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 category of claim this is.

Affects which fields and value sets are used.

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

The version of the specification on which this instance relies.

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

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

Insurer Identifier, typical BIN number (6 digit).

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.

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

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.

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

Facility where the services were provided.

Prescription to support the dispensing of Pharmacy or Vision products.

For type=Pharmacy and Vision only.

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

The party to be reimbursed for the services.

Party to be reimbursed: Subscriber, provider, other.

The provider who is to be reimbursed for the claim (the party to whom any benefit is assigned).

The organization who is to be reimbursed for the claim (the party to whom any benefit is assigned).

The person other than the subscriber 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.

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.

Required to adjudicate services rendered to condition presented.

List of patient conditions for which care is sought.

Patient Resource.

Financial instrument by which payment information for health care.

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

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.

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.

The contract number of a business agreement which describes the terms and conditions.

The relationship of the patient to the subscriber.

To determine relationship between the patient and the subscriber.

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

To provide any pre=determination or prior authorization reference.

The Coverages adjudication details.

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.

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.

Factors which may influence the applicability of coverage.

To determine extenuating circumstances for coverage.

Name of school for over-aged dependants.

Often required for over-age dependents.

Date of an accident which these services are addressing.

Coverage may be dependant on accidents.

Type of accident: work, auto, etc.

Coverage may be dependant on the type of accident.

A list of intervention and exception codes which may influence the adjudication of the claim.

Coverage may be modified based on exception information provided.

First tier of goods and services.

A service line number.

The type of product or service.

The practitioner who is responsible for the services rendered to the patient.

Diagnosis applicable for this service or product line.

If a grouping item then 'GROUP' otherwise it is a node therefore a code to indicate the Professional Service or Product supplied.

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

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.

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.

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

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.

List of Unique Device Identifiers associated with this line item.

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

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

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

Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.

May impact on adjudication.

Second tier of goods and services.

A service line number.

The type of product or service.

If a grouping item then 'GROUP' otherwise it is a node therefore a code to indicate the Professional Service or Product supplied.

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 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.

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.

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

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.

List of Unique Device Identifiers associated with this line item.

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

Third tier of goods and services.

A service line number.

The type of product or service.

The fee for an addittional service or product or charge.

The number of repetitions of a service or product.

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.

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.

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

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.

List of Unique Device Identifiers associated with this line item.

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

The materials and placement date of prior fixed prosthesis.

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

May impact on adjudication.

Date of the initial placement.

May impact on adjudication.

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

May impact on adjudication.

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

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.

The code identifying which tooth is missing.

Provides the tooth number of the missing tooth.

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

Provides the reason for the missing tooth.

The date of the extraction either known from records or patient reported estimate.

Some services and adjudications require this information.