Consumer Real-Time Pharmacy Benefit Check FHIR IG
2.0.0 - CI Build United States of America flag

Consumer Real-Time Pharmacy Benefit Check FHIR IG, published by HL7 International / Pharmacy. This guide is not an authorized publication; it is the continuous build for version 2.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/carin-rtpbc/ and changes regularly. See the Directory of published versions

Resource Profile: RTPBC Request Using Claim - Non-PHI

Official URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-request-claim-non-phi Version: 2.0.0
Standards status: Trial-use Active as of 2025-12-12 Maturity Level: 4 Computable Name: RtpbcRequestClaimNonPHI

This profile provides minimal, non-persoanlly-identifiable content for submission in an RTPBC request to data sources that can provide benefit or price information without receiving patient details.

Usages:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

Description Differentials, Snapshots, and other representations.

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Claim 0..* Claim Claim, Pre-determination or Pre-authorization
... id SΣ 1..1 id Unique Claim Resource Identifier
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
.... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
.... value SΣ 1..1 string Unique RTPBC request ID
Example General: 123456
... status ?!SΣ 1..1 code Request status
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
Fixed Value: active
... type SΣ 1..1 CodeableConcept Requested Service Type
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
.... coding SΣ 1..1 Coding Code defined by a terminology system
..... system SΣ 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... code SΣ 1..1 code Symbol in syntax defined by the system
Fixed Value: pharmacy
..... display SΣ 1..1 string Representation defined by the system
Fixed Value: Pharmacy
... use SΣ 1..1 code Processing Mode
Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim.
Fixed Value: predetermination
... patient SΣ 1..1 Reference(RTPBC Patient - Non-PHI) Request Patient Information
.... reference SΣC 0..1 string Patient Reference
... created SΣ 1..1 dateTime Created DateTime
... provider SΣ 1..1 Reference(RTPBC Pharmacy Organization) Preferred Pharmacy
.... reference SΣC 0..1 string Reference to Pharmacy Organization
... priority SΣ 1..1 CodeableConcept Processing priority
Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.
.... coding SΣ 1..1 Coding Code defined by a terminology system
..... system SΣ 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/processpriority
..... code SΣ 1..1 code Symbol in syntax defined by the system
Fixed Value: normal
..... display SΣ 1..1 string Representation defined by the system
Fixed Value: Normal
... prescription S 1..1 Reference(RTPBC Medication Request - Non-PHI) Prescription Reference
.... reference SΣC 1..1 string Literal reference, Relative, internal or absolute URL
... careTeam S 0..1 BackboneElement Prescriber
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence S 1..1 positiveInt Order of care team
Fixed Value: 1
.... provider S 1..1 Reference(US Core Practitioner Profile) Prescriber
..... reference SΣC 0..1 string Prescriber Reference
... insurance Σ 1..* BackboneElement Pharmacy Coverage
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence SΣ 1..1 positiveInt Insurance instance identifier
Fixed Value: 1
.... focal SΣ 1..1 boolean Coverage to be used for adjudication
Fixed Value: true
.... coverage Σ 1..1 Reference(RTPBC Coverage) Pharmacy Coverage Reference
..... reference SΣC 0..1 string Pharmacy Coverage Reference
... item S 1..1 BackboneElement Max 1 item per request
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence S 1..1 positiveInt Item instance identifier
Fixed Value: 1
.... careTeamSequence S 1..1 positiveInt Care Team Sequence ID Reference
.... productOrService S 1..1 CodeableConcept Prescribed Product
Binding: RTPBC Prescribable Product Code Value Set (extensible): RTPBC prescribable product codes (NDC11 and RxNorm)
..... coding SΣ 0..* Coding Code defined by a terminology system
...... system SΣ 0..1 uri Identity of the terminology system
...... code SΣ 0..1 code Symbol in syntax defined by the system
...... display SΣ 0..1 string Product Description
..... text SΣ 0..1 string Plain text representation of the concept
.... quantity S 1..1 SimpleQuantity(4.0.1) Prescribed Quantity
..... value SΣ 1..1 decimal Quantity in Billing Units
..... unit SΣ 1..1 string Billing unit of measure
Binding: RTPBC Billing Unit Value Set (extensible): Billing quantity unit of measure

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Claim.identifier.use Base required IdentifierUse 📍4.0.1 FHIR Std.
Claim.status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
Claim.type Base extensible Claim Type Codes 📍4.0.1 FHIR Std.
Claim.use Base required Use 📍4.0.1 FHIR Std.
Claim.priority Base example Process Priority Codes 📍4.0.1 FHIR Std.
Claim.item.productOrService Base extensible RTPBC Prescribable Product Code Value Set 📦2.0.0 This IG
Claim.item.quantity.​unit Base extensible RTPBC Billing Unit Value Set 📦2.0.0 This IG

Constraints

Id Grade Path(s) Description Expression
dom-2 error Claim If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Claim If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error Claim If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error Claim If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Claim A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Claim Claim
... id S 1..1 id Unique Claim Resource Identifier
... identifier S 1..1 Identifier RTPBC request identifier
.... value S 1..1 string Unique RTPBC request ID
... status S 1..1 code Request status
Fixed Value: active
.... coding S 1..1 Coding Code defined by a terminology system
..... system S 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... code S 1..1 code Symbol in syntax defined by the system
Fixed Value: pharmacy
..... display S 1..1 string Representation defined by the system
Fixed Value: Pharmacy
... use S 1..1 code Processing Mode
Fixed Value: predetermination
... patient S 1..1 Reference(RTPBC Patient - Non-PHI) Request Patient Information
.... reference S 0..1 string Patient Reference
... created S 1..1 dateTime Created DateTime
... provider S 1..1 Reference(RTPBC Pharmacy Organization) Preferred Pharmacy
.... reference S 0..1 string Reference to Pharmacy Organization
... priority S 1..1 CodeableConcept Processing priority
.... coding S 1..1 Coding Code defined by a terminology system
..... system S 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/processpriority
..... code S 1..1 code Symbol in syntax defined by the system
Fixed Value: normal
..... display S 1..1 string Representation defined by the system
Fixed Value: Normal
... prescription S 1..1 Reference(RTPBC Medication Request - Non-PHI) Prescription Reference
.... reference S 1..1 string Literal reference, Relative, internal or absolute URL
... careTeam S 0..1 BackboneElement Prescriber
.... sequence S 1..1 positiveInt Order of care team
Fixed Value: 1
.... provider S 1..1 Reference(US Core Practitioner Profile) Prescriber
..... reference S 0..1 string Prescriber Reference
... insurance 1..* BackboneElement Pharmacy Coverage
.... sequence S 1..1 positiveInt Insurance instance identifier
Fixed Value: 1
.... focal S 1..1 boolean Coverage to be used for adjudication
Fixed Value: true
.... coverage 1..1 Reference(RTPBC Coverage) Pharmacy Coverage Reference
..... reference S 0..1 string Pharmacy Coverage Reference
... item S 1..1 BackboneElement Max 1 item per request
.... sequence S 1..1 positiveInt Item instance identifier
Fixed Value: 1
.... careTeamSequence S 1..1 positiveInt Care Team Sequence ID Reference
.... productOrService S 1..1 CodeableConcept Prescribed Product
Binding: RTPBC Prescribable Product Code Value Set (extensible): RTPBC prescribable product codes (NDC11 and RxNorm)
..... coding S 0..* Coding Code defined by a terminology system
...... system S 0..1 uri Identity of the terminology system
...... code S 0..1 code Symbol in syntax defined by the system
...... display S 0..1 string Product Description
..... text S 0..1 string Plain text representation of the concept
.... quantity S 1..1 SimpleQuantity(4.0.1) Prescribed Quantity
..... value S 1..1 decimal Quantity in Billing Units
..... unit S 1..1 string Billing unit of measure
Binding: RTPBC Billing Unit Value Set (extensible): Billing quantity unit of measure

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
Claim.item.productOrService Base extensible RTPBC Prescribable Product Code Value Set 📦2.0.0 This IG
Claim.item.quantity.​unit Base extensible RTPBC Billing Unit Value Set 📦2.0.0 This IG
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Claim 0..* Claim Claim, Pre-determination or Pre-authorization
... id SΣ 1..1 id Unique Claim Resource Identifier
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier S 1..1 Identifier RTPBC request identifier
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
.... type Σ 0..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
.... system Σ 0..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
.... value SΣ 1..1 string Unique RTPBC request ID
Example General: 123456
.... period Σ 0..1 Period Time period when id is/was valid for use
.... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
... status ?!SΣ 1..1 code Request status
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
Fixed Value: active
... type SΣ 1..1 CodeableConcept Requested Service Type
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... coding SΣ 1..1 Coding Code defined by a terminology system
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... system SΣ 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... version Σ 0..1 string Version of the system - if relevant
..... code SΣ 1..1 code Symbol in syntax defined by the system
Fixed Value: pharmacy
..... display SΣ 1..1 string Representation defined by the system
Fixed Value: Pharmacy
..... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text Σ 0..1 string Plain text representation of the concept
... subType 0..1 CodeableConcept More granular claim type
Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
... use SΣ 1..1 code Processing Mode
Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim.
Fixed Value: predetermination
... patient SΣ 1..1 Reference(RTPBC Patient - Non-PHI) Request Patient Information
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣC 0..1 string Patient Reference
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Text alternative for the resource
... billablePeriod Σ 0..1 Period Relevant time frame for the claim
... created SΣ 1..1 dateTime Created DateTime
... enterer 0..1 Reference(Practitioner | PractitionerRole) Author of the claim
... insurer Σ 0..1 Reference(Organization) Target
... provider SΣ 1..1 Reference(RTPBC Pharmacy Organization) Preferred Pharmacy
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣC 0..1 string Reference to Pharmacy Organization
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Text alternative for the resource
... priority SΣ 1..1 CodeableConcept Processing priority
Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... coding SΣ 1..1 Coding Code defined by a terminology system
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... system SΣ 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/processpriority
..... version Σ 0..1 string Version of the system - if relevant
..... code SΣ 1..1 code Symbol in syntax defined by the system
Fixed Value: normal
..... display SΣ 1..1 string Representation defined by the system
Fixed Value: Normal
..... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text Σ 0..1 string Plain text representation of the concept
... fundsReserve 0..1 CodeableConcept For whom to reserve funds
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
... related 0..* BackboneElement Prior or corollary claims
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... claim 0..1 Reference(Claim) Reference to the related claim
.... relationship 0..1 CodeableConcept How the reference claim is related
Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim.
.... reference 0..1 Identifier File or case reference
... prescription S 1..1 Reference(RTPBC Medication Request - Non-PHI) Prescription Reference
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣC 1..1 string Literal reference, Relative, internal or absolute URL
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Text alternative for the resource
... originalPrescription 0..1 Reference(DeviceRequest | MedicationRequest | VisionPrescription) Original prescription if superseded by fulfiller
... payee 0..1 BackboneElement Recipient of benefits payable
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type 1..1 CodeableConcept Category of recipient
Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
.... party 0..1 Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) Recipient reference
... referral 0..1 Reference(ServiceRequest) Treatment referral
... facility 0..1 Reference(Location) Servicing facility
... careTeam S 0..1 BackboneElement Prescriber
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence S 1..1 positiveInt Order of care team
Fixed Value: 1
.... provider S 1..1 Reference(US Core Practitioner Profile) Prescriber
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... reference SΣC 0..1 string Prescriber Reference
..... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
..... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
..... display Σ 0..1 string Text alternative for the resource
.... responsible 0..1 boolean Indicator of the lead practitioner
.... role 0..1 CodeableConcept Function within the team
Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members.
.... qualification 0..1 CodeableConcept Practitioner credential or specialization
Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.
... supportingInfo 0..* BackboneElement Supporting information
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Information instance identifier
.... category 1..1 CodeableConcept Classification of the supplied information
Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes.
.... code 0..1 CodeableConcept Type of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.
.... timing[x] 0..1 When it occurred
..... timingDate date
..... timingPeriod Period
.... value[x] 0..1 Data to be provided
..... valueBoolean boolean
..... valueString string
..... valueQuantity Quantity
..... valueAttachment Attachment
..... valueReference Reference(Resource)
.... reason 0..1 CodeableConcept Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
... diagnosis 0..* BackboneElement Pertinent diagnosis information
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Diagnosis instance identifier
.... diagnosis[x] 1..1 Nature of illness or problem
Binding: ICD-10Codes (example): Example ICD10 Diagnostic codes.
..... diagnosisCodeableConcept CodeableConcept
..... diagnosisReference Reference(Condition)
.... type 0..* CodeableConcept Timing or nature of the diagnosis
Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge.
.... onAdmission 0..1 CodeableConcept Present on admission
Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.
.... packageCode 0..1 CodeableConcept Package billing code
Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.
... procedure 0..* BackboneElement Clinical procedures performed
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Procedure instance identifier
.... type 0..* CodeableConcept Category of Procedure
Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.
.... date 0..1 dateTime When the procedure was performed
.... procedure[x] 1..1 Specific clinical procedure
Binding: ICD-10ProcedureCodes (example): Example ICD10 Procedure codes.
..... procedureCodeableConcept CodeableConcept
..... procedureReference Reference(Procedure)
.... udi 0..* Reference(Device) Unique device identifier
... insurance Σ 1..* BackboneElement Pharmacy Coverage
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence SΣ 1..1 positiveInt Insurance instance identifier
Fixed Value: 1
.... focal SΣ 1..1 boolean Coverage to be used for adjudication
Fixed Value: true
.... identifier 0..1 Identifier Pre-assigned Claim number
.... coverage Σ 1..1 Reference(RTPBC Coverage) Pharmacy Coverage Reference
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... reference SΣC 0..1 string Pharmacy Coverage Reference
..... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
..... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
..... display Σ 0..1 string Text alternative for the resource
.... businessArrangement 0..1 string Additional provider contract number
.... preAuthRef 0..* string Prior authorization reference number
.... claimResponse 0..1 Reference(ClaimResponse) Adjudication results
... accident 0..1 BackboneElement Details of the event
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... date 1..1 date When the incident occurred
.... type 0..1 CodeableConcept The nature of the accident
Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc.
.... location[x] 0..1 Where the event occurred
..... locationAddress Address
..... locationReference Reference(Location)
... item S 1..1 BackboneElement Max 1 item per request
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence S 1..1 positiveInt Item instance identifier
Fixed Value: 1
.... careTeamSequence S 1..1 positiveInt Care Team Sequence ID Reference
.... diagnosisSequence 0..* positiveInt Applicable diagnoses
.... procedureSequence 0..* positiveInt Applicable procedures
.... informationSequence 0..* positiveInt Applicable exception and supporting information
.... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
.... category 0..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.
.... productOrService S 1..1 CodeableConcept Prescribed Product
Binding: RTPBC Prescribable Product Code Value Set (extensible): RTPBC prescribable product codes (NDC11 and RxNorm)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... coding SΣ 0..* Coding Code defined by a terminology system
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ 0..1 uri Identity of the terminology system
...... version Σ 0..1 string Version of the system - if relevant
...... code SΣ 0..1 code Symbol in syntax defined by the system
...... display SΣ 0..1 string Product Description
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
..... text SΣ 0..1 string Plain text representation of the concept
.... modifier 0..* CodeableConcept Product or service billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
.... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
.... serviced[x] 0..1 Date or dates of service or product delivery
..... servicedDate date
..... servicedPeriod Period
.... location[x] 0..1 Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.
..... locationCodeableConcept CodeableConcept
..... locationAddress Address
..... locationReference Reference(Location)
.... quantity S 1..1 SimpleQuantity(4.0.1) Prescribed Quantity
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... value SΣ 1..1 decimal Quantity in Billing Units
..... unit SΣ 1..1 string Billing unit of measure
Binding: RTPBC Billing Unit Value Set (extensible): Billing quantity unit of measure
..... system ΣC 0..1 uri System that defines coded unit form
..... code Σ 0..1 code Coded form of the unit
.... unitPrice 0..1 Money Fee, charge or cost per item
.... factor 0..1 decimal Price scaling factor
.... net 0..1 Money Total item cost
.... udi 0..* Reference(Device) Unique device identifier
.... bodySite 0..1 CodeableConcept Anatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
.... subSite 0..* CodeableConcept Anatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
.... encounter 0..* Reference(Encounter) Encounters related to this billed item
.... detail 0..* BackboneElement Product or service provided
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Item instance identifier
..... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
..... category 0..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.
..... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
..... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
..... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
..... quantity 0..1 SimpleQuantity(4.0.1) Count of products or services
..... unitPrice 0..1 Money Fee, charge or cost per item
..... factor 0..1 decimal Price scaling factor
..... net 0..1 Money Total item cost
..... udi 0..* Reference(Device) Unique device identifier
..... subDetail 0..* BackboneElement Product or service provided
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... sequence 1..1 positiveInt Item instance identifier
...... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
...... category 0..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.
...... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
...... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
...... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
...... quantity 0..1 SimpleQuantity(4.0.1) Count of products or services
...... unitPrice 0..1 Money Fee, charge or cost per item
...... factor 0..1 decimal Price scaling factor
...... net 0..1 Money Total item cost
...... udi 0..* Reference(Device) Unique device identifier
... total 0..1 Money Total claim cost

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Claim.language Base preferred Common Languages 📍4.0.1 FHIR Std.
Claim.identifier.use Base required IdentifierUse 📍4.0.1 FHIR Std.
Claim.identifier.type Base extensible IdentifierType 📍4.0.1 FHIR Std.
Claim.status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
Claim.type Base extensible Claim Type Codes 📍4.0.1 FHIR Std.
Claim.subType Base example Example Claim SubType Codes 📍4.0.1 FHIR Std.
Claim.use Base required Use 📍4.0.1 FHIR Std.
Claim.patient.type Base extensible ResourceType 📍4.0.1 FHIR Std.
Claim.provider.type Base extensible ResourceType 📍4.0.1 FHIR Std.
Claim.priority Base example Process Priority Codes 📍4.0.1 FHIR Std.
Claim.fundsReserve Base example FundsReserve 📍4.0.1 FHIR Std.
Claim.related.relationship Base example Example Related Claim Relationship Codes 📍4.0.1 FHIR Std.
Claim.prescription.type Base extensible ResourceType 📍4.0.1 FHIR Std.
Claim.payee.type Base example PayeeType 📍4.0.1 FHIR Std.
Claim.careTeam.provider.​type Base extensible ResourceType 📍4.0.1 FHIR Std.
Claim.careTeam.role Base example Claim Care Team Role Codes 📍4.0.1 FHIR Std.
Claim.careTeam.qualification Base example Example Provider Qualification Codes 📍4.0.1 FHIR Std.
Claim.supportingInfo.​category Base example Claim Information Category Codes 📍4.0.1 FHIR Std.
Claim.supportingInfo.​code Base example Exception Codes 📍4.0.1 FHIR Std.
Claim.supportingInfo.​reason Base example Missing Tooth Reason Codes 📍4.0.1 FHIR Std.
Claim.diagnosis.diagnosis[x] Base example ICD-10 Codes 📍4.0.1 FHIR Std.
Claim.diagnosis.type Base example Example Diagnosis Type Codes 📍4.0.1 FHIR Std.
Claim.diagnosis.onAdmission Base example Example Diagnosis on Admission Codes 📍4.0.1 FHIR Std.
Claim.diagnosis.packageCode Base example Example Diagnosis Related Group Codes 📍4.0.1 FHIR Std.
Claim.procedure.type Base example Example Procedure Type Codes 📍4.0.1 FHIR Std.
Claim.procedure.procedure[x] Base example ICD-10 Procedure Codes 📍4.0.1 FHIR Std.
Claim.insurance.coverage.​type Base extensible ResourceType 📍4.0.1 FHIR Std.
Claim.accident.type Base extensible ActIncidentCode 📦3.0.0 THO v7.0
Claim.item.revenue Base example Example Revenue Center Codes 📍4.0.1 FHIR Std.
Claim.item.category Base example Benefit Category Codes 📍4.0.1 FHIR Std.
Claim.item.productOrService Base extensible RTPBC Prescribable Product Code Value Set 📦2.0.0 This IG
Claim.item.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
Claim.item.programCode Base example Example Program Reason Codes 📍4.0.1 FHIR Std.
Claim.item.location[x] Base example Example Service Place Codes 📍4.0.1 FHIR Std.
Claim.item.quantity.​unit Base extensible RTPBC Billing Unit Value Set 📦2.0.0 This IG
Claim.item.bodySite Base example Oral Site Codes 📍4.0.1 FHIR Std.
Claim.item.subSite Base example Surface Codes 📍4.0.1 FHIR Std.
Claim.item.detail.revenue Base example Example Revenue Center Codes 📍4.0.1 FHIR Std.
Claim.item.detail.category Base example Benefit Category Codes 📍4.0.1 FHIR Std.
Claim.item.detail.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
Claim.item.detail.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
Claim.item.detail.programCode Base example Example Program Reason Codes 📍4.0.1 FHIR Std.
Claim.item.detail.subDetail.​revenue Base example Example Revenue Center Codes 📍4.0.1 FHIR Std.
Claim.item.detail.subDetail.​category Base example Benefit Category Codes 📍4.0.1 FHIR Std.
Claim.item.detail.subDetail.​productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
Claim.item.detail.subDetail.​modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
Claim.item.detail.subDetail.​programCode Base example Example Program Reason Codes 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error Claim If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Claim If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error Claim If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error Claim If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Claim A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Claim 0..* Claim Claim, Pre-determination or Pre-authorization
... id SΣ 1..1 id Unique Claim Resource Identifier
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
.... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
.... value SΣ 1..1 string Unique RTPBC request ID
Example General: 123456
... status ?!SΣ 1..1 code Request status
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
Fixed Value: active
... type SΣ 1..1 CodeableConcept Requested Service Type
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
.... coding SΣ 1..1 Coding Code defined by a terminology system
..... system SΣ 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... code SΣ 1..1 code Symbol in syntax defined by the system
Fixed Value: pharmacy
..... display SΣ 1..1 string Representation defined by the system
Fixed Value: Pharmacy
... use SΣ 1..1 code Processing Mode
Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim.
Fixed Value: predetermination
... patient SΣ 1..1 Reference(RTPBC Patient - Non-PHI) Request Patient Information
.... reference SΣC 0..1 string Patient Reference
... created SΣ 1..1 dateTime Created DateTime
... provider SΣ 1..1 Reference(RTPBC Pharmacy Organization) Preferred Pharmacy
.... reference SΣC 0..1 string Reference to Pharmacy Organization
... priority SΣ 1..1 CodeableConcept Processing priority
Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.
.... coding SΣ 1..1 Coding Code defined by a terminology system
..... system SΣ 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/processpriority
..... code SΣ 1..1 code Symbol in syntax defined by the system
Fixed Value: normal
..... display SΣ 1..1 string Representation defined by the system
Fixed Value: Normal
... prescription S 1..1 Reference(RTPBC Medication Request - Non-PHI) Prescription Reference
.... reference SΣC 1..1 string Literal reference, Relative, internal or absolute URL
... careTeam S 0..1 BackboneElement Prescriber
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence S 1..1 positiveInt Order of care team
Fixed Value: 1
.... provider S 1..1 Reference(US Core Practitioner Profile) Prescriber
..... reference SΣC 0..1 string Prescriber Reference
... insurance Σ 1..* BackboneElement Pharmacy Coverage
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence SΣ 1..1 positiveInt Insurance instance identifier
Fixed Value: 1
.... focal SΣ 1..1 boolean Coverage to be used for adjudication
Fixed Value: true
.... coverage Σ 1..1 Reference(RTPBC Coverage) Pharmacy Coverage Reference
..... reference SΣC 0..1 string Pharmacy Coverage Reference
... item S 1..1 BackboneElement Max 1 item per request
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence S 1..1 positiveInt Item instance identifier
Fixed Value: 1
.... careTeamSequence S 1..1 positiveInt Care Team Sequence ID Reference
.... productOrService S 1..1 CodeableConcept Prescribed Product
Binding: RTPBC Prescribable Product Code Value Set (extensible): RTPBC prescribable product codes (NDC11 and RxNorm)
..... coding SΣ 0..* Coding Code defined by a terminology system
...... system SΣ 0..1 uri Identity of the terminology system
...... code SΣ 0..1 code Symbol in syntax defined by the system
...... display SΣ 0..1 string Product Description
..... text SΣ 0..1 string Plain text representation of the concept
.... quantity S 1..1 SimpleQuantity(4.0.1) Prescribed Quantity
..... value SΣ 1..1 decimal Quantity in Billing Units
..... unit SΣ 1..1 string Billing unit of measure
Binding: RTPBC Billing Unit Value Set (extensible): Billing quantity unit of measure

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Claim.identifier.use Base required IdentifierUse 📍4.0.1 FHIR Std.
Claim.status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
Claim.type Base extensible Claim Type Codes 📍4.0.1 FHIR Std.
Claim.use Base required Use 📍4.0.1 FHIR Std.
Claim.priority Base example Process Priority Codes 📍4.0.1 FHIR Std.
Claim.item.productOrService Base extensible RTPBC Prescribable Product Code Value Set 📦2.0.0 This IG
Claim.item.quantity.​unit Base extensible RTPBC Billing Unit Value Set 📦2.0.0 This IG

Constraints

Id Grade Path(s) Description Expression
dom-2 error Claim If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Claim If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error Claim If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error Claim If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Claim A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

Differential View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Claim Claim
... id S 1..1 id Unique Claim Resource Identifier
... identifier S 1..1 Identifier RTPBC request identifier
.... value S 1..1 string Unique RTPBC request ID
... status S 1..1 code Request status
Fixed Value: active
.... coding S 1..1 Coding Code defined by a terminology system
..... system S 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... code S 1..1 code Symbol in syntax defined by the system
Fixed Value: pharmacy
..... display S 1..1 string Representation defined by the system
Fixed Value: Pharmacy
... use S 1..1 code Processing Mode
Fixed Value: predetermination
... patient S 1..1 Reference(RTPBC Patient - Non-PHI) Request Patient Information
.... reference S 0..1 string Patient Reference
... created S 1..1 dateTime Created DateTime
... provider S 1..1 Reference(RTPBC Pharmacy Organization) Preferred Pharmacy
.... reference S 0..1 string Reference to Pharmacy Organization
... priority S 1..1 CodeableConcept Processing priority
.... coding S 1..1 Coding Code defined by a terminology system
..... system S 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/processpriority
..... code S 1..1 code Symbol in syntax defined by the system
Fixed Value: normal
..... display S 1..1 string Representation defined by the system
Fixed Value: Normal
... prescription S 1..1 Reference(RTPBC Medication Request - Non-PHI) Prescription Reference
.... reference S 1..1 string Literal reference, Relative, internal or absolute URL
... careTeam S 0..1 BackboneElement Prescriber
.... sequence S 1..1 positiveInt Order of care team
Fixed Value: 1
.... provider S 1..1 Reference(US Core Practitioner Profile) Prescriber
..... reference S 0..1 string Prescriber Reference
... insurance 1..* BackboneElement Pharmacy Coverage
.... sequence S 1..1 positiveInt Insurance instance identifier
Fixed Value: 1
.... focal S 1..1 boolean Coverage to be used for adjudication
Fixed Value: true
.... coverage 1..1 Reference(RTPBC Coverage) Pharmacy Coverage Reference
..... reference S 0..1 string Pharmacy Coverage Reference
... item S 1..1 BackboneElement Max 1 item per request
.... sequence S 1..1 positiveInt Item instance identifier
Fixed Value: 1
.... careTeamSequence S 1..1 positiveInt Care Team Sequence ID Reference
.... productOrService S 1..1 CodeableConcept Prescribed Product
Binding: RTPBC Prescribable Product Code Value Set (extensible): RTPBC prescribable product codes (NDC11 and RxNorm)
..... coding S 0..* Coding Code defined by a terminology system
...... system S 0..1 uri Identity of the terminology system
...... code S 0..1 code Symbol in syntax defined by the system
...... display S 0..1 string Product Description
..... text S 0..1 string Plain text representation of the concept
.... quantity S 1..1 SimpleQuantity(4.0.1) Prescribed Quantity
..... value S 1..1 decimal Quantity in Billing Units
..... unit S 1..1 string Billing unit of measure
Binding: RTPBC Billing Unit Value Set (extensible): Billing quantity unit of measure

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
Claim.item.productOrService Base extensible RTPBC Prescribable Product Code Value Set 📦2.0.0 This IG
Claim.item.quantity.​unit Base extensible RTPBC Billing Unit Value Set 📦2.0.0 This IG

Snapshot ViewView

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Claim 0..* Claim Claim, Pre-determination or Pre-authorization
... id SΣ 1..1 id Unique Claim Resource Identifier
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier S 1..1 Identifier RTPBC request identifier
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
.... type Σ 0..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
.... system Σ 0..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
.... value SΣ 1..1 string Unique RTPBC request ID
Example General: 123456
.... period Σ 0..1 Period Time period when id is/was valid for use
.... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
... status ?!SΣ 1..1 code Request status
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
Fixed Value: active
... type SΣ 1..1 CodeableConcept Requested Service Type
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... coding SΣ 1..1 Coding Code defined by a terminology system
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... system SΣ 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... version Σ 0..1 string Version of the system - if relevant
..... code SΣ 1..1 code Symbol in syntax defined by the system
Fixed Value: pharmacy
..... display SΣ 1..1 string Representation defined by the system
Fixed Value: Pharmacy
..... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text Σ 0..1 string Plain text representation of the concept
... subType 0..1 CodeableConcept More granular claim type
Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
... use SΣ 1..1 code Processing Mode
Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim.
Fixed Value: predetermination
... patient SΣ 1..1 Reference(RTPBC Patient - Non-PHI) Request Patient Information
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣC 0..1 string Patient Reference
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Text alternative for the resource
... billablePeriod Σ 0..1 Period Relevant time frame for the claim
... created SΣ 1..1 dateTime Created DateTime
... enterer 0..1 Reference(Practitioner | PractitionerRole) Author of the claim
... insurer Σ 0..1 Reference(Organization) Target
... provider SΣ 1..1 Reference(RTPBC Pharmacy Organization) Preferred Pharmacy
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣC 0..1 string Reference to Pharmacy Organization
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Text alternative for the resource
... priority SΣ 1..1 CodeableConcept Processing priority
Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... coding SΣ 1..1 Coding Code defined by a terminology system
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... system SΣ 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/processpriority
..... version Σ 0..1 string Version of the system - if relevant
..... code SΣ 1..1 code Symbol in syntax defined by the system
Fixed Value: normal
..... display SΣ 1..1 string Representation defined by the system
Fixed Value: Normal
..... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text Σ 0..1 string Plain text representation of the concept
... fundsReserve 0..1 CodeableConcept For whom to reserve funds
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
... related 0..* BackboneElement Prior or corollary claims
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... claim 0..1 Reference(Claim) Reference to the related claim
.... relationship 0..1 CodeableConcept How the reference claim is related
Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim.
.... reference 0..1 Identifier File or case reference
... prescription S 1..1 Reference(RTPBC Medication Request - Non-PHI) Prescription Reference
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣC 1..1 string Literal reference, Relative, internal or absolute URL
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Text alternative for the resource
... originalPrescription 0..1 Reference(DeviceRequest | MedicationRequest | VisionPrescription) Original prescription if superseded by fulfiller
... payee 0..1 BackboneElement Recipient of benefits payable
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type 1..1 CodeableConcept Category of recipient
Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
.... party 0..1 Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) Recipient reference
... referral 0..1 Reference(ServiceRequest) Treatment referral
... facility 0..1 Reference(Location) Servicing facility
... careTeam S 0..1 BackboneElement Prescriber
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence S 1..1 positiveInt Order of care team
Fixed Value: 1
.... provider S 1..1 Reference(US Core Practitioner Profile) Prescriber
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... reference SΣC 0..1 string Prescriber Reference
..... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
..... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
..... display Σ 0..1 string Text alternative for the resource
.... responsible 0..1 boolean Indicator of the lead practitioner
.... role 0..1 CodeableConcept Function within the team
Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members.
.... qualification 0..1 CodeableConcept Practitioner credential or specialization
Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.
... supportingInfo 0..* BackboneElement Supporting information
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Information instance identifier
.... category 1..1 CodeableConcept Classification of the supplied information
Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes.
.... code 0..1 CodeableConcept Type of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.
.... timing[x] 0..1 When it occurred
..... timingDate date
..... timingPeriod Period
.... value[x] 0..1 Data to be provided
..... valueBoolean boolean
..... valueString string
..... valueQuantity Quantity
..... valueAttachment Attachment
..... valueReference Reference(Resource)
.... reason 0..1 CodeableConcept Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
... diagnosis 0..* BackboneElement Pertinent diagnosis information
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Diagnosis instance identifier
.... diagnosis[x] 1..1 Nature of illness or problem
Binding: ICD-10Codes (example): Example ICD10 Diagnostic codes.
..... diagnosisCodeableConcept CodeableConcept
..... diagnosisReference Reference(Condition)
.... type 0..* CodeableConcept Timing or nature of the diagnosis
Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge.
.... onAdmission 0..1 CodeableConcept Present on admission
Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.
.... packageCode 0..1 CodeableConcept Package billing code
Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.
... procedure 0..* BackboneElement Clinical procedures performed
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Procedure instance identifier
.... type 0..* CodeableConcept Category of Procedure
Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.
.... date 0..1 dateTime When the procedure was performed
.... procedure[x] 1..1 Specific clinical procedure
Binding: ICD-10ProcedureCodes (example): Example ICD10 Procedure codes.
..... procedureCodeableConcept CodeableConcept
..... procedureReference Reference(Procedure)
.... udi 0..* Reference(Device) Unique device identifier
... insurance Σ 1..* BackboneElement Pharmacy Coverage
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence SΣ 1..1 positiveInt Insurance instance identifier
Fixed Value: 1
.... focal SΣ 1..1 boolean Coverage to be used for adjudication
Fixed Value: true
.... identifier 0..1 Identifier Pre-assigned Claim number
.... coverage Σ 1..1 Reference(RTPBC Coverage) Pharmacy Coverage Reference
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... reference SΣC 0..1 string Pharmacy Coverage Reference
..... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
..... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
..... display Σ 0..1 string Text alternative for the resource
.... businessArrangement 0..1 string Additional provider contract number
.... preAuthRef 0..* string Prior authorization reference number
.... claimResponse 0..1 Reference(ClaimResponse) Adjudication results
... accident 0..1 BackboneElement Details of the event
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... date 1..1 date When the incident occurred
.... type 0..1 CodeableConcept The nature of the accident
Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc.
.... location[x] 0..1 Where the event occurred
..... locationAddress Address
..... locationReference Reference(Location)
... item S 1..1 BackboneElement Max 1 item per request
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence S 1..1 positiveInt Item instance identifier
Fixed Value: 1
.... careTeamSequence S 1..1 positiveInt Care Team Sequence ID Reference
.... diagnosisSequence 0..* positiveInt Applicable diagnoses
.... procedureSequence 0..* positiveInt Applicable procedures
.... informationSequence 0..* positiveInt Applicable exception and supporting information
.... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
.... category 0..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.
.... productOrService S 1..1 CodeableConcept Prescribed Product
Binding: RTPBC Prescribable Product Code Value Set (extensible): RTPBC prescribable product codes (NDC11 and RxNorm)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... coding SΣ 0..* Coding Code defined by a terminology system
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ 0..1 uri Identity of the terminology system
...... version Σ 0..1 string Version of the system - if relevant
...... code SΣ 0..1 code Symbol in syntax defined by the system
...... display SΣ 0..1 string Product Description
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
..... text SΣ 0..1 string Plain text representation of the concept
.... modifier 0..* CodeableConcept Product or service billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
.... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
.... serviced[x] 0..1 Date or dates of service or product delivery
..... servicedDate date
..... servicedPeriod Period
.... location[x] 0..1 Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.
..... locationCodeableConcept CodeableConcept
..... locationAddress Address
..... locationReference Reference(Location)
.... quantity S 1..1 SimpleQuantity(4.0.1) Prescribed Quantity
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... value SΣ 1..1 decimal Quantity in Billing Units
..... unit SΣ 1..1 string Billing unit of measure
Binding: RTPBC Billing Unit Value Set (extensible): Billing quantity unit of measure
..... system ΣC 0..1 uri System that defines coded unit form
..... code Σ 0..1 code Coded form of the unit
.... unitPrice 0..1 Money Fee, charge or cost per item
.... factor 0..1 decimal Price scaling factor
.... net 0..1 Money Total item cost
.... udi 0..* Reference(Device) Unique device identifier
.... bodySite 0..1 CodeableConcept Anatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
.... subSite 0..* CodeableConcept Anatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
.... encounter 0..* Reference(Encounter) Encounters related to this billed item
.... detail 0..* BackboneElement Product or service provided
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Item instance identifier
..... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
..... category 0..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.
..... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
..... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
..... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
..... quantity 0..1 SimpleQuantity(4.0.1) Count of products or services
..... unitPrice 0..1 Money Fee, charge or cost per item
..... factor 0..1 decimal Price scaling factor
..... net 0..1 Money Total item cost
..... udi 0..* Reference(Device) Unique device identifier
..... subDetail 0..* BackboneElement Product or service provided
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... sequence 1..1 positiveInt Item instance identifier
...... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
...... category 0..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.
...... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
...... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
...... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
...... quantity 0..1 SimpleQuantity(4.0.1) Count of products or services
...... unitPrice 0..1 Money Fee, charge or cost per item
...... factor 0..1 decimal Price scaling factor
...... net 0..1 Money Total item cost
...... udi 0..* Reference(Device) Unique device identifier
... total 0..1 Money Total claim cost

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Claim.language Base preferred Common Languages 📍4.0.1 FHIR Std.
Claim.identifier.use Base required IdentifierUse 📍4.0.1 FHIR Std.
Claim.identifier.type Base extensible IdentifierType 📍4.0.1 FHIR Std.
Claim.status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
Claim.type Base extensible Claim Type Codes 📍4.0.1 FHIR Std.
Claim.subType Base example Example Claim SubType Codes 📍4.0.1 FHIR Std.
Claim.use Base required Use 📍4.0.1 FHIR Std.
Claim.patient.type Base extensible ResourceType 📍4.0.1 FHIR Std.
Claim.provider.type Base extensible ResourceType 📍4.0.1 FHIR Std.
Claim.priority Base example Process Priority Codes 📍4.0.1 FHIR Std.
Claim.fundsReserve Base example FundsReserve 📍4.0.1 FHIR Std.
Claim.related.relationship Base example Example Related Claim Relationship Codes 📍4.0.1 FHIR Std.
Claim.prescription.type Base extensible ResourceType 📍4.0.1 FHIR Std.
Claim.payee.type Base example PayeeType 📍4.0.1 FHIR Std.
Claim.careTeam.provider.​type Base extensible ResourceType 📍4.0.1 FHIR Std.
Claim.careTeam.role Base example Claim Care Team Role Codes 📍4.0.1 FHIR Std.
Claim.careTeam.qualification Base example Example Provider Qualification Codes 📍4.0.1 FHIR Std.
Claim.supportingInfo.​category Base example Claim Information Category Codes 📍4.0.1 FHIR Std.
Claim.supportingInfo.​code Base example Exception Codes 📍4.0.1 FHIR Std.
Claim.supportingInfo.​reason Base example Missing Tooth Reason Codes 📍4.0.1 FHIR Std.
Claim.diagnosis.diagnosis[x] Base example ICD-10 Codes 📍4.0.1 FHIR Std.
Claim.diagnosis.type Base example Example Diagnosis Type Codes 📍4.0.1 FHIR Std.
Claim.diagnosis.onAdmission Base example Example Diagnosis on Admission Codes 📍4.0.1 FHIR Std.
Claim.diagnosis.packageCode Base example Example Diagnosis Related Group Codes 📍4.0.1 FHIR Std.
Claim.procedure.type Base example Example Procedure Type Codes 📍4.0.1 FHIR Std.
Claim.procedure.procedure[x] Base example ICD-10 Procedure Codes 📍4.0.1 FHIR Std.
Claim.insurance.coverage.​type Base extensible ResourceType 📍4.0.1 FHIR Std.
Claim.accident.type Base extensible ActIncidentCode 📦3.0.0 THO v7.0
Claim.item.revenue Base example Example Revenue Center Codes 📍4.0.1 FHIR Std.
Claim.item.category Base example Benefit Category Codes 📍4.0.1 FHIR Std.
Claim.item.productOrService Base extensible RTPBC Prescribable Product Code Value Set 📦2.0.0 This IG
Claim.item.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
Claim.item.programCode Base example Example Program Reason Codes 📍4.0.1 FHIR Std.
Claim.item.location[x] Base example Example Service Place Codes 📍4.0.1 FHIR Std.
Claim.item.quantity.​unit Base extensible RTPBC Billing Unit Value Set 📦2.0.0 This IG
Claim.item.bodySite Base example Oral Site Codes 📍4.0.1 FHIR Std.
Claim.item.subSite Base example Surface Codes 📍4.0.1 FHIR Std.
Claim.item.detail.revenue Base example Example Revenue Center Codes 📍4.0.1 FHIR Std.
Claim.item.detail.category Base example Benefit Category Codes 📍4.0.1 FHIR Std.
Claim.item.detail.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
Claim.item.detail.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
Claim.item.detail.programCode Base example Example Program Reason Codes 📍4.0.1 FHIR Std.
Claim.item.detail.subDetail.​revenue Base example Example Revenue Center Codes 📍4.0.1 FHIR Std.
Claim.item.detail.subDetail.​category Base example Benefit Category Codes 📍4.0.1 FHIR Std.
Claim.item.detail.subDetail.​productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
Claim.item.detail.subDetail.​modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
Claim.item.detail.subDetail.​programCode Base example Example Program Reason Codes 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error Claim If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Claim If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error Claim If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error Claim If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Claim A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

 

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