription to support the dispensing of pharmacy services, medications or products originalPrescription originalPrescription[x] : Type [0..1] « Identifier : | Reference [0..1] « ( MedicationOrder » ) » The referral resource which lists the date, practitioner, reason and other supporting information The referral resource which lists the date, practitioner, reason and other supporting information referral referral[x] : Type [0..1] « Identifier : | Reference [0..1] « ( ReferralRequest » ) » List of patient conditions for which care is sought **Insert definition of Occurrence codes condition : occurrenceCode : Coding [0..*] « [0..*] « Patient conditions and symptoms. (Strength=Example) Occurrence codes (Strength=Example) Conditions ?? » Example Occurrance ?? » Patient Resource **Insert definition of Occurrence Span codes patient : Reference [1..1] « Patient » occurenceSpanCode : Coding [0..*] « Occurrence Span codes (Strength=Example) Example Occurrance Span ?? » Factors which may influence the applicability of coverage **Insert definition of Value codes exception : valueCode : Coding [0..*] « [0..*] « The eligibility exception codes. (Strength=Example) Value code (Strength=Example) Exception ?? » Example Value ?? » Name of school for over-aged dependents List of special conditions relating to the setting, treatment or patient for which care is sought which may influence the adjudication school specialCondition : Coding [0..*] « Patient conditions and symptoms (Strength=Example) Conditions ?? » Patient Resource patient[x] : Type [1..1] « Identifier : string | Reference [0..1] ( Patient ) » Date of an accident which these services are addressing Date of an accident which these services are addressing accident : accidentDate : date [0..1] [0..1] Type of accident: work, auto, etc Type of accident: work, auto, etc accidentType : : Coding [0..1] « [0..1] « Type of accident: work place, auto, etc. (Strength=Required) Type of accident: work place, auto, etc. (Strength=Required) ActIncidentCode ! » ! » A list of intervention and exception codes which may influence the adjudication of the claim Accident Place interventionException accidentLocation[x] : Type [0..1] « Address : Coding | Reference [0..*] « Intervention and exception codes (Pharm). (Strength=Example) Intervention ( Location ?? » ) » Code to indicate that Xrays, images, emails, documents, models or attachments are being sent in support of this submission A list of intervention and exception codes which may influence the adjudication of the claim additionalMaterials : interventionException : Coding [0..*] « [0..*] « Code to indicate that Xrays, images, emails, documents, models or attachments are being sent in support of this submission. (Strength=Example) Intervention and exception codes (Pharm) (Strength=Example) Additional Material ?? » Intervention ?? » The start and optional end dates of when the patient was precluded from working due to the treatable condition(s) employmentImpacted : Period [0..1] Payee The start and optional end dates of when the patient was confined to a treatment center hospitalization : Period [0..1] Party to be reimbursed: Subscriber, provider, other The total value of the claim type total : Quantity : Coding ( Money [0..1] « ) [0..1] A code for the party to be reimbursed. (Strength=Example) Code to indicate that Xrays, images, emails, documents, models or attachments are being sent in support of this submission Payee Type ?? » additionalMaterial : Coding [0..*] « Code to indicate that Xrays, images, emails, documents, models or attachments are being sent in support of this submission. (Strength=Example) Additional Material ?? » RelatedClaims The provider who is to be reimbursed for the claim (the party to whom any benefit is assigned) Other claims which are related to this claim such as prior claim versions or for related services provider claim[x] : Type [0..1] « Identifier : | Reference [0..1] « Practitioner ( Claim » ) » The organization who is to be reimbursed for the claim (the party to whom any benefit is assigned) For example prior or umbrella organization : Reference [0..1] « Organization relationship : Coding [0..1] « Relationship of this claim to a related Claim (Strength=Example) Example Related Claim Relatio... » ?? » The person other than the subscriber who is to be reimbursed for the claim (the party to whom any benefit is assigned) An alternate organizational reference to the case or file to which this particular claim pertains - eg Property/Casualy insurer claim # or Workers Compensation case # reference : Identifier [0..1] Payee Type of Party to be reimbursed: Subscriber, provider, other person type : Coding [1..1] « A code for the party to be reimbursed. (Strength=Example) Payee Type ?? » Party to be reimbursed: Subscriber, provider, other party[x] : Type [0..1] « Identifier : | Reference [0..1] « ( Practitioner | Organization | Patient » | RelatedPerson ) » Diagnosis Sequence of diagnosis which serves to order and provide a link Sequence of diagnosis which serves to order and provide a link sequence : : positiveInt [1..1] [1..1] The diagnosis The diagnosis diagnosis : : Coding [1..1] « ICD10 Diagnostic codes (Strength=Example) ICD-10 ?? » Procedure Sequence of procedures which serves to order and provide a link sequence : positiveInt [1..1] Date and optionally time the procedure was performed date : dateTime [0..1] The procedure code procedure[x] : Type [1..1] « Coding [1..1] « | Reference ( Procedure ); ICD10 diagnostic codes. (Strength=Example) ICD10 Procedure codes (Strength=Example) ICD-10 ?? » Procedure ?? » Coverage A service line item A service line item sequence : : positiveInt [1..1] [1..1] The instance number of the Coverage which is the focus for adjudication. The Coverage against which the claim is to be adjudicated The instance number of the Coverage which is the focus for adjudication. The Coverage against which the claim is to be adjudicated focal : : boolean [1..1] [1..1] Reference to the program or plan identification, underwriter or payor Reference to the program or plan identification, underwriter or payor coverage coverage[x] : Type [1..1] « Identifier : | Reference [1..1] « ( Coverage » ) » The contract number of a business agreement which describes the terms and conditions The contract number of a business agreement which describes the terms and conditions businessArrangement : : string [0..1] The relationship of the patient to the subscriber relationship : Coding [1..1] « The code for the relationship of the patient to the subscriber. (Strength=Example) Surface ?? » [0..1] A list of references from the Insurer to which these services pertain A list of references from the Insurer to which these services pertain preAuthRef : : string [0..*] [0..*] The Coverages adjudication details The Coverages adjudication details claimResponse : : Reference [0..1] « [0..1] « ClaimResponse » » The style (standard) and version of the original material which was converted into this resource The style (standard) and version of the original material which was converted into this resource originalRuleset : : Coding [0..1] « [0..1] « The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example) The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example) Ruleset Ruleset ?? » Onset The start or start and end dates for the treatable condition time[x] : Type [0..1] « date ?? » | Period » Onset typifications eg. Start of pregnancy, start of illnes, etc type : Coding [0..1] « Condition related start, end and period codes (Strength=Example) Example Onset Type (Reason) ?? » Items A service line number A service line number sequence : : positiveInt [1..1] [1..1] The type of product or service The type of product or service type : : Coding [1..1] « [1..1] « Service, Product, Rx Dispense, Rx Compound etc. (Strength=Required) Group, Service, Product. (Strength=Required) ActInvoiceGroupCode ! » Exception ! » The practitioner who is responsible for the services rendered to the patient The practitioner who is responsible for the services rendered to the patient provider provider[x] : Type [0..1] « Identifier : | Reference [0..1] « ( Practitioner » ) » The practitioner who is supervising the work of the servicing provider(s) supervisor[x] : Type [0..1] « Identifier | Reference ( Practitioner ) » The qualification which is applicable for this service providerQualification : Coding [0..1] « Provider professional qualifications (Strength=Example) Example Provider Qualificatio... ?? » Diagnosis applicable for this service or product line Diagnosis applicable for this service or product line diagnosisLinkId : : positiveInt [0..*] [0..*] If a grouping item then 'GROUP' otherwise it is a node therefore a code to indicate the Professional Service or Product supplied If a grouping item then 'GROUP' otherwise it is a node therefore a code to indicate the Professional Service or Product supplied service : : Coding [1..1] « [1..1] « Allowable service and product codes. (Strength=Example) Allowable service and product codes (Strength=Example) USCLS ?? » USCLS ?? » The date when the enclosed suite of services were performed or completed Unusual circumstances which may influence adjudication serviceDate : serviceModifier : Coding [0..*] « Factors which may influce adjudication of services (Strength=Example) Example Service Modifier ?? » Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen modifier : Coding [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example) Modifier type ?? » For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program programCode : Coding [0..*] « Program specific reason codes (Strength=Example) Example Program Reason ?? » The date or dates when the enclosed suite of services were performed or completed serviced[x] : Type [0..1] « date [0..1] | Period » Where the service was provided place : Coding [0..1] « (Strength=Example) Example Service Place ?? » The number of repetitions of a service or product The number of repetitions of a service or product quantity : : Quantity ( SimpleQuantity ) [0..1] ) [0..1] If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group unitPrice : : Quantity ( Money ) [0..1] ) [0..1] 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 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 factor : : decimal [0..1] [0..1] An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each point An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each point points : : decimal [0..1] [0..1] The quantity times the unit price for an additional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied net : : Quantity ( Money ) [0..1] ) [0..1] List of Unique Device Identifiers associated with this line item List of Unique Device Identifiers associated with this line item udi : Coding [0..1] « The FDA, or other, UDI repository. (Strength=Example) UDI ?? » : Reference [0..*] « Device » Physical service site on the patient (limb, tooth, etc.) Physical service site on the patient (limb, tooth, etc) bodySite : : Coding [0..1] « [0..1] « The code for the teeth, quadrant, sextant and arch. (Strength=Example) The code for the teeth, quadrant, sextant and arch (Strength=Example) Surface ?? » Oral Site ?? » A region or surface of the site, e.g. limb region or tooth surface(s) A region or surface of the site, eg. limb region or tooth surface(s) subSite : Coding [0..*] « The code for the tooth surface and surface combinations. (Strength=Example) Surface ?? » Item typification or modifiers codes, e.g. for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen modifier : : Coding [0..*] « [0..*] « Item type or modifiers codes, e.g. for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example) The code for the tooth surface and surface combinations (Strength=Example) Modifier type ?? » Surface ?? » Detail A service line number A service line number sequence : : positiveInt [1..1] [1..1] The type of product or service The type of product or service type : : Coding [1..1] « [1..1] « Service, Product, Rx Dispense, Rx Compound etc. (Strength=Required) Group, Service, Product. (Strength=Required) ActInvoiceGroupCode ! » Exception ! » If a grouping item then 'GROUP' otherwise it is a node therefore a code to indicate the Professional Service or Product supplied If a grouping item then 'GROUP' otherwise it is a node therefore a code to indicate the Professional Service or Product supplied service : : Coding [1..1] « [1..1] « Allowable service and product codes. (Strength=Example) Allowable service and product codes (Strength=Example) USCLS ?? » USCLS ?? » For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program programCode : Coding [0..*] « Program specific reason codes (Strength=Example) Example Program Reason ?? » The number of repetitions of a service or product The number of repetitions of a service or product quantity : : Quantity ( SimpleQuantity ) [0..1] ) [0..1] If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group unitPrice : : Quantity ( Money ) [0..1] ) [0..1] 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 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 factor : : decimal [0..1] [0..1] An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each point An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each point points : : decimal [0..1] [0..1] The quantity times the unit price for an additional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied net : : Quantity ( Money ) [0..1] ) [0..1] List of Unique Device Identifiers associated with this line item List of Unique Device Identifiers associated with this line item udi : Coding [0..1] « The FDA, or other, UDI repository. (Strength=Example) UDI ?? » : Reference [0..*] « Device » SubDetail A service line number A service line number sequence : : positiveInt [1..1] [1..1] The type of product or service The type of product or service type : : Coding [1..1] « [1..1] « Service, Product, Rx Dispense, Rx Compound etc. (Strength=Required) Group, Service, Product. (Strength=Required) ActInvoiceGroupCode ! » Exception ! » The fee for an additional service or product or charge The fee for an addittional service or product or charge service : : Coding [1..1] « [1..1] « Allowable service and product codes. (Strength=Example) Allowable service and product codes (Strength=Example) USCLS ?? » USCLS ?? » For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program programCode : Coding [0..*] « Program specific reason codes (Strength=Example) Example Program Reason ?? » The number of repetitions of a service or product The number of repetitions of a service or product quantity : : Quantity ( SimpleQuantity ) [0..1] ) [0..1] The fee for an additional service or product or charge The fee for an addittional service or product or charge unitPrice : : Quantity ( Money ) [0..1] ) [0..1] 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 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 factor : : decimal [0..1] [0..1] An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each point An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each point points : : decimal [0..1] [0..1] The quantity times the unit price for an additional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied net : : Quantity ( Money ) [0..1] ) [0..1] List of Unique Device Identifiers associated with this line item List of Unique Device Identifiers associated with this line item udi : Coding [0..1] « The FDA, or other, UDI repository. (Strength=Example) UDI ?? » : Reference [0..*] « Device » Prosthesis Indicates whether this is the initial placement of a fixed prosthesis Indicates whether this is the initial placement of a fixed prosthesis initial : : boolean [0..1] [0..1] Date of the initial placement Date of the initial placement priorDate : : date [0..1] [0..1] Material of the prior denture or bridge prosthesis. (Oral) Material of the prior denture or bridge prosthesis. (Oral) priorMaterial : : Coding [0..1] « [0..1] « Material of the prior denture or bridge prosthesis. (Oral) (Strength=Example) Material of the prior denture or bridge prosthesis. (Oral) (Strength=Example) Oral Prostho Material type ?? » Oral Prostho Material type ?? » MissingTeeth The code identifying which tooth is missing The code identifying which tooth is missing tooth : : Coding [1..1] « [1..1] « The codes for the teeth, subset of OralSites. (Strength=Example) The codes for the teeth, subset of OralSites (Strength=Example) Teeth ?? » Teeth ?? » Missing reason may be: E-extraction, O-other Missing reason may be: E-extraction, O-other reason : : Coding [0..1] « [0..1] « Reason codes for the missing teeth. (Strength=Example) Reason codes for the missing teeth (Strength=Example) Missing Tooth Reason ?? » Missing Tooth Reason ?? » The date of the extraction either known from records or patient reported estimate The date of the extraction either known from records or patient reported estimate extractionDate : : date [0..1] [0..1] Other claims which are related to this claim such as prior claim versions or for related services related [0..*] The party to be reimbursed for the services The party to be reimbursed for the services payee [0..1] Ordered list of patient diagnosis for which care is sought Ordered list of patient diagnosis for which care is sought diagnosis [0..*] Ordered list of patient procedures performed to support the adjudication procedure [0..*] Financial instrument by which payment information for health care Financial instrument by which payment information for health care coverage [0..*] Period, start and last dates of aspects of the Condition or related services onset [0..*] Third tier of goods and services Third tier of goods and services subDetail [0..*] Second tier of goods and services Second tier of goods and services detail [0..*] The materials and placement date of prior fixed prosthesis The materials and placement date of prior fixed prosthesis prosthesis [0..1] First tier of goods and services First tier of goods and services item [0..*] A list of teeth which would be expected but are not found due to having been previously extracted or for other reasons A list of teeth which would be expected but are not found due to having been previously extracted or for other reasons missingTeeth [0..*]

XML Template XML Template 

<Claim xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <
 <</identifier>

 <type value="[code]"/><!-- 1..1 institutional | oral | pharmacy | professional | vision -->
 <subType><!-- 0..* Coding Finer grained claim type information --></subType>
 <identifier><!-- 0..* Identifier Claim number --></identifier>

 <ruleset><!-- 0..1 Coding Current specification followed --></ruleset>
 <originalRuleset><!-- 0..1 Coding Original specification followed --></originalRuleset>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <</target>
 <</provider>
 <</organization>

 <billablePeriod><!-- 0..1 Period Period for charge submission --></billablePeriod>
 <target[x]><!-- 0..1 Identifier|Reference(Organization) Insurer --></target[x]>
 <provider[x]><!-- 0..1 Identifier|Reference(Practitioner) Responsible provider --></provider[x]>
 <organization[x]><!-- 0..1 Identifier|Reference(Organization) Responsible organization --></organization[x]>

 <use value="[code]"/><!-- 0..1 complete | proposed | exploratory | other -->
 <</priority>

 <priority><!-- 0..1 Coding Desired processing priority --></priority>

 <fundsReserve><!-- 0..1 Coding Funds requested to be reserved --></fundsReserve>
 <</enterer>
 <</facility>
 <</prescription>
 <</originalPrescription>
 <
  <</type>
  <</provider>
  <</organization>
  <</person>

 <enterer[x]><!-- 0..1 Identifier|Reference(Practitioner) Author --></enterer[x]>
 <facility[x]><!-- 0..1 Identifier|Reference(Location) Servicing Facility --></facility[x]>
 <related>  <!-- 0..* Related Claims which may be revelant to processing this claimn -->
  <claim[x]><!-- 0..1 Identifier|Reference(Claim) Reference to the related claim --></claim[x]>
  <relationship><!-- 0..1 Coding How the reference claim is related --></relationship>
  <reference><!-- 0..1 Identifier Related file or case reference --></reference>
 </related>
 <prescription[x]><!-- 0..1 Identifier|Reference(MedicationOrder|
   VisionPrescription) Prescription --></prescription[x]>

 <originalPrescription[x]><!-- 0..1 Identifier|Reference(MedicationOrder) Original Prescription --></originalPrescription[x]>
 <payee>  <!-- 0..1 Party to be paid any benefits payable -->
  <type><!-- 1..1 Coding Type of party: Subscriber, Provider, other --></type>
  <party[x]><!-- 0..1 Identifier|Reference(Practitioner|Organization|Patient|
    RelatedPerson) Party to receive the payable --></party[x]>
 </payee>
 <</referral>

 <referral[x]><!-- 0..1 Identifier|Reference(ReferralRequest) Treatment Referral --></referral[x]>
 <occurrenceCode><!-- 0..* Coding Occurrence Codes --></occurrenceCode>
 <occurenceSpanCode><!-- 0..* Coding Occurrence Span Codes --></occurenceSpanCode>
 <valueCode><!-- 0..* Coding Value Codes --></valueCode>

 <diagnosis>  <!-- 0..* Diagnosis -->
  <

  <sequence value="[positiveInt]"/><!-- 1..1 Number to covey order of diagnosis -->

  <diagnosis><!-- 1..1 Coding Patient's list of diagnosis --></diagnosis>
 </diagnosis>
 <</condition>
 <</patient>

 <procedure>  <!-- 0..* Procedures performed -->
  <sequence value="[positiveInt]"/><!-- 1..1 Procedure sequence for reference -->
  <date value="[dateTime]"/><!-- 0..1 When the procedure was performed -->
  <procedure[x]><!-- 1..1 Coding|Reference(Procedure) Patient's list of procedures performed --></procedure[x]>
 </procedure>
 <specialCondition><!-- 0..* Coding List of special Conditions --></specialCondition>
 <patient[x]><!-- 1..1 Identifier|Reference(Patient) The subject of the Products and Services --></patient[x]>

 <coverage>  <!-- 0..* Insurance or medical plan -->
  <sequence value="[positiveInt]"/><!-- 1..1 Service instance identifier -->
  <
  <</coverage>

  <focal value="[boolean]"/><!-- 1..1 Is the focal Coverage -->
  <coverage[x]><!-- 1..1 Identifier|Reference(Coverage) Insurance information --></coverage[x]>

  <businessArrangement value="[string]"/><!-- 0..1 Business agreement -->
  <</relationship>

  <preAuthRef value="[string]"/><!-- 0..* Pre-Authorization/Determination Reference -->
  <claimResponse><!-- 0..1 Reference(ClaimResponse) Adjudication results --></claimResponse>
  <originalRuleset><!-- 0..1 Coding Original version --></originalRuleset>
 </coverage>
 <</exception>
 <
 <
 <</accidentType>

 <accidentDate value="[date]"/><!-- 0..1 When the accident occurred -->
 <accidentType><!-- 0..1 Coding The nature of the accident --></accidentType>
 <accidentLocation[x]><!-- 0..1 Address|Reference(Location) Accident Place --></accidentLocation[x]>

 <interventionException><!-- 0..* Coding Intervention and exception code (Pharma) --></interventionException>
 <onset>  <!-- 0..* Condition related Onset related dates and codes -->
  <time[x]><!-- 0..1 date|Period Illness, injury or treatable condition date --></time[x]>
  <type><!-- 0..1 Coding Onset of what --></type>
 </onset>
 <employmentImpacted><!-- 0..1 Period Period unable to work --></employmentImpacted>
 <hospitalization><!-- 0..1 Period Period in hospital --></hospitalization>

 <item>  <!-- 0..* Goods and Services -->
  <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
  <</type>
  <</provider>
  <

  <type><!-- 1..1 Coding Group or type of product or service --></type>
  <provider[x]><!-- 0..1 Identifier|Reference(Practitioner) Responsible practitioner --></provider[x]>
  <supervisor[x]><!-- 0..1 Identifier|Reference(Practitioner) Supervising Practitioner --></supervisor[x]>
  <providerQualification><!-- 0..1 Coding Type, classification or Specialization --></providerQualification>
  <diagnosisLinkId value="[positiveInt]"/><!-- 0..* Applicable diagnoses -->

  <service><!-- 1..1 Coding Item Code --></service>
  <

  <serviceModifier><!-- 0..* Coding Service/Product modifiers --></serviceModifier>
  <modifier><!-- 0..* Coding Service/Product billing modifiers --></modifier>
  <programCode><!-- 0..* Coding Program specific reason for item inclusion --></programCode>
  <serviced[x]><!-- 0..1 date|Period Date or dates of Service --></serviced[x]>
  <place><!-- 0..1 Coding Place of service --></place>

  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
  <unitPrice><!-- 0..1 Quantity(Money) Fee, charge or cost per point --></unitPrice>
  <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
  <points value="[decimal]"/><!-- 0..1 Difficulty scaling factor -->
  <</net>
  <</udi>
  <</bodySite>
  <</subSite>
  <</modifier>

  <net><!-- 0..1 Quantity(Money) Total item cost --></net>
  <udi><!-- 0..* Reference(Device) Unique Device Identifier --></udi>
  <bodySite><!-- 0..1 Coding Service Location --></bodySite>
  <subSite><!-- 0..* Coding Service Sub-location --></subSite>

  <detail>  <!-- 0..* Additional items -->
   <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
   <</type>

   <type><!-- 1..1 Coding Group or type of product or service --></type>

   <service><!-- 1..1 Coding Additional item codes --></service>
   <programCode><!-- 0..* Coding Program specific reason for item inclusion --></programCode>

   <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
   <unitPrice><!-- 0..1 Quantity(Money) Fee, charge or cost per point --></unitPrice>
   <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
   <points value="[decimal]"/><!-- 0..1 Difficulty scaling factor -->
   <</net>
   <</udi>

   <net><!-- 0..1 Quantity(Money) Total additional item cost --></net>
   <udi><!-- 0..* Reference(Device) Unique Device Identifier --></udi>

   <subDetail>  <!-- 0..* Additional items -->
    <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
    <</type>
    <</service>

    <type><!-- 1..1 Coding Type of product or service --></type>
    <service><!-- 1..1 Coding Additional item codes --></service>
    <programCode><!-- 0..* Coding Program specific reason for item inclusion --></programCode>

    <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
    <</unitPrice>

    <unitPrice><!-- 0..1 Quantity(Money) Fee, charge or cost per point --></unitPrice>

    <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
    <points value="[decimal]"/><!-- 0..1 Difficulty scaling factor -->
    <</net>
    <</udi>

    <net><!-- 0..1 Quantity(Money) Net additional item cost --></net>
    <udi><!-- 0..* Reference(Device) Unique Device Identifier --></udi>

   </subDetail>
  </detail>
  <prosthesis>  <!-- 0..1 Prosthetic details -->
   <initial value="[boolean]"/><!-- 0..1 Is this the initial service -->
   <priorDate value="[date]"/><!-- 0..1 Initial service Date -->
   <priorMaterial><!-- 0..1 Coding Prosthetic Material --></priorMaterial>
  </prosthesis>
 </item>
 <</additionalMaterials>

 <total><!-- 0..1 Quantity(Money) Total claim cost --></total>
 <additionalMaterial><!-- 0..* Coding Additional supporting materials and documents --></additionalMaterial>

 <missingTeeth>  <!-- 0..* Only if type = oral -->
  <tooth><!-- 1..1 Coding Tooth Code --></tooth>
  <</reason>
  <

  <reason><!-- 0..1 Coding Indicates whether it was extracted or other reason --></reason>
  <extractionDate value="[date]"/><!-- 0..1 Date tooth was extracted if known -->

 </missingTeeth>
</Claim>

JSON Template JSON Template 

{doco
  "resourceType" : "Claim",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "
  "

  "type" : "<code>", // R!  institutional | oral | pharmacy | professional | vision
  "subType" : [{ Coding }], // Finer grained claim type information
  "identifier" : [{ Identifier }], // Claim number

  "ruleset" : { Coding }, // Current specification followed
  "originalRuleset" : { Coding }, // Original specification followed
  "created" : "<dateTime>", // Creation date
  "
  "
  "

  "billablePeriod" : { Period }, // Period for charge submission
  // target[x]: Insurer. One of these 2:

  "targetIdentifier" : { Identifier },
  "targetReference" : { Reference(Organization) },
  // provider[x]: Responsible provider. One of these 2:

  "providerIdentifier" : { Identifier },
  "providerReference" : { Reference(Practitioner) },
  // organization[x]: Responsible organization. One of these 2:

  "organizationIdentifier" : { Identifier },
  "organizationReference" : { Reference(Organization) },

  "use" : "<code>", // complete | proposed | exploratory | other
  "

  "priority" : { Coding }, // Desired processing priority

  "fundsReserve" : { Coding }, // Funds requested to be reserved
  "
  "
  "
  "
  "
    "
    "
    "
    "

  // enterer[x]: Author. One of these 2:
  "entererIdentifier" : { Identifier },
  "entererReference" : { Reference(Practitioner) },
  // facility[x]: Servicing Facility. One of these 2:

  "facilityIdentifier" : { Identifier },
  "facilityReference" : { Reference(Location) },
  "related" : [{ // Related Claims which may be revelant to processing this claimn
    // claim[x]: Reference to the related claim. One of these 2:

    "claimIdentifier" : { Identifier },
    "claimReference" : { Reference(Claim) },
    "relationship" : { Coding }, // How the reference claim is related
    "reference" : { Identifier } // Related file or case reference
  }],
  // prescription[x]: Prescription. One of these 2:

  "prescriptionIdentifier" : { Identifier },
  "prescriptionReference" : { Reference(MedicationOrder|VisionPrescription) },
  // originalPrescription[x]: Original Prescription. One of these 2:

  "originalPrescriptionIdentifier" : { Identifier },
  "originalPrescriptionReference" : { Reference(MedicationOrder) },
  "payee" : { // Party to be paid any benefits payable
    "type" : { Coding }, // R!  Type of party: Subscriber, Provider, other
    // party[x]: Party to receive the payable. One of these 2:

    "partyIdentifier" : { Identifier }
    "partyReference" : { Reference(Practitioner|Organization|Patient|RelatedPerson) }

  },
  "

  // referral[x]: Treatment Referral. One of these 2:
  "referralIdentifier" : { Identifier },
  "referralReference" : { Reference(ReferralRequest) },
  "occurrenceCode" : [{ Coding }], // Occurrence Codes
  "occurenceSpanCode" : [{ Coding }], // Occurrence Span Codes
  "valueCode" : [{ Coding }], // Value Codes

  "diagnosis" : [{ // Diagnosis
    "

    "sequence" : "<positiveInt>", // R!  Number to covey order of diagnosis

    "diagnosis" : { Coding } // R!  Patient's list of diagnosis
  }],
  "
  "

  "procedure" : [{ // Procedures performed
    "sequence" : "<positiveInt>", // R!  Procedure sequence for reference
    "date" : "<dateTime>", // When the procedure was performed
    // procedure[x]: Patient's list of procedures performed. One of these 2:

    "procedureCoding" : { Coding }
    "procedureReference" : { Reference(Procedure) }
  }],
  "specialCondition" : [{ Coding }], // List of special Conditions
  // patient[x]: The subject of the Products and Services. One of these 2:

  "patientIdentifier" : { Identifier },
  "patientReference" : { Reference(Patient) },

  "coverage" : [{ // Insurance or medical plan
    "sequence" : "<positiveInt>", // R!  Service instance identifier
    "
    "

    "focal" : <boolean>, // R!  Is the focal Coverage
    // coverage[x]: Insurance information. One of these 2:

    "coverageIdentifier" : { Identifier },
    "coverageReference" : { Reference(Coverage) },

    "businessArrangement" : "<string>", // Business agreement
    "

    "preAuthRef" : ["<string>"], // Pre-Authorization/Determination Reference
    "claimResponse" : { Reference(ClaimResponse) }, // Adjudication results
    "originalRuleset" : { Coding } // Original version
  }],
  "
  "
  "
  "

  "accidentDate" : "<date>", // When the accident occurred
  "accidentType" : { Coding }, // The nature of the accident
  // accidentLocation[x]: Accident Place. One of these 2:

  "accidentLocationAddress" : { Address },
  "accidentLocationReference" : { Reference(Location) },

  "interventionException" : [{ Coding }], // Intervention and exception code (Pharma)
  "onset" : [{ // Condition related Onset related dates and codes
    // time[x]: Illness, injury or treatable condition date. One of these 2:

    "timeDate" : "<date>",
    "timePeriod" : { Period },
    "type" : { Coding } // Onset of what
  }],
  "employmentImpacted" : { Period }, // Period unable to work
  "hospitalization" : { Period }, // Period in hospital

  "item" : [{ // Goods and Services
    "sequence" : "<positiveInt>", // R!  Service instance
    "
    "
    "

    "type" : { Coding }, // R!  Group or type of product or service
    // provider[x]: Responsible practitioner. One of these 2:

    "providerIdentifier" : { Identifier },
    "providerReference" : { Reference(Practitioner) },
    // supervisor[x]: Supervising Practitioner. One of these 2:

    "supervisorIdentifier" : { Identifier },
    "supervisorReference" : { Reference(Practitioner) },
    "providerQualification" : { Coding }, // Type, classification or Specialization
    "diagnosisLinkId" : ["<positiveInt>"], // Applicable diagnoses

    "service" : { Coding }, // R!  Item Code
    "

    "serviceModifier" : [{ Coding }], // Service/Product modifiers
    "modifier" : [{ Coding }], // Service/Product billing modifiers
    "programCode" : [{ Coding }], // Program specific reason for item inclusion
    // serviced[x]: Date or dates of Service. One of these 2:

    "servicedDate" : "<date>",
    "servicedPeriod" : { Period },
    "place" : { Coding }, // Place of service

    "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
    "unitPrice" : { Quantity(Money) }, // Fee, charge or cost per point
    "factor" : <decimal>, // Price scaling factor
    "points" : <decimal>, // Difficulty scaling factor
    "
    "
    "
    "
    "

    "net" : { Quantity(Money) }, // Total item cost
    "udi" : [{ Reference(Device) }], // Unique Device Identifier
    "bodySite" : { Coding }, // Service Location
    "subSite" : [{ Coding }], // Service Sub-location

    "detail" : [{ // Additional items
      "sequence" : "<positiveInt>", // R!  Service instance
      "

      "type" : { Coding }, // R!  Group or type of product or service

      "service" : { Coding }, // R!  Additional item codes
      "programCode" : [{ Coding }], // Program specific reason for item inclusion

      "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
      "unitPrice" : { Quantity(Money) }, // Fee, charge or cost per point
      "factor" : <decimal>, // Price scaling factor
      "points" : <decimal>, // Difficulty scaling factor
      "
      "

      "net" : { Quantity(Money) }, // Total additional item cost
      "udi" : [{ Reference(Device) }], // Unique Device Identifier

      "subDetail" : [{ // Additional items
        "sequence" : "<positiveInt>", // R!  Service instance
        "
        "

        "type" : { Coding }, // R!  Type of product or service
        "service" : { Coding }, // R!  Additional item codes
        "programCode" : [{ Coding }], // Program specific reason for item inclusion

        "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
        "

        "unitPrice" : { Quantity(Money) }, // Fee, charge or cost per point

        "factor" : <decimal>, // Price scaling factor
        "points" : <decimal>, // Difficulty scaling factor
        "
        "

        "net" : { Quantity(Money) }, // Net additional item cost
        "udi" : [{ Reference(Device) }] // Unique Device Identifier

      }]
    }],
    "prosthesis" : { // Prosthetic details
      "initial" : <boolean>, // Is this the initial service
      "priorDate" : "<date>", // Initial service Date
      "priorMaterial" : { Coding } // Prosthetic Material
    }
  }],
  "

  "total" : { Quantity(Money) }, // Total claim cost
  "additionalMaterial" : [{ Coding }], // Additional supporting materials and documents

  "missingTeeth" : [{ // Only if type = oral
    "tooth" : { Coding }, // R!  Tooth Code
    "
    "

    "reason" : { Coding }, // Indicates whether it was extracted or other reason
    "extractionDate" : "<date>" // Date tooth was extracted if known

  }]
}

Structure

Insurer Responsible provider Responsible organization Author Provider who is the payee The subject of the Products and Services Insurance information Surface Codes Intervention Codes UDI Codes Surface Codes
Name Flags Card. Type Description & Constraints Description & Constraints doco
. . Claim Σ DomainResource Claim, Pre-determination or Pre-authorization Claim, Pre-determination or Pre-authorization
. . . type Σ 1..1 code institutional | oral | pharmacy | professional | vision institutional | oral | pharmacy | professional | vision
ClaimType ( ( Required )
. . identifier . subType Σ 0..* Coding Finer grained claim type information
Example Claim SubType Codes ( Example )
... identifier Σ 0..* Identifier Claim number Claim number
. . . ruleset Σ 0..1 Coding Current specification followed Current specification followed
Ruleset Codes ( Ruleset Codes ( Example )
. . . originalRuleset Σ 0..1 Coding Original specification followed Original specification followed
Ruleset Codes ( Ruleset Codes ( Example )
. . . created Σ 0..1 dateTime Creation date Creation date
. . target . billablePeriod Σ 0..1 Period Period for charge submission
... target[x] Σ 0..1 Insurer
.... targetIdentifier Identifier
.... targetReference Reference ( Organization )
. . provider . provider[x] Σ 0..1 Responsible provider
.... providerIdentifier Identifier
.... providerReference Reference ( Practitioner )
. . organization . organization[x] Σ 0..1 Responsible organization
.... organizationIdentifier Identifier
.... organizationReference Reference ( Organization )
. . . use Σ 0..1 code complete | proposed | exploratory | other complete | proposed | exploratory | other
Use ( ( Required )
. . . priority Σ 0..1 Coding Desired processing priority Desired processing priority
Priority Codes ( Priority Codes ( Example )
. . . fundsReserve Σ 0..1 Coding Funds requested to be reserved Funds requested to be reserved
Funds Reservation Codes ( Funds Reservation Codes ( Example )
. . enterer . enterer[x] Σ 0..1 Author
.... entererIdentifier Identifier
.... entererReference Reference ( Practitioner )
. . facility . facility[x] Σ 0..1 Servicing Facility
.... facilityIdentifier Identifier
.... facilityReference Reference ( Location )
. . . related Servicing Facility Σ 0..* BackboneElement Related Claims which may be revelant to processing this claimn
. . . prescription . claim[x] Σ 0..1 Reference to the related claim
..... claimIdentifier Identifier
..... claimReference Reference ( MedicationOrder Claim | VisionPrescription )
.... relationship Σ 0..1 Coding How the reference claim is related
Example Related Claim Relationship Codes ( Example )
. . . . reference Prescription Σ 0..1 Identifier Related file or case reference
. . originalPrescription . prescription[x] Σ 0..1 Prescription
.... prescriptionIdentifier Identifier
.... prescriptionReference Reference ( MedicationOrder | VisionPrescription )
. . . originalPrescription[x] Original Prescription Σ 0..1 Original Prescription
.... originalPrescriptionIdentifier Identifier
.... originalPrescriptionReference Reference ( MedicationOrder )
. . . payee Σ 0..1 BackboneElement Payee Party to be paid any benefits payable
. . . . type Σ 0..1 1..1 Coding Party to be paid any benefits payable Type of party: Subscriber, Provider, other
Payee Type Codes ( Payee Type Codes ( Example )
. . . provider . party[x] Σ 0..1 Party to receive the payable
..... partyIdentifier Identifier
..... partyReference Reference ( Practitioner | Organization | Patient | RelatedPerson )
. . organization . referral[x] Σ 0..1 Treatment Referral
.... referralIdentifier Reference ( Organization ) Organization who is the payee Identifier
. . . person . referralReference Reference ( ReferralRequest )
. . . occurrenceCode Σ 0..1 0..* Reference ( Patient Coding ) Other person who is the payee Occurrence Codes
Example Occurrance Codes ( Example )
. . referral . occurenceSpanCode Σ 0..1 0..* Reference Coding ( ReferralRequest Occurrence Span Codes
Example Occurrance Span Codes ( Example )
. . . valueCode Treatment Referral Σ 0..* Coding Value Codes
Example Value Codes ( Example )
. . . diagnosis Σ 0..* BackboneElement Diagnosis
. . . . sequence Σ 1..1 positiveInt Sequence of diagnosis Number to covey order of diagnosis
. . . . diagnosis Σ 1..1 Coding Patient's list of diagnosis Patient's list of diagnosis
ICD-10 Codes ICD-10 Codes ( Example ( )
... procedure Σ 0..* BackboneElement Procedures performed
.... sequence Σ 1..1 positiveInt Procedure sequence for reference
.... date Σ 0..1 dateTime When the procedure was performed
.... procedure[x] Σ 1..1 Patient's list of procedures performed
ICD-10 Procedure Codes ( Example )
. . . . condition . procedureCoding Coding
. . . . . procedureReference Reference ( Procedure )
... specialCondition Σ 0..* Coding List of presenting Conditions List of special Conditions
Conditions Codes ( Conditions Codes ( Example )
. . patient . patient[x] Σ 1..1 The subject of the Products and Services
.... patientIdentifier Identifier
.... patientReference Reference ( Patient )
. . . coverage Σ 0..* BackboneElement Insurance or medical plan Insurance or medical plan
. . . . sequence Σ 1..1 positiveInt Service instance identifier Service instance identifier
. . . . focal Σ 1..1 boolean The focal Coverage Is the focal Coverage
. . . coverage . coverage[x] Σ 1..1 Insurance information
..... coverageIdentifier Identifier
..... coverageReference Reference ( Coverage )
. . . . businessArrangement Σ 0..1 string Business agreement Business agreement
. . . relationship . preAuthRef Σ 1..1 0..* Coding string Patient relationship to subscriber Pre-Authorization/Determination Reference
. . . . claimResponse Σ 0..1 Reference ( Example ClaimResponse ) Adjudication results
. . . preAuthRef . originalRuleset Σ 0..* 0..1 string Coding Pre-Authorization/Determination Reference Original version
Ruleset Codes ( Example )
. . claimResponse . accidentDate Σ 0..1 Reference ( ClaimResponse date ) Adjudication results When the accident occurred
. . originalRuleset . accidentType Σ 0..1 Coding Original version The nature of the accident
Ruleset Codes ActIncidentCode ( Required )
... accidentLocation[x] Σ 0..1 Accident Place
.... accidentLocationAddress Address
.... accidentLocationReference Reference ( Example Location )
. . exception . interventionException Σ 0..* Coding Eligibility exceptions Intervention and exception code (Pharma)
Exception Codes ( Intervention Codes ( Example )
. . school . onset Σ 0..1 0..* string BackboneElement Name of School Condition related Onset related dates and codes
. . . accident . time[x] Σ 0..1 Illness, injury or treatable condition date
..... timeDate date
. . . . . timePeriod Accident Date Period
. . accidentType . . type Σ 0..1 Coding Accident Type Onset of what
ActIncidentCode ( Required Example Onset Type (Reason) Codes ( Example )
. . interventionException . employmentImpacted Σ 0..* 0..1 Coding Period Intervention and exception code (Pharma) Period unable to work
. . . hospitalization ( Example Σ 0..1 Period ) Period in hospital
. . . item Σ 0..* BackboneElement Goods and Services Goods and Services
. . . . sequence Σ 1..1 positiveInt Service instance Service instance
. . . . type Σ 1..1 Coding Group or type of product or service Group or type of product or service
ActInvoiceGroupCode ( Exception Codes ( Required )
. . . provider . provider[x] Σ 0..1 Responsible practitioner
..... providerIdentifier Identifier
. . . . . providerReference Reference ( Practitioner )
.... supervisor[x] Σ 0..1 Supervising Practitioner
..... supervisorIdentifier Identifier
..... supervisorReference Reference ( Practitioner )
. . . . providerQualification Responsible practitioner Σ 0..1 Coding Type, classification or Specialization
Example Provider Qualification Codes ( Example )
. . . . diagnosisLinkId Σ 0..* positiveInt Diagnosis Link Applicable diagnoses
. . . . service Σ 1..1 Coding Item Code Item Code
USCLS Codes ( USCLS Codes ( Example )
. . . serviceDate . serviceModifier Σ 0..1 0..* date Coding Date of Service Service/Product modifiers
Example Service Modifier Codes ( Example )
. . . quantity . modifier Σ 0..1 0..* SimpleQuantity Coding Count of Products or Services Service/Product billing modifiers
Modifier type Codes ( Example )
. . . unitPrice . programCode Σ 0..* Coding Program specific reason for item inclusion
Example Program Reason Codes ( Example )
.... serviced[x] Σ 0..1 Date or dates of Service
..... servicedDate Money date
. . . . . servicedPeriod Fee, charge or cost per point Period
. . . factor . place Σ 0..1 decimal Coding Price scaling factor Place of service
Example Service Place Codes ( Example )
. . . points . quantity Σ 0..1 decimal SimpleQuantity Difficulty scaling factor Count of Products or Services
. . . net . unitPrice Σ 0..1 Money Total item cost Fee, charge or cost per point
. . . udi . factor Σ 0..1 Coding decimal Unique Device Identifier Price scaling factor
. . . . points ( Example Σ 0..1 decimal ) Difficulty scaling factor
. . . bodySite . net Σ 0..1 Coding Money Service Location Total item cost
. . . . udi Σ 0..* Reference ( Example Device ) Unique Device Identifier
. . . subSite . bodySite Σ 0..* 0..1 Coding Service Sub-location Service Location
Surface Codes ( Oral Site Codes ( Example )
. . . modifier . subSite Σ 0..* Coding Service/Product billing modifiers Service Sub-location
Modifier type Codes ( Surface Codes ( Example )
. . . . detail Σ 0..* BackboneElement Additional items Additional items
. . . . . sequence Σ 1..1 positiveInt Service instance Service instance
. . . . . type Σ 1..1 Coding Group or type of product or service Group or type of product or service
ActInvoiceGroupCode ( Exception Codes ( Required )
. . . . . service Σ 1..1 Coding Additional item codes Additional item codes
USCLS Codes USCLS Codes ( Example ( )
..... programCode Σ 0..* Coding Program specific reason for item inclusion
Example Program Reason Codes ( Example )
. . . . . quantity Σ 0..1 SimpleQuantity Count of Products or Services Count of Products or Services
. . . . . unitPrice Σ 0..1 Money Fee, charge or cost per point Fee, charge or cost per point
. . . . . factor Σ 0..1 decimal Price scaling factor Price scaling factor
. . . . . points Σ 0..1 decimal Difficulty scaling factor Difficulty scaling factor
. . . . . net Σ 0..1 Money Total additional item cost Total additional item cost
. . . . . udi Σ 0..1 Coding 0..* Unique Device Identifier UDI Codes Reference ( Example Device ) Unique Device Identifier
. . . . . subDetail Σ 0..* BackboneElement Additional items Additional items
. . . . . . sequence Σ 1..1 positiveInt Service instance Service instance
. . . . . . type Σ 1..1 Coding Type of product or service Type of product or service
ActInvoiceGroupCode ( Exception Codes ( Required )
. . . . . . service Σ 1..1 Coding Additional item codes Additional item codes
USCLS Codes USCLS Codes ( Example ( )
...... programCode Σ 0..* Coding Program specific reason for item inclusion
Example Program Reason Codes ( Example )
. . . . . . quantity Σ 0..1 SimpleQuantity Count of Products or Services Count of Products or Services
. . . . . . unitPrice Σ 0..1 Money Fee, charge or cost per point Fee, charge or cost per point
. . . . . . factor Σ 0..1 decimal Price scaling factor Price scaling factor
. . . . . . points Σ 0..1 decimal Difficulty scaling factor Difficulty scaling factor
. . . . . . net Σ 0..1 Money Net additional item cost Net additional item cost
. . . . . . udi Σ 0..1 Coding 0..* Unique Device Identifier UDI Codes Reference ( Example Device ) Unique Device Identifier
. . . . prosthesis Σ 0..1 BackboneElement Prosthetic details Prosthetic details
. . . . . initial Σ 0..1 boolean Is this the initial service Is this the initial service
. . . . . priorDate Σ 0..1 date Initial service Date Initial service Date
. . . . . priorMaterial Σ 0..1 Coding Prosthetic Material Prosthetic Material
Oral Prostho Material type Codes ( Oral Prostho Material type Codes ( Example )
. . additionalMaterials . total Σ 0..1 Money Total claim cost
... additionalMaterial Σ 0..* Coding Additional materials, documents, etc. Additional supporting materials and documents
Additional Material Codes ( Additional Material Codes ( Example )
. . . missingTeeth Σ 0..* BackboneElement Only if type = oral Only if type = oral
. . . . tooth Σ 1..1 Coding Tooth Code Tooth Code
Teeth Codes ( Teeth Codes ( Example )
. . . . reason Σ 0..1 Coding Reason for missing Indicates whether it was extracted or other reason
Missing Tooth Reason Codes ( Missing Tooth Reason Codes ( Example )
. . . . extractionDate Σ 0..1 date Date of Extraction Date tooth was extracted if known

Documentation for this format doco Documentation for this format

UML Diagram UML Diagram

Claim ( ( DomainResource ) The category of claim this is The category of claim type : : code [1..1] « [1..1] « The type or discipline-style of the claim. (Strength=Required) The type or discipline-style of the claim (Strength=Required) ClaimType ! » ! » A finer grained suite of claim subtype codes which may convey Inpatient vs Outpatient and/or a specialty service. In the US the BillType subType : Coding [0..*] « A more granulat claim typecode (Strength=Example) Example Claim SubType ?? » The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization number The business identifier for the instance: claim number, pre-determination or pre-authorization number identifier : : Identifier [0..*] [0..*] The version of the specification on which this instance relies The version of the specification on which this instance relies ruleset : : Coding [0..1] « [0..1] « The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example) The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example) Ruleset ?? » Ruleset ?? » The version of the specification from which the original instance was created The version of the specification from which the original instance was created originalRuleset : : Coding [0..1] « [0..1] « The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example) The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example) Ruleset ?? » Ruleset ?? » The date when the enclosed suite of services were performed or completed The date when the enclosed suite of services were performed or completed created : : dateTime [0..1] [0..1] Insurer Identifier, typical BIN number (6 digit) The billable period for which charges are being submitted target billablePeriod : Period [0..1] Insurer Identifier, typical BIN number (6 digit) target[x] : Type [0..1] « Identifier : | Reference [0..1] « ( Organization » ) » The provider which is responsible for the bill, claim pre-determination, pre-authorization The provider which is responsible for the bill, claim pre-determination, pre-authorization provider provider[x] : Type [0..1] « Identifier : | Reference [0..1] « ( Practitioner » ) » The organization which is responsible for the bill, claim pre-determination, pre-authorization The organization which is responsible for the bill, claim pre-determination, pre-authorization organization organization[x] : Type [0..1] « Identifier : | Reference [0..1] « ( Organization » ) » Complete (Bill or Claim), Proposed (Pre-Authorization), Exploratory (Pre-determination) Complete (Bill or Claim), Proposed (Pre-Authorization), Exploratory (Pre-determination) use : : code [0..1] « [0..1] « Complete, proposed, exploratory, other. (Strength=Required) Complete, proposed, exploratory, other (Strength=Required) Use ! » ! » Immediate (stat), best effort (normal), deferred (deferred) Immediate (STAT), best effort (NORMAL), deferred (DEFER) priority : : Coding [0..1] « [0..1] « The timeliness with which processing is required: STAT, Normal, Deferred. (Strength=Example) The timeliness with which processing is required: STAT, normal, Deferred (Strength=Example) Priority ?? » Priority ?? » 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 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 fundsReserve : : Coding [0..1] « [0..1] « For whom funds are to be reserved: (Patient, Provider, None). (Strength=Example) For whom funds are to be reserved: (Patient, Provider, None). (Strength=Example) Funds Reservation ?? » Funds Reservation ?? » Person who created the invoice/claim/pre-determination or pre-authorization Person who created the invoice/claim/pre-determination or pre-authorization enterer enterer[x] : Type [0..1] « Identifier : | Reference [0..1] « ( Practitioner » ) » Facility where the services were provided Facility where the services were provided facility facility[x] : Type [0..1] « Identifier : | Reference [0..1] « ( Location » ) » Prescription to support the dispensing of Pharmacy or Vision products Prescription to support the dispensing of Pharmacy or Vision products prescription prescription[x] : Type [0..1] « Identifier : | Reference [0..1] « ( MedicationOrder | VisionPrescription » ) » Original prescription to support the dispensing of pharmacy services, medications or products Original prescription which has been superceded by this prescription to support the dispensing of pharmacy services, medications or products originalPrescription originalPrescription[x] : Type [0..1] « Identifier : | Reference [0..1] « ( MedicationOrder » ) » The referral resource which lists the date, practitioner, reason and other supporting information The referral resource which lists the date, practitioner, reason and other supporting information referral referral[x] : Type [0..1] « Identifier : | Reference [0..1] « ( ReferralRequest » ) » List of patient conditions for which care is sought **Insert definition of Occurrence codes condition : occurrenceCode : Coding [0..*] « [0..*] « Patient conditions and symptoms. (Strength=Example) Occurrence codes (Strength=Example) Conditions ?? » Example Occurrance ?? » Patient Resource **Insert definition of Occurrence Span codes patient : Reference [1..1] « Patient » occurenceSpanCode : Coding [0..*] « Occurrence Span codes (Strength=Example) Example Occurrance Span ?? » Factors which may influence the applicability of coverage **Insert definition of Value codes exception : valueCode : Coding [0..*] « [0..*] « The eligibility exception codes. (Strength=Example) Value code (Strength=Example) Exception ?? » Example Value ?? » Name of school for over-aged dependents List of special conditions relating to the setting, treatment or patient for which care is sought which may influence the adjudication school specialCondition : Coding [0..*] « Patient conditions and symptoms (Strength=Example) Conditions ?? » Patient Resource patient[x] : Type [1..1] « Identifier : string | Reference [0..1] ( Patient ) » Date of an accident which these services are addressing Date of an accident which these services are addressing accident : accidentDate : date [0..1] [0..1] Type of accident: work, auto, etc Type of accident: work, auto, etc accidentType : : Coding [0..1] « [0..1] « Type of accident: work place, auto, etc. (Strength=Required) Type of accident: work place, auto, etc. (Strength=Required) ActIncidentCode ! » ! » A list of intervention and exception codes which may influence the adjudication of the claim Accident Place interventionException accidentLocation[x] : Type [0..1] « Address : Coding | Reference [0..*] « Intervention and exception codes (Pharm). (Strength=Example) Intervention ( Location ?? » ) » Code to indicate that Xrays, images, emails, documents, models or attachments are being sent in support of this submission A list of intervention and exception codes which may influence the adjudication of the claim additionalMaterials : interventionException : Coding [0..*] « [0..*] « Code to indicate that Xrays, images, emails, documents, models or attachments are being sent in support of this submission. (Strength=Example) Intervention and exception codes (Pharm) (Strength=Example) Additional Material ?? » Intervention ?? » The start and optional end dates of when the patient was precluded from working due to the treatable condition(s) employmentImpacted : Period [0..1] Payee The start and optional end dates of when the patient was confined to a treatment center hospitalization : Period [0..1] Party to be reimbursed: Subscriber, provider, other The total value of the claim type total : Quantity : Coding ( Money [0..1] « ) [0..1] A code for the party to be reimbursed. (Strength=Example) Code to indicate that Xrays, images, emails, documents, models or attachments are being sent in support of this submission Payee Type ?? » additionalMaterial : Coding [0..*] « Code to indicate that Xrays, images, emails, documents, models or attachments are being sent in support of this submission. (Strength=Example) Additional Material ?? » RelatedClaims The provider who is to be reimbursed for the claim (the party to whom any benefit is assigned) Other claims which are related to this claim such as prior claim versions or for related services provider claim[x] : Type [0..1] « Identifier : | Reference [0..1] « Practitioner ( Claim » ) » The organization who is to be reimbursed for the claim (the party to whom any benefit is assigned) For example prior or umbrella organization : Reference [0..1] « Organization relationship : Coding [0..1] « Relationship of this claim to a related Claim (Strength=Example) Example Related Claim Relatio... » ?? » The person other than the subscriber who is to be reimbursed for the claim (the party to whom any benefit is assigned) An alternate organizational reference to the case or file to which this particular claim pertains - eg Property/Casualy insurer claim # or Workers Compensation case # reference : Identifier [0..1] Payee Type of Party to be reimbursed: Subscriber, provider, other person type : Coding [1..1] « A code for the party to be reimbursed. (Strength=Example) Payee Type ?? » Party to be reimbursed: Subscriber, provider, other party[x] : Type [0..1] « Identifier : | Reference [0..1] « ( Practitioner | Organization | Patient » | RelatedPerson ) » Diagnosis Sequence of diagnosis which serves to order and provide a link Sequence of diagnosis which serves to order and provide a link sequence : : positiveInt [1..1] [1..1] The diagnosis The diagnosis diagnosis : : Coding [1..1] « ICD10 Diagnostic codes (Strength=Example) ICD-10 ?? » Procedure Sequence of procedures which serves to order and provide a link sequence : positiveInt [1..1] Date and optionally time the procedure was performed date : dateTime [0..1] The procedure code procedure[x] : Type [1..1] « Coding [1..1] « | Reference ( Procedure ); ICD10 diagnostic codes. (Strength=Example) ICD10 Procedure codes (Strength=Example) ICD-10 ?? » Procedure ?? » Coverage A service line item A service line item sequence : : positiveInt [1..1] [1..1] The instance number of the Coverage which is the focus for adjudication. The Coverage against which the claim is to be adjudicated The instance number of the Coverage which is the focus for adjudication. The Coverage against which the claim is to be adjudicated focal : : boolean [1..1] [1..1] Reference to the program or plan identification, underwriter or payor Reference to the program or plan identification, underwriter or payor coverage coverage[x] : Type [1..1] « Identifier : | Reference [1..1] « ( Coverage » ) » The contract number of a business agreement which describes the terms and conditions The contract number of a business agreement which describes the terms and conditions businessArrangement : : string [0..1] The relationship of the patient to the subscriber relationship : Coding [1..1] « The code for the relationship of the patient to the subscriber. (Strength=Example) Surface ?? » [0..1] A list of references from the Insurer to which these services pertain A list of references from the Insurer to which these services pertain preAuthRef : : string [0..*] [0..*] The Coverages adjudication details The Coverages adjudication details claimResponse : : Reference [0..1] « [0..1] « ClaimResponse » » The style (standard) and version of the original material which was converted into this resource The style (standard) and version of the original material which was converted into this resource originalRuleset : : Coding [0..1] « [0..1] « The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example) The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example) Ruleset Ruleset ?? » Onset The start or start and end dates for the treatable condition time[x] : Type [0..1] « date ?? » | Period » Onset typifications eg. Start of pregnancy, start of illnes, etc type : Coding [0..1] « Condition related start, end and period codes (Strength=Example) Example Onset Type (Reason) ?? » Items A service line number A service line number sequence : : positiveInt [1..1] [1..1] The type of product or service The type of product or service type : : Coding [1..1] « [1..1] « Service, Product, Rx Dispense, Rx Compound etc. (Strength=Required) Group, Service, Product. (Strength=Required) ActInvoiceGroupCode ! » Exception ! » The practitioner who is responsible for the services rendered to the patient The practitioner who is responsible for the services rendered to the patient provider provider[x] : Type [0..1] « Identifier : | Reference [0..1] « ( Practitioner » ) » The practitioner who is supervising the work of the servicing provider(s) supervisor[x] : Type [0..1] « Identifier | Reference ( Practitioner ) » The qualification which is applicable for this service providerQualification : Coding [0..1] « Provider professional qualifications (Strength=Example) Example Provider Qualificatio... ?? » Diagnosis applicable for this service or product line Diagnosis applicable for this service or product line diagnosisLinkId : : positiveInt [0..*] [0..*] If a grouping item then 'GROUP' otherwise it is a node therefore a code to indicate the Professional Service or Product supplied If a grouping item then 'GROUP' otherwise it is a node therefore a code to indicate the Professional Service or Product supplied service : : Coding [1..1] « [1..1] « Allowable service and product codes. (Strength=Example) Allowable service and product codes (Strength=Example) USCLS ?? » USCLS ?? » The date when the enclosed suite of services were performed or completed Unusual circumstances which may influence adjudication serviceDate : serviceModifier : Coding [0..*] « Factors which may influce adjudication of services (Strength=Example) Example Service Modifier ?? » Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen modifier : Coding [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example) Modifier type ?? » For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program programCode : Coding [0..*] « Program specific reason codes (Strength=Example) Example Program Reason ?? » The date or dates when the enclosed suite of services were performed or completed serviced[x] : Type [0..1] « date [0..1] | Period » Where the service was provided place : Coding [0..1] « (Strength=Example) Example Service Place ?? » The number of repetitions of a service or product The number of repetitions of a service or product quantity : : Quantity ( SimpleQuantity ) [0..1] ) [0..1] If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group unitPrice : : Quantity ( Money ) [0..1] ) [0..1] 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 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 factor : : decimal [0..1] [0..1] An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each point An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each point points : : decimal [0..1] [0..1] The quantity times the unit price for an additional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied net : : Quantity ( Money ) [0..1] ) [0..1] List of Unique Device Identifiers associated with this line item List of Unique Device Identifiers associated with this line item udi : Coding [0..1] « The FDA, or other, UDI repository. (Strength=Example) UDI ?? » : Reference [0..*] « Device » Physical service site on the patient (limb, tooth, etc.) Physical service site on the patient (limb, tooth, etc) bodySite : : Coding [0..1] « [0..1] « The code for the teeth, quadrant, sextant and arch. (Strength=Example) The code for the teeth, quadrant, sextant and arch (Strength=Example) Surface ?? » Oral Site ?? » A region or surface of the site, e.g. limb region or tooth surface(s) A region or surface of the site, eg. limb region or tooth surface(s) subSite : Coding [0..*] « The code for the tooth surface and surface combinations. (Strength=Example) Surface ?? » Item typification or modifiers codes, e.g. for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen modifier : : Coding [0..*] « [0..*] « Item type or modifiers codes, e.g. for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example) The code for the tooth surface and surface combinations (Strength=Example) Modifier type ?? » Surface ?? » Detail A service line number A service line number sequence : : positiveInt [1..1] [1..1] The type of product or service The type of product or service type : : Coding [1..1] « [1..1] « Service, Product, Rx Dispense, Rx Compound etc. (Strength=Required) Group, Service, Product. (Strength=Required) ActInvoiceGroupCode ! » Exception ! » If a grouping item then 'GROUP' otherwise it is a node therefore a code to indicate the Professional Service or Product supplied If a grouping item then 'GROUP' otherwise it is a node therefore a code to indicate the Professional Service or Product supplied service : : Coding [1..1] « [1..1] « Allowable service and product codes. (Strength=Example) Allowable service and product codes (Strength=Example) USCLS ?? » USCLS ?? » For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program programCode : Coding [0..*] « Program specific reason codes (Strength=Example) Example Program Reason ?? » The number of repetitions of a service or product The number of repetitions of a service or product quantity : : Quantity ( SimpleQuantity ) [0..1] ) [0..1] If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group unitPrice : : Quantity ( Money ) [0..1] ) [0..1] 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 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 factor : : decimal [0..1] [0..1] An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each point An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each point points : : decimal [0..1] [0..1] The quantity times the unit price for an additional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied net : : Quantity ( Money ) [0..1] ) [0..1] List of Unique Device Identifiers associated with this line item List of Unique Device Identifiers associated with this line item udi : Coding [0..1] « The FDA, or other, UDI repository. (Strength=Example) UDI ?? » : Reference [0..*] « Device » SubDetail A service line number A service line number sequence : : positiveInt [1..1] [1..1] The type of product or service The type of product or service type : : Coding [1..1] « [1..1] « Service, Product, Rx Dispense, Rx Compound etc. (Strength=Required) Group, Service, Product. (Strength=Required) ActInvoiceGroupCode ! » Exception ! » The fee for an additional service or product or charge The fee for an addittional service or product or charge service : : Coding [1..1] « [1..1] « Allowable service and product codes. (Strength=Example) Allowable service and product codes (Strength=Example) USCLS ?? » USCLS ?? » For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program programCode : Coding [0..*] « Program specific reason codes (Strength=Example) Example Program Reason ?? » The number of repetitions of a service or product The number of repetitions of a service or product quantity : : Quantity ( SimpleQuantity ) [0..1] ) [0..1] The fee for an additional service or product or charge The fee for an addittional service or product or charge unitPrice : : Quantity ( Money ) [0..1] ) [0..1] 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 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 factor : : decimal [0..1] [0..1] An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each point An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each point points : : decimal [0..1] [0..1] The quantity times the unit price for an additional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied net : : Quantity ( Money ) [0..1] ) [0..1] List of Unique Device Identifiers associated with this line item List of Unique Device Identifiers associated with this line item udi : Coding [0..1] « The FDA, or other, UDI repository. (Strength=Example) UDI ?? » : Reference [0..*] « Device » Prosthesis Indicates whether this is the initial placement of a fixed prosthesis Indicates whether this is the initial placement of a fixed prosthesis initial : : boolean [0..1] [0..1] Date of the initial placement Date of the initial placement priorDate : : date [0..1] [0..1] Material of the prior denture or bridge prosthesis. (Oral) Material of the prior denture or bridge prosthesis. (Oral) priorMaterial : : Coding [0..1] « [0..1] « Material of the prior denture or bridge prosthesis. (Oral) (Strength=Example) Material of the prior denture or bridge prosthesis. (Oral) (Strength=Example) Oral Prostho Material type ?? » Oral Prostho Material type ?? » MissingTeeth The code identifying which tooth is missing The code identifying which tooth is missing tooth : : Coding [1..1] « [1..1] « The codes for the teeth, subset of OralSites. (Strength=Example) The codes for the teeth, subset of OralSites (Strength=Example) Teeth ?? » Teeth ?? » Missing reason may be: E-extraction, O-other Missing reason may be: E-extraction, O-other reason : : Coding [0..1] « [0..1] « Reason codes for the missing teeth. (Strength=Example) Reason codes for the missing teeth (Strength=Example) Missing Tooth Reason ?? » Missing Tooth Reason ?? » The date of the extraction either known from records or patient reported estimate The date of the extraction either known from records or patient reported estimate extractionDate : : date [0..1] [0..1] Other claims which are related to this claim such as prior claim versions or for related services related [0..*] The party to be reimbursed for the services The party to be reimbursed for the services payee [0..1] Ordered list of patient diagnosis for which care is sought Ordered list of patient diagnosis for which care is sought diagnosis [0..*] Ordered list of patient procedures performed to support the adjudication procedure [0..*] Financial instrument by which payment information for health care Financial instrument by which payment information for health care coverage [0..*] Period, start and last dates of aspects of the Condition or related services onset [0..*] Third tier of goods and services Third tier of goods and services subDetail [0..*] Second tier of goods and services Second tier of goods and services detail [0..*] The materials and placement date of prior fixed prosthesis The materials and placement date of prior fixed prosthesis prosthesis [0..1] First tier of goods and services First tier of goods and services item [0..*] A list of teeth which would be expected but are not found due to having been previously extracted or for other reasons A list of teeth which would be expected but are not found due to having been previously extracted or for other reasons missingTeeth [0..*]

XML Template XML Template 

<Claim xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <
 <</identifier>

 <type value="[code]"/><!-- 1..1 institutional | oral | pharmacy | professional | vision -->
 <subType><!-- 0..* Coding Finer grained claim type information --></subType>
 <identifier><!-- 0..* Identifier Claim number --></identifier>

 <ruleset><!-- 0..1 Coding Current specification followed --></ruleset>
 <originalRuleset><!-- 0..1 Coding Original specification followed --></originalRuleset>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <</target>
 <</provider>
 <</organization>

 <billablePeriod><!-- 0..1 Period Period for charge submission --></billablePeriod>
 <target[x]><!-- 0..1 Identifier|Reference(Organization) Insurer --></target[x]>
 <provider[x]><!-- 0..1 Identifier|Reference(Practitioner) Responsible provider --></provider[x]>
 <organization[x]><!-- 0..1 Identifier|Reference(Organization) Responsible organization --></organization[x]>

 <use value="[code]"/><!-- 0..1 complete | proposed | exploratory | other -->
 <</priority>

 <priority><!-- 0..1 Coding Desired processing priority --></priority>

 <fundsReserve><!-- 0..1 Coding Funds requested to be reserved --></fundsReserve>
 <</enterer>
 <</facility>
 <</prescription>
 <</originalPrescription>
 <
  <</type>
  <</provider>
  <</organization>
  <</person>

 <enterer[x]><!-- 0..1 Identifier|Reference(Practitioner) Author --></enterer[x]>
 <facility[x]><!-- 0..1 Identifier|Reference(Location) Servicing Facility --></facility[x]>
 <related>  <!-- 0..* Related Claims which may be revelant to processing this claimn -->
  <claim[x]><!-- 0..1 Identifier|Reference(Claim) Reference to the related claim --></claim[x]>
  <relationship><!-- 0..1 Coding How the reference claim is related --></relationship>
  <reference><!-- 0..1 Identifier Related file or case reference --></reference>
 </related>
 <prescription[x]><!-- 0..1 Identifier|Reference(MedicationOrder|
   VisionPrescription) Prescription --></prescription[x]>

 <originalPrescription[x]><!-- 0..1 Identifier|Reference(MedicationOrder) Original Prescription --></originalPrescription[x]>
 <payee>  <!-- 0..1 Party to be paid any benefits payable -->
  <type><!-- 1..1 Coding Type of party: Subscriber, Provider, other --></type>
  <party[x]><!-- 0..1 Identifier|Reference(Practitioner|Organization|Patient|
    RelatedPerson) Party to receive the payable --></party[x]>
 </payee>
 <</referral>

 <referral[x]><!-- 0..1 Identifier|Reference(ReferralRequest) Treatment Referral --></referral[x]>
 <occurrenceCode><!-- 0..* Coding Occurrence Codes --></occurrenceCode>
 <occurenceSpanCode><!-- 0..* Coding Occurrence Span Codes --></occurenceSpanCode>
 <valueCode><!-- 0..* Coding Value Codes --></valueCode>

 <diagnosis>  <!-- 0..* Diagnosis -->
  <

  <sequence value="[positiveInt]"/><!-- 1..1 Number to covey order of diagnosis -->

  <diagnosis><!-- 1..1 Coding Patient's list of diagnosis --></diagnosis>
 </diagnosis>
 <</condition>
 <</patient>

 <procedure>  <!-- 0..* Procedures performed -->
  <sequence value="[positiveInt]"/><!-- 1..1 Procedure sequence for reference -->
  <date value="[dateTime]"/><!-- 0..1 When the procedure was performed -->
  <procedure[x]><!-- 1..1 Coding|Reference(Procedure) Patient's list of procedures performed --></procedure[x]>
 </procedure>
 <specialCondition><!-- 0..* Coding List of special Conditions --></specialCondition>
 <patient[x]><!-- 1..1 Identifier|Reference(Patient) The subject of the Products and Services --></patient[x]>

 <coverage>  <!-- 0..* Insurance or medical plan -->
  <sequence value="[positiveInt]"/><!-- 1..1 Service instance identifier -->
  <
  <</coverage>

  <focal value="[boolean]"/><!-- 1..1 Is the focal Coverage -->
  <coverage[x]><!-- 1..1 Identifier|Reference(Coverage) Insurance information --></coverage[x]>

  <businessArrangement value="[string]"/><!-- 0..1 Business agreement -->
  <</relationship>

  <preAuthRef value="[string]"/><!-- 0..* Pre-Authorization/Determination Reference -->
  <claimResponse><!-- 0..1 Reference(ClaimResponse) Adjudication results --></claimResponse>
  <originalRuleset><!-- 0..1 Coding Original version --></originalRuleset>
 </coverage>
 <</exception>
 <
 <
 <</accidentType>

 <accidentDate value="[date]"/><!-- 0..1 When the accident occurred -->
 <accidentType><!-- 0..1 Coding The nature of the accident --></accidentType>
 <accidentLocation[x]><!-- 0..1 Address|Reference(Location) Accident Place --></accidentLocation[x]>

 <interventionException><!-- 0..* Coding Intervention and exception code (Pharma) --></interventionException>
 <onset>  <!-- 0..* Condition related Onset related dates and codes -->
  <time[x]><!-- 0..1 date|Period Illness, injury or treatable condition date --></time[x]>
  <type><!-- 0..1 Coding Onset of what --></type>
 </onset>
 <employmentImpacted><!-- 0..1 Period Period unable to work --></employmentImpacted>
 <hospitalization><!-- 0..1 Period Period in hospital --></hospitalization>

 <item>  <!-- 0..* Goods and Services -->
  <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
  <</type>
  <</provider>
  <

  <type><!-- 1..1 Coding Group or type of product or service --></type>
  <provider[x]><!-- 0..1 Identifier|Reference(Practitioner) Responsible practitioner --></provider[x]>
  <supervisor[x]><!-- 0..1 Identifier|Reference(Practitioner) Supervising Practitioner --></supervisor[x]>
  <providerQualification><!-- 0..1 Coding Type, classification or Specialization --></providerQualification>
  <diagnosisLinkId value="[positiveInt]"/><!-- 0..* Applicable diagnoses -->

  <service><!-- 1..1 Coding Item Code --></service>
  <

  <serviceModifier><!-- 0..* Coding Service/Product modifiers --></serviceModifier>
  <modifier><!-- 0..* Coding Service/Product billing modifiers --></modifier>
  <programCode><!-- 0..* Coding Program specific reason for item inclusion --></programCode>
  <serviced[x]><!-- 0..1 date|Period Date or dates of Service --></serviced[x]>
  <place><!-- 0..1 Coding Place of service --></place>

  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
  <unitPrice><!-- 0..1 Quantity(Money) Fee, charge or cost per point --></unitPrice>
  <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
  <points value="[decimal]"/><!-- 0..1 Difficulty scaling factor -->
  <</net>
  <</udi>
  <</bodySite>
  <</subSite>
  <</modifier>

  <net><!-- 0..1 Quantity(Money) Total item cost --></net>
  <udi><!-- 0..* Reference(Device) Unique Device Identifier --></udi>
  <bodySite><!-- 0..1 Coding Service Location --></bodySite>
  <subSite><!-- 0..* Coding Service Sub-location --></subSite>

  <detail>  <!-- 0..* Additional items -->
   <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
   <</type>

   <type><!-- 1..1 Coding Group or type of product or service --></type>

   <service><!-- 1..1 Coding Additional item codes --></service>
   <programCode><!-- 0..* Coding Program specific reason for item inclusion --></programCode>

   <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
   <unitPrice><!-- 0..1 Quantity(Money) Fee, charge or cost per point --></unitPrice>
   <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
   <points value="[decimal]"/><!-- 0..1 Difficulty scaling factor -->
   <</net>
   <</udi>

   <net><!-- 0..1 Quantity(Money) Total additional item cost --></net>
   <udi><!-- 0..* Reference(Device) Unique Device Identifier --></udi>

   <subDetail>  <!-- 0..* Additional items -->
    <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
    <</type>
    <</service>

    <type><!-- 1..1 Coding Type of product or service --></type>
    <service><!-- 1..1 Coding Additional item codes --></service>
    <programCode><!-- 0..* Coding Program specific reason for item inclusion --></programCode>

    <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
    <</unitPrice>

    <unitPrice><!-- 0..1 Quantity(Money) Fee, charge or cost per point --></unitPrice>

    <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
    <points value="[decimal]"/><!-- 0..1 Difficulty scaling factor -->
    <</net>
    <</udi>

    <net><!-- 0..1 Quantity(Money) Net additional item cost --></net>
    <udi><!-- 0..* Reference(Device) Unique Device Identifier --></udi>

   </subDetail>
  </detail>
  <prosthesis>  <!-- 0..1 Prosthetic details -->
   <initial value="[boolean]"/><!-- 0..1 Is this the initial service -->
   <priorDate value="[date]"/><!-- 0..1 Initial service Date -->
   <priorMaterial><!-- 0..1 Coding Prosthetic Material --></priorMaterial>
  </prosthesis>
 </item>
 <</additionalMaterials>

 <total><!-- 0..1 Quantity(Money) Total claim cost --></total>
 <additionalMaterial><!-- 0..* Coding Additional supporting materials and documents --></additionalMaterial>

 <missingTeeth>  <!-- 0..* Only if type = oral -->
  <tooth><!-- 1..1 Coding Tooth Code --></tooth>
  <</reason>
  <

  <reason><!-- 0..1 Coding Indicates whether it was extracted or other reason --></reason>
  <extractionDate value="[date]"/><!-- 0..1 Date tooth was extracted if known -->

 </missingTeeth>
</Claim>

JSON Template JSON Template 

{doco
  "resourceType" : "Claim",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "
  "

  "type" : "<code>", // R!  institutional | oral | pharmacy | professional | vision
  "subType" : [{ Coding }], // Finer grained claim type information
  "identifier" : [{ Identifier }], // Claim number

  "ruleset" : { Coding }, // Current specification followed
  "originalRuleset" : { Coding }, // Original specification followed
  "created" : "<dateTime>", // Creation date
  "
  "
  "

  "billablePeriod" : { Period }, // Period for charge submission
  // target[x]: Insurer. One of these 2:

  "targetIdentifier" : { Identifier },
  "targetReference" : { Reference(Organization) },
  // provider[x]: Responsible provider. One of these 2:

  "providerIdentifier" : { Identifier },
  "providerReference" : { Reference(Practitioner) },
  // organization[x]: Responsible organization. One of these 2:

  "organizationIdentifier" : { Identifier },
  "organizationReference" : { Reference(Organization) },

  "use" : "<code>", // complete | proposed | exploratory | other
  "

  "priority" : { Coding }, // Desired processing priority

  "fundsReserve" : { Coding }, // Funds requested to be reserved
  "
  "
  "
  "
  "
    "
    "
    "
    "

  // enterer[x]: Author. One of these 2:
  "entererIdentifier" : { Identifier },
  "entererReference" : { Reference(Practitioner) },
  // facility[x]: Servicing Facility. One of these 2:

  "facilityIdentifier" : { Identifier },
  "facilityReference" : { Reference(Location) },
  "related" : [{ // Related Claims which may be revelant to processing this claimn
    // claim[x]: Reference to the related claim. One of these 2:

    "claimIdentifier" : { Identifier },
    "claimReference" : { Reference(Claim) },
    "relationship" : { Coding }, // How the reference claim is related
    "reference" : { Identifier } // Related file or case reference
  }],
  // prescription[x]: Prescription. One of these 2:

  "prescriptionIdentifier" : { Identifier },
  "prescriptionReference" : { Reference(MedicationOrder|VisionPrescription) },
  // originalPrescription[x]: Original Prescription. One of these 2:

  "originalPrescriptionIdentifier" : { Identifier },
  "originalPrescriptionReference" : { Reference(MedicationOrder) },
  "payee" : { // Party to be paid any benefits payable
    "type" : { Coding }, // R!  Type of party: Subscriber, Provider, other
    // party[x]: Party to receive the payable. One of these 2:

    "partyIdentifier" : { Identifier }
    "partyReference" : { Reference(Practitioner|Organization|Patient|RelatedPerson) }

  },
  "

  // referral[x]: Treatment Referral. One of these 2:
  "referralIdentifier" : { Identifier },
  "referralReference" : { Reference(ReferralRequest) },
  "occurrenceCode" : [{ Coding }], // Occurrence Codes
  "occurenceSpanCode" : [{ Coding }], // Occurrence Span Codes
  "valueCode" : [{ Coding }], // Value Codes

  "diagnosis" : [{ // Diagnosis
    "

    "sequence" : "<positiveInt>", // R!  Number to covey order of diagnosis

    "diagnosis" : { Coding } // R!  Patient's list of diagnosis
  }],
  "
  "

  "procedure" : [{ // Procedures performed
    "sequence" : "<positiveInt>", // R!  Procedure sequence for reference
    "date" : "<dateTime>", // When the procedure was performed
    // procedure[x]: Patient's list of procedures performed. One of these 2:

    "procedureCoding" : { Coding }
    "procedureReference" : { Reference(Procedure) }
  }],
  "specialCondition" : [{ Coding }], // List of special Conditions
  // patient[x]: The subject of the Products and Services. One of these 2:

  "patientIdentifier" : { Identifier },
  "patientReference" : { Reference(Patient) },

  "coverage" : [{ // Insurance or medical plan
    "sequence" : "<positiveInt>", // R!  Service instance identifier
    "
    "

    "focal" : <boolean>, // R!  Is the focal Coverage
    // coverage[x]: Insurance information. One of these 2:

    "coverageIdentifier" : { Identifier },
    "coverageReference" : { Reference(Coverage) },

    "businessArrangement" : "<string>", // Business agreement
    "

    "preAuthRef" : ["<string>"], // Pre-Authorization/Determination Reference
    "claimResponse" : { Reference(ClaimResponse) }, // Adjudication results
    "originalRuleset" : { Coding } // Original version
  }],
  "
  "
  "
  "

  "accidentDate" : "<date>", // When the accident occurred
  "accidentType" : { Coding }, // The nature of the accident
  // accidentLocation[x]: Accident Place. One of these 2:

  "accidentLocationAddress" : { Address },
  "accidentLocationReference" : { Reference(Location) },

  "interventionException" : [{ Coding }], // Intervention and exception code (Pharma)
  "onset" : [{ // Condition related Onset related dates and codes
    // time[x]: Illness, injury or treatable condition date. One of these 2:

    "timeDate" : "<date>",
    "timePeriod" : { Period },
    "type" : { Coding } // Onset of what
  }],
  "employmentImpacted" : { Period }, // Period unable to work
  "hospitalization" : { Period }, // Period in hospital

  "item" : [{ // Goods and Services
    "sequence" : "<positiveInt>", // R!  Service instance
    "
    "
    "

    "type" : { Coding }, // R!  Group or type of product or service
    // provider[x]: Responsible practitioner. One of these 2:

    "providerIdentifier" : { Identifier },
    "providerReference" : { Reference(Practitioner) },
    // supervisor[x]: Supervising Practitioner. One of these 2:

    "supervisorIdentifier" : { Identifier },
    "supervisorReference" : { Reference(Practitioner) },
    "providerQualification" : { Coding }, // Type, classification or Specialization
    "diagnosisLinkId" : ["<positiveInt>"], // Applicable diagnoses

    "service" : { Coding }, // R!  Item Code
    "

    "serviceModifier" : [{ Coding }], // Service/Product modifiers
    "modifier" : [{ Coding }], // Service/Product billing modifiers
    "programCode" : [{ Coding }], // Program specific reason for item inclusion
    // serviced[x]: Date or dates of Service. One of these 2:

    "servicedDate" : "<date>",
    "servicedPeriod" : { Period },
    "place" : { Coding }, // Place of service

    "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
    "unitPrice" : { Quantity(Money) }, // Fee, charge or cost per point
    "factor" : <decimal>, // Price scaling factor
    "points" : <decimal>, // Difficulty scaling factor
    "
    "
    "
    "
    "

    "net" : { Quantity(Money) }, // Total item cost
    "udi" : [{ Reference(Device) }], // Unique Device Identifier
    "bodySite" : { Coding }, // Service Location
    "subSite" : [{ Coding }], // Service Sub-location

    "detail" : [{ // Additional items
      "sequence" : "<positiveInt>", // R!  Service instance
      "

      "type" : { Coding }, // R!  Group or type of product or service

      "service" : { Coding }, // R!  Additional item codes
      "programCode" : [{ Coding }], // Program specific reason for item inclusion

      "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
      "unitPrice" : { Quantity(Money) }, // Fee, charge or cost per point
      "factor" : <decimal>, // Price scaling factor
      "points" : <decimal>, // Difficulty scaling factor
      "
      "

      "net" : { Quantity(Money) }, // Total additional item cost
      "udi" : [{ Reference(Device) }], // Unique Device Identifier

      "subDetail" : [{ // Additional items
        "sequence" : "<positiveInt>", // R!  Service instance
        "
        "

        "type" : { Coding }, // R!  Type of product or service
        "service" : { Coding }, // R!  Additional item codes
        "programCode" : [{ Coding }], // Program specific reason for item inclusion

        "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
        "

        "unitPrice" : { Quantity(Money) }, // Fee, charge or cost per point

        "factor" : <decimal>, // Price scaling factor
        "points" : <decimal>, // Difficulty scaling factor
        "
        "

        "net" : { Quantity(Money) }, // Net additional item cost
        "udi" : [{ Reference(Device) }] // Unique Device Identifier

      }]
    }],
    "prosthesis" : { // Prosthetic details
      "initial" : <boolean>, // Is this the initial service
      "priorDate" : "<date>", // Initial service Date
      "priorMaterial" : { Coding } // Prosthetic Material
    }
  }],
  "

  "total" : { Quantity(Money) }, // Total claim cost
  "additionalMaterial" : [{ Coding }], // Additional supporting materials and documents

  "missingTeeth" : [{ // Only if type = oral
    "tooth" : { Coding }, // R!  Tooth Code
    "
    "

    "reason" : { Coding }, // Indicates whether it was extracted or other reason
    "extractionDate" : "<date>" // Date tooth was extracted if known

  }]
}

  Alternate definitions:

Alternate definitions: Schema / Schematron , Resource Profile ( , Resource Profile ( XML , , JSON ), ), Questionnaire

7.1.2.1 Terminology Bindings Terminology Bindings

Claim.diagnosis.diagnosis Claim.condition Claim.coverage.relationship Claim.exception Claim.item.udi Claim.item.detail.udi Claim.item.detail.subDetail.udi Claim.item.bodySite Claim.item.subSite
Path Definition Type Reference
Claim.type Claim.type The type or discipline-style of the claim. The type or discipline-style of the claim Required ClaimType
Claim.subType A more granulat claim typecode Example Example Claim SubType Codes
Claim.ruleset
Claim.originalRuleset
Claim.coverage.originalRuleset Claim.coverage.originalRuleset 		The static and dynamic model to which contents conform, which may be business version or standard/version. The static and dynamic model to which contents conform, which may be business version or standard/version. Example Ruleset Codes Ruleset Codes
Claim.use Claim.use Complete, proposed, exploratory, other. Complete, proposed, exploratory, other Required Use
Claim.priority Claim.priority The timeliness with which processing is required: STAT, Normal, Deferred. The timeliness with which processing is required: STAT, normal, Deferred Example Priority Codes Priority Codes
Claim.fundsReserve Claim.fundsReserve For whom funds are to be reserved: (Patient, Provider, None). For whom funds are to be reserved: (Patient, Provider, None). Example Funds Reservation Codes Funds Reservation Codes
Claim.related.relationship Relationship of this claim to a related Claim Example Example Related Claim Relationship Codes
Claim.payee.type Claim.payee.type A code for the party to be reimbursed. A code for the party to be reimbursed. Example Payee Type Codes Payee Type Codes
Claim.occurrenceCode ICD10 diagnostic codes. Occurrence codes Example ICD-10 Codes Example Occurrance Codes
Claim.occurenceSpanCode Patient conditions and symptoms. Occurrence Span codes Example Conditions Codes Example Occurrance Span Codes
Claim.valueCode The code for the relationship of the patient to the subscriber. Value code Example Surface Codes Example Value Codes
Claim.diagnosis.diagnosis ICD10 Diagnostic codes Example The eligibility exception codes. ICD-10 Codes
Claim.procedure.procedure[x] ICD10 Procedure codes Example Exception Codes ICD-10 Procedure Codes
Claim.specialCondition Patient conditions and symptoms Example Conditions Codes
Claim.accidentType Claim.accidentType Type of accident: work place, auto, etc. Type of accident: work place, auto, etc. Required ActIncidentCode
Claim.interventionException Claim.interventionException Intervention and exception codes (Pharm). Intervention and exception codes (Pharm) Example Intervention Codes Intervention Codes
Claim.onset.type Condition related start, end and period codes Example Example Onset Type (Reason) Codes
Claim.item.type
Claim.item.detail.type
Claim.item.detail.subDetail.type Claim.item.detail.subDetail.type 		Service, Product, Rx Dispense, Rx Compound etc. Group, Service, Product. Required ActInvoiceGroupCode Exception Codes
Claim.item.providerQualification Provider professional qualifications Example Example Provider Qualification Codes
Claim.item.service
Claim.item.detail.service
Claim.item.detail.subDetail.service Claim.item.detail.subDetail.service 		Allowable service and product codes. Allowable service and product codes Example USCLS Codes USCLS Codes
Claim.item.serviceModifier The FDA, or other, UDI repository. Factors which may influce adjudication of services Example UDI Codes Example Service Modifier Codes
Claim.item.modifier The code for the teeth, quadrant, sextant and arch. Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. Example Surface Codes Modifier type Codes
Claim.item.programCode
Claim.item.detail.programCode
Claim.item.detail.subDetail.programCode 		The code for the tooth surface and surface combinations. Program specific reason codes Example Surface Codes Example Program Reason Codes
Claim.item.place Example Claim.item.modifier Item type or modifiers codes, e.g. for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. Example Service Place Codes
Claim.item.bodySite The code for the teeth, quadrant, sextant and arch Example Modifier type Codes Oral Site Codes
Claim.item.subSite The code for the tooth surface and surface combinations Example Surface Codes
Claim.item.prosthesis.priorMaterial Claim.item.prosthesis.priorMaterial Material of the prior denture or bridge prosthesis. (Oral) Material of the prior denture or bridge prosthesis. (Oral) Example Oral Prostho Material type Codes Oral Prostho Material type Codes
Claim.additionalMaterials Claim.additionalMaterial Code to indicate that Xrays, images, emails, documents, models or attachments are being sent in support of this submission. Code to indicate that Xrays, images, emails, documents, models or attachments are being sent in support of this submission. Example Additional Material Codes Additional Material Codes
Claim.missingTeeth.tooth Claim.missingTeeth.tooth The codes for the teeth, subset of OralSites. The codes for the teeth, subset of OralSites Example Teeth Codes Teeth Codes
Claim.missingTeeth.reason Claim.missingTeeth.reason Reason codes for the missing teeth. Reason codes for the missing teeth Example Missing Tooth Reason Codes Missing Tooth Reason Codes

7.1.3 Search Parameters Search Parameters Search parameters for this resource. The common parameters also apply. See

Search parameters for this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services. for more information about searching in REST, messaging, and services.

© HL7.org 2011+. FHIR DSTU2 (v1.0.2-7202) generated on Sat, Oct 24, 2015 07:43+1100. Links: Search | Version History | Table of Contents | Compare to DSTU1 | Propose a change
Name Type Description Paths
identifier created date The creation date for the Claim Claim.created
facilityidentifier token The primary Facility responsible for the goods and services Claim.facilityIdentifier
facilityreference reference Facility responsible for the goods and services Claim.facilityReference
( Location )
identifier of the financial resource token The primary identifier of the financial resource Claim.identifier
patient organizationidentifier token The reference to the providing organization Claim.organizationIdentifier
organizationreference reference Patient The reference to the providing organization Claim.patient Claim.organizationReference
( Organization )
patientidentifier token Patient receiving the services Claim.patientIdentifier
patientreference reference Patient receiving the services Claim.patientReference
( Patient )
priority token Processing priority requested Processing priority requested Claim.priority
provider provideridentifier token Provider responsible for the Claim Claim.providerIdentifier
providerreference reference Provider responsible for the claim Provider responsible for the Claim Claim.provider Claim.providerReference
( Practitioner )
use targetidentifier token The kind of financial resource The target payor/insurer for the Claim Claim.use Claim.targetIdentifier
targetreference reference | The target payor/insurer for the Claim Claim.targetReference
( Organization try { var currentTabIndex = sessionStorage.getItem('fhir-resource-tab-index'); } catch(exception){ } if (!currentTabIndex) currentTabIndex = '0'; $( '#tabs' ).tabs({ active: currentTabIndex, activate: function( event, ui ) { var active = $('.selector').tabs('option', 'active'); currentTabIndex = ui.newTab.index(); document.activeElement.blur(); try { sessionStorage.setItem('fhir-resource-tab-index', currentTabIndex); } catch(exception){ } } });
use token The kind of financial resource Claim.use