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 - 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:

- Use this Profile: RTPBC Request Bundle - Non-PHI
- Examples for this Profile: Claim/rtpbc-claim-non-phi-1 and Claim/rtpbc-claim-non-phi-2

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 - Non-PHI) | Request Patient Information
reference | S Σ C | 0..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 | 0..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 - Non-PHI) | Prescription Reference
reference | S Σ C | 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 | S Σ C | 0..1 | string | Prescriber Reference
insurance | Σ | 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 | 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 | 0..* | Coding | Code defined by a terminology system
system | S Σ | 0..1 | uri | Identity of the terminology system
code | S Σ | 0..1 | code | Symbol in syntax defined by the system
display | S Σ | 0..1 | string | Product Description
text | S Σ | 0..1 | string | Plain text representation of the concept
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 - 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
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 - 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 | S Σ C | 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 | 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 | 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 | 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 - 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 | 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 | 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 | S Σ C | 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 | 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 | 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 | 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 | S Σ | 0..1 | uri | Identity of the terminology system
version | Σ | 0..1 | string | Version of the system - if relevant
code | S Σ | 0..1 | code | Symbol in syntax defined by the system
display | S Σ | 0..1 | string | Product Description
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user
text | S 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: 18 elements
Must-Support: 41 elements
Fixed: 12 elements

Structures

This structure refers to these other structures:

- RTPBC Patient - Non-PHI (http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-patient-non-phi)
- RTPBC Pharmacy Organization (http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-pharmacy-organization)
- RTPBC Medication Request - Non-PHI (http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-medicationrequest-non-phi)
- 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 - Non-PHI) | Request Patient Information
reference | S Σ C | 0..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 | 0..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 - Non-PHI) | Prescription Reference
reference | S Σ C | 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 | S Σ C | 0..1 | string | Prescriber Reference
insurance | Σ | 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 | 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 | 0..* | Coding | Code defined by a terminology system
system | S Σ | 0..1 | uri | Identity of the terminology system
code | S Σ | 0..1 | code | Symbol in syntax defined by the system
display | S Σ | 0..1 | string | Product Description
text | S Σ | 0..1 | string | Plain text representation of the concept
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 - 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
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 - 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 | S Σ C | 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 | 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 | 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 | 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 - 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 | 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 | 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 | S Σ C | 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 | 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 | 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 | 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 | S Σ | 0..1 | uri | Identity of the terminology system
version | Σ | 0..1 | string | Version of the system - if relevant
code | S Σ | 0..1 | code | Symbol in syntax defined by the system
display | S Σ | 0..1 | string | Product Description
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user
text | S 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: 18 elements
Must-Support: 41 elements
Fixed: 12 elements

Structures

This structure refers to these other structures:

- RTPBC Patient - Non-PHI (http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-patient-non-phi)
- RTPBC Pharmacy Organization (http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-pharmacy-organization)
- RTPBC Medication Request - Non-PHI (http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-medicationrequest-non-phi)
- 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