This page is part of the FHIR Specification (v0.0.82: DSTU 1). The current version which supercedes this version is 5.0.0 . For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2

7.1 Resource Claim - Content

This resource maintained by the Financial Management Work Group

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

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:

The Claim also supports:

Todo

This resource is referenced by ClaimResponse and ExplanationOfBenefit

7.1.2 Resource Content

Structure

Name Flags Card. Type Description & Constraints doco
. . Claim DomainResource Claim, Pre-determination or Pre-authorization
. . . type 1..1 code institutional | oral | pharmacy | professional | vision
ClaimType ( Required )
. . . identifier 0..* Identifier Claim number
. . . ruleset 0..1 Coding Current specification followed
Ruleset ( Example )
. . . originalRuleset 0..1 Coding Original specification followed
Ruleset ( Example )
. . . created 0..1 dateTime Creation date
. . . target 0..1 Organization Insurer
. . . provider 0..1 Practitioner Responsible provider
. . . organization 0..1 Organization Responsible organization
. . . use 0..1 code complete | proposed | exploratory | other
Use ( Required )
. . . priority 0..1 Coding Desired processing priority
ProcessPriority ( Example )
. . . fundsReserve 0..1 Coding Funds requested to be reserved
FundsReserve ( Example )
. . . enterer 0..1 Practitioner Author
. . . facility 0..1 Location Servicing Facility
. . . prescription 0..1 MedicationPrescription | VisionPrescription Prescription
. . . originalPrescription 0..1 MedicationPrescription Original Prescription
. . . payee 0..1 Element Payee
. . . . type 0..1 Coding Party to be paid any benefits payable
PayeeType ( Example )
. . . . provider 0..1 Practitioner Provider who is the payee
. . . . organization 0..1 Organization Organization who is the payee
. . . . person 0..1 Patient Other person who is the payee
. . . referral 0..1 ReferralRequest Treatment Referral
. . . diagnosis 0..* Element Diagnosis
. . . . sequence 1..1 integer Sequence of diagnosis
. . . . diagnosis 1..1 Coding Patient's list of diagnosis
ICD10 ( Example )
. . . condition 0..* Coding List of presenting Conditions
Conditions ( Example )
. . . patient 1..1 Patient The subject of the Products and Services
. . . coverage 0..* Element Insurance or medical plan
. . . . sequence 1..1 integer Service instance identifier
. . . . focal 1..1 boolean Is the focal Coverage
. . . . coverage 1..1 Coverage Insurance information
. . . . businessArrangement 0..1 string Business agreement
. . . . relationship 1..1 Coding Patient relationship to subscriber
Relationship ( Example )
. . . . preAuthRef 0..* string Pre-Authorization/Determination Reference
. . . . claimResponse 0..1 ClaimResponse Adjudication results
. . . . originalRuleset 0..1 Coding Original version
Ruleset ( Example )
. . . exception 0..* Coding Eligibility exceptions
Exception ( Example )
. . . school 0..1 string Name of School
. . . accident 0..1 date Accident Date
. . . accidentType 0..1 Coding Accident Type
AccidentType ( Example )
. . . interventionException 0..* Coding Intervention and exception code (Pharma)
Intervention ( Example )
. . . item 0..* Element Goods and Services
. . . . sequence 1..1 integer Service instance
. . . . type 1..1 Coding Group or type of product or service
ItemType ( Example )
. . . . provider 0..1 Practitioner Responsible practitioner
. . . . diagnosisLinkId 0..* integer Diagnosis Link
. . . . service 1..1 Coding Item Code
ServiceProduct ( Example )
. . . . serviceDate 0..1 date Date of Service
. . . . quantity 0..1 Quantity Count of Products or Services
. . . . unitPrice 0..1 Money Fee, charge or cost per point
. . . . factor 0..1 decimal Price scaling factor
. . . . points 0..1 decimal Difficulty scaling factor
. . . . net 0..1 Money Total item cost
. . . . udi 0..1 Coding Unique Device Identifier
UDI ( Example )
. . . . bodySite 0..1 Coding Service Location
OralSites ( Example )
. . . . subSite 0..* Coding Service Sub-location
Surface ( Example )
. . . . modifier 0..* Coding Service/Product billing modifiers
Modifiers ( Example )
. . . . detail 0..* Element Additional items
. . . . . sequence 1..1 integer Service instance
. . . . . type 1..1 Coding Group or type of product or service
ItemType ( Example )
. . . . . service 1..1 Coding Additional item codes
ServiceProduct ( Example )
. . . . . quantity 0..1 Quantity Count of Products or Services
. . . . . unitPrice 0..1 Money Fee, charge or cost per point
. . . . . factor 0..1 decimal Price scaling factor
. . . . . points 0..1 decimal Difficulty scaling factor
. . . . . net 0..1 Money Total additional item cost
. . . . . udi 0..1 Coding Unique Device Identifier
UDI ( Example )
. . . . . subDetail 0..* Element Additional items
. . . . . . sequence 1..1 integer Service instance
. . . . . . type 1..1 Coding Type of product or service
ItemType ( Example )
. . . . . . service 1..1 Coding Additional item codes
ServiceProduct ( Example )
. . . . . . quantity 0..1 Quantity Count of Products or Services
. . . . . . unitPrice 0..1 Money Fee, charge or cost per point
. . . . . . factor 0..1 decimal Price scaling factor
. . . . . . points 0..1 decimal Difficulty scaling factor
. . . . . . net 0..1 Money Net additional item cost
. . . . . . udi 0..1 Coding Unique Device Identifier
UDI ( Example )
. . . . prosthesis 0..1 Element Prosthetic details
. . . . . initial 0..1 boolean Is this the initial service
. . . . . priorDate 0..1 date Initial service Date
. . . . . priorMaterial 0..1 Coding Prosthetic Material
OralProsthoMaterial ( Example )
. . . additionalMaterials 0..* Coding Additional materials, documents, etc.
AdditionalMaterials ( Example )
. . . missingTeeth 0..* Element Only if type = oral
. . . . tooth 1..1 Coding Tooth Code
Tooth ( Example )
. . . . reason 0..1 Coding Reason for missing
MissingReason ( Example )
. . . . extractionDate 0..1 date Date of Extraction

UML Diagram

Claim ( DomainResource ) The category of claim this is type : code 1..1 « The type or discipline-style of the claim ClaimType » The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization number identifier : Identifier 0..* The version of the specification on which this instance relies ruleset : Coding 0..1 « ( The static and dynamic model to which contents conform, may be business version or standard and version. Ruleset ) » The version of the specification from which the original instance was created originalRuleset : Coding 0..1 « ( The static and dynamic model to which contents conform, may be business version or standard and version. Ruleset ) » The date when the enclosed suite of services were performed or completed created : dateTime 0..1 Insurer Identifier, typical BIN number (6 digit) target : Reference ( Organization ) 0..1 The provider which is responsible for the bill, claim pre-determination, pre-authorization provider : Reference ( Practitioner ) 0..1 The organization which is responsible for the bill, claim pre-determination, pre-authorization organization : Reference ( Organization ) 0..1 Complete (Bill or Claim), Proposed (Pre-Authorization), Exploratory (Pre-determination) use : code 0..1 « Complete, proposed, exploratory, other Use » Immediate (STAT), best effort (NORMAL), deferred (DEFER) priority : Coding 0..1 « ( The timeliness with which processing is required: STAT, normal, Deferred ProcessPriority ) » 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 « ( For whom funds are to be reserved: (Patient, Provider, None) FundsReserve ) » Person who created the invoice/claim/pre-determination or pre-authorization enterer : Reference ( Practitioner ) 0..1 Facility where the services were provided facility : Reference ( Location ) 0..1 Prescription to support the dispensing of Pharmacy or Vision products prescription : Reference ( MedicationPrescription | VisionPrescription ) 0..1 Original prescription to support the dispensing of pharmacy services, medications or products originalPrescription : Reference ( MedicationPrescription ) 0..1 The referral resource which lists the date, practitioner, reason and other supporting information referral : Reference ( ReferralRequest ) 0..1 List of patient conditions for which care is sought condition : Coding 0..* « ( Patient conditions and symptoms Conditions ) » Patient Resource patient : Reference ( Patient ) 1..1 Factors which may influence the applicability of coverage exception : Coding 0..* « ( The eligibility exception codes. Exception ) » Name of school for over-aged dependants school : string 0..1 Date of an accident which these services are addressing accident : date 0..1 Type of accident: work, auto, etc accidentType : Coding 0..1 « ( Type of accident: work place, auto, etc. AccidentType ) » A list of intervention and exception codes which may influence the adjudication of the claim interventionException : Coding 0..* « ( Intervention and exception codes (Pharm) Intervention ) » Code to indicate that Xrays, images, emails, documents, models or attachments are being sent in support of this submission additionalMaterials : Coding 0..* « ( Code to indicate that Xrays, images, emails, documents, models or attachments are being sent in support of this submission. AdditionalMaterials ) » Payee Party to be reimbursed: Subscriber, provider, other type : Coding 0..1 « ( A code for the party to be reimbursed. PayeeType ) » The provider who is to be reimbursed for the claim (the party to whom any benefit is assigned) provider : Reference ( Practitioner ) 0..1 The organization who is to be reimbursed for the claim (the party to whom any benefit is assigned) organization : Reference ( Organization ) 0..1 The person other than the subscriber who is to be reimbursed for the claim (the party to whom any benefit is assigned) person : Reference ( Patient ) 0..1 Diagnosis Sequence of diagnosis which serves to order and provide a link sequence : integer 1..1 The diagnosis diagnosis : Coding 1..1 « ( ICD10 Diagnostic codes ICD10 ) » Coverage A service line item sequence : integer 1..1 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 Reference to the program or plan identification, underwriter or payor coverage : Reference ( Coverage ) 1..1 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 Relationship ) » A list of references from the Insurer to which these services pertain preAuthRef : string 0..* The Coverages adjudication details claimResponse : Reference ( ClaimResponse ) 0..1 The style (standard) and version of the original material which was converted into this resource originalRuleset : Coding 0..1 « ( The static and dynamic model to which contents conform, may be business version or standard and version. Ruleset ) » Items A service line number sequence : integer 1..1 The type of product or service type : Coding 1..1 « ( Service, Product, Rx Dispense, Rx Compound etc. ItemType ) » The practitioner who is responsible for the services rendered to the patient provider : Reference ( Practitioner ) 0..1 Diagnosis applicable for this service or product line diagnosisLinkId : integer 0..* 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 « ( Allowable service and product codes ServiceProduct ) » The date when the enclosed suite of services were performed or completed serviceDate : date 0..1 The number of repetitions of a service or product quantity : Quantity 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 unitPrice : Money 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 factor : decimal 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 points : decimal 0..1 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 : Money 0..1 List of Unique Device Identifiers associated with this line item udi : Coding 0..1 « ( The FDA, or other, UDI repository. UDI ) » Physical service site on the patient (limb, tooth, etc) bodySite : Coding 0..1 « ( The code for the teeth, quadrant, sextant and arch OralSites ) » 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 Surface ) » 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. Modifiers ) » Detail A service line number sequence : integer 1..1 The type of product or service type : Coding 1..1 « ( Service, Product, Rx Dispense, Rx Compound etc. ItemType ) » 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 « ( Allowable service and product codes ServiceProduct ) » The number of repetitions of a service or product quantity : Quantity 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 unitPrice : Money 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 factor : decimal 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 points : decimal 0..1 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 : Money 0..1 List of Unique Device Identifiers associated with this line item udi : Coding 0..1 « ( The FDA, or other, UDI repository. UDI ) » SubDetail A service line number sequence : integer 1..1 The type of product or service type : Coding 1..1 « ( Service, Product, Rx Dispense, Rx Compound etc. ItemType ) » The fee for an addittional service or product or charge service : Coding 1..1 « ( Allowable service and product codes ServiceProduct ) » The number of repetitions of a service or product quantity : Quantity 0..1 The fee for an addittional service or product or charge unitPrice : Money 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 factor : decimal 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 points : decimal 0..1 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 : Money 0..1 List of Unique Device Identifiers associated with this line item udi : Coding 0..1 « ( The FDA, or other, UDI repository. UDI ) » Prosthesis Indicates whether this is the initial placement of a fixed prosthesis initial : boolean 0..1 Date of the initial placement priorDate : date 0..1 Material of the prior denture or bridge prosthesis. (Oral) priorMaterial : Coding 0..1 « ( Material of the prior denture or bridge prosthesis. (Oral) OralProsthoMaterial ) » MissingTeeth The code identifying which tooth is missing tooth : Coding 1..1 « ( The codes for the teeth, subset of OralSites Tooth ) » Missing reason may be: E-extraction, O-other reason : Coding 0..1 « ( Reason codes for the missing teeth MissingReason ) » The date of the extraction either known from records or patient reported estimate extractionDate : date 0..1 The party to be reimbursed for the services payee 0..1 Ordered list of patient diagnosis for which care is sought diagnosis 0..* Financial instrument by which payment information for health care coverage 0..* Third tier of goods and services subDetail 0..* Second tier of goods and services detail 0..* The materials and placement date of prior fixed prosthesis prosthesis 0..1 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 missingTeeth 0..*

XML Template 

<Claim xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <type value="[code]"/><!-- 1..1 institutional | oral | pharmacy | professional | vision -->
 <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><!-- 0..1 Reference(Organization) Insurer --></target>
 <provider><!-- 0..1 Reference(Practitioner) Responsible provider --></provider>
 <organization><!-- 0..1 Reference(Organization) Responsible organization --></organization>
 <use value="[code]"/><!-- 0..1 complete | proposed | exploratory | other -->
 <priority><!-- 0..1 Coding Desired processing priority --></priority>
 <fundsReserve><!-- 0..1 Coding Funds requested to be reserved --></fundsReserve>
 <enterer><!-- 0..1 Reference(Practitioner) Author --></enterer>
 <facility><!-- 0..1 Reference(Location) Servicing Facility --></facility>
 <prescription><!-- 0..1 Reference(MedicationPrescription|VisionPrescription) 
     Prescription --></prescription>
 <originalPrescription><!-- 0..1 Reference(MedicationPrescription) 
     Original Prescription --></originalPrescription>
 <payee>  <!-- 0..1 Payee -->
  <type><!-- 0..1 Coding Party to be paid any benefits payable --></type>
  <provider><!-- 0..1 Reference(Practitioner) Provider who is the payee --></provider>
  <organization><!-- 0..1 Reference(Organization) Organization who is the payee --></organization>
  <person><!-- 0..1 Reference(Patient) Other person who is the payee --></person>
 </payee>
 <referral><!-- 0..1 Reference(ReferralRequest) Treatment Referral --></referral>
 <diagnosis>  <!-- 0..* Diagnosis -->
  <sequence value="[integer]"/><!-- 1..1 Sequence of diagnosis -->
  <diagnosis><!-- 1..1 Coding Patient's list of diagnosis --></diagnosis>
 </diagnosis>
 <condition><!-- 0..* Coding List of presenting Conditions --></condition>
 <patient><!-- 1..1 Reference(Patient) The subject of the Products and Services --></patient>
 <coverage>  <!-- 0..* Insurance or medical plan -->
  <sequence value="[integer]"/><!-- 1..1 Service instance identifier -->
  <focal value="[boolean]"/><!-- 1..1 Is the focal Coverage -->
  <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage>
  <businessArrangement value="[string]"/><!-- 0..1 Business agreement -->
  <relationship><!-- 1..1 Coding Patient relationship to subscriber --></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><!-- 0..* Coding Eligibility exceptions --></exception>
 <school value="[string]"/><!-- 0..1 Name of School -->
 <accident value="[date]"/><!-- 0..1 Accident Date -->
 <accidentType><!-- 0..1 Coding Accident Type --></accidentType>
 <interventionException><!-- 0..* Coding Intervention and exception code (Pharma) --></interventionException>
 <item>  <!-- 0..* Goods and Services -->
  <sequence value="[integer]"/><!-- 1..1 Service instance -->
  <type><!-- 1..1 Coding Group or type of product or service --></type>
  <provider><!-- 0..1 Reference(Practitioner) Responsible practitioner --></provider>
  <diagnosisLinkId value="[integer]"/><!-- 0..* Diagnosis Link -->
  <service><!-- 1..1 Coding Item Code --></service>
  <serviceDate value="[date]"/><!-- 0..1 Date of Service -->
  <quantity><!-- 0..1 Quantity Count of Products or Services --></quantity>
  <unitPrice><!-- 0..1 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><!-- 0..1 Money Total item cost --></net>
  <udi><!-- 0..1 Coding Unique Device Identifier --></udi>
  <bodySite><!-- 0..1 Coding Service Location --></bodySite>
  <subSite><!-- 0..* Coding Service Sub-location --></subSite>
  <modifier><!-- 0..* Coding Service/Product billing modifiers --></modifier>
  <detail>  <!-- 0..* Additional items -->
   <sequence value="[integer]"/><!-- 1..1 Service instance -->
   <type><!-- 1..1 Coding Group or type of product or service --></type>
   <service><!-- 1..1 Coding Additional item codes --></service>
   <quantity><!-- 0..1 Quantity Count of Products or Services --></quantity>
   <unitPrice><!-- 0..1 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><!-- 0..1 Money Total additional item cost --></net>
   <udi><!-- 0..1 Coding Unique Device Identifier --></udi>
   <subDetail>  <!-- 0..* Additional items -->
    <sequence value="[integer]"/><!-- 1..1 Service instance -->
    <type><!-- 1..1 Coding Type of product or service --></type>
    <service><!-- 1..1 Coding Additional item codes --></service>
    <quantity><!-- 0..1 Quantity Count of Products or Services --></quantity>
    <unitPrice><!-- 0..1 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><!-- 0..1 Money Net additional item cost --></net>
    <udi><!-- 0..1 Coding 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><!-- 0..* Coding Additional materials, documents, etc. --></additionalMaterials>
 <missingTeeth>  <!-- 0..* Only if type = oral -->
  <tooth><!-- 1..1 Coding Tooth Code --></tooth>
  <reason><!-- 0..1 Coding Reason for missing --></reason>
  <extractionDate value="[date]"/><!-- 0..1 Date of Extraction -->
 </missingTeeth>
</Claim>

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
  "identifier" : [{ Identifier }], // Claim number
  "ruleset" : { Coding }, // Current specification followed
  "originalRuleset" : { Coding }, // Original specification followed
  "created" : "<dateTime>", // Creation date
  "target" : { Reference(Organization) }, // Insurer
  "provider" : { Reference(Practitioner) }, // Responsible provider
  "organization" : { Reference(Organization) }, // Responsible organization
  "use" : "<code>", // complete | proposed | exploratory | other
  "priority" : { Coding }, // Desired processing priority
  "fundsReserve" : { Coding }, // Funds requested to be reserved
  "enterer" : { Reference(Practitioner) }, // Author
  "facility" : { Reference(Location) }, // Servicing Facility
  "prescription" : { Reference(MedicationPrescription|VisionPrescription) }, // 
     Prescription
  "originalPrescription" : { Reference(MedicationPrescription) }, // 
     Original Prescription
  "payee" : { // Payee
    "type" : { Coding }, // Party to be paid any benefits payable
    "provider" : { Reference(Practitioner) }, // Provider who is the payee
    "organization" : { Reference(Organization) }, // Organization who is the payee
    "person" : { Reference(Patient) } // Other person who is the payee
  },
  "referral" : { Reference(ReferralRequest) }, // Treatment Referral
  "diagnosis" : [{ // Diagnosis
    "sequence" : <integer>, // R!  Sequence of diagnosis
    "diagnosis" : { Coding } // R!  Patient's list of diagnosis
  }],
  "condition" : [{ Coding }], // List of presenting Conditions
  "patient" : { Reference(Patient) }, // R!  The subject of the Products and Services
  "coverage" : [{ // Insurance or medical plan
    "sequence" : <integer>, // R!  Service instance identifier
    "focal" : <boolean>, // R!  Is the focal Coverage
    "coverage" : { Reference(Coverage) }, // R!  Insurance information
    "businessArrangement" : "<string>", // Business agreement
    "relationship" : { Coding }, // R!  Patient relationship to subscriber
    "preAuthRef" : ["<string>"], // Pre-Authorization/Determination Reference
    "claimResponse" : { Reference(ClaimResponse) }, // Adjudication results
    "originalRuleset" : { Coding } // Original version
  }],
  "exception" : [{ Coding }], // Eligibility exceptions
  "school" : "<string>", // Name of School
  "accident" : "<date>", // Accident Date
  "accidentType" : { Coding }, // Accident Type
  "interventionException" : [{ Coding }], // Intervention and exception code (Pharma)
  "item" : [{ // Goods and Services
    "sequence" : <integer>, // R!  Service instance
    "type" : { Coding }, // R!  Group or type of product or service
    "provider" : { Reference(Practitioner) }, // Responsible practitioner
    "diagnosisLinkId" : [<integer>], // Diagnosis Link
    "service" : { Coding }, // R!  Item Code
    "serviceDate" : "<date>", // Date of Service
    "quantity" : { Quantity }, // Count of Products or Services
    "unitPrice" : { Money }, // Fee, charge or cost per point
    "factor" : <decimal>, // Price scaling factor
    "points" : <decimal>, // Difficulty scaling factor
    "net" : { Money }, // Total item cost
    "udi" : { Coding }, // Unique Device Identifier
    "bodySite" : { Coding }, // Service Location
    "subSite" : [{ Coding }], // Service Sub-location
    "modifier" : [{ Coding }], // Service/Product billing modifiers
    "detail" : [{ // Additional items
      "sequence" : <integer>, // R!  Service instance
      "type" : { Coding }, // R!  Group or type of product or service
      "service" : { Coding }, // R!  Additional item codes
      "quantity" : { Quantity }, // Count of Products or Services
      "unitPrice" : { Money }, // Fee, charge or cost per point
      "factor" : <decimal>, // Price scaling factor
      "points" : <decimal>, // Difficulty scaling factor
      "net" : { Money }, // Total additional item cost
      "udi" : { Coding }, // Unique Device Identifier
      "subDetail" : [{ // Additional items
        "sequence" : <integer>, // R!  Service instance
        "type" : { Coding }, // R!  Type of product or service
        "service" : { Coding }, // R!  Additional item codes
        "quantity" : { Quantity }, // Count of Products or Services
        "unitPrice" : { Money }, // Fee, charge or cost per point
        "factor" : <decimal>, // Price scaling factor
        "points" : <decimal>, // Difficulty scaling factor
        "net" : { Money }, // Net additional item cost
        "udi" : { Coding } // Unique Device Identifier
      }]
    }],
    "prosthesis" : { // Prosthetic details
      "initial" : <boolean>, // Is this the initial service
      "priorDate" : "<date>", // Initial service Date
      "priorMaterial" : { Coding } // Prosthetic Material
    }
  }],
  "additionalMaterials" : [{ Coding }], // Additional materials, documents, etc.
  "missingTeeth" : [{ // Only if type = oral
    "tooth" : { Coding }, // R!  Tooth Code
    "reason" : { Coding }, // Reason for missing
    "extractionDate" : "<date>" // Date of Extraction
  }]
}

Structure

Name Flags Card. Type Description & Constraints doco
. . Claim DomainResource Claim, Pre-determination or Pre-authorization
. . . type 1..1 code institutional | oral | pharmacy | professional | vision
ClaimType ( Required )
. . . identifier 0..* Identifier Claim number
. . . ruleset 0..1 Coding Current specification followed
Ruleset ( Example )
. . . originalRuleset 0..1 Coding Original specification followed
Ruleset ( Example )
. . . created 0..1 dateTime Creation date
. . . target 0..1 Organization Insurer
. . . provider 0..1 Practitioner Responsible provider
. . . organization 0..1 Organization Responsible organization
. . . use 0..1 code complete | proposed | exploratory | other
Use ( Required )
. . . priority 0..1 Coding Desired processing priority
ProcessPriority ( Example )
. . . fundsReserve 0..1 Coding Funds requested to be reserved
FundsReserve ( Example )
. . . enterer 0..1 Practitioner Author
. . . facility 0..1 Location Servicing Facility
. . . prescription 0..1 MedicationPrescription | VisionPrescription Prescription
. . . originalPrescription 0..1 MedicationPrescription Original Prescription
. . . payee 0..1 Element Payee
. . . . type 0..1 Coding Party to be paid any benefits payable
PayeeType ( Example )
. . . . provider 0..1 Practitioner Provider who is the payee
. . . . organization 0..1 Organization Organization who is the payee
. . . . person 0..1 Patient Other person who is the payee
. . . referral 0..1 ReferralRequest Treatment Referral
. . . diagnosis 0..* Element Diagnosis
. . . . sequence 1..1 integer Sequence of diagnosis
. . . . diagnosis 1..1 Coding Patient's list of diagnosis
ICD10 ( Example )
. . . condition 0..* Coding List of presenting Conditions
Conditions ( Example )
. . . patient 1..1 Patient The subject of the Products and Services
. . . coverage 0..* Element Insurance or medical plan
. . . . sequence 1..1 integer Service instance identifier
. . . . focal 1..1 boolean Is the focal Coverage
. . . . coverage 1..1 Coverage Insurance information
. . . . businessArrangement 0..1 string Business agreement
. . . . relationship 1..1 Coding Patient relationship to subscriber
Relationship ( Example )
. . . . preAuthRef 0..* string Pre-Authorization/Determination Reference
. . . . claimResponse 0..1 ClaimResponse Adjudication results
. . . . originalRuleset 0..1 Coding Original version
Ruleset ( Example )
. . . exception 0..* Coding Eligibility exceptions
Exception ( Example )
. . . school 0..1 string Name of School
. . . accident 0..1 date Accident Date
. . . accidentType 0..1 Coding Accident Type
AccidentType ( Example )
. . . interventionException 0..* Coding Intervention and exception code (Pharma)
Intervention ( Example )
. . . item 0..* Element Goods and Services
. . . . sequence 1..1 integer Service instance
. . . . type 1..1 Coding Group or type of product or service
ItemType ( Example )
. . . . provider 0..1 Practitioner Responsible practitioner
. . . . diagnosisLinkId 0..* integer Diagnosis Link
. . . . service 1..1 Coding Item Code
ServiceProduct ( Example )
. . . . serviceDate 0..1 date Date of Service
. . . . quantity 0..1 Quantity Count of Products or Services
. . . . unitPrice 0..1 Money Fee, charge or cost per point
. . . . factor 0..1 decimal Price scaling factor
. . . . points 0..1 decimal Difficulty scaling factor
. . . . net 0..1 Money Total item cost
. . . . udi 0..1 Coding Unique Device Identifier
UDI ( Example )
. . . . bodySite 0..1 Coding Service Location
OralSites ( Example )
. . . . subSite 0..* Coding Service Sub-location
Surface ( Example )
. . . . modifier 0..* Coding Service/Product billing modifiers
Modifiers ( Example )
. . . . detail 0..* Element Additional items
. . . . . sequence 1..1 integer Service instance
. . . . . type 1..1 Coding Group or type of product or service
ItemType ( Example )
. . . . . service 1..1 Coding Additional item codes
ServiceProduct ( Example )
. . . . . quantity 0..1 Quantity Count of Products or Services
. . . . . unitPrice 0..1 Money Fee, charge or cost per point
. . . . . factor 0..1 decimal Price scaling factor
. . . . . points 0..1 decimal Difficulty scaling factor
. . . . . net 0..1 Money Total additional item cost
. . . . . udi 0..1 Coding Unique Device Identifier
UDI ( Example )
. . . . . subDetail 0..* Element Additional items
. . . . . . sequence 1..1 integer Service instance
. . . . . . type 1..1 Coding Type of product or service
ItemType ( Example )
. . . . . . service 1..1 Coding Additional item codes
ServiceProduct ( Example )
. . . . . . quantity 0..1 Quantity Count of Products or Services
. . . . . . unitPrice 0..1 Money Fee, charge or cost per point
. . . . . . factor 0..1 decimal Price scaling factor
. . . . . . points 0..1 decimal Difficulty scaling factor
. . . . . . net 0..1 Money Net additional item cost
. . . . . . udi 0..1 Coding Unique Device Identifier
UDI ( Example )
. . . . prosthesis 0..1 Element Prosthetic details
. . . . . initial 0..1 boolean Is this the initial service
. . . . . priorDate 0..1 date Initial service Date
. . . . . priorMaterial 0..1 Coding Prosthetic Material
OralProsthoMaterial ( Example )
. . . additionalMaterials 0..* Coding Additional materials, documents, etc.
AdditionalMaterials ( Example )
. . . missingTeeth 0..* Element Only if type = oral
. . . . tooth 1..1 Coding Tooth Code
Tooth ( Example )
. . . . reason 0..1 Coding Reason for missing
MissingReason ( Example )
. . . . extractionDate 0..1 date Date of Extraction

UML Diagram

Claim ( DomainResource ) The category of claim this is type : code 1..1 « The type or discipline-style of the claim ClaimType » The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization number identifier : Identifier 0..* The version of the specification on which this instance relies ruleset : Coding 0..1 « ( The static and dynamic model to which contents conform, may be business version or standard and version. Ruleset ) » The version of the specification from which the original instance was created originalRuleset : Coding 0..1 « ( The static and dynamic model to which contents conform, may be business version or standard and version. Ruleset ) » The date when the enclosed suite of services were performed or completed created : dateTime 0..1 Insurer Identifier, typical BIN number (6 digit) target : Reference ( Organization ) 0..1 The provider which is responsible for the bill, claim pre-determination, pre-authorization provider : Reference ( Practitioner ) 0..1 The organization which is responsible for the bill, claim pre-determination, pre-authorization organization : Reference ( Organization ) 0..1 Complete (Bill or Claim), Proposed (Pre-Authorization), Exploratory (Pre-determination) use : code 0..1 « Complete, proposed, exploratory, other Use » Immediate (STAT), best effort (NORMAL), deferred (DEFER) priority : Coding 0..1 « ( The timeliness with which processing is required: STAT, normal, Deferred ProcessPriority ) » 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 « ( For whom funds are to be reserved: (Patient, Provider, None) FundsReserve ) » Person who created the invoice/claim/pre-determination or pre-authorization enterer : Reference ( Practitioner ) 0..1 Facility where the services were provided facility : Reference ( Location ) 0..1 Prescription to support the dispensing of Pharmacy or Vision products prescription : Reference ( MedicationPrescription | VisionPrescription ) 0..1 Original prescription to support the dispensing of pharmacy services, medications or products originalPrescription : Reference ( MedicationPrescription ) 0..1 The referral resource which lists the date, practitioner, reason and other supporting information referral : Reference ( ReferralRequest ) 0..1 List of patient conditions for which care is sought condition : Coding 0..* « ( Patient conditions and symptoms Conditions ) » Patient Resource patient : Reference ( Patient ) 1..1 Factors which may influence the applicability of coverage exception : Coding 0..* « ( The eligibility exception codes. Exception ) » Name of school for over-aged dependants school : string 0..1 Date of an accident which these services are addressing accident : date 0..1 Type of accident: work, auto, etc accidentType : Coding 0..1 « ( Type of accident: work place, auto, etc. AccidentType ) » A list of intervention and exception codes which may influence the adjudication of the claim interventionException : Coding 0..* « ( Intervention and exception codes (Pharm) Intervention ) » Code to indicate that Xrays, images, emails, documents, models or attachments are being sent in support of this submission additionalMaterials : Coding 0..* « ( Code to indicate that Xrays, images, emails, documents, models or attachments are being sent in support of this submission. AdditionalMaterials ) » Payee Party to be reimbursed: Subscriber, provider, other type : Coding 0..1 « ( A code for the party to be reimbursed. PayeeType ) » The provider who is to be reimbursed for the claim (the party to whom any benefit is assigned) provider : Reference ( Practitioner ) 0..1 The organization who is to be reimbursed for the claim (the party to whom any benefit is assigned) organization : Reference ( Organization ) 0..1 The person other than the subscriber who is to be reimbursed for the claim (the party to whom any benefit is assigned) person : Reference ( Patient ) 0..1 Diagnosis Sequence of diagnosis which serves to order and provide a link sequence : integer 1..1 The diagnosis diagnosis : Coding 1..1 « ( ICD10 Diagnostic codes ICD10 ) » Coverage A service line item sequence : integer 1..1 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 Reference to the program or plan identification, underwriter or payor coverage : Reference ( Coverage ) 1..1 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 Relationship ) » A list of references from the Insurer to which these services pertain preAuthRef : string 0..* The Coverages adjudication details claimResponse : Reference ( ClaimResponse ) 0..1 The style (standard) and version of the original material which was converted into this resource originalRuleset : Coding 0..1 « ( The static and dynamic model to which contents conform, may be business version or standard and version. Ruleset ) » Items A service line number sequence : integer 1..1 The type of product or service type : Coding 1..1 « ( Service, Product, Rx Dispense, Rx Compound etc. ItemType ) » The practitioner who is responsible for the services rendered to the patient provider : Reference ( Practitioner ) 0..1 Diagnosis applicable for this service or product line diagnosisLinkId : integer 0..* 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 « ( Allowable service and product codes ServiceProduct ) » The date when the enclosed suite of services were performed or completed serviceDate : date 0..1 The number of repetitions of a service or product quantity : Quantity 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 unitPrice : Money 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 factor : decimal 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 points : decimal 0..1 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 : Money 0..1 List of Unique Device Identifiers associated with this line item udi : Coding 0..1 « ( The FDA, or other, UDI repository. UDI ) » Physical service site on the patient (limb, tooth, etc) bodySite : Coding 0..1 « ( The code for the teeth, quadrant, sextant and arch OralSites ) » 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 Surface ) » 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. Modifiers ) » Detail A service line number sequence : integer 1..1 The type of product or service type : Coding 1..1 « ( Service, Product, Rx Dispense, Rx Compound etc. ItemType ) » 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 « ( Allowable service and product codes ServiceProduct ) » The number of repetitions of a service or product quantity : Quantity 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 unitPrice : Money 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 factor : decimal 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 points : decimal 0..1 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 : Money 0..1 List of Unique Device Identifiers associated with this line item udi : Coding 0..1 « ( The FDA, or other, UDI repository. UDI ) » SubDetail A service line number sequence : integer 1..1 The type of product or service type : Coding 1..1 « ( Service, Product, Rx Dispense, Rx Compound etc. ItemType ) » The fee for an addittional service or product or charge service : Coding 1..1 « ( Allowable service and product codes ServiceProduct ) » The number of repetitions of a service or product quantity : Quantity 0..1 The fee for an addittional service or product or charge unitPrice : Money 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 factor : decimal 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 points : decimal 0..1 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 : Money 0..1 List of Unique Device Identifiers associated with this line item udi : Coding 0..1 « ( The FDA, or other, UDI repository. UDI ) » Prosthesis Indicates whether this is the initial placement of a fixed prosthesis initial : boolean 0..1 Date of the initial placement priorDate : date 0..1 Material of the prior denture or bridge prosthesis. (Oral) priorMaterial : Coding 0..1 « ( Material of the prior denture or bridge prosthesis. (Oral) OralProsthoMaterial ) » MissingTeeth The code identifying which tooth is missing tooth : Coding 1..1 « ( The codes for the teeth, subset of OralSites Tooth ) » Missing reason may be: E-extraction, O-other reason : Coding 0..1 « ( Reason codes for the missing teeth MissingReason ) » The date of the extraction either known from records or patient reported estimate extractionDate : date 0..1 The party to be reimbursed for the services payee 0..1 Ordered list of patient diagnosis for which care is sought diagnosis 0..* Financial instrument by which payment information for health care coverage 0..* Third tier of goods and services subDetail 0..* Second tier of goods and services detail 0..* The materials and placement date of prior fixed prosthesis prosthesis 0..1 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 missingTeeth 0..*

XML Template 

<Claim xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <type value="[code]"/><!-- 1..1 institutional | oral | pharmacy | professional | vision -->
 <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><!-- 0..1 Reference(Organization) Insurer --></target>
 <provider><!-- 0..1 Reference(Practitioner) Responsible provider --></provider>
 <organization><!-- 0..1 Reference(Organization) Responsible organization --></organization>
 <use value="[code]"/><!-- 0..1 complete | proposed | exploratory | other -->
 <priority><!-- 0..1 Coding Desired processing priority --></priority>
 <fundsReserve><!-- 0..1 Coding Funds requested to be reserved --></fundsReserve>
 <enterer><!-- 0..1 Reference(Practitioner) Author --></enterer>
 <facility><!-- 0..1 Reference(Location) Servicing Facility --></facility>
 <prescription><!-- 0..1 Reference(MedicationPrescription|VisionPrescription) 
     Prescription --></prescription>
 <originalPrescription><!-- 0..1 Reference(MedicationPrescription) 
     Original Prescription --></originalPrescription>
 <payee>  <!-- 0..1 Payee -->
  <type><!-- 0..1 Coding Party to be paid any benefits payable --></type>
  <provider><!-- 0..1 Reference(Practitioner) Provider who is the payee --></provider>
  <organization><!-- 0..1 Reference(Organization) Organization who is the payee --></organization>
  <person><!-- 0..1 Reference(Patient) Other person who is the payee --></person>
 </payee>
 <referral><!-- 0..1 Reference(ReferralRequest) Treatment Referral --></referral>
 <diagnosis>  <!-- 0..* Diagnosis -->
  <sequence value="[integer]"/><!-- 1..1 Sequence of diagnosis -->
  <diagnosis><!-- 1..1 Coding Patient's list of diagnosis --></diagnosis>
 </diagnosis>
 <condition><!-- 0..* Coding List of presenting Conditions --></condition>
 <patient><!-- 1..1 Reference(Patient) The subject of the Products and Services --></patient>
 <coverage>  <!-- 0..* Insurance or medical plan -->
  <sequence value="[integer]"/><!-- 1..1 Service instance identifier -->
  <focal value="[boolean]"/><!-- 1..1 Is the focal Coverage -->
  <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage>
  <businessArrangement value="[string]"/><!-- 0..1 Business agreement -->
  <relationship><!-- 1..1 Coding Patient relationship to subscriber --></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><!-- 0..* Coding Eligibility exceptions --></exception>
 <school value="[string]"/><!-- 0..1 Name of School -->
 <accident value="[date]"/><!-- 0..1 Accident Date -->
 <accidentType><!-- 0..1 Coding Accident Type --></accidentType>
 <interventionException><!-- 0..* Coding Intervention and exception code (Pharma) --></interventionException>
 <item>  <!-- 0..* Goods and Services -->
  <sequence value="[integer]"/><!-- 1..1 Service instance -->
  <type><!-- 1..1 Coding Group or type of product or service --></type>
  <provider><!-- 0..1 Reference(Practitioner) Responsible practitioner --></provider>
  <diagnosisLinkId value="[integer]"/><!-- 0..* Diagnosis Link -->
  <service><!-- 1..1 Coding Item Code --></service>
  <serviceDate value="[date]"/><!-- 0..1 Date of Service -->
  <quantity><!-- 0..1 Quantity Count of Products or Services --></quantity>
  <unitPrice><!-- 0..1 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><!-- 0..1 Money Total item cost --></net>
  <udi><!-- 0..1 Coding Unique Device Identifier --></udi>
  <bodySite><!-- 0..1 Coding Service Location --></bodySite>
  <subSite><!-- 0..* Coding Service Sub-location --></subSite>
  <modifier><!-- 0..* Coding Service/Product billing modifiers --></modifier>
  <detail>  <!-- 0..* Additional items -->
   <sequence value="[integer]"/><!-- 1..1 Service instance -->
   <type><!-- 1..1 Coding Group or type of product or service --></type>
   <service><!-- 1..1 Coding Additional item codes --></service>
   <quantity><!-- 0..1 Quantity Count of Products or Services --></quantity>
   <unitPrice><!-- 0..1 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><!-- 0..1 Money Total additional item cost --></net>
   <udi><!-- 0..1 Coding Unique Device Identifier --></udi>
   <subDetail>  <!-- 0..* Additional items -->
    <sequence value="[integer]"/><!-- 1..1 Service instance -->
    <type><!-- 1..1 Coding Type of product or service --></type>
    <service><!-- 1..1 Coding Additional item codes --></service>
    <quantity><!-- 0..1 Quantity Count of Products or Services --></quantity>
    <unitPrice><!-- 0..1 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><!-- 0..1 Money Net additional item cost --></net>
    <udi><!-- 0..1 Coding 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><!-- 0..* Coding Additional materials, documents, etc. --></additionalMaterials>
 <missingTeeth>  <!-- 0..* Only if type = oral -->
  <tooth><!-- 1..1 Coding Tooth Code --></tooth>
  <reason><!-- 0..1 Coding Reason for missing --></reason>
  <extractionDate value="[date]"/><!-- 0..1 Date of Extraction -->
 </missingTeeth>
</Claim>

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
  "identifier" : [{ Identifier }], // Claim number
  "ruleset" : { Coding }, // Current specification followed
  "originalRuleset" : { Coding }, // Original specification followed
  "created" : "<dateTime>", // Creation date
  "target" : { Reference(Organization) }, // Insurer
  "provider" : { Reference(Practitioner) }, // Responsible provider
  "organization" : { Reference(Organization) }, // Responsible organization
  "use" : "<code>", // complete | proposed | exploratory | other
  "priority" : { Coding }, // Desired processing priority
  "fundsReserve" : { Coding }, // Funds requested to be reserved
  "enterer" : { Reference(Practitioner) }, // Author
  "facility" : { Reference(Location) }, // Servicing Facility
  "prescription" : { Reference(MedicationPrescription|VisionPrescription) }, // 
     Prescription
  "originalPrescription" : { Reference(MedicationPrescription) }, // 
     Original Prescription
  "payee" : { // Payee
    "type" : { Coding }, // Party to be paid any benefits payable
    "provider" : { Reference(Practitioner) }, // Provider who is the payee
    "organization" : { Reference(Organization) }, // Organization who is the payee
    "person" : { Reference(Patient) } // Other person who is the payee
  },
  "referral" : { Reference(ReferralRequest) }, // Treatment Referral
  "diagnosis" : [{ // Diagnosis
    "sequence" : <integer>, // R!  Sequence of diagnosis
    "diagnosis" : { Coding } // R!  Patient's list of diagnosis
  }],
  "condition" : [{ Coding }], // List of presenting Conditions
  "patient" : { Reference(Patient) }, // R!  The subject of the Products and Services
  "coverage" : [{ // Insurance or medical plan
    "sequence" : <integer>, // R!  Service instance identifier
    "focal" : <boolean>, // R!  Is the focal Coverage
    "coverage" : { Reference(Coverage) }, // R!  Insurance information
    "businessArrangement" : "<string>", // Business agreement
    "relationship" : { Coding }, // R!  Patient relationship to subscriber
    "preAuthRef" : ["<string>"], // Pre-Authorization/Determination Reference
    "claimResponse" : { Reference(ClaimResponse) }, // Adjudication results
    "originalRuleset" : { Coding } // Original version
  }],
  "exception" : [{ Coding }], // Eligibility exceptions
  "school" : "<string>", // Name of School
  "accident" : "<date>", // Accident Date
  "accidentType" : { Coding }, // Accident Type
  "interventionException" : [{ Coding }], // Intervention and exception code (Pharma)
  "item" : [{ // Goods and Services
    "sequence" : <integer>, // R!  Service instance
    "type" : { Coding }, // R!  Group or type of product or service
    "provider" : { Reference(Practitioner) }, // Responsible practitioner
    "diagnosisLinkId" : [<integer>], // Diagnosis Link
    "service" : { Coding }, // R!  Item Code
    "serviceDate" : "<date>", // Date of Service
    "quantity" : { Quantity }, // Count of Products or Services
    "unitPrice" : { Money }, // Fee, charge or cost per point
    "factor" : <decimal>, // Price scaling factor
    "points" : <decimal>, // Difficulty scaling factor
    "net" : { Money }, // Total item cost
    "udi" : { Coding }, // Unique Device Identifier
    "bodySite" : { Coding }, // Service Location
    "subSite" : [{ Coding }], // Service Sub-location
    "modifier" : [{ Coding }], // Service/Product billing modifiers
    "detail" : [{ // Additional items
      "sequence" : <integer>, // R!  Service instance
      "type" : { Coding }, // R!  Group or type of product or service
      "service" : { Coding }, // R!  Additional item codes
      "quantity" : { Quantity }, // Count of Products or Services
      "unitPrice" : { Money }, // Fee, charge or cost per point
      "factor" : <decimal>, // Price scaling factor
      "points" : <decimal>, // Difficulty scaling factor
      "net" : { Money }, // Total additional item cost
      "udi" : { Coding }, // Unique Device Identifier
      "subDetail" : [{ // Additional items
        "sequence" : <integer>, // R!  Service instance
        "type" : { Coding }, // R!  Type of product or service
        "service" : { Coding }, // R!  Additional item codes
        "quantity" : { Quantity }, // Count of Products or Services
        "unitPrice" : { Money }, // Fee, charge or cost per point
        "factor" : <decimal>, // Price scaling factor
        "points" : <decimal>, // Difficulty scaling factor
        "net" : { Money }, // Net additional item cost
        "udi" : { Coding } // Unique Device Identifier
      }]
    }],
    "prosthesis" : { // Prosthetic details
      "initial" : <boolean>, // Is this the initial service
      "priorDate" : "<date>", // Initial service Date
      "priorMaterial" : { Coding } // Prosthetic Material
    }
  }],
  "additionalMaterials" : [{ Coding }], // Additional materials, documents, etc.
  "missingTeeth" : [{ // Only if type = oral
    "tooth" : { Coding }, // R!  Tooth Code
    "reason" : { Coding }, // Reason for missing
    "extractionDate" : "<date>" // Date of Extraction
  }]
}

 

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

7.1.2.1 Terminology Bindings

Path Definition Type Reference
Claim.type The type or discipline-style of the claim Required http://hl7.org/fhir/type-link
Claim.ruleset
Claim.originalRuleset
Claim.coverage.originalRuleset 		The static and dynamic model to which contents conform, may be business version or standard and version. Example http://hl7.org/fhir/vs/ruleset
Claim.use Complete, proposed, exploratory, other Required http://hl7.org/fhir/use-link
Claim.priority The timeliness with which processing is required: STAT, normal, Deferred Example http://hl7.org/fhir/vs/process-priority
Claim.fundsReserve For whom funds are to be reserved: (Patient, Provider, None) Example http://hl7.org/fhir/vs/fundsreserve
Claim.payee.type A code for the party to be reimbursed. Example http://hl7.org/fhir/vs/payeetype
Claim.diagnosis.diagnosis ICD10 Diagnostic codes Example http://hl7.org/fhir/vs/icd-10
Claim.condition Patient conditions and symptoms Example http://hl7.org/fhir/vs/fm-conditions
Claim.coverage.relationship The code for the relationship of the patient to the subscriber Example http://hl7.org/fhir/vs/relationship
Claim.exception The eligibility exception codes. Example http://hl7.org/fhir/vs/exception
Claim.accidentType Type of accident: work place, auto, etc. Example http://hl7.org/fhir/vs/ActIncidentCode
Claim.interventionException Intervention and exception codes (Pharm) Example http://hl7.org/fhir/vs/intervention
Claim.item.type
Claim.item.detail.type
Claim.item.detail.subDetail.type 		Service, Product, Rx Dispense, Rx Compound etc. Example http://hl7.org/fhir/vs/ActInvoiceGroupCode
Claim.item.service
Claim.item.detail.service
Claim.item.detail.subDetail.service 		Allowable service and product codes Example http://hl7.org/fhir/vs/service-uscls
Claim.item.udi
Claim.item.detail.udi
Claim.item.detail.subDetail.udi 		The FDA, or other, UDI repository. Example http://hl7.org/fhir/vs/udi
Claim.item.bodySite The code for the teeth, quadrant, sextant and arch Example http://hl7.org/fhir/vs/tooth
Claim.item.subSite The code for the tooth surface and surface combinations Example http://hl7.org/fhir/vs/surface
Claim.item.modifier 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 http://hl7.org/fhir/vs/modifiers
Claim.item.prosthesis.priorMaterial Material of the prior denture or bridge prosthesis. (Oral) Example http://hl7.org/fhir/vs/oral-prosthodontic-material
Claim.additionalMaterials Code to indicate that Xrays, images, emails, documents, models or attachments are being sent in support of this submission. Example http://hl7.org/fhir/vs/additionalmaterials
Claim.missingTeeth.tooth The codes for the teeth, subset of OralSites Example http://hl7.org/fhir/vs/teeth
Claim.missingTeeth.reason Reason codes for the missing teeth Example http://hl7.org/fhir/vs/missing-tooth-reason

7.1.3 Search Parameters

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

Name Type Description Paths
identifier token The primary identifier of the financial resource Claim.identifier
patient reference Patient Claim.patient
( Patient )
priority token Processing priority requested Claim.priority
provider reference Provider responsible for the claim Claim.provider
( Practitioner )
use token The kind of financial resource Claim.use