QI-Core Implementation Guide
7.0.2 - STU 7

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 7.0.2 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

## Resource Profile: QICore Claim

Official URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-claim | Version: 7.0.2
Standards status: Trial-use | Maturity Level: 4 | 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.

"Must Have", "QI Elements" and "primary code path" are defined in the QI-Core Must Support section.
QI Elements:

- provider: (QI) Party responsible for the claim
- patient: (QI) The recipient of the products and services
- type: (QI) category | discipline
- billablePeriod: (QI) Relevant time frame for the claim
- Claim: Claim, Pre-determination or Pre-authorization
- use: (QI) claim | preauthorization | predetermination
- diagnosis: (QI) Pertinent diagnosis information
- procedure: (QI) Clinical procedures performed
- created: (QI) Resource creation date
- prescription: (QI) Prescription authorizing services and products
- status: (QI) active

Primary code path: type
(PCPath) This element is the primary code path for this resource CQL Retrieve
Usage

See the patterns page for implementation and usage patterns.

### Examples

Simple Vision Claim

Usages:

- Refer to this Profile: QICore ClaimResponse
- Examples for this Profile: Claim/example

You can also check for usages in the FHIR IG Statistics

### Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

- 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
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 | (QI) active Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Fixed Value: active
type | Σ | 1..1 | CodeableConcept | (QI) category | discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
use | Σ | 1..1 | code | (QI) 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 (preferred): 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(QICore Coverage) | Insurance information
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
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.payee.type | Base | example | PayeeType | 📍4.0.1 | FHIR Std.
Claim.diagnosis.diagnosis[x] | Base | example | ICD-10 Codes | 📦4.0.1 | FHIR Std.
Claim.diagnosis.type | Base | preferred | Example Diagnosis Type Codes | 📦4.0.1 | FHIR Std.
Claim.diagnosis.onAdmission | Base | required | Present on Admission Indicators | 📦2.0.0 | THO v6.5
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.

#### 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()`

This structure is derived from Claim

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Claim |  | 0..* | Claim | Claim, Pre-determination or Pre-authorization
status |  | 1..1 | code | (QI) active Fixed Value: active
type |  | 1..1 | CodeableConcept | (QI) category | discipline
use |  | 1..1 | code | (QI) claim | preauthorization | predetermination
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 (preferred): 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) |
insurance |  |  |  |
coverage |  | 1..1 | Reference(QICore Coverage) | Insurance information
item |  |  |  |
encounter |  | 0..* | Reference(QICore Encounter) | (QI) Encounters related to this billed item
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
Claim.diagnosis.diagnosis[x] | Base | example | ICD-10 Codes | 📦4.0.1 | FHIR Std.
Claim.diagnosis.type | Base | preferred | Example Diagnosis Type Codes | 📦4.0.1 | FHIR Std.
Claim.diagnosis.onAdmission | Base | required | Present on Admission Indicators | 📦2.0.0 | THO v6.5
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.

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
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.
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 |  | 0..* | Identifier | Business Identifier for claim
status | ?!Σ | 1..1 | code | (QI) active Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Fixed Value: active
type | Σ | 1..1 | CodeableConcept | (QI) category | 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 | (QI) 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 (preferred): 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(QICore 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(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
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(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.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.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.payee.type | Base | example | PayeeType | 📍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 | preferred | Example Diagnosis Type Codes | 📦4.0.1 | FHIR Std.
Claim.diagnosis.onAdmission | Base | required | Present on Admission Indicators | 📦2.0.0 | THO v6.5
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.accident.type | Base | extensible | ActIncidentCode | 📦3.0.0 | THO v6.5
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 | example | USCLS Codes | 📍4.0.1 | FHIR Std.
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.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()`

This structure is derived from Claim

Summary

Mandatory: 4 elements
Fixed: 1 element

Structures

This structure refers to these other structures:

- QICore Patient (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-patient)
- QICore Practitioner (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-practitioner)
- QICore PractitionerRole (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-practitionerrole)
- QICore Organization (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-organization)
- QICore DeviceRequest (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-devicerequest)
- QICore MedicationRequest (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-medicationrequest)
- QICore RelatedPerson (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-relatedperson)
- QICore ServiceRequest (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-servicerequest)
- QICore Location (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-location)
- QICore Condition Encounter Diagnosis (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition-encounter-diagnosis)
- QICore Procedure (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-procedure)
- QICore Coverage (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-coverage)
- QICore Encounter (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-encounter)

Maturity: 4

Key Elements View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
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 | (QI) active Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Fixed Value: active
type | Σ | 1..1 | CodeableConcept | (QI) category | discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
use | Σ | 1..1 | code | (QI) 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 (preferred): 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(QICore Coverage) | Insurance information
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
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.payee.type | Base | example | PayeeType | 📍4.0.1 | FHIR Std.
Claim.diagnosis.diagnosis[x] | Base | example | ICD-10 Codes | 📦4.0.1 | FHIR Std.
Claim.diagnosis.type | Base | preferred | Example Diagnosis Type Codes | 📦4.0.1 | FHIR Std.
Claim.diagnosis.onAdmission | Base | required | Present on Admission Indicators | 📦2.0.0 | THO v6.5
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.

#### 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

This structure is derived from Claim

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Claim |  | 0..* | Claim | Claim, Pre-determination or Pre-authorization
status |  | 1..1 | code | (QI) active Fixed Value: active
type |  | 1..1 | CodeableConcept | (QI) category | discipline
use |  | 1..1 | code | (QI) claim | preauthorization | predetermination
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 (preferred): 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) |
insurance |  |  |  |
coverage |  | 1..1 | Reference(QICore Coverage) | Insurance information
item |  |  |  |
encounter |  | 0..* | Reference(QICore Encounter) | (QI) Encounters related to this billed item
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
Claim.diagnosis.diagnosis[x] | Base | example | ICD-10 Codes | 📦4.0.1 | FHIR Std.
Claim.diagnosis.type | Base | preferred | Example Diagnosis Type Codes | 📦4.0.1 | FHIR Std.
Claim.diagnosis.onAdmission | Base | required | Present on Admission Indicators | 📦2.0.0 | THO v6.5
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.

Snapshot View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
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.
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 |  | 0..* | Identifier | Business Identifier for claim
status | ?!Σ | 1..1 | code | (QI) active Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Fixed Value: active
type | Σ | 1..1 | CodeableConcept | (QI) category | 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 | (QI) 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 (preferred): 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(QICore 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(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
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(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.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.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.payee.type | Base | example | PayeeType | 📍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 | preferred | Example Diagnosis Type Codes | 📦4.0.1 | FHIR Std.
Claim.diagnosis.onAdmission | Base | required | Present on Admission Indicators | 📦2.0.0 | THO v6.5
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.accident.type | Base | extensible | ActIncidentCode | 📦3.0.0 | THO v6.5
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 | example | USCLS Codes | 📍4.0.1 | FHIR Std.
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.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()`

This structure is derived from Claim

Summary

Mandatory: 4 elements
Fixed: 1 element

Structures

This structure refers to these other structures:

- QICore Patient (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-patient)
- QICore Practitioner (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-practitioner)
- QICore PractitionerRole (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-practitionerrole)
- QICore Organization (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-organization)
- QICore DeviceRequest (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-devicerequest)
- QICore MedicationRequest (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-medicationrequest)
- QICore RelatedPerson (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-relatedperson)
- QICore ServiceRequest (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-servicerequest)
- QICore Location (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-location)
- QICore Condition Encounter Diagnosis (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition-encounter-diagnosis)
- QICore Procedure (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-procedure)
- QICore Coverage (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-coverage)
- QICore Encounter (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-encounter)

Maturity: 4

Other representations of profile: CSV, Excel, Schematron