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13.6 Resource Claim - Content

Financial Management icon Work Group Maturity Level : 2   Trial Use Security Category : Patient Compartments : Device , Encounter , Patient , Practitioner , RelatedPerson

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

13.6.1 Scope and Usage

The Claim is used by providers and payors, insurers, to exchange the financial information, and supporting clinical information, regarding the provision of health care services with payors and for reporting to regulatory bodies and firms which provide data analytics. The primary uses of this resource is to support eClaims, the exchange of information relating to the proposed or actual provision of healthcare-related goods and services for patients to their benefit payors, insurers and national health programs, for treatment payment planning and reimbursement.

The Claim resource is a "request" resource from a FHIR workflow perspective - see Workflow Request.

The Claim resource may be interpreted differently depending on its intended use (and the Claim.use element contains the code to indicate):

  • claim - where the provision of goods and services is complete and adjudication under a plan and payment is sought.
  • preauthorization - where the provision of goods and services is proposed and authorization and/or the reservation of funds is desired.
  • predetermination - where the provision of goods and services is explored to determine what services may be covered and to what amount. Essentially a 'what if' claim.

The Claim.type code system provides oral, pharmacy, vision, professional and institutional claim types. Claim types supported are influenced by the requirements of the implementing jurisdiction. The valueset is extensible to accommodate other types of claims as required by the jurisdiction.

The Claim also supports:

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

Mapping to other Claim specifications: Mappings are currently maintained by the Financial Management Work Group to UB04 and CMS1500 and are available at https://confluence.hl7.org/display/FM/FHIR+Resource+Development icon . Mappings to other specifications may be made available where IP restrictions permit.

13.6.1.1 Additional Information

Additional information regarding electronic claims content and usage may be found at:

  • Financial Resource Status Lifecycle : how .status is used in the financial resources.
  • Secondary Use of Resources : how resources such as Claim and ExplanationOfBenefit may used for reporting and data exchange for analytics, not just for eClaims exchange between providers and payors.
  • Subrogation : how eClaims may handle patient insurance coverages when another insurer rather than the provider will settle the claim and potentially recover costs against specified coverages.
  • Coordination of Benefit : how eClaims may handle multiple patient insurance coverages.
  • Batches : how eClaims may handle batches of eligibility, claims and responses.
  • Attachments and Supporting Information : how eClaims may handle the provision of supporting information, whether provided by content or reference, within the eClaim resource when submitted to the payor or later in a resource which refers to the subject eClaim resource. This also includes how payors may request additional supporting information from providers.
  • 3-Tier Line Item Hierarchy : 3-tier hierarchy of Goods, products, and Services, to support simple to complex billing.
  • Tax : Tax handling of Goods, products, and Services.

13.6.2 Boundaries and Relationships

The Claim resource is used to request the adjudication and/or authorization of a set of healthcare-related goods and services for a patient against the patient's insurance coverages, or to request what the adjudication would be for a supplied set of goods or services should they be actually supplied to the patient.

When requesting whether the patient's coverage is inforce, whether it is valid at this or a specified date, or requesting the benefit details or preauthorization requirements associated with a coverage, then CoverageEligibilityRequest should be used instead.

When using the resources for reporting and transferring claims data, which may have originated in some standard other than FHIR, the Claim resource is useful if only the request side of the information exchange is of interest. If, however, both the request and the adjudication information is to be reported then the ExplanationOfBenefit should be used instead.

For reporting out to patients or transferring data to patient centered applications, such as patient health Personal Health Record (PHR) application, the ExplanationOfBenefit should be used instead of the Claim and ClaimResponse resources as those resources may contain provider and payer specific information which is not appropriate for sharing with the patient.

The eClaim domain includes a number of related resources

Claim A suite of goods and services and insurances coverages under which adjudication or authorization is requested.
CoverageEligibilityRequest A request to a payor to: ascertain whether a coverage is in-force at the current or at a specified time; list the table of benefits; determine whether coverage is provided for specified categories or specific services; and whether preauthorization is required, and if so what supporting information would be required.
ClaimResponse A payor's adjudication and/or authorization response to the suite of services provided in a Claim. Typically the ClaimResponse references the Claim but does not duplicate the clinical or financial information provided in the claim.
ExplanationOfBenefit This resource combines the information from the Claim and the ClaimResponse, stripping out any provider or payor proprietary information, into a unified information model suitable for use for: patient reporting; transferring information to a Patient Health Record system; and, supporting complete claim and adjudication information exchange with regulatory and analytics organizations and other parts of the provider's organization.
This resource is referenced by itself,

13.6.3 References to this Resource

13.6.3 13.6.4 Resource Content

Structure

1..1 1..1 Anatomical sub-location
Name Flags Card. Type Description & Constraints doco
. . Claim TU DomainResource Claim, Pre-determination or Pre-authorization

Elements defined in Ancestors: id , meta , implicitRules , language , text , contained , extension , modifierExtension
. . . identifier 0..* Identifier Business Identifier for claim

. . status . traceNumber 0..* Identifier Number for tracking

... status ?! Σ 1..1 code active | cancelled | draft | entered-in-error
Binding: Financial Resource Status Codes ( Required )
. . . type Σ 1..1 CodeableConcept Category or discipline
Binding: Claim Type Codes ( Extensible )
. . . subType 0..1 CodeableConcept More granular claim type
Binding: Example Claim SubType Codes ( Example )
. . . use Σ 1..1 code claim | preauthorization | predetermination
Binding: Use ( Required )
. . . patient Σ 1..1 Reference ( Patient ) The recipient of the products and services
. . . billablePeriod Σ 0..1 Period Relevant time frame for the claim
. . . created Σ 1..1 dateTime Resource creation date
. . . enterer 0..1 Reference ( Practitioner | PractitionerRole | Patient | RelatedPerson ) Author of the claim
. . . insurer Σ 0..1 Reference ( Organization ) Target
. . . provider Σ 0..1 Reference ( Practitioner | PractitionerRole | Organization ) Party responsible for the claim
. . . priority Σ 0..1 CodeableConcept Desired processing ugency urgency
Binding: Process Priority Codes ( Example )
. . . fundsReserve 0..1 CodeableConcept For whom to reserve funds
FundsReserve Binding: Funds Reservation Codes ( Example )
. . . related 0..* BackboneElement Prior or corollary claims

. . . . claim 0..1 Reference ( Claim ) Reference to the related claim
. . . . relationship 0..1 CodeableConcept How the reference claim is related
Binding: Example Related Claim Relationship Codes ( Example )
. . . . reference 0..1 Identifier File or case reference
. . . prescription 0..1 Reference ( DeviceRequest | MedicationRequest | VisionPrescription ) Prescription authorizing services and products
. . . originalPrescription 0..1 Reference ( DeviceRequest | MedicationRequest | VisionPrescription ) Original prescription if superseded by fulfiller
. . . payee 0..1 BackboneElement Recipient of benefits payable
. . . . type 1..1 CodeableConcept Category of recipient
PayeeType Binding: Claim Payee Type Codes ( Example )
. . . . party 0..1 Reference ( Practitioner | PractitionerRole | Organization | Patient | RelatedPerson ) Recipient reference
. . . referral 0..1 Reference ( ServiceRequest ) Treatment referral
. . . encounter 0..* Reference ( Encounter ) Encounters associated with the listed treatments

. . . facility 0..1 Reference ( Location | Organization ) Servicing facility
. . careTeam . diagnosisRelatedGroup 0..1 CodeableConcept Package billing code
Binding: Example Diagnosis Related Group Codes ( Example )
... event 0..* BackboneElement Event information

.... type 1..1 CodeableConcept Specific event
Binding: Dates Type Codes ( Example )
.... when[x] 1..1 Occurance date or period
..... whenDateTime dateTime
..... whenPeriod Period
... careTeam 0..* BackboneElement Members of the care team

. . . . sequence 1..1 positiveInt Order of care team
. . . . provider 1..1 Reference ( Practitioner | PractitionerRole | Organization ) Practitioner or organization
. . . . responsible 0..1 boolean Indicator of the lead practitioner
. . . . role 0..1 CodeableConcept Function within the team
Binding: Claim Care Team Role Codes ( Example )
. . . . qualification specialty 0..1 CodeableConcept Practitioner credential or provider specialization
Binding: Example Provider Qualification Codes ( Example )
. . . supportingInfo 0..* BackboneElement Supporting information

. . . . sequence 1..1 positiveInt Information instance identifier
. . . . category 1..1 CodeableConcept Classification of the supplied information
Binding: Claim Information Category Codes ( Example )
. . . . code 0..1 CodeableConcept Type of information
Binding: Exception Codes ( Example )
. . . . timing[x] 0..1 When it occurred
. . . . . timingDate date
. . . . . timingPeriod Period
. . . . value[x] 0..1 Data to be provided
. . . . . valueBoolean boolean
. . . . . valueString string
. . . . . valueQuantity Quantity
. . . . . valueAttachment Attachment
. . . . . valueReference Reference ( Any )
. . . . . valueIdentifier Identifier
. . . . reason 0..1 CodeableConcept Explanation for the information
Binding: Missing Tooth Reason Codes ( Example )
. . . diagnosis 0..* BackboneElement Pertinent diagnosis information

. . . . sequence 1..1 positiveInt Diagnosis instance identifier
. . . . diagnosis[x] 1..1 Nature of illness or problem
Binding: ICD-10 Codes ( Example )
. . . . . diagnosisCodeableConcept CodeableConcept
. . . . . diagnosisReference Reference ( Condition )
. . . . type 0..* CodeableConcept Timing or nature of the diagnosis
Binding: Example Diagnosis Type Codes ( Example )
onAdmission 0..1 CodeableConcept Present on admission
Example Diagnosis on Admission Codes ( Example )
. . . . packageCode onAdmission 0..1 CodeableConcept Package billing code Present on admission
Binding: Example Diagnosis Related Group on Admission Codes ( Example )
. . . procedure 0..* BackboneElement Clinical procedures performed

. . . . sequence 1..1 positiveInt Procedure instance identifier
. . . . type 0..* CodeableConcept Category of Procedure
Binding: Example Procedure Type Codes ( Example )

. . . . date 0..1 dateTime When the procedure was performed
. . . . procedure[x] 1..1 Specific clinical procedure
Binding: ICD-10 Procedure Codes ( Example )
. . . . . procedureCodeableConcept CodeableConcept
. . . . . procedureReference Reference ( Procedure )
. . . . udi 0..* Reference ( Device ) Unique device identifier

. . . insurance Σ 1..* 0..* BackboneElement Patient insurance information

. . . . sequence Σ 1..1 positiveInt Insurance instance identifier
. . . . focal Σ 1..1 boolean Coverage to be used for adjudication
. . . . identifier 0..1 Identifier Pre-assigned Claim number
. . . . coverage Σ 1..1 Reference ( Coverage ) Insurance information
. . . . businessArrangement 0..1 string Additional provider contract number
. . . . preAuthRef 0..* string Prior authorization reference number

. . . . claimResponse 0..1 Reference ( ClaimResponse ) Adjudication results
. . . accident 0..1 BackboneElement Details of the event
. . . . date 1..1 date When the incident occurred
. . . . type 0..1 CodeableConcept The nature of the accident
Binding: ActIncidentCode icon V3 Value SetActIncidentCode ( Extensible )
. . . . location[x] 0..1 Where the event occurred
. . . . . locationAddress Address
. . . . . locationReference Reference ( Location )
. . item . patientPaid 0..1 Money Paid by the patient
... item 0..* BackboneElement Product or service provided

. . . . sequence 1..1 positiveInt Item instance identifier
. . . . traceNumber 0..* Identifier Number for tracking

. . . . careTeamSequence 0..* positiveInt Applicable careTeam members

. . . . diagnosisSequence 0..* positiveInt Applicable diagnoses

. . . . procedureSequence 0..* positiveInt Applicable procedures

. . . . informationSequence 0..* positiveInt Applicable exception and supporting information

. . . . revenue 0..1 CodeableConcept Revenue or cost center code
Binding: Example Revenue Center Codes ( Example )
. . . . category 0..1 CodeableConcept Benefit classification
Binding: Benefit Category Codes ( Example )
. . . . productOrService 1..1 0..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLS Codes ( Example )
. . . . modifier productOrServiceEnd 0..1 CodeableConcept End of a range of codes
Binding: USCLS Codes ( Example )
.... request 0..* Reference ( DeviceRequest | MedicationRequest | NutritionOrder | ServiceRequest | SupplyRequest | VisionPrescription ) Request or Referral for Service

.... modifier 0..* CodeableConcept Product or service billing modifiers
Binding: Modifier type Codes ( Example )

. . . . programCode 0..* CodeableConcept Program the product or service is provided under
Binding: Example Program Reason Codes ( Example )

. . . . serviced[x] 0..1 Date or dates of service or product delivery
. . . . . servicedDate date
. . . . . servicedPeriod Period
. . . . location[x] 0..1 Place of service or where product was supplied
Binding: Example Service Place Codes ( Example )
. . . . . locationCodeableConcept CodeableConcept
. . . . . locationAddress Address
. . . . . locationReference Reference ( Location )
. . . . quantity patientPaid 0..1 Money Paid by the patient
.... quantity 0..1 SimpleQuantity Count of products or services
. . . . unitPrice 0..1 Money Fee, charge or cost per item
. . . . factor 0..1 decimal Price scaling factor
. . . . tax 0..1 Money Total tax
. . . . net 0..1 Money Total item cost
. . . . udi 0..* Reference ( Device ) Unique device identifier

. . . . bodySite 0..1 0..* CodeableConcept BackboneElement Anatomical location

. . . . . site 1..* CodeableReference ( BodyStructure ) Location
Binding: Oral Site Codes ( Example )

. . . . . subSite 0..* CodeableConcept Sub-location
Binding: Surface Codes ( Example )

. . . . encounter 0..* Reference ( Encounter ) Encounters related to this billed item associated with the listed treatments

. . . . detail 0..* BackboneElement Product or service provided

. . . . . sequence 1..1 positiveInt Item instance identifier
. . . . . traceNumber 0..* Identifier Number for tracking

. . . . . revenue 0..1 CodeableConcept Revenue or cost center code
Binding: Example Revenue Center Codes ( Example )
. . . . . category 0..1 CodeableConcept Benefit classification
Binding: Benefit Category Codes ( Example )
. . . . . productOrService 1..1 0..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLS Codes ( Example )
. . . . . modifier productOrServiceEnd 0..1 CodeableConcept End of a range of codes
Binding: USCLS Codes ( Example )
..... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: Modifier type Codes ( Example )

. . . . . programCode 0..* CodeableConcept Program the product or service is provided under
Binding: Example Program Reason Codes ( Example )

. . . . . patientPaid 0..1 Money Paid by the patient
. . . . . quantity 0..1 SimpleQuantity Count of products or services
. . . . . unitPrice 0..1 Money Fee, charge or cost per item
. . . . . factor 0..1 decimal Price scaling factor
. . . . . net tax 0..1 Money Total item cost tax
. . . . udi . net 0..1 Money Total item cost
..... udi 0..* Reference ( Device ) Unique device identifier

. . . . . subDetail 0..* BackboneElement Product or service provided

. . . . . . sequence 1..1 positiveInt Item instance identifier
. . . . . . traceNumber 0..* Identifier Number for tracking

. . . . . . revenue 0..1 CodeableConcept Revenue or cost center code
Binding: Example Revenue Center Codes ( Example )
. . . . . . category 0..1 CodeableConcept Benefit classification
Binding: Benefit Category Codes ( Example )
. . . . . . productOrService 1..1 0..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLS Codes ( Example )
. . . . . . modifier productOrServiceEnd 0..1 CodeableConcept End of a range of codes
Binding: USCLS Codes ( Example )
...... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: Modifier type Codes ( Example )

. . . . . . programCode 0..* CodeableConcept Program the product or service is provided under
Binding: Example Program Reason Codes ( Example )

. . . . . . patientPaid 0..1 Money Paid by the patient
. . . . . . quantity 0..1 SimpleQuantity Count of products or services
. . . . . . unitPrice 0..1 Money Fee, charge or cost per item
. . . . . . factor 0..1 decimal Price scaling factor
. . . . . . net tax 0..1 Money Total tax
...... net 0..1 Money Total item cost
. . . . . . udi 0..* Reference ( Device ) Unique device identifier

. . . total 0..1 Money Total claim cost

doco Documentation for this format icon

See the Extensions for this resource

UML Diagram ( Legend )

Claim ( DomainResource ) A unique identifier assigned to this claim identifier : Identifier [0..*] Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners traceNumber : Identifier [0..*] The status of the resource instance (this element modifies the meaning of other elements) status : code [1..1] « A code specifying the state of the resource instance. null (Strength=Required) FinancialResourceStatusCodes ! » The category of claim, e.g. oral, pharmacy, vision, institutional, professional type : CodeableConcept [1..1] « The type or discipline-style of the claim. null (Strength=Extensible) ClaimTypeCodes + » A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service subType : CodeableConcept [0..1] « A more granular claim typecode. null (Strength=Example) ExampleClaimSubTypeCodes ?? » A code to indicate whether the nature of the request is: to Claim - A request adjudication of products to an Insurer to adjudicate the supplied charges for health care goods and services previously rendered; or requesting authorization under the identified policy and adjudication to pay the determined Benefit amount, if any; Preauthorization - A request to an Insurer to adjudicate the supplied proposed future charges for provision in health care goods and services under the future; or requesting identified policy and to approve the non-binding adjudication of services and provide the listed products expected benefit amounts and potentially to reserve funds to pay the benefits when Claims for the indicated services which could are later submitted; or, Pre-determination - A request to an Insurer to adjudicate the supplied 'what if' charges for health care goods and services under the identified policy and report back what the Benefit payable would be provided in had the future services actually been provided use : code [1..1] « The purpose of the Claim: predetermination, preauthorization, claim. null (Strength=Required) Use ! » The party to whom the professional services and/or products have been supplied or are being considered and for whom actual or forecast reimbursement is sought patient : Reference [1..1] « Patient » The period for which charges are being submitted billablePeriod : Period [0..1] The date this resource was created created : dateTime [1..1] Individual who created the claim, predetermination or preauthorization enterer : Reference [0..1] « Practitioner | PractitionerRole | Patient | RelatedPerson » The Insurer who is target of the request insurer : Reference [0..1] « Organization » The provider which is responsible for the claim, predetermination or preauthorization provider : Reference [1..1] [0..1] « Practitioner | PractitionerRole | Organization » The provider-required urgency of processing the request. Typical values include: stat, routine normal, deferred priority : CodeableConcept [1..1] [0..1] « The timeliness with which processing is required: stat, normal, deferred. null (Strength=Example) ProcessPriorityCodes ?? » A code to indicate whether and for whom funds are to be reserved for future claims fundsReserve : CodeableConcept [0..1] « For whom funds are to be reserved: (Patient, Provider, None). null (Strength=Example) Funds Reservation FundsReservationCodes ?? » Prescription is the document/authorization given to support the dispensing of pharmacy, device or vision claim author for them to provide products and services for which consideration (reimbursement) is sought. Could be a RX for medications, an 'order' for oxygen or wheelchair or physiotherapy treatments prescription : Reference [0..1] « DeviceRequest | MedicationRequest | VisionPrescription » Original prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or products originalPrescription : Reference [0..1] « DeviceRequest | MedicationRequest | VisionPrescription » A reference The referral information received by the claim author, it is not to be used when the author generates a referral resource for a patient. A copy of that referral may be provided as supporting information. Some insurers require proof of referral to pay for services or to pay specialist rates for services referral : Reference [0..1] « ServiceRequest » Healthcare encounters related to this claim encounter : Reference [0..*] « Encounter » Facility where the services were provided facility : Reference [0..1] « Location | Organization » A package billing code or bundle code used to group products and services to a particular health condition (such as heart attack) which is based on a predetermined grouping code system diagnosisRelatedGroup : CodeableConcept [0..1] « null (Strength=Example) ExampleDiagnosisRelatedGroupC... ?? » The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services patientPaid : Money [0..1] The total value of the all the items in the claim total : Money [0..1] RelatedClaim Reference to a related claim claim : Reference [0..1] « Claim » A code to convey how the claims are related relationship : CodeableConcept [0..1] « Relationship of this claim to a related Claim. null (Strength=Example) ExampleRelatedClaimRelationsh... ?? » An alternate organizational reference to the case or file to which this particular claim pertains reference : Identifier [0..1] Payee Type of Party to be reimbursed: subscriber, provider, other type : CodeableConcept [1..1] « A code for the party to be reimbursed. null (Strength=Example) Claim Payee Type ClaimPayeeTypeCodes ?? » Reference to the individual or organization to whom any payment will be made party : Reference [0..1] « Practitioner | PractitionerRole | Organization | Patient | RelatedPerson » Event A coded event such as when a service is expected or a card printed type : CodeableConcept [1..1] « null (Strength=Example) DatesTypeCodes ?? » A date or period in the past or future indicating when the event occurred or is expectd to occur when[x] : DataType [1..1] « dateTime | Period » CareTeam A number to uniquely identify care team entries sequence : positiveInt [1..1] Member of the team who provided the product or service provider : Reference [1..1] « Practitioner | PractitionerRole | Organization » The party who is billing and/or responsible for the claimed products or services responsible : boolean [0..1] The lead, assisting or supervising practitioner and their discipline if a multidisciplinary team role : CodeableConcept [0..1] « The role codes for the care team members. null (Strength=Example) ClaimCareTeamRoleCodes ?? » The qualification specialization of the practitioner or provider which is applicable for this service qualification specialty : CodeableConcept [0..1] « Provider professional qualifications. null (Strength=Example) ExampleProviderQualificationC... ?? » SupportingInformation A number to uniquely identify supporting information entries sequence : positiveInt [1..1] The general class of the information supplied: information; exception; accident, employment; onset, etc category : CodeableConcept [1..1] « The valuset used for additional information category codes. null (Strength=Example) ClaimInformationCategoryCodes ?? » System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought code : CodeableConcept [0..1] « The valuset used for additional information codes. null (Strength=Example) ExceptionCodes ?? » The date when or period to which this information refers timing[x] : Type DataType [0..1] « date | Period » Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data value[x] : Type DataType [0..1] « boolean | string | Quantity | Attachment | Reference ( Any ) )| Identifier » Provides the reason in the situation where a reason code is required in addition to the content reason : CodeableConcept [0..1] « Reason codes for the missing teeth. null (Strength=Example) MissingToothReasonCodes ?? » Diagnosis A number to uniquely identify diagnosis entries sequence : positiveInt [1..1] The nature of illness or problem in a coded form or as a reference to an external defined Condition diagnosis[x] : Type DataType [1..1] « CodeableConcept | Reference ( Condition ); Example ICD10 Diagnostic codes. null (Strength=Example) ICD-10Codes ICD10Codes ?? » When the condition was observed or the relative ranking type : CodeableConcept [0..*] « The type of the diagnosis: admitting, principal, discharge. null (Strength=Example) ExampleDiagnosisTypeCodes ?? » Indication of whether the diagnosis was present on admission to a facility onAdmission : CodeableConcept [0..1] « Present on admission. null (Strength=Example) ExampleDiagnosisOnAdmissionCo... ?? » A package billing code or bundle code used to group products and services to a particular health condition (such as heart attack) which is based on a predetermined grouping code system packageCode : CodeableConcept [0..1] « The DRG codes associated with the diagnosis. (Strength=Example) ExampleDiagnosisRelatedGroupC... ?? » Procedure A number to uniquely identify procedure entries sequence : positiveInt [1..1] When the condition was observed or the relative ranking type : CodeableConcept [0..*] « Example procedure type codes. null (Strength=Example) ExampleProcedureTypeCodes ?? » Date and optionally time the procedure was performed date : dateTime [0..1] The code or reference to a Procedure resource which identifies the clinical intervention performed procedure[x] : Type DataType [1..1] « CodeableConcept | Reference ( Procedure ); Example ICD10 Procedure codes. null (Strength=Example) ICD-10ProcedureCodes ICD10ProcedureCodes ?? » Unique Device Identifiers associated with this line item udi : Reference [0..*] « Device » Insurance A number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order sequence : positiveInt [1..1] A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true focal : boolean [1..1] The business identifier to be used when the claim is sent for adjudication against this insurance policy identifier : Identifier [0..1] Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system coverage : Reference [1..1] « Coverage » A business agreement number established between the provider and the insurer for special business processing purposes businessArrangement : string [0..1] Reference numbers previously provided by the insurer to the provider to be quoted on subsequent claims containing services or products related to the prior authorization preAuthRef : string [0..*] The result of the adjudication of the line items for the Coverage specified in this insurance claimResponse : Reference [0..1] « ClaimResponse » Accident Date of an accident event related to the products and services contained in the claim date : date [1..1] The type or context of the accident event for the purposes of selection of potential insurance coverages and determination of coordination between insurers type : CodeableConcept [0..1] « Type of accident: work place, auto, etc. null (Strength=Extensible) v3.ActIncidentCode ActIncidentCode + » The physical location of the accident event location[x] : Type DataType [0..1] « Address | Reference ( Location ) » Item A number to uniquely identify item entries sequence : positiveInt [1..1] Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners traceNumber : Identifier [0..*] CareTeam members related to this service or product careTeamSequence : positiveInt [0..*] Diagnosis applicable for this service or product diagnosisSequence : positiveInt [0..*] Procedures applicable for this service or product procedureSequence : positiveInt [0..*] Exceptions, special conditions and supporting information applicable for this service or product informationSequence : positiveInt [0..*] The type of revenue or cost center providing the product and/or service revenue : CodeableConcept [0..1] « Codes for the revenue or cost centers supplying the service and/or products. null (Strength=Example) ExampleRevenueCenterCodes ?? » Code to identify the general type of benefits under which products and services are provided category : CodeableConcept [0..1] « Benefit categories such as: oral-basic, major, glasses. null (Strength=Example) BenefitCategoryCodes ?? » When the value is a group code then this item collects a set of related claim item details, otherwise this contains the product, service, drug or other billing code for the item item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used productOrService : CodeableConcept [1..1] [0..1] « Allowable service null (Strength=Example) USCLSCodes ?? » This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and product codes. not with claims productOrServiceEnd : CodeableConcept [0..1] « null (Strength=Example) USCLSCodes ?? » Request or Referral for Goods or Service to be rendered request : Reference [0..*] « DeviceRequest | MedicationRequest | NutritionOrder | ServiceRequest | SupplyRequest | VisionPrescription » Item typification or modifiers codes to convey additional context for the product or service modifier : CodeableConcept [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. null (Strength=Example) ModifierTypeCodes ?? » Identifies the program under which this may be recovered programCode : CodeableConcept [0..*] « Program specific reason codes. null (Strength=Example) ExampleProgramReasonCodes ?? » The date or dates when the service or product was supplied, performed or completed serviced[x] : Type DataType [0..1] « date | Period » Where the product or service was provided location[x] : Type DataType [0..1] « CodeableConcept | Address | Reference ( Location ); Place of service: pharmacy, school, prison, etc. null (Strength=Example) ExampleServicePlaceCodes ?? » The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services patientPaid : Money [0..1] The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details 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] The quantity times the unit price total of taxes applicable for an additional service or this product or charge service tax : Money [0..1] The total amount claimed for the group (if a grouper) or the line item. Net = unit price * quantity * factor net : Money [0..1] Unique Device Identifiers associated with this line item udi : Reference [0..*] « Device » Healthcare encounters related to this claim encounter : Reference [0..*] « Encounter » BodySite Physical service site on the patient (limb, tooth, etc.) bodySite site : CodeableConcept CodeableReference [0..1] [1..*] « BodyStructure ; The code for the teeth, quadrant, sextant and arch. null (Strength=Example) OralSiteCodes ?? » A region or surface of the bodySite, e.g. limb region or tooth surface(s) subSite : CodeableConcept [0..*] « The code for the tooth surface and surface combinations. null (Strength=Example) SurfaceCodes ?? » The Encounters during which this Claim was created or to which the creation of this record is tightly associated encounter : Reference [0..*] « Encounter » Detail A number to uniquely identify item entries sequence : positiveInt [1..1] Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners traceNumber : Identifier [0..*] The type of revenue or cost center providing the product and/or service revenue : CodeableConcept [0..1] « Codes for the revenue or cost centers supplying the service and/or products. null (Strength=Example) ExampleRevenueCenterCodes ?? » Code to identify the general type of benefits under which products and services are provided category : CodeableConcept [0..1] « Benefit categories such as: oral-basic, major, glasses. null (Strength=Example) BenefitCategoryCodes ?? » When the value is a group code then this item collects a set of related claim item details, otherwise this contains the product, service, drug or other billing code for the item item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used productOrService : CodeableConcept [1..1] [0..1] « Allowable service null (Strength=Example) USCLSCodes ?? » This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and product codes. not with claims productOrServiceEnd : CodeableConcept [0..1] « null (Strength=Example) USCLSCodes ?? » Item typification or modifiers codes to convey additional context for the product or service modifier : CodeableConcept [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. null (Strength=Example) ModifierTypeCodes ?? » Identifies the program under which this may be recovered programCode : CodeableConcept [0..*] « Program specific reason codes. null (Strength=Example) ExampleProgramReasonCodes ?? » The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services patientPaid : Money [0..1] The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details 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] The quantity times the unit price total of taxes applicable for an additional service or this product or charge service tax : Money [0..1] The total amount claimed for the group (if a grouper) or the line item.detail. Net = unit price * quantity * factor net : Money [0..1] Unique Device Identifiers associated with this line item udi : Reference [0..*] « Device » SubDetail A number to uniquely identify item entries sequence : positiveInt [1..1] Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners traceNumber : Identifier [0..*] The type of revenue or cost center providing the product and/or service revenue : CodeableConcept [0..1] « Codes for the revenue or cost centers supplying the service and/or products. null (Strength=Example) ExampleRevenueCenterCodes ?? » Code to identify the general type of benefits under which products and services are provided category : CodeableConcept [0..1] « Benefit categories such as: oral-basic, major, glasses. null (Strength=Example) BenefitCategoryCodes ?? » When the value is a group code then this item collects a set of related claim item details, otherwise this contains the product, service, drug or other billing code for the item item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used productOrService : CodeableConcept [1..1] [0..1] « Allowable service null (Strength=Example) USCLSCodes ?? » This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and product codes. not with claims productOrServiceEnd : CodeableConcept [0..1] « null (Strength=Example) USCLSCodes ?? » Item typification or modifiers codes to convey additional context for the product or service modifier : CodeableConcept [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. null (Strength=Example) ModifierTypeCodes ?? » Identifies the program under which this may be recovered programCode : CodeableConcept [0..*] « Program specific reason codes. null (Strength=Example) ExampleProgramReasonCodes ?? » The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services patientPaid : Money [0..1] The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details 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] The quantity times the unit price total of taxes applicable for an additional service or this product or charge service tax : Money [0..1] The total amount claimed for line item.detail.subDetail. Net = unit price * quantity * factor net : Money [0..1] Unique Device Identifiers associated with this line item udi : Reference [0..*] « Device » Other claims which are related to this claim such as prior submissions or claims for related services or for the same event related [0..*] The party to be reimbursed for cost of the products and services according to the terms of the policy payee [0..1] Information code for an event with a corresponding date or period event [0..*] The members of the team who provided the products and services careTeam [0..*] Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues supportingInfo [0..*] Information about diagnoses relevant to the claim items diagnosis [0..*] Procedures performed on the patient relevant to the billing items with the claim procedure [0..*] Financial instruments for reimbursement for the health care products and services specified on the claim insurance [1..*] [0..*] Details of an accident which resulted in injuries which required the products and services listed in the claim accident [0..1] Physical location where the service is performed or applies bodySite [0..*] A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items subDetail [0..*] A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items detail [0..*] A claim line. Either a simple product or service or a 'group' of details which can each be a simple items or groups of sub-details item [0..*]

XML Template 

<Claim xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Business Identifier for claim --></identifier>
 <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>

 <status value="[code]"/><!-- 1..1 active | cancelled | draft | entered-in-error -->
 <type><!-- 1..1 CodeableConcept Category or discipline --></type>
 <subType><!-- 0..1 CodeableConcept More granular claim type --></subType>
 <

 <use value="[code]"/><!-- 1..1 claim | preauthorization | predetermination -->

 <patient><!-- 1..1 Reference(Patient) The recipient of the products and services --></patient>
 <billablePeriod><!-- 0..1 Period Relevant time frame for the claim --></billablePeriod>
 <created value="[dateTime]"/><!-- 1..1 Resource creation date -->
 <</enterer>

 <enterer><!-- 0..1 Reference(Patient|Practitioner|PractitionerRole|RelatedPerson) Author of the claim --></enterer>

 <insurer><!-- 0..1 Reference(Organization) Target --></insurer>
 <</provider>
 <</priority>

 <provider><!-- 0..1 Reference(Organization|Practitioner|PractitionerRole) Party responsible for the claim --></provider>
 <priority><!-- 0..1 CodeableConcept Desired processing urgency --></priority>

 <fundsReserve><!-- 0..1 CodeableConcept For whom to reserve funds --></fundsReserve>
 <related>  <!-- 0..* Prior or corollary claims -->
  <claim><!-- 0..1 Reference(Claim) Reference to the related claim --></claim>
  <relationship><!-- 0..1 CodeableConcept How the reference claim is related --></relationship>
  <reference><!-- 0..1 Identifier File or case reference --></reference>
 </related>
 <|

 <prescription><!-- 0..1 Reference(DeviceRequest|MedicationRequest|

   VisionPrescription) Prescription authorizing services and products --></prescription>
 <originalPrescription><!-- 0..1 Reference(DeviceRequest|MedicationRequest|
   VisionPrescription) Original prescription if superseded by fulfiller --></originalPrescription>
 <payee>  <!-- 0..1 Recipient of benefits payable -->
  <type><!-- 1..1 CodeableConcept Category of recipient --></type>
  <|

  <party><!-- 0..1 Reference(Organization|Patient|Practitioner|PractitionerRole|

    RelatedPerson) Recipient reference --></party>
 </payee>
 <</referral>
 <</facility>

 <referral><!-- 0..1 Reference(ServiceRequest) Treatment referral --></referral>
 <encounter><!-- 0..* Reference(Encounter) Encounters associated with the listed treatments --></encounter>
 <facility><!-- 0..1 Reference(Location|Organization) Servicing facility --></facility>
 <diagnosisRelatedGroup><!-- 0..1 CodeableConcept Package billing code --></diagnosisRelatedGroup>
 <event>  <!-- 0..* Event information -->
  <type><!-- 1..1 CodeableConcept Specific event --></type>
  <when[x]><!-- 1..1 dateTime|Period Occurance date or period --></when[x]>
 </event>

 <careTeam>  <!-- 0..* Members of the care team -->
  <sequence value="[positiveInt]"/><!-- 1..1 Order of care team -->
  <</provider>

  <provider><!-- 1..1 Reference(Organization|Practitioner|PractitionerRole) Practitioner or organization --></provider>

  <responsible value="[boolean]"/><!-- 0..1 Indicator of the lead practitioner -->
  <role><!-- 0..1 CodeableConcept Function within the team --></role>
  <</qualification>

  <specialty><!-- 0..1 CodeableConcept Practitioner or provider specialization --></specialty>

 </careTeam>
 <supportingInfo>  <!-- 0..* Supporting information -->
  <sequence value="[positiveInt]"/><!-- 1..1 Information instance identifier -->
  <category><!-- 1..1 CodeableConcept Classification of the supplied information --></category>
  <code><!-- 0..1 CodeableConcept Type of information --></code>
  <timing[x]><!-- 0..1 date|Period When it occurred --></timing[x]>
  <</value[x]>

  <value[x]><!-- 0..1 boolean|string|Quantity|Attachment|Reference(Any)|
    Identifier Data to be provided --></value[x]>
  <reason><!-- 0..1 CodeableConcept Explanation for the information --></reason>
 </supportingInfo>
 <diagnosis>  <!-- 0..* Pertinent diagnosis information -->
  <sequence value="[positiveInt]"/><!-- 1..1 Diagnosis instance identifier -->
  <diagnosis[x]><!-- 1..1 CodeableConcept|Reference(Condition) Nature of illness or problem --></diagnosis[x]>
  <type><!-- 0..* CodeableConcept Timing or nature of the diagnosis --></type>
  <onAdmission><!-- 0..1 CodeableConcept Present on admission --></onAdmission>
  <</packageCode>

 </diagnosis>
 <procedure>  <!-- 0..* Clinical procedures performed -->
  <sequence value="[positiveInt]"/><!-- 1..1 Procedure instance identifier -->
  <type><!-- 0..* CodeableConcept Category of Procedure --></type>
  <date value="[dateTime]"/><!-- 0..1 When the procedure was performed -->
  <procedure[x]><!-- 1..1 CodeableConcept|Reference(Procedure) Specific clinical procedure --></procedure[x]>
  <udi><!-- 0..* Reference(Device) Unique device identifier --></udi>
 </procedure>
 <

 <insurance>  <!-- 0..* Patient insurance information -->

  <sequence value="[positiveInt]"/><!-- 1..1 Insurance instance identifier -->
  <focal value="[boolean]"/><!-- 1..1 Coverage to be used for adjudication -->
  <identifier><!-- 0..1 Identifier Pre-assigned Claim number --></identifier>
  <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage>
  <businessArrangement value="[string]"/><!-- 0..1 Additional provider contract number -->
  <preAuthRef value="[string]"/><!-- 0..* Prior authorization reference number -->
  <claimResponse><!-- 0..1 Reference(ClaimResponse) Adjudication results --></claimResponse>
 </insurance>
 <accident>  <!-- 0..1 Details of the event -->
  <date value="[date]"/><!-- 1..1 When the incident occurred -->
  <</type>

  <type><!-- 0..1 CodeableConcept The nature of the accident icon --></type>

  <location[x]><!-- 0..1 Address|Reference(Location) Where the event occurred --></location[x]>
 </accident>
 <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid>

 <item>  <!-- 0..* Product or service provided -->
  <sequence value="[positiveInt]"/><!-- 1..1 Item instance identifier -->
  <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>

  <careTeamSequence value="[positiveInt]"/><!-- 0..* Applicable careTeam members -->
  <diagnosisSequence value="[positiveInt]"/><!-- 0..* Applicable diagnoses -->
  <procedureSequence value="[positiveInt]"/><!-- 0..* Applicable procedures -->
  <informationSequence value="[positiveInt]"/><!-- 0..* Applicable exception and supporting information -->
  <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
  <category><!-- 0..1 CodeableConcept Benefit classification --></category>
  <</productOrService>

  <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
  <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd>
  <request><!-- 0..* Reference(DeviceRequest|MedicationRequest|NutritionOrder|
    ServiceRequest|SupplyRequest|VisionPrescription) Request or Referral for Service --></request>
  <modifier><!-- 0..* CodeableConcept Product or service billing modifiers --></modifier>
  <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode>
  <serviced[x]><!-- 0..1 date|Period Date or dates of service or product delivery --></serviced[x]>
  <location[x]><!-- 0..1 CodeableConcept|Address|Reference(Location) Place of service or where product was supplied --></location[x]>
  <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid>

  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
  <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
  <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
  <</net>

  <tax><!-- 0..1 Money Total tax --></tax>
  <net><!-- 0..1 Money Total item cost --></net>

  <udi><!-- 0..* Reference(Device) Unique device identifier --></udi>
  <</bodySite>
  <</subSite>
  <</encounter>

  <bodySite>  <!-- 0..* Anatomical location -->
   <site><!-- 1..* CodeableReference(BodyStructure) Location --></site>
   <subSite><!-- 0..* CodeableConcept Sub-location --></subSite>
  </bodySite>
  <encounter><!-- 0..* Reference(Encounter) Encounters associated with the listed treatments --></encounter>

  <detail>  <!-- 0..* Product or service provided -->
   <sequence value="[positiveInt]"/><!-- 1..1 Item instance identifier -->
   <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>

   <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
   <category><!-- 0..1 CodeableConcept Benefit classification --></category>
   <</productOrService>

   <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
   <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd>

   <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
   <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode>
   <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid>

   <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
   <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
   <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
   <</net>

   <tax><!-- 0..1 Money Total tax --></tax>
   <net><!-- 0..1 Money Total item cost --></net>

   <udi><!-- 0..* Reference(Device) Unique device identifier --></udi>
   <subDetail>  <!-- 0..* Product or service provided -->
    <sequence value="[positiveInt]"/><!-- 1..1 Item instance identifier -->
    <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>

    <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
    <category><!-- 0..1 CodeableConcept Benefit classification --></category>
    <</productOrService>

    <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
    <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd>

    <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
    <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode>
    <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid>

    <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
    <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
    <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
    <</net>

    <tax><!-- 0..1 Money Total tax --></tax>
    <net><!-- 0..1 Money Total item cost --></net>

    <udi><!-- 0..* Reference(Device) Unique device identifier --></udi>
   </subDetail>
  </detail>
 </item>
 <total><!-- 0..1 Money Total claim cost --></total>
</Claim>

JSON Template 

{doco
  "resourceType" : "Claim",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier for claim
  "traceNumber" : [{ Identifier }], // Number for tracking

  "status" : "<code>", // R!  active | cancelled | draft | entered-in-error
  "type" : { CodeableConcept }, // R!  Category or discipline
  "subType" : { CodeableConcept }, // More granular claim type
  "

  "use" : "<code>", // R!  claim | preauthorization | predetermination

  "patient" : { Reference(Patient) }, // R!  The recipient of the products and services
  "billablePeriod" : { Period }, // Relevant time frame for the claim
  "created" : "<dateTime>", // R!  Resource creation date
  "

  "enterer" : { Reference(Patient|Practitioner|PractitionerRole|RelatedPerson) }, // Author of the claim

  "insurer" : { Reference(Organization) }, // Target
  "
  "

  "provider" : { Reference(Organization|Practitioner|PractitionerRole) }, // Party responsible for the claim
  "priority" : { CodeableConcept }, // Desired processing urgency

  "fundsReserve" : { CodeableConcept }, // For whom to reserve funds
  "related" : [{ // Prior or corollary claims
    "claim" : { Reference(Claim) }, // Reference to the related claim
    "relationship" : { CodeableConcept }, // How the reference claim is related
    "reference" : { Identifier } // File or case reference
  }],
  "|

  "prescription" : { Reference(DeviceRequest|MedicationRequest|

   VisionPrescription) }, // Prescription authorizing services and products
  "originalPrescription" : { Reference(DeviceRequest|MedicationRequest|
   VisionPrescription) }, // Original prescription if superseded by fulfiller
  "payee" : { // Recipient of benefits payable
    "type" : { CodeableConcept }, // R!  Category of recipient
    "|

    "party" : { Reference(Organization|Patient|Practitioner|PractitionerRole|

    RelatedPerson) } // Recipient reference
  },
  "
  "

  "referral" : { Reference(ServiceRequest) }, // Treatment referral
  "encounter" : [{ Reference(Encounter) }], // Encounters associated with the listed treatments
  "facility" : { Reference(Location|Organization) }, // Servicing facility
  "diagnosisRelatedGroup" : { CodeableConcept }, // Package billing code
  "event" : [{ // Event information
    "type" : { CodeableConcept }, // R!  Specific event
    // when[x]: Occurance date or period. One of these 2:

    "whenDateTime" : "<dateTime>",
    "whenPeriod" : { Period }
  }],

  "careTeam" : [{ // Members of the care team
    "sequence" : "<positiveInt>", // R!  Order of care team
    "

    "provider" : { Reference(Organization|Practitioner|PractitionerRole) }, // R!  Practitioner or organization

    "responsible" : <boolean>, // Indicator of the lead practitioner
    "role" : { CodeableConcept }, // Function within the team
    "

    "specialty" : { CodeableConcept } // Practitioner or provider specialization

  }],
  "supportingInfo" : [{ // Supporting information
    "sequence" : "<positiveInt>", // R!  Information instance identifier
    "category" : { CodeableConcept }, // R!  Classification of the supplied information
    "code" : { CodeableConcept }, // Type of information
    // timing[x]: When it occurred. One of these 2:
    "timingDate" : "<date>",
    "timingPeriod" : { Period },
    

    // value[x]: Data to be provided. One of these 6:
    "valueBoolean" : <boolean>,
    "valueString" : "<string>",
    "valueQuantity" : { Quantity },
    "valueAttachment" : { Attachment },
    "valueReference" : { Reference(Any) },
    "valueIdentifier" : { Identifier },

    "reason" : { CodeableConcept } // Explanation for the information
  }],
  "diagnosis" : [{ // Pertinent diagnosis information
    "sequence" : "<positiveInt>", // R!  Diagnosis instance identifier
    // diagnosis[x]: Nature of illness or problem. One of these 2:
    "diagnosisCodeableConcept" : { CodeableConcept },
    "diagnosisReference" : { Reference(Condition) },
    "type" : [{ CodeableConcept }], // Timing or nature of the diagnosis
    "
    "

    "onAdmission" : { CodeableConcept } // Present on admission

  }],
  "procedure" : [{ // Clinical procedures performed
    "sequence" : "<positiveInt>", // R!  Procedure instance identifier
    "type" : [{ CodeableConcept }], // Category of Procedure
    "date" : "<dateTime>", // When the procedure was performed
    // procedure[x]: Specific clinical procedure. One of these 2:
    "procedureCodeableConcept" : { CodeableConcept },
    "procedureReference" : { Reference(Procedure) },
    "udi" : [{ Reference(Device) }] // Unique device identifier
  }],
  "

  "insurance" : [{ // Patient insurance information

    "sequence" : "<positiveInt>", // R!  Insurance instance identifier
    "focal" : <boolean>, // R!  Coverage to be used for adjudication
    "identifier" : { Identifier }, // Pre-assigned Claim number
    "coverage" : { Reference(Coverage) }, // R!  Insurance information
    "businessArrangement" : "<string>", // Additional provider contract number
    "preAuthRef" : ["<string>"], // Prior authorization reference number
    "claimResponse" : { Reference(ClaimResponse) } // Adjudication results
  }],
  "accident" : { // Details of the event
    "date" : "<date>", // R!  When the incident occurred
    "

    "type" : { CodeableConcept }, // The nature of the accident icon

    // location[x]: Where the event occurred. One of these 2:
    " }

    "locationAddress" : { Address },

    "locationReference" : { Reference(Location) }
  },
  "patientPaid" : { Money }, // Paid by the patient

  "item" : [{ // Product or service provided
    "sequence" : "<positiveInt>", // R!  Item instance identifier
    "traceNumber" : [{ Identifier }], // Number for tracking

    "careTeamSequence" : ["<positiveInt>"], // Applicable careTeam members
    "diagnosisSequence" : ["<positiveInt>"], // Applicable diagnoses
    "procedureSequence" : ["<positiveInt>"], // Applicable procedures
    "informationSequence" : ["<positiveInt>"], // Applicable exception and supporting information
    "revenue" : { CodeableConcept }, // Revenue or cost center code
    "category" : { CodeableConcept }, // Benefit classification
    "

    "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
    "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes
    "request" : [{ Reference(DeviceRequest|MedicationRequest|NutritionOrder|
    ServiceRequest|SupplyRequest|VisionPrescription) }], // Request or Referral for Service
    "modifier" : [{ CodeableConcept }], // Product or service billing modifiers
    "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
    // serviced[x]: Date or dates of service or product delivery. One of these 2:
    "servicedDate" : "<date>",
    "servicedPeriod" : { Period },
    // location[x]: Place of service or where product was supplied. One of these 3:
    "locationCodeableConcept" : { CodeableConcept },
    "locationAddress" : { Address },
    "locationReference" : { Reference(Location) },
    "patientPaid" : { Money }, // Paid by the patient

    "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
    "unitPrice" : { Money }, // Fee, charge or cost per item
    "factor" : <decimal>, // Price scaling factor
    "

    "tax" : { Money }, // Total tax
    "net" : { Money }, // Total item cost

    "udi" : [{ Reference(Device) }], // Unique device identifier
    "
    "
    "

    "bodySite" : [{ // Anatomical location
      "site" : [{ CodeableReference(BodyStructure) }], // R!  Location
      "subSite" : [{ CodeableConcept }] // Sub-location
    }],
    "encounter" : [{ Reference(Encounter) }], // Encounters associated with the listed treatments

    "detail" : [{ // Product or service provided
      "sequence" : "<positiveInt>", // R!  Item instance identifier
      "traceNumber" : [{ Identifier }], // Number for tracking

      "revenue" : { CodeableConcept }, // Revenue or cost center code
      "category" : { CodeableConcept }, // Benefit classification
      "

      "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
      "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes

      "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
      "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
      "patientPaid" : { Money }, // Paid by the patient

      "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
      "unitPrice" : { Money }, // Fee, charge or cost per item
      "factor" : <decimal>, // Price scaling factor
      "

      "tax" : { Money }, // Total tax
      "net" : { Money }, // Total item cost

      "udi" : [{ Reference(Device) }], // Unique device identifier
      "subDetail" : [{ // Product or service provided
        "sequence" : "<positiveInt>", // R!  Item instance identifier
        "traceNumber" : [{ Identifier }], // Number for tracking

        "revenue" : { CodeableConcept }, // Revenue or cost center code
        "category" : { CodeableConcept }, // Benefit classification
        "

        "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
        "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes

        "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
        "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
        "patientPaid" : { Money }, // Paid by the patient

        "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
        "unitPrice" : { Money }, // Fee, charge or cost per item
        "factor" : <decimal>, // Price scaling factor
        "

        "tax" : { Money }, // Total tax
        "net" : { Money }, // Total item cost

        "udi" : [{ Reference(Device) }] // Unique device identifier
      }]
    }]
  }],
  "total" : { Money } // Total claim cost
}

Turtle Template 

@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:Claim;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
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  fhir:
    fhir:
    fhir:
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  ], ...;
  fhir:
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    fhir:
    fhir:
  ];
  fhir:
  fhir:
  fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
  ], ...;
  fhir:
    fhir:
    fhir:
    fhir:
    # . One of these 2
      fhir: ]
      fhir: ]
    # . One of these 5
      fhir: ]
      fhir: ]
      fhir: ]
      fhir: ]
      fhir:) ]
    fhir:
  ], ...;
  fhir:
    fhir:
    # . One of these 2
      fhir: ]
      fhir:) ]
    fhir:
    fhir:
    fhir:
  ], ...;
  fhir:
    fhir:
    fhir:
    fhir:
    # . One of these 2
      fhir: ]
      fhir:) ]
    fhir:
  ], ...;
  fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
  ], ...;
  fhir:
    fhir:
    fhir:
    # . One of these 2
      fhir: ]
      fhir:) ]
  ];
  fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    # . One of these 2
      fhir: ]
      fhir: ]
    # . One of these 3
      fhir: ]
      fhir: ]
      fhir:) ]
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
      fhir:
      fhir:
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      fhir:
        fhir:
        fhir:
        fhir:
        fhir:
        fhir:
        fhir:
        fhir:
        fhir:
        fhir:
        fhir:
        fhir:
      ], ...;
    ], ...;
  ], ...;
  fhir:

  fhir:identifier  ( [ Identifier ] ... ) ; # 0..* Business Identifier for claim
  fhir:traceNumber  ( [ Identifier ] ... ) ; # 0..* Number for tracking
  fhir:status [ code ] ; # 1..1 active | cancelled | draft | entered-in-error
  fhir:type [ CodeableConcept ] ; # 1..1 Category or discipline
  fhir:subType [ CodeableConcept ] ; # 0..1 More granular claim type
  fhir:use [ code ] ; # 1..1 claim | preauthorization | predetermination
  fhir:patient [ Reference(Patient) ] ; # 1..1 The recipient of the products and services
  fhir:billablePeriod [ Period ] ; # 0..1 Relevant time frame for the claim
  fhir:created [ dateTime ] ; # 1..1 Resource creation date
  fhir:enterer [ Reference(Patient|Practitioner|PractitionerRole|RelatedPerson) ] ; # 0..1 Author of the claim
  fhir:insurer [ Reference(Organization) ] ; # 0..1 Target
  fhir:provider [ Reference(Organization|Practitioner|PractitionerRole) ] ; # 0..1 Party responsible for the claim
  fhir:priority [ CodeableConcept ] ; # 0..1 Desired processing urgency
  fhir:fundsReserve [ CodeableConcept ] ; # 0..1 For whom to reserve funds
  fhir:related ( [ # 0..* Prior or corollary claims
    fhir:claim [ Reference(Claim) ] ; # 0..1 Reference to the related claim
    fhir:relationship [ CodeableConcept ] ; # 0..1 How the reference claim is related
    fhir:reference [ Identifier ] ; # 0..1 File or case reference
  ] ... ) ;
  fhir:prescription [ Reference(DeviceRequest|MedicationRequest|VisionPrescription) ] ; # 0..1 Prescription authorizing services and products
  fhir:originalPrescription [ Reference(DeviceRequest|MedicationRequest|VisionPrescription) ] ; # 0..1 Original prescription if superseded by fulfiller
  fhir:payee [ # 0..1 Recipient of benefits payable
    fhir:type [ CodeableConcept ] ; # 1..1 Category of recipient
    fhir:party [ Reference(Organization|Patient|Practitioner|PractitionerRole|RelatedPerson) ] ; # 0..1 Recipient reference
  ] ;
  fhir:referral [ Reference(ServiceRequest) ] ; # 0..1 Treatment referral
  fhir:encounter  ( [ Reference(Encounter) ] ... ) ; # 0..* Encounters associated with the listed treatments
  fhir:facility [ Reference(Location|Organization) ] ; # 0..1 Servicing facility
  fhir:diagnosisRelatedGroup [ CodeableConcept ] ; # 0..1 Package billing code
  fhir:event ( [ # 0..* Event information
    fhir:type [ CodeableConcept ] ; # 1..1 Specific event
    # when[x] : 1..1 Occurance date or period. One of these 2
      fhir:when [  a fhir:dateTime ; dateTime ]
      fhir:when [  a fhir:Period ; Period ]
  ] ... ) ;
  fhir:careTeam ( [ # 0..* Members of the care team
    fhir:sequence [ positiveInt ] ; # 1..1 Order of care team
    fhir:provider [ Reference(Organization|Practitioner|PractitionerRole) ] ; # 1..1 Practitioner or organization
    fhir:responsible [ boolean ] ; # 0..1 Indicator of the lead practitioner
    fhir:role [ CodeableConcept ] ; # 0..1 Function within the team
    fhir:specialty [ CodeableConcept ] ; # 0..1 Practitioner or provider specialization
  ] ... ) ;
  fhir:supportingInfo ( [ # 0..* Supporting information
    fhir:sequence [ positiveInt ] ; # 1..1 Information instance identifier
    fhir:category [ CodeableConcept ] ; # 1..1 Classification of the supplied information
    fhir:code [ CodeableConcept ] ; # 0..1 Type of information
    # timing[x] : 0..1 When it occurred. One of these 2
      fhir:timing [  a fhir:date ; date ]
      fhir:timing [  a fhir:Period ; Period ]
    # value[x] : 0..1 Data to be provided. One of these 6
      fhir:value [  a fhir:boolean ; boolean ]
      fhir:value [  a fhir:string ; string ]
      fhir:value [  a fhir:Quantity ; Quantity ]
      fhir:value [  a fhir:Attachment ; Attachment ]
      fhir:value [  a fhir:Reference ; Reference(Any) ]
      fhir:value [  a fhir:Identifier ; Identifier ]
    fhir:reason [ CodeableConcept ] ; # 0..1 Explanation for the information
  ] ... ) ;
  fhir:diagnosis ( [ # 0..* Pertinent diagnosis information
    fhir:sequence [ positiveInt ] ; # 1..1 Diagnosis instance identifier
    # diagnosis[x] : 1..1 Nature of illness or problem. One of these 2
      fhir:diagnosis [  a fhir:CodeableConcept ; CodeableConcept ]
      fhir:diagnosis [  a fhir:Reference ; Reference(Condition) ]
    fhir:type  ( [ CodeableConcept ] ... ) ; # 0..* Timing or nature of the diagnosis
    fhir:onAdmission [ CodeableConcept ] ; # 0..1 Present on admission
  ] ... ) ;
  fhir:procedure ( [ # 0..* Clinical procedures performed
    fhir:sequence [ positiveInt ] ; # 1..1 Procedure instance identifier
    fhir:type  ( [ CodeableConcept ] ... ) ; # 0..* Category of Procedure
    fhir:date [ dateTime ] ; # 0..1 When the procedure was performed
    # procedure[x] : 1..1 Specific clinical procedure. One of these 2
      fhir:procedure [  a fhir:CodeableConcept ; CodeableConcept ]
      fhir:procedure [  a fhir:Reference ; Reference(Procedure) ]
    fhir:udi  ( [ Reference(Device) ] ... ) ; # 0..* Unique device identifier
  ] ... ) ;
  fhir:insurance ( [ # 0..* Patient insurance information
    fhir:sequence [ positiveInt ] ; # 1..1 Insurance instance identifier
    fhir:focal [ boolean ] ; # 1..1 Coverage to be used for adjudication
    fhir:identifier [ Identifier ] ; # 0..1 Pre-assigned Claim number
    fhir:coverage [ Reference(Coverage) ] ; # 1..1 Insurance information
    fhir:businessArrangement [ string ] ; # 0..1 Additional provider contract number
    fhir:preAuthRef  ( [ string ] ... ) ; # 0..* Prior authorization reference number
    fhir:claimResponse [ Reference(ClaimResponse) ] ; # 0..1 Adjudication results
  ] ... ) ;
  fhir:accident [ # 0..1 Details of the event
    fhir:date [ date ] ; # 1..1 When the incident occurred
    fhir:type [ CodeableConcept ] ; # 0..1 The nature of the accident
    # location[x] : 0..1 Where the event occurred. One of these 2
      fhir:location [  a fhir:Address ; Address ]
      fhir:location [  a fhir:Reference ; Reference(Location) ]
  ] ;
  fhir:patientPaid [ Money ] ; # 0..1 Paid by the patient
  fhir:item ( [ # 0..* Product or service provided
    fhir:sequence [ positiveInt ] ; # 1..1 Item instance identifier
    fhir:traceNumber  ( [ Identifier ] ... ) ; # 0..* Number for tracking
    fhir:careTeamSequence  ( [ positiveInt ] ... ) ; # 0..* Applicable careTeam members
    fhir:diagnosisSequence  ( [ positiveInt ] ... ) ; # 0..* Applicable diagnoses
    fhir:procedureSequence  ( [ positiveInt ] ... ) ; # 0..* Applicable procedures
    fhir:informationSequence  ( [ positiveInt ] ... ) ; # 0..* Applicable exception and supporting information
    fhir:revenue [ CodeableConcept ] ; # 0..1 Revenue or cost center code
    fhir:category [ CodeableConcept ] ; # 0..1 Benefit classification
    fhir:productOrService [ CodeableConcept ] ; # 0..1 Billing, service, product, or drug code
    fhir:productOrServiceEnd [ CodeableConcept ] ; # 0..1 End of a range of codes
    fhir:request  ( [ Reference(DeviceRequest|MedicationRequest|NutritionOrder|ServiceRequest|SupplyRequest|
  VisionPrescription) ] ... ) ; # 0..* Request or Referral for Service

    fhir:modifier  ( [ CodeableConcept ] ... ) ; # 0..* Product or service billing modifiers
    fhir:programCode  ( [ CodeableConcept ] ... ) ; # 0..* Program the product or service is provided under
    # serviced[x] : 0..1 Date or dates of service or product delivery. One of these 2
      fhir:serviced [  a fhir:date ; date ]
      fhir:serviced [  a fhir:Period ; Period ]
    # location[x] : 0..1 Place of service or where product was supplied. One of these 3
      fhir:location [  a fhir:CodeableConcept ; CodeableConcept ]
      fhir:location [  a fhir:Address ; Address ]
      fhir:location [  a fhir:Reference ; Reference(Location) ]
    fhir:patientPaid [ Money ] ; # 0..1 Paid by the patient
    fhir:quantity [ Quantity(SimpleQuantity) ] ; # 0..1 Count of products or services
    fhir:unitPrice [ Money ] ; # 0..1 Fee, charge or cost per item
    fhir:factor [ decimal ] ; # 0..1 Price scaling factor
    fhir:tax [ Money ] ; # 0..1 Total tax
    fhir:net [ Money ] ; # 0..1 Total item cost
    fhir:udi  ( [ Reference(Device) ] ... ) ; # 0..* Unique device identifier
    fhir:bodySite ( [ # 0..* Anatomical location
      fhir:site  ( [ CodeableReference(BodyStructure) ] ... ) ; # 1..* Location
      fhir:subSite  ( [ CodeableConcept ] ... ) ; # 0..* Sub-location
    ] ... ) ;
    fhir:encounter  ( [ Reference(Encounter) ] ... ) ; # 0..* Encounters associated with the listed treatments
    fhir:detail ( [ # 0..* Product or service provided
      fhir:sequence [ positiveInt ] ; # 1..1 Item instance identifier
      fhir:traceNumber  ( [ Identifier ] ... ) ; # 0..* Number for tracking
      fhir:revenue [ CodeableConcept ] ; # 0..1 Revenue or cost center code
      fhir:category [ CodeableConcept ] ; # 0..1 Benefit classification
      fhir:productOrService [ CodeableConcept ] ; # 0..1 Billing, service, product, or drug code
      fhir:productOrServiceEnd [ CodeableConcept ] ; # 0..1 End of a range of codes
      fhir:modifier  ( [ CodeableConcept ] ... ) ; # 0..* Service/Product billing modifiers
      fhir:programCode  ( [ CodeableConcept ] ... ) ; # 0..* Program the product or service is provided under
      fhir:patientPaid [ Money ] ; # 0..1 Paid by the patient
      fhir:quantity [ Quantity(SimpleQuantity) ] ; # 0..1 Count of products or services
      fhir:unitPrice [ Money ] ; # 0..1 Fee, charge or cost per item
      fhir:factor [ decimal ] ; # 0..1 Price scaling factor
      fhir:tax [ Money ] ; # 0..1 Total tax
      fhir:net [ Money ] ; # 0..1 Total item cost
      fhir:udi  ( [ Reference(Device) ] ... ) ; # 0..* Unique device identifier
      fhir:subDetail ( [ # 0..* Product or service provided
        fhir:sequence [ positiveInt ] ; # 1..1 Item instance identifier
        fhir:traceNumber  ( [ Identifier ] ... ) ; # 0..* Number for tracking
        fhir:revenue [ CodeableConcept ] ; # 0..1 Revenue or cost center code
        fhir:category [ CodeableConcept ] ; # 0..1 Benefit classification
        fhir:productOrService [ CodeableConcept ] ; # 0..1 Billing, service, product, or drug code
        fhir:productOrServiceEnd [ CodeableConcept ] ; # 0..1 End of a range of codes
        fhir:modifier  ( [ CodeableConcept ] ... ) ; # 0..* Service/Product billing modifiers
        fhir:programCode  ( [ CodeableConcept ] ... ) ; # 0..* Program the product or service is provided under
        fhir:patientPaid [ Money ] ; # 0..1 Paid by the patient
        fhir:quantity [ Quantity(SimpleQuantity) ] ; # 0..1 Count of products or services
        fhir:unitPrice [ Money ] ; # 0..1 Fee, charge or cost per item
        fhir:factor [ decimal ] ; # 0..1 Price scaling factor
        fhir:tax [ Money ] ; # 0..1 Total tax
        fhir:net [ Money ] ; # 0..1 Total item cost
        fhir:udi  ( [ Reference(Device) ] ... ) ; # 0..* Unique device identifier
      ] ... ) ;
    ] ... ) ;
  ] ... ) ;
  fhir:total [ Money ] ; # 0..1 Total claim cost

]

Changes since R3 from both R4 and R4B

Claim.status Min Cardinality changed from 0 to 1 Change value set from http://hl7.org/fhir/ValueSet/fm-status to http://hl7.org/fhir/ValueSet/fm-status|4.0.1
Claim
Claim.type Claim.traceNumber
  • Min Cardinality changed from 0 to 1 Change binding strength from required to extensible Added Element
Claim.subType Claim.enterer
  • Max Cardinality changed from * to 1 Type Reference: Added Target Types Patient, RelatedPerson
Claim.use Claim.provider
  • Min Cardinality changed from 0 to 1 Change value set from http://hl7.org/fhir/ValueSet/claim-use to http://hl7.org/fhir/ValueSet/claim-use|4.0.1 Claim.patient Min Cardinality changed from 0 to 1
Claim.created Claim.priority
  • Min Cardinality changed from 0 to 1 to 0
Claim.enterer Claim.encounter
  • Type Reference: Added Target Type PractitionerRole Element
Claim.provider Claim.facility
    Min Cardinality changed from 0 to 1
  • Type Reference: Added Target Types PractitionerRole, Type Organization
Claim.priority Claim.diagnosisRelatedGroup
  • Min Cardinality changed from 0 to 1 Added Element
Claim.prescription Claim.event
  • Type Reference: Added Target Type DeviceRequest Element
Claim.originalPrescription Claim.event.type
  • Type Reference: Added Target Types DeviceRequest, VisionPrescription Mandatory Element
Claim.payee.party Claim.event.when[x]
  • Type Reference: Added Target Type PractitionerRole Mandatory Element
Claim.referral Claim.careTeam.specialty
  • Type Reference: Added Target Type ServiceRequest Type Reference: Removed Target Type ReferralRequest Element
Claim.careTeam.provider Claim.supportingInfo.value[x]
  • Add Type Reference: Added Target Type PractitionerRole Identifier
Claim.supportingInfo Claim.insurance
  • Renamed Min Cardinality changed from information 1 to supportingInfo 0
Claim.supportingInfo.sequence Claim.patientPaid
  • Moved from Claim.information to Claim.supportingInfo Added Element
Claim.supportingInfo.category Claim.item.traceNumber
  • Moved from Claim.information to Claim.supportingInfo Added Element
Claim.supportingInfo.code Claim.item.productOrService
  • Moved Min Cardinality changed from Claim.information 1 to Claim.supportingInfo 0
Claim.supportingInfo.timing[x] Claim.item.productOrServiceEnd
  • Moved from Claim.information to Claim.supportingInfo Added Element
Claim.supportingInfo.value[x] Claim.item.request
  • Moved from Claim.information to Claim.supportingInfo Add Type boolean Added Element
Claim.supportingInfo.reason Claim.item.patientPaid
  • Moved from Claim.information to Claim.supportingInfo Added Element
Claim.diagnosis.onAdmission Claim.item.tax
  • Added Element
Claim.procedure.type Claim.item.bodySite
  • Added Element Max Cardinality changed from 1 to *
  • Type changed from CodeableConcept to BackboneElement
Claim.procedure.udi Claim.item.bodySite.site
  • Added Mandatory Element
Claim.insurance Claim.item.bodySite.subSite
  • Min Cardinality changed from 0 to 1 Added Element
Claim.insurance.identifier Claim.item.detail.traceNumber
  • Added Element
Claim.accident.type Claim.item.detail.productOrService
  • Change binding strength Min Cardinality changed from required 1 to extensible 0
Claim.item.careTeamSequence Claim.item.detail.productOrServiceEnd
  • Renamed from careTeamLinkId to careTeamSequence Added Element
Claim.item.diagnosisSequence Claim.item.detail.patientPaid
  • Renamed from diagnosisLinkId to diagnosisSequence Added Element
Claim.item.procedureSequence Claim.item.detail.tax
  • Renamed from procedureLinkId to procedureSequence Added Element
Claim.item.informationSequence Claim.item.detail.subDetail.traceNumber
  • Renamed from informationLinkId to informationSequence Added Element
Claim.item.productOrService Claim.item.detail.subDetail.productOrService
    Renamed from service to productOrService
  • Min Cardinality changed from 0 to 1 to 0
Claim.item.detail.productOrService Claim.item.detail.subDetail.productOrServiceEnd
  • Renamed from service to productOrService Min Cardinality changed from 0 to 1 Added Element
Claim.item.detail.subDetail.productOrService Claim.item.detail.subDetail.patientPaid
  • Renamed from service to productOrService Min Cardinality changed from 0 to 1 Added Element
Claim.organization Claim.item.detail.subDetail.tax
  • deleted Added Element
Claim.payee.resourceType Claim.careTeam.qualification
  • deleted Deleted
Claim.employmentImpacted Claim.diagnosis.packageCode
  • deleted Deleted
Claim.hospitalization Claim.item.subSite
  • deleted Deleted

See the Full Difference for further information

This analysis is available for R4 as XML or JSON and for R4B as XML or JSON .

See R3 <--> R4 <--> R5 Conversion Maps (status = 16 tests of which 3 fail to execute . 13 fail round-trip testing and 3 r3 resources are invalid (0 errors). ) See Conversions Summary .)

Structure

1..1 1..1 Anatomical sub-location
Name Flags Card. Type Description & Constraints doco
. . Claim TU DomainResource Claim, Pre-determination or Pre-authorization

Elements defined in Ancestors: id , meta , implicitRules , language , text , contained , extension , modifierExtension
. . . identifier 0..* Identifier Business Identifier for claim

. . status . traceNumber 0..* Identifier Number for tracking

... status ?! Σ 1..1 code active | cancelled | draft | entered-in-error
Binding: Financial Resource Status Codes ( Required )
. . . type Σ 1..1 CodeableConcept Category or discipline
Binding: Claim Type Codes ( Extensible )
. . . subType 0..1 CodeableConcept More granular claim type
Binding: Example Claim SubType Codes ( Example )
. . . use Σ 1..1 code claim | preauthorization | predetermination
Binding: Use ( Required )
. . . patient Σ 1..1 Reference ( Patient ) The recipient of the products and services
. . . billablePeriod Σ 0..1 Period Relevant time frame for the claim
. . . created Σ 1..1 dateTime Resource creation date
. . . enterer 0..1 Reference ( Practitioner | PractitionerRole | Patient | RelatedPerson ) Author of the claim
. . . insurer Σ 0..1 Reference ( Organization ) Target
. . . provider Σ 0..1 Reference ( Practitioner | PractitionerRole | Organization ) Party responsible for the claim
. . . priority Σ 0..1 CodeableConcept Desired processing ugency urgency
Binding: Process Priority Codes ( Example )
. . . fundsReserve 0..1 CodeableConcept For whom to reserve funds
FundsReserve Binding: Funds Reservation Codes ( Example )
. . . related 0..* BackboneElement Prior or corollary claims

. . . . claim 0..1 Reference ( Claim ) Reference to the related claim
. . . . relationship 0..1 CodeableConcept How the reference claim is related
Binding: Example Related Claim Relationship Codes ( Example )
. . . . reference 0..1 Identifier File or case reference
. . . prescription 0..1 Reference ( DeviceRequest | MedicationRequest | VisionPrescription ) Prescription authorizing services and products
. . . originalPrescription 0..1 Reference ( DeviceRequest | MedicationRequest | VisionPrescription ) Original prescription if superseded by fulfiller
. . . payee 0..1 BackboneElement Recipient of benefits payable
. . . . type 1..1 CodeableConcept Category of recipient
PayeeType Binding: Claim Payee Type Codes ( Example )
. . . . party 0..1 Reference ( Practitioner | PractitionerRole | Organization | Patient | RelatedPerson ) Recipient reference
. . . referral 0..1 Reference ( ServiceRequest ) Treatment referral
. . . encounter 0..* Reference ( Encounter ) Encounters associated with the listed treatments

. . . facility 0..1 Reference ( Location | Organization ) Servicing facility
. . careTeam . diagnosisRelatedGroup 0..1 CodeableConcept Package billing code
Binding: Example Diagnosis Related Group Codes ( Example )
... event 0..* BackboneElement Event information

.... type 1..1 CodeableConcept Specific event
Binding: Dates Type Codes ( Example )
.... when[x] 1..1 Occurance date or period
..... whenDateTime dateTime
..... whenPeriod Period
... careTeam 0..* BackboneElement Members of the care team

. . . . sequence 1..1 positiveInt Order of care team
. . . . provider 1..1 Reference ( Practitioner | PractitionerRole | Organization ) Practitioner or organization
. . . . responsible 0..1 boolean Indicator of the lead practitioner
. . . . role 0..1 CodeableConcept Function within the team
Binding: Claim Care Team Role Codes ( Example )
. . . . qualification specialty 0..1 CodeableConcept Practitioner credential or provider specialization
Binding: Example Provider Qualification Codes ( Example )
. . . supportingInfo 0..* BackboneElement Supporting information

. . . . sequence 1..1 positiveInt Information instance identifier
. . . . category 1..1 CodeableConcept Classification of the supplied information
Binding: Claim Information Category Codes ( Example )
. . . . code 0..1 CodeableConcept Type of information
Binding: Exception Codes ( Example )
. . . . timing[x] 0..1 When it occurred
. . . . . timingDate date
. . . . . timingPeriod Period
. . . . value[x] 0..1 Data to be provided
. . . . . valueBoolean boolean
. . . . . valueString string
. . . . . valueQuantity Quantity
. . . . . valueAttachment Attachment
. . . . . valueReference Reference ( Any )
. . . . . valueIdentifier Identifier
. . . . reason 0..1 CodeableConcept Explanation for the information
Binding: Missing Tooth Reason Codes ( Example )
. . . diagnosis 0..* BackboneElement Pertinent diagnosis information

. . . . sequence 1..1 positiveInt Diagnosis instance identifier
. . . . diagnosis[x] 1..1 Nature of illness or problem
Binding: ICD-10 Codes ( Example )
. . . . . diagnosisCodeableConcept CodeableConcept
. . . . . diagnosisReference Reference ( Condition )
. . . . type 0..* CodeableConcept Timing or nature of the diagnosis
Binding: Example Diagnosis Type Codes ( Example )
onAdmission 0..1 CodeableConcept Present on admission
Example Diagnosis on Admission Codes ( Example )
. . . . packageCode onAdmission 0..1 CodeableConcept Package billing code Present on admission
Binding: Example Diagnosis Related Group on Admission Codes ( Example )
. . . procedure 0..* BackboneElement Clinical procedures performed

. . . . sequence 1..1 positiveInt Procedure instance identifier
. . . . type 0..* CodeableConcept Category of Procedure
Binding: Example Procedure Type Codes ( Example )

. . . . date 0..1 dateTime When the procedure was performed
. . . . procedure[x] 1..1 Specific clinical procedure
Binding: ICD-10 Procedure Codes ( Example )
. . . . . procedureCodeableConcept CodeableConcept
. . . . . procedureReference Reference ( Procedure )
. . . . udi 0..* Reference ( Device ) Unique device identifier

. . . insurance Σ 1..* 0..* BackboneElement Patient insurance information

. . . . sequence Σ 1..1 positiveInt Insurance instance identifier
. . . . focal Σ 1..1 boolean Coverage to be used for adjudication
. . . . identifier 0..1 Identifier Pre-assigned Claim number
. . . . coverage Σ 1..1 Reference ( Coverage ) Insurance information
. . . . businessArrangement 0..1 string Additional provider contract number
. . . . preAuthRef 0..* string Prior authorization reference number

. . . . claimResponse 0..1 Reference ( ClaimResponse ) Adjudication results
. . . accident 0..1 BackboneElement Details of the event
. . . . date 1..1 date When the incident occurred
. . . . type 0..1 CodeableConcept The nature of the accident
Binding: ActIncidentCode icon V3 Value SetActIncidentCode ( Extensible )
. . . . location[x] 0..1 Where the event occurred
. . . . . locationAddress Address
. . . . . locationReference Reference ( Location )
. . item . patientPaid 0..1 Money Paid by the patient
... item 0..* BackboneElement Product or service provided

. . . . sequence 1..1 positiveInt Item instance identifier
. . . . traceNumber 0..* Identifier Number for tracking

. . . . careTeamSequence 0..* positiveInt Applicable careTeam members

. . . . diagnosisSequence 0..* positiveInt Applicable diagnoses

. . . . procedureSequence 0..* positiveInt Applicable procedures

. . . . informationSequence 0..* positiveInt Applicable exception and supporting information

. . . . revenue 0..1 CodeableConcept Revenue or cost center code
Binding: Example Revenue Center Codes ( Example )
. . . . category 0..1 CodeableConcept Benefit classification
Binding: Benefit Category Codes ( Example )
. . . . productOrService 1..1 0..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLS Codes ( Example )
. . . . modifier productOrServiceEnd 0..1 CodeableConcept End of a range of codes
Binding: USCLS Codes ( Example )
.... request 0..* Reference ( DeviceRequest | MedicationRequest | NutritionOrder | ServiceRequest | SupplyRequest | VisionPrescription ) Request or Referral for Service

.... modifier 0..* CodeableConcept Product or service billing modifiers
Binding: Modifier type Codes ( Example )

. . . . programCode 0..* CodeableConcept Program the product or service is provided under
Binding: Example Program Reason Codes ( Example )

. . . . serviced[x] 0..1 Date or dates of service or product delivery
. . . . . servicedDate date
. . . . . servicedPeriod Period
. . . . location[x] 0..1 Place of service or where product was supplied
Binding: Example Service Place Codes ( Example )
. . . . . locationCodeableConcept CodeableConcept
. . . . . locationAddress Address
. . . . . locationReference Reference ( Location )
. . . . quantity patientPaid 0..1 Money Paid by the patient
.... quantity 0..1 SimpleQuantity Count of products or services
. . . . unitPrice 0..1 Money Fee, charge or cost per item
. . . . factor 0..1 decimal Price scaling factor
. . . . tax 0..1 Money Total tax
. . . . net 0..1 Money Total item cost
. . . . udi 0..* Reference ( Device ) Unique device identifier

. . . . bodySite 0..1 0..* CodeableConcept BackboneElement Anatomical location

. . . . . site 1..* CodeableReference ( BodyStructure ) Location
Binding: Oral Site Codes ( Example )

. . . . . subSite 0..* CodeableConcept Sub-location
Binding: Surface Codes ( Example )

. . . . encounter 0..* Reference ( Encounter ) Encounters related to this billed item associated with the listed treatments

. . . . detail 0..* BackboneElement Product or service provided

. . . . . sequence 1..1 positiveInt Item instance identifier
. . . . . traceNumber 0..* Identifier Number for tracking

. . . . . revenue 0..1 CodeableConcept Revenue or cost center code
Binding: Example Revenue Center Codes ( Example )
. . . . . category 0..1 CodeableConcept Benefit classification
Binding: Benefit Category Codes ( Example )
. . . . . productOrService 1..1 0..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLS Codes ( Example )
. . . . . modifier productOrServiceEnd 0..1 CodeableConcept End of a range of codes
Binding: USCLS Codes ( Example )
..... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: Modifier type Codes ( Example )

. . . . . programCode 0..* CodeableConcept Program the product or service is provided under
Binding: Example Program Reason Codes ( Example )

. . . . . patientPaid 0..1 Money Paid by the patient
. . . . . quantity 0..1 SimpleQuantity Count of products or services
. . . . . unitPrice 0..1 Money Fee, charge or cost per item
. . . . . factor 0..1 decimal Price scaling factor
. . . . . net tax 0..1 Money Total item cost tax
. . . . udi . net 0..1 Money Total item cost
..... udi 0..* Reference ( Device ) Unique device identifier

. . . . . subDetail 0..* BackboneElement Product or service provided

. . . . . . sequence 1..1 positiveInt Item instance identifier
. . . . . . traceNumber 0..* Identifier Number for tracking

. . . . . . revenue 0..1 CodeableConcept Revenue or cost center code
Binding: Example Revenue Center Codes ( Example )
. . . . . . category 0..1 CodeableConcept Benefit classification
Binding: Benefit Category Codes ( Example )
. . . . . . productOrService 1..1 0..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLS Codes ( Example )
. . . . . . modifier productOrServiceEnd 0..1 CodeableConcept End of a range of codes
Binding: USCLS Codes ( Example )
...... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: Modifier type Codes ( Example )

. . . . . . programCode 0..* CodeableConcept Program the product or service is provided under
Binding: Example Program Reason Codes ( Example )

. . . . . . patientPaid 0..1 Money Paid by the patient
. . . . . . quantity 0..1 SimpleQuantity Count of products or services
. . . . . . unitPrice 0..1 Money Fee, charge or cost per item
. . . . . . factor 0..1 decimal Price scaling factor
. . . . . . net tax 0..1 Money Total tax
...... net 0..1 Money Total item cost
. . . . . . udi 0..* Reference ( Device ) Unique device identifier

. . . total 0..1 Money Total claim cost

doco Documentation for this format icon

See the Extensions for this resource

UML Diagram ( Legend )

Claim ( DomainResource ) A unique identifier assigned to this claim identifier : Identifier [0..*] Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners traceNumber : Identifier [0..*] The status of the resource instance (this element modifies the meaning of other elements) status : code [1..1] « A code specifying the state of the resource instance. null (Strength=Required) FinancialResourceStatusCodes ! » The category of claim, e.g. oral, pharmacy, vision, institutional, professional type : CodeableConcept [1..1] « The type or discipline-style of the claim. null (Strength=Extensible) ClaimTypeCodes + » A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service subType : CodeableConcept [0..1] « A more granular claim typecode. null (Strength=Example) ExampleClaimSubTypeCodes ?? » A code to indicate whether the nature of the request is: to Claim - A request adjudication of products to an Insurer to adjudicate the supplied charges for health care goods and services previously rendered; or requesting authorization under the identified policy and adjudication to pay the determined Benefit amount, if any; Preauthorization - A request to an Insurer to adjudicate the supplied proposed future charges for provision in health care goods and services under the future; or requesting identified policy and to approve the non-binding adjudication of services and provide the listed products expected benefit amounts and potentially to reserve funds to pay the benefits when Claims for the indicated services which could are later submitted; or, Pre-determination - A request to an Insurer to adjudicate the supplied 'what if' charges for health care goods and services under the identified policy and report back what the Benefit payable would be provided in had the future services actually been provided use : code [1..1] « The purpose of the Claim: predetermination, preauthorization, claim. null (Strength=Required) Use ! » The party to whom the professional services and/or products have been supplied or are being considered and for whom actual or forecast reimbursement is sought patient : Reference [1..1] « Patient » The period for which charges are being submitted billablePeriod : Period [0..1] The date this resource was created created : dateTime [1..1] Individual who created the claim, predetermination or preauthorization enterer : Reference [0..1] « Practitioner | PractitionerRole | Patient | RelatedPerson » The Insurer who is target of the request insurer : Reference [0..1] « Organization » The provider which is responsible for the claim, predetermination or preauthorization provider : Reference [1..1] [0..1] « Practitioner | PractitionerRole | Organization » The provider-required urgency of processing the request. Typical values include: stat, routine normal, deferred priority : CodeableConcept [1..1] [0..1] « The timeliness with which processing is required: stat, normal, deferred. null (Strength=Example) ProcessPriorityCodes ?? » A code to indicate whether and for whom funds are to be reserved for future claims fundsReserve : CodeableConcept [0..1] « For whom funds are to be reserved: (Patient, Provider, None). null (Strength=Example) Funds Reservation FundsReservationCodes ?? » Prescription is the document/authorization given to support the dispensing of pharmacy, device or vision claim author for them to provide products and services for which consideration (reimbursement) is sought. Could be a RX for medications, an 'order' for oxygen or wheelchair or physiotherapy treatments prescription : Reference [0..1] « DeviceRequest | MedicationRequest | VisionPrescription » Original prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or products originalPrescription : Reference [0..1] « DeviceRequest | MedicationRequest | VisionPrescription » A reference The referral information received by the claim author, it is not to be used when the author generates a referral resource for a patient. A copy of that referral may be provided as supporting information. Some insurers require proof of referral to pay for services or to pay specialist rates for services referral : Reference [0..1] « ServiceRequest » Healthcare encounters related to this claim encounter : Reference [0..*] « Encounter » Facility where the services were provided facility : Reference [0..1] « Location | Organization » A package billing code or bundle code used to group products and services to a particular health condition (such as heart attack) which is based on a predetermined grouping code system diagnosisRelatedGroup : CodeableConcept [0..1] « null (Strength=Example) ExampleDiagnosisRelatedGroupC... ?? » The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services patientPaid : Money [0..1] The total value of the all the items in the claim total : Money [0..1] RelatedClaim Reference to a related claim claim : Reference [0..1] « Claim » A code to convey how the claims are related relationship : CodeableConcept [0..1] « Relationship of this claim to a related Claim. null (Strength=Example) ExampleRelatedClaimRelationsh... ?? » An alternate organizational reference to the case or file to which this particular claim pertains reference : Identifier [0..1] Payee Type of Party to be reimbursed: subscriber, provider, other type : CodeableConcept [1..1] « A code for the party to be reimbursed. null (Strength=Example) Claim Payee Type ClaimPayeeTypeCodes ?? » Reference to the individual or organization to whom any payment will be made party : Reference [0..1] « Practitioner | PractitionerRole | Organization | Patient | RelatedPerson » Event A coded event such as when a service is expected or a card printed type : CodeableConcept [1..1] « null (Strength=Example) DatesTypeCodes ?? » A date or period in the past or future indicating when the event occurred or is expectd to occur when[x] : DataType [1..1] « dateTime | Period » CareTeam A number to uniquely identify care team entries sequence : positiveInt [1..1] Member of the team who provided the product or service provider : Reference [1..1] « Practitioner | PractitionerRole | Organization » The party who is billing and/or responsible for the claimed products or services responsible : boolean [0..1] The lead, assisting or supervising practitioner and their discipline if a multidisciplinary team role : CodeableConcept [0..1] « The role codes for the care team members. null (Strength=Example) ClaimCareTeamRoleCodes ?? » The qualification specialization of the practitioner or provider which is applicable for this service qualification specialty : CodeableConcept [0..1] « Provider professional qualifications. null (Strength=Example) ExampleProviderQualificationC... ?? » SupportingInformation A number to uniquely identify supporting information entries sequence : positiveInt [1..1] The general class of the information supplied: information; exception; accident, employment; onset, etc category : CodeableConcept [1..1] « The valuset used for additional information category codes. null (Strength=Example) ClaimInformationCategoryCodes ?? » System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought code : CodeableConcept [0..1] « The valuset used for additional information codes. null (Strength=Example) ExceptionCodes ?? » The date when or period to which this information refers timing[x] : Type DataType [0..1] « date | Period » Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data value[x] : Type DataType [0..1] « boolean | string | Quantity | Attachment | Reference ( Any ) )| Identifier » Provides the reason in the situation where a reason code is required in addition to the content reason : CodeableConcept [0..1] « Reason codes for the missing teeth. null (Strength=Example) MissingToothReasonCodes ?? » Diagnosis A number to uniquely identify diagnosis entries sequence : positiveInt [1..1] The nature of illness or problem in a coded form or as a reference to an external defined Condition diagnosis[x] : Type DataType [1..1] « CodeableConcept | Reference ( Condition ); Example ICD10 Diagnostic codes. null (Strength=Example) ICD-10Codes ICD10Codes ?? » When the condition was observed or the relative ranking type : CodeableConcept [0..*] « The type of the diagnosis: admitting, principal, discharge. null (Strength=Example) ExampleDiagnosisTypeCodes ?? » Indication of whether the diagnosis was present on admission to a facility onAdmission : CodeableConcept [0..1] « Present on admission. null (Strength=Example) ExampleDiagnosisOnAdmissionCo... ?? » A package billing code or bundle code used to group products and services to a particular health condition (such as heart attack) which is based on a predetermined grouping code system packageCode : CodeableConcept [0..1] « The DRG codes associated with the diagnosis. (Strength=Example) ExampleDiagnosisRelatedGroupC... ?? » Procedure A number to uniquely identify procedure entries sequence : positiveInt [1..1] When the condition was observed or the relative ranking type : CodeableConcept [0..*] « Example procedure type codes. null (Strength=Example) ExampleProcedureTypeCodes ?? » Date and optionally time the procedure was performed date : dateTime [0..1] The code or reference to a Procedure resource which identifies the clinical intervention performed procedure[x] : Type DataType [1..1] « CodeableConcept | Reference ( Procedure ); Example ICD10 Procedure codes. null (Strength=Example) ICD-10ProcedureCodes ICD10ProcedureCodes ?? » Unique Device Identifiers associated with this line item udi : Reference [0..*] « Device » Insurance A number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order sequence : positiveInt [1..1] A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true focal : boolean [1..1] The business identifier to be used when the claim is sent for adjudication against this insurance policy identifier : Identifier [0..1] Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system coverage : Reference [1..1] « Coverage » A business agreement number established between the provider and the insurer for special business processing purposes businessArrangement : string [0..1] Reference numbers previously provided by the insurer to the provider to be quoted on subsequent claims containing services or products related to the prior authorization preAuthRef : string [0..*] The result of the adjudication of the line items for the Coverage specified in this insurance claimResponse : Reference [0..1] « ClaimResponse » Accident Date of an accident event related to the products and services contained in the claim date : date [1..1] The type or context of the accident event for the purposes of selection of potential insurance coverages and determination of coordination between insurers type : CodeableConcept [0..1] « Type of accident: work place, auto, etc. null (Strength=Extensible) v3.ActIncidentCode ActIncidentCode + » The physical location of the accident event location[x] : Type DataType [0..1] « Address | Reference ( Location ) » Item A number to uniquely identify item entries sequence : positiveInt [1..1] Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners traceNumber : Identifier [0..*] CareTeam members related to this service or product careTeamSequence : positiveInt [0..*] Diagnosis applicable for this service or product diagnosisSequence : positiveInt [0..*] Procedures applicable for this service or product procedureSequence : positiveInt [0..*] Exceptions, special conditions and supporting information applicable for this service or product informationSequence : positiveInt [0..*] The type of revenue or cost center providing the product and/or service revenue : CodeableConcept [0..1] « Codes for the revenue or cost centers supplying the service and/or products. null (Strength=Example) ExampleRevenueCenterCodes ?? » Code to identify the general type of benefits under which products and services are provided category : CodeableConcept [0..1] « Benefit categories such as: oral-basic, major, glasses. null (Strength=Example) BenefitCategoryCodes ?? » When the value is a group code then this item collects a set of related claim item details, otherwise this contains the product, service, drug or other billing code for the item item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used productOrService : CodeableConcept [1..1] [0..1] « Allowable service null (Strength=Example) USCLSCodes ?? » This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and product codes. not with claims productOrServiceEnd : CodeableConcept [0..1] « null (Strength=Example) USCLSCodes ?? » Request or Referral for Goods or Service to be rendered request : Reference [0..*] « DeviceRequest | MedicationRequest | NutritionOrder | ServiceRequest | SupplyRequest | VisionPrescription » Item typification or modifiers codes to convey additional context for the product or service modifier : CodeableConcept [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. null (Strength=Example) ModifierTypeCodes ?? » Identifies the program under which this may be recovered programCode : CodeableConcept [0..*] « Program specific reason codes. null (Strength=Example) ExampleProgramReasonCodes ?? » The date or dates when the service or product was supplied, performed or completed serviced[x] : Type DataType [0..1] « date | Period » Where the product or service was provided location[x] : Type DataType [0..1] « CodeableConcept | Address | Reference ( Location ); Place of service: pharmacy, school, prison, etc. null (Strength=Example) ExampleServicePlaceCodes ?? » The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services patientPaid : Money [0..1] The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details 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] The quantity times the unit price total of taxes applicable for an additional service or this product or charge service tax : Money [0..1] The total amount claimed for the group (if a grouper) or the line item. Net = unit price * quantity * factor net : Money [0..1] Unique Device Identifiers associated with this line item udi : Reference [0..*] « Device » Healthcare encounters related to this claim encounter : Reference [0..*] « Encounter » BodySite Physical service site on the patient (limb, tooth, etc.) bodySite site : CodeableConcept CodeableReference [0..1] [1..*] « BodyStructure ; The code for the teeth, quadrant, sextant and arch. null (Strength=Example) OralSiteCodes ?? » A region or surface of the bodySite, e.g. limb region or tooth surface(s) subSite : CodeableConcept [0..*] « The code for the tooth surface and surface combinations. null (Strength=Example) SurfaceCodes ?? » The Encounters during which this Claim was created or to which the creation of this record is tightly associated encounter : Reference [0..*] « Encounter » Detail A number to uniquely identify item entries sequence : positiveInt [1..1] Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners traceNumber : Identifier [0..*] The type of revenue or cost center providing the product and/or service revenue : CodeableConcept [0..1] « Codes for the revenue or cost centers supplying the service and/or products. null (Strength=Example) ExampleRevenueCenterCodes ?? » Code to identify the general type of benefits under which products and services are provided category : CodeableConcept [0..1] « Benefit categories such as: oral-basic, major, glasses. null (Strength=Example) BenefitCategoryCodes ?? » When the value is a group code then this item collects a set of related claim item details, otherwise this contains the product, service, drug or other billing code for the item item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used productOrService : CodeableConcept [1..1] [0..1] « Allowable service null (Strength=Example) USCLSCodes ?? » This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and product codes. not with claims productOrServiceEnd : CodeableConcept [0..1] « null (Strength=Example) USCLSCodes ?? » Item typification or modifiers codes to convey additional context for the product or service modifier : CodeableConcept [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. null (Strength=Example) ModifierTypeCodes ?? » Identifies the program under which this may be recovered programCode : CodeableConcept [0..*] « Program specific reason codes. null (Strength=Example) ExampleProgramReasonCodes ?? » The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services patientPaid : Money [0..1] The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details 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] The quantity times the unit price total of taxes applicable for an additional service or this product or charge service tax : Money [0..1] The total amount claimed for the group (if a grouper) or the line item.detail. Net = unit price * quantity * factor net : Money [0..1] Unique Device Identifiers associated with this line item udi : Reference [0..*] « Device » SubDetail A number to uniquely identify item entries sequence : positiveInt [1..1] Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners traceNumber : Identifier [0..*] The type of revenue or cost center providing the product and/or service revenue : CodeableConcept [0..1] « Codes for the revenue or cost centers supplying the service and/or products. null (Strength=Example) ExampleRevenueCenterCodes ?? » Code to identify the general type of benefits under which products and services are provided category : CodeableConcept [0..1] « Benefit categories such as: oral-basic, major, glasses. null (Strength=Example) BenefitCategoryCodes ?? » When the value is a group code then this item collects a set of related claim item details, otherwise this contains the product, service, drug or other billing code for the item item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used productOrService : CodeableConcept [1..1] [0..1] « Allowable service null (Strength=Example) USCLSCodes ?? » This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and product codes. not with claims productOrServiceEnd : CodeableConcept [0..1] « null (Strength=Example) USCLSCodes ?? » Item typification or modifiers codes to convey additional context for the product or service modifier : CodeableConcept [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. null (Strength=Example) ModifierTypeCodes ?? » Identifies the program under which this may be recovered programCode : CodeableConcept [0..*] « Program specific reason codes. null (Strength=Example) ExampleProgramReasonCodes ?? » The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services patientPaid : Money [0..1] The number of repetitions of a service or product quantity : Quantity ( SimpleQuantity ) [0..1] If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details 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] The quantity times the unit price total of taxes applicable for an additional service or this product or charge service tax : Money [0..1] The total amount claimed for line item.detail.subDetail. Net = unit price * quantity * factor net : Money [0..1] Unique Device Identifiers associated with this line item udi : Reference [0..*] « Device » Other claims which are related to this claim such as prior submissions or claims for related services or for the same event related [0..*] The party to be reimbursed for cost of the products and services according to the terms of the policy payee [0..1] Information code for an event with a corresponding date or period event [0..*] The members of the team who provided the products and services careTeam [0..*] Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues supportingInfo [0..*] Information about diagnoses relevant to the claim items diagnosis [0..*] Procedures performed on the patient relevant to the billing items with the claim procedure [0..*] Financial instruments for reimbursement for the health care products and services specified on the claim insurance [1..*] [0..*] Details of an accident which resulted in injuries which required the products and services listed in the claim accident [0..1] Physical location where the service is performed or applies bodySite [0..*] A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items subDetail [0..*] A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items detail [0..*] A claim line. Either a simple product or service or a 'group' of details which can each be a simple items or groups of sub-details item [0..*]

XML Template 

<Claim xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Business Identifier for claim --></identifier>
 <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>

 <status value="[code]"/><!-- 1..1 active | cancelled | draft | entered-in-error -->
 <type><!-- 1..1 CodeableConcept Category or discipline --></type>
 <subType><!-- 0..1 CodeableConcept More granular claim type --></subType>
 <

 <use value="[code]"/><!-- 1..1 claim | preauthorization | predetermination -->

 <patient><!-- 1..1 Reference(Patient) The recipient of the products and services --></patient>
 <billablePeriod><!-- 0..1 Period Relevant time frame for the claim --></billablePeriod>
 <created value="[dateTime]"/><!-- 1..1 Resource creation date -->
 <</enterer>

 <enterer><!-- 0..1 Reference(Patient|Practitioner|PractitionerRole|RelatedPerson) Author of the claim --></enterer>

 <insurer><!-- 0..1 Reference(Organization) Target --></insurer>
 <</provider>
 <</priority>

 <provider><!-- 0..1 Reference(Organization|Practitioner|PractitionerRole) Party responsible for the claim --></provider>
 <priority><!-- 0..1 CodeableConcept Desired processing urgency --></priority>

 <fundsReserve><!-- 0..1 CodeableConcept For whom to reserve funds --></fundsReserve>
 <related>  <!-- 0..* Prior or corollary claims -->
  <claim><!-- 0..1 Reference(Claim) Reference to the related claim --></claim>
  <relationship><!-- 0..1 CodeableConcept How the reference claim is related --></relationship>
  <reference><!-- 0..1 Identifier File or case reference --></reference>
 </related>
 <|

 <prescription><!-- 0..1 Reference(DeviceRequest|MedicationRequest|

   VisionPrescription) Prescription authorizing services and products --></prescription>
 <originalPrescription><!-- 0..1 Reference(DeviceRequest|MedicationRequest|
   VisionPrescription) Original prescription if superseded by fulfiller --></originalPrescription>
 <payee>  <!-- 0..1 Recipient of benefits payable -->
  <type><!-- 1..1 CodeableConcept Category of recipient --></type>
  <|

  <party><!-- 0..1 Reference(Organization|Patient|Practitioner|PractitionerRole|

    RelatedPerson) Recipient reference --></party>
 </payee>
 <</referral>
 <</facility>

 <referral><!-- 0..1 Reference(ServiceRequest) Treatment referral --></referral>
 <encounter><!-- 0..* Reference(Encounter) Encounters associated with the listed treatments --></encounter>
 <facility><!-- 0..1 Reference(Location|Organization) Servicing facility --></facility>
 <diagnosisRelatedGroup><!-- 0..1 CodeableConcept Package billing code --></diagnosisRelatedGroup>
 <event>  <!-- 0..* Event information -->
  <type><!-- 1..1 CodeableConcept Specific event --></type>
  <when[x]><!-- 1..1 dateTime|Period Occurance date or period --></when[x]>
 </event>

 <careTeam>  <!-- 0..* Members of the care team -->
  <sequence value="[positiveInt]"/><!-- 1..1 Order of care team -->
  <</provider>

  <provider><!-- 1..1 Reference(Organization|Practitioner|PractitionerRole) Practitioner or organization --></provider>

  <responsible value="[boolean]"/><!-- 0..1 Indicator of the lead practitioner -->
  <role><!-- 0..1 CodeableConcept Function within the team --></role>
  <</qualification>

  <specialty><!-- 0..1 CodeableConcept Practitioner or provider specialization --></specialty>

 </careTeam>
 <supportingInfo>  <!-- 0..* Supporting information -->
  <sequence value="[positiveInt]"/><!-- 1..1 Information instance identifier -->
  <category><!-- 1..1 CodeableConcept Classification of the supplied information --></category>
  <code><!-- 0..1 CodeableConcept Type of information --></code>
  <timing[x]><!-- 0..1 date|Period When it occurred --></timing[x]>
  <</value[x]>

  <value[x]><!-- 0..1 boolean|string|Quantity|Attachment|Reference(Any)|
    Identifier Data to be provided --></value[x]>
  <reason><!-- 0..1 CodeableConcept Explanation for the information --></reason>
 </supportingInfo>
 <diagnosis>  <!-- 0..* Pertinent diagnosis information -->
  <sequence value="[positiveInt]"/><!-- 1..1 Diagnosis instance identifier -->
  <diagnosis[x]><!-- 1..1 CodeableConcept|Reference(Condition) Nature of illness or problem --></diagnosis[x]>
  <type><!-- 0..* CodeableConcept Timing or nature of the diagnosis --></type>
  <onAdmission><!-- 0..1 CodeableConcept Present on admission --></onAdmission>
  <</packageCode>

 </diagnosis>
 <procedure>  <!-- 0..* Clinical procedures performed -->
  <sequence value="[positiveInt]"/><!-- 1..1 Procedure instance identifier -->
  <type><!-- 0..* CodeableConcept Category of Procedure --></type>
  <date value="[dateTime]"/><!-- 0..1 When the procedure was performed -->
  <procedure[x]><!-- 1..1 CodeableConcept|Reference(Procedure) Specific clinical procedure --></procedure[x]>
  <udi><!-- 0..* Reference(Device) Unique device identifier --></udi>
 </procedure>
 <

 <insurance>  <!-- 0..* Patient insurance information -->

  <sequence value="[positiveInt]"/><!-- 1..1 Insurance instance identifier -->
  <focal value="[boolean]"/><!-- 1..1 Coverage to be used for adjudication -->
  <identifier><!-- 0..1 Identifier Pre-assigned Claim number --></identifier>
  <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage>
  <businessArrangement value="[string]"/><!-- 0..1 Additional provider contract number -->
  <preAuthRef value="[string]"/><!-- 0..* Prior authorization reference number -->
  <claimResponse><!-- 0..1 Reference(ClaimResponse) Adjudication results --></claimResponse>
 </insurance>
 <accident>  <!-- 0..1 Details of the event -->
  <date value="[date]"/><!-- 1..1 When the incident occurred -->
  <</type>

  <type><!-- 0..1 CodeableConcept The nature of the accident icon --></type>

  <location[x]><!-- 0..1 Address|Reference(Location) Where the event occurred --></location[x]>
 </accident>
 <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid>

 <item>  <!-- 0..* Product or service provided -->
  <sequence value="[positiveInt]"/><!-- 1..1 Item instance identifier -->
  <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>

  <careTeamSequence value="[positiveInt]"/><!-- 0..* Applicable careTeam members -->
  <diagnosisSequence value="[positiveInt]"/><!-- 0..* Applicable diagnoses -->
  <procedureSequence value="[positiveInt]"/><!-- 0..* Applicable procedures -->
  <informationSequence value="[positiveInt]"/><!-- 0..* Applicable exception and supporting information -->
  <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
  <category><!-- 0..1 CodeableConcept Benefit classification --></category>
  <</productOrService>

  <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
  <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd>
  <request><!-- 0..* Reference(DeviceRequest|MedicationRequest|NutritionOrder|
    ServiceRequest|SupplyRequest|VisionPrescription) Request or Referral for Service --></request>
  <modifier><!-- 0..* CodeableConcept Product or service billing modifiers --></modifier>
  <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode>
  <serviced[x]><!-- 0..1 date|Period Date or dates of service or product delivery --></serviced[x]>
  <location[x]><!-- 0..1 CodeableConcept|Address|Reference(Location) Place of service or where product was supplied --></location[x]>
  <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid>

  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
  <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
  <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
  <</net>

  <tax><!-- 0..1 Money Total tax --></tax>
  <net><!-- 0..1 Money Total item cost --></net>

  <udi><!-- 0..* Reference(Device) Unique device identifier --></udi>
  <</bodySite>
  <</subSite>
  <</encounter>

  <bodySite>  <!-- 0..* Anatomical location -->
   <site><!-- 1..* CodeableReference(BodyStructure) Location --></site>
   <subSite><!-- 0..* CodeableConcept Sub-location --></subSite>
  </bodySite>
  <encounter><!-- 0..* Reference(Encounter) Encounters associated with the listed treatments --></encounter>

  <detail>  <!-- 0..* Product or service provided -->
   <sequence value="[positiveInt]"/><!-- 1..1 Item instance identifier -->
   <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>

   <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
   <category><!-- 0..1 CodeableConcept Benefit classification --></category>
   <</productOrService>

   <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
   <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd>

   <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
   <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode>
   <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid>

   <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
   <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
   <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
   <</net>

   <tax><!-- 0..1 Money Total tax --></tax>
   <net><!-- 0..1 Money Total item cost --></net>

   <udi><!-- 0..* Reference(Device) Unique device identifier --></udi>
   <subDetail>  <!-- 0..* Product or service provided -->
    <sequence value="[positiveInt]"/><!-- 1..1 Item instance identifier -->
    <traceNumber><!-- 0..* Identifier Number for tracking --></traceNumber>

    <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
    <category><!-- 0..1 CodeableConcept Benefit classification --></category>
    <</productOrService>

    <productOrService><!-- 0..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
    <productOrServiceEnd><!-- 0..1 CodeableConcept End of a range of codes --></productOrServiceEnd>

    <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
    <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode>
    <patientPaid><!-- 0..1 Money Paid by the patient --></patientPaid>

    <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
    <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
    <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
    <</net>

    <tax><!-- 0..1 Money Total tax --></tax>
    <net><!-- 0..1 Money Total item cost --></net>

    <udi><!-- 0..* Reference(Device) Unique device identifier --></udi>
   </subDetail>
  </detail>
 </item>
 <total><!-- 0..1 Money Total claim cost --></total>
</Claim>

JSON Template 

{doco
  "resourceType" : "Claim",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier for claim
  "traceNumber" : [{ Identifier }], // Number for tracking

  "status" : "<code>", // R!  active | cancelled | draft | entered-in-error
  "type" : { CodeableConcept }, // R!  Category or discipline
  "subType" : { CodeableConcept }, // More granular claim type
  "

  "use" : "<code>", // R!  claim | preauthorization | predetermination

  "patient" : { Reference(Patient) }, // R!  The recipient of the products and services
  "billablePeriod" : { Period }, // Relevant time frame for the claim
  "created" : "<dateTime>", // R!  Resource creation date
  "

  "enterer" : { Reference(Patient|Practitioner|PractitionerRole|RelatedPerson) }, // Author of the claim

  "insurer" : { Reference(Organization) }, // Target
  "
  "

  "provider" : { Reference(Organization|Practitioner|PractitionerRole) }, // Party responsible for the claim
  "priority" : { CodeableConcept }, // Desired processing urgency

  "fundsReserve" : { CodeableConcept }, // For whom to reserve funds
  "related" : [{ // Prior or corollary claims
    "claim" : { Reference(Claim) }, // Reference to the related claim
    "relationship" : { CodeableConcept }, // How the reference claim is related
    "reference" : { Identifier } // File or case reference
  }],
  "|

  "prescription" : { Reference(DeviceRequest|MedicationRequest|

   VisionPrescription) }, // Prescription authorizing services and products
  "originalPrescription" : { Reference(DeviceRequest|MedicationRequest|
   VisionPrescription) }, // Original prescription if superseded by fulfiller
  "payee" : { // Recipient of benefits payable
    "type" : { CodeableConcept }, // R!  Category of recipient
    "|

    "party" : { Reference(Organization|Patient|Practitioner|PractitionerRole|

    RelatedPerson) } // Recipient reference
  },
  "
  "

  "referral" : { Reference(ServiceRequest) }, // Treatment referral
  "encounter" : [{ Reference(Encounter) }], // Encounters associated with the listed treatments
  "facility" : { Reference(Location|Organization) }, // Servicing facility
  "diagnosisRelatedGroup" : { CodeableConcept }, // Package billing code
  "event" : [{ // Event information
    "type" : { CodeableConcept }, // R!  Specific event
    // when[x]: Occurance date or period. One of these 2:

    "whenDateTime" : "<dateTime>",
    "whenPeriod" : { Period }
  }],

  "careTeam" : [{ // Members of the care team
    "sequence" : "<positiveInt>", // R!  Order of care team
    "

    "provider" : { Reference(Organization|Practitioner|PractitionerRole) }, // R!  Practitioner or organization

    "responsible" : <boolean>, // Indicator of the lead practitioner
    "role" : { CodeableConcept }, // Function within the team
    "

    "specialty" : { CodeableConcept } // Practitioner or provider specialization

  }],
  "supportingInfo" : [{ // Supporting information
    "sequence" : "<positiveInt>", // R!  Information instance identifier
    "category" : { CodeableConcept }, // R!  Classification of the supplied information
    "code" : { CodeableConcept }, // Type of information
    // timing[x]: When it occurred. One of these 2:
    "timingDate" : "<date>",
    "timingPeriod" : { Period },
    

    // value[x]: Data to be provided. One of these 6:
    "valueBoolean" : <boolean>,
    "valueString" : "<string>",
    "valueQuantity" : { Quantity },
    "valueAttachment" : { Attachment },
    "valueReference" : { Reference(Any) },
    "valueIdentifier" : { Identifier },

    "reason" : { CodeableConcept } // Explanation for the information
  }],
  "diagnosis" : [{ // Pertinent diagnosis information
    "sequence" : "<positiveInt>", // R!  Diagnosis instance identifier
    // diagnosis[x]: Nature of illness or problem. One of these 2:
    "diagnosisCodeableConcept" : { CodeableConcept },
    "diagnosisReference" : { Reference(Condition) },
    "type" : [{ CodeableConcept }], // Timing or nature of the diagnosis
    "
    "

    "onAdmission" : { CodeableConcept } // Present on admission

  }],
  "procedure" : [{ // Clinical procedures performed
    "sequence" : "<positiveInt>", // R!  Procedure instance identifier
    "type" : [{ CodeableConcept }], // Category of Procedure
    "date" : "<dateTime>", // When the procedure was performed
    // procedure[x]: Specific clinical procedure. One of these 2:
    "procedureCodeableConcept" : { CodeableConcept },
    "procedureReference" : { Reference(Procedure) },
    "udi" : [{ Reference(Device) }] // Unique device identifier
  }],
  "

  "insurance" : [{ // Patient insurance information

    "sequence" : "<positiveInt>", // R!  Insurance instance identifier
    "focal" : <boolean>, // R!  Coverage to be used for adjudication
    "identifier" : { Identifier }, // Pre-assigned Claim number
    "coverage" : { Reference(Coverage) }, // R!  Insurance information
    "businessArrangement" : "<string>", // Additional provider contract number
    "preAuthRef" : ["<string>"], // Prior authorization reference number
    "claimResponse" : { Reference(ClaimResponse) } // Adjudication results
  }],
  "accident" : { // Details of the event
    "date" : "<date>", // R!  When the incident occurred
    "

    "type" : { CodeableConcept }, // The nature of the accident icon

    // location[x]: Where the event occurred. One of these 2:
    " }

    "locationAddress" : { Address },

    "locationReference" : { Reference(Location) }
  },
  "patientPaid" : { Money }, // Paid by the patient

  "item" : [{ // Product or service provided
    "sequence" : "<positiveInt>", // R!  Item instance identifier
    "traceNumber" : [{ Identifier }], // Number for tracking

    "careTeamSequence" : ["<positiveInt>"], // Applicable careTeam members
    "diagnosisSequence" : ["<positiveInt>"], // Applicable diagnoses
    "procedureSequence" : ["<positiveInt>"], // Applicable procedures
    "informationSequence" : ["<positiveInt>"], // Applicable exception and supporting information
    "revenue" : { CodeableConcept }, // Revenue or cost center code
    "category" : { CodeableConcept }, // Benefit classification
    "

    "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
    "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes
    "request" : [{ Reference(DeviceRequest|MedicationRequest|NutritionOrder|
    ServiceRequest|SupplyRequest|VisionPrescription) }], // Request or Referral for Service
    "modifier" : [{ CodeableConcept }], // Product or service billing modifiers
    "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
    // serviced[x]: Date or dates of service or product delivery. One of these 2:
    "servicedDate" : "<date>",
    "servicedPeriod" : { Period },
    // location[x]: Place of service or where product was supplied. One of these 3:
    "locationCodeableConcept" : { CodeableConcept },
    "locationAddress" : { Address },
    "locationReference" : { Reference(Location) },
    "patientPaid" : { Money }, // Paid by the patient

    "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
    "unitPrice" : { Money }, // Fee, charge or cost per item
    "factor" : <decimal>, // Price scaling factor
    "

    "tax" : { Money }, // Total tax
    "net" : { Money }, // Total item cost

    "udi" : [{ Reference(Device) }], // Unique device identifier
    "
    "
    "

    "bodySite" : [{ // Anatomical location
      "site" : [{ CodeableReference(BodyStructure) }], // R!  Location
      "subSite" : [{ CodeableConcept }] // Sub-location
    }],
    "encounter" : [{ Reference(Encounter) }], // Encounters associated with the listed treatments

    "detail" : [{ // Product or service provided
      "sequence" : "<positiveInt>", // R!  Item instance identifier
      "traceNumber" : [{ Identifier }], // Number for tracking

      "revenue" : { CodeableConcept }, // Revenue or cost center code
      "category" : { CodeableConcept }, // Benefit classification
      "

      "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
      "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes

      "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
      "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
      "patientPaid" : { Money }, // Paid by the patient

      "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
      "unitPrice" : { Money }, // Fee, charge or cost per item
      "factor" : <decimal>, // Price scaling factor
      "

      "tax" : { Money }, // Total tax
      "net" : { Money }, // Total item cost

      "udi" : [{ Reference(Device) }], // Unique device identifier
      "subDetail" : [{ // Product or service provided
        "sequence" : "<positiveInt>", // R!  Item instance identifier
        "traceNumber" : [{ Identifier }], // Number for tracking

        "revenue" : { CodeableConcept }, // Revenue or cost center code
        "category" : { CodeableConcept }, // Benefit classification
        "

        "productOrService" : { CodeableConcept }, // Billing, service, product, or drug code
        "productOrServiceEnd" : { CodeableConcept }, // End of a range of codes

        "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
        "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
        "patientPaid" : { Money }, // Paid by the patient

        "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
        "unitPrice" : { Money }, // Fee, charge or cost per item
        "factor" : <decimal>, // Price scaling factor
        "

        "tax" : { Money }, // Total tax
        "net" : { Money }, // Total item cost

        "udi" : [{ Reference(Device) }] // Unique device identifier
      }]
    }]
  }],
  "total" : { Money } // Total claim cost
}

Turtle Template 

@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:Claim;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:
  fhir:
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  ], ...;
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  ];
  fhir:
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  ], ...;
  fhir:
    fhir:
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    fhir:
    # . One of these 2
      fhir: ]
      fhir: ]
    # . One of these 5
      fhir: ]
      fhir: ]
      fhir: ]
      fhir: ]
      fhir:) ]
    fhir:
  ], ...;
  fhir:
    fhir:
    # . One of these 2
      fhir: ]
      fhir:) ]
    fhir:
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  ], ...;
  fhir:
    fhir:
    fhir:
    fhir:
    # . One of these 2
      fhir: ]
      fhir:) ]
    fhir:
  ], ...;
  fhir:
    fhir:
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  ], ...;
  fhir:
    fhir:
    fhir:
    # . One of these 2
      fhir: ]
      fhir:) ]
  ];
  fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
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    fhir:
    # . One of these 2
      fhir: ]
      fhir: ]
    # . One of these 3
      fhir: ]
      fhir: ]
      fhir:) ]
    fhir:
    fhir:
    fhir:
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        fhir:
        fhir:
        fhir:
      ], ...;
    ], ...;
  ], ...;
  fhir:

  fhir:identifier  ( [ Identifier ] ... ) ; # 0..* Business Identifier for claim
  fhir:traceNumber  ( [ Identifier ] ... ) ; # 0..* Number for tracking
  fhir:status [ code ] ; # 1..1 active | cancelled | draft | entered-in-error
  fhir:type [ CodeableConcept ] ; # 1..1 Category or discipline
  fhir:subType [ CodeableConcept ] ; # 0..1 More granular claim type
  fhir:use [ code ] ; # 1..1 claim | preauthorization | predetermination
  fhir:patient [ Reference(Patient) ] ; # 1..1 The recipient of the products and services
  fhir:billablePeriod [ Period ] ; # 0..1 Relevant time frame for the claim
  fhir:created [ dateTime ] ; # 1..1 Resource creation date
  fhir:enterer [ Reference(Patient|Practitioner|PractitionerRole|RelatedPerson) ] ; # 0..1 Author of the claim
  fhir:insurer [ Reference(Organization) ] ; # 0..1 Target
  fhir:provider [ Reference(Organization|Practitioner|PractitionerRole) ] ; # 0..1 Party responsible for the claim
  fhir:priority [ CodeableConcept ] ; # 0..1 Desired processing urgency
  fhir:fundsReserve [ CodeableConcept ] ; # 0..1 For whom to reserve funds
  fhir:related ( [ # 0..* Prior or corollary claims
    fhir:claim [ Reference(Claim) ] ; # 0..1 Reference to the related claim
    fhir:relationship [ CodeableConcept ] ; # 0..1 How the reference claim is related
    fhir:reference [ Identifier ] ; # 0..1 File or case reference
  ] ... ) ;
  fhir:prescription [ Reference(DeviceRequest|MedicationRequest|VisionPrescription) ] ; # 0..1 Prescription authorizing services and products
  fhir:originalPrescription [ Reference(DeviceRequest|MedicationRequest|VisionPrescription) ] ; # 0..1 Original prescription if superseded by fulfiller
  fhir:payee [ # 0..1 Recipient of benefits payable
    fhir:type [ CodeableConcept ] ; # 1..1 Category of recipient
    fhir:party [ Reference(Organization|Patient|Practitioner|PractitionerRole|RelatedPerson) ] ; # 0..1 Recipient reference
  ] ;
  fhir:referral [ Reference(ServiceRequest) ] ; # 0..1 Treatment referral
  fhir:encounter  ( [ Reference(Encounter) ] ... ) ; # 0..* Encounters associated with the listed treatments
  fhir:facility [ Reference(Location|Organization) ] ; # 0..1 Servicing facility
  fhir:diagnosisRelatedGroup [ CodeableConcept ] ; # 0..1 Package billing code
  fhir:event ( [ # 0..* Event information
    fhir:type [ CodeableConcept ] ; # 1..1 Specific event
    # when[x] : 1..1 Occurance date or period. One of these 2
      fhir:when [  a fhir:dateTime ; dateTime ]
      fhir:when [  a fhir:Period ; Period ]
  ] ... ) ;
  fhir:careTeam ( [ # 0..* Members of the care team
    fhir:sequence [ positiveInt ] ; # 1..1 Order of care team
    fhir:provider [ Reference(Organization|Practitioner|PractitionerRole) ] ; # 1..1 Practitioner or organization
    fhir:responsible [ boolean ] ; # 0..1 Indicator of the lead practitioner
    fhir:role [ CodeableConcept ] ; # 0..1 Function within the team
    fhir:specialty [ CodeableConcept ] ; # 0..1 Practitioner or provider specialization
  ] ... ) ;
  fhir:supportingInfo ( [ # 0..* Supporting information
    fhir:sequence [ positiveInt ] ; # 1..1 Information instance identifier
    fhir:category [ CodeableConcept ] ; # 1..1 Classification of the supplied information
    fhir:code [ CodeableConcept ] ; # 0..1 Type of information
    # timing[x] : 0..1 When it occurred. One of these 2
      fhir:timing [  a fhir:date ; date ]
      fhir:timing [  a fhir:Period ; Period ]
    # value[x] : 0..1 Data to be provided. One of these 6
      fhir:value [  a fhir:boolean ; boolean ]
      fhir:value [  a fhir:string ; string ]
      fhir:value [  a fhir:Quantity ; Quantity ]
      fhir:value [  a fhir:Attachment ; Attachment ]
      fhir:value [  a fhir:Reference ; Reference(Any) ]
      fhir:value [  a fhir:Identifier ; Identifier ]
    fhir:reason [ CodeableConcept ] ; # 0..1 Explanation for the information
  ] ... ) ;
  fhir:diagnosis ( [ # 0..* Pertinent diagnosis information
    fhir:sequence [ positiveInt ] ; # 1..1 Diagnosis instance identifier
    # diagnosis[x] : 1..1 Nature of illness or problem. One of these 2
      fhir:diagnosis [  a fhir:CodeableConcept ; CodeableConcept ]
      fhir:diagnosis [  a fhir:Reference ; Reference(Condition) ]
    fhir:type  ( [ CodeableConcept ] ... ) ; # 0..* Timing or nature of the diagnosis
    fhir:onAdmission [ CodeableConcept ] ; # 0..1 Present on admission
  ] ... ) ;
  fhir:procedure ( [ # 0..* Clinical procedures performed
    fhir:sequence [ positiveInt ] ; # 1..1 Procedure instance identifier
    fhir:type  ( [ CodeableConcept ] ... ) ; # 0..* Category of Procedure
    fhir:date [ dateTime ] ; # 0..1 When the procedure was performed
    # procedure[x] : 1..1 Specific clinical procedure. One of these 2
      fhir:procedure [  a fhir:CodeableConcept ; CodeableConcept ]
      fhir:procedure [  a fhir:Reference ; Reference(Procedure) ]
    fhir:udi  ( [ Reference(Device) ] ... ) ; # 0..* Unique device identifier
  ] ... ) ;
  fhir:insurance ( [ # 0..* Patient insurance information
    fhir:sequence [ positiveInt ] ; # 1..1 Insurance instance identifier
    fhir:focal [ boolean ] ; # 1..1 Coverage to be used for adjudication
    fhir:identifier [ Identifier ] ; # 0..1 Pre-assigned Claim number
    fhir:coverage [ Reference(Coverage) ] ; # 1..1 Insurance information
    fhir:businessArrangement [ string ] ; # 0..1 Additional provider contract number
    fhir:preAuthRef  ( [ string ] ... ) ; # 0..* Prior authorization reference number
    fhir:claimResponse [ Reference(ClaimResponse) ] ; # 0..1 Adjudication results
  ] ... ) ;
  fhir:accident [ # 0..1 Details of the event
    fhir:date [ date ] ; # 1..1 When the incident occurred
    fhir:type [ CodeableConcept ] ; # 0..1 The nature of the accident
    # location[x] : 0..1 Where the event occurred. One of these 2
      fhir:location [  a fhir:Address ; Address ]
      fhir:location [  a fhir:Reference ; Reference(Location) ]
  ] ;
  fhir:patientPaid [ Money ] ; # 0..1 Paid by the patient
  fhir:item ( [ # 0..* Product or service provided
    fhir:sequence [ positiveInt ] ; # 1..1 Item instance identifier
    fhir:traceNumber  ( [ Identifier ] ... ) ; # 0..* Number for tracking
    fhir:careTeamSequence  ( [ positiveInt ] ... ) ; # 0..* Applicable careTeam members
    fhir:diagnosisSequence  ( [ positiveInt ] ... ) ; # 0..* Applicable diagnoses
    fhir:procedureSequence  ( [ positiveInt ] ... ) ; # 0..* Applicable procedures
    fhir:informationSequence  ( [ positiveInt ] ... ) ; # 0..* Applicable exception and supporting information
    fhir:revenue [ CodeableConcept ] ; # 0..1 Revenue or cost center code
    fhir:category [ CodeableConcept ] ; # 0..1 Benefit classification
    fhir:productOrService [ CodeableConcept ] ; # 0..1 Billing, service, product, or drug code
    fhir:productOrServiceEnd [ CodeableConcept ] ; # 0..1 End of a range of codes
    fhir:request  ( [ Reference(DeviceRequest|MedicationRequest|NutritionOrder|ServiceRequest|SupplyRequest|
  VisionPrescription) ] ... ) ; # 0..* Request or Referral for Service

    fhir:modifier  ( [ CodeableConcept ] ... ) ; # 0..* Product or service billing modifiers
    fhir:programCode  ( [ CodeableConcept ] ... ) ; # 0..* Program the product or service is provided under
    # serviced[x] : 0..1 Date or dates of service or product delivery. One of these 2
      fhir:serviced [  a fhir:date ; date ]
      fhir:serviced [  a fhir:Period ; Period ]
    # location[x] : 0..1 Place of service or where product was supplied. One of these 3
      fhir:location [  a fhir:CodeableConcept ; CodeableConcept ]
      fhir:location [  a fhir:Address ; Address ]
      fhir:location [  a fhir:Reference ; Reference(Location) ]
    fhir:patientPaid [ Money ] ; # 0..1 Paid by the patient
    fhir:quantity [ Quantity(SimpleQuantity) ] ; # 0..1 Count of products or services
    fhir:unitPrice [ Money ] ; # 0..1 Fee, charge or cost per item
    fhir:factor [ decimal ] ; # 0..1 Price scaling factor
    fhir:tax [ Money ] ; # 0..1 Total tax
    fhir:net [ Money ] ; # 0..1 Total item cost
    fhir:udi  ( [ Reference(Device) ] ... ) ; # 0..* Unique device identifier
    fhir:bodySite ( [ # 0..* Anatomical location
      fhir:site  ( [ CodeableReference(BodyStructure) ] ... ) ; # 1..* Location
      fhir:subSite  ( [ CodeableConcept ] ... ) ; # 0..* Sub-location
    ] ... ) ;
    fhir:encounter  ( [ Reference(Encounter) ] ... ) ; # 0..* Encounters associated with the listed treatments
    fhir:detail ( [ # 0..* Product or service provided
      fhir:sequence [ positiveInt ] ; # 1..1 Item instance identifier
      fhir:traceNumber  ( [ Identifier ] ... ) ; # 0..* Number for tracking
      fhir:revenue [ CodeableConcept ] ; # 0..1 Revenue or cost center code
      fhir:category [ CodeableConcept ] ; # 0..1 Benefit classification
      fhir:productOrService [ CodeableConcept ] ; # 0..1 Billing, service, product, or drug code
      fhir:productOrServiceEnd [ CodeableConcept ] ; # 0..1 End of a range of codes
      fhir:modifier  ( [ CodeableConcept ] ... ) ; # 0..* Service/Product billing modifiers
      fhir:programCode  ( [ CodeableConcept ] ... ) ; # 0..* Program the product or service is provided under
      fhir:patientPaid [ Money ] ; # 0..1 Paid by the patient
      fhir:quantity [ Quantity(SimpleQuantity) ] ; # 0..1 Count of products or services
      fhir:unitPrice [ Money ] ; # 0..1 Fee, charge or cost per item
      fhir:factor [ decimal ] ; # 0..1 Price scaling factor
      fhir:tax [ Money ] ; # 0..1 Total tax
      fhir:net [ Money ] ; # 0..1 Total item cost
      fhir:udi  ( [ Reference(Device) ] ... ) ; # 0..* Unique device identifier
      fhir:subDetail ( [ # 0..* Product or service provided
        fhir:sequence [ positiveInt ] ; # 1..1 Item instance identifier
        fhir:traceNumber  ( [ Identifier ] ... ) ; # 0..* Number for tracking
        fhir:revenue [ CodeableConcept ] ; # 0..1 Revenue or cost center code
        fhir:category [ CodeableConcept ] ; # 0..1 Benefit classification
        fhir:productOrService [ CodeableConcept ] ; # 0..1 Billing, service, product, or drug code
        fhir:productOrServiceEnd [ CodeableConcept ] ; # 0..1 End of a range of codes
        fhir:modifier  ( [ CodeableConcept ] ... ) ; # 0..* Service/Product billing modifiers
        fhir:programCode  ( [ CodeableConcept ] ... ) ; # 0..* Program the product or service is provided under
        fhir:patientPaid [ Money ] ; # 0..1 Paid by the patient
        fhir:quantity [ Quantity(SimpleQuantity) ] ; # 0..1 Count of products or services
        fhir:unitPrice [ Money ] ; # 0..1 Fee, charge or cost per item
        fhir:factor [ decimal ] ; # 0..1 Price scaling factor
        fhir:tax [ Money ] ; # 0..1 Total tax
        fhir:net [ Money ] ; # 0..1 Total item cost
        fhir:udi  ( [ Reference(Device) ] ... ) ; # 0..* Unique device identifier
      ] ... ) ;
    ] ... ) ;
  ] ... ) ;
  fhir:total [ Money ] ; # 0..1 Total claim cost

]

Changes since Release 3 from both R4 and R4B

Claim.status Min Cardinality changed from 0 to 1 Change value set from http://hl7.org/fhir/ValueSet/fm-status to http://hl7.org/fhir/ValueSet/fm-status|4.0.1
Claim
Claim.type Claim.traceNumber
  • Min Cardinality changed from 0 to 1 Change binding strength from required to extensible Added Element
Claim.subType Claim.enterer
  • Max Cardinality changed from * to 1 Type Reference: Added Target Types Patient, RelatedPerson
Claim.use Claim.provider
  • Min Cardinality changed from 0 to 1 Change value set from http://hl7.org/fhir/ValueSet/claim-use to http://hl7.org/fhir/ValueSet/claim-use|4.0.1 Claim.patient Min Cardinality changed from 0 to 1
Claim.created Claim.priority
  • Min Cardinality changed from 0 to 1 to 0
Claim.enterer Claim.encounter
  • Type Reference: Added Target Type PractitionerRole Element
Claim.provider Claim.facility
    Min Cardinality changed from 0 to 1
  • Type Reference: Added Target Types PractitionerRole, Type Organization
Claim.priority Claim.diagnosisRelatedGroup
  • Min Cardinality changed from 0 to 1 Added Element
Claim.prescription Claim.event
  • Type Reference: Added Target Type DeviceRequest Element
Claim.originalPrescription Claim.event.type
  • Type Reference: Added Target Types DeviceRequest, VisionPrescription Mandatory Element
Claim.payee.party Claim.event.when[x]
  • Type Reference: Added Target Type PractitionerRole Mandatory Element
Claim.referral Claim.careTeam.specialty
  • Type Reference: Added Target Type ServiceRequest Type Reference: Removed Target Type ReferralRequest Element
Claim.careTeam.provider Claim.supportingInfo.value[x]
  • Add Type Reference: Added Target Type PractitionerRole Identifier
Claim.supportingInfo Claim.insurance
  • Renamed Min Cardinality changed from information 1 to supportingInfo 0
Claim.supportingInfo.sequence Claim.patientPaid
  • Moved from Claim.information to Claim.supportingInfo Added Element
Claim.supportingInfo.category Claim.item.traceNumber
  • Moved from Claim.information to Claim.supportingInfo Added Element
Claim.supportingInfo.code Claim.item.productOrService
  • Moved Min Cardinality changed from Claim.information 1 to Claim.supportingInfo 0
Claim.supportingInfo.timing[x] Claim.item.productOrServiceEnd
  • Moved from Claim.information to Claim.supportingInfo Added Element
Claim.supportingInfo.value[x] Claim.item.request
  • Moved from Claim.information to Claim.supportingInfo Add Type boolean Added Element
Claim.supportingInfo.reason Claim.item.patientPaid
  • Moved from Claim.information to Claim.supportingInfo Added Element
Claim.diagnosis.onAdmission Claim.item.tax
  • Added Element
Claim.procedure.type Claim.item.bodySite
  • Added Element Max Cardinality changed from 1 to *
  • Type changed from CodeableConcept to BackboneElement
Claim.procedure.udi Claim.item.bodySite.site
  • Added Mandatory Element
Claim.insurance Claim.item.bodySite.subSite
  • Min Cardinality changed from 0 to 1 Added Element
Claim.insurance.identifier Claim.item.detail.traceNumber
  • Added Element
Claim.accident.type Claim.item.detail.productOrService
  • Change binding strength Min Cardinality changed from required 1 to extensible 0
Claim.item.careTeamSequence Claim.item.detail.productOrServiceEnd
  • Renamed from careTeamLinkId to careTeamSequence Added Element
Claim.item.diagnosisSequence Claim.item.detail.patientPaid
  • Renamed from diagnosisLinkId to diagnosisSequence Added Element
Claim.item.procedureSequence Claim.item.detail.tax
  • Renamed from procedureLinkId to procedureSequence Added Element
Claim.item.informationSequence Claim.item.detail.subDetail.traceNumber
  • Renamed from informationLinkId to informationSequence Added Element
Claim.item.productOrService Claim.item.detail.subDetail.productOrService
    Renamed from service to productOrService
  • Min Cardinality changed from 0 to 1 to 0
Claim.item.detail.productOrService Claim.item.detail.subDetail.productOrServiceEnd
  • Renamed from service to productOrService Min Cardinality changed from 0 to 1 Added Element
Claim.item.detail.subDetail.productOrService Claim.item.detail.subDetail.patientPaid
  • Renamed from service to productOrService Min Cardinality changed from 0 to 1 Added Element
Claim.organization Claim.item.detail.subDetail.tax
  • deleted Added Element
Claim.payee.resourceType Claim.careTeam.qualification
  • deleted Deleted
Claim.employmentImpacted Claim.diagnosis.packageCode
  • deleted Deleted
Claim.hospitalization Claim.item.subSite
  • deleted Deleted

See the Full Difference for further information

This analysis is available for R4 as XML or JSON and for R4B as XML or JSON .

See R3 <--> R4 <--> R5 Conversion Maps (status = 16 tests of which 3 fail to execute . 13 fail round-trip testing and 3 r3 resources are invalid (0 errors). ) See Conversions Summary .)

 

See the Profiles & Extensions and the alternate Additional definitions: Master Definition XML + JSON , XML Schema / Schematron + JSON Schema , ShEx (for Turtle ) + see the extensions , the spreadsheet version & the dependency analysis

13.6.3.1 13.6.4.1 Terminology Bindings

Claim.careTeam.role Claim.diagnosis.packageCode Claim.procedure.type Claim.procedure.procedure[x] Claim.accident.type Claim.item.revenue Claim.item.detail.revenue Claim.item.detail.subDetail.revenue Claim.item.location[x] Claim.item.bodySite Claim.item.subSite
Path Definition ValueSet Type Reference Documentation
Claim.status A code specifying the state of the resource instance. FinancialResourceStatusCodes Required FinancialResourceStatusCodes

This value set includes Status codes.

Claim.type The type or discipline-style of the claim. ClaimTypeCodes Extensible ClaimTypeCodes

This value set includes Claim Type codes.

Claim.subType A more granular claim typecode. ExampleClaimSubTypeCodes Example ExampleClaimSubTypeCodes

This value set includes sample Claim SubType codes which are used to distinguish the claim types for example within type institutional there may be subtypes for emergency services, bed stay and transportation.

Claim.use The purpose of the Claim: predetermination, preauthorization, claim. Use Required Use

The purpose of the Claim: predetermination, preauthorization, claim.

Claim.priority The timeliness with which processing is required: stat, normal, deferred. ProcessPriorityCodes Example ProcessPriorityCodes

This value set includes the financial processing priority codes.

Claim.fundsReserve For whom funds are to be reserved: (Patient, Provider, None). FundsReservationCodes Example Funds Reservation Codes

This value set includes sample funds reservation type codes.

Claim.related.relationship Relationship of this claim to a related Claim. ExampleRelatedClaimRelationshipCodes Example ExampleRelatedClaimRelationshipCodes

This value set includes sample Related Claim Relationship codes.

Claim.payee.type A code for the party to be reimbursed. ClaimPayeeTypeCodes Example Claim

This value set includes sample Payee Type Codes codes.

Claim.diagnosisRelatedGroup ExampleDiagnosisRelatedGroupCodes Example

This value set includes example Diagnosis Related Group codes.

Claim.event.type The role codes for the care team members. DatesTypeCodes (a valid code from Dates Event Type Codes ) Example

This value set includes sample Dates Type codes.

Claim.careTeam.role ClaimCareTeamRoleCodes Example

This value set includes sample Claim Care Team Role codes.

Claim.careTeam.qualification Claim.careTeam.specialty Provider professional qualifications. ExampleProviderQualificationCodes Example ExampleProviderQualificationCodes

This value set includes sample Provider Qualification codes.

Claim.supportingInfo.category The valuset used for additional information category codes. ClaimInformationCategoryCodes Example ClaimInformationCategoryCodes

This value set includes sample Information Category codes.

Claim.supportingInfo.code The valuset used for additional information codes. ExceptionCodes Example ExceptionCodes

This value set includes sample Exception codes.

Claim.supportingInfo.reason Reason codes for the missing teeth. MissingToothReasonCodes Example MissingToothReasonCodes

This value set includes sample Missing Tooth Reason codes.

Claim.diagnosis.diagnosis[x] Example ICD10 Diagnostic codes. ICD10Codes (a valid code from ICD-10 icon ) Example ICD-10Codes

This value set includes sample ICD-10 codes.

Claim.diagnosis.type The type of the diagnosis: admitting, principal, discharge. ExampleDiagnosisTypeCodes Example ExampleDiagnosisTypeCodes

This value set includes example Diagnosis Type codes.

Claim.diagnosis.onAdmission Present ExampleDiagnosisOnAdmissionCodes Example

This value set includes example Diagnosis on admission. Admission codes.

Claim.procedure.type ExampleProcedureTypeCodes Example ExampleDiagnosisOnAdmissionCodes

This value set includes example Procedure Type codes.

Claim.procedure.procedure[x] ICD10ProcedureCodes (a valid code from ICD-10 Procedure Codes ) Example

This value set includes sample ICD-10 Procedure codes.

Claim.accident.type The DRG ActIncidentCode icon Extensible

Set of codes associated with indicating the diagnosis. type of incident or accident.

Claim.item.revenue ExampleRevenueCenterCodes Example ExampleDiagnosisRelatedGroupCodes

This value set includes sample Revenue Center codes.

Claim.item.category BenefitCategoryCodes Example procedure type

This value set includes examples of Benefit Category codes.

Claim.item.productOrService USCLSCodes Example ExampleProcedureTypeCodes

This value set includes a smattering of USCLS codes.

Claim.item.productOrServiceEnd USCLSCodes Example ICD10 Procedure

This value set includes a smattering of USCLS codes.

Claim.item.modifier ModifierTypeCodes Example ICD-10ProcedureCodes

This value set includes sample Modifier type codes.

Claim.item.programCode ExampleProgramReasonCodes Example

This value set includes sample Program Reason Span codes.

Claim.item.location[x] Type of accident: work place, auto, etc. ExampleServicePlaceCodes Extensible Example v3.ActIncidentCode

This value set includes a smattering of Service Place codes.

Claim.item.bodySite.site OralSiteCodes Example

This value set includes a smattering of FDI oral site codes.

Claim.item.bodySite.subSite Codes for the revenue or cost centers supplying the service and/or products. SurfaceCodes Example

This value set includes a smattering of FDI tooth surface codes.

Claim.item.detail.revenue ExampleRevenueCenterCodes Example

This value set includes sample Revenue Center codes.

Claim.item.category Claim.item.detail.category Claim.item.detail.subDetail.category Benefit categories such as: oral-basic, major, glasses. BenefitCategoryCodes Example BenefitCategoryCodes

This value set includes examples of Benefit Category codes.

Claim.item.productOrService Claim.item.detail.productOrService Claim.item.detail.subDetail.productOrService Allowable service and product codes. USCLSCodes Example

This value set includes a smattering of USCLS codes.

Claim.item.detail.productOrServiceEnd USCLSCodes Example

This value set includes a smattering of USCLS codes.

Claim.item.modifier Claim.item.detail.modifier Claim.item.detail.subDetail.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. ModifierTypeCodes Example ModifierTypeCodes

This value set includes sample Modifier type codes.

Claim.item.programCode Claim.item.detail.programCode Claim.item.detail.subDetail.programCode ExampleProgramReasonCodes Example

This value set includes sample Program specific reason Reason Span codes.

Claim.item.detail.subDetail.revenue ExampleRevenueCenterCodes Example ExampleProgramReasonCodes

This value set includes sample Revenue Center codes.

Claim.item.detail.subDetail.category Place of service: pharmacy, school, prison, etc. BenefitCategoryCodes Example ExampleServicePlaceCodes

This value set includes examples of Benefit Category codes.

Claim.item.detail.subDetail.productOrService The code for the teeth, quadrant, sextant and arch. USCLSCodes Example OralSiteCodes

This value set includes a smattering of USCLS codes.

Claim.item.detail.subDetail.productOrServiceEnd USCLSCodes Example

This value set includes a smattering of USCLS codes.

Claim.item.detail.subDetail.modifier The code for the tooth surface and surface combinations. ModifierTypeCodes Example SurfaceCodes

This value set includes sample Modifier type codes.

Claim.item.detail.subDetail.programCode ExampleProgramReasonCodes Example

This value set includes sample Program Reason Span codes.

13.6.5 Additional Information

The information presented in different backbone elements, such as .supportingInfo or .adjudication, has a different context based on the .category code presented in each, for example, adjudication occurrence may represent an amount paid by the patient while another may represent the amount paid to the provider.

Additionally, there are several places in the resource which point to other sections of the resource via the use of a .sequence number in the referred-to element and an . element Sequence in the referring element. Sequence numbers appear in such element as .careTeam referred to by .careTeamSequence,.diagnosis referred to by .diagnosisSequence,.procedure referred to by .procedureSequence,.supportingInfo referred to by .informationSequence and .item referred to by .itemSequence.

13.6.4 13.6.6 Search Parameters

Search parameters for this resource. See also the full list of search parameters for this resource , and check the Extensions registry for search parameters on extensions related to this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.

Name Type Description Expression In Common
care-team reference Member of the CareTeam Claim.careTeam.provider
( Practitioner , Organization , PractitionerRole )
created date The creation date for the Claim Claim.created
detail-udi reference UDI associated with a line item, detail product or service Claim.item.detail.udi
( Device )
encounter reference Encounters associated with a billed line item Claim.item.encounter
( Encounter ) 		29 Resources
enterer reference The party responsible for the entry of the Claim Claim.enterer
( Practitioner , Patient , PractitionerRole , RelatedPerson )
facility reference Facility where the products or services have been or will be provided Claim.facility
( Organization , Location )
identifier token The primary identifier of the financial resource Claim.identifier 65 Resources
insurer reference The target payor/insurer for the Claim Claim.insurer
( Organization )
item-udi reference UDI associated with a line item product or service Claim.item.udi
( Device )
patient reference Patient receiving the products or services Claim.patient
( Patient ) 		66 Resources
payee reference The party receiving any payment for the Claim Claim.payee.party
( Practitioner , Organization , Patient , PractitionerRole , RelatedPerson )
priority token Processing priority requested Claim.priority
procedure-udi reference UDI associated with a procedure Claim.procedure.udi
( Device )
provider reference Provider responsible for the Claim Claim.provider
( Practitioner , Organization , PractitionerRole )
status token The status of the Claim instance. Claim.status
subdetail-udi reference UDI associated with a line item, detail, subdetail product or service Claim.item.detail.subDetail.udi
( Device )
use token The kind of financial resource Claim.use