QI-Core Implementation Guide, published by HL7 International / Clinical Quality Information. This guide is not an authorized publication; it is the continuous build for version 7.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-qi-core/ and changes regularly. See the Directory of published versions
Official URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-claim | Version: 7.0.0 | |||
Active as of 2018-08-22 | Computable Name: QICoreClaim |
Profile of Claim for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.
Simple Vision Claim |
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Claim
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Claim | 0..* | Claim | Claim, Pre-determination or Pre-authorization | |
patient | 1..1 | Reference(QICore Patient) | (QI) The recipient of the products and services | |
billablePeriod | 0..1 | Period | (QI) Relevant time frame for the claim | |
created | 1..1 | dateTime | (QI) Resource creation date | |
provider | 1..1 | Reference(QICore Practitioner | QICore PractitionerRole | QICore Organization) | (QI) Party responsible for the claim | |
prescription | 0..1 | Reference(QICore DeviceRequest | QICore MedicationRequest | VisionPrescription) | (QI) Prescription authorizing services and products | |
payee | 0..1 | BackboneElement | Recipient of benefits payable | |
party | 0..1 | Reference(QICore Practitioner | QICore PractitionerRole | QICore Organization | QICore Patient | QICore RelatedPerson) | Recipient reference | |
referral | 0..1 | Reference(QICore ServiceRequest) | Treatment referral | |
facility | 0..1 | Reference(QICore Location) | Servicing facility | |
careTeam | 0..* | BackboneElement | Members of the care team | |
provider | 1..1 | Reference(QICore Practitioner | QICore PractitionerRole | QICore Organization) | Practitioner or organization | |
diagnosis | 0..* | BackboneElement | (QI) Pertinent diagnosis information | |
sequence | 1..1 | positiveInt | (QI) Diagnosis instance identifier | |
diagnosis[x] | 1..1 | (QI) Nature of illness or problem Binding: ICD-10Codes (example): Example ICD10 Diagnostic codes. | ||
diagnosisCodeableConcept | CodeableConcept | |||
diagnosisReference | Reference(QICore Condition Encounter Diagnosis) | |||
type | 0..* | CodeableConcept | (QI) Timing or nature of the diagnosis Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge. | |
onAdmission | 0..1 | CodeableConcept | (QI) Present on admission Binding: Present on Admission Indicators (required): Present on admission. | |
procedure | 0..* | BackboneElement | (QI) Clinical procedures performed | |
sequence | 1..1 | positiveInt | (QI) Procedure instance identifier | |
type | 0..* | CodeableConcept | (QI) Category of Procedure Binding: ExampleProcedureTypeCodes (example): Example procedure type codes. | |
procedure[x] | 1..1 | (QI) Specific clinical procedure Binding: ICD-10ProcedureCodes (example): Example ICD10 Procedure codes. | ||
procedureCodeableConcept | CodeableConcept | |||
procedureReference | Reference(QICore Procedure) | |||
item | ||||
encounter | 0..* | Reference(QICore Encounter) | (QI) Encounters related to this billed item | |
Documentation for this format |
Path | Conformance | ValueSet | URI |
Claim.diagnosis.diagnosis[x] | example | ICD-10Codeshttp://hl7.org/fhir/ValueSet/icd-10 from the FHIR Standard | |
Claim.diagnosis.type | example | ExampleDiagnosisTypeCodeshttp://hl7.org/fhir/ValueSet/ex-diagnosistype from the FHIR Standard | |
Claim.diagnosis.onAdmission | required | PresentOnAdmissionIndicatorshttp://terminology.hl7.org/ValueSet/POAIndicators | |
Claim.procedure.type | example | ExampleProcedureTypeCodeshttp://hl7.org/fhir/ValueSet/ex-procedure-type from the FHIR Standard | |
Claim.procedure.procedure[x] | example | ICD-10ProcedureCodeshttp://hl7.org/fhir/ValueSet/icd-10-procedures from the FHIR Standard |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Claim | 0..* | Claim | Claim, Pre-determination or Pre-authorization | |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. |
type | Σ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. |
use | Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim. |
patient | Σ | 1..1 | Reference(QICore Patient) | (QI) The recipient of the products and services |
billablePeriod | Σ | 0..1 | Period | (QI) Relevant time frame for the claim |
created | Σ | 1..1 | dateTime | (QI) Resource creation date |
provider | Σ | 1..1 | Reference(QICore Practitioner | QICore PractitionerRole | QICore Organization) | (QI) Party responsible for the claim |
priority | Σ | 1..1 | CodeableConcept | Desired processing ugency Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred. |
prescription | 0..1 | Reference(QICore DeviceRequest | QICore MedicationRequest | VisionPrescription) | (QI) Prescription authorizing services and products | |
payee | 0..1 | BackboneElement | Recipient of benefits payable | |
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(QICore Practitioner | QICore PractitionerRole | QICore Organization | QICore Patient | QICore RelatedPerson) | Recipient reference | |
referral | 0..1 | Reference(QICore ServiceRequest) | Treatment referral | |
facility | 0..1 | Reference(QICore Location) | Servicing facility | |
careTeam | 0..* | BackboneElement | Members of the care team | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Order of care team | |
provider | 1..1 | Reference(QICore Practitioner | QICore PractitionerRole | QICore Organization) | Practitioner or organization | |
diagnosis | 0..* | BackboneElement | (QI) Pertinent diagnosis information | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | (QI) Diagnosis instance identifier | |
diagnosis[x] | 1..1 | (QI) Nature of illness or problem Binding: ICD-10Codes (example): Example ICD10 Diagnostic codes. | ||
diagnosisCodeableConcept | CodeableConcept | |||
diagnosisReference | Reference(QICore Condition Encounter Diagnosis) | |||
type | 0..* | CodeableConcept | (QI) Timing or nature of the diagnosis Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge. | |
onAdmission | 0..1 | CodeableConcept | (QI) Present on admission Binding: Present on Admission Indicators (required): Present on admission. | |
procedure | 0..* | BackboneElement | (QI) Clinical procedures performed | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | (QI) Procedure instance identifier | |
type | 0..* | CodeableConcept | (QI) Category of Procedure Binding: ExampleProcedureTypeCodes (example): Example procedure type codes. | |
procedure[x] | 1..1 | (QI) Specific clinical procedure Binding: ICD-10ProcedureCodes (example): Example ICD10 Procedure codes. | ||
procedureCodeableConcept | CodeableConcept | |||
procedureReference | Reference(QICore Procedure) | |||
insurance | Σ | 1..* | BackboneElement | Patient insurance information |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | Σ | 1..1 | positiveInt | Insurance instance identifier |
focal | Σ | 1..1 | boolean | Coverage to be used for adjudication |
coverage | Σ | 1..1 | Reference(Coverage) | Insurance information |
Documentation for this format |
Path | Conformance | ValueSet | URI |
Claim.status | required | FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard | |
Claim.type | extensible | ClaimTypeCodeshttp://hl7.org/fhir/ValueSet/claim-type from the FHIR Standard | |
Claim.use | required | Usehttp://hl7.org/fhir/ValueSet/claim-use|4.0.1 from the FHIR Standard | |
Claim.priority | example | ProcessPriorityCodeshttp://hl7.org/fhir/ValueSet/process-priority from the FHIR Standard | |
Claim.payee.type | example | Claim Payee Type Codeshttp://hl7.org/fhir/ValueSet/payeetype from the FHIR Standard | |
Claim.diagnosis.diagnosis[x] | example | ICD-10Codeshttp://hl7.org/fhir/ValueSet/icd-10 from the FHIR Standard | |
Claim.diagnosis.type | example | ExampleDiagnosisTypeCodeshttp://hl7.org/fhir/ValueSet/ex-diagnosistype from the FHIR Standard | |
Claim.diagnosis.onAdmission | required | PresentOnAdmissionIndicatorshttp://terminology.hl7.org/ValueSet/POAIndicators | |
Claim.procedure.type | example | ExampleProcedureTypeCodeshttp://hl7.org/fhir/ValueSet/ex-procedure-type from the FHIR Standard | |
Claim.procedure.procedure[x] | example | ICD-10ProcedureCodeshttp://hl7.org/fhir/ValueSet/icd-10-procedures from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
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 | ||||
---|---|---|---|---|---|---|---|---|
Claim | 0..* | Claim | Claim, Pre-determination or Pre-authorization | |||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
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.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | 0..* | Identifier | Business Identifier for claim | |||||
status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. | ||||
type | Σ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. | ||||
subType | 0..1 | CodeableConcept | More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode. | |||||
use | Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim. | ||||
patient | Σ | 1..1 | Reference(QICore Patient) | (QI) The recipient of the products and services | ||||
billablePeriod | Σ | 0..1 | Period | (QI) Relevant time frame for the claim | ||||
created | Σ | 1..1 | dateTime | (QI) Resource creation date | ||||
enterer | 0..1 | Reference(Practitioner | PractitionerRole) | Author of the claim | |||||
insurer | Σ | 0..1 | Reference(Organization) | Target | ||||
provider | Σ | 1..1 | Reference(QICore Practitioner | QICore PractitionerRole | QICore Organization) | (QI) Party responsible for the claim | ||||
priority | Σ | 1..1 | CodeableConcept | Desired processing ugency Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred. | ||||
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 | 0..1 | Reference(QICore DeviceRequest | QICore MedicationRequest | VisionPrescription) | (QI) Prescription authorizing services and products | |||||
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(QICore Practitioner | QICore PractitionerRole | QICore Organization | QICore Patient | QICore RelatedPerson) | Recipient reference | |||||
referral | 0..1 | Reference(QICore ServiceRequest) | Treatment referral | |||||
facility | 0..1 | Reference(QICore Location) | Servicing facility | |||||
careTeam | 0..* | BackboneElement | Members of the care team | |||||
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 | Order of care team | |||||
provider | 1..1 | Reference(QICore Practitioner | QICore PractitionerRole | QICore Organization) | Practitioner or organization | |||||
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 | (QI) 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 | (QI) Diagnosis instance identifier | |||||
diagnosis[x] | 1..1 | (QI) Nature of illness or problem Binding: ICD-10Codes (example): Example ICD10 Diagnostic codes. | ||||||
diagnosisCodeableConcept | CodeableConcept | |||||||
diagnosisReference | Reference(QICore Condition Encounter Diagnosis) | |||||||
type | 0..* | CodeableConcept | (QI) Timing or nature of the diagnosis Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge. | |||||
onAdmission | 0..1 | CodeableConcept | (QI) Present on admission Binding: Present on Admission Indicators (required): Present on admission. | |||||
packageCode | 0..1 | CodeableConcept | Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis. | |||||
procedure | 0..* | BackboneElement | (QI) 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 | (QI) Procedure instance identifier | |||||
type | 0..* | CodeableConcept | (QI) Category of Procedure Binding: ExampleProcedureTypeCodes (example): Example procedure type codes. | |||||
date | 0..1 | dateTime | When the procedure was performed | |||||
procedure[x] | 1..1 | (QI) Specific clinical procedure Binding: ICD-10ProcedureCodes (example): Example ICD10 Procedure codes. | ||||||
procedureCodeableConcept | CodeableConcept | |||||||
procedureReference | Reference(QICore Procedure) | |||||||
udi | 0..* | Reference(Device) | Unique device identifier | |||||
insurance | Σ | 1..* | BackboneElement | Patient insurance 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 | Σ | 1..1 | positiveInt | Insurance instance identifier | ||||
focal | Σ | 1..1 | boolean | Coverage to be used for adjudication | ||||
identifier | 0..1 | Identifier | Pre-assigned Claim number | |||||
coverage | Σ | 1..1 | Reference(Coverage) | Insurance information | ||||
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 | 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 | |||||
careTeamSequence | 0..* | positiveInt | Applicable careTeam members | |||||
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 | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
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 | 0..1 | SimpleQuantity | 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 | |||||
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(QICore Encounter) | (QI) 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 | 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 | 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 |
Path | Conformance | ValueSet | URI | |||
Claim.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
Claim.status | required | FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard | ||||
Claim.type | extensible | ClaimTypeCodeshttp://hl7.org/fhir/ValueSet/claim-type from the FHIR Standard | ||||
Claim.subType | example | ExampleClaimSubTypeCodeshttp://hl7.org/fhir/ValueSet/claim-subtype from the FHIR Standard | ||||
Claim.use | required | Usehttp://hl7.org/fhir/ValueSet/claim-use|4.0.1 from the FHIR Standard | ||||
Claim.priority | example | ProcessPriorityCodeshttp://hl7.org/fhir/ValueSet/process-priority from the FHIR Standard | ||||
Claim.fundsReserve | example | Funds Reservation Codeshttp://hl7.org/fhir/ValueSet/fundsreserve from the FHIR Standard | ||||
Claim.related.relationship | example | ExampleRelatedClaimRelationshipCodeshttp://hl7.org/fhir/ValueSet/related-claim-relationship from the FHIR Standard | ||||
Claim.payee.type | example | Claim Payee Type Codeshttp://hl7.org/fhir/ValueSet/payeetype from the FHIR Standard | ||||
Claim.careTeam.role | example | ClaimCareTeamRoleCodeshttp://hl7.org/fhir/ValueSet/claim-careteamrole from the FHIR Standard | ||||
Claim.careTeam.qualification | example | ExampleProviderQualificationCodeshttp://hl7.org/fhir/ValueSet/provider-qualification from the FHIR Standard | ||||
Claim.supportingInfo.category | example | ClaimInformationCategoryCodeshttp://hl7.org/fhir/ValueSet/claim-informationcategory from the FHIR Standard | ||||
Claim.supportingInfo.code | example | ExceptionCodeshttp://hl7.org/fhir/ValueSet/claim-exception from the FHIR Standard | ||||
Claim.supportingInfo.reason | example | MissingToothReasonCodeshttp://hl7.org/fhir/ValueSet/missing-tooth-reason from the FHIR Standard | ||||
Claim.diagnosis.diagnosis[x] | example | ICD-10Codeshttp://hl7.org/fhir/ValueSet/icd-10 from the FHIR Standard | ||||
Claim.diagnosis.type | example | ExampleDiagnosisTypeCodeshttp://hl7.org/fhir/ValueSet/ex-diagnosistype from the FHIR Standard | ||||
Claim.diagnosis.onAdmission | required | PresentOnAdmissionIndicatorshttp://terminology.hl7.org/ValueSet/POAIndicators | ||||
Claim.diagnosis.packageCode | example | ExampleDiagnosisRelatedGroupCodeshttp://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup from the FHIR Standard | ||||
Claim.procedure.type | example | ExampleProcedureTypeCodeshttp://hl7.org/fhir/ValueSet/ex-procedure-type from the FHIR Standard | ||||
Claim.procedure.procedure[x] | example | ICD-10ProcedureCodeshttp://hl7.org/fhir/ValueSet/icd-10-procedures from the FHIR Standard | ||||
Claim.accident.type | extensible | ActIncidentCodehttp://terminology.hl7.org/ValueSet/v3-ActIncidentCode | ||||
Claim.item.revenue | example | ExampleRevenueCenterCodeshttp://hl7.org/fhir/ValueSet/ex-revenue-center from the FHIR Standard | ||||
Claim.item.category | example | BenefitCategoryCodeshttp://hl7.org/fhir/ValueSet/ex-benefitcategory from the FHIR Standard | ||||
Claim.item.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard | ||||
Claim.item.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard | ||||
Claim.item.programCode | example | ExampleProgramReasonCodeshttp://hl7.org/fhir/ValueSet/ex-program-code from the FHIR Standard | ||||
Claim.item.location[x] | example | ExampleServicePlaceCodeshttp://hl7.org/fhir/ValueSet/service-place from the FHIR Standard | ||||
Claim.item.bodySite | example | OralSiteCodeshttp://hl7.org/fhir/ValueSet/tooth from the FHIR Standard | ||||
Claim.item.subSite | example | SurfaceCodeshttp://hl7.org/fhir/ValueSet/surface from the FHIR Standard | ||||
Claim.item.detail.revenue | example | ExampleRevenueCenterCodeshttp://hl7.org/fhir/ValueSet/ex-revenue-center from the FHIR Standard | ||||
Claim.item.detail.category | example | BenefitCategoryCodeshttp://hl7.org/fhir/ValueSet/ex-benefitcategory from the FHIR Standard | ||||
Claim.item.detail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard | ||||
Claim.item.detail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard | ||||
Claim.item.detail.programCode | example | ExampleProgramReasonCodeshttp://hl7.org/fhir/ValueSet/ex-program-code from the FHIR Standard | ||||
Claim.item.detail.subDetail.revenue | example | ExampleRevenueCenterCodeshttp://hl7.org/fhir/ValueSet/ex-revenue-center from the FHIR Standard | ||||
Claim.item.detail.subDetail.category | example | BenefitCategoryCodeshttp://hl7.org/fhir/ValueSet/ex-benefitcategory from the FHIR Standard | ||||
Claim.item.detail.subDetail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard | ||||
Claim.item.detail.subDetail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard | ||||
Claim.item.detail.subDetail.programCode | example | ExampleProgramReasonCodeshttp://hl7.org/fhir/ValueSet/ex-program-code from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
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() |
This structure is derived from Claim
Summary
Structures
This structure refers to these other structures:
Differential View
This structure is derived from Claim
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Claim | 0..* | Claim | Claim, Pre-determination or Pre-authorization | |
patient | 1..1 | Reference(QICore Patient) | (QI) The recipient of the products and services | |
billablePeriod | 0..1 | Period | (QI) Relevant time frame for the claim | |
created | 1..1 | dateTime | (QI) Resource creation date | |
provider | 1..1 | Reference(QICore Practitioner | QICore PractitionerRole | QICore Organization) | (QI) Party responsible for the claim | |
prescription | 0..1 | Reference(QICore DeviceRequest | QICore MedicationRequest | VisionPrescription) | (QI) Prescription authorizing services and products | |
payee | 0..1 | BackboneElement | Recipient of benefits payable | |
party | 0..1 | Reference(QICore Practitioner | QICore PractitionerRole | QICore Organization | QICore Patient | QICore RelatedPerson) | Recipient reference | |
referral | 0..1 | Reference(QICore ServiceRequest) | Treatment referral | |
facility | 0..1 | Reference(QICore Location) | Servicing facility | |
careTeam | 0..* | BackboneElement | Members of the care team | |
provider | 1..1 | Reference(QICore Practitioner | QICore PractitionerRole | QICore Organization) | Practitioner or organization | |
diagnosis | 0..* | BackboneElement | (QI) Pertinent diagnosis information | |
sequence | 1..1 | positiveInt | (QI) Diagnosis instance identifier | |
diagnosis[x] | 1..1 | (QI) Nature of illness or problem Binding: ICD-10Codes (example): Example ICD10 Diagnostic codes. | ||
diagnosisCodeableConcept | CodeableConcept | |||
diagnosisReference | Reference(QICore Condition Encounter Diagnosis) | |||
type | 0..* | CodeableConcept | (QI) Timing or nature of the diagnosis Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge. | |
onAdmission | 0..1 | CodeableConcept | (QI) Present on admission Binding: Present on Admission Indicators (required): Present on admission. | |
procedure | 0..* | BackboneElement | (QI) Clinical procedures performed | |
sequence | 1..1 | positiveInt | (QI) Procedure instance identifier | |
type | 0..* | CodeableConcept | (QI) Category of Procedure Binding: ExampleProcedureTypeCodes (example): Example procedure type codes. | |
procedure[x] | 1..1 | (QI) Specific clinical procedure Binding: ICD-10ProcedureCodes (example): Example ICD10 Procedure codes. | ||
procedureCodeableConcept | CodeableConcept | |||
procedureReference | Reference(QICore Procedure) | |||
item | ||||
encounter | 0..* | Reference(QICore Encounter) | (QI) Encounters related to this billed item | |
Documentation for this format |
Path | Conformance | ValueSet | URI |
Claim.diagnosis.diagnosis[x] | example | ICD-10Codeshttp://hl7.org/fhir/ValueSet/icd-10 from the FHIR Standard | |
Claim.diagnosis.type | example | ExampleDiagnosisTypeCodeshttp://hl7.org/fhir/ValueSet/ex-diagnosistype from the FHIR Standard | |
Claim.diagnosis.onAdmission | required | PresentOnAdmissionIndicatorshttp://terminology.hl7.org/ValueSet/POAIndicators | |
Claim.procedure.type | example | ExampleProcedureTypeCodeshttp://hl7.org/fhir/ValueSet/ex-procedure-type from the FHIR Standard | |
Claim.procedure.procedure[x] | example | ICD-10ProcedureCodeshttp://hl7.org/fhir/ValueSet/icd-10-procedures from the FHIR Standard |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Claim | 0..* | Claim | Claim, Pre-determination or Pre-authorization | |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. |
type | Σ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. |
use | Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim. |
patient | Σ | 1..1 | Reference(QICore Patient) | (QI) The recipient of the products and services |
billablePeriod | Σ | 0..1 | Period | (QI) Relevant time frame for the claim |
created | Σ | 1..1 | dateTime | (QI) Resource creation date |
provider | Σ | 1..1 | Reference(QICore Practitioner | QICore PractitionerRole | QICore Organization) | (QI) Party responsible for the claim |
priority | Σ | 1..1 | CodeableConcept | Desired processing ugency Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred. |
prescription | 0..1 | Reference(QICore DeviceRequest | QICore MedicationRequest | VisionPrescription) | (QI) Prescription authorizing services and products | |
payee | 0..1 | BackboneElement | Recipient of benefits payable | |
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(QICore Practitioner | QICore PractitionerRole | QICore Organization | QICore Patient | QICore RelatedPerson) | Recipient reference | |
referral | 0..1 | Reference(QICore ServiceRequest) | Treatment referral | |
facility | 0..1 | Reference(QICore Location) | Servicing facility | |
careTeam | 0..* | BackboneElement | Members of the care team | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Order of care team | |
provider | 1..1 | Reference(QICore Practitioner | QICore PractitionerRole | QICore Organization) | Practitioner or organization | |
diagnosis | 0..* | BackboneElement | (QI) Pertinent diagnosis information | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | (QI) Diagnosis instance identifier | |
diagnosis[x] | 1..1 | (QI) Nature of illness or problem Binding: ICD-10Codes (example): Example ICD10 Diagnostic codes. | ||
diagnosisCodeableConcept | CodeableConcept | |||
diagnosisReference | Reference(QICore Condition Encounter Diagnosis) | |||
type | 0..* | CodeableConcept | (QI) Timing or nature of the diagnosis Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge. | |
onAdmission | 0..1 | CodeableConcept | (QI) Present on admission Binding: Present on Admission Indicators (required): Present on admission. | |
procedure | 0..* | BackboneElement | (QI) Clinical procedures performed | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | (QI) Procedure instance identifier | |
type | 0..* | CodeableConcept | (QI) Category of Procedure Binding: ExampleProcedureTypeCodes (example): Example procedure type codes. | |
procedure[x] | 1..1 | (QI) Specific clinical procedure Binding: ICD-10ProcedureCodes (example): Example ICD10 Procedure codes. | ||
procedureCodeableConcept | CodeableConcept | |||
procedureReference | Reference(QICore Procedure) | |||
insurance | Σ | 1..* | BackboneElement | Patient insurance information |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | Σ | 1..1 | positiveInt | Insurance instance identifier |
focal | Σ | 1..1 | boolean | Coverage to be used for adjudication |
coverage | Σ | 1..1 | Reference(Coverage) | Insurance information |
Documentation for this format |
Path | Conformance | ValueSet | URI |
Claim.status | required | FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard | |
Claim.type | extensible | ClaimTypeCodeshttp://hl7.org/fhir/ValueSet/claim-type from the FHIR Standard | |
Claim.use | required | Usehttp://hl7.org/fhir/ValueSet/claim-use|4.0.1 from the FHIR Standard | |
Claim.priority | example | ProcessPriorityCodeshttp://hl7.org/fhir/ValueSet/process-priority from the FHIR Standard | |
Claim.payee.type | example | Claim Payee Type Codeshttp://hl7.org/fhir/ValueSet/payeetype from the FHIR Standard | |
Claim.diagnosis.diagnosis[x] | example | ICD-10Codeshttp://hl7.org/fhir/ValueSet/icd-10 from the FHIR Standard | |
Claim.diagnosis.type | example | ExampleDiagnosisTypeCodeshttp://hl7.org/fhir/ValueSet/ex-diagnosistype from the FHIR Standard | |
Claim.diagnosis.onAdmission | required | PresentOnAdmissionIndicatorshttp://terminology.hl7.org/ValueSet/POAIndicators | |
Claim.procedure.type | example | ExampleProcedureTypeCodeshttp://hl7.org/fhir/ValueSet/ex-procedure-type from the FHIR Standard | |
Claim.procedure.procedure[x] | example | ICD-10ProcedureCodeshttp://hl7.org/fhir/ValueSet/icd-10-procedures from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
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() |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Claim | 0..* | Claim | Claim, Pre-determination or Pre-authorization | |||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
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.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | 0..* | Identifier | Business Identifier for claim | |||||
status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. | ||||
type | Σ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. | ||||
subType | 0..1 | CodeableConcept | More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode. | |||||
use | Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim. | ||||
patient | Σ | 1..1 | Reference(QICore Patient) | (QI) The recipient of the products and services | ||||
billablePeriod | Σ | 0..1 | Period | (QI) Relevant time frame for the claim | ||||
created | Σ | 1..1 | dateTime | (QI) Resource creation date | ||||
enterer | 0..1 | Reference(Practitioner | PractitionerRole) | Author of the claim | |||||
insurer | Σ | 0..1 | Reference(Organization) | Target | ||||
provider | Σ | 1..1 | Reference(QICore Practitioner | QICore PractitionerRole | QICore Organization) | (QI) Party responsible for the claim | ||||
priority | Σ | 1..1 | CodeableConcept | Desired processing ugency Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred. | ||||
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 | 0..1 | Reference(QICore DeviceRequest | QICore MedicationRequest | VisionPrescription) | (QI) Prescription authorizing services and products | |||||
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(QICore Practitioner | QICore PractitionerRole | QICore Organization | QICore Patient | QICore RelatedPerson) | Recipient reference | |||||
referral | 0..1 | Reference(QICore ServiceRequest) | Treatment referral | |||||
facility | 0..1 | Reference(QICore Location) | Servicing facility | |||||
careTeam | 0..* | BackboneElement | Members of the care team | |||||
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 | Order of care team | |||||
provider | 1..1 | Reference(QICore Practitioner | QICore PractitionerRole | QICore Organization) | Practitioner or organization | |||||
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 | (QI) 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 | (QI) Diagnosis instance identifier | |||||
diagnosis[x] | 1..1 | (QI) Nature of illness or problem Binding: ICD-10Codes (example): Example ICD10 Diagnostic codes. | ||||||
diagnosisCodeableConcept | CodeableConcept | |||||||
diagnosisReference | Reference(QICore Condition Encounter Diagnosis) | |||||||
type | 0..* | CodeableConcept | (QI) Timing or nature of the diagnosis Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge. | |||||
onAdmission | 0..1 | CodeableConcept | (QI) Present on admission Binding: Present on Admission Indicators (required): Present on admission. | |||||
packageCode | 0..1 | CodeableConcept | Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis. | |||||
procedure | 0..* | BackboneElement | (QI) 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 | (QI) Procedure instance identifier | |||||
type | 0..* | CodeableConcept | (QI) Category of Procedure Binding: ExampleProcedureTypeCodes (example): Example procedure type codes. | |||||
date | 0..1 | dateTime | When the procedure was performed | |||||
procedure[x] | 1..1 | (QI) Specific clinical procedure Binding: ICD-10ProcedureCodes (example): Example ICD10 Procedure codes. | ||||||
procedureCodeableConcept | CodeableConcept | |||||||
procedureReference | Reference(QICore Procedure) | |||||||
udi | 0..* | Reference(Device) | Unique device identifier | |||||
insurance | Σ | 1..* | BackboneElement | Patient insurance 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 | Σ | 1..1 | positiveInt | Insurance instance identifier | ||||
focal | Σ | 1..1 | boolean | Coverage to be used for adjudication | ||||
identifier | 0..1 | Identifier | Pre-assigned Claim number | |||||
coverage | Σ | 1..1 | Reference(Coverage) | Insurance information | ||||
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 | 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 | |||||
careTeamSequence | 0..* | positiveInt | Applicable careTeam members | |||||
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 | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
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 | 0..1 | SimpleQuantity | 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 | |||||
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(QICore Encounter) | (QI) 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 | 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) |