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R2
| Financial Management Work Group | Maturity Level : N/A | Ballot Status : Informative | Compartments : Encounter , Patient , Practitioner , RelatedPerson |
StructureDefinition for claim
Financial
{
"resourceType": "StructureDefinition",
"id": "Claim",
"meta": {
"lastUpdated": "2015-10-24T07:41:03.495+11:00"
"lastUpdated": "2019-10-24T11:53:00+11:00"
},
"text": {
"status": "generated",
"div": "<div>!-- Snipped for Brevity --></div>"
},
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm",
"valueInteger": 0
"valueInteger": 2
},
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
"valueCode": "fm"
}
],
"url": "http://hl7.org/fhir/StructureDefinition/Claim",
"name": "Claim",
"status": "draft",
"date": "2019-10-24T11:53:00+11:00",
"publisher": "Health Level Seven International (Financial Management)",
"contact": [
{
"telecom": [
{
"system": "other",
"system": "url",
"value": "http://hl7.org/fhir"
}
]
},
{
"telecom": [
{
"system": "other",
"system": "url",
"value": "http://www.hl7.org/Special/committees/fm/index.cfm"
}
]
}
],
"date": "2015-10-24T07:41:03+11:00",
"description": "Base StructureDefinition for Claim Resource",
"fhirVersion": "1.0.2",
"fhirVersion": "3.0.2",
"mapping": [
{
"identity": "workflow",
"uri": "http://hl7.org/fhir/workflow",
"name": "Workflow Mapping"
},
{
"identity": "w5",
"uri": "http://hl7.org/fhir/w5",
"name": "W5 Mapping"
},
{
"identity": "rim",
"uri": "http://hl7.org/v3",
"name": "RIM"
"name": "RIM Mapping"
}
],
"kind": "resource",
"abstract": false,
"base": "http://hl7.org/fhir/StructureDefinition/DomainResource",
"type": "Claim",
"baseDefinition": "http://hl7.org/fhir/StructureDefinition/DomainResource",
"derivation": "specialization",
"snapshot": {
"element": [
{
"id": "Claim",
"path": "Claim",
"short": "Claim, Pre-determination or Pre-authorization",
"definition": "A provider issued list of services and products provided, or to be provided, to a patient which is provided to an insurer for payment recovery.",
"min": 0,
"max": "*",
"type": [
"constraint": [
{
"code": "DomainResource"
"key": "dom-2",
"severity": "error",
"human": "If the resource is contained in another resource, it SHALL NOT contain nested Resources",
"expression": "contained.contained.empty()",
"xpath": "not(parent::f:contained and f:contained)",
"source": "DomainResource"
},
{
"key": "dom-1",
"severity": "error",
"human": "If the resource is contained in another resource, it SHALL NOT contain any narrative",
"expression": "contained.text.empty()",
"xpath": "not(parent::f:contained and f:text)",
"source": "DomainResource"
},
{
"key": "dom-4",
"severity": "error",
"human": "If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated",
"expression": "contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()",
"xpath": "not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))",
"source": "DomainResource"
},
{
"key": "dom-3",
"severity": "error",
"human": "If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource",
"expression": "contained.where(('#'+id in %resource.descendants().reference).not()).empty()",
"xpath": "not(exists(for $id in f:contained/*/@id return $id[not(ancestor::f:contained/parent::*/descendant::f:reference/@value=concat('#', $id))]))",
"source": "DomainResource"
}
],
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "Entity. Role, or Act"
},
{
"identity": "workflow",
"map": "Request"
},
{
"identity": "w5",
"map": "financial.billing"
}
]
},
{
"id": "Claim.id",
"path": "Claim.id",
"short": "Logical id of this artifact",
"definition": "The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.",
"comments": "The only time that a resource does not have an id is when it is being submitted to the server using a create operation. Bundles always have an id, though it is usually a generated UUID.",
"comment": "The only time that a resource does not have an id is when it is being submitted to the server using a create operation.",
"min": 0,
"max": "1",
"base": {
"path": "Resource.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "id"
}
],
"isSummary": true
},
{
"id": "Claim.meta",
"path": "Claim.meta",
"short": "Metadata about the resource",
"definition": "The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content may not always be associated with version changes to the resource.",
"min": 0,
"max": "1",
"base": {
"path": "Resource.meta",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Meta"
}
],
"isSummary": true
},
{
"id": "Claim.implicitRules",
"path": "Claim.implicitRules",
"short": "A set of rules under which this content was created",
"definition": "A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content.",
"comments": "Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element as much as possible.",
"comment": "Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. \n\nThis element is labelled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation.",
"min": 0,
"max": "1",
"base": {
"path": "Resource.implicitRules",
"min": 0,
"max": "1"
},
"type": [
{
"code": "uri"
}
],
"isModifier": true,
"isSummary": true
},
{
"id": "Claim.language",
"path": "Claim.language",
"short": "Language of the resource content",
"definition": "The base language in which the resource is written.",
"comments": "Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).",
"comment": "Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).",
"min": 0,
"max": "1",
"base": {
"path": "Resource.language",
"min": 0,
"max": "1"
},
"type": [
{
"code": "code"
}
],
"binding": {
"strength": "required",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-maxValueSet",
"valueReference": {
"reference": "http://hl7.org/fhir/ValueSet/all-languages"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Language"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
}
],
"strength": "extensible",
"description": "A human language.",
"valueSetUri": "http://tools.ietf.org/html/bcp47"
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/languages"
}
}
},
{
"id": "Claim.text",
"path": "Claim.text",
"short": "Text summary of the resource, for human interpretation",
"definition": "A human-readable narrative that contains a summary of the resource, and may be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it \"clinically safe\" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.",
"comments": "Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative.",
"comment": "Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a \"text blob\" or where text is additionally entered raw or narrated and encoded in formation is added later.",
"alias": [
"narrative",
"html",
"xhtml",
"display"
],
"min": 0,
"max": "1",
"base": {
"path": "DomainResource.text",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Narrative"
}
],
"condition": [
"dom-1"
],
"mapping": [
{
"identity": "rim",
"map": "Act.text?"
}
]
},
{
"id": "Claim.contained",
"path": "Claim.contained",
"short": "Contained, inline Resources",
"definition": "These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.",
"comments": "This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again.",
"comment": "This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again.",
"alias": [
"inline resources",
"anonymous resources",
"contained resources"
],
"min": 0,
"max": "*",
"base": {
"path": "DomainResource.contained",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Resource"
}
],
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "Claim.extension",
"path": "Claim.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the resource. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "DomainResource.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "Claim.modifierExtension",
"path": "Claim.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the resource, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "DomainResource.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"path": "Claim.type",
"short": "institutional | oral | pharmacy | professional | vision",
"definition": "The category of claim this is.",
"comments": "Affects which fields and value sets are used.",
"min": 1,
"id": "Claim.identifier",
"path": "Claim.identifier",
"short": "Claim number",
"definition": "The business identifier for the instance: claim number, pre-determination or pre-authorization number.",
"min": 0,
"max": "*",
"type": [
{
"code": "Identifier"
}
],
"mapping": [
{
"identity": "workflow",
"map": "Request.identifier"
},
{
"identity": "w5",
"map": "id"
}
]
},
{
"id": "Claim.status",
"path": "Claim.status",
"short": "active | cancelled | draft | entered-in-error",
"definition": "The status of the resource instance.",
"comment": "This element is labeled as a modifier because the status contains the code entered-in-error that marks the claim as not currently valid.",
"min": 0,
"max": "1",
"type": [
{
"code": "code"
}
],
"isModifier": true,
"isSummary": true,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ClaimStatus"
}
],
"strength": "required",
"description": "The type or discipline-style of the claim.",
"description": "A code specifying the state of the resource instance.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-type-link"
"reference": "http://hl7.org/fhir/ValueSet/fm-status"
}
}
},
"mapping": [
{
"identity": "workflow",
"map": "Request.status"
},
{
"identity": "w5",
"map": "status"
}
]
},
{
"path": "Claim.identifier",
"short": "Claim number",
"definition": "The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization number.",
"id": "Claim.type",
"path": "Claim.type",
"short": "Type or discipline",
"definition": "The category of claim, eg, oral, pharmacy, vision, insitutional, professional.",
"comment": "Affects which fields and value sets are used.",
"min": 0,
"max": "*",
"max": "1",
"type": [
{
"code": "Identifier"
"code": "CodeableConcept"
}
],
"isSummary": true
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ClaimType"
}
],
"strength": "required",
"description": "The type or discipline-style of the claim",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-type"
}
},
"mapping": [
{
"identity": "w5",
"map": "class"
}
]
},
{
"path": "Claim.ruleset",
"short": "Current specification followed",
"definition": "The version of the specification on which this instance relies.",
"alias": [
"BusinessVersion"
],
"id": "Claim.subType",
"path": "Claim.subType",
"short": "Finer grained claim type information",
"definition": "A finer grained suite of claim subtype codes which may convey Inpatient vs Outpatient and/or a specialty service. In the US the BillType.",
"comment": "This may contain the local bill type codes such as the US UB-04 bill type code.",
"min": 0,
"max": "1",
"max": "*",
"type": [
{
"code": "Coding"
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ClaimSubType"
}
],
"strength": "example",
"description": "The static and dynamic model to which contents conform, which may be business version or standard/version.",
"description": "A more granular claim typecode",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ruleset"
"reference": "http://hl7.org/fhir/ValueSet/claim-subtype"
}
}
},
"mapping": [
{
"identity": "w5",
"map": "class"
}
]
},
{
"path": "Claim.originalRuleset",
"short": "Original specification followed",
"definition": "The version of the specification from which the original instance was created.",
"alias": [
"OriginalBusinessVersion"
],
"id": "Claim.use",
"path": "Claim.use",
"short": "complete | proposed | exploratory | other",
"definition": "Complete (Bill or Claim), Proposed (Pre-Authorization), Exploratory (Pre-determination).",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
"code": "code"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "The static and dynamic model to which contents conform, which may be business version or standard/version.",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Use"
}
],
"strength": "required",
"description": "Complete, proposed, exploratory, other",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ruleset"
"reference": "http://hl7.org/fhir/ValueSet/claim-use"
}
}
},
"mapping": [
{
"identity": "w5",
"map": "class"
}
]
},
{
"id": "Claim.patient",
"path": "Claim.patient",
"short": "The subject of the Products and Services",
"definition": "Patient Resource.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Patient"
}
],
"mapping": [
{
"identity": "workflow",
"map": "Request.subject"
},
{
"identity": "w5",
"map": "who.focus"
}
]
},
{
"id": "Claim.billablePeriod",
"path": "Claim.billablePeriod",
"short": "Period for charge submission",
"definition": "The billable period for which charges are being submitted.",
"min": 0,
"max": "1",
"type": [
{
"code": "Period"
}
],
"mapping": [
{
"identity": "w5",
"map": "when.done"
}
]
},
{
"id": "Claim.created",
"path": "Claim.created",
"short": "Creation date",
"definition": "The date when the enclosed suite of services were performed or completed.",
"min": 0,
"max": "1",
"type": [
{
"code": "dateTime"
}
],
"isSummary": true
"mapping": [
{
"identity": "workflow",
"map": "Request.authoredOn"
},
{
"identity": "w5",
"map": "when.recorded"
}
]
},
{
"path": "Claim.target",
"short": "Insurer",
"definition": "Insurer Identifier, typical BIN number (6 digit).",
"id": "Claim.enterer",
"path": "Claim.enterer",
"short": "Author",
"definition": "Person who created the invoice/claim/pre-determination or pre-authorization.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Organization"
]
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Practitioner"
}
],
"isSummary": true
"mapping": [
{
"identity": "w5",
"map": "who.author"
}
]
},
{
"path": "Claim.provider",
"short": "Responsible provider",
"definition": "The provider which is responsible for the bill, claim pre-determination, pre-authorization.",
"id": "Claim.insurer",
"path": "Claim.insurer",
"short": "Target",
"definition": "The Insurer who is target of the request.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Practitioner"
]
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization"
}
],
"isSummary": true
"mapping": [
{
"identity": "workflow",
"map": "Request.performer"
}
]
},
{
"path": "Claim.organization",
"short": "Responsible organization",
"definition": "The organization which is responsible for the bill, claim pre-determination, pre-authorization.",
"id": "Claim.provider",
"path": "Claim.provider",
"short": "Responsible provider",
"definition": "The provider which is responsible for the bill, claim pre-determination, pre-authorization.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Organization"
]
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Practitioner"
}
],
"isSummary": true
"mapping": [
{
"identity": "workflow",
"map": "Request.requester.agent"
},
{
"identity": "w5",
"map": "who.source"
}
]
},
{
"path": "Claim.use",
"short": "complete | proposed | exploratory | other",
"definition": "Complete (Bill or Claim), Proposed (Pre-Authorization), Exploratory (Pre-determination).",
"id": "Claim.organization",
"path": "Claim.organization",
"short": "Responsible organization",
"definition": "The organization which is responsible for the bill, claim pre-determination, pre-authorization.",
"min": 0,
"max": "1",
"type": [
{
"code": "code"
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization"
}
],
"isSummary": true,
"binding": {
"strength": "required",
"description": "Complete, proposed, exploratory, other.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-use-link"
"mapping": [
{
"identity": "workflow",
"map": "Request.requester.onBehalfOf"
},
{
"identity": "w5",
"map": "who.source"
}
}
]
},
{
"id": "Claim.priority",
"path": "Claim.priority",
"short": "Desired processing priority",
"definition": "Immediate (stat), best effort (normal), deferred (deferred).",
"definition": "Immediate (STAT), best effort (NORMAL), deferred (DEFER).",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProcessPriority"
}
],
"strength": "example",
"description": "The timeliness with which processing is required: STAT, Normal, Deferred.",
"description": "The timeliness with which processing is required: STAT, normal, Deferred",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/process-priority"
}
}
},
"mapping": [
{
"identity": "workflow",
"map": "Request.priority"
}
]
},
{
"id": "Claim.fundsReserve",
"path": "Claim.fundsReserve",
"short": "Funds requested to be reserved",
"definition": "In the case of a Pre-Determination/Pre-Authorization the provider may request that funds in the amount of the expected Benefit be reserved ('Patient' or 'Provider') to pay for the Benefits determined on the subsequent claim(s). 'None' explicitly indicates no funds reserving is requested.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "FundsReserve"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
}
],
"strength": "example",
"description": "For whom funds are to be reserved: (Patient, Provider, None).",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/fundsreserve"
}
}
},
{
"path": "Claim.enterer",
"short": "Author",
"definition": "Person who created the invoice/claim/pre-determination or pre-authorization.",
"id": "Claim.related",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "RelatedClaim"
}
],
"path": "Claim.related",
"short": "Related Claims which may be revelant to processing this claimn",
"definition": "Other claims which are related to this claim such as prior claim versions or for related services.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
]
},
{
"id": "Claim.related.id",
"path": "Claim.related.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Practitioner"
]
"code": "string"
}
],
"isSummary": true
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "Claim.facility",
"short": "Servicing Facility",
"definition": "Facility where the services were provided.",
"id": "Claim.related.extension",
"path": "Claim.related.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Claim.related.modifierExtension",
"path": "Claim.related.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "Claim.related.claim",
"path": "Claim.related.claim",
"short": "Reference to the related claim",
"definition": "Other claims which are related to this claim such as prior claim versions or for related services.",
"comment": "Do we need a relationship code?",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Location"
]
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Claim"
}
],
"isSummary": true
"mapping": [
{
"identity": "workflow",
"map": "Request.replaces"
}
]
},
{
"id": "Claim.related.relationship",
"path": "Claim.related.relationship",
"short": "How the reference claim is related",
"definition": "For example prior or umbrella.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "RelatedClaimRelationship"
}
],
"strength": "example",
"description": "Relationship of this claim to a related Claim",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/related-claim-relationship"
}
}
},
{
"id": "Claim.related.reference",
"path": "Claim.related.reference",
"short": "Related file or case reference",
"definition": "An alternate organizational reference to the case or file to which this particular claim pertains - eg Property/Casualy insurer claim # or Workers Compensation case # .",
"min": 0,
"max": "1",
"type": [
{
"code": "Identifier"
}
]
},
{
"id": "Claim.prescription",
"path": "Claim.prescription",
"short": "Prescription",
"short": "Prescription authorizing services or products",
"definition": "Prescription to support the dispensing of Pharmacy or Vision products.",
"comment": "Should we create a group to hold multiple prescriptions and add a sequence number and on the line items a link to the sequence.",
"requirements": "For type=Pharmacy and Vision only.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/MedicationOrder"
]
"targetProfile": "http://hl7.org/fhir/StructureDefinition/MedicationRequest"
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/VisionPrescription"
]
"targetProfile": "http://hl7.org/fhir/StructureDefinition/VisionPrescription"
}
],
"isSummary": true
]
},
{
"id": "Claim.originalPrescription",
"path": "Claim.originalPrescription",
"short": "Original Prescription",
"definition": "Original prescription to support the dispensing of pharmacy services, medications or products.",
"short": "Original prescription if superceded by fulfiller",
"definition": "Original prescription which has been superceded by this prescription to support the dispensing of pharmacy services, medications or products. For example, a physician may prescribe a medication which the pharmacy determines is contraindicated, or for which the patient has an intolerance, and therefor issues a new precription for an alternate medication which has the same theraputic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription'.",
"comment": "as above.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/MedicationOrder"
]
"targetProfile": "http://hl7.org/fhir/StructureDefinition/MedicationRequest"
}
],
"isSummary": true
]
},
{
"id": "Claim.payee",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Payee"
}
],
"path": "Claim.payee",
"short": "Payee",
"short": "Party to be paid any benefits payable",
"definition": "The party to be reimbursed for the services.",
"min": 0,
"max": "1",
"type": [
{
"code": "BackboneElement"
}
],
"isSummary": true
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
]
},
{
"id": "Claim.payee.id",
"path": "Claim.payee.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references).",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "id"
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Claim.payee.extension",
"path": "Claim.payee.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Claim.payee.modifierExtension",
"path": "Claim.payee.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "Claim.payee.type",
"path": "Claim.payee.type",
"short": "Party to be paid any benefits payable",
"definition": "Party to be reimbursed: Subscriber, provider, other.",
"min": 0,
"short": "Type of party: Subscriber, Provider, other",
"definition": "Type of Party to be reimbursed: Subscriber, provider, other.",
"min": 1,
"max": "1",
"type": [
{
"code": "Coding"
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "PayeeType"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
}
],
"strength": "example",
"description": "A code for the party to be reimbursed.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/payeetype"
}
}
},
{
"path": "Claim.payee.provider",
"short": "Provider who is the payee",
"definition": "The provider who is to be reimbursed for the claim (the party to whom any benefit is assigned).",
"id": "Claim.payee.resourceType",
"path": "Claim.payee.resourceType",
"short": "organization | patient | practitioner | relatedperson",
"definition": "organization | patient | practitioner | relatedperson.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Practitioner"
]
"code": "Coding"
}
],
"isSummary": true
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ClaimPayeeResourceType"
}
],
"strength": "example",
"description": "The type of Claim payee Resource",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-payee-resource-type"
}
}
},
{
"path": "Claim.payee.organization",
"short": "Organization who is the payee",
"definition": "The organization who is to be reimbursed for the claim (the party to whom any benefit is assigned).",
"id": "Claim.payee.party",
"path": "Claim.payee.party",
"short": "Party to receive the payable",
"definition": "Party to be reimbursed: Subscriber, provider, other.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Organization"
]
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Practitioner"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Patient"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/RelatedPerson"
}
],
"isSummary": true
]
},
{
"path": "Claim.payee.person",
"short": "Other person who is the payee",
"definition": "The person other than the subscriber who is to be reimbursed for the claim (the party to whom any benefit is assigned).",
"id": "Claim.referral",
"path": "Claim.referral",
"short": "Treatment Referral",
"definition": "The referral resource which lists the date, practitioner, reason and other supporting information.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Patient"
]
"targetProfile": "http://hl7.org/fhir/StructureDefinition/ReferralRequest"
}
],
"isSummary": true
"mapping": [
{
"identity": "w5",
"map": "who.cause"
}
]
},
{
"path": "Claim.referral",
"short": "Treatment Referral",
"definition": "The referral resource which lists the date, practitioner, reason and other supporting information.",
"id": "Claim.facility",
"path": "Claim.facility",
"short": "Servicing Facility",
"definition": "Facility where the services were provided.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/ReferralRequest"
]
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Location"
}
],
"isSummary": true
"mapping": [
{
"identity": "w5",
"map": "where"
}
]
},
{
"id": "Claim.careTeam",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Diagnosis"
"valueString": "CareTeam"
}
],
"path": "Claim.diagnosis",
"short": "Diagnosis",
"definition": "Ordered list of patient diagnosis for which care is sought.",
"path": "Claim.careTeam",
"short": "Members of the care team",
"definition": "The members of the team who provided the overall service as well as their role and whether responsible and qualifications.",
"requirements": "Role and Responsible may not be required when there is only a single provider listed.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"isSummary": true
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
]
},
{
"path": "Claim.diagnosis.id",
"id": "Claim.careTeam.id",
"path": "Claim.careTeam.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references).",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "id"
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "Claim.diagnosis.extension",
"id": "Claim.careTeam.extension",
"path": "Claim.careTeam.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "Claim.diagnosis.modifierExtension",
"id": "Claim.careTeam.modifierExtension",
"path": "Claim.careTeam.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"path": "Claim.diagnosis.sequence",
"short": "Sequence of diagnosis",
"definition": "Sequence of diagnosis which serves to order and provide a link.",
"requirements": "Required to maintain order of the diagnoses.",
"id": "Claim.careTeam.sequence",
"path": "Claim.careTeam.sequence",
"short": "Number to covey order of careTeam",
"definition": "Sequence of the careTeam which serves to order and provide a link.",
"requirements": "Required to maintain order of the careTeam.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
],
"isSummary": true
]
},
{
"path": "Claim.diagnosis.diagnosis",
"short": "Patient's list of diagnosis",
"definition": "The diagnosis.",
"requirements": "Required to adjudicate services rendered to condition presented.",
"id": "Claim.careTeam.provider",
"path": "Claim.careTeam.provider",
"short": "Provider individual or organization",
"definition": "Member of the team who provided the overall service.",
"min": 1,
"max": "1",
"type": [
{
"code": "Coding"
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Practitioner"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "ICD10 diagnostic codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/icd-10"
"mapping": [
{
"identity": "w5",
"map": "who.actor"
}
}
]
},
{
"path": "Claim.condition",
"short": "List of presenting Conditions",
"definition": "List of patient conditions for which care is sought.",
"id": "Claim.careTeam.responsible",
"path": "Claim.careTeam.responsible",
"short": "Billing provider",
"definition": "The party who is billing and responsible for the claimed good or service rendered to the patient.",
"min": 0,
"max": "*",
"max": "1",
"type": [
{
"code": "Coding"
"code": "boolean"
}
]
},
{
"id": "Claim.careTeam.role",
"path": "Claim.careTeam.role",
"short": "Role on the team",
"definition": "The lead, assisting or supervising practitioner and their discipline if a multidisiplinary team.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CareTeamRole"
}
],
"strength": "example",
"description": "Patient conditions and symptoms.",
"description": "The role codes for the care team members.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/fm-conditions"
"reference": "http://hl7.org/fhir/ValueSet/claim-careteamrole"
}
}
},
{
"path": "Claim.patient",
"short": "The subject of the Products and Services",
"definition": "Patient Resource.",
"min": 1,
"id": "Claim.careTeam.qualification",
"path": "Claim.careTeam.qualification",
"short": "Type, classification or Specialization",
"definition": "The qualification which is applicable for this service.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Patient"
]
"code": "CodeableConcept"
}
],
"isSummary": true
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProviderQualification"
}
],
"strength": "example",
"description": "Provider professional qualifications",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/provider-qualification"
}
}
},
{
"id": "Claim.information",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Coverage"
"valueString": "SpecialCondition"
}
],
"path": "Claim.coverage",
"short": "Insurance or medical plan",
"definition": "Financial instrument by which payment information for health care.",
"requirements": "Health care programs and insurers are significant payors of health service costs.",
"path": "Claim.information",
"short": "Exceptions, special considerations, the condition, situation, prior or concurrent issues",
"definition": "Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. Often there are mutiple jurisdiction specific valuesets which are required.",
"requirements": "Typically these information codes are required to support the services rendered or the adjudication of the services rendered.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"isSummary": true,
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
],
"mapping": [
{
"identity": "rim",
"map": "Coverage"
"identity": "workflow",
"map": "Request.supportingInfo"
}
]
},
{
"path": "Claim.coverage.id",
"id": "Claim.information.id",
"path": "Claim.information.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references).",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "id"
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "Claim.coverage.extension",
"id": "Claim.information.extension",
"path": "Claim.information.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "Claim.coverage.modifierExtension",
"id": "Claim.information.modifierExtension",
"path": "Claim.information.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"path": "Claim.coverage.sequence",
"short": "Service instance identifier",
"definition": "A service line item.",
"requirements": "To maintain order of the coverages.",
"id": "Claim.information.sequence",
"path": "Claim.information.sequence",
"short": "Information instance identifier",
"definition": "Sequence of the information element which serves to provide a link.",
"requirements": "To provide a reference link.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
],
"isSummary": true
]
},
{
"path": "Claim.coverage.focal",
"short": "The focal Coverage",
"definition": "The instance number of the Coverage which is the focus for adjudication. The Coverage against which the claim is to be adjudicated.",
"requirements": "To identify which coverage is being adjudicated.",
"id": "Claim.information.category",
"path": "Claim.information.category",
"short": "General class of information",
"definition": "The general class of the information supplied: information; exception; accident, employment; onset, etc.",
"comment": "This may contain the local bill type codes such as the US UB-04 bill type code.",
"min": 1,
"max": "1",
"type": [
{
"code": "boolean"
"code": "CodeableConcept"
}
],
"isSummary": true
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "InformationCategory"
}
],
"strength": "example",
"description": "The valuset used for additional information category codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-informationcategory"
}
}
},
{
"path": "Claim.coverage.coverage",
"short": "Insurance information",
"definition": "Reference to the program or plan identification, underwriter or payor.",
"requirements": "Need to identify the issuer to target for processing and for coordination of benefit processing.",
"min": 1,
"id": "Claim.information.code",
"path": "Claim.information.code",
"short": "Type of information",
"definition": "System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought which may influence the adjudication.",
"comment": "This may contain the local bill type codes such as the US UB-04 bill type code.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Coverage"
]
"code": "CodeableConcept"
}
],
"isSummary": true
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "InformationCode"
}
],
"strength": "example",
"description": "The valuset used for additional information codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-exception"
}
}
},
{
"path": "Claim.coverage.businessArrangement",
"short": "Business agreement",
"definition": "The contract number of a business agreement which describes the terms and conditions.",
"id": "Claim.information.timing[x]",
"path": "Claim.information.timing[x]",
"short": "When it occurred",
"definition": "The date when or period to which this information refers.",
"min": 0,
"max": "1",
"type": [
{
"code": "date"
},
{
"code": "Period"
}
]
},
{
"id": "Claim.information.value[x]",
"path": "Claim.information.value[x]",
"short": "Additional Data or supporting information",
"definition": "Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
},
{
"code": "Quantity"
},
{
"code": "Attachment"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Resource"
}
],
"isSummary": true
]
},
{
"path": "Claim.coverage.relationship",
"short": "Patient relationship to subscriber",
"definition": "The relationship of the patient to the subscriber.",
"requirements": "To determine the relationship between the patient and the subscriber.",
"min": 1,
"id": "Claim.information.reason",
"path": "Claim.information.reason",
"short": "Reason associated with the information",
"definition": "For example, provides the reason for: the additional stay, or missing tooth or any other situation where a reason code is required in addition to the content.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "MissingReason"
}
],
"strength": "example",
"description": "The code for the relationship of the patient to the subscriber.",
"description": "Reason codes for the missing teeth",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/relationship"
"reference": "http://hl7.org/fhir/ValueSet/missing-tooth-reason"
}
}
},
{
"path": "Claim.coverage.preAuthRef",
"short": "Pre-Authorization/Determination Reference",
"definition": "A list of references from the Insurer to which these services pertain.",
"requirements": "To provide any pre=determination or prior authorization reference.",
"id": "Claim.diagnosis",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Diagnosis"
}
],
"path": "Claim.diagnosis",
"short": "List of Diagnosis",
"definition": "List of patient diagnosis for which care is sought.",
"min": 0,
"max": "*",
"type": [
{
"code": "string"
"code": "BackboneElement"
}
],
"isSummary": true
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
],
"mapping": [
{
"identity": "workflow",
"map": "Request.reasonReference"
}
]
},
{
"path": "Claim.coverage.claimResponse",
"short": "Adjudication results",
"definition": "The Coverages adjudication details.",
"requirements": "Used by downstream payers to determine what balance remains and the net payable.",
"id": "Claim.diagnosis.id",
"path": "Claim.diagnosis.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/ClaimResponse"
]
"code": "string"
}
],
"isSummary": true
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "Claim.coverage.originalRuleset",
"short": "Original version",
"definition": "The style (standard) and version of the original material which was converted into this resource.",
"requirements": "Knowledge of the original version can inform the processing of this instance so that information which is processable by the originating system may be generated.",
"id": "Claim.diagnosis.extension",
"path": "Claim.diagnosis.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "1",
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Coding"
"code": "Extension"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "The static and dynamic model to which contents conform, which may be business version or standard/version.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ruleset"
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
}
]
},
{
"path": "Claim.exception",
"short": "Eligibility exceptions",
"definition": "Factors which may influence the applicability of coverage.",
"requirements": "To determine extenuating circumstances for coverage.",
"id": "Claim.diagnosis.modifierExtension",
"path": "Claim.diagnosis.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Coding"
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"binding": {
"strength": "example",
"description": "The eligibility exception codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-exception"
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
}
]
},
{
"path": "Claim.school",
"short": "Name of School",
"definition": "Name of school for over-aged dependents.",
"requirements": "Often required for over-age dependents.",
"min": 0,
"id": "Claim.diagnosis.sequence",
"path": "Claim.diagnosis.sequence",
"short": "Number to covey order of diagnosis",
"definition": "Sequence of diagnosis which serves to provide a link.",
"requirements": "Required to allow line items to reference the diagnoses.",
"min": 1,
"max": "1",
"type": [
{
"code": "string"
"code": "positiveInt"
}
],
"isSummary": true
]
},
{
"path": "Claim.accident",
"short": "Accident Date",
"definition": "Date of an accident which these services are addressing.",
"requirements": "Coverage may be dependent on accidents.",
"min": 0,
"id": "Claim.diagnosis.diagnosis[x]",
"path": "Claim.diagnosis.diagnosis[x]",
"short": "Patient's diagnosis",
"definition": "The diagnosis.",
"requirements": "Required to adjudicate services rendered to condition presented.",
"min": 1,
"max": "1",
"type": [
{
"code": "date"
"code": "CodeableConcept"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Condition"
}
],
"isSummary": true
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ICD10"
}
],
"strength": "example",
"description": "ICD10 Diagnostic codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/icd-10"
}
}
},
{
"path": "Claim.accidentType",
"short": "Accident Type",
"definition": "Type of accident: work, auto, etc.",
"requirements": "Coverage may be dependent on the type of accident.",
"id": "Claim.diagnosis.type",
"path": "Claim.diagnosis.type",
"short": "Timing or nature of the diagnosis",
"definition": "The type of the Diagnosis, for example: admitting, primary, secondary, discharge.",
"comment": "Diagnosis are presented in list order to their expected importance: primary, secondary, etc.",
"requirements": "May be required to adjudicate services rendered.",
"min": 0,
"max": "1",
"max": "*",
"type": [
{
"code": "Coding"
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"strength": "required",
"description": "Type of accident: work place, auto, etc.",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "DiagnosisType"
}
],
"strength": "example",
"description": "The type of the diagnosis: admitting, principal, discharge",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/v3-ActIncidentCode"
"reference": "http://hl7.org/fhir/ValueSet/ex-diagnosistype"
}
}
},
{
"path": "Claim.interventionException",
"short": "Intervention and exception code (Pharma)",
"definition": "A list of intervention and exception codes which may influence the adjudication of the claim.",
"requirements": "Coverage may be modified based on exception information provided.",
"id": "Claim.diagnosis.packageCode",
"path": "Claim.diagnosis.packageCode",
"short": "Package billing code",
"definition": "The package billing code, for example DRG, based on the assigned grouping code system.",
"requirements": "May be required to adjudicate services rendered to the mandated grouping system.",
"min": 0,
"max": "*",
"max": "1",
"type": [
{
"code": "Coding"
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "DiagnosisRelatedGroup"
}
],
"strength": "example",
"description": "Intervention and exception codes (Pharm).",
"description": "The DRG codes associated with the diagnosis",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/intervention"
"reference": "http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup"
}
}
},
{
"id": "Claim.procedure",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Items"
"valueString": "Procedure"
}
],
"path": "Claim.item",
"short": "Goods and Services",
"definition": "First tier of goods and services.",
"path": "Claim.procedure",
"short": "Procedures performed",
"definition": "Ordered list of patient procedures performed to support the adjudication.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"isSummary": true
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
]
},
{
"path": "Claim.item.id",
"id": "Claim.procedure.id",
"path": "Claim.procedure.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references).",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "id"
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "Claim.item.extension",
"id": "Claim.procedure.extension",
"path": "Claim.procedure.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "Claim.item.modifierExtension",
"id": "Claim.procedure.modifierExtension",
"path": "Claim.procedure.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"path": "Claim.item.sequence",
"short": "Service instance",
"definition": "A service line number.",
"id": "Claim.procedure.sequence",
"path": "Claim.procedure.sequence",
"short": "Procedure sequence for reference",
"definition": "Sequence of procedures which serves to order and provide a link.",
"requirements": "Required to maintain order of the procudures.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
],
"isSummary": true
]
},
{
"path": "Claim.item.type",
"short": "Group or type of product or service",
"definition": "The type of product or service.",
"id": "Claim.procedure.date",
"path": "Claim.procedure.date",
"short": "When the procedure was performed",
"definition": "Date and optionally time the procedure was performed .",
"comment": "SB DateTime??",
"requirements": "Required to adjudicate services rendered.",
"min": 0,
"max": "1",
"type": [
{
"code": "dateTime"
}
]
},
{
"id": "Claim.procedure.procedure[x]",
"path": "Claim.procedure.procedure[x]",
"short": "Patient's list of procedures performed",
"definition": "The procedure code.",
"requirements": "Required to adjudicate services rendered.",
"min": 1,
"max": "1",
"type": [
{
"code": "Coding"
"code": "CodeableConcept"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Procedure"
}
],
"isSummary": true,
"binding": {
"strength": "required",
"description": "Service, Product, Rx Dispense, Rx Compound etc.",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ICD10_Procedures"
}
],
"strength": "example",
"description": "ICD10 Procedure codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/v3-ActInvoiceGroupCode"
"reference": "http://hl7.org/fhir/ValueSet/icd-10-procedures"
}
}
},
{
"path": "Claim.item.provider",
"short": "Responsible practitioner",
"definition": "The practitioner who is responsible for the services rendered to the patient.",
"id": "Claim.insurance",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Insurance"
}
],
"path": "Claim.insurance",
"short": "Insurance or medical plan",
"definition": "Financial instrument by which payment information for health care.",
"requirements": "Health care programs and insurers are significant payors of health service costs.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
],
"mapping": [
{
"identity": "rim",
"map": "Coverage"
}
]
},
{
"id": "Claim.insurance.id",
"path": "Claim.insurance.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Practitioner"
]
"code": "string"
}
],
"isSummary": true
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "Claim.item.diagnosisLinkId",
"short": "Diagnosis Link",
"definition": "Diagnosis applicable for this service or product line.",
"id": "Claim.insurance.extension",
"path": "Claim.insurance.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "positiveInt"
"code": "Extension"
}
],
"isSummary": true
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "Claim.item.service",
"short": "Item Code",
"definition": "If a grouping item then 'GROUP' otherwise it is a node therefore a code to indicate the Professional Service or Product supplied.",
"min": 1,
"max": "1",
"id": "Claim.insurance.modifierExtension",
"path": "Claim.insurance.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Coding"
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"binding": {
"strength": "example",
"description": "Allowable service and product codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
}
]
},
{
"path": "Claim.item.serviceDate",
"short": "Date of Service",
"definition": "The date when the enclosed suite of services were performed or completed.",
"min": 0,
"id": "Claim.insurance.sequence",
"path": "Claim.insurance.sequence",
"short": "Service instance identifier",
"definition": "Sequence of coverage which serves to provide a link and convey coordination of benefit order.",
"requirements": "To maintain order of the coverages.",
"min": 1,
"max": "1",
"type": [
{
"code": "date"
"code": "positiveInt"
}
],
"isSummary": true
]
},
{
"path": "Claim.item.quantity",
"short": "Count of Products or Services",
"definition": "The number of repetitions of a service or product.",
"min": 0,
"id": "Claim.insurance.focal",
"path": "Claim.insurance.focal",
"short": "Is the focal Coverage",
"definition": "A flag to indicate that this Coverage is the focus for adjudication. The Coverage against which the claim is to be adjudicated.",
"requirements": "To identify which coverage is being adjudicated.",
"min": 1,
"max": "1",
"type": [
{
"code": "Quantity",
"profile": [
"http://hl7.org/fhir/StructureDefinition/SimpleQuantity"
]
"code": "boolean"
}
],
"isSummary": true
]
},
{
"path": "Claim.item.unitPrice",
"short": "Fee, charge or cost per point",
"definition": "If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group.",
"min": 0,
"id": "Claim.insurance.coverage",
"path": "Claim.insurance.coverage",
"short": "Insurance information",
"definition": "Reference to the program or plan identification, underwriter or payor.",
"requirements": "Need to identify the issuer to target for processing and for coordination of benefit processing.",
"min": 1,
"max": "1",
"type": [
{
"code": "Quantity",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Money"
]
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Coverage"
}
],
"isSummary": true
]
},
{
"path": "Claim.item.factor",
"short": "Price scaling factor",
"definition": "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.",
"requirements": "If a fee is present the associated product/service code must be present.",
"id": "Claim.insurance.businessArrangement",
"path": "Claim.insurance.businessArrangement",
"short": "Business agreement",
"definition": "The contract number of a business agreement which describes the terms and conditions.",
"min": 0,
"max": "1",
"type": [
{
"code": "decimal"
"code": "string"
}
],
"isSummary": true
]
},
{
"path": "Claim.item.points",
"short": "Difficulty scaling factor",
"definition": "An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each point.",
"requirements": "If a fee is present the associated product/service code must be present.",
"id": "Claim.insurance.preAuthRef",
"path": "Claim.insurance.preAuthRef",
"short": "Pre-Authorization/Determination Reference",
"definition": "A list of references from the Insurer to which these services pertain.",
"requirements": "To provide any pre=determination or prior authorization reference.",
"min": 0,
"max": "1",
"max": "*",
"type": [
{
"code": "decimal"
"code": "string"
}
],
"isSummary": true
]
},
{
"path": "Claim.item.net",
"short": "Total item cost",
"definition": "The quantity times the unit price for an additional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.",
"requirements": "If a fee is present the associated product/service code must be present.",
"id": "Claim.insurance.claimResponse",
"path": "Claim.insurance.claimResponse",
"short": "Adjudication results",
"definition": "The Coverages adjudication details.",
"requirements": "Used by downstream payers to determine what balance remains and the net payable.",
"min": 0,
"max": "1",
"type": [
{
"code": "Quantity",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Money"
]
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/ClaimResponse"
}
],
"isSummary": true
]
},
{
"path": "Claim.item.udi",
"short": "Unique Device Identifier",
"definition": "List of Unique Device Identifiers associated with this line item.",
"requirements": "The UDI code and issuer if applicable for the supplied product.",
"id": "Claim.accident",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Accident"
}
],
"path": "Claim.accident",
"short": "Details about an accident",
"definition": "An accident which resulted in the need for healthcare services.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
"code": "BackboneElement"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "The FDA, or other, UDI repository.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/udi"
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
}
]
},
{
"path": "Claim.item.bodySite",
"short": "Service Location",
"definition": "Physical service site on the patient (limb, tooth, etc.).",
"id": "Claim.accident.id",
"path": "Claim.accident.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Coding"
"code": "string"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "The code for the teeth, quadrant, sextant and arch.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/tooth"
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
}
]
},
{
"path": "Claim.item.subSite",
"short": "Service Sub-location",
"definition": "A region or surface of the site, e.g. limb region or tooth surface(s).",
"id": "Claim.accident.extension",
"path": "Claim.accident.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Coding"
"code": "Extension"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "The code for the tooth surface and surface combinations.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/surface"
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
}
]
},
{
"path": "Claim.item.modifier",
"short": "Service/Product billing modifiers",
"definition": "Item typification or modifiers codes, e.g. for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.",
"requirements": "May impact on adjudication.",
"id": "Claim.accident.modifierExtension",
"path": "Claim.accident.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Coding"
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "Claim.accident.date",
"path": "Claim.accident.date",
"short": "When the accident occurred\nsee information codes\nsee information codes",
"definition": "Date of an accident which these services are addressing.",
"requirements": "Coverage may be dependant on accidents.",
"min": 1,
"max": "1",
"type": [
{
"code": "date"
}
]
},
{
"id": "Claim.accident.type",
"path": "Claim.accident.type",
"short": "The nature of the accident",
"definition": "Type of accident: work, auto, etc.",
"requirements": "Coverage may be dependant on the type of accident.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"strength": "example",
"description": "Item type or modifiers codes, e.g. for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "AccidentType"
}
],
"strength": "required",
"description": "Type of accident: work place, auto, etc.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-modifiers"
"reference": "http://hl7.org/fhir/ValueSet/v3-ActIncidentCode"
}
}
},
{
"id": "Claim.accident.location[x]",
"path": "Claim.accident.location[x]",
"short": "Accident Place",
"definition": "Accident Place.",
"min": 0,
"max": "1",
"type": [
{
"code": "Address"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Location"
}
]
},
{
"id": "Claim.employmentImpacted",
"path": "Claim.employmentImpacted",
"short": "Period unable to work",
"definition": "The start and optional end dates of when the patient was precluded from working due to the treatable condition(s).",
"min": 0,
"max": "1",
"type": [
{
"code": "Period"
}
]
},
{
"id": "Claim.hospitalization",
"path": "Claim.hospitalization",
"short": "Period in hospital",
"definition": "The start and optional end dates of when the patient was confined to a treatment center.",
"min": 0,
"max": "1",
"type": [
{
"code": "Period"
}
]
},
{
"id": "Claim.item",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Detail"
"valueString": "Item"
}
],
"path": "Claim.item.detail",
"short": "Additional items",
"definition": "Second tier of goods and services.",
"path": "Claim.item",
"short": "Goods and Services",
"definition": "First tier of goods and services.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"isSummary": true
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
]
},
{
"path": "Claim.item.detail.id",
"id": "Claim.item.id",
"path": "Claim.item.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references).",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "id"
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "Claim.item.detail.extension",
"id": "Claim.item.extension",
"path": "Claim.item.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "Claim.item.detail.modifierExtension",
"id": "Claim.item.modifierExtension",
"path": "Claim.item.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"path": "Claim.item.detail.sequence",
"id": "Claim.item.sequence",
"path": "Claim.item.sequence",
"short": "Service instance",
"definition": "A service line number.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "Claim.item.careTeamLinkId",
"path": "Claim.item.careTeamLinkId",
"short": "Applicable careTeam members",
"definition": "CareTeam applicable for this service or product line.",
"min": 0,
"max": "*",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "Claim.item.diagnosisLinkId",
"path": "Claim.item.diagnosisLinkId",
"short": "Applicable diagnoses",
"definition": "Diagnosis applicable for this service or product line.",
"min": 0,
"max": "*",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "Claim.item.procedureLinkId",
"path": "Claim.item.procedureLinkId",
"short": "Applicable procedures",
"definition": "Procedures applicable for this service or product line.",
"min": 0,
"max": "*",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "Claim.item.informationLinkId",
"path": "Claim.item.informationLinkId",
"short": "Applicable exception and supporting information",
"definition": "Exceptions, special conditions and supporting information pplicable for this service or product line.",
"min": 0,
"max": "*",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "Claim.item.revenue",
"path": "Claim.item.revenue",
"short": "Revenue or cost center code",
"definition": "The type of reveneu or cost center providing the product and/or service.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"isSummary": true
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "RevenueCenter"
}
],
"strength": "example",
"description": "Codes for the revenue or cost centers supplying the service and/or products.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-revenue-center"
}
}
},
{
"path": "Claim.item.detail.type",
"short": "Group or type of product or service",
"definition": "The type of product or service.",
"min": 1,
"id": "Claim.item.category",
"path": "Claim.item.category",
"short": "Type of service or product",
"definition": "Health Care Service Type Codes to identify the classification of service or benefits.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"strength": "required",
"description": "Service, Product, Rx Dispense, Rx Compound etc.",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitSubCategory"
}
],
"strength": "example",
"description": "Benefit subcategories such as: oral-basic, major, glasses",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/v3-ActInvoiceGroupCode"
"reference": "http://hl7.org/fhir/ValueSet/benefit-subcategory"
}
}
},
{
"path": "Claim.item.detail.service",
"short": "Additional item codes",
"definition": "If a grouping item then 'GROUP' otherwise it is a node therefore a code to indicate the Professional Service or Product supplied.",
"min": 1,
"id": "Claim.item.service",
"path": "Claim.item.service",
"short": "Billing Code",
"definition": "If this is an actual service or product line, ie. not a Group, then use code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,RXNorm,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
}
],
"strength": "example",
"description": "Allowable service and product codes.",
"description": "Allowable service and product codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
}
},
{
"path": "Claim.item.detail.quantity",
"id": "Claim.item.modifier",
"path": "Claim.item.modifier",
"short": "Service/Product billing modifiers",
"definition": "Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.",
"requirements": "May impact on adjudication.",
"min": 0,
"max": "*",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Modifiers"
}
],
"strength": "example",
"description": "Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-modifiers"
}
}
},
{
"id": "Claim.item.programCode",
"path": "Claim.item.programCode",
"short": "Program specific reason for item inclusion",
"definition": "For programs which require reason codes for the inclusion or covering of this billed item under the program or sub-program.",
"min": 0,
"max": "*",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProgramCode"
}
],
"strength": "example",
"description": "Program specific reason codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-program-code"
}
}
},
{
"id": "Claim.item.serviced[x]",
"path": "Claim.item.serviced[x]",
"short": "Date or dates of Service",
"definition": "The date or dates when the enclosed suite of services were performed or completed.",
"min": 0,
"max": "1",
"type": [
{
"code": "date"
},
{
"code": "Period"
}
],
"mapping": [
{
"identity": "w5",
"map": "when.done"
}
]
},
{
"id": "Claim.item.location[x]",
"path": "Claim.item.location[x]",
"short": "Place of service",
"definition": "Where the service was provided.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
},
{
"code": "Address"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Location"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServicePlace"
}
],
"strength": "example",
"description": "Place of service: pharmacy,school, prison, etc.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-place"
}
},
"mapping": [
{
"identity": "w5",
"map": "where"
}
]
},
{
"id": "Claim.item.quantity",
"path": "Claim.item.quantity",
"short": "Count of Products or Services",
"definition": "The number of repetitions of a service or product.",
"min": 0,
"max": "1",
"type": [
{
"code": "Quantity",
"profile": [
"http://hl7.org/fhir/StructureDefinition/SimpleQuantity"
]
"profile": "http://hl7.org/fhir/StructureDefinition/SimpleQuantity"
}
],
"isSummary": true
]
},
{
"path": "Claim.item.detail.unitPrice",
"id": "Claim.item.unitPrice",
"path": "Claim.item.unitPrice",
"short": "Fee, charge or cost per point",
"definition": "If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "Quantity",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Money"
]
"code": "Money"
}
],
"isSummary": true
]
},
{
"path": "Claim.item.detail.factor",
"id": "Claim.item.factor",
"path": "Claim.item.factor",
"short": "Price scaling factor",
"definition": "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.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "decimal"
}
],
"isSummary": true
]
},
{
"path": "Claim.item.detail.points",
"short": "Difficulty scaling factor",
"definition": "An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each point.",
"id": "Claim.item.net",
"path": "Claim.item.net",
"short": "Total item cost",
"definition": "The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "decimal"
"code": "Money"
}
],
"isSummary": true
]
},
{
"path": "Claim.item.detail.net",
"short": "Total additional item cost",
"definition": "The quantity times the unit price for an additional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.",
"requirements": "If a fee is present the associated product/service code must be present.",
"id": "Claim.item.udi",
"path": "Claim.item.udi",
"short": "Unique Device Identifier",
"definition": "List of Unique Device Identifiers associated with this line item.",
"requirements": "The UDI code and issuer if applicable for the supplied product.",
"min": 0,
"max": "*",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Device"
}
]
},
{
"id": "Claim.item.bodySite",
"path": "Claim.item.bodySite",
"short": "Service Location",
"definition": "Physical service site on the patient (limb, tooth, etc).",
"min": 0,
"max": "1",
"type": [
{
"code": "Quantity",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Money"
]
"code": "CodeableConcept"
}
],
"isSummary": true
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "OralSites"
}
],
"strength": "example",
"description": "The code for the teeth, quadrant, sextant and arch",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/tooth"
}
}
},
{
"path": "Claim.item.detail.udi",
"short": "Unique Device Identifier",
"definition": "List of Unique Device Identifiers associated with this line item.",
"requirements": "The UDI code and issuer if applicable for the supplied product.",
"id": "Claim.item.subSite",
"path": "Claim.item.subSite",
"short": "Service Sub-location",
"definition": "A region or surface of the site, eg. limb region or tooth surface(s).",
"min": 0,
"max": "1",
"max": "*",
"type": [
{
"code": "Coding"
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Surface"
}
],
"strength": "example",
"description": "The FDA, or other, UDI repository.",
"description": "The code for the tooth surface and surface combinations",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/udi"
"reference": "http://hl7.org/fhir/ValueSet/surface"
}
}
},
{
"id": "Claim.item.encounter",
"path": "Claim.item.encounter",
"short": "Encounters related to this billed item",
"definition": "A billed item may include goods or services provided in multiple encounters.",
"min": 0,
"max": "*",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Encounter"
}
],
"mapping": [
{
"identity": "workflow",
"map": "Request.context"
}
]
},
{
"id": "Claim.item.detail",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "SubDetail"
"valueString": "Detail"
}
],
"path": "Claim.item.detail.subDetail",
"path": "Claim.item.detail",
"short": "Additional items",
"definition": "Third tier of goods and services.",
"definition": "Second tier of goods and services.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"isSummary": true
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
]
},
{
"path": "Claim.item.detail.subDetail.id",
"id": "Claim.item.detail.id",
"path": "Claim.item.detail.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references).",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "id"
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "Claim.item.detail.subDetail.extension",
"id": "Claim.item.detail.extension",
"path": "Claim.item.detail.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "Claim.item.detail.subDetail.modifierExtension",
"id": "Claim.item.detail.modifierExtension",
"path": "Claim.item.detail.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"path": "Claim.item.detail.subDetail.sequence",
"id": "Claim.item.detail.sequence",
"path": "Claim.item.detail.sequence",
"short": "Service instance",
"definition": "A service line number.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "Claim.item.detail.revenue",
"path": "Claim.item.detail.revenue",
"short": "Revenue or cost center code",
"definition": "The type of reveneu or cost center providing the product and/or service.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"isSummary": true
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "RevenueCenter"
}
],
"strength": "example",
"description": "Codes for the revenue or cost centers supplying the service and/or products.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-revenue-center"
}
}
},
{
"path": "Claim.item.detail.subDetail.type",
"short": "Type of product or service",
"definition": "The type of product or service.",
"min": 1,
"id": "Claim.item.detail.category",
"path": "Claim.item.detail.category",
"short": "Type of service or product",
"definition": "Health Care Service Type Codes to identify the classification of service or benefits.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"strength": "required",
"description": "Service, Product, Rx Dispense, Rx Compound etc.",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitSubCategory"
}
],
"strength": "example",
"description": "Benefit subcategories such as: oral-basic, major, glasses",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/v3-ActInvoiceGroupCode"
"reference": "http://hl7.org/fhir/ValueSet/benefit-subcategory"
}
}
},
{
"path": "Claim.item.detail.subDetail.service",
"short": "Additional item codes",
"definition": "The fee for an additional service or product or charge.",
"min": 1,
"id": "Claim.item.detail.service",
"path": "Claim.item.detail.service",
"short": "Billing Code",
"definition": "If this is an actual service or product line, ie. not a Group, then use code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
}
],
"strength": "example",
"description": "Allowable service and product codes.",
"description": "Allowable service and product codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
}
},
{
"path": "Claim.item.detail.subDetail.quantity",
"short": "Count of Products or Services",
"definition": "The number of repetitions of a service or product.",
"id": "Claim.item.detail.modifier",
"path": "Claim.item.detail.modifier",
"short": "Service/Product billing modifiers",
"definition": "Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.",
"requirements": "May impact on adjudication.",
"min": 0,
"max": "1",
"max": "*",
"type": [
{
"code": "Quantity",
"profile": [
"http://hl7.org/fhir/StructureDefinition/SimpleQuantity"
]
"code": "CodeableConcept"
}
],
"isSummary": true
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Modifiers"
}
],
"strength": "example",
"description": "Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-modifiers"
}
}
},
{
"path": "Claim.item.detail.subDetail.unitPrice",
"short": "Fee, charge or cost per point",
"definition": "The fee for an additional service or product or charge.",
"requirements": "If a fee is present the associated product/service code must be present.",
"id": "Claim.item.detail.programCode",
"path": "Claim.item.detail.programCode",
"short": "Program specific reason for item inclusion",
"definition": "For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program.",
"min": 0,
"max": "*",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProgramCode"
}
],
"strength": "example",
"description": "Program specific reason codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-program-code"
}
}
},
{
"id": "Claim.item.detail.quantity",
"path": "Claim.item.detail.quantity",
"short": "Count of Products or Services",
"definition": "The number of repetitions of a service or product.",
"min": 0,
"max": "1",
"type": [
{
"code": "Quantity",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Money"
]
"profile": "http://hl7.org/fhir/StructureDefinition/SimpleQuantity"
}
],
"isSummary": true
]
},
{
"path": "Claim.item.detail.subDetail.factor",
"short": "Price scaling factor",
"definition": "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.",
"id": "Claim.item.detail.unitPrice",
"path": "Claim.item.detail.unitPrice",
"short": "Fee, charge or cost per point",
"definition": "If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "decimal"
"code": "Money"
}
],
"isSummary": true
]
},
{
"path": "Claim.item.detail.subDetail.points",
"short": "Difficulty scaling factor",
"definition": "An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each point.",
"id": "Claim.item.detail.factor",
"path": "Claim.item.detail.factor",
"short": "Price scaling factor",
"definition": "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.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "decimal"
}
],
"isSummary": true
]
},
{
"path": "Claim.item.detail.subDetail.net",
"short": "Net additional item cost",
"definition": "The quantity times the unit price for an additional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.",
"id": "Claim.item.detail.net",
"path": "Claim.item.detail.net",
"short": "Total additional item cost",
"definition": "The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "Quantity",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Money"
]
"code": "Money"
}
],
"isSummary": true
]
},
{
"path": "Claim.item.detail.subDetail.udi",
"id": "Claim.item.detail.udi",
"path": "Claim.item.detail.udi",
"short": "Unique Device Identifier",
"definition": "List of Unique Device Identifiers associated with this line item.",
"requirements": "The UDI code and issuer if applicable for the supplied product.",
"min": 0,
"max": "1",
"max": "*",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "The FDA, or other, UDI repository.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/udi"
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Device"
}
}
]
},
{
"id": "Claim.item.detail.subDetail",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Prosthesis"
"valueString": "SubDetail"
}
],
"path": "Claim.item.prosthesis",
"short": "Prosthetic details",
"definition": "The materials and placement date of prior fixed prosthesis.",
"path": "Claim.item.detail.subDetail",
"short": "Additional items",
"definition": "Third tier of goods and services.",
"min": 0,
"max": "1",
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"isSummary": true
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
]
},
{
"path": "Claim.item.prosthesis.id",
"id": "Claim.item.detail.subDetail.id",
"path": "Claim.item.detail.subDetail.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references).",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "id"
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "Claim.item.prosthesis.extension",
"id": "Claim.item.detail.subDetail.extension",
"path": "Claim.item.detail.subDetail.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "Claim.item.prosthesis.modifierExtension",
"id": "Claim.item.detail.subDetail.modifierExtension",
"path": "Claim.item.detail.subDetail.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"path": "Claim.item.prosthesis.initial",
"short": "Is this the initial service",
"definition": "Indicates whether this is the initial placement of a fixed prosthesis.",
"requirements": "May impact on adjudication.",
"min": 0,
"id": "Claim.item.detail.subDetail.sequence",
"path": "Claim.item.detail.subDetail.sequence",
"short": "Service instance",
"definition": "A service line number.",
"min": 1,
"max": "1",
"type": [
{
"code": "boolean"
"code": "positiveInt"
}
],
"isSummary": true
]
},
{
"path": "Claim.item.prosthesis.priorDate",
"short": "Initial service Date",
"definition": "Date of the initial placement.",
"requirements": "May impact on adjudication.",
"id": "Claim.item.detail.subDetail.revenue",
"path": "Claim.item.detail.subDetail.revenue",
"short": "Revenue or cost center code",
"definition": "The type of reveneu or cost center providing the product and/or service.",
"min": 0,
"max": "1",
"type": [
{
"code": "date"
"code": "CodeableConcept"
}
],
"isSummary": true
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "RevenueCenter"
}
],
"strength": "example",
"description": "Codes for the revenue or cost centers supplying the service and/or products.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-revenue-center"
}
}
},
{
"path": "Claim.item.prosthesis.priorMaterial",
"short": "Prosthetic Material",
"definition": "Material of the prior denture or bridge prosthesis. (Oral).",
"requirements": "May impact on adjudication.",
"id": "Claim.item.detail.subDetail.category",
"path": "Claim.item.detail.subDetail.category",
"short": "Type of service or product",
"definition": "Health Care Service Type Codes to identify the classification of service or benefits.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitSubCategory"
}
],
"strength": "example",
"description": "Material of the prior denture or bridge prosthesis. (Oral)",
"description": "Benefit subcategories such as: oral-basic, major, glasses",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/oral-prosthodontic-material"
"reference": "http://hl7.org/fhir/ValueSet/benefit-subcategory"
}
}
},
{
"path": "Claim.additionalMaterials",
"short": "Additional materials, documents, etc.",
"definition": "Code to indicate that Xrays, images, emails, documents, models or attachments are being sent in support of this submission.",
"id": "Claim.item.detail.subDetail.service",
"path": "Claim.item.detail.subDetail.service",
"short": "Billing Code",
"definition": "A code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI).",
"min": 0,
"max": "*",
"max": "1",
"type": [
{
"code": "Coding"
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
}
],
"strength": "example",
"description": "Code to indicate that Xrays, images, emails, documents, models or attachments are being sent in support of this submission.",
"description": "Allowable service and product codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/additionalmaterials"
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
}
},
{
"extension": [
"id": "Claim.item.detail.subDetail.modifier",
"path": "Claim.item.detail.subDetail.modifier",
"short": "Service/Product billing modifiers",
"definition": "Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.",
"requirements": "May impact on adjudication.",
"min": 0,
"max": "*",
"type": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "MissingTeeth"
"code": "CodeableConcept"
}
],
"path": "Claim.missingTeeth",
"short": "Only if type = oral",
"definition": "A list of teeth which would be expected but are not found due to having been previously extracted or for other reasons.",
"requirements": "The list of missing teeth may influence the adjudication of services for example with Bridges.",
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Modifiers"
}
],
"strength": "example",
"description": "Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-modifiers"
}
}
},
{
"id": "Claim.item.detail.subDetail.programCode",
"path": "Claim.item.detail.subDetail.programCode",
"short": "Program specific reason for item inclusion",
"definition": "For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
"code": "CodeableConcept"
}
],
"isSummary": true
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProgramCode"
}
],
"strength": "example",
"description": "Program specific reason codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-program-code"
}
}
},
{
"path": "Claim.missingTeeth.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references).",
"id": "Claim.item.detail.subDetail.quantity",
"path": "Claim.item.detail.subDetail.quantity",
"short": "Count of Products or Services",
"definition": "The number of repetitions of a service or product.",
"min": 0,
"max": "1",
"type": [
{
"code": "id"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
"code": "Quantity",
"profile": "http://hl7.org/fhir/StructureDefinition/SimpleQuantity"
}
]
},
{
"path": "Claim.missingTeeth.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"id": "Claim.item.detail.subDetail.unitPrice",
"path": "Claim.item.detail.subDetail.unitPrice",
"short": "Fee, charge or cost per point",
"definition": "The fee for an addittional service or product or charge.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "*",
"max": "1",
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
"code": "Money"
}
]
},
{
"path": "Claim.missingTeeth.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"id": "Claim.item.detail.subDetail.factor",
"path": "Claim.item.detail.subDetail.factor",
"short": "Price scaling factor",
"definition": "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.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "*",
"max": "1",
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
"code": "decimal"
}
]
},
{
"path": "Claim.missingTeeth.tooth",
"short": "Tooth Code",
"definition": "The code identifying which tooth is missing.",
"requirements": "Provides the tooth number of the missing tooth.",
"min": 1,
"id": "Claim.item.detail.subDetail.net",
"path": "Claim.item.detail.subDetail.net",
"short": "Net additional item cost",
"definition": "The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "The codes for the teeth, subset of OralSites.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/teeth"
"code": "Money"
}
}
]
},
{
"path": "Claim.missingTeeth.reason",
"short": "Reason for missing",
"definition": "Missing reason may be: E-extraction, O-other.",
"requirements": "Provides the reason for the missing tooth.",
"id": "Claim.item.detail.subDetail.udi",
"path": "Claim.item.detail.subDetail.udi",
"short": "Unique Device Identifier",
"definition": "List of Unique Device Identifiers associated with this line item.",
"requirements": "The UDI code and issuer if applicable for the supplied product.",
"min": 0,
"max": "1",
"max": "*",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "Reason codes for the missing teeth.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/missing-tooth-reason"
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Device"
}
}
]
},
{
"path": "Claim.missingTeeth.extractionDate",
"short": "Date of Extraction",
"definition": "The date of the extraction either known from records or patient reported estimate.",
"requirements": "Some services and adjudications require this information.",
"id": "Claim.total",
"path": "Claim.total",
"short": "Total claim cost",
"definition": "The total value of the claim.",
"min": 0,
"max": "1",
"type": [
{
"code": "date"
"code": "Money"
}
],
"isSummary": true
]
}
]
},
"differential": {
"element": [
{
"id": "Claim",
"path": "Claim",
"short": "Claim, Pre-determination or Pre-authorization",
"definition": "A provider issued list of services and products provided, or to be provided, to a patient which is provided to an insurer for payment recovery.",
"min": 0,
"max": "*",
"mapping": [
{
"identity": "workflow",
"map": "Request"
},
{
"identity": "w5",
"map": "financial.billing"
}
]
},
{
"id": "Claim.identifier",
"path": "Claim.identifier",
"short": "Claim number",
"definition": "The business identifier for the instance: claim number, pre-determination or pre-authorization number.",
"min": 0,
"max": "*",
"type": [
{
"code": "DomainResource"
"code": "Identifier"
}
],
"isSummary": true,
"mapping": [
{
"identity": "workflow",
"map": "Request.identifier"
},
{
"identity": "w5",
"map": "financial.billing"
"map": "id"
}
]
},
{
"path": "Claim.type",
"short": "institutional | oral | pharmacy | professional | vision",
"definition": "The category of claim this is.",
"comments": "Affects which fields and value sets are used.",
"min": 1,
"id": "Claim.status",
"path": "Claim.status",
"short": "active | cancelled | draft | entered-in-error",
"definition": "The status of the resource instance.",
"comment": "This element is labeled as a modifier because the status contains the code entered-in-error that marks the claim as not currently valid.",
"min": 0,
"max": "1",
"type": [
{
"code": "code"
}
],
"isModifier": true,
"isSummary": true,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ClaimStatus"
}
],
"strength": "required",
"description": "The type or discipline-style of the claim.",
"description": "A code specifying the state of the resource instance.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-type-link"
"reference": "http://hl7.org/fhir/ValueSet/fm-status"
}
}
},
"mapping": [
{
"identity": "workflow",
"map": "Request.status"
},
{
"identity": "w5",
"map": "status"
}
]
},
{
"path": "Claim.identifier",
"short": "Claim number",
"definition": "The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization number.",
"id": "Claim.type",
"path": "Claim.type",
"short": "Type or discipline",
"definition": "The category of claim, eg, oral, pharmacy, vision, insitutional, professional.",
"comment": "Affects which fields and value sets are used.",
"min": 0,
"max": "*",
"max": "1",
"type": [
{
"code": "Identifier"
"code": "CodeableConcept"
}
],
"isSummary": true
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ClaimType"
}
],
"strength": "required",
"description": "The type or discipline-style of the claim",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-type"
}
},
"mapping": [
{
"identity": "w5",
"map": "class"
}
]
},
{
"path": "Claim.ruleset",
"short": "Current specification followed",
"definition": "The version of the specification on which this instance relies.",
"alias": [
"BusinessVersion"
],
"id": "Claim.subType",
"path": "Claim.subType",
"short": "Finer grained claim type information",
"definition": "A finer grained suite of claim subtype codes which may convey Inpatient vs Outpatient and/or a specialty service. In the US the BillType.",
"comment": "This may contain the local bill type codes such as the US UB-04 bill type code.",
"min": 0,
"max": "1",
"max": "*",
"type": [
{
"code": "Coding"
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ClaimSubType"
}
],
"strength": "example",
"description": "The static and dynamic model to which contents conform, which may be business version or standard/version.",
"description": "A more granular claim typecode",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ruleset"
"reference": "http://hl7.org/fhir/ValueSet/claim-subtype"
}
}
},
"mapping": [
{
"identity": "w5",
"map": "class"
}
]
},
{
"path": "Claim.originalRuleset",
"short": "Original specification followed",
"definition": "The version of the specification from which the original instance was created.",
"alias": [
"OriginalBusinessVersion"
],
"id": "Claim.use",
"path": "Claim.use",
"short": "complete | proposed | exploratory | other",
"definition": "Complete (Bill or Claim), Proposed (Pre-Authorization), Exploratory (Pre-determination).",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
"code": "code"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "The static and dynamic model to which contents conform, which may be business version or standard/version.",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Use"
}
],
"strength": "required",
"description": "Complete, proposed, exploratory, other",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ruleset"
"reference": "http://hl7.org/fhir/ValueSet/claim-use"
}
}
},
"mapping": [
{
"identity": "w5",
"map": "class"
}
]
},
{
"id": "Claim.patient",
"path": "Claim.patient",
"short": "The subject of the Products and Services",
"definition": "Patient Resource.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Patient"
}
],
"mapping": [
{
"identity": "workflow",
"map": "Request.subject"
},
{
"identity": "w5",
"map": "who.focus"
}
]
},
{
"id": "Claim.billablePeriod",
"path": "Claim.billablePeriod",
"short": "Period for charge submission",
"definition": "The billable period for which charges are being submitted.",
"min": 0,
"max": "1",
"type": [
{
"code": "Period"
}
],
"mapping": [
{
"identity": "w5",
"map": "when.done"
}
]
},
{
"id": "Claim.created",
"path": "Claim.created",
"short": "Creation date",
"definition": "The date when the enclosed suite of services were performed or completed.",
"min": 0,
"max": "1",
"type": [
{
"code": "dateTime"
}
],
"isSummary": true
"mapping": [
{
"identity": "workflow",
"map": "Request.authoredOn"
},
{
"identity": "w5",
"map": "when.recorded"
}
]
},
{
"path": "Claim.target",
"short": "Insurer",
"definition": "Insurer Identifier, typical BIN number (6 digit).",
"id": "Claim.enterer",
"path": "Claim.enterer",
"short": "Author",
"definition": "Person who created the invoice/claim/pre-determination or pre-authorization.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Organization"
]
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Practitioner"
}
],
"isSummary": true
"mapping": [
{
"identity": "w5",
"map": "who.author"
}
]
},
{
"path": "Claim.provider",
"short": "Responsible provider",
"definition": "The provider which is responsible for the bill, claim pre-determination, pre-authorization.",
"id": "Claim.insurer",
"path": "Claim.insurer",
"short": "Target",
"definition": "The Insurer who is target of the request.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Practitioner"
]
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization"
}
],
"isSummary": true
"mapping": [
{
"identity": "workflow",
"map": "Request.performer"
}
]
},
{
"path": "Claim.organization",
"short": "Responsible organization",
"definition": "The organization which is responsible for the bill, claim pre-determination, pre-authorization.",
"id": "Claim.provider",
"path": "Claim.provider",
"short": "Responsible provider",
"definition": "The provider which is responsible for the bill, claim pre-determination, pre-authorization.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Organization"
]
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Practitioner"
}
],
"isSummary": true
"mapping": [
{
"identity": "workflow",
"map": "Request.requester.agent"
},
{
"identity": "w5",
"map": "who.source"
}
]
},
{
"path": "Claim.use",
"short": "complete | proposed | exploratory | other",
"definition": "Complete (Bill or Claim), Proposed (Pre-Authorization), Exploratory (Pre-determination).",
"id": "Claim.organization",
"path": "Claim.organization",
"short": "Responsible organization",
"definition": "The organization which is responsible for the bill, claim pre-determination, pre-authorization.",
"min": 0,
"max": "1",
"type": [
{
"code": "code"
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization"
}
],
"isSummary": true,
"binding": {
"strength": "required",
"description": "Complete, proposed, exploratory, other.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-use-link"
"mapping": [
{
"identity": "workflow",
"map": "Request.requester.onBehalfOf"
},
{
"identity": "w5",
"map": "who.source"
}
}
]
},
{
"id": "Claim.priority",
"path": "Claim.priority",
"short": "Desired processing priority",
"definition": "Immediate (stat), best effort (normal), deferred (deferred).",
"definition": "Immediate (STAT), best effort (NORMAL), deferred (DEFER).",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProcessPriority"
}
],
"strength": "example",
"description": "The timeliness with which processing is required: STAT, Normal, Deferred.",
"description": "The timeliness with which processing is required: STAT, normal, Deferred",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/process-priority"
}
}
},
"mapping": [
{
"identity": "workflow",
"map": "Request.priority"
}
]
},
{
"id": "Claim.fundsReserve",
"path": "Claim.fundsReserve",
"short": "Funds requested to be reserved",
"definition": "In the case of a Pre-Determination/Pre-Authorization the provider may request that funds in the amount of the expected Benefit be reserved ('Patient' or 'Provider') to pay for the Benefits determined on the subsequent claim(s). 'None' explicitly indicates no funds reserving is requested.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "FundsReserve"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
}
],
"strength": "example",
"description": "For whom funds are to be reserved: (Patient, Provider, None).",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/fundsreserve"
}
}
},
{
"path": "Claim.enterer",
"short": "Author",
"definition": "Person who created the invoice/claim/pre-determination or pre-authorization.",
"id": "Claim.related",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "RelatedClaim"
}
],
"path": "Claim.related",
"short": "Related Claims which may be revelant to processing this claimn",
"definition": "Other claims which are related to this claim such as prior claim versions or for related services.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "Claim.related.claim",
"path": "Claim.related.claim",
"short": "Reference to the related claim",
"definition": "Other claims which are related to this claim such as prior claim versions or for related services.",
"comment": "Do we need a relationship code?",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Practitioner"
]
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Claim"
}
],
"isSummary": true
"mapping": [
{
"identity": "workflow",
"map": "Request.replaces"
}
]
},
{
"path": "Claim.facility",
"short": "Servicing Facility",
"definition": "Facility where the services were provided.",
"id": "Claim.related.relationship",
"path": "Claim.related.relationship",
"short": "How the reference claim is related",
"definition": "For example prior or umbrella.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Location"
]
"code": "CodeableConcept"
}
],
"isSummary": true
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "RelatedClaimRelationship"
}
],
"strength": "example",
"description": "Relationship of this claim to a related Claim",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/related-claim-relationship"
}
}
},
{
"id": "Claim.related.reference",
"path": "Claim.related.reference",
"short": "Related file or case reference",
"definition": "An alternate organizational reference to the case or file to which this particular claim pertains - eg Property/Casualy insurer claim # or Workers Compensation case # .",
"min": 0,
"max": "1",
"type": [
{
"code": "Identifier"
}
]
},
{
"id": "Claim.prescription",
"path": "Claim.prescription",
"short": "Prescription",
"short": "Prescription authorizing services or products",
"definition": "Prescription to support the dispensing of Pharmacy or Vision products.",
"comment": "Should we create a group to hold multiple prescriptions and add a sequence number and on the line items a link to the sequence.",
"requirements": "For type=Pharmacy and Vision only.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/MedicationOrder"
]
"targetProfile": "http://hl7.org/fhir/StructureDefinition/MedicationRequest"
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/VisionPrescription"
]
"targetProfile": "http://hl7.org/fhir/StructureDefinition/VisionPrescription"
}
],
"isSummary": true
]
},
{
"id": "Claim.originalPrescription",
"path": "Claim.originalPrescription",
"short": "Original Prescription",
"definition": "Original prescription to support the dispensing of pharmacy services, medications or products.",
"short": "Original prescription if superceded by fulfiller",
"definition": "Original prescription which has been superceded by this prescription to support the dispensing of pharmacy services, medications or products. For example, a physician may prescribe a medication which the pharmacy determines is contraindicated, or for which the patient has an intolerance, and therefor issues a new precription for an alternate medication which has the same theraputic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription'.",
"comment": "as above.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/MedicationOrder"
]
"targetProfile": "http://hl7.org/fhir/StructureDefinition/MedicationRequest"
}
],
"isSummary": true
]
},
{
"id": "Claim.payee",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Payee"
}
],
"path": "Claim.payee",
"short": "Payee",
"short": "Party to be paid any benefits payable",
"definition": "The party to be reimbursed for the services.",
"min": 0,
"max": "1",
"type": [
{
"code": "BackboneElement"
}
],
"isSummary": true
]
},
{
"id": "Claim.payee.type",
"path": "Claim.payee.type",
"short": "Party to be paid any benefits payable",
"definition": "Party to be reimbursed: Subscriber, provider, other.",
"min": 0,
"short": "Type of party: Subscriber, Provider, other",
"definition": "Type of Party to be reimbursed: Subscriber, provider, other.",
"min": 1,
"max": "1",
"type": [
{
"code": "Coding"
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "PayeeType"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
}
],
"strength": "example",
"description": "A code for the party to be reimbursed.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/payeetype"
}
}
},
{
"path": "Claim.payee.provider",
"short": "Provider who is the payee",
"definition": "The provider who is to be reimbursed for the claim (the party to whom any benefit is assigned).",
"id": "Claim.payee.resourceType",
"path": "Claim.payee.resourceType",
"short": "organization | patient | practitioner | relatedperson",
"definition": "organization | patient | practitioner | relatedperson.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Practitioner"
]
"code": "Coding"
}
],
"isSummary": true
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ClaimPayeeResourceType"
}
],
"strength": "example",
"description": "The type of Claim payee Resource",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-payee-resource-type"
}
}
},
{
"path": "Claim.payee.organization",
"short": "Organization who is the payee",
"definition": "The organization who is to be reimbursed for the claim (the party to whom any benefit is assigned).",
"id": "Claim.payee.party",
"path": "Claim.payee.party",
"short": "Party to receive the payable",
"definition": "Party to be reimbursed: Subscriber, provider, other.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Organization"
]
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Practitioner"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Patient"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/RelatedPerson"
}
],
"isSummary": true
]
},
{
"path": "Claim.payee.person",
"short": "Other person who is the payee",
"definition": "The person other than the subscriber who is to be reimbursed for the claim (the party to whom any benefit is assigned).",
"id": "Claim.referral",
"path": "Claim.referral",
"short": "Treatment Referral",
"definition": "The referral resource which lists the date, practitioner, reason and other supporting information.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Patient"
]
"targetProfile": "http://hl7.org/fhir/StructureDefinition/ReferralRequest"
}
],
"isSummary": true
"mapping": [
{
"identity": "w5",
"map": "who.cause"
}
]
},
{
"path": "Claim.referral",
"short": "Treatment Referral",
"definition": "The referral resource which lists the date, practitioner, reason and other supporting information.",
"id": "Claim.facility",
"path": "Claim.facility",
"short": "Servicing Facility",
"definition": "Facility where the services were provided.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/ReferralRequest"
]
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Location"
}
],
"isSummary": true
"mapping": [
{
"identity": "w5",
"map": "where"
}
]
},
{
"id": "Claim.careTeam",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Diagnosis"
"valueString": "CareTeam"
}
],
"path": "Claim.diagnosis",
"short": "Diagnosis",
"definition": "Ordered list of patient diagnosis for which care is sought.",
"path": "Claim.careTeam",
"short": "Members of the care team",
"definition": "The members of the team who provided the overall service as well as their role and whether responsible and qualifications.",
"requirements": "Role and Responsible may not be required when there is only a single provider listed.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"isSummary": true
]
},
{
"path": "Claim.diagnosis.sequence",
"short": "Sequence of diagnosis",
"definition": "Sequence of diagnosis which serves to order and provide a link.",
"requirements": "Required to maintain order of the diagnoses.",
"id": "Claim.careTeam.sequence",
"path": "Claim.careTeam.sequence",
"short": "Number to covey order of careTeam",
"definition": "Sequence of the careTeam which serves to order and provide a link.",
"requirements": "Required to maintain order of the careTeam.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
],
"isSummary": true
]
},
{
"path": "Claim.diagnosis.diagnosis",
"short": "Patient's list of diagnosis",
"definition": "The diagnosis.",
"requirements": "Required to adjudicate services rendered to condition presented.",
"id": "Claim.careTeam.provider",
"path": "Claim.careTeam.provider",
"short": "Provider individual or organization",
"definition": "Member of the team who provided the overall service.",
"min": 1,
"max": "1",
"type": [
{
"code": "Coding"
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Practitioner"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "ICD10 diagnostic codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/icd-10"
"mapping": [
{
"identity": "w5",
"map": "who.actor"
}
}
]
},
{
"path": "Claim.condition",
"short": "List of presenting Conditions",
"definition": "List of patient conditions for which care is sought.",
"id": "Claim.careTeam.responsible",
"path": "Claim.careTeam.responsible",
"short": "Billing provider",
"definition": "The party who is billing and responsible for the claimed good or service rendered to the patient.",
"min": 0,
"max": "*",
"max": "1",
"type": [
{
"code": "Coding"
"code": "boolean"
}
]
},
{
"id": "Claim.careTeam.role",
"path": "Claim.careTeam.role",
"short": "Role on the team",
"definition": "The lead, assisting or supervising practitioner and their discipline if a multidisiplinary team.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CareTeamRole"
}
],
"strength": "example",
"description": "Patient conditions and symptoms.",
"description": "The role codes for the care team members.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/fm-conditions"
"reference": "http://hl7.org/fhir/ValueSet/claim-careteamrole"
}
}
},
{
"path": "Claim.patient",
"short": "The subject of the Products and Services",
"definition": "Patient Resource.",
"min": 1,
"id": "Claim.careTeam.qualification",
"path": "Claim.careTeam.qualification",
"short": "Type, classification or Specialization",
"definition": "The qualification which is applicable for this service.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Patient"
]
"code": "CodeableConcept"
}
],
"isSummary": true
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProviderQualification"
}
],
"strength": "example",
"description": "Provider professional qualifications",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/provider-qualification"
}
}
},
{
"id": "Claim.information",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Coverage"
"valueString": "SpecialCondition"
}
],
"path": "Claim.coverage",
"short": "Insurance or medical plan",
"definition": "Financial instrument by which payment information for health care.",
"requirements": "Health care programs and insurers are significant payors of health service costs.",
"path": "Claim.information",
"short": "Exceptions, special considerations, the condition, situation, prior or concurrent issues",
"definition": "Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. Often there are mutiple jurisdiction specific valuesets which are required.",
"requirements": "Typically these information codes are required to support the services rendered or the adjudication of the services rendered.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "Coverage"
"identity": "workflow",
"map": "Request.supportingInfo"
}
]
},
{
"path": "Claim.coverage.sequence",
"short": "Service instance identifier",
"definition": "A service line item.",
"requirements": "To maintain order of the coverages.",
"id": "Claim.information.sequence",
"path": "Claim.information.sequence",
"short": "Information instance identifier",
"definition": "Sequence of the information element which serves to provide a link.",
"requirements": "To provide a reference link.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
],
"isSummary": true
]
},
{
"path": "Claim.coverage.focal",
"short": "The focal Coverage",
"definition": "The instance number of the Coverage which is the focus for adjudication. The Coverage against which the claim is to be adjudicated.",
"requirements": "To identify which coverage is being adjudicated.",
"id": "Claim.information.category",
"path": "Claim.information.category",
"short": "General class of information",
"definition": "The general class of the information supplied: information; exception; accident, employment; onset, etc.",
"comment": "This may contain the local bill type codes such as the US UB-04 bill type code.",
"min": 1,
"max": "1",
"type": [
{
"code": "boolean"
"code": "CodeableConcept"
}
],
"isSummary": true
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "InformationCategory"
}
],
"strength": "example",
"description": "The valuset used for additional information category codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-informationcategory"
}
}
},
{
"path": "Claim.coverage.coverage",
"short": "Insurance information",
"definition": "Reference to the program or plan identification, underwriter or payor.",
"requirements": "Need to identify the issuer to target for processing and for coordination of benefit processing.",
"min": 1,
"id": "Claim.information.code",
"path": "Claim.information.code",
"short": "Type of information",
"definition": "System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought which may influence the adjudication.",
"comment": "This may contain the local bill type codes such as the US UB-04 bill type code.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Coverage"
]
"code": "CodeableConcept"
}
],
"isSummary": true
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "InformationCode"
}
],
"strength": "example",
"description": "The valuset used for additional information codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-exception"
}
}
},
{
"path": "Claim.coverage.businessArrangement",
"short": "Business agreement",
"definition": "The contract number of a business agreement which describes the terms and conditions.",
"id": "Claim.information.timing[x]",
"path": "Claim.information.timing[x]",
"short": "When it occurred",
"definition": "The date when or period to which this information refers.",
"min": 0,
"max": "1",
"type": [
{
"code": "date"
},
{
"code": "Period"
}
]
},
{
"id": "Claim.information.value[x]",
"path": "Claim.information.value[x]",
"short": "Additional Data or supporting information",
"definition": "Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
},
{
"code": "Quantity"
},
{
"code": "Attachment"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Resource"
}
],
"isSummary": true
]
},
{
"path": "Claim.coverage.relationship",
"short": "Patient relationship to subscriber",
"definition": "The relationship of the patient to the subscriber.",
"requirements": "To determine the relationship between the patient and the subscriber.",
"min": 1,
"id": "Claim.information.reason",
"path": "Claim.information.reason",
"short": "Reason associated with the information",
"definition": "For example, provides the reason for: the additional stay, or missing tooth or any other situation where a reason code is required in addition to the content.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "MissingReason"
}
],
"strength": "example",
"description": "The code for the relationship of the patient to the subscriber.",
"description": "Reason codes for the missing teeth",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/relationship"
"reference": "http://hl7.org/fhir/ValueSet/missing-tooth-reason"
}
}
},
{
"path": "Claim.coverage.preAuthRef",
"short": "Pre-Authorization/Determination Reference",
"definition": "A list of references from the Insurer to which these services pertain.",
"requirements": "To provide any pre=determination or prior authorization reference.",
"id": "Claim.diagnosis",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Diagnosis"
}
],
"path": "Claim.diagnosis",
"short": "List of Diagnosis",
"definition": "List of patient diagnosis for which care is sought.",
"min": 0,
"max": "*",
"type": [
{
"code": "string"
"code": "BackboneElement"
}
],
"isSummary": true
"mapping": [
{
"identity": "workflow",
"map": "Request.reasonReference"
}
]
},
{
"path": "Claim.coverage.claimResponse",
"short": "Adjudication results",
"definition": "The Coverages adjudication details.",
"requirements": "Used by downstream payers to determine what balance remains and the net payable.",
"min": 0,
"id": "Claim.diagnosis.sequence",
"path": "Claim.diagnosis.sequence",
"short": "Number to covey order of diagnosis",
"definition": "Sequence of diagnosis which serves to provide a link.",
"requirements": "Required to allow line items to reference the diagnoses.",
"min": 1,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/ClaimResponse"
]
"code": "positiveInt"
}
],
"isSummary": true
]
},
{
"path": "Claim.coverage.originalRuleset",
"short": "Original version",
"definition": "The style (standard) and version of the original material which was converted into this resource.",
"requirements": "Knowledge of the original version can inform the processing of this instance so that information which is processable by the originating system may be generated.",
"min": 0,
"id": "Claim.diagnosis.diagnosis[x]",
"path": "Claim.diagnosis.diagnosis[x]",
"short": "Patient's diagnosis",
"definition": "The diagnosis.",
"requirements": "Required to adjudicate services rendered to condition presented.",
"min": 1,
"max": "1",
"type": [
{
"code": "Coding"
"code": "CodeableConcept"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Condition"
}
],
"isSummary": true,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ICD10"
}
],
"strength": "example",
"description": "The static and dynamic model to which contents conform, which may be business version or standard/version.",
"description": "ICD10 Diagnostic codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ruleset"
"reference": "http://hl7.org/fhir/ValueSet/icd-10"
}
}
},
{
"path": "Claim.exception",
"short": "Eligibility exceptions",
"definition": "Factors which may influence the applicability of coverage.",
"requirements": "To determine extenuating circumstances for coverage.",
"id": "Claim.diagnosis.type",
"path": "Claim.diagnosis.type",
"short": "Timing or nature of the diagnosis",
"definition": "The type of the Diagnosis, for example: admitting, primary, secondary, discharge.",
"comment": "Diagnosis are presented in list order to their expected importance: primary, secondary, etc.",
"requirements": "May be required to adjudicate services rendered.",
"min": 0,
"max": "*",
"type": [
{
"code": "Coding"
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "DiagnosisType"
}
],
"strength": "example",
"description": "The eligibility exception codes.",
"description": "The type of the diagnosis: admitting, principal, discharge",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-exception"
"reference": "http://hl7.org/fhir/ValueSet/ex-diagnosistype"
}
}
},
{
"path": "Claim.school",
"short": "Name of School",
"definition": "Name of school for over-aged dependents.",
"requirements": "Often required for over-age dependents.",
"id": "Claim.diagnosis.packageCode",
"path": "Claim.diagnosis.packageCode",
"short": "Package billing code",
"definition": "The package billing code, for example DRG, based on the assigned grouping code system.",
"requirements": "May be required to adjudicate services rendered to the mandated grouping system.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
"code": "CodeableConcept"
}
],
"isSummary": true
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "DiagnosisRelatedGroup"
}
],
"strength": "example",
"description": "The DRG codes associated with the diagnosis",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup"
}
}
},
{
"path": "Claim.accident",
"short": "Accident Date",
"definition": "Date of an accident which these services are addressing.",
"requirements": "Coverage may be dependent on accidents.",
"id": "Claim.procedure",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Procedure"
}
],
"path": "Claim.procedure",
"short": "Procedures performed",
"definition": "Ordered list of patient procedures performed to support the adjudication.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "Claim.procedure.sequence",
"path": "Claim.procedure.sequence",
"short": "Procedure sequence for reference",
"definition": "Sequence of procedures which serves to order and provide a link.",
"requirements": "Required to maintain order of the procudures.",
"min": 1,
"max": "1",
"type": [
{
"code": "date"
"code": "positiveInt"
}
],
"isSummary": true
]
},
{
"path": "Claim.accidentType",
"short": "Accident Type",
"definition": "Type of accident: work, auto, etc.",
"requirements": "Coverage may be dependent on the type of accident.",
"id": "Claim.procedure.date",
"path": "Claim.procedure.date",
"short": "When the procedure was performed",
"definition": "Date and optionally time the procedure was performed .",
"comment": "SB DateTime??",
"requirements": "Required to adjudicate services rendered.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "required",
"description": "Type of accident: work place, auto, etc.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/v3-ActIncidentCode"
"code": "dateTime"
}
}
]
},
{
"path": "Claim.interventionException",
"short": "Intervention and exception code (Pharma)",
"definition": "A list of intervention and exception codes which may influence the adjudication of the claim.",
"requirements": "Coverage may be modified based on exception information provided.",
"min": 0,
"max": "*",
"id": "Claim.procedure.procedure[x]",
"path": "Claim.procedure.procedure[x]",
"short": "Patient's list of procedures performed",
"definition": "The procedure code.",
"requirements": "Required to adjudicate services rendered.",
"min": 1,
"max": "1",
"type": [
{
"code": "Coding"
"code": "CodeableConcept"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Procedure"
}
],
"isSummary": true,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ICD10_Procedures"
}
],
"strength": "example",
"description": "Intervention and exception codes (Pharm).",
"description": "ICD10 Procedure codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/intervention"
"reference": "http://hl7.org/fhir/ValueSet/icd-10-procedures"
}
}
},
{
"id": "Claim.insurance",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Items"
"valueString": "Insurance"
}
],
"path": "Claim.item",
"short": "Goods and Services",
"definition": "First tier of goods and services.",
"path": "Claim.insurance",
"short": "Insurance or medical plan",
"definition": "Financial instrument by which payment information for health care.",
"requirements": "Health care programs and insurers are significant payors of health service costs.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"isSummary": true
"mapping": [
{
"identity": "rim",
"map": "Coverage"
}
]
},
{
"path": "Claim.item.sequence",
"short": "Service instance",
"definition": "A service line number.",
"id": "Claim.insurance.sequence",
"path": "Claim.insurance.sequence",
"short": "Service instance identifier",
"definition": "Sequence of coverage which serves to provide a link and convey coordination of benefit order.",
"requirements": "To maintain order of the coverages.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
],
"isSummary": true
]
},
{
"path": "Claim.item.type",
"short": "Group or type of product or service",
"definition": "The type of product or service.",
"id": "Claim.insurance.focal",
"path": "Claim.insurance.focal",
"short": "Is the focal Coverage",
"definition": "A flag to indicate that this Coverage is the focus for adjudication. The Coverage against which the claim is to be adjudicated.",
"requirements": "To identify which coverage is being adjudicated.",
"min": 1,
"max": "1",
"type": [
{
"code": "Coding"
"code": "boolean"
}
],
"isSummary": true,
"binding": {
"strength": "required",
"description": "Service, Product, Rx Dispense, Rx Compound etc.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/v3-ActInvoiceGroupCode"
]
},
{
"id": "Claim.insurance.coverage",
"path": "Claim.insurance.coverage",
"short": "Insurance information",
"definition": "Reference to the program or plan identification, underwriter or payor.",
"requirements": "Need to identify the issuer to target for processing and for coordination of benefit processing.",
"min": 1,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Coverage"
}
}
]
},
{
"path": "Claim.item.provider",
"short": "Responsible practitioner",
"definition": "The practitioner who is responsible for the services rendered to the patient.",
"id": "Claim.insurance.businessArrangement",
"path": "Claim.insurance.businessArrangement",
"short": "Business agreement",
"definition": "The contract number of a business agreement which describes the terms and conditions.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Practitioner"
]
"code": "string"
}
],
"isSummary": true
]
},
{
"path": "Claim.item.diagnosisLinkId",
"short": "Diagnosis Link",
"definition": "Diagnosis applicable for this service or product line.",
"id": "Claim.insurance.preAuthRef",
"path": "Claim.insurance.preAuthRef",
"short": "Pre-Authorization/Determination Reference",
"definition": "A list of references from the Insurer to which these services pertain.",
"requirements": "To provide any pre=determination or prior authorization reference.",
"min": 0,
"max": "*",
"type": [
{
"code": "positiveInt"
"code": "string"
}
]
},
{
"id": "Claim.insurance.claimResponse",
"path": "Claim.insurance.claimResponse",
"short": "Adjudication results",
"definition": "The Coverages adjudication details.",
"requirements": "Used by downstream payers to determine what balance remains and the net payable.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/ClaimResponse"
}
]
},
{
"id": "Claim.accident",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Accident"
}
],
"isSummary": true
"path": "Claim.accident",
"short": "Details about an accident",
"definition": "An accident which resulted in the need for healthcare services.",
"min": 0,
"max": "1",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"path": "Claim.item.service",
"short": "Item Code",
"definition": "If a grouping item then 'GROUP' otherwise it is a node therefore a code to indicate the Professional Service or Product supplied.",
"id": "Claim.accident.date",
"path": "Claim.accident.date",
"short": "When the accident occurred\nsee information codes\nsee information codes",
"definition": "Date of an accident which these services are addressing.",
"requirements": "Coverage may be dependant on accidents.",
"min": 1,
"max": "1",
"type": [
{
"code": "Coding"
"code": "date"
}
]
},
{
"id": "Claim.accident.type",
"path": "Claim.accident.type",
"short": "The nature of the accident",
"definition": "Type of accident: work, auto, etc.",
"requirements": "Coverage may be dependant on the type of accident.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "Allowable service and product codes.",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "AccidentType"
}
],
"strength": "required",
"description": "Type of accident: work place, auto, etc.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
"reference": "http://hl7.org/fhir/ValueSet/v3-ActIncidentCode"
}
}
},
{
"path": "Claim.item.serviceDate",
"short": "Date of Service",
"definition": "The date when the enclosed suite of services were performed or completed.",
"id": "Claim.accident.location[x]",
"path": "Claim.accident.location[x]",
"short": "Accident Place",
"definition": "Accident Place.",
"min": 0,
"max": "1",
"type": [
{
"code": "date"
"code": "Address"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Location"
}
],
"isSummary": true
]
},
{
"path": "Claim.item.quantity",
"short": "Count of Products or Services",
"definition": "The number of repetitions of a service or product.",
"id": "Claim.employmentImpacted",
"path": "Claim.employmentImpacted",
"short": "Period unable to work",
"definition": "The start and optional end dates of when the patient was precluded from working due to the treatable condition(s).",
"min": 0,
"max": "1",
"type": [
{
"code": "Quantity",
"profile": [
"http://hl7.org/fhir/StructureDefinition/SimpleQuantity"
]
"code": "Period"
}
],
"isSummary": true
]
},
{
"path": "Claim.item.unitPrice",
"short": "Fee, charge or cost per point",
"definition": "If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group.",
"id": "Claim.hospitalization",
"path": "Claim.hospitalization",
"short": "Period in hospital",
"definition": "The start and optional end dates of when the patient was confined to a treatment center.",
"min": 0,
"max": "1",
"type": [
{
"code": "Quantity",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Money"
]
"code": "Period"
}
],
"isSummary": true
]
},
{
"path": "Claim.item.factor",
"short": "Price scaling factor",
"definition": "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.",
"requirements": "If a fee is present the associated product/service code must be present.",
"id": "Claim.item",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Item"
}
],
"path": "Claim.item",
"short": "Goods and Services",
"definition": "First tier of goods and services.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "Claim.item.sequence",
"path": "Claim.item.sequence",
"short": "Service instance",
"definition": "A service line number.",
"min": 1,
"max": "1",
"type": [
{
"code": "decimal"
"code": "positiveInt"
}
],
"isSummary": true
]
},
{
"path": "Claim.item.points",
"short": "Difficulty scaling factor",
"definition": "An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each point.",
"requirements": "If a fee is present the associated product/service code must be present.",
"id": "Claim.item.careTeamLinkId",
"path": "Claim.item.careTeamLinkId",
"short": "Applicable careTeam members",
"definition": "CareTeam applicable for this service or product line.",
"min": 0,
"max": "1",
"max": "*",
"type": [
{
"code": "decimal"
"code": "positiveInt"
}
],
"isSummary": true
]
},
{
"path": "Claim.item.net",
"short": "Total item cost",
"definition": "The quantity times the unit price for an additional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.",
"requirements": "If a fee is present the associated product/service code must be present.",
"id": "Claim.item.diagnosisLinkId",
"path": "Claim.item.diagnosisLinkId",
"short": "Applicable diagnoses",
"definition": "Diagnosis applicable for this service or product line.",
"min": 0,
"max": "1",
"max": "*",
"type": [
{
"code": "Quantity",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Money"
]
"code": "positiveInt"
}
],
"isSummary": true
]
},
{
"path": "Claim.item.udi",
"short": "Unique Device Identifier",
"definition": "List of Unique Device Identifiers associated with this line item.",
"requirements": "The UDI code and issuer if applicable for the supplied product.",
"id": "Claim.item.procedureLinkId",
"path": "Claim.item.procedureLinkId",
"short": "Applicable procedures",
"definition": "Procedures applicable for this service or product line.",
"min": 0,
"max": "*",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "Claim.item.informationLinkId",
"path": "Claim.item.informationLinkId",
"short": "Applicable exception and supporting information",
"definition": "Exceptions, special conditions and supporting information pplicable for this service or product line.",
"min": 0,
"max": "*",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "Claim.item.revenue",
"path": "Claim.item.revenue",
"short": "Revenue or cost center code",
"definition": "The type of reveneu or cost center providing the product and/or service.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "RevenueCenter"
}
],
"strength": "example",
"description": "The FDA, or other, UDI repository.",
"description": "Codes for the revenue or cost centers supplying the service and/or products.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/udi"
"reference": "http://hl7.org/fhir/ValueSet/ex-revenue-center"
}
}
},
{
"path": "Claim.item.bodySite",
"short": "Service Location",
"definition": "Physical service site on the patient (limb, tooth, etc.).",
"id": "Claim.item.category",
"path": "Claim.item.category",
"short": "Type of service or product",
"definition": "Health Care Service Type Codes to identify the classification of service or benefits.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitSubCategory"
}
],
"strength": "example",
"description": "The code for the teeth, quadrant, sextant and arch.",
"description": "Benefit subcategories such as: oral-basic, major, glasses",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/tooth"
"reference": "http://hl7.org/fhir/ValueSet/benefit-subcategory"
}
}
},
{
"path": "Claim.item.subSite",
"short": "Service Sub-location",
"definition": "A region or surface of the site, e.g. limb region or tooth surface(s).",
"id": "Claim.item.service",
"path": "Claim.item.service",
"short": "Billing Code",
"definition": "If this is an actual service or product line, ie. not a Group, then use code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,RXNorm,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'.",
"min": 0,
"max": "*",
"max": "1",
"type": [
{
"code": "Coding"
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
}
],
"strength": "example",
"description": "The code for the tooth surface and surface combinations.",
"description": "Allowable service and product codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/surface"
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
}
},
{
"id": "Claim.item.modifier",
"path": "Claim.item.modifier",
"short": "Service/Product billing modifiers",
"definition": "Item typification or modifiers codes, e.g. for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.",
"definition": "Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.",
"requirements": "May impact on adjudication.",
"min": 0,
"max": "*",
"type": [
{
"code": "Coding"
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Modifiers"
}
],
"strength": "example",
"description": "Item type or modifiers codes, e.g. for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.",
"description": "Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-modifiers"
}
}
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Detail"
}
],
"path": "Claim.item.detail",
"short": "Additional items",
"definition": "Second tier of goods and services.",
"id": "Claim.item.programCode",
"path": "Claim.item.programCode",
"short": "Program specific reason for item inclusion",
"definition": "For programs which require reason codes for the inclusion or covering of this billed item under the program or sub-program.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
"code": "CodeableConcept"
}
],
"isSummary": true
},
{
"path": "Claim.item.detail.sequence",
"short": "Service instance",
"definition": "A service line number.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProgramCode"
}
],
"strength": "example",
"description": "Program specific reason codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-program-code"
}
],
"isSummary": true
}
},
{
"path": "Claim.item.detail.type",
"short": "Group or type of product or service",
"definition": "The type of product or service.",
"min": 1,
"id": "Claim.item.serviced[x]",
"path": "Claim.item.serviced[x]",
"short": "Date or dates of Service",
"definition": "The date or dates when the enclosed suite of services were performed or completed.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
"code": "date"
},
{
"code": "Period"
}
],
"isSummary": true,
"binding": {
"strength": "required",
"description": "Service, Product, Rx Dispense, Rx Compound etc.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/v3-ActInvoiceGroupCode"
"mapping": [
{
"identity": "w5",
"map": "when.done"
}
}
]
},
{
"path": "Claim.item.detail.service",
"short": "Additional item codes",
"definition": "If a grouping item then 'GROUP' otherwise it is a node therefore a code to indicate the Professional Service or Product supplied.",
"min": 1,
"id": "Claim.item.location[x]",
"path": "Claim.item.location[x]",
"short": "Place of service",
"definition": "Where the service was provided.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
"code": "CodeableConcept"
},
{
"code": "Address"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Location"
}
],
"isSummary": true,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServicePlace"
}
],
"strength": "example",
"description": "Allowable service and product codes.",
"description": "Place of service: pharmacy,school, prison, etc.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
"reference": "http://hl7.org/fhir/ValueSet/service-place"
}
}
},
"mapping": [
{
"identity": "w5",
"map": "where"
}
]
},
{
"path": "Claim.item.detail.quantity",
"id": "Claim.item.quantity",
"path": "Claim.item.quantity",
"short": "Count of Products or Services",
"definition": "The number of repetitions of a service or product.",
"min": 0,
"max": "1",
"type": [
{
"code": "Quantity",
"profile": [
"http://hl7.org/fhir/StructureDefinition/SimpleQuantity"
]
"profile": "http://hl7.org/fhir/StructureDefinition/SimpleQuantity"
}
],
"isSummary": true
]
},
{
"path": "Claim.item.detail.unitPrice",
"id": "Claim.item.unitPrice",
"path": "Claim.item.unitPrice",
"short": "Fee, charge or cost per point",
"definition": "If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "Quantity",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Money"
]
"code": "Money"
}
],
"isSummary": true
]
},
{
"path": "Claim.item.detail.factor",
"id": "Claim.item.factor",
"path": "Claim.item.factor",
"short": "Price scaling factor",
"definition": "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.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "decimal"
}
],
"isSummary": true
]
},
{
"path": "Claim.item.detail.points",
"short": "Difficulty scaling factor",
"definition": "An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each point.",
"id": "Claim.item.net",
"path": "Claim.item.net",
"short": "Total item cost",
"definition": "The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "decimal"
"code": "Money"
}
],
"isSummary": true
]
},
{
"path": "Claim.item.detail.net",
"short": "Total additional item cost",
"definition": "The quantity times the unit price for an additional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.",
"requirements": "If a fee is present the associated product/service code must be present.",
"id": "Claim.item.udi",
"path": "Claim.item.udi",
"short": "Unique Device Identifier",
"definition": "List of Unique Device Identifiers associated with this line item.",
"requirements": "The UDI code and issuer if applicable for the supplied product.",
"min": 0,
"max": "*",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Device"
}
]
},
{
"id": "Claim.item.bodySite",
"path": "Claim.item.bodySite",
"short": "Service Location",
"definition": "Physical service site on the patient (limb, tooth, etc).",
"min": 0,
"max": "1",
"type": [
{
"code": "Quantity",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Money"
]
"code": "CodeableConcept"
}
],
"isSummary": true
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "OralSites"
}
],
"strength": "example",
"description": "The code for the teeth, quadrant, sextant and arch",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/tooth"
}
}
},
{
"path": "Claim.item.detail.udi",
"short": "Unique Device Identifier",
"definition": "List of Unique Device Identifiers associated with this line item.",
"requirements": "The UDI code and issuer if applicable for the supplied product.",
"id": "Claim.item.subSite",
"path": "Claim.item.subSite",
"short": "Service Sub-location",
"definition": "A region or surface of the site, eg. limb region or tooth surface(s).",
"min": 0,
"max": "1",
"max": "*",
"type": [
{
"code": "Coding"
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Surface"
}
],
"strength": "example",
"description": "The FDA, or other, UDI repository.",
"description": "The code for the tooth surface and surface combinations",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/udi"
"reference": "http://hl7.org/fhir/ValueSet/surface"
}
}
},
{
"id": "Claim.item.encounter",
"path": "Claim.item.encounter",
"short": "Encounters related to this billed item",
"definition": "A billed item may include goods or services provided in multiple encounters.",
"min": 0,
"max": "*",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Encounter"
}
],
"mapping": [
{
"identity": "workflow",
"map": "Request.context"
}
]
},
{
"id": "Claim.item.detail",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "SubDetail"
"valueString": "Detail"
}
],
"path": "Claim.item.detail.subDetail",
"path": "Claim.item.detail",
"short": "Additional items",
"definition": "Third tier of goods and services.",
"definition": "Second tier of goods and services.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"isSummary": true
]
},
{
"path": "Claim.item.detail.subDetail.sequence",
"id": "Claim.item.detail.sequence",
"path": "Claim.item.detail.sequence",
"short": "Service instance",
"definition": "A service line number.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "Claim.item.detail.revenue",
"path": "Claim.item.detail.revenue",
"short": "Revenue or cost center code",
"definition": "The type of reveneu or cost center providing the product and/or service.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"isSummary": true
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "RevenueCenter"
}
],
"strength": "example",
"description": "Codes for the revenue or cost centers supplying the service and/or products.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-revenue-center"
}
}
},
{
"path": "Claim.item.detail.subDetail.type",
"short": "Type of product or service",
"definition": "The type of product or service.",
"min": 1,
"id": "Claim.item.detail.category",
"path": "Claim.item.detail.category",
"short": "Type of service or product",
"definition": "Health Care Service Type Codes to identify the classification of service or benefits.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"strength": "required",
"description": "Service, Product, Rx Dispense, Rx Compound etc.",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitSubCategory"
}
],
"strength": "example",
"description": "Benefit subcategories such as: oral-basic, major, glasses",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/v3-ActInvoiceGroupCode"
"reference": "http://hl7.org/fhir/ValueSet/benefit-subcategory"
}
}
},
{
"path": "Claim.item.detail.subDetail.service",
"short": "Additional item codes",
"definition": "The fee for an additional service or product or charge.",
"min": 1,
"id": "Claim.item.detail.service",
"path": "Claim.item.detail.service",
"short": "Billing Code",
"definition": "If this is an actual service or product line, ie. not a Group, then use code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
}
],
"strength": "example",
"description": "Allowable service and product codes.",
"description": "Allowable service and product codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
}
},
{
"path": "Claim.item.detail.subDetail.quantity",
"short": "Count of Products or Services",
"definition": "The number of repetitions of a service or product.",
"id": "Claim.item.detail.modifier",
"path": "Claim.item.detail.modifier",
"short": "Service/Product billing modifiers",
"definition": "Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.",
"requirements": "May impact on adjudication.",
"min": 0,
"max": "1",
"max": "*",
"type": [
{
"code": "Quantity",
"profile": [
"http://hl7.org/fhir/StructureDefinition/SimpleQuantity"
]
"code": "CodeableConcept"
}
],
"isSummary": true
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Modifiers"
}
],
"strength": "example",
"description": "Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-modifiers"
}
}
},
{
"path": "Claim.item.detail.subDetail.unitPrice",
"short": "Fee, charge or cost per point",
"definition": "The fee for an additional service or product or charge.",
"requirements": "If a fee is present the associated product/service code must be present.",
"id": "Claim.item.detail.programCode",
"path": "Claim.item.detail.programCode",
"short": "Program specific reason for item inclusion",
"definition": "For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program.",
"min": 0,
"max": "*",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProgramCode"
}
],
"strength": "example",
"description": "Program specific reason codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-program-code"
}
}
},
{
"id": "Claim.item.detail.quantity",
"path": "Claim.item.detail.quantity",
"short": "Count of Products or Services",
"definition": "The number of repetitions of a service or product.",
"min": 0,
"max": "1",
"type": [
{
"code": "Quantity",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Money"
]
"profile": "http://hl7.org/fhir/StructureDefinition/SimpleQuantity"
}
],
"isSummary": true
]
},
{
"path": "Claim.item.detail.subDetail.factor",
"short": "Price scaling factor",
"definition": "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.",
"id": "Claim.item.detail.unitPrice",
"path": "Claim.item.detail.unitPrice",
"short": "Fee, charge or cost per point",
"definition": "If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "decimal"
"code": "Money"
}
],
"isSummary": true
]
},
{
"path": "Claim.item.detail.subDetail.points",
"short": "Difficulty scaling factor",
"definition": "An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each point.",
"id": "Claim.item.detail.factor",
"path": "Claim.item.detail.factor",
"short": "Price scaling factor",
"definition": "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.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "decimal"
}
],
"isSummary": true
]
},
{
"path": "Claim.item.detail.subDetail.net",
"short": "Net additional item cost",
"definition": "The quantity times the unit price for an additional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.",
"id": "Claim.item.detail.net",
"path": "Claim.item.detail.net",
"short": "Total additional item cost",
"definition": "The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "Quantity",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Money"
]
"code": "Money"
}
],
"isSummary": true
]
},
{
"path": "Claim.item.detail.subDetail.udi",
"id": "Claim.item.detail.udi",
"path": "Claim.item.detail.udi",
"short": "Unique Device Identifier",
"definition": "List of Unique Device Identifiers associated with this line item.",
"requirements": "The UDI code and issuer if applicable for the supplied product.",
"min": 0,
"max": "1",
"max": "*",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "The FDA, or other, UDI repository.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/udi"
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Device"
}
}
]
},
{
"id": "Claim.item.detail.subDetail",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Prosthesis"
"valueString": "SubDetail"
}
],
"path": "Claim.item.prosthesis",
"short": "Prosthetic details",
"definition": "The materials and placement date of prior fixed prosthesis.",
"path": "Claim.item.detail.subDetail",
"short": "Additional items",
"definition": "Third tier of goods and services.",
"min": 0,
"max": "1",
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"isSummary": true
]
},
{
"path": "Claim.item.prosthesis.initial",
"short": "Is this the initial service",
"definition": "Indicates whether this is the initial placement of a fixed prosthesis.",
"requirements": "May impact on adjudication.",
"min": 0,
"id": "Claim.item.detail.subDetail.sequence",
"path": "Claim.item.detail.subDetail.sequence",
"short": "Service instance",
"definition": "A service line number.",
"min": 1,
"max": "1",
"type": [
{
"code": "boolean"
"code": "positiveInt"
}
],
"isSummary": true
]
},
{
"path": "Claim.item.prosthesis.priorDate",
"short": "Initial service Date",
"definition": "Date of the initial placement.",
"requirements": "May impact on adjudication.",
"id": "Claim.item.detail.subDetail.revenue",
"path": "Claim.item.detail.subDetail.revenue",
"short": "Revenue or cost center code",
"definition": "The type of reveneu or cost center providing the product and/or service.",
"min": 0,
"max": "1",
"type": [
{
"code": "date"
"code": "CodeableConcept"
}
],
"isSummary": true
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "RevenueCenter"
}
],
"strength": "example",
"description": "Codes for the revenue or cost centers supplying the service and/or products.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-revenue-center"
}
}
},
{
"path": "Claim.item.prosthesis.priorMaterial",
"short": "Prosthetic Material",
"definition": "Material of the prior denture or bridge prosthesis. (Oral).",
"requirements": "May impact on adjudication.",
"id": "Claim.item.detail.subDetail.category",
"path": "Claim.item.detail.subDetail.category",
"short": "Type of service or product",
"definition": "Health Care Service Type Codes to identify the classification of service or benefits.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BenefitSubCategory"
}
],
"strength": "example",
"description": "Material of the prior denture or bridge prosthesis. (Oral)",
"description": "Benefit subcategories such as: oral-basic, major, glasses",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/oral-prosthodontic-material"
"reference": "http://hl7.org/fhir/ValueSet/benefit-subcategory"
}
}
},
{
"path": "Claim.additionalMaterials",
"short": "Additional materials, documents, etc.",
"definition": "Code to indicate that Xrays, images, emails, documents, models or attachments are being sent in support of this submission.",
"id": "Claim.item.detail.subDetail.service",
"path": "Claim.item.detail.subDetail.service",
"short": "Billing Code",
"definition": "A code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI).",
"min": 0,
"max": "*",
"max": "1",
"type": [
{
"code": "Coding"
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
}
],
"strength": "example",
"description": "Code to indicate that Xrays, images, emails, documents, models or attachments are being sent in support of this submission.",
"description": "Allowable service and product codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/additionalmaterials"
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
}
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "MissingTeeth"
}
],
"path": "Claim.missingTeeth",
"short": "Only if type = oral",
"definition": "A list of teeth which would be expected but are not found due to having been previously extracted or for other reasons.",
"requirements": "The list of missing teeth may influence the adjudication of services for example with Bridges.",
"id": "Claim.item.detail.subDetail.modifier",
"path": "Claim.item.detail.subDetail.modifier",
"short": "Service/Product billing modifiers",
"definition": "Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.",
"requirements": "May impact on adjudication.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
"code": "CodeableConcept"
}
],
"isSummary": true
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Modifiers"
}
],
"strength": "example",
"description": "Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-modifiers"
}
}
},
{
"path": "Claim.missingTeeth.tooth",
"short": "Tooth Code",
"definition": "The code identifying which tooth is missing.",
"requirements": "Provides the tooth number of the missing tooth.",
"min": 1,
"max": "1",
"id": "Claim.item.detail.subDetail.programCode",
"path": "Claim.item.detail.subDetail.programCode",
"short": "Program specific reason for item inclusion",
"definition": "For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program.",
"min": 0,
"max": "*",
"type": [
{
"code": "Coding"
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProgramCode"
}
],
"strength": "example",
"description": "The codes for the teeth, subset of OralSites.",
"description": "Program specific reason codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/teeth"
"reference": "http://hl7.org/fhir/ValueSet/ex-program-code"
}
}
},
{
"path": "Claim.missingTeeth.reason",
"short": "Reason for missing",
"definition": "Missing reason may be: E-extraction, O-other.",
"requirements": "Provides the reason for the missing tooth.",
"id": "Claim.item.detail.subDetail.quantity",
"path": "Claim.item.detail.subDetail.quantity",
"short": "Count of Products or Services",
"definition": "The number of repetitions of a service or product.",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
"code": "Quantity",
"profile": "http://hl7.org/fhir/StructureDefinition/SimpleQuantity"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "Reason codes for the missing teeth.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/missing-tooth-reason"
]
},
{
"id": "Claim.item.detail.subDetail.unitPrice",
"path": "Claim.item.detail.subDetail.unitPrice",
"short": "Fee, charge or cost per point",
"definition": "The fee for an addittional service or product or charge.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
}
]
},
{
"path": "Claim.missingTeeth.extractionDate",
"short": "Date of Extraction",
"definition": "The date of the extraction either known from records or patient reported estimate.",
"requirements": "Some services and adjudications require this information.",
"id": "Claim.item.detail.subDetail.factor",
"path": "Claim.item.detail.subDetail.factor",
"short": "Price scaling factor",
"definition": "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.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "date"
"code": "decimal"
}
],
"isSummary": true
]
},
{
"id": "Claim.item.detail.subDetail.net",
"path": "Claim.item.detail.subDetail.net",
"short": "Net additional item cost",
"definition": "The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.",
"requirements": "If a fee is present the associated product/service code must be present.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "Claim.item.detail.subDetail.udi",
"path": "Claim.item.detail.subDetail.udi",
"short": "Unique Device Identifier",
"definition": "List of Unique Device Identifiers associated with this line item.",
"requirements": "The UDI code and issuer if applicable for the supplied product.",
"min": 0,
"max": "*",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Device"
}
]
},
{
"id": "Claim.total",
"path": "Claim.total",
"short": "Total claim cost",
"definition": "The total value of the claim.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
}
]
}
}
Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.
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®©
HL7.org
2011+.
FHIR
DSTU2
(v1.0.2-7202)
Release
3
(STU;
v3.0.2-11200)
generated
on
Sat,
Thurs,
Oct
24,
2015
07:43+1100.
2019
11:53+1100.
QA
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