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13.6 Resource Claim - Content

Financial Management Work GroupMaturity Level: 2 Trial Use Compartments: Encounter, Patient, Practitioner, RelatedPerson

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

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

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

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

The Claim also supports:

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

Mapping to other Claim specifications: Mappings are currently maintained by the Financial Management Work Group to UB04 and CMS1500 and are available at http://wiki.hl7.org/index.php?title=Financial_Management_FHIR_Resource_Development . Mappings to other specifications may be made available where IP restrictions permit.

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

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

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

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

The eClaim domain includes a number of related resources

Claim A suite of goods and services and insurances coverages under which adjudication or authorization is requested.
ClaimResponse A payor's adjudication and/or authorization response to the suite of services provided in a Claim. Typically the ClaimResponse references the Claim but does not duplicate the clinical or financial information provided in the claim.
ExplanationOfBenefit This resource combines the information from the Claim and the ClaimResponse, stripping out any provider or payor proprietary information, into a unified information model suitable for use for: patient reporting; transferring information to a Patient Health Record system; and, supporting complete claim and adjudication information exchange with regulatory and analytics organizations and other parts of the provider's organization.

This resource is referenced by itself, ClaimResponse, DeviceUseStatement and ExplanationOfBenefit

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim TUDomainResourceClaim, Pre-determination or Pre-authorization
Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier 0..*IdentifierClaim number
... status ?!Σ0..1codeactive | cancelled | draft | entered-in-error
Financial Resource Status Codes (Required)
... type 0..1CodeableConceptType or discipline
Claim Type Codes (Extensible)
... subType 0..1CodeableConceptFiner grained claim type information
Example Claim SubType Codes (Example)
... use Σ0..1codeclaim | preauthorization | predetermination
Use (Required)
... patient 0..1Reference(Patient)The subject of the Products and Services
... billablePeriod 0..1PeriodPeriod for charge submission
... created 0..1dateTimeCreation date
... enterer 0..1Reference(Practitioner | PractitionerRole)Author
... insurer 0..1Reference(Organization)Target
... provider 0..1Reference(Practitioner | PractitionerRole | Organization)Responsible provider
... priority 0..1CodeableConceptDesired processing priority
Process Priority Codes (Example)
... fundsReserve 0..1CodeableConceptFunds requested to be reserved
FundsReserve (Example)
... related 0..*BackboneElementRelated Claims which may be relevant to processing this claim
.... claim 0..1Reference(Claim)Reference to the related claim
.... relationship 0..1CodeableConceptHow the reference claim is related
Example Related Claim Relationship Codes (Example)
.... reference 0..1IdentifierRelated file or case reference
... prescription 0..1Reference(MedicationRequest | VisionPrescription)Prescription authorizing services or products
... originalPrescription 0..1Reference(MedicationRequest)Original prescription if superseded by fulfiller
... payee 0..1BackboneElementParty to be paid any benefits payable
.... type 1..1CodeableConceptType of party: Subscriber, Provider, other
PayeeType (Example)
.... resource 0..1Codingorganization | patient | practitioner | relatedperson
ClaimPayeeResourceType (Extensible)
.... party 0..1Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson)Party to receive the payable
... referral 0..1Reference(ServiceRequest)Treatment Referral
... facility 0..1Reference(Location)Servicing Facility
... careTeam 0..*BackboneElementMembers of the care team
.... sequence 1..1positiveIntNumber to convey order of careTeam
.... provider 1..1Reference(Practitioner | PractitionerRole | Organization)Provider individual or organization
.... responsible 0..1booleanBilling provider
.... role 0..1CodeableConceptRole on the team
Claim Care Team Role Codes (Example)
.... qualification 0..1CodeableConceptType, classification or Specialization
Example Provider Qualification Codes (Example)
... information 0..*BackboneElementExceptions, special considerations, the condition, situation, prior or concurrent issues
.... sequence 1..1positiveIntInformation instance identifier
.... category 1..1CodeableConceptGeneral class of information
Claim Information Category Codes (Example)
.... code 0..1CodeableConceptType of information
Exception Codes (Example)
.... timing[x] 0..1When it occurred
..... timingDatedate
..... timingPeriodPeriod
.... value[x] 0..1Additional Data or supporting information
..... valueBooleanboolean
..... valueStringstring
..... valueQuantityQuantity
..... valueAttachmentAttachment
..... valueReferenceReference(Any)
.... reason 0..1CodeableConceptReason associated with the information
Missing Tooth Reason Codes (Example)
... diagnosis 0..*BackboneElementList of Diagnosis
.... sequence 1..1positiveIntNumber to convey order of diagnosis
.... diagnosis[x] 1..1Patient's diagnosis
ICD-10 Codes (Example)
..... diagnosisCodeableConceptCodeableConcept
..... diagnosisReferenceReference(Condition)
.... type 0..*CodeableConceptTiming or nature of the diagnosis
Example Diagnosis Type Codes (Example)
.... onAdmission 0..1CodeableConceptPresent on admission
Example Diagnosis on Admission Codes (Example)
.... packageCode 0..1CodeableConceptPackage billing code
Example Diagnosis Related Group Codes (Example)
... procedure 0..*BackboneElementProcedures performed
.... sequence 1..1positiveIntProcedure sequence for reference
.... date 0..1dateTimeWhen the procedure was performed
.... procedure[x] 1..1Patient's list of procedures performed
ICD-10 Procedure Codes (Example)
..... procedureCodeableConceptCodeableConcept
..... procedureReferenceReference(Procedure)
... insurance 0..*BackboneElementInsurance or medical plan
.... sequence 1..1positiveIntService instance identifier
.... focal 1..1booleanIs the focal Coverage
.... identifier 0..1IdentifierClaim number
.... coverage 1..1Reference(Coverage)Insurance information
.... businessArrangement 0..1stringBusiness agreement
.... preAuthRef 0..*stringPre-Authorization/Determination Reference
.... claimResponse 0..1Reference(ClaimResponse)Adjudication results
... accident 0..1BackboneElementDetails about an accident
.... date 1..1dateWhen the accident occurred see information codes see information codes
.... type 0..1CodeableConceptThe nature of the accident
V3 Value SetActIncidentCode (Extensible)
.... location[x] 0..1Accident Place
..... locationAddressAddress
..... locationReferenceReference(Location)
... item 0..*BackboneElementGoods and Services
.... sequence 1..1positiveIntService instance
.... careTeamSequence 0..*positiveIntApplicable careTeam members
.... diagnosisSequence 0..*positiveIntApplicable diagnoses
.... procedureSequence 0..*positiveIntApplicable procedures
.... informationSequence 0..*positiveIntApplicable exception and supporting information
.... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
.... category 0..1CodeableConceptType of service or product
Benefit Category Codes (Example)
.... billcode 0..1CodeableConceptBilling Code
USCLS Codes (Example)
.... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
.... programCode 0..*CodeableConceptProgram specific reason for item inclusion
Example Program Reason Codes (Example)
.... serviced[x] 0..1Date or dates of Service
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service
Example Service Place Codes (Example)
..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1SimpleQuantityCount of Products or Services
.... unitPrice 0..1MoneyFee, charge or cost per point
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... udi 0..*Reference(Device)Unique Device Identifier
.... bodySite 0..1CodeableConceptService Location
Oral Site Codes (Example)
.... subSite 0..*CodeableConceptService Sub-location
Surface Codes (Example)
.... encounter 0..*Reference(Encounter)Encounters related to this billed item
.... detail 0..*BackboneElementAdditional items
..... sequence 1..1positiveIntService instance
..... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
..... category 0..1CodeableConceptType of service or product
Benefit Category Codes (Example)
..... billcode 0..1CodeableConceptBilling Code
USCLS Codes (Example)
..... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
..... programCode 0..*CodeableConceptProgram specific reason for item inclusion
Example Program Reason Codes (Example)
..... quantity 0..1SimpleQuantityCount of Products or Services
..... unitPrice 0..1MoneyFee, charge or cost per point
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal additional item cost
..... udi 0..*Reference(Device)Unique Device Identifier
..... subDetail 0..*BackboneElementAdditional items
...... sequence 1..1positiveIntService instance
...... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
...... category 0..1CodeableConceptType of service or product
Benefit Category Codes (Example)
...... billcode 0..1CodeableConceptBilling Code
USCLS Codes (Example)
...... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
...... programCode 0..*CodeableConceptProgram specific reason for item inclusion
Example Program Reason Codes (Example)
...... quantity 0..1SimpleQuantityCount of Products or Services
...... unitPrice 0..1MoneyFee, charge or cost per point
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyNet additional item cost
...... udi 0..*Reference(Device)Unique Device Identifier
... total 0..1MoneyTotal claim cost

doco Documentation for this format

UML Diagram (Legend)

Claim (DomainResource)The business identifier for the instance: claim number, pre-determination or pre-authorization numberidentifier : Identifier [0..*]The status of the resource instance (this element modifies the meaning of other elements)status : code [0..1] « A code specifying the state of the resource instance. (Strength=Required)FinancialResourceStatusCodes! »The category of claim, e.g. oral, pharmacy, vision, institutional, professionaltype : CodeableConcept [0..1] « The type or discipline-style of the claim. (Strength=Extensible)ClaimTypeCodes+ »A finer grained suite of claim subtype codes which may convey Inpatient vs Outpatient and/or a specialty service. In the US the CMS Bill TypesubType : CodeableConcept [0..1] « A more granular claim typecode. (Strength=Example)ExampleClaimSubTypeCodes?? »A claim, a list of completed goods and services; a preauthorization, a list or proposed goods and services; or a predetermination, a set of goods and services being considered, for which insurer adjudication is soughtuse : code [0..1] « Complete, proposed, exploratory, other. (Strength=Required)Use! »Patient Resourcepatient : Reference [0..1] « Patient »The billable period for which charges are being submittedbillablePeriod : Period [0..1]The date when this resource was createdcreated : dateTime [0..1]Person who created the invoice/claim/pre-determination or pre-authorizationenterer : Reference [0..1] « Practitioner|PractitionerRole »The Insurer who is target of the requestinsurer : Reference [0..1] « Organization »The provider which is responsible for the bill, claim pre-determination, pre-authorizationprovider : Reference [0..1] « Practitioner|PractitionerRole| Organization »Immediate (STAT), best effort (NORMAL), deferred (DEFER)priority : CodeableConcept [0..1] « The timeliness with which processing is required: STAT, normal, Deferred. (Strength=Example)ProcessPriorityCodes?? »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 requestedfundsReserve : CodeableConcept [0..1] « For whom funds are to be reserved: (Patient, Provider, None). (Strength=Example)Funds Reservation ?? »Prescription to support the dispensing of Pharmacy or Vision productsprescription : Reference [0..1] « MedicationRequest| VisionPrescription »Original prescription which has been superseded 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 prescription for an alternate medication which has the same therapeutic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription'originalPrescription : Reference [0..1] « MedicationRequest »The referral resource which lists the date, practitioner, reason and other supporting informationreferral : Reference [0..1] « ServiceRequest »Facility where the services were providedfacility : Reference [0..1] « Location »The total value of the claimtotal : Money [0..1]RelatedClaimOther claims which are related to this claim such as prior claim versions or for related servicesclaim : Reference [0..1] « Claim »For example, prior or umbrellarelationship : CodeableConcept [0..1] « Relationship of this claim to a related Claim. (Strength=Example) ExampleRelatedClaimRelationsh...?? »An alternate organizational reference to the case or file to which this particular claim pertains - e.g. Property/Casualty insurer claim # or Workers Compensation case # reference : Identifier [0..1]PayeeType of Party to be reimbursed: Subscriber, provider, othertype : CodeableConcept [1..1] « A code for the party to be reimbursed. (Strength=Example)Claim Payee Type ?? »organization | patient | practitioner | relatedpersonresource : Coding [0..1] « The type of Claim payee Resource. (Strength=Extensible)ClaimPayeeResourceType+ »Party to be reimbursed: Subscriber, provider, otherparty : Reference [0..1] « Practitioner|PractitionerRole| Organization|Patient|RelatedPerson »CareTeamSequence of the careTeam which serves to order and provide a linksequence : positiveInt [1..1]Member of the team who provided the overall serviceprovider : Reference [1..1] « Practitioner|PractitionerRole| Organization »The party who is billing and responsible for the claimed good or service rendered to the patientresponsible : boolean [0..1]The lead, assisting or supervising practitioner and their discipline if a multidisciplinary teamrole : CodeableConcept [0..1] « The role codes for the care team members. (Strength=Example)ClaimCareTeamRoleCodes?? »The qualification which is applicable for this servicequalification : CodeableConcept [0..1] « Provider professional qualifications. (Strength=Example) ExampleProviderQualificationC...?? »SpecialConditionSequence of the information element which serves to provide a linksequence : positiveInt [1..1]The general class of the information supplied: information; exception; accident, employment; onset, etccategory : CodeableConcept [1..1] « The valuset used for additional information category codes. (Strength=Example)ClaimInformationCategoryCodes?? »System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought which may influence the adjudicationcode : CodeableConcept [0..1] « The valuset used for additional information codes. (Strength=Example)ExceptionCodes?? »The date when or period to which this information referstiming[x] : Type [0..1] « date|Period »Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the datavalue[x] : Type [0..1] « boolean|string|Quantity|Attachment| Reference(Any) »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 contentreason : CodeableConcept [0..1] « Reason codes for the missing teeth. (Strength=Example)MissingToothReasonCodes?? »DiagnosisSequence of diagnosis which serves to provide a linksequence : positiveInt [1..1]The diagnosisdiagnosis[x] : Type [1..1] « CodeableConcept|Reference(Condition); ICD10 Diagnostic codes. (Strength=Example) ICD-10Codes?? »The type of the Diagnosis, for example: admitting, primary, secondary, dischargetype : CodeableConcept [0..*] « The type of the diagnosis: admitting, principal, discharge. (Strength=Example)ExampleDiagnosisTypeCodes?? »Indication of whether the diagnosis was present on admission to a facilityonAdmission : CodeableConcept [0..1] « Present on admission. (Strength=Example) ExampleDiagnosisOnAdmissionCo...?? »The package billing code, for example DRG, based on the assigned grouping code systempackageCode : CodeableConcept [0..1] « The DRG codes associated with the diagnosis. (Strength=Example) ExampleDiagnosisRelatedGroupC...?? »ProcedureSequence of procedures which serves to order and provide a linksequence : positiveInt [1..1]Date and optionally time the procedure was performed date : dateTime [0..1]The procedure codeprocedure[x] : Type [1..1] « CodeableConcept|Reference(Procedure); ICD10 Procedure codes. (Strength=Example) ICD-10ProcedureCodes?? »InsuranceSequence of coverage which serves to provide a link and convey coordination of benefit ordersequence : positiveInt [1..1]A flag to indicate that this Coverage is the focus for adjudication. The Coverage against which the claim is to be adjudicatedfocal : boolean [1..1]The business identifier for the instance: claim number, pre-determination or pre-authorization numberidentifier : Identifier [0..1]Reference to the program or plan identification, underwriter or payorcoverage : Reference [1..1] « Coverage »The contract number of a business agreement which describes the terms and conditionsbusinessArrangement : string [0..1]A list of references from the Insurer to which these services pertainpreAuthRef : string [0..*]The Coverages adjudication detailsclaimResponse : Reference [0..1] « ClaimResponse »AccidentDate of an accident which these services are addressingdate : date [1..1]Type of accident: work, auto, etctype : CodeableConcept [0..1] « Type of accident: work place, auto, etc. (Strength=Extensible)v3.ActIncidentCode+ »Accident Placelocation[x] : Type [0..1] « Address|Reference(Location) »ItemA service line numbersequence : positiveInt [1..1]CareTeam applicable for this service or product linecareTeamSequence : positiveInt [0..*]Diagnosis applicable for this service or product linediagnosisSequence : positiveInt [0..*]Procedures applicable for this service or product lineprocedureSequence : positiveInt [0..*]Exceptions, special conditions and supporting information applicable for this service or product lineinformationSequence : positiveInt [0..*]The type of revenue or cost center providing the product and/or servicerevenue : CodeableConcept [0..1] « Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example)ExampleRevenueCenterCodes?? »Health Care Service Type Codes to identify the classification of service or benefitscategory : CodeableConcept [0..1] « Benefit categories such as: oral-basic, major, glasses. (Strength=Example)BenefitCategoryCodes?? »If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. 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 e.g. 'glasses' or 'compound'billcode : CodeableConcept [0..1] « Allowable service and product codes. (Strength=Example)USCLSCodes?? »Item typification or modifiers codes, e.g. 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 hoursmodifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)ModifierTypeCodes?? »For programs which require reason codes for the inclusion or covering of this billed item under the program or sub-programprogramCode : CodeableConcept [0..*] « Program specific reason codes. (Strength=Example)ExampleProgramReasonCodes?? »The date or dates when the service or product was supplied, performed or completedserviced[x] : Type [0..1] « date|Period »Where the service was providedlocation[x] : Type [0..1] « CodeableConcept|Address|Reference( Location); Place of service: pharmacy, school, prison, etc. (Strength=Example)ExampleServicePlaceCodes?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the groupunitPrice : Money [0..1]A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amountfactor : decimal [0..1]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 suppliednet : Money [0..1]List of Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »Physical service site on the patient (limb, tooth, etc.)bodySite : CodeableConcept [0..1] « The code for the teeth, quadrant, sextant and arch. (Strength=Example)OralSiteCodes?? »A region or surface of the site, e.g. limb region or tooth surface(s)subSite : CodeableConcept [0..*] « The code for the tooth surface and surface combinations. (Strength=Example)SurfaceCodes?? »A billed item may include goods or services provided in multiple encountersencounter : Reference [0..*] « Encounter »DetailA service line numbersequence : positiveInt [1..1]The type of revenue or cost center providing the product and/or servicerevenue : CodeableConcept [0..1] « Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example)ExampleRevenueCenterCodes?? »Health Care Service Type Codes to identify the classification of service or benefitscategory : CodeableConcept [0..1] « Benefit categories such as: oral-basic, major, glasses. (Strength=Example)BenefitCategoryCodes?? »If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. 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'billcode : CodeableConcept [0..1] « Allowable service and product codes. (Strength=Example)USCLSCodes?? »Item typification or modifiers codes, e.g. 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 hoursmodifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)ModifierTypeCodes?? »For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-programprogramCode : CodeableConcept [0..*] « Program specific reason codes. (Strength=Example)ExampleProgramReasonCodes?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the groupunitPrice : Money [0..1]A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amountfactor : decimal [0..1]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 suppliednet : Money [0..1]List of Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »SubDetailA service line numbersequence : positiveInt [1..1]The type of revenue or cost center providing the product and/or servicerevenue : CodeableConcept [0..1] « Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example)ExampleRevenueCenterCodes?? »Health Care Service Type Codes to identify the classification of service or benefitscategory : CodeableConcept [0..1] « Benefit categories such as: oral-basic, major, glasses. (Strength=Example)BenefitCategoryCodes?? »A code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI)billcode : CodeableConcept [0..1] « Allowable service and product codes. (Strength=Example)USCLSCodes?? »Item typification or modifiers codes, e.g. 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 hoursmodifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)ModifierTypeCodes?? »For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-programprogramCode : CodeableConcept [0..*] « Program specific reason codes. (Strength=Example)ExampleProgramReasonCodes?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]The fee for an addittional service or product or chargeunitPrice : Money [0..1]A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amountfactor : decimal [0..1]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 suppliednet : Money [0..1]List of Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »Other claims which are related to this claim such as prior claim versions or for related servicesrelated[0..*]The party to be reimbursed for the servicespayee[0..1]The members of the team who provided the overall service as well as their role and whether responsible and qualificationscareTeam[0..*]Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. Often there are multiple jurisdiction specific valuesets which are requiredinformation[0..*]List of patient diagnosis for which care is soughtdiagnosis[0..*]Ordered list of patient procedures performed to support the adjudicationprocedure[0..*]Financial instrument by which payment information for health careinsurance[0..*]An accident which resulted in the need for healthcare servicesaccident[0..1]Third tier of goods and servicessubDetail[0..*]Second tier of goods and servicesdetail[0..*]First tier of goods and servicesitem[0..*]

XML Template

<Claim xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Claim number --></identifier>
 <status value="[code]"/><!-- 0..1 active | cancelled | draft | entered-in-error -->
 <type><!-- 0..1 CodeableConcept Type or discipline --></type>
 <subType><!-- 0..1 CodeableConcept Finer grained claim type information --></subType>
 <use value="[code]"/><!-- 0..1 claim | preauthorization | predetermination -->
 <patient><!-- 0..1 Reference(Patient) The subject of the Products and Services --></patient>
 <billablePeriod><!-- 0..1 Period Period for charge submission --></billablePeriod>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <enterer><!-- 0..1 Reference(Practitioner|PractitionerRole) Author --></enterer>
 <insurer><!-- 0..1 Reference(Organization) Target --></insurer>
 <provider><!-- 0..1 Reference(Practitioner|PractitionerRole|Organization) Responsible provider --></provider>
 <priority><!-- 0..1 CodeableConcept Desired processing priority --></priority>
 <fundsReserve><!-- 0..1 CodeableConcept Funds requested to be reserved --></fundsReserve>
 <related>  <!-- 0..* Related Claims which may be relevant to processing this claim -->
  <claim><!-- 0..1 Reference(Claim) Reference to the related claim --></claim>
  <relationship><!-- 0..1 CodeableConcept How the reference claim is related --></relationship>
  <reference><!-- 0..1 Identifier Related file or case reference --></reference>
 </related>
 <prescription><!-- 0..1 Reference(MedicationRequest|VisionPrescription) Prescription authorizing services or products --></prescription>
 <originalPrescription><!-- 0..1 Reference(MedicationRequest) Original prescription if superseded by fulfiller --></originalPrescription>
 <payee>  <!-- 0..1 Party to be paid any benefits payable -->
  <type><!-- 1..1 CodeableConcept Type of party: Subscriber, Provider, other --></type>
  <resource><!-- 0..1 Coding organization | patient | practitioner | relatedperson --></resource>
  <party><!-- 0..1 Reference(Practitioner|PractitionerRole|Organization|Patient|
    RelatedPerson) Party to receive the payable --></party>
 </payee>
 <referral><!-- 0..1 Reference(ServiceRequest) Treatment Referral --></referral>
 <facility><!-- 0..1 Reference(Location) Servicing Facility --></facility>
 <careTeam>  <!-- 0..* Members of the care team -->
  <sequence value="[positiveInt]"/><!-- 1..1 Number to convey order of careTeam -->
  <provider><!-- 1..1 Reference(Practitioner|PractitionerRole|Organization) Provider individual or organization --></provider>
  <responsible value="[boolean]"/><!-- 0..1 Billing provider -->
  <role><!-- 0..1 CodeableConcept Role on the team --></role>
  <qualification><!-- 0..1 CodeableConcept Type, classification or Specialization --></qualification>
 </careTeam>
 <information>  <!-- 0..* Exceptions, special considerations, the condition, situation, prior or concurrent issues -->
  <sequence value="[positiveInt]"/><!-- 1..1 Information instance identifier -->
  <category><!-- 1..1 CodeableConcept General class of information --></category>
  <code><!-- 0..1 CodeableConcept Type of information --></code>
  <timing[x]><!-- 0..1 date|Period When it occurred --></timing[x]>
  <value[x]><!-- 0..1 boolean|string|Quantity|Attachment|Reference(Any) Additional Data or supporting information --></value[x]>
  <reason><!-- 0..1 CodeableConcept Reason associated with the information --></reason>
 </information>
 <diagnosis>  <!-- 0..* List of Diagnosis -->
  <sequence value="[positiveInt]"/><!-- 1..1 Number to convey order of diagnosis -->
  <diagnosis[x]><!-- 1..1 CodeableConcept|Reference(Condition) Patient's diagnosis --></diagnosis[x]>
  <type><!-- 0..* CodeableConcept Timing or nature of the diagnosis --></type>
  <onAdmission><!-- 0..1 CodeableConcept Present on admission --></onAdmission>
  <packageCode><!-- 0..1 CodeableConcept Package billing code --></packageCode>
 </diagnosis>
 <procedure>  <!-- 0..* Procedures performed -->
  <sequence value="[positiveInt]"/><!-- 1..1 Procedure sequence for reference -->
  <date value="[dateTime]"/><!-- 0..1 When the procedure was performed -->
  <procedure[x]><!-- 1..1 CodeableConcept|Reference(Procedure) Patient's list of procedures performed --></procedure[x]>
 </procedure>
 <insurance>  <!-- 0..* Insurance or medical plan -->
  <sequence value="[positiveInt]"/><!-- 1..1 Service instance identifier -->
  <focal value="[boolean]"/><!-- 1..1 Is the focal Coverage -->
  <identifier><!-- 0..1 Identifier Claim number --></identifier>
  <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage>
  <businessArrangement value="[string]"/><!-- 0..1 Business agreement -->
  <preAuthRef value="[string]"/><!-- 0..* Pre-Authorization/Determination Reference -->
  <claimResponse><!-- 0..1 Reference(ClaimResponse) Adjudication results --></claimResponse>
 </insurance>
 <accident>  <!-- 0..1 Details about an accident -->
  <date value="[date]"/><!-- 1..1 When the accident occurred
see information codes
see information codes -->
  <type><!-- 0..1 CodeableConcept The nature of the accident --></type>
  <location[x]><!-- 0..1 Address|Reference(Location) Accident Place --></location[x]>
 </accident>
 <item>  <!-- 0..* Goods and Services -->
  <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
  <careTeamSequence value="[positiveInt]"/><!-- 0..* Applicable careTeam members -->
  <diagnosisSequence value="[positiveInt]"/><!-- 0..* Applicable diagnoses -->
  <procedureSequence value="[positiveInt]"/><!-- 0..* Applicable procedures -->
  <informationSequence value="[positiveInt]"/><!-- 0..* Applicable exception and supporting information -->
  <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
  <category><!-- 0..1 CodeableConcept Type of service or product --></category>
  <billcode><!-- 0..1 CodeableConcept Billing Code --></billcode>
  <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
  <programCode><!-- 0..* CodeableConcept Program specific reason for item inclusion --></programCode>
  <serviced[x]><!-- 0..1 date|Period Date or dates of Service --></serviced[x]>
  <location[x]><!-- 0..1 CodeableConcept|Address|Reference(Location) Place of service --></location[x]>
  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
  <unitPrice><!-- 0..1 Money Fee, charge or cost per point --></unitPrice>
  <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
  <net><!-- 0..1 Money Total item cost --></net>
  <udi><!-- 0..* Reference(Device) Unique Device Identifier --></udi>
  <bodySite><!-- 0..1 CodeableConcept Service Location --></bodySite>
  <subSite><!-- 0..* CodeableConcept Service Sub-location --></subSite>
  <encounter><!-- 0..* Reference(Encounter) Encounters related to this billed item --></encounter>
  <detail>  <!-- 0..* Additional items -->
   <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
   <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
   <category><!-- 0..1 CodeableConcept Type of service or product --></category>
   <billcode><!-- 0..1 CodeableConcept Billing Code --></billcode>
   <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
   <programCode><!-- 0..* CodeableConcept Program specific reason for item inclusion --></programCode>
   <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
   <unitPrice><!-- 0..1 Money Fee, charge or cost per point --></unitPrice>
   <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
   <net><!-- 0..1 Money Total additional item cost --></net>
   <udi><!-- 0..* Reference(Device) Unique Device Identifier --></udi>
   <subDetail>  <!-- 0..* Additional items -->
    <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
    <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
    <category><!-- 0..1 CodeableConcept Type of service or product --></category>
    <billcode><!-- 0..1 CodeableConcept Billing Code --></billcode>
    <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
    <programCode><!-- 0..* CodeableConcept Program specific reason for item inclusion --></programCode>
    <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
    <unitPrice><!-- 0..1 Money Fee, charge or cost per point --></unitPrice>
    <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
    <net><!-- 0..1 Money Net additional item cost --></net>
    <udi><!-- 0..* Reference(Device) Unique Device Identifier --></udi>
   </subDetail>
  </detail>
 </item>
 <total><!-- 0..1 Money Total claim cost --></total>
</Claim>

JSON Template

{doco
  "resourceType" : "Claim",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Claim number
  "status" : "<code>", // active | cancelled | draft | entered-in-error
  "type" : { CodeableConcept }, // Type or discipline
  "subType" : { CodeableConcept }, // Finer grained claim type information
  "use" : "<code>", // claim | preauthorization | predetermination
  "patient" : { Reference(Patient) }, // The subject of the Products and Services
  "billablePeriod" : { Period }, // Period for charge submission
  "created" : "<dateTime>", // Creation date
  "enterer" : { Reference(Practitioner|PractitionerRole) }, // Author
  "insurer" : { Reference(Organization) }, // Target
  "provider" : { Reference(Practitioner|PractitionerRole|Organization) }, // Responsible provider
  "priority" : { CodeableConcept }, // Desired processing priority
  "fundsReserve" : { CodeableConcept }, // Funds requested to be reserved
  "related" : [{ // Related Claims which may be relevant to processing this claim
    "claim" : { Reference(Claim) }, // Reference to the related claim
    "relationship" : { CodeableConcept }, // How the reference claim is related
    "reference" : { Identifier } // Related file or case reference
  }],
  "prescription" : { Reference(MedicationRequest|VisionPrescription) }, // Prescription authorizing services or products
  "originalPrescription" : { Reference(MedicationRequest) }, // Original prescription if superseded by fulfiller
  "payee" : { // Party to be paid any benefits payable
    "type" : { CodeableConcept }, // R!  Type of party: Subscriber, Provider, other
    "resource" : { Coding }, // organization | patient | practitioner | relatedperson
    "party" : { Reference(Practitioner|PractitionerRole|Organization|Patient|
    RelatedPerson) } // Party to receive the payable
  },
  "referral" : { Reference(ServiceRequest) }, // Treatment Referral
  "facility" : { Reference(Location) }, // Servicing Facility
  "careTeam" : [{ // Members of the care team
    "sequence" : "<positiveInt>", // R!  Number to convey order of careTeam
    "provider" : { Reference(Practitioner|PractitionerRole|Organization) }, // R!  Provider individual or organization
    "responsible" : <boolean>, // Billing provider
    "role" : { CodeableConcept }, // Role on the team
    "qualification" : { CodeableConcept } // Type, classification or Specialization
  }],
  "information" : [{ // Exceptions, special considerations, the condition, situation, prior or concurrent issues
    "sequence" : "<positiveInt>", // R!  Information instance identifier
    "category" : { CodeableConcept }, // R!  General class of information
    "code" : { CodeableConcept }, // Type of information
    // timing[x]: When it occurred. One of these 2:
    "timingDate" : "<date>",
    "timingPeriod" : { Period },
    // value[x]: Additional Data or supporting information. One of these 5:
    "valueBoolean" : <boolean>,
    "valueString" : "<string>",
    "valueQuantity" : { Quantity },
    "valueAttachment" : { Attachment },
    "valueReference" : { Reference(Any) },
    "reason" : { CodeableConcept } // Reason associated with the information
  }],
  "diagnosis" : [{ // List of Diagnosis
    "sequence" : "<positiveInt>", // R!  Number to convey order of diagnosis
    // diagnosis[x]: Patient's diagnosis. One of these 2:
    "diagnosisCodeableConcept" : { CodeableConcept },
    "diagnosisReference" : { Reference(Condition) },
    "type" : [{ CodeableConcept }], // Timing or nature of the diagnosis
    "onAdmission" : { CodeableConcept }, // Present on admission
    "packageCode" : { CodeableConcept } // Package billing code
  }],
  "procedure" : [{ // Procedures performed
    "sequence" : "<positiveInt>", // R!  Procedure sequence for reference
    "date" : "<dateTime>", // When the procedure was performed
    // procedure[x]: Patient's list of procedures performed. One of these 2:
    "procedureCodeableConcept" : { CodeableConcept }
    "procedureReference" : { Reference(Procedure) }
  }],
  "insurance" : [{ // Insurance or medical plan
    "sequence" : "<positiveInt>", // R!  Service instance identifier
    "focal" : <boolean>, // R!  Is the focal Coverage
    "identifier" : { Identifier }, // Claim number
    "coverage" : { Reference(Coverage) }, // R!  Insurance information
    "businessArrangement" : "<string>", // Business agreement
    "preAuthRef" : ["<string>"], // Pre-Authorization/Determination Reference
    "claimResponse" : { Reference(ClaimResponse) } // Adjudication results
  }],
  "accident" : { // Details about an accident
    "date" : "<date>", // R!  When the accident occurred
see information codes
see information codes
    "type" : { CodeableConcept }, // The nature of the accident
    // location[x]: Accident Place. One of these 2:
    "locationAddress" : { Address }
    "locationReference" : { Reference(Location) }
  },
  "item" : [{ // Goods and Services
    "sequence" : "<positiveInt>", // R!  Service instance
    "careTeamSequence" : ["<positiveInt>"], // Applicable careTeam members
    "diagnosisSequence" : ["<positiveInt>"], // Applicable diagnoses
    "procedureSequence" : ["<positiveInt>"], // Applicable procedures
    "informationSequence" : ["<positiveInt>"], // Applicable exception and supporting information
    "revenue" : { CodeableConcept }, // Revenue or cost center code
    "category" : { CodeableConcept }, // Type of service or product
    "billcode" : { CodeableConcept }, // Billing Code
    "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
    "programCode" : [{ CodeableConcept }], // Program specific reason for item inclusion
    // serviced[x]: Date or dates of Service. One of these 2:
    "servicedDate" : "<date>",
    "servicedPeriod" : { Period },
    // location[x]: Place of service. One of these 3:
    "locationCodeableConcept" : { CodeableConcept },
    "locationAddress" : { Address },
    "locationReference" : { Reference(Location) },
    "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
    "unitPrice" : { Money }, // Fee, charge or cost per point
    "factor" : <decimal>, // Price scaling factor
    "net" : { Money }, // Total item cost
    "udi" : [{ Reference(Device) }], // Unique Device Identifier
    "bodySite" : { CodeableConcept }, // Service Location
    "subSite" : [{ CodeableConcept }], // Service Sub-location
    "encounter" : [{ Reference(Encounter) }], // Encounters related to this billed item
    "detail" : [{ // Additional items
      "sequence" : "<positiveInt>", // R!  Service instance
      "revenue" : { CodeableConcept }, // Revenue or cost center code
      "category" : { CodeableConcept }, // Type of service or product
      "billcode" : { CodeableConcept }, // Billing Code
      "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
      "programCode" : [{ CodeableConcept }], // Program specific reason for item inclusion
      "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
      "unitPrice" : { Money }, // Fee, charge or cost per point
      "factor" : <decimal>, // Price scaling factor
      "net" : { Money }, // Total additional item cost
      "udi" : [{ Reference(Device) }], // Unique Device Identifier
      "subDetail" : [{ // Additional items
        "sequence" : "<positiveInt>", // R!  Service instance
        "revenue" : { CodeableConcept }, // Revenue or cost center code
        "category" : { CodeableConcept }, // Type of service or product
        "billcode" : { CodeableConcept }, // Billing Code
        "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
        "programCode" : [{ CodeableConcept }], // Program specific reason for item inclusion
        "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
        "unitPrice" : { Money }, // Fee, charge or cost per point
        "factor" : <decimal>, // Price scaling factor
        "net" : { Money }, // Net additional item cost
        "udi" : [{ Reference(Device) }] // Unique Device Identifier
      }]
    }]
  }],
  "total" : { Money } // Total claim cost
}

Turtle Template

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


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

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:Claim.identifier [ Identifier ], ... ; # 0..* Claim number
  fhir:Claim.status [ code ]; # 0..1 active | cancelled | draft | entered-in-error
  fhir:Claim.type [ CodeableConcept ]; # 0..1 Type or discipline
  fhir:Claim.subType [ CodeableConcept ]; # 0..1 Finer grained claim type information
  fhir:Claim.use [ code ]; # 0..1 claim | preauthorization | predetermination
  fhir:Claim.patient [ Reference(Patient) ]; # 0..1 The subject of the Products and Services
  fhir:Claim.billablePeriod [ Period ]; # 0..1 Period for charge submission
  fhir:Claim.created [ dateTime ]; # 0..1 Creation date
  fhir:Claim.enterer [ Reference(Practitioner|PractitionerRole) ]; # 0..1 Author
  fhir:Claim.insurer [ Reference(Organization) ]; # 0..1 Target
  fhir:Claim.provider [ Reference(Practitioner|PractitionerRole|Organization) ]; # 0..1 Responsible provider
  fhir:Claim.priority [ CodeableConcept ]; # 0..1 Desired processing priority
  fhir:Claim.fundsReserve [ CodeableConcept ]; # 0..1 Funds requested to be reserved
  fhir:Claim.related [ # 0..* Related Claims which may be relevant to processing this claim
    fhir:Claim.related.claim [ Reference(Claim) ]; # 0..1 Reference to the related claim
    fhir:Claim.related.relationship [ CodeableConcept ]; # 0..1 How the reference claim is related
    fhir:Claim.related.reference [ Identifier ]; # 0..1 Related file or case reference
  ], ...;
  fhir:Claim.prescription [ Reference(MedicationRequest|VisionPrescription) ]; # 0..1 Prescription authorizing services or products
  fhir:Claim.originalPrescription [ Reference(MedicationRequest) ]; # 0..1 Original prescription if superseded by fulfiller
  fhir:Claim.payee [ # 0..1 Party to be paid any benefits payable
    fhir:Claim.payee.type [ CodeableConcept ]; # 1..1 Type of party: Subscriber, Provider, other
    fhir:Claim.payee.resource [ Coding ]; # 0..1 organization | patient | practitioner | relatedperson
    fhir:Claim.payee.party [ Reference(Practitioner|PractitionerRole|Organization|Patient|RelatedPerson) ]; # 0..1 Party to receive the payable
  ];
  fhir:Claim.referral [ Reference(ServiceRequest) ]; # 0..1 Treatment Referral
  fhir:Claim.facility [ Reference(Location) ]; # 0..1 Servicing Facility
  fhir:Claim.careTeam [ # 0..* Members of the care team
    fhir:Claim.careTeam.sequence [ positiveInt ]; # 1..1 Number to convey order of careTeam
    fhir:Claim.careTeam.provider [ Reference(Practitioner|PractitionerRole|Organization) ]; # 1..1 Provider individual or organization
    fhir:Claim.careTeam.responsible [ boolean ]; # 0..1 Billing provider
    fhir:Claim.careTeam.role [ CodeableConcept ]; # 0..1 Role on the team
    fhir:Claim.careTeam.qualification [ CodeableConcept ]; # 0..1 Type, classification or Specialization
  ], ...;
  fhir:Claim.information [ # 0..* Exceptions, special considerations, the condition, situation, prior or concurrent issues
    fhir:Claim.information.sequence [ positiveInt ]; # 1..1 Information instance identifier
    fhir:Claim.information.category [ CodeableConcept ]; # 1..1 General class of information
    fhir:Claim.information.code [ CodeableConcept ]; # 0..1 Type of information
    # Claim.information.timing[x] : 0..1 When it occurred. One of these 2
      fhir:Claim.information.timingDate [ date ]
      fhir:Claim.information.timingPeriod [ Period ]
    # Claim.information.value[x] : 0..1 Additional Data or supporting information. One of these 5
      fhir:Claim.information.valueBoolean [ boolean ]
      fhir:Claim.information.valueString [ string ]
      fhir:Claim.information.valueQuantity [ Quantity ]
      fhir:Claim.information.valueAttachment [ Attachment ]
      fhir:Claim.information.valueReference [ Reference(Any) ]
    fhir:Claim.information.reason [ CodeableConcept ]; # 0..1 Reason associated with the information
  ], ...;
  fhir:Claim.diagnosis [ # 0..* List of Diagnosis
    fhir:Claim.diagnosis.sequence [ positiveInt ]; # 1..1 Number to convey order of diagnosis
    # Claim.diagnosis.diagnosis[x] : 1..1 Patient's diagnosis. One of these 2
      fhir:Claim.diagnosis.diagnosisCodeableConcept [ CodeableConcept ]
      fhir:Claim.diagnosis.diagnosisReference [ Reference(Condition) ]
    fhir:Claim.diagnosis.type [ CodeableConcept ], ... ; # 0..* Timing or nature of the diagnosis
    fhir:Claim.diagnosis.onAdmission [ CodeableConcept ]; # 0..1 Present on admission
    fhir:Claim.diagnosis.packageCode [ CodeableConcept ]; # 0..1 Package billing code
  ], ...;
  fhir:Claim.procedure [ # 0..* Procedures performed
    fhir:Claim.procedure.sequence [ positiveInt ]; # 1..1 Procedure sequence for reference
    fhir:Claim.procedure.date [ dateTime ]; # 0..1 When the procedure was performed
    # Claim.procedure.procedure[x] : 1..1 Patient's list of procedures performed. One of these 2
      fhir:Claim.procedure.procedureCodeableConcept [ CodeableConcept ]
      fhir:Claim.procedure.procedureReference [ Reference(Procedure) ]
  ], ...;
  fhir:Claim.insurance [ # 0..* Insurance or medical plan
    fhir:Claim.insurance.sequence [ positiveInt ]; # 1..1 Service instance identifier
    fhir:Claim.insurance.focal [ boolean ]; # 1..1 Is the focal Coverage
    fhir:Claim.insurance.identifier [ Identifier ]; # 0..1 Claim number
    fhir:Claim.insurance.coverage [ Reference(Coverage) ]; # 1..1 Insurance information
    fhir:Claim.insurance.businessArrangement [ string ]; # 0..1 Business agreement
    fhir:Claim.insurance.preAuthRef [ string ], ... ; # 0..* Pre-Authorization/Determination Reference
    fhir:Claim.insurance.claimResponse [ Reference(ClaimResponse) ]; # 0..1 Adjudication results
  ], ...;
  fhir:Claim.accident [ # 0..1 Details about an accident
    fhir:Claim.accident.date [ date ]; # 1..1 When the accident occurred
see information codes
see information codes
    fhir:Claim.accident.type [ CodeableConcept ]; # 0..1 The nature of the accident
    # Claim.accident.location[x] : 0..1 Accident Place. One of these 2
      fhir:Claim.accident.locationAddress [ Address ]
      fhir:Claim.accident.locationReference [ Reference(Location) ]
  ];
  fhir:Claim.item [ # 0..* Goods and Services
    fhir:Claim.item.sequence [ positiveInt ]; # 1..1 Service instance
    fhir:Claim.item.careTeamSequence [ positiveInt ], ... ; # 0..* Applicable careTeam members
    fhir:Claim.item.diagnosisSequence [ positiveInt ], ... ; # 0..* Applicable diagnoses
    fhir:Claim.item.procedureSequence [ positiveInt ], ... ; # 0..* Applicable procedures
    fhir:Claim.item.informationSequence [ positiveInt ], ... ; # 0..* Applicable exception and supporting information
    fhir:Claim.item.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
    fhir:Claim.item.category [ CodeableConcept ]; # 0..1 Type of service or product
    fhir:Claim.item.billcode [ CodeableConcept ]; # 0..1 Billing Code
    fhir:Claim.item.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
    fhir:Claim.item.programCode [ CodeableConcept ], ... ; # 0..* Program specific reason for item inclusion
    # Claim.item.serviced[x] : 0..1 Date or dates of Service. One of these 2
      fhir:Claim.item.servicedDate [ date ]
      fhir:Claim.item.servicedPeriod [ Period ]
    # Claim.item.location[x] : 0..1 Place of service. One of these 3
      fhir:Claim.item.locationCodeableConcept [ CodeableConcept ]
      fhir:Claim.item.locationAddress [ Address ]
      fhir:Claim.item.locationReference [ Reference(Location) ]
    fhir:Claim.item.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of Products or Services
    fhir:Claim.item.unitPrice [ Money ]; # 0..1 Fee, charge or cost per point
    fhir:Claim.item.factor [ decimal ]; # 0..1 Price scaling factor
    fhir:Claim.item.net [ Money ]; # 0..1 Total item cost
    fhir:Claim.item.udi [ Reference(Device) ], ... ; # 0..* Unique Device Identifier
    fhir:Claim.item.bodySite [ CodeableConcept ]; # 0..1 Service Location
    fhir:Claim.item.subSite [ CodeableConcept ], ... ; # 0..* Service Sub-location
    fhir:Claim.item.encounter [ Reference(Encounter) ], ... ; # 0..* Encounters related to this billed item
    fhir:Claim.item.detail [ # 0..* Additional items
      fhir:Claim.item.detail.sequence [ positiveInt ]; # 1..1 Service instance
      fhir:Claim.item.detail.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
      fhir:Claim.item.detail.category [ CodeableConcept ]; # 0..1 Type of service or product
      fhir:Claim.item.detail.billcode [ CodeableConcept ]; # 0..1 Billing Code
      fhir:Claim.item.detail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
      fhir:Claim.item.detail.programCode [ CodeableConcept ], ... ; # 0..* Program specific reason for item inclusion
      fhir:Claim.item.detail.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of Products or Services
      fhir:Claim.item.detail.unitPrice [ Money ]; # 0..1 Fee, charge or cost per point
      fhir:Claim.item.detail.factor [ decimal ]; # 0..1 Price scaling factor
      fhir:Claim.item.detail.net [ Money ]; # 0..1 Total additional item cost
      fhir:Claim.item.detail.udi [ Reference(Device) ], ... ; # 0..* Unique Device Identifier
      fhir:Claim.item.detail.subDetail [ # 0..* Additional items
        fhir:Claim.item.detail.subDetail.sequence [ positiveInt ]; # 1..1 Service instance
        fhir:Claim.item.detail.subDetail.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
        fhir:Claim.item.detail.subDetail.category [ CodeableConcept ]; # 0..1 Type of service or product
        fhir:Claim.item.detail.subDetail.billcode [ CodeableConcept ]; # 0..1 Billing Code
        fhir:Claim.item.detail.subDetail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
        fhir:Claim.item.detail.subDetail.programCode [ CodeableConcept ], ... ; # 0..* Program specific reason for item inclusion
        fhir:Claim.item.detail.subDetail.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of Products or Services
        fhir:Claim.item.detail.subDetail.unitPrice [ Money ]; # 0..1 Fee, charge or cost per point
        fhir:Claim.item.detail.subDetail.factor [ decimal ]; # 0..1 Price scaling factor
        fhir:Claim.item.detail.subDetail.net [ Money ]; # 0..1 Net additional item cost
        fhir:Claim.item.detail.subDetail.udi [ Reference(Device) ], ... ; # 0..* Unique Device Identifier
      ], ...;
    ], ...;
  ], ...;
  fhir:Claim.total [ Money ]; # 0..1 Total claim cost
]

Changes since R3

Claim
Claim.type
  • Change binding strength from required to extensible
Claim.subType
  • Max Cardinality changed from * to 1
Claim.enterer
  • Type Reference: Added Target Type PractitionerRole
Claim.provider
  • Type Reference: Added Target Types PractitionerRole, Organization
Claim.payee.resource
  • Added Element
Claim.payee.party
  • Type Reference: Added Target Type PractitionerRole
Claim.referral
  • Type Reference: Added Target Type ServiceRequest
  • Type Reference: Removed Target Type ReferralRequest
Claim.careTeam.provider
  • Type Reference: Added Target Type PractitionerRole
Claim.information.value[x]
  • Add Type boolean
Claim.diagnosis.onAdmission
  • Added Element
Claim.insurance.identifier
  • Added Element
Claim.accident.type
  • Change binding strength from required to extensible
Claim.item.careTeamSequence
  • Added Element
Claim.item.diagnosisSequence
  • Added Element
Claim.item.procedureSequence
  • Added Element
Claim.item.informationSequence
  • Added Element
Claim.item.billcode
  • Added Element
Claim.item.detail.billcode
  • Added Element
Claim.item.detail.subDetail.billcode
  • Added Element
Claim.organization
  • deleted
Claim.payee.resourceType
  • deleted
Claim.employmentImpacted
  • deleted
Claim.hospitalization
  • deleted
Claim.item.careTeamLinkId
  • deleted
Claim.item.diagnosisLinkId
  • deleted
Claim.item.procedureLinkId
  • deleted
Claim.item.informationLinkId
  • deleted
Claim.item.service
  • deleted
Claim.item.detail.service
  • deleted
Claim.item.detail.subDetail.service
  • deleted

See the Full Difference for further information

This analysis is available as XML or JSON.

See R3 <--> R4 Conversion Maps (status = 16 tests of which 3 fail to execute. 13 fail round-trip testing and 1 r3 resources are invalid (0 errors).)

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim TUDomainResourceClaim, Pre-determination or Pre-authorization
Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier 0..*IdentifierClaim number
... status ?!Σ0..1codeactive | cancelled | draft | entered-in-error
Financial Resource Status Codes (Required)
... type 0..1CodeableConceptType or discipline
Claim Type Codes (Extensible)
... subType 0..1CodeableConceptFiner grained claim type information
Example Claim SubType Codes (Example)
... use Σ0..1codeclaim | preauthorization | predetermination
Use (Required)
... patient 0..1Reference(Patient)The subject of the Products and Services
... billablePeriod 0..1PeriodPeriod for charge submission
... created 0..1dateTimeCreation date
... enterer 0..1Reference(Practitioner | PractitionerRole)Author
... insurer 0..1Reference(Organization)Target
... provider 0..1Reference(Practitioner | PractitionerRole | Organization)Responsible provider
... priority 0..1CodeableConceptDesired processing priority
Process Priority Codes (Example)
... fundsReserve 0..1CodeableConceptFunds requested to be reserved
FundsReserve (Example)
... related 0..*BackboneElementRelated Claims which may be relevant to processing this claim
.... claim 0..1Reference(Claim)Reference to the related claim
.... relationship 0..1CodeableConceptHow the reference claim is related
Example Related Claim Relationship Codes (Example)
.... reference 0..1IdentifierRelated file or case reference
... prescription 0..1Reference(MedicationRequest | VisionPrescription)Prescription authorizing services or products
... originalPrescription 0..1Reference(MedicationRequest)Original prescription if superseded by fulfiller
... payee 0..1BackboneElementParty to be paid any benefits payable
.... type 1..1CodeableConceptType of party: Subscriber, Provider, other
PayeeType (Example)
.... resource 0..1Codingorganization | patient | practitioner | relatedperson
ClaimPayeeResourceType (Extensible)
.... party 0..1Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson)Party to receive the payable
... referral 0..1Reference(ServiceRequest)Treatment Referral
... facility 0..1Reference(Location)Servicing Facility
... careTeam 0..*BackboneElementMembers of the care team
.... sequence 1..1positiveIntNumber to convey order of careTeam
.... provider 1..1Reference(Practitioner | PractitionerRole | Organization)Provider individual or organization
.... responsible 0..1booleanBilling provider
.... role 0..1CodeableConceptRole on the team
Claim Care Team Role Codes (Example)
.... qualification 0..1CodeableConceptType, classification or Specialization
Example Provider Qualification Codes (Example)
... information 0..*BackboneElementExceptions, special considerations, the condition, situation, prior or concurrent issues
.... sequence 1..1positiveIntInformation instance identifier
.... category 1..1CodeableConceptGeneral class of information
Claim Information Category Codes (Example)
.... code 0..1CodeableConceptType of information
Exception Codes (Example)
.... timing[x] 0..1When it occurred
..... timingDatedate
..... timingPeriodPeriod
.... value[x] 0..1Additional Data or supporting information
..... valueBooleanboolean
..... valueStringstring
..... valueQuantityQuantity
..... valueAttachmentAttachment
..... valueReferenceReference(Any)
.... reason 0..1CodeableConceptReason associated with the information
Missing Tooth Reason Codes (Example)
... diagnosis 0..*BackboneElementList of Diagnosis
.... sequence 1..1positiveIntNumber to convey order of diagnosis
.... diagnosis[x] 1..1Patient's diagnosis
ICD-10 Codes (Example)
..... diagnosisCodeableConceptCodeableConcept
..... diagnosisReferenceReference(Condition)
.... type 0..*CodeableConceptTiming or nature of the diagnosis
Example Diagnosis Type Codes (Example)
.... onAdmission 0..1CodeableConceptPresent on admission
Example Diagnosis on Admission Codes (Example)
.... packageCode 0..1CodeableConceptPackage billing code
Example Diagnosis Related Group Codes (Example)
... procedure 0..*BackboneElementProcedures performed
.... sequence 1..1positiveIntProcedure sequence for reference
.... date 0..1dateTimeWhen the procedure was performed
.... procedure[x] 1..1Patient's list of procedures performed
ICD-10 Procedure Codes (Example)
..... procedureCodeableConceptCodeableConcept
..... procedureReferenceReference(Procedure)
... insurance 0..*BackboneElementInsurance or medical plan
.... sequence 1..1positiveIntService instance identifier
.... focal 1..1booleanIs the focal Coverage
.... identifier 0..1IdentifierClaim number
.... coverage 1..1Reference(Coverage)Insurance information
.... businessArrangement 0..1stringBusiness agreement
.... preAuthRef 0..*stringPre-Authorization/Determination Reference
.... claimResponse 0..1Reference(ClaimResponse)Adjudication results
... accident 0..1BackboneElementDetails about an accident
.... date 1..1dateWhen the accident occurred see information codes see information codes
.... type 0..1CodeableConceptThe nature of the accident
V3 Value SetActIncidentCode (Extensible)
.... location[x] 0..1Accident Place
..... locationAddressAddress
..... locationReferenceReference(Location)
... item 0..*BackboneElementGoods and Services
.... sequence 1..1positiveIntService instance
.... careTeamSequence 0..*positiveIntApplicable careTeam members
.... diagnosisSequence 0..*positiveIntApplicable diagnoses
.... procedureSequence 0..*positiveIntApplicable procedures
.... informationSequence 0..*positiveIntApplicable exception and supporting information
.... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
.... category 0..1CodeableConceptType of service or product
Benefit Category Codes (Example)
.... billcode 0..1CodeableConceptBilling Code
USCLS Codes (Example)
.... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
.... programCode 0..*CodeableConceptProgram specific reason for item inclusion
Example Program Reason Codes (Example)
.... serviced[x] 0..1Date or dates of Service
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service
Example Service Place Codes (Example)
..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1SimpleQuantityCount of Products or Services
.... unitPrice 0..1MoneyFee, charge or cost per point
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... udi 0..*Reference(Device)Unique Device Identifier
.... bodySite 0..1CodeableConceptService Location
Oral Site Codes (Example)
.... subSite 0..*CodeableConceptService Sub-location
Surface Codes (Example)
.... encounter 0..*Reference(Encounter)Encounters related to this billed item
.... detail 0..*BackboneElementAdditional items
..... sequence 1..1positiveIntService instance
..... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
..... category 0..1CodeableConceptType of service or product
Benefit Category Codes (Example)
..... billcode 0..1CodeableConceptBilling Code
USCLS Codes (Example)
..... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
..... programCode 0..*CodeableConceptProgram specific reason for item inclusion
Example Program Reason Codes (Example)
..... quantity 0..1SimpleQuantityCount of Products or Services
..... unitPrice 0..1MoneyFee, charge or cost per point
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal additional item cost
..... udi 0..*Reference(Device)Unique Device Identifier
..... subDetail 0..*BackboneElementAdditional items
...... sequence 1..1positiveIntService instance
...... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
...... category 0..1CodeableConceptType of service or product
Benefit Category Codes (Example)
...... billcode 0..1CodeableConceptBilling Code
USCLS Codes (Example)
...... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
...... programCode 0..*CodeableConceptProgram specific reason for item inclusion
Example Program Reason Codes (Example)
...... quantity 0..1SimpleQuantityCount of Products or Services
...... unitPrice 0..1MoneyFee, charge or cost per point
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyNet additional item cost
...... udi 0..*Reference(Device)Unique Device Identifier
... total 0..1MoneyTotal claim cost

doco Documentation for this format

UML Diagram (Legend)

Claim (DomainResource)The business identifier for the instance: claim number, pre-determination or pre-authorization numberidentifier : Identifier [0..*]The status of the resource instance (this element modifies the meaning of other elements)status : code [0..1] « A code specifying the state of the resource instance. (Strength=Required)FinancialResourceStatusCodes! »The category of claim, e.g. oral, pharmacy, vision, institutional, professionaltype : CodeableConcept [0..1] « The type or discipline-style of the claim. (Strength=Extensible)ClaimTypeCodes+ »A finer grained suite of claim subtype codes which may convey Inpatient vs Outpatient and/or a specialty service. In the US the CMS Bill TypesubType : CodeableConcept [0..1] « A more granular claim typecode. (Strength=Example)ExampleClaimSubTypeCodes?? »A claim, a list of completed goods and services; a preauthorization, a list or proposed goods and services; or a predetermination, a set of goods and services being considered, for which insurer adjudication is soughtuse : code [0..1] « Complete, proposed, exploratory, other. (Strength=Required)Use! »Patient Resourcepatient : Reference [0..1] « Patient »The billable period for which charges are being submittedbillablePeriod : Period [0..1]The date when this resource was createdcreated : dateTime [0..1]Person who created the invoice/claim/pre-determination or pre-authorizationenterer : Reference [0..1] « Practitioner|PractitionerRole »The Insurer who is target of the requestinsurer : Reference [0..1] « Organization »The provider which is responsible for the bill, claim pre-determination, pre-authorizationprovider : Reference [0..1] « Practitioner|PractitionerRole| Organization »Immediate (STAT), best effort (NORMAL), deferred (DEFER)priority : CodeableConcept [0..1] « The timeliness with which processing is required: STAT, normal, Deferred. (Strength=Example)ProcessPriorityCodes?? »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 requestedfundsReserve : CodeableConcept [0..1] « For whom funds are to be reserved: (Patient, Provider, None). (Strength=Example)Funds Reservation ?? »Prescription to support the dispensing of Pharmacy or Vision productsprescription : Reference [0..1] « MedicationRequest| VisionPrescription »Original prescription which has been superseded 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 prescription for an alternate medication which has the same therapeutic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription'originalPrescription : Reference [0..1] « MedicationRequest »The referral resource which lists the date, practitioner, reason and other supporting informationreferral : Reference [0..1] « ServiceRequest »Facility where the services were providedfacility : Reference [0..1] « Location »The total value of the claimtotal : Money [0..1]RelatedClaimOther claims which are related to this claim such as prior claim versions or for related servicesclaim : Reference [0..1] « Claim »For example, prior or umbrellarelationship : CodeableConcept [0..1] « Relationship of this claim to a related Claim. (Strength=Example) ExampleRelatedClaimRelationsh...?? »An alternate organizational reference to the case or file to which this particular claim pertains - e.g. Property/Casualty insurer claim # or Workers Compensation case # reference : Identifier [0..1]PayeeType of Party to be reimbursed: Subscriber, provider, othertype : CodeableConcept [1..1] « A code for the party to be reimbursed. (Strength=Example)Claim Payee Type ?? »organization | patient | practitioner | relatedpersonresource : Coding [0..1] « The type of Claim payee Resource. (Strength=Extensible)ClaimPayeeResourceType+ »Party to be reimbursed: Subscriber, provider, otherparty : Reference [0..1] « Practitioner|PractitionerRole| Organization|Patient|RelatedPerson »CareTeamSequence of the careTeam which serves to order and provide a linksequence : positiveInt [1..1]Member of the team who provided the overall serviceprovider : Reference [1..1] « Practitioner|PractitionerRole| Organization »The party who is billing and responsible for the claimed good or service rendered to the patientresponsible : boolean [0..1]The lead, assisting or supervising practitioner and their discipline if a multidisciplinary teamrole : CodeableConcept [0..1] « The role codes for the care team members. (Strength=Example)ClaimCareTeamRoleCodes?? »The qualification which is applicable for this servicequalification : CodeableConcept [0..1] « Provider professional qualifications. (Strength=Example) ExampleProviderQualificationC...?? »SpecialConditionSequence of the information element which serves to provide a linksequence : positiveInt [1..1]The general class of the information supplied: information; exception; accident, employment; onset, etccategory : CodeableConcept [1..1] « The valuset used for additional information category codes. (Strength=Example)ClaimInformationCategoryCodes?? »System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought which may influence the adjudicationcode : CodeableConcept [0..1] « The valuset used for additional information codes. (Strength=Example)ExceptionCodes?? »The date when or period to which this information referstiming[x] : Type [0..1] « date|Period »Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the datavalue[x] : Type [0..1] « boolean|string|Quantity|Attachment| Reference(Any) »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 contentreason : CodeableConcept [0..1] « Reason codes for the missing teeth. (Strength=Example)MissingToothReasonCodes?? »DiagnosisSequence of diagnosis which serves to provide a linksequence : positiveInt [1..1]The diagnosisdiagnosis[x] : Type [1..1] « CodeableConcept|Reference(Condition); ICD10 Diagnostic codes. (Strength=Example) ICD-10Codes?? »The type of the Diagnosis, for example: admitting, primary, secondary, dischargetype : CodeableConcept [0..*] « The type of the diagnosis: admitting, principal, discharge. (Strength=Example)ExampleDiagnosisTypeCodes?? »Indication of whether the diagnosis was present on admission to a facilityonAdmission : CodeableConcept [0..1] « Present on admission. (Strength=Example) ExampleDiagnosisOnAdmissionCo...?? »The package billing code, for example DRG, based on the assigned grouping code systempackageCode : CodeableConcept [0..1] « The DRG codes associated with the diagnosis. (Strength=Example) ExampleDiagnosisRelatedGroupC...?? »ProcedureSequence of procedures which serves to order and provide a linksequence : positiveInt [1..1]Date and optionally time the procedure was performed date : dateTime [0..1]The procedure codeprocedure[x] : Type [1..1] « CodeableConcept|Reference(Procedure); ICD10 Procedure codes. (Strength=Example) ICD-10ProcedureCodes?? »InsuranceSequence of coverage which serves to provide a link and convey coordination of benefit ordersequence : positiveInt [1..1]A flag to indicate that this Coverage is the focus for adjudication. The Coverage against which the claim is to be adjudicatedfocal : boolean [1..1]The business identifier for the instance: claim number, pre-determination or pre-authorization numberidentifier : Identifier [0..1]Reference to the program or plan identification, underwriter or payorcoverage : Reference [1..1] « Coverage »The contract number of a business agreement which describes the terms and conditionsbusinessArrangement : string [0..1]A list of references from the Insurer to which these services pertainpreAuthRef : string [0..*]The Coverages adjudication detailsclaimResponse : Reference [0..1] « ClaimResponse »AccidentDate of an accident which these services are addressingdate : date [1..1]Type of accident: work, auto, etctype : CodeableConcept [0..1] « Type of accident: work place, auto, etc. (Strength=Extensible)v3.ActIncidentCode+ »Accident Placelocation[x] : Type [0..1] « Address|Reference(Location) »ItemA service line numbersequence : positiveInt [1..1]CareTeam applicable for this service or product linecareTeamSequence : positiveInt [0..*]Diagnosis applicable for this service or product linediagnosisSequence : positiveInt [0..*]Procedures applicable for this service or product lineprocedureSequence : positiveInt [0..*]Exceptions, special conditions and supporting information applicable for this service or product lineinformationSequence : positiveInt [0..*]The type of revenue or cost center providing the product and/or servicerevenue : CodeableConcept [0..1] « Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example)ExampleRevenueCenterCodes?? »Health Care Service Type Codes to identify the classification of service or benefitscategory : CodeableConcept [0..1] « Benefit categories such as: oral-basic, major, glasses. (Strength=Example)BenefitCategoryCodes?? »If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. 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 e.g. 'glasses' or 'compound'billcode : CodeableConcept [0..1] « Allowable service and product codes. (Strength=Example)USCLSCodes?? »Item typification or modifiers codes, e.g. 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 hoursmodifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)ModifierTypeCodes?? »For programs which require reason codes for the inclusion or covering of this billed item under the program or sub-programprogramCode : CodeableConcept [0..*] « Program specific reason codes. (Strength=Example)ExampleProgramReasonCodes?? »The date or dates when the service or product was supplied, performed or completedserviced[x] : Type [0..1] « date|Period »Where the service was providedlocation[x] : Type [0..1] « CodeableConcept|Address|Reference( Location); Place of service: pharmacy, school, prison, etc. (Strength=Example)ExampleServicePlaceCodes?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the groupunitPrice : Money [0..1]A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amountfactor : decimal [0..1]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 suppliednet : Money [0..1]List of Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »Physical service site on the patient (limb, tooth, etc.)bodySite : CodeableConcept [0..1] « The code for the teeth, quadrant, sextant and arch. (Strength=Example)OralSiteCodes?? »A region or surface of the site, e.g. limb region or tooth surface(s)subSite : CodeableConcept [0..*] « The code for the tooth surface and surface combinations. (Strength=Example)SurfaceCodes?? »A billed item may include goods or services provided in multiple encountersencounter : Reference [0..*] « Encounter »DetailA service line numbersequence : positiveInt [1..1]The type of revenue or cost center providing the product and/or servicerevenue : CodeableConcept [0..1] « Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example)ExampleRevenueCenterCodes?? »Health Care Service Type Codes to identify the classification of service or benefitscategory : CodeableConcept [0..1] « Benefit categories such as: oral-basic, major, glasses. (Strength=Example)BenefitCategoryCodes?? »If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. 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'billcode : CodeableConcept [0..1] « Allowable service and product codes. (Strength=Example)USCLSCodes?? »Item typification or modifiers codes, e.g. 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 hoursmodifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)ModifierTypeCodes?? »For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-programprogramCode : CodeableConcept [0..*] « Program specific reason codes. (Strength=Example)ExampleProgramReasonCodes?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the groupunitPrice : Money [0..1]A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amountfactor : decimal [0..1]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 suppliednet : Money [0..1]List of Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »SubDetailA service line numbersequence : positiveInt [1..1]The type of revenue or cost center providing the product and/or servicerevenue : CodeableConcept [0..1] « Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example)ExampleRevenueCenterCodes?? »Health Care Service Type Codes to identify the classification of service or benefitscategory : CodeableConcept [0..1] « Benefit categories such as: oral-basic, major, glasses. (Strength=Example)BenefitCategoryCodes?? »A code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI)billcode : CodeableConcept [0..1] « Allowable service and product codes. (Strength=Example)USCLSCodes?? »Item typification or modifiers codes, e.g. 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 hoursmodifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)ModifierTypeCodes?? »For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-programprogramCode : CodeableConcept [0..*] « Program specific reason codes. (Strength=Example)ExampleProgramReasonCodes?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]The fee for an addittional service or product or chargeunitPrice : Money [0..1]A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amountfactor : decimal [0..1]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 suppliednet : Money [0..1]List of Unique Device Identifiers associated with this line itemudi : Reference [0..*] « Device »Other claims which are related to this claim such as prior claim versions or for related servicesrelated[0..*]The party to be reimbursed for the servicespayee[0..1]The members of the team who provided the overall service as well as their role and whether responsible and qualificationscareTeam[0..*]Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. Often there are multiple jurisdiction specific valuesets which are requiredinformation[0..*]List of patient diagnosis for which care is soughtdiagnosis[0..*]Ordered list of patient procedures performed to support the adjudicationprocedure[0..*]Financial instrument by which payment information for health careinsurance[0..*]An accident which resulted in the need for healthcare servicesaccident[0..1]Third tier of goods and servicessubDetail[0..*]Second tier of goods and servicesdetail[0..*]First tier of goods and servicesitem[0..*]

XML Template

<Claim xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Claim number --></identifier>
 <status value="[code]"/><!-- 0..1 active | cancelled | draft | entered-in-error -->
 <type><!-- 0..1 CodeableConcept Type or discipline --></type>
 <subType><!-- 0..1 CodeableConcept Finer grained claim type information --></subType>
 <use value="[code]"/><!-- 0..1 claim | preauthorization | predetermination -->
 <patient><!-- 0..1 Reference(Patient) The subject of the Products and Services --></patient>
 <billablePeriod><!-- 0..1 Period Period for charge submission --></billablePeriod>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <enterer><!-- 0..1 Reference(Practitioner|PractitionerRole) Author --></enterer>
 <insurer><!-- 0..1 Reference(Organization) Target --></insurer>
 <provider><!-- 0..1 Reference(Practitioner|PractitionerRole|Organization) Responsible provider --></provider>
 <priority><!-- 0..1 CodeableConcept Desired processing priority --></priority>
 <fundsReserve><!-- 0..1 CodeableConcept Funds requested to be reserved --></fundsReserve>
 <related>  <!-- 0..* Related Claims which may be relevant to processing this claim -->
  <claim><!-- 0..1 Reference(Claim) Reference to the related claim --></claim>
  <relationship><!-- 0..1 CodeableConcept How the reference claim is related --></relationship>
  <reference><!-- 0..1 Identifier Related file or case reference --></reference>
 </related>
 <prescription><!-- 0..1 Reference(MedicationRequest|VisionPrescription) Prescription authorizing services or products --></prescription>
 <originalPrescription><!-- 0..1 Reference(MedicationRequest) Original prescription if superseded by fulfiller --></originalPrescription>
 <payee>  <!-- 0..1 Party to be paid any benefits payable -->
  <type><!-- 1..1 CodeableConcept Type of party: Subscriber, Provider, other --></type>
  <resource><!-- 0..1 Coding organization | patient | practitioner | relatedperson --></resource>
  <party><!-- 0..1 Reference(Practitioner|PractitionerRole|Organization|Patient|
    RelatedPerson) Party to receive the payable --></party>
 </payee>
 <referral><!-- 0..1 Reference(ServiceRequest) Treatment Referral --></referral>
 <facility><!-- 0..1 Reference(Location) Servicing Facility --></facility>
 <careTeam>  <!-- 0..* Members of the care team -->
  <sequence value="[positiveInt]"/><!-- 1..1 Number to convey order of careTeam -->
  <provider><!-- 1..1 Reference(Practitioner|PractitionerRole|Organization) Provider individual or organization --></provider>
  <responsible value="[boolean]"/><!-- 0..1 Billing provider -->
  <role><!-- 0..1 CodeableConcept Role on the team --></role>
  <qualification><!-- 0..1 CodeableConcept Type, classification or Specialization --></qualification>
 </careTeam>
 <information>  <!-- 0..* Exceptions, special considerations, the condition, situation, prior or concurrent issues -->
  <sequence value="[positiveInt]"/><!-- 1..1 Information instance identifier -->
  <category><!-- 1..1 CodeableConcept General class of information --></category>
  <code><!-- 0..1 CodeableConcept Type of information --></code>
  <timing[x]><!-- 0..1 date|Period When it occurred --></timing[x]>
  <value[x]><!-- 0..1 boolean|string|Quantity|Attachment|Reference(Any) Additional Data or supporting information --></value[x]>
  <reason><!-- 0..1 CodeableConcept Reason associated with the information --></reason>
 </information>
 <diagnosis>  <!-- 0..* List of Diagnosis -->
  <sequence value="[positiveInt]"/><!-- 1..1 Number to convey order of diagnosis -->
  <diagnosis[x]><!-- 1..1 CodeableConcept|Reference(Condition) Patient's diagnosis --></diagnosis[x]>
  <type><!-- 0..* CodeableConcept Timing or nature of the diagnosis --></type>
  <onAdmission><!-- 0..1 CodeableConcept Present on admission --></onAdmission>
  <packageCode><!-- 0..1 CodeableConcept Package billing code --></packageCode>
 </diagnosis>
 <procedure>  <!-- 0..* Procedures performed -->
  <sequence value="[positiveInt]"/><!-- 1..1 Procedure sequence for reference -->
  <date value="[dateTime]"/><!-- 0..1 When the procedure was performed -->
  <procedure[x]><!-- 1..1 CodeableConcept|Reference(Procedure) Patient's list of procedures performed --></procedure[x]>
 </procedure>
 <insurance>  <!-- 0..* Insurance or medical plan -->
  <sequence value="[positiveInt]"/><!-- 1..1 Service instance identifier -->
  <focal value="[boolean]"/><!-- 1..1 Is the focal Coverage -->
  <identifier><!-- 0..1 Identifier Claim number --></identifier>
  <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage>
  <businessArrangement value="[string]"/><!-- 0..1 Business agreement -->
  <preAuthRef value="[string]"/><!-- 0..* Pre-Authorization/Determination Reference -->
  <claimResponse><!-- 0..1 Reference(ClaimResponse) Adjudication results --></claimResponse>
 </insurance>
 <accident>  <!-- 0..1 Details about an accident -->
  <date value="[date]"/><!-- 1..1 When the accident occurred
see information codes
see information codes -->
  <type><!-- 0..1 CodeableConcept The nature of the accident --></type>
  <location[x]><!-- 0..1 Address|Reference(Location) Accident Place --></location[x]>
 </accident>
 <item>  <!-- 0..* Goods and Services -->
  <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
  <careTeamSequence value="[positiveInt]"/><!-- 0..* Applicable careTeam members -->
  <diagnosisSequence value="[positiveInt]"/><!-- 0..* Applicable diagnoses -->
  <procedureSequence value="[positiveInt]"/><!-- 0..* Applicable procedures -->
  <informationSequence value="[positiveInt]"/><!-- 0..* Applicable exception and supporting information -->
  <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
  <category><!-- 0..1 CodeableConcept Type of service or product --></category>
  <billcode><!-- 0..1 CodeableConcept Billing Code --></billcode>
  <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
  <programCode><!-- 0..* CodeableConcept Program specific reason for item inclusion --></programCode>
  <serviced[x]><!-- 0..1 date|Period Date or dates of Service --></serviced[x]>
  <location[x]><!-- 0..1 CodeableConcept|Address|Reference(Location) Place of service --></location[x]>
  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
  <unitPrice><!-- 0..1 Money Fee, charge or cost per point --></unitPrice>
  <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
  <net><!-- 0..1 Money Total item cost --></net>
  <udi><!-- 0..* Reference(Device) Unique Device Identifier --></udi>
  <bodySite><!-- 0..1 CodeableConcept Service Location --></bodySite>
  <subSite><!-- 0..* CodeableConcept Service Sub-location --></subSite>
  <encounter><!-- 0..* Reference(Encounter) Encounters related to this billed item --></encounter>
  <detail>  <!-- 0..* Additional items -->
   <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
   <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
   <category><!-- 0..1 CodeableConcept Type of service or product --></category>
   <billcode><!-- 0..1 CodeableConcept Billing Code --></billcode>
   <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
   <programCode><!-- 0..* CodeableConcept Program specific reason for item inclusion --></programCode>
   <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
   <unitPrice><!-- 0..1 Money Fee, charge or cost per point --></unitPrice>
   <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
   <net><!-- 0..1 Money Total additional item cost --></net>
   <udi><!-- 0..* Reference(Device) Unique Device Identifier --></udi>
   <subDetail>  <!-- 0..* Additional items -->
    <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
    <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
    <category><!-- 0..1 CodeableConcept Type of service or product --></category>
    <billcode><!-- 0..1 CodeableConcept Billing Code --></billcode>
    <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
    <programCode><!-- 0..* CodeableConcept Program specific reason for item inclusion --></programCode>
    <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity>
    <unitPrice><!-- 0..1 Money Fee, charge or cost per point --></unitPrice>
    <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
    <net><!-- 0..1 Money Net additional item cost --></net>
    <udi><!-- 0..* Reference(Device) Unique Device Identifier --></udi>
   </subDetail>
  </detail>
 </item>
 <total><!-- 0..1 Money Total claim cost --></total>
</Claim>

JSON Template

{doco
  "resourceType" : "Claim",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Claim number
  "status" : "<code>", // active | cancelled | draft | entered-in-error
  "type" : { CodeableConcept }, // Type or discipline
  "subType" : { CodeableConcept }, // Finer grained claim type information
  "use" : "<code>", // claim | preauthorization | predetermination
  "patient" : { Reference(Patient) }, // The subject of the Products and Services
  "billablePeriod" : { Period }, // Period for charge submission
  "created" : "<dateTime>", // Creation date
  "enterer" : { Reference(Practitioner|PractitionerRole) }, // Author
  "insurer" : { Reference(Organization) }, // Target
  "provider" : { Reference(Practitioner|PractitionerRole|Organization) }, // Responsible provider
  "priority" : { CodeableConcept }, // Desired processing priority
  "fundsReserve" : { CodeableConcept }, // Funds requested to be reserved
  "related" : [{ // Related Claims which may be relevant to processing this claim
    "claim" : { Reference(Claim) }, // Reference to the related claim
    "relationship" : { CodeableConcept }, // How the reference claim is related
    "reference" : { Identifier } // Related file or case reference
  }],
  "prescription" : { Reference(MedicationRequest|VisionPrescription) }, // Prescription authorizing services or products
  "originalPrescription" : { Reference(MedicationRequest) }, // Original prescription if superseded by fulfiller
  "payee" : { // Party to be paid any benefits payable
    "type" : { CodeableConcept }, // R!  Type of party: Subscriber, Provider, other
    "resource" : { Coding }, // organization | patient | practitioner | relatedperson
    "party" : { Reference(Practitioner|PractitionerRole|Organization|Patient|
    RelatedPerson) } // Party to receive the payable
  },
  "referral" : { Reference(ServiceRequest) }, // Treatment Referral
  "facility" : { Reference(Location) }, // Servicing Facility
  "careTeam" : [{ // Members of the care team
    "sequence" : "<positiveInt>", // R!  Number to convey order of careTeam
    "provider" : { Reference(Practitioner|PractitionerRole|Organization) }, // R!  Provider individual or organization
    "responsible" : <boolean>, // Billing provider
    "role" : { CodeableConcept }, // Role on the team
    "qualification" : { CodeableConcept } // Type, classification or Specialization
  }],
  "information" : [{ // Exceptions, special considerations, the condition, situation, prior or concurrent issues
    "sequence" : "<positiveInt>", // R!  Information instance identifier
    "category" : { CodeableConcept }, // R!  General class of information
    "code" : { CodeableConcept }, // Type of information
    // timing[x]: When it occurred. One of these 2:
    "timingDate" : "<date>",
    "timingPeriod" : { Period },
    // value[x]: Additional Data or supporting information. One of these 5:
    "valueBoolean" : <boolean>,
    "valueString" : "<string>",
    "valueQuantity" : { Quantity },
    "valueAttachment" : { Attachment },
    "valueReference" : { Reference(Any) },
    "reason" : { CodeableConcept } // Reason associated with the information
  }],
  "diagnosis" : [{ // List of Diagnosis
    "sequence" : "<positiveInt>", // R!  Number to convey order of diagnosis
    // diagnosis[x]: Patient's diagnosis. One of these 2:
    "diagnosisCodeableConcept" : { CodeableConcept },
    "diagnosisReference" : { Reference(Condition) },
    "type" : [{ CodeableConcept }], // Timing or nature of the diagnosis
    "onAdmission" : { CodeableConcept }, // Present on admission
    "packageCode" : { CodeableConcept } // Package billing code
  }],
  "procedure" : [{ // Procedures performed
    "sequence" : "<positiveInt>", // R!  Procedure sequence for reference
    "date" : "<dateTime>", // When the procedure was performed
    // procedure[x]: Patient's list of procedures performed. One of these 2:
    "procedureCodeableConcept" : { CodeableConcept }
    "procedureReference" : { Reference(Procedure) }
  }],
  "insurance" : [{ // Insurance or medical plan
    "sequence" : "<positiveInt>", // R!  Service instance identifier
    "focal" : <boolean>, // R!  Is the focal Coverage
    "identifier" : { Identifier }, // Claim number
    "coverage" : { Reference(Coverage) }, // R!  Insurance information
    "businessArrangement" : "<string>", // Business agreement
    "preAuthRef" : ["<string>"], // Pre-Authorization/Determination Reference
    "claimResponse" : { Reference(ClaimResponse) } // Adjudication results
  }],
  "accident" : { // Details about an accident
    "date" : "<date>", // R!  When the accident occurred
see information codes
see information codes
    "type" : { CodeableConcept }, // The nature of the accident
    // location[x]: Accident Place. One of these 2:
    "locationAddress" : { Address }
    "locationReference" : { Reference(Location) }
  },
  "item" : [{ // Goods and Services
    "sequence" : "<positiveInt>", // R!  Service instance
    "careTeamSequence" : ["<positiveInt>"], // Applicable careTeam members
    "diagnosisSequence" : ["<positiveInt>"], // Applicable diagnoses
    "procedureSequence" : ["<positiveInt>"], // Applicable procedures
    "informationSequence" : ["<positiveInt>"], // Applicable exception and supporting information
    "revenue" : { CodeableConcept }, // Revenue or cost center code
    "category" : { CodeableConcept }, // Type of service or product
    "billcode" : { CodeableConcept }, // Billing Code
    "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
    "programCode" : [{ CodeableConcept }], // Program specific reason for item inclusion
    // serviced[x]: Date or dates of Service. One of these 2:
    "servicedDate" : "<date>",
    "servicedPeriod" : { Period },
    // location[x]: Place of service. One of these 3:
    "locationCodeableConcept" : { CodeableConcept },
    "locationAddress" : { Address },
    "locationReference" : { Reference(Location) },
    "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
    "unitPrice" : { Money }, // Fee, charge or cost per point
    "factor" : <decimal>, // Price scaling factor
    "net" : { Money }, // Total item cost
    "udi" : [{ Reference(Device) }], // Unique Device Identifier
    "bodySite" : { CodeableConcept }, // Service Location
    "subSite" : [{ CodeableConcept }], // Service Sub-location
    "encounter" : [{ Reference(Encounter) }], // Encounters related to this billed item
    "detail" : [{ // Additional items
      "sequence" : "<positiveInt>", // R!  Service instance
      "revenue" : { CodeableConcept }, // Revenue or cost center code
      "category" : { CodeableConcept }, // Type of service or product
      "billcode" : { CodeableConcept }, // Billing Code
      "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
      "programCode" : [{ CodeableConcept }], // Program specific reason for item inclusion
      "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
      "unitPrice" : { Money }, // Fee, charge or cost per point
      "factor" : <decimal>, // Price scaling factor
      "net" : { Money }, // Total additional item cost
      "udi" : [{ Reference(Device) }], // Unique Device Identifier
      "subDetail" : [{ // Additional items
        "sequence" : "<positiveInt>", // R!  Service instance
        "revenue" : { CodeableConcept }, // Revenue or cost center code
        "category" : { CodeableConcept }, // Type of service or product
        "billcode" : { CodeableConcept }, // Billing Code
        "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
        "programCode" : [{ CodeableConcept }], // Program specific reason for item inclusion
        "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services
        "unitPrice" : { Money }, // Fee, charge or cost per point
        "factor" : <decimal>, // Price scaling factor
        "net" : { Money }, // Net additional item cost
        "udi" : [{ Reference(Device) }] // Unique Device Identifier
      }]
    }]
  }],
  "total" : { Money } // Total claim cost
}

Turtle Template

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


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

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:Claim.identifier [ Identifier ], ... ; # 0..* Claim number
  fhir:Claim.status [ code ]; # 0..1 active | cancelled | draft | entered-in-error
  fhir:Claim.type [ CodeableConcept ]; # 0..1 Type or discipline
  fhir:Claim.subType [ CodeableConcept ]; # 0..1 Finer grained claim type information
  fhir:Claim.use [ code ]; # 0..1 claim | preauthorization | predetermination
  fhir:Claim.patient [ Reference(Patient) ]; # 0..1 The subject of the Products and Services
  fhir:Claim.billablePeriod [ Period ]; # 0..1 Period for charge submission
  fhir:Claim.created [ dateTime ]; # 0..1 Creation date
  fhir:Claim.enterer [ Reference(Practitioner|PractitionerRole) ]; # 0..1 Author
  fhir:Claim.insurer [ Reference(Organization) ]; # 0..1 Target
  fhir:Claim.provider [ Reference(Practitioner|PractitionerRole|Organization) ]; # 0..1 Responsible provider
  fhir:Claim.priority [ CodeableConcept ]; # 0..1 Desired processing priority
  fhir:Claim.fundsReserve [ CodeableConcept ]; # 0..1 Funds requested to be reserved
  fhir:Claim.related [ # 0..* Related Claims which may be relevant to processing this claim
    fhir:Claim.related.claim [ Reference(Claim) ]; # 0..1 Reference to the related claim
    fhir:Claim.related.relationship [ CodeableConcept ]; # 0..1 How the reference claim is related
    fhir:Claim.related.reference [ Identifier ]; # 0..1 Related file or case reference
  ], ...;
  fhir:Claim.prescription [ Reference(MedicationRequest|VisionPrescription) ]; # 0..1 Prescription authorizing services or products
  fhir:Claim.originalPrescription [ Reference(MedicationRequest) ]; # 0..1 Original prescription if superseded by fulfiller
  fhir:Claim.payee [ # 0..1 Party to be paid any benefits payable
    fhir:Claim.payee.type [ CodeableConcept ]; # 1..1 Type of party: Subscriber, Provider, other
    fhir:Claim.payee.resource [ Coding ]; # 0..1 organization | patient | practitioner | relatedperson
    fhir:Claim.payee.party [ Reference(Practitioner|PractitionerRole|Organization|Patient|RelatedPerson) ]; # 0..1 Party to receive the payable
  ];
  fhir:Claim.referral [ Reference(ServiceRequest) ]; # 0..1 Treatment Referral
  fhir:Claim.facility [ Reference(Location) ]; # 0..1 Servicing Facility
  fhir:Claim.careTeam [ # 0..* Members of the care team
    fhir:Claim.careTeam.sequence [ positiveInt ]; # 1..1 Number to convey order of careTeam
    fhir:Claim.careTeam.provider [ Reference(Practitioner|PractitionerRole|Organization) ]; # 1..1 Provider individual or organization
    fhir:Claim.careTeam.responsible [ boolean ]; # 0..1 Billing provider
    fhir:Claim.careTeam.role [ CodeableConcept ]; # 0..1 Role on the team
    fhir:Claim.careTeam.qualification [ CodeableConcept ]; # 0..1 Type, classification or Specialization
  ], ...;
  fhir:Claim.information [ # 0..* Exceptions, special considerations, the condition, situation, prior or concurrent issues
    fhir:Claim.information.sequence [ positiveInt ]; # 1..1 Information instance identifier
    fhir:Claim.information.category [ CodeableConcept ]; # 1..1 General class of information
    fhir:Claim.information.code [ CodeableConcept ]; # 0..1 Type of information
    # Claim.information.timing[x] : 0..1 When it occurred. One of these 2
      fhir:Claim.information.timingDate [ date ]
      fhir:Claim.information.timingPeriod [ Period ]
    # Claim.information.value[x] : 0..1 Additional Data or supporting information. One of these 5
      fhir:Claim.information.valueBoolean [ boolean ]
      fhir:Claim.information.valueString [ string ]
      fhir:Claim.information.valueQuantity [ Quantity ]
      fhir:Claim.information.valueAttachment [ Attachment ]
      fhir:Claim.information.valueReference [ Reference(Any) ]
    fhir:Claim.information.reason [ CodeableConcept ]; # 0..1 Reason associated with the information
  ], ...;
  fhir:Claim.diagnosis [ # 0..* List of Diagnosis
    fhir:Claim.diagnosis.sequence [ positiveInt ]; # 1..1 Number to convey order of diagnosis
    # Claim.diagnosis.diagnosis[x] : 1..1 Patient's diagnosis. One of these 2
      fhir:Claim.diagnosis.diagnosisCodeableConcept [ CodeableConcept ]
      fhir:Claim.diagnosis.diagnosisReference [ Reference(Condition) ]
    fhir:Claim.diagnosis.type [ CodeableConcept ], ... ; # 0..* Timing or nature of the diagnosis
    fhir:Claim.diagnosis.onAdmission [ CodeableConcept ]; # 0..1 Present on admission
    fhir:Claim.diagnosis.packageCode [ CodeableConcept ]; # 0..1 Package billing code
  ], ...;
  fhir:Claim.procedure [ # 0..* Procedures performed
    fhir:Claim.procedure.sequence [ positiveInt ]; # 1..1 Procedure sequence for reference
    fhir:Claim.procedure.date [ dateTime ]; # 0..1 When the procedure was performed
    # Claim.procedure.procedure[x] : 1..1 Patient's list of procedures performed. One of these 2
      fhir:Claim.procedure.procedureCodeableConcept [ CodeableConcept ]
      fhir:Claim.procedure.procedureReference [ Reference(Procedure) ]
  ], ...;
  fhir:Claim.insurance [ # 0..* Insurance or medical plan
    fhir:Claim.insurance.sequence [ positiveInt ]; # 1..1 Service instance identifier
    fhir:Claim.insurance.focal [ boolean ]; # 1..1 Is the focal Coverage
    fhir:Claim.insurance.identifier [ Identifier ]; # 0..1 Claim number
    fhir:Claim.insurance.coverage [ Reference(Coverage) ]; # 1..1 Insurance information
    fhir:Claim.insurance.businessArrangement [ string ]; # 0..1 Business agreement
    fhir:Claim.insurance.preAuthRef [ string ], ... ; # 0..* Pre-Authorization/Determination Reference
    fhir:Claim.insurance.claimResponse [ Reference(ClaimResponse) ]; # 0..1 Adjudication results
  ], ...;
  fhir:Claim.accident [ # 0..1 Details about an accident
    fhir:Claim.accident.date [ date ]; # 1..1 When the accident occurred
see information codes
see information codes
    fhir:Claim.accident.type [ CodeableConcept ]; # 0..1 The nature of the accident
    # Claim.accident.location[x] : 0..1 Accident Place. One of these 2
      fhir:Claim.accident.locationAddress [ Address ]
      fhir:Claim.accident.locationReference [ Reference(Location) ]
  ];
  fhir:Claim.item [ # 0..* Goods and Services
    fhir:Claim.item.sequence [ positiveInt ]; # 1..1 Service instance
    fhir:Claim.item.careTeamSequence [ positiveInt ], ... ; # 0..* Applicable careTeam members
    fhir:Claim.item.diagnosisSequence [ positiveInt ], ... ; # 0..* Applicable diagnoses
    fhir:Claim.item.procedureSequence [ positiveInt ], ... ; # 0..* Applicable procedures
    fhir:Claim.item.informationSequence [ positiveInt ], ... ; # 0..* Applicable exception and supporting information
    fhir:Claim.item.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
    fhir:Claim.item.category [ CodeableConcept ]; # 0..1 Type of service or product
    fhir:Claim.item.billcode [ CodeableConcept ]; # 0..1 Billing Code
    fhir:Claim.item.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
    fhir:Claim.item.programCode [ CodeableConcept ], ... ; # 0..* Program specific reason for item inclusion
    # Claim.item.serviced[x] : 0..1 Date or dates of Service. One of these 2
      fhir:Claim.item.servicedDate [ date ]
      fhir:Claim.item.servicedPeriod [ Period ]
    # Claim.item.location[x] : 0..1 Place of service. One of these 3
      fhir:Claim.item.locationCodeableConcept [ CodeableConcept ]
      fhir:Claim.item.locationAddress [ Address ]
      fhir:Claim.item.locationReference [ Reference(Location) ]
    fhir:Claim.item.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of Products or Services
    fhir:Claim.item.unitPrice [ Money ]; # 0..1 Fee, charge or cost per point
    fhir:Claim.item.factor [ decimal ]; # 0..1 Price scaling factor
    fhir:Claim.item.net [ Money ]; # 0..1 Total item cost
    fhir:Claim.item.udi [ Reference(Device) ], ... ; # 0..* Unique Device Identifier
    fhir:Claim.item.bodySite [ CodeableConcept ]; # 0..1 Service Location
    fhir:Claim.item.subSite [ CodeableConcept ], ... ; # 0..* Service Sub-location
    fhir:Claim.item.encounter [ Reference(Encounter) ], ... ; # 0..* Encounters related to this billed item
    fhir:Claim.item.detail [ # 0..* Additional items
      fhir:Claim.item.detail.sequence [ positiveInt ]; # 1..1 Service instance
      fhir:Claim.item.detail.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
      fhir:Claim.item.detail.category [ CodeableConcept ]; # 0..1 Type of service or product
      fhir:Claim.item.detail.billcode [ CodeableConcept ]; # 0..1 Billing Code
      fhir:Claim.item.detail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
      fhir:Claim.item.detail.programCode [ CodeableConcept ], ... ; # 0..* Program specific reason for item inclusion
      fhir:Claim.item.detail.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of Products or Services
      fhir:Claim.item.detail.unitPrice [ Money ]; # 0..1 Fee, charge or cost per point
      fhir:Claim.item.detail.factor [ decimal ]; # 0..1 Price scaling factor
      fhir:Claim.item.detail.net [ Money ]; # 0..1 Total additional item cost
      fhir:Claim.item.detail.udi [ Reference(Device) ], ... ; # 0..* Unique Device Identifier
      fhir:Claim.item.detail.subDetail [ # 0..* Additional items
        fhir:Claim.item.detail.subDetail.sequence [ positiveInt ]; # 1..1 Service instance
        fhir:Claim.item.detail.subDetail.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
        fhir:Claim.item.detail.subDetail.category [ CodeableConcept ]; # 0..1 Type of service or product
        fhir:Claim.item.detail.subDetail.billcode [ CodeableConcept ]; # 0..1 Billing Code
        fhir:Claim.item.detail.subDetail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
        fhir:Claim.item.detail.subDetail.programCode [ CodeableConcept ], ... ; # 0..* Program specific reason for item inclusion
        fhir:Claim.item.detail.subDetail.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of Products or Services
        fhir:Claim.item.detail.subDetail.unitPrice [ Money ]; # 0..1 Fee, charge or cost per point
        fhir:Claim.item.detail.subDetail.factor [ decimal ]; # 0..1 Price scaling factor
        fhir:Claim.item.detail.subDetail.net [ Money ]; # 0..1 Net additional item cost
        fhir:Claim.item.detail.subDetail.udi [ Reference(Device) ], ... ; # 0..* Unique Device Identifier
      ], ...;
    ], ...;
  ], ...;
  fhir:Claim.total [ Money ]; # 0..1 Total claim cost
]

Changes since Release 3

Claim
Claim.type
  • Change binding strength from required to extensible
Claim.subType
  • Max Cardinality changed from * to 1
Claim.enterer
  • Type Reference: Added Target Type PractitionerRole
Claim.provider
  • Type Reference: Added Target Types PractitionerRole, Organization
Claim.payee.resource
  • Added Element
Claim.payee.party
  • Type Reference: Added Target Type PractitionerRole
Claim.referral
  • Type Reference: Added Target Type ServiceRequest
  • Type Reference: Removed Target Type ReferralRequest
Claim.careTeam.provider
  • Type Reference: Added Target Type PractitionerRole
Claim.information.value[x]
  • Add Type boolean
Claim.diagnosis.onAdmission
  • Added Element
Claim.insurance.identifier
  • Added Element
Claim.accident.type
  • Change binding strength from required to extensible
Claim.item.careTeamSequence
  • Added Element
Claim.item.diagnosisSequence
  • Added Element
Claim.item.procedureSequence
  • Added Element
Claim.item.informationSequence
  • Added Element
Claim.item.billcode
  • Added Element
Claim.item.detail.billcode
  • Added Element
Claim.item.detail.subDetail.billcode
  • Added Element
Claim.organization
  • deleted
Claim.payee.resourceType
  • deleted
Claim.employmentImpacted
  • deleted
Claim.hospitalization
  • deleted
Claim.item.careTeamLinkId
  • deleted
Claim.item.diagnosisLinkId
  • deleted
Claim.item.procedureLinkId
  • deleted
Claim.item.informationLinkId
  • deleted
Claim.item.service
  • deleted
Claim.item.detail.service
  • deleted
Claim.item.detail.subDetail.service
  • deleted

See the Full Difference for further information

This analysis is available as XML or JSON.

See R3 <--> R4 Conversion Maps (status = 16 tests of which 3 fail to execute. 13 fail round-trip testing and 1 r3 resources are invalid (0 errors).)

 

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

PathDefinitionTypeReference
Claim.status A code specifying the state of the resource instance.RequiredFinancialResourceStatusCodes
Claim.type The type or discipline-style of the claim.ExtensibleClaimTypeCodes
Claim.subType A more granular claim typecode.ExampleExampleClaimSubTypeCodes
Claim.use Complete, proposed, exploratory, other.RequiredUse
Claim.priority The timeliness with which processing is required: STAT, normal, Deferred.ExampleProcessPriorityCodes
Claim.fundsReserve For whom funds are to be reserved: (Patient, Provider, None).ExampleFunds Reservation Codes
Claim.related.relationship Relationship of this claim to a related Claim.ExampleExampleRelatedClaimRelationshipCodes
Claim.payee.type A code for the party to be reimbursed.ExampleClaim Payee Type Codes
Claim.payee.resource The type of Claim payee Resource.ExtensibleClaimPayeeResourceType
Claim.careTeam.role The role codes for the care team members.ExampleClaimCareTeamRoleCodes
Claim.careTeam.qualification Provider professional qualifications.ExampleExampleProviderQualificationCodes
Claim.information.category The valuset used for additional information category codes.ExampleClaimInformationCategoryCodes
Claim.information.code The valuset used for additional information codes.ExampleExceptionCodes
Claim.information.reason Reason codes for the missing teeth.ExampleMissingToothReasonCodes
Claim.diagnosis.diagnosis[x] ICD10 Diagnostic codes.ExampleICD-10Codes
Claim.diagnosis.type The type of the diagnosis: admitting, principal, discharge.ExampleExampleDiagnosisTypeCodes
Claim.diagnosis.onAdmission Present on admission.ExampleExampleDiagnosisOnAdmissionCodes
Claim.diagnosis.packageCode The DRG codes associated with the diagnosis.ExampleExampleDiagnosisRelatedGroupCodes
Claim.procedure.procedure[x] ICD10 Procedure codes.ExampleICD-10ProcedureCodes
Claim.accident.type Type of accident: work place, auto, etc.Extensiblev3.ActIncidentCode
Claim.item.revenue
Claim.item.detail.revenue
Claim.item.detail.subDetail.revenue
Codes for the revenue or cost centers supplying the service and/or products.ExampleExampleRevenueCenterCodes
Claim.item.category
Claim.item.detail.category
Claim.item.detail.subDetail.category
Benefit categories such as: oral-basic, major, glasses.ExampleBenefitCategoryCodes
Claim.item.billcode
Claim.item.detail.billcode
Claim.item.detail.subDetail.billcode
Allowable service and product codes.ExampleUSCLSCodes
Claim.item.modifier
Claim.item.detail.modifier
Claim.item.detail.subDetail.modifier
Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.ExampleModifierTypeCodes
Claim.item.programCode
Claim.item.detail.programCode
Claim.item.detail.subDetail.programCode
Program specific reason codes.ExampleExampleProgramReasonCodes
Claim.item.location[x] Place of service: pharmacy, school, prison, etc.ExampleExampleServicePlaceCodes
Claim.item.bodySite The code for the teeth, quadrant, sextant and arch.ExampleOralSiteCodes
Claim.item.subSite The code for the tooth surface and surface combinations.ExampleSurfaceCodes

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

NameTypeDescriptionExpressionIn Common
care-teamreferenceMember of the CareTeamClaim.careTeam.provider
(Practitioner, Organization, PractitionerRole)
createddateThe creation date for the ClaimClaim.created
encounterreferenceEncounters associated with a billed line itemClaim.item.encounter
(Encounter)
entererreferenceThe party responsible for the entry of the ClaimClaim.enterer
(Practitioner, PractitionerRole)
facilityreferenceFacility responsible for the goods and servicesClaim.facility
(Location)
identifiertokenThe primary identifier of the financial resourceClaim.identifier
insurerreferenceThe target payor/insurer for the ClaimClaim.insurer
(Organization)
patientreferencePatient receiving the servicesClaim.patient
(Patient)
payeereferenceThe party receiving any payment for the ClaimClaim.payee.party
(Practitioner, Organization, Patient, PractitionerRole, RelatedPerson)
prioritytokenProcessing priority requestedClaim.priority
providerreferenceProvider responsible for the ClaimClaim.provider
(Practitioner, Organization, PractitionerRole)
statustokenThe status of the Claim instance.Claim.status
usetokenThe kind of financial resourceClaim.use