Consumer Real-Time Pharmacy Benefit Check FHIR IG
2.0.0 - CI Build

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

Official URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-request-claim | Version: 2.0.0
Standards status: Trial-use Active as of 2020-05-23 | Maturity Level: 4 | Computable Name: RtpbcRequestClaim

This profile constrains the Claim resource so that it can serve as the RTPBC Request in the consumer real-time pharmacy benefit check process

This profile constrains the Claim resource so that it can serve as the request in the consumer Real-time Pharmacy Benefit Check (RTPBC) process.
Data population is similar to a typical Claim predetermination request (where Claim.use set to "predetermination"), with the following key differences: Certain elements are fixed to values reflecting a medication-related request…

- Claim.type = "pharmacy"
- Claim.provider references an Organization resource that represents the patient's preferred pharmacy
- Claim.prescription is mandatory (referencing a MedicationRequest resource)
- Claim.careTeam.provider is mandatory, referencing a Practitioner resource that identifies the prescriber
- Claim.item elements are constrained to product identifiers and quantity units of measure describing medications

In addition, no pricing / cost information is submitted in the request since the goal of the exchange is learn the expected cost to the patient rather than reimbursement information for a pharmacy.

In this profile, the Claim references the following supported resources. All are profiled in this guide except Practitioner, which uses the US Core Practitioner profile without further constraints.

- Patient (containing a small amount of identifying information to enable the insurer to locate the patient's records)
- Coverage (containing identification of the patient's pharmacy benefit coverage)
- MedicationRequest (containing excerpts from the prescription to be priced)
- Practitioner (identifying the prescriber. Uses US Core Practitioner)
- Organization (identifying the pharmacy)

### Must Support elements in this profile

Client systems

- Elements that are marked Must Support are essential for the responder to identify the applicable plan rules and accurately determine patient costs and coverage. The submitter MUST ensure that content in these elements is accurate and complete in order to receive reliable information in the response.
- A reference to a coverage resource MUST be included when submitting to an insurer. It is not required when submitting to a pricing source.

Responding systems

- MUST make use of all pertinent information provided in the Claim request when determining cost and coverage.

Usages:

- Use this Profile: RTPBC Request Bundle
- Examples for this Profile: Claim/rtpbc-claim-03

You can also check for usages in the FHIR IG Statistics

### Formal Views of Profile Content

Description Differentials, Snapshots, and other representations.

- Key Elements Table
- Differential Table
- Snapshot Table
- Statistics/References
- All

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Claim |  | 0..* | Claim | Claim, Pre-determination or Pre-authorization
id | S Σ | 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
identifier | S | 1..1 | Identifier | RTPBC request identifier
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
value | S Σ | 1..1 | string | Unique RTPBC request ID Example General: 123456
status | ?!S Σ | 1..1 | code | Request status Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Fixed Value: active
type | S Σ | 1..1 | CodeableConcept | Requested Service Type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
coding | S Σ | 1..1 | Coding | Code defined by a terminology system
system | S Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
code | S Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: pharmacy
display | S Σ | 1..1 | string | Representation defined by the system Fixed Value: Pharmacy
use | S Σ | 1..1 | code | Processing Mode Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim. Fixed Value: predetermination
patient | S Σ | 1..1 | Reference(RTPBC Patient) | Request Patient Information
reference | S Σ C | 1..1 | string | Patient Reference
created | S Σ | 1..1 | dateTime | Created DateTime
provider | S Σ | 1..1 | Reference(RTPBC Pharmacy Organization) | Preferred Pharmacy
reference | S Σ C | 1..1 | string | Reference to Pharmacy Organization
priority | S Σ | 1..1 | CodeableConcept | Processing priority Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.
coding | S Σ | 1..1 | Coding | Code defined by a terminology system
system | S Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/processpriority
code | S Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: normal
display | S Σ | 1..1 | string | Representation defined by the system Fixed Value: Normal
prescription | S | 1..1 | Reference(RTPBC Medication Request) | Prescription Reference
reference | S Σ C | 1..1 | string | Literal reference, Relative, internal or absolute URL
careTeam | S | 1..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 | S Σ C | 1..1 | string | Prescriber Reference
insurance | S Σ | 1..1 | BackboneElement | Pharmacy Coverage
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence | S Σ | 1..1 | positiveInt | Insurance instance identifier Fixed Value: 1
focal | S Σ | 1..1 | boolean | Coverage to be used for adjudication Fixed Value: true
coverage | S Σ | 1..1 | Reference(RTPBC Coverage) | Pharmacy Coverage Reference
reference | S Σ C | 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 | S Σ | 1..* | Coding | Code defined by a terminology system
system | S Σ | 1..1 | uri | Identity of the terminology system
code | S Σ | 1..1 | code | Symbol in syntax defined by the system
display | S Σ | 1..1 | string | Product Description
quantity | S | 1..1 | SimpleQuantity(4.0.1) | Prescribed Quantity
value | S Σ | 1..1 | decimal | Quantity in Billing Units
unit | S Σ | 1..1 | string | Billing unit of measure Binding: RTPBC Billing Unit Value Set (extensible): Billing quantity unit of measure
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()`

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
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
type | S | 1..1 | CodeableConcept | Requested Service Type
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) | Request Patient Information
reference | S | 1..1 | string | Patient Reference
created | S | 1..1 | dateTime | Created DateTime
provider | S | 1..1 | Reference(RTPBC Pharmacy Organization) | Preferred Pharmacy
reference | S | 1..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) | Prescription Reference
reference | S | 1..1 | string | Literal reference, Relative, internal or absolute URL
careTeam | S | 1..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 | 1..1 | string | Prescriber Reference
insurance | S | 1..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 | S | 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 | 1..* | Coding | Code defined by a terminology system
system | S | 1..1 | uri | Identity of the terminology system
code | S | 1..1 | code | Symbol in syntax defined by the system
display | S | 1..1 | string | Product Description
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
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

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Claim |  | 0..* | Claim | Claim, Pre-determination or Pre-authorization
id | S Σ | 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 Bindings | Purpose
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 | S Σ | 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 | ?!S Σ | 1..1 | code | Request status Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Fixed Value: active
type | S Σ | 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 | S Σ | 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 | S Σ | 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 | S Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: pharmacy
display | S Σ | 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 | S Σ | 1..1 | code | Processing Mode Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim. Fixed Value: predetermination
patient | S Σ | 1..1 | Reference(RTPBC Patient) | 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 | S Σ C | 1..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 | S Σ | 1..1 | dateTime | Created DateTime
enterer |  | 0..1 | Reference(Practitioner | PractitionerRole) | Author of the claim
insurer | Σ | 0..1 | Reference(Organization) | Target
provider | S Σ | 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 | S Σ C | 1..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 | S Σ | 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 | S Σ | 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 | S Σ | 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 | S Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: normal
display | S Σ | 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) | 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 | S Σ C | 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 | 1..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 | S Σ C | 1..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 | S Σ | 1..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 | S Σ | 1..1 | positiveInt | Insurance instance identifier Fixed Value: 1
focal | S Σ | 1..1 | boolean | Coverage to be used for adjudication Fixed Value: true
identifier |  | 0..1 | Identifier | Pre-assigned Claim number
coverage | S 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 | S Σ C | 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 | S Σ | 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 | S Σ | 1..1 | uri | Identity of the terminology system
version | Σ | 0..1 | string | Version of the system - if relevant
code | S Σ | 1..1 | code | Symbol in syntax defined by the system
display | S Σ | 1..1 | string | Product Description
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
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 | S Σ | 1..1 | decimal | Quantity in Billing Units
unit | S Σ | 1..1 | string | Billing unit of measure Binding: RTPBC Billing Unit Value Set (extensible): Billing quantity unit of measure
system | Σ C | 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
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()`

Summary

Mandatory: 26 elements
Must-Support: 42 elements
Fixed: 12 elements

Structures

This structure refers to these other structures:

- RTPBC Patient (http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-patient)
- RTPBC Pharmacy Organization (http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-pharmacy-organization)
- RTPBC Medication Request (http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-medicationrequest)
- US Core Practitioner Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner)
- RTPBC Coverage (http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-coverage)

Maturity: 4

Key Elements View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Claim |  | 0..* | Claim | Claim, Pre-determination or Pre-authorization
id | S Σ | 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
identifier | S | 1..1 | Identifier | RTPBC request identifier
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
value | S Σ | 1..1 | string | Unique RTPBC request ID Example General: 123456
status | ?!S Σ | 1..1 | code | Request status Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Fixed Value: active
type | S Σ | 1..1 | CodeableConcept | Requested Service Type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
coding | S Σ | 1..1 | Coding | Code defined by a terminology system
system | S Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
code | S Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: pharmacy
display | S Σ | 1..1 | string | Representation defined by the system Fixed Value: Pharmacy
use | S Σ | 1..1 | code | Processing Mode Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim. Fixed Value: predetermination
patient | S Σ | 1..1 | Reference(RTPBC Patient) | Request Patient Information
reference | S Σ C | 1..1 | string | Patient Reference
created | S Σ | 1..1 | dateTime | Created DateTime
provider | S Σ | 1..1 | Reference(RTPBC Pharmacy Organization) | Preferred Pharmacy
reference | S Σ C | 1..1 | string | Reference to Pharmacy Organization
priority | S Σ | 1..1 | CodeableConcept | Processing priority Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.
coding | S Σ | 1..1 | Coding | Code defined by a terminology system
system | S Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/processpriority
code | S Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: normal
display | S Σ | 1..1 | string | Representation defined by the system Fixed Value: Normal
prescription | S | 1..1 | Reference(RTPBC Medication Request) | Prescription Reference
reference | S Σ C | 1..1 | string | Literal reference, Relative, internal or absolute URL
careTeam | S | 1..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 | S Σ C | 1..1 | string | Prescriber Reference
insurance | S Σ | 1..1 | BackboneElement | Pharmacy Coverage
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence | S Σ | 1..1 | positiveInt | Insurance instance identifier Fixed Value: 1
focal | S Σ | 1..1 | boolean | Coverage to be used for adjudication Fixed Value: true
coverage | S Σ | 1..1 | Reference(RTPBC Coverage) | Pharmacy Coverage Reference
reference | S Σ C | 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 | S Σ | 1..* | Coding | Code defined by a terminology system
system | S Σ | 1..1 | uri | Identity of the terminology system
code | S Σ | 1..1 | code | Symbol in syntax defined by the system
display | S Σ | 1..1 | string | Product Description
quantity | S | 1..1 | SimpleQuantity(4.0.1) | Prescribed Quantity
value | S Σ | 1..1 | decimal | Quantity in Billing Units
unit | S Σ | 1..1 | string | Billing unit of measure Binding: RTPBC Billing Unit Value Set (extensible): Billing quantity unit of measure
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

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
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
type | S | 1..1 | CodeableConcept | Requested Service Type
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) | Request Patient Information
reference | S | 1..1 | string | Patient Reference
created | S | 1..1 | dateTime | Created DateTime
provider | S | 1..1 | Reference(RTPBC Pharmacy Organization) | Preferred Pharmacy
reference | S | 1..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) | Prescription Reference
reference | S | 1..1 | string | Literal reference, Relative, internal or absolute URL
careTeam | S | 1..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 | 1..1 | string | Prescriber Reference
insurance | S | 1..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 | S | 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 | 1..* | Coding | Code defined by a terminology system
system | S | 1..1 | uri | Identity of the terminology system
code | S | 1..1 | code | Symbol in syntax defined by the system
display | S | 1..1 | string | Product Description
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
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

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Claim |  | 0..* | Claim | Claim, Pre-determination or Pre-authorization
id | S Σ | 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 Bindings | Purpose
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 | S Σ | 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 | ?!S Σ | 1..1 | code | Request status Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Fixed Value: active
type | S Σ | 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 | S Σ | 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 | S Σ | 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 | S Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: pharmacy
display | S Σ | 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 | S Σ | 1..1 | code | Processing Mode Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim. Fixed Value: predetermination
patient | S Σ | 1..1 | Reference(RTPBC Patient) | 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 | S Σ C | 1..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 | S Σ | 1..1 | dateTime | Created DateTime
enterer |  | 0..1 | Reference(Practitioner | PractitionerRole) | Author of the claim
insurer | Σ | 0..1 | Reference(Organization) | Target
provider | S Σ | 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 | S Σ C | 1..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 | S Σ | 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 | S Σ | 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 | S Σ | 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 | S Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: normal
display | S Σ | 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) | 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 | S Σ C | 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 | 1..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 | S Σ C | 1..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 | S Σ | 1..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 | S Σ | 1..1 | positiveInt | Insurance instance identifier Fixed Value: 1
focal | S Σ | 1..1 | boolean | Coverage to be used for adjudication Fixed Value: true
identifier |  | 0..1 | Identifier | Pre-assigned Claim number
coverage | S 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 | S Σ C | 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 | S Σ | 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 | S Σ | 1..1 | uri | Identity of the terminology system
version | Σ | 0..1 | string | Version of the system - if relevant
code | S Σ | 1..1 | code | Symbol in syntax defined by the system
display | S Σ | 1..1 | string | Product Description
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
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 | S Σ | 1..1 | decimal | Quantity in Billing Units
unit | S Σ | 1..1 | string | Billing unit of measure Binding: RTPBC Billing Unit Value Set (extensible): Billing quantity unit of measure
system | Σ C | 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
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()`

Summary

Mandatory: 26 elements
Must-Support: 42 elements
Fixed: 12 elements

Structures

This structure refers to these other structures:

- RTPBC Patient (http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-patient)
- RTPBC Pharmacy Organization (http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-pharmacy-organization)
- RTPBC Medication Request (http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-medicationrequest)
- US Core Practitioner Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner)
- RTPBC Coverage (http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-coverage)

Maturity: 4

Other representations of profile: CSV, Excel, Schematron