A provider issued list of services and products provided, or to be provided, to a patient which is provided to an insurer for payment recovery.

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

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

Affects which fields and value sets are used. This element is labeled as a modifier because the status contains the code entered-in-error that marks the claim as not currently valid.

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

Affects which fields and value sets are used.

The version A finer grained suite of the specification on claim subtype codes which this instance relies. may convey Inpatient vs Outpatient and/or a specialty service. In the US the BillType.

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

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

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

The billable period for which charges are being submitted.

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

Insurer Identifier, typical BIN number (6 digit). Person who created the invoice/claim/pre-determination or pre-authorization.

The provider which Insurer who is responsible for target of the bill, claim pre-determination, pre-authorization. request.

The organization provider which is responsible for the bill, claim pre-determination, pre-authorization.

Complete (Bill or Claim), Proposed (Pre-Authorization), Exploratory (Pre-determination). The organization which is responsible for the bill, claim pre-determination, pre-authorization.

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

In the case of a Pre-Determination/Pre-Authorization the provider may request that funds in the amount of the expected Benefit be reserved ('Patient' or 'Provider') to pay for the Benefits determined on the subsequent claim(s). 'None' explicitly indicates no funds reserving is requested.

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

Person who created the invoice/claim/pre-determination Other claims which are related to this claim such as prior claim versions or pre-authorization. for related services.

Do we need a relationship code?

Facility where the services were provided. For example prior or umbrella.

An alternate organizational reference to the case or file to which this particular claim pertains - eg Property/Casualy insurer claim # or Workers Compensation case # .

Prescription to support the dispensing of Pharmacy or Vision products.

For type=Pharmacy and Vision only.

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

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'.

as above.

The party to be reimbursed for the services.

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

The provider who is to be reimbursed for the claim (the party to whom any benefit is assigned). organization | patient | practitioner | relatedperson.

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

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

The referral resource which lists Facility where the date, practitioner, reason and other supporting information. services were provided.

Ordered list The members of patient diagnosis for which care is sought. the team who provided the overall service as well as their role and whether responsible and qualifications.

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

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

Required to maintain order of the diagnoses. careTeam.

The diagnosis. Member of the team who provided the overall service.

Required to adjudicate services The party who is billing and responsible for the claimed good or service rendered to condition presented. the patient.

List of patient conditions for which care is sought. The lead, assisting or supervising practitioner and their discipline if a multidisiplinary team.

Patient Resource. The qualification which is applicable for this service.

Financial instrument by which payment Additional information for health care. codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. Often there are mutiple jurisdiction specific valuesets which are required.

Health care programs and insurers Typically these information codes are significant payors required to support the services rendered or the adjudication of health service costs. the services rendered.

A service line item. Sequence of the information element which serves to provide a link.

To maintain order of the coverages. provide a reference link.

The instance number general class of the Coverage which is the focus for adjudication. The Coverage against which the claim is to be adjudicated. information supplied: information; exception; accident, employment; onset, etc.

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

Reference System and code pertaining to the program or plan identification, underwriter specific information regarding special conditions relating to the setting, treatment or payor. patient for which care is sought which may influence the adjudication.

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

The date when or period to target for processing and for coordination of benefit processing. which this information refers.

The contract number Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of a business agreement which describes the terms and conditions. data.

The relationship of For example, provides the patient reason for: the additional stay, or missing tooth or any other situation where a reason code is required in addition to the subscriber. content.

To determine the relationship between the List of patient and the subscriber. diagnosis for which care is sought.

A list Sequence of references from the Insurer to diagnosis which these services pertain. serves to provide a link.

To provide any pre=determination or prior authorization reference. Required to allow line items to reference the diagnoses.

The Coverages adjudication details. diagnosis.

Required to adjudicate services rendered to condition presented.

The style (standard) and version type of the original material which was converted into this resource. Diagnosis, for example: admitting, primary, secondary, discharge.

Knowledge of the original version can inform the processing of this instance so that information which is processable by the originating system may May be generated. required to adjudicate services rendered.

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

Factors which may influence The package billing code, for example DRG, based on the applicability of coverage. assigned grouping code system.

To determine extenuating circumstances for coverage. May be required to adjudicate services rendered to the mandated grouping system.

Ordered list of patient procedures performed to support the adjudication.

Name Sequence of school for over-aged dependents. procedures which serves to order and provide a link.

Often required for over-age dependents. Required to maintain order of the procudures.

Date of an accident which these services are addressing. and optionally time the procedure was performed .

Coverage may be dependent on accidents. Required to adjudicate services rendered.

SB DateTime??

Type of accident: work, auto, etc. The procedure code.

Required to adjudicate services rendered.

A list of intervention and exception codes Financial instrument by which may influence the adjudication of the claim. payment information for health care.

Health care programs and exception codes (Pharm). ( Example ) insurers are significant payors of health service costs.

Sequence of coverage which serves to provide a link and convey coordination of benefit order.

To maintain order of the coverages.

First tier of goods and services. A flag to indicate that this Coverage is the focus for adjudication. The Coverage against which the claim is to be adjudicated.

To identify which coverage is being adjudicated.

A service line number. Reference to the program or plan identification, underwriter or payor.

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

The type contract number of product or service. a business agreement which describes the terms and conditions.

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

To provide any pre=determination or prior authorization reference.

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

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

An accident which resulted in the need for healthcare services.

Diagnosis applicable for this service or product line. Date of an accident which these services are addressing.

Coverage may be dependant on accidents.

If a grouping item then 'GROUP' otherwise it is a node therefore a code to indicate the Professional Service or Product supplied. Type of accident: work, auto, etc.

Coverage may be dependant on the type of accident.

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

The number of repetitions start and optional end dates of a service or product. when the patient was precluded from working due to the treatable condition(s).

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 The start and optional end dates of when the group. patient was confined to a treatment center.

A real number that represents a multiplier used in determining the overall value First tier 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. and services.

A service line number.

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 CareTeam applicable for services and/or goods, such that a monetary amount can be assigned to each point. this service or product line.

If a fee is present the associated product/service code must be present. Diagnosis applicable for this service or product line.

The quantity times the unit price Procedures applicable for an additional this 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. line.

If a fee is present the associated product/service code must be present. Exceptions, special conditions and supporting information pplicable for this service or product line.

List The type of Unique Device Identifiers associated with this line item. reveneu or cost center providing the product and/or service.

Physical service site on Health Care Service Type Codes to identify the patient (limb, tooth, etc.). classification of service or benefits.

A region If this is an actual service or surface of product line, ie. not a Group, then use code to indicate the site, e.g. limb region Professional Service or tooth surface(s). 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'.

Item typification or modifiers codes, e.g. eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance for medical whether the treatment was lost outside the clinic or stolen. out of office hours.

May impact on adjudication.

Second tier For programs which require reason codes for the inclusion or covering of goods and services. this billed item under the program or sub-program.

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

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

The number of repetitions of a service or product.

If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group.

A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

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

An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values quantity times the unit price for services and/or goods, such that a monetary amount can be assigned 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 each point. be 1 if not supplied.

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

List of Unique Device Identifiers associated with this line item.

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

The quantity times the unit price for an additional Physical service or product or charge. For example, site on 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. patient (limb, tooth, etc).

List A region or surface of Unique Device Identifiers associated with this line item. the site, eg. limb region or tooth surface(s).

The UDI code and issuer if applicable for the supplied product. A billed item may include goods or services provided in multiple encounters.

Third Second tier of goods and services.

A service line number.

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

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

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

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

May impact on adjudication.

The fee For programs which require reson codes for an additional service or product the inclusion, covering, of this billed item under the program or charge. sub-program.

If The number of repetitions of a fee is present the associated product/service code must be present. service or product.

A real number that represents a multiplier used in determining If the overall value of services delivered and/or goods received. The concept of item is a Factor allows node then this is the fee for a discount the product or surcharge multiplier to be applied to a monetary amount. service, otherwise this is the total of the fees for the children of the group.

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

An amount A real number that expresses represents a multiplier used in determining the weighting (based on difficulty, cost overall value of services delivered and/or resource intensiveness) associated with the good or service delivered. goods received. The concept of Points a Factor allows for assignment of point values for services and/or goods, such that a monetary amount can discount or surcharge multiplier to be assigned applied to each point. a monetary amount.

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

The quantity times the unit price for an additional addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.

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

List of Unique Device Identifiers associated with this line item.

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

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

The materials and placement date of prior fixed prosthesis. A service line number.

Indicates whether this is the initial placement The type of a fixed prosthesis. reveneu or cost center providing the product and/or service.

Date of Health Care Service Type Codes to identify the initial placement. classification of service or benefits.

Material of A code to indicate the prior denture Professional Service or bridge prosthesis. (Oral). Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI).

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

May impact on adjudication.

A list of teeth For programs which would be expected but are not found due to having been previously extracted or require reson codes for other reasons. the inclusion, covering, of this billed item under the program or sub-program.

The code identifying which tooth is missing. number of repetitions of a service or product.

The fee for an addittional service or product or charge.

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

Missing reason may be: E-extraction, O-other. A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

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

Provides The quantity times the reason unit price for an addittional service or product or charge. For example, the missing tooth. formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.

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

The date List of the extraction either known from records or patient reported estimate. Unique Device Identifiers associated with this line item.

Some services The UDI code and adjudications require this information. issuer if applicable for the supplied product.

The total value of the claim.