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. 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.

The business identifier for the instance: claim number, pre-determination or pre-authorization number.

The category of claim this is. The status of the resource instance.

The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization number. The category of claim, eg, oral, pharmacy, vision, insitutional, professional.

Affects which fields and value sets are used.

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

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

The version of the specification on which this instance relies. The version of the specification on which this instance relies.

The version of the specification from which the original instance was created. The version of the specification from which the original instance was created.

The date when the enclosed suite of services were performed or completed. The date when the enclosed suite of services were performed or completed.

The billable period for which charges are being submitted.

Insurer Identifier, typical BIN number (6 digit). The Insurer who is target of the request.

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.

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.

Complete (Bill or Claim), Proposed (Pre-Authorization), Exploratory (Pre-determination). Complete (Bill or Claim), Proposed (Pre-Authorization), Exploratory (Pre-determination).

Immediate (stat), best effort (normal), deferred (deferred). Immediate (STAT), best effort (NORMAL), deferred (DEFER).

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.

Person who created the invoice/claim/pre-determination or pre-authorization.

Person who created the invoice/claim/pre-determination or pre-authorization. Facility where the services were provided.

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

Facility where the services were provided. Other claims which are related to this claim such as prior claim versions or for related services.

Do we need a relationship code?

Prescription to support the dispensing of Pharmacy or Vision products. For example prior or umbrella.

For type=Pharmacy and Vision only. An alternate organizational reference to the case or file to which this particular claim pertains - eg Property/Casualy insurer claim # or Workers Compensation case # .

Original prescription to support the dispensing of pharmacy services, medications or products. Prescription to support the dispensing of Pharmacy or Vision products.

For type=Pharmacy and Vision only.

Should we create a group to hold multiple prescriptions and add a sequence number and on the line items a link to the sequence.

The party to be reimbursed for the services. Original prescription which has been superceded by this prescription to support the dispensing of pharmacy services, medications or products.

as above.

The party to be reimbursed for the services.

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

organization | patient | practitioner | relatedperson.

The provider who is to be reimbursed for the claim (the party to whom any benefit is assigned). Party to be reimbursed: Subscriber, provider, other.

The organization who is to be reimbursed for the claim (the party to whom any benefit is assigned). The referral resource which lists the date, practitioner, reason and other supporting information.

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

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

The person other than the subscriber who is to be reimbursed for the claim (the party to whom any benefit is assigned). The general class of the information supplied: information; exception; accident, employment; onset, etc.

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

The referral resource which lists the date, practitioner, reason and other supporting information. System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought which may influence the adjudication.

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

Ordered list of patient diagnosis for which care is sought. The date when or period to which this information refers.

Sequence of diagnosis which serves to order and provide a link. Additional data.

Ordered list of patient diagnosis for which care is sought.

Sequence of diagnosis which serves to order and provide a link.

Required to maintain order of the diagnoses.

The diagnosis. The diagnosis.

Required to adjudicate services rendered to condition presented. Summary true Required to adjudicate services rendered to condition presented.

List of patient conditions for which care is sought. The type of the Diagnosis, for example: admitting,.

Required to adjudicate services rendered to the mandated diagnosis grouping system.

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

Patient Resource. The Diagnosis Related Group (DRG) code based on the assigned grouping code system.

Required to adjudicate services rendered to the mandated diagnosis grouping system.

Financial instrument by which payment information for health care. Ordered list of patient procedures performed to support the adjudication.

Health care programs and insurers are significant payors of health service costs. Sequence of procedures which serves to order and provide a link.

Required to maintain order of the procudures.

A service line item. Date and optionally time the procedure was performed .

To maintain order of the coverages. Required to adjudicate services rendered.

SB DateTime??

The instance number of the Coverage which is the focus for adjudication. The Coverage against which the claim is to be adjudicated. The procedure code.

Required to adjudicate services rendered.

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

Financial instrument by which payment information for health care.

Health care programs and insurers are significant payors of health service costs.

The contract number of a business agreement which describes the terms and conditions. A service line item.

To maintain order of the coverages.

The instance number of the Coverage which is the focus for adjudication. The Coverage against which the claim is to be adjudicated.

To identify which coverage is being adjudicated.

The relationship of the patient to the subscriber. Reference to the program or plan identification, underwriter or payor.

Need to identify the issuer to target for processing and for coordination of benefit processing.

To determine the relationship between the patient and the subscriber. The contract number of a business agreement which describes the terms and conditions.

A list of references from the Insurer to which these services pertain. A list of references from the Insurer to which these services pertain.

To provide any pre=determination or prior authorization reference. Summary true To provide any pre=determination or prior authorization reference.

The Coverages adjudication details. The Coverages adjudication details.

Used by downstream payers to determine what balance remains and the net payable. Summary true Used by downstream payers to determine what balance remains and the net payable.

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.

Knowledge of the original version can inform the processing of this instance so that information which is processable by the originating system may be generated. Knowledge of the original version can inform the processing of this instance so that information which is processable by the originating system may be generated.

An accident which resulted in the need for healthcare services.

Factors which may influence the applicability of coverage. Date of an accident which these services are addressing.

Coverage may be dependant on accidents.

Type of accident: work, auto, etc.

To determine extenuating circumstances for coverage. Coverage may be dependant on the type of accident.

Accident Place.

Name of school for over-aged dependents. The start and optional end dates of when the patient was precluded from working due to the treatable condition(s).

Often required for over-age dependents. The start and optional end dates of when the patient was confined to a treatment center.

Date of an accident which these services are addressing. First tier of goods and services.

A service line number.

Coverage may be dependent on accidents. The members of the team who provided the overall service as well as their role and whether responsible and qualifications.

Role and Responsible may not be required when there is only a single provider listed.

Type of accident: work, auto, etc. Member of the team who provided the overall service.

Coverage may be dependent on the type of accident. The party who is billing and responsible for the claimed good or service rendered to the patient.

A list of intervention and exception codes which may influence the adjudication of the claim. The lead, assisting or supervising practitioner and their discipline if a multidisiplinary team.

Coverage may be modified based on exception information provided. The qualification which is applicable for this service.

First tier of goods and services. Diagnosis applicable for this service or product line.

A service line number. The type of reveneu or cost center providing the product and/or service.

The type of product or service. Health Care Service Type Codes to identify the classification of service or benefits.

The practitioner who is responsible for the services rendered to the patient. If this is an actual service or product line, ie. not a Group, then use code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'.

Diagnosis applicable for this service or product line. Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.

May impact on adjudication.

If a grouping item then 'GROUP' otherwise it is a node therefore a code to indicate the Professional Service or Product supplied. For programs which require reason codes for the inclusion or covering of this billed item under the program or sub-program.

The date when the enclosed suite of services were performed or completed. The date or dates when the enclosed suite of services were performed or completed.

The number of repetitions of a service or product. Where the service was provided.

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. The number of repetitions of a service or product.

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.

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.

If a fee is present the associated product/service code must be present. Summary true If a fee is present the associated product/service code must be present.

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.

If a fee is present the associated product/service code must be present. Summary true If a fee is present the associated product/service code must be present.

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.

If a fee is present the associated product/service code must be present. Summary true If a fee is present the associated product/service code must be present.

List of Unique Device Identifiers associated with this line item. List of Unique Device Identifiers associated with this line item.

The UDI code and issuer if applicable for the supplied product. Summary true The UDI code and issuer if applicable for the supplied product.

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

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).

Second tier of goods and services.

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. A service line number.

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

Second tier of goods and services. Health Care Service Type Codes to identify the classification of service or benefits.

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

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

May impact on adjudication.

If a grouping item then 'GROUP' otherwise it is a node therefore a code to indicate the Professional Service or Product supplied. For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program.

The number of repetitions of a service or product. The number of repetitions of a service or product.

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.

If a fee is present the associated product/service code must be present. Summary true If a fee is present the associated product/service code must be present.

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.

If a fee is present the associated product/service code must be present. Summary true If a fee is present the associated product/service code must be present.

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.

If a fee is present the associated product/service code must be present. Summary true If a fee is present the associated product/service code must be present.

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.

If a fee is present the associated product/service code must be present. Summary true If a fee is present the associated product/service code must be present.

List of Unique Device Identifiers associated with this line item. List of Unique Device Identifiers associated with this line item.

The UDI code and issuer if applicable for the supplied product.

The UDI code and issuer if applicable for the supplied product. Third tier of goods and services.

Third tier of goods and services. A service line number.

A service line number. The type of reveneu or cost center providing the product and/or service.

The type of product or service. Health Care Service Type Codes to identify the classification of service or benefits.

A code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI).

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

May impact on adjudication.

The number of repetitions of a service or product. For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program.

The fee for an additional service or product or charge. The number of repetitions of a service or product.

If a fee is present the associated product/service code must be present. The fee for an addittional service or product or charge.

If a fee is present the associated product/service code must be present.

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.

If a fee is present the associated product/service code must be present. Summary true If a fee is present the associated product/service code must be present.

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.

If a fee is present the associated product/service code must be present. Summary true If a fee is present the associated product/service code must be present.

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.

If a fee is present the associated product/service code must be present. Summary true If a fee is present the associated product/service code must be present.

List of Unique Device Identifiers associated with this line item. List of Unique Device Identifiers associated with this line item.

The UDI code and issuer if applicable for the supplied product. Summary true The UDI code and issuer if applicable for the supplied product.

The materials and placement date of prior fixed prosthesis. The materials and placement date of prior fixed prosthesis.

Indicates whether this is the initial placement of a fixed prosthesis. Indicates whether this is the initial placement of a fixed prosthesis.

May impact on adjudication. Summary true May impact on adjudication.

Date of the initial placement. Date of the initial placement.

May impact on adjudication. Summary true May impact on adjudication.

Material of the prior denture or bridge prosthesis. (Oral). Material of the prior denture or bridge prosthesis. (Oral).

May impact on adjudication. Summary true May impact on adjudication.

Code to indicate that Xrays, images, emails, documents, models or attachments are being sent in support of this submission. The total value of the claim.

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.

The list of missing teeth may influence the adjudication of services for example with Bridges. Summary true The list of missing teeth may influence the adjudication of services for example with Bridges.

The code identifying which tooth is missing. The code identifying which tooth is missing.

Provides the tooth number of the missing tooth. Summary true Provides the tooth number of the missing tooth.

Missing reason may be: E-extraction, O-other. Missing reason may be: E-extraction, O-other.

Provides the reason for the missing tooth. Summary true Provides the reason for the missing tooth.

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.

Some services and adjudications require this information. Summary true © HL7.org 2011+. FHIR DSTU2 (v1.0.2-7202) generated on Sat, Oct 24, 2015 07:43+1100. Links: Search Some services and adjudications require this information.