Consumer Real-Time Pharmacy Benefit Check FHIR IG, published by HL7 International / Pharmacy. This guide is not an authorized publication; it is the continuous build for version 2.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/carin-rtpbc/ and changes regularly. See the Directory of published versions
Official URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-request-claim | Version: 2.0.0 | |||
Standards status: Trial-use | Maturity Level: 4 | Computable Name: RtpbcRequestClaim |
This profile constrains the Claim resource so that it can serve as the RTPBC Request in the consumer real-time pharmacy benefit check process
This profile constrains the Claim resource so that it can serve as the request in the consumer Real-time Pharmacy Benefit Check (RTPBC) process.
Data population is similar to a typical Claim predetermination request (where Claim.use set to "predetermination"), with the following key differences:
Certain elements are fixed to values reflecting a medication-related request…
In addition, no pricing / cost information is submitted in the request since the goal of the exchange is learn the expected cost to the patient rather than reimbursement information for a pharmacy.
In this profile, the Claim references the following supported resources. All are profiled in this guide except Practitioner, which uses the US Core Practitioner profile without further constraints.
Client systems
Responding systems
Usages:
You can also check for usages in the FHIR IG Statistics
Description of Profiles, Differentials, Snapshots and how the different presentations work.
Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() |
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0..* | Claim | Claim, Pre-determination or Pre-authorization | |
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SΣ | 1..1 | id | Unique Claim Resource Identifier |
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?!Σ | 0..1 | uri | A set of rules under which this content was created |
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?! | 0..* | Extension | Extensions that cannot be ignored |
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S | 1..1 | Identifier | RTPBC request identifier |
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?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . |
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SΣ | 1..1 | string | Unique RTPBC request ID Example General: 123456 |
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?!SΣ | 1..1 | code | Request status Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Fixed Value: active |
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SΣ | 1..1 | CodeableConcept | Requested Service Type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. |
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SΣ | 1..1 | Coding | Code defined by a terminology system |
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SΣ | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type |
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SΣ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: pharmacy |
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SΣ | 1..1 | string | Representation defined by the system Fixed Value: Pharmacy |
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SΣ | 1..1 | code | Processing Mode Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim. Fixed Value: predetermination |
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SΣ | 1..1 | Reference(RTPBC Patient) | Request Patient Information |
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SΣC | 1..1 | string | Patient Reference |
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SΣ | 1..1 | dateTime | Created DateTime |
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SΣ | 1..1 | Reference(RTPBC Pharmacy Organization) | Preferred Pharmacy |
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SΣC | 1..1 | string | Reference to Pharmacy Organization |
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SΣ | 1..1 | CodeableConcept | Processing priority Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred. |
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SΣ | 1..1 | Coding | Code defined by a terminology system |
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SΣ | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/processpriority |
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SΣ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: normal |
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SΣ | 1..1 | string | Representation defined by the system Fixed Value: Normal |
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S | 1..1 | Reference(RTPBC Medication Request) | Prescription Reference |
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SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
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S | 1..1 | BackboneElement | Prescriber |
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
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S | 1..1 | positiveInt | Order of care team Fixed Value: 1 |
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S | 1..1 | Reference(US Core Practitioner Profile) | Prescriber |
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SΣC | 1..1 | string | Prescriber Reference |
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SΣ | 1..1 | BackboneElement | Pharmacy Coverage |
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
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SΣ | 1..1 | positiveInt | Insurance instance identifier Fixed Value: 1 |
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SΣ | 1..1 | boolean | Coverage to be used for adjudication Fixed Value: true |
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SΣ | 1..1 | Reference(RTPBC Coverage) | Pharmacy Coverage Reference |
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SΣC | 0..1 | string | Pharmacy Coverage Reference |
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S | 1..1 | BackboneElement | Max 1 item per request |
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
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S | 1..1 | positiveInt | Item instance identifier Fixed Value: 1 |
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S | 1..1 | positiveInt | Care Team Sequence ID Reference |
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S | 1..1 | CodeableConcept | Prescribed Product Binding: RTPBC Prescribable Product Code Value Set (extensible): RTPBC prescribable product codes (NDC11 and RxNorm) |
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SΣ | 1..* | Coding | Code defined by a terminology system |
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SΣ | 1..1 | uri | Identity of the terminology system |
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SΣ | 1..1 | code | Symbol in syntax defined by the system |
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SΣ | 1..1 | string | Product Description |
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S | 1..1 | SimpleQuantity | Prescribed Quantity |
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SΣ | 1..1 | decimal | Quantity in Billing Units |
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SΣ | 1..1 | string | Billing unit of measure Binding: RTPBC Billing Unit Value Set (extensible): Billing quantity unit of measure |
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Path | Conformance | ValueSet / Code | URI |
Claim.identifier.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 From the FHIR Standard | |
Claim.status | required | Fixed Value: activehttp://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 | Fixed Value: predeterminationhttp://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.item.productOrService | extensible | RTPBCPrescribableProductCodeValueSethttp://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-prescribable-product-code From this IG | |
Claim.item.quantity.unit | extensible | RtbpcBillingUnitValueSethttp://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-billing-unit From this IG |
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
Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() |
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Claim | |||
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S | 1..1 | id | Unique Claim Resource Identifier |
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S | 1..1 | Identifier | RTPBC request identifier |
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S | 1..1 | string | Unique RTPBC request ID |
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S | 1..1 | code | Request status Fixed Value: active |
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S | 1..1 | CodeableConcept | Requested Service Type |
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S | 1..1 | Coding | Code defined by a terminology system |
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S | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type |
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S | 1..1 | code | Symbol in syntax defined by the system Fixed Value: pharmacy |
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S | 1..1 | string | Representation defined by the system Fixed Value: Pharmacy |
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S | 1..1 | code | Processing Mode Fixed Value: predetermination |
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S | 1..1 | Reference(RTPBC Patient) | Request Patient Information |
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S | 1..1 | string | Patient Reference |
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S | 1..1 | dateTime | Created DateTime |
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S | 1..1 | Reference(RTPBC Pharmacy Organization) | Preferred Pharmacy |
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S | 1..1 | string | Reference to Pharmacy Organization |
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S | 1..1 | CodeableConcept | Processing priority |
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S | 1..1 | Coding | Code defined by a terminology system |
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S | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/processpriority |
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S | 1..1 | code | Symbol in syntax defined by the system Fixed Value: normal |
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S | 1..1 | string | Representation defined by the system Fixed Value: Normal |
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S | 1..1 | Reference(RTPBC Medication Request) | Prescription Reference |
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S | 1..1 | string | Literal reference, Relative, internal or absolute URL |
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S | 1..1 | BackboneElement | Prescriber |
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S | 1..1 | positiveInt | Order of care team Fixed Value: 1 |
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S | 1..1 | Reference(US Core Practitioner Profile) | Prescriber |
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S | 1..1 | string | Prescriber Reference |
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S | 1..1 | BackboneElement | Pharmacy Coverage |
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S | 1..1 | positiveInt | Insurance instance identifier Fixed Value: 1 |
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S | 1..1 | boolean | Coverage to be used for adjudication Fixed Value: true |
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S | 1..1 | Reference(RTPBC Coverage) | Pharmacy Coverage Reference |
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S | 0..1 | string | Pharmacy Coverage Reference |
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S | 1..1 | BackboneElement | Max 1 item per request |
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S | 1..1 | positiveInt | Item instance identifier Fixed Value: 1 |
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S | 1..1 | positiveInt | Care Team Sequence ID Reference |
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S | 1..1 | CodeableConcept | Prescribed Product Binding: RTPBC Prescribable Product Code Value Set (extensible): RTPBC prescribable product codes (NDC11 and RxNorm) |
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S | 1..* | Coding | Code defined by a terminology system |
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S | 1..1 | uri | Identity of the terminology system |
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S | 1..1 | code | Symbol in syntax defined by the system |
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S | 1..1 | string | Product Description |
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S | 1..1 | SimpleQuantity | Prescribed Quantity |
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S | 1..1 | decimal | Quantity in Billing Units |
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S | 1..1 | string | Billing unit of measure Binding: RTPBC Billing Unit Value Set (extensible): Billing quantity unit of measure |
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Path | Conformance | ValueSet | URI |
Claim.item.productOrService | extensible | RTPBCPrescribableProductCodeValueSethttp://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-prescribable-product-code From this IG | |
Claim.item.quantity.unit | extensible | RtbpcBillingUnitValueSethttp://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-billing-unit From this IG |
Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() | ||||
---|---|---|---|---|---|---|---|---|
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0..* | Claim | Claim, Pre-determination or Pre-authorization | |||||
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SΣ | 1..1 | id | Unique Claim Resource Identifier | ||||
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Σ | 0..1 | Meta | Metadata about the resource | ||||
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?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
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0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
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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 | |||||
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0..* | Resource | Contained, inline Resources | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?! | 0..* | Extension | Extensions that cannot be ignored | ||||
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S | 1..1 | Identifier | RTPBC request identifier | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
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?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
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Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. | ||||
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Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
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SΣ | 1..1 | string | Unique RTPBC request ID Example General: 123456 | ||||
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Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
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Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||
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?!SΣ | 1..1 | code | Request status Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Fixed Value: active | ||||
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SΣ | 1..1 | CodeableConcept | Requested Service Type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
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SΣ | 1..1 | Coding | Code defined by a terminology system | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
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SΣ | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type | ||||
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Σ | 0..1 | string | Version of the system - if relevant | ||||
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SΣ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: pharmacy | ||||
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SΣ | 1..1 | string | Representation defined by the system Fixed Value: Pharmacy | ||||
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Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
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Σ | 0..1 | string | Plain text representation of the concept | ||||
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0..1 | CodeableConcept | More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode. | |||||
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SΣ | 1..1 | code | Processing Mode Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim. Fixed Value: predetermination | ||||
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SΣ | 1..1 | Reference(RTPBC Patient) | Request Patient Information | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
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SΣC | 1..1 | string | Patient Reference | ||||
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Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
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Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
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Σ | 0..1 | string | Text alternative for the resource | ||||
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Σ | 0..1 | Period | Relevant time frame for the claim | ||||
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SΣ | 1..1 | dateTime | Created DateTime | ||||
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0..1 | Reference(Practitioner | PractitionerRole) | Author of the claim | |||||
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Σ | 0..1 | Reference(Organization) | Target | ||||
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SΣ | 1..1 | Reference(RTPBC Pharmacy Organization) | Preferred Pharmacy | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
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SΣC | 1..1 | string | Reference to Pharmacy Organization | ||||
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Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
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Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
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Σ | 0..1 | string | Text alternative for the resource | ||||
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SΣ | 1..1 | CodeableConcept | Processing priority Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred. | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
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SΣ | 1..1 | Coding | Code defined by a terminology system | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
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SΣ | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/processpriority | ||||
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Σ | 0..1 | string | Version of the system - if relevant | ||||
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SΣ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: normal | ||||
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SΣ | 1..1 | string | Representation defined by the system Fixed Value: Normal | ||||
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Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
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Σ | 0..1 | string | Plain text representation of the concept | ||||
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0..1 | CodeableConcept | For whom to reserve funds Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None). | |||||
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0..* | BackboneElement | Prior or corollary claims | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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0..1 | Reference(Claim) | Reference to the related claim | |||||
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0..1 | CodeableConcept | How the reference claim is related Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim. | |||||
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0..1 | Identifier | File or case reference | |||||
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S | 1..1 | Reference(RTPBC Medication Request) | Prescription Reference | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
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SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
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Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
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Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
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Σ | 0..1 | string | Text alternative for the resource | ||||
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0..1 | Reference(DeviceRequest | MedicationRequest | VisionPrescription) | Original prescription if superseded by fulfiller | |||||
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0..1 | BackboneElement | Recipient of benefits payable | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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1..1 | CodeableConcept | Category of recipient Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed. | |||||
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0..1 | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) | Recipient reference | |||||
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0..1 | Reference(ServiceRequest) | Treatment referral | |||||
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0..1 | Reference(Location) | Servicing facility | |||||
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S | 1..1 | BackboneElement | Prescriber | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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S | 1..1 | positiveInt | Order of care team Fixed Value: 1 | ||||
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S | 1..1 | Reference(US Core Practitioner Profile) | Prescriber | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
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SΣC | 1..1 | string | Prescriber Reference | ||||
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Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
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Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
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Σ | 0..1 | string | Text alternative for the resource | ||||
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0..1 | boolean | Indicator of the lead practitioner | |||||
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0..1 | CodeableConcept | Function within the team Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members. | |||||
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0..1 | CodeableConcept | Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications. | |||||
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0..* | BackboneElement | Supporting information | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() |
1..1 | positiveInt | Information instance identifier | |||||
![]() ![]() ![]() ![]() |
1..1 | CodeableConcept | Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. | |||||
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0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes. | |||||
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0..1 | When it occurred | ||||||
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date | |||||||
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Period | |||||||
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0..1 | Data to be provided | ||||||
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boolean | |||||||
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string | |||||||
![]() ![]() ![]() ![]() ![]() |
Quantity | |||||||
![]() ![]() ![]() ![]() ![]() |
Attachment | |||||||
![]() ![]() ![]() ![]() ![]() |
Reference(Resource) | |||||||
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0..1 | CodeableConcept | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth. | |||||
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0..* | BackboneElement | Pertinent diagnosis information | |||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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1..1 | positiveInt | Diagnosis instance identifier | |||||
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1..1 | Nature of illness or problem Binding: ICD-10Codes (example): Example ICD10 Diagnostic codes. | ||||||
![]() ![]() ![]() ![]() ![]() |
CodeableConcept | |||||||
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Reference(Condition) | |||||||
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0..* | CodeableConcept | Timing or nature of the diagnosis Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge. | |||||
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0..1 | CodeableConcept | Present on admission Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission. | |||||
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0..1 | CodeableConcept | Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis. | |||||
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0..* | BackboneElement | Clinical procedures performed | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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1..1 | positiveInt | Procedure instance identifier | |||||
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0..* | CodeableConcept | Category of Procedure Binding: ExampleProcedureTypeCodes (example): Example procedure type codes. | |||||
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0..1 | dateTime | When the procedure was performed | |||||
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1..1 | Specific clinical procedure Binding: ICD-10ProcedureCodes (example): Example ICD10 Procedure codes. | ||||||
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CodeableConcept | |||||||
![]() ![]() ![]() ![]() ![]() |
Reference(Procedure) | |||||||
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0..* | Reference(Device) | Unique device identifier | |||||
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SΣ | 1..1 | BackboneElement | Pharmacy Coverage | ||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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SΣ | 1..1 | positiveInt | Insurance instance identifier Fixed Value: 1 | ||||
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SΣ | 1..1 | boolean | Coverage to be used for adjudication Fixed Value: true | ||||
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0..1 | Identifier | Pre-assigned Claim number | |||||
![]() ![]() ![]() ![]() |
SΣ | 1..1 | Reference(RTPBC Coverage) | Pharmacy Coverage Reference | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
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SΣC | 0..1 | string | Pharmacy Coverage Reference | ||||
![]() ![]() ![]() ![]() ![]() |
Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
![]() ![]() ![]() ![]() ![]() |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
![]() ![]() ![]() ![]() ![]() |
Σ | 0..1 | string | Text alternative for the resource | ||||
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0..1 | string | Additional provider contract number | |||||
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0..* | string | Prior authorization reference number | |||||
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0..1 | Reference(ClaimResponse) | Adjudication results | |||||
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0..1 | BackboneElement | Details of the event | |||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() |
1..1 | date | When the incident occurred | |||||
![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | The nature of the accident Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc. | |||||
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0..1 | Where the event occurred | ||||||
![]() ![]() ![]() ![]() ![]() |
Address | |||||||
![]() ![]() ![]() ![]() ![]() |
Reference(Location) | |||||||
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S | 1..1 | BackboneElement | Max 1 item per request | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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S | 1..1 | positiveInt | Item instance identifier Fixed Value: 1 | ||||
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S | 1..1 | positiveInt | Care Team Sequence ID Reference | ||||
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0..* | positiveInt | Applicable diagnoses | |||||
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0..* | positiveInt | Applicable procedures | |||||
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0..* | positiveInt | Applicable exception and supporting information | |||||
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0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |||||
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0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses. | |||||
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S | 1..1 | CodeableConcept | Prescribed Product Binding: RTPBC Prescribable Product Code Value Set (extensible): RTPBC prescribable product codes (NDC11 and RxNorm) | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..* | Coding | Code defined by a terminology system | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | uri | Identity of the terminology system | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
Σ | 0..1 | string | Version of the system - if relevant | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | code | Symbol in syntax defined by the system | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | string | Product Description | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
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Σ | 0..1 | string | Plain text representation of the concept | ||||
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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. | |||||
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0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||
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0..1 | Date or dates of service or product delivery | ||||||
![]() ![]() ![]() ![]() ![]() |
date | |||||||
![]() ![]() ![]() ![]() ![]() |
Period | |||||||
![]() ![]() ![]() ![]() |
0..1 | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc. | ||||||
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CodeableConcept | |||||||
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Address | |||||||
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Reference(Location) | |||||||
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S | 1..1 | SimpleQuantity | Prescribed Quantity | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | decimal | Quantity in Billing Units | ||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | string | Billing unit of measure Binding: RTPBC Billing Unit Value Set (extensible): Billing quantity unit of measure | ||||
![]() ![]() ![]() ![]() ![]() |
ΣC | 0..1 | uri | System that defines coded unit form | ||||
![]() ![]() ![]() ![]() ![]() |
Σ | 0..1 | code | Coded form of the unit | ||||
![]() ![]() ![]() ![]() |
0..1 | Money | Fee, charge or cost per item | |||||
![]() ![]() ![]() ![]() |
0..1 | decimal | Price scaling factor | |||||
![]() ![]() ![]() ![]() |
0..1 | Money | Total item cost | |||||
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0..* | Reference(Device) | Unique device identifier | |||||
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0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch. | |||||
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0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations. | |||||
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0..* | Reference(Encounter) | Encounters related to this billed item | |||||
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0..* | BackboneElement | Product or service provided | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
1..1 | positiveInt | Item instance identifier | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses. | |||||
![]() ![]() ![]() ![]() ![]() |
1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
![]() ![]() ![]() ![]() ![]() |
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. | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | SimpleQuantity | Count of products or services | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | Money | Fee, charge or cost per item | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | decimal | Price scaling factor | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | Money | Total item cost | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Reference(Device) | Unique device identifier | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | BackboneElement | Product or service provided | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | positiveInt | Item instance identifier | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses. | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
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. | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | SimpleQuantity | Count of products or services | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | Money | Fee, charge or cost per item | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | decimal | Price scaling factor | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | Money | Total item cost | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Reference(Device) | Unique device identifier | |||||
![]() ![]() ![]() |
0..1 | Money | Total claim cost | |||||
![]() |
Path | Conformance | ValueSet / Code | URI | |||
Claim.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languages From the FHIR Standard
| ||||
Claim.identifier.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 From the FHIR Standard | ||||
Claim.identifier.type | extensible | Identifier Type Codeshttp://hl7.org/fhir/ValueSet/identifier-type From the FHIR Standard | ||||
Claim.status | required | Fixed Value: activehttp://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 | Fixed Value: predeterminationhttp://hl7.org/fhir/ValueSet/claim-use|4.0.1 From the FHIR Standard | ||||
Claim.patient.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types From the FHIR Standard | ||||
Claim.provider.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types 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.prescription.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types From the FHIR Standard | ||||
Claim.payee.type | example | Claim Payee Type Codeshttp://hl7.org/fhir/ValueSet/payeetype From the FHIR Standard | ||||
Claim.careTeam.provider.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types 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 | example | ExampleDiagnosisOnAdmissionCodeshttp://hl7.org/fhir/ValueSet/ex-diagnosis-on-admission From the FHIR Standard | ||||
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.insurance.coverage.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types 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 | extensible | RTPBCPrescribableProductCodeValueSethttp://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-prescribable-product-code From this IG | ||||
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.quantity.unit | extensible | RtbpcBillingUnitValueSethttp://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-billing-unit From this IG | ||||
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
Mandatory: 26 elements
Must-Support: 42 elements
Fixed: 12 elements
Structures
This structure refers to these other structures:
Maturity: 4
Key Elements View
Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() |
---|---|---|---|---|
![]() ![]() |
0..* | Claim | Claim, Pre-determination or Pre-authorization | |
![]() ![]() ![]() |
SΣ | 1..1 | id | Unique Claim Resource Identifier |
![]() ![]() ![]() |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
![]() ![]() ![]() |
?! | 0..* | Extension | Extensions that cannot be ignored |
![]() ![]() ![]() |
S | 1..1 | Identifier | RTPBC request identifier |
![]() ![]() ![]() ![]() |
?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . |
![]() ![]() ![]() ![]() |
SΣ | 1..1 | string | Unique RTPBC request ID Example General: 123456 |
![]() ![]() ![]() |
?!SΣ | 1..1 | code | Request status Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Fixed Value: active |
![]() ![]() ![]() |
SΣ | 1..1 | CodeableConcept | Requested Service Type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. |
![]() ![]() ![]() ![]() |
SΣ | 1..1 | Coding | Code defined by a terminology system |
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type |
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: pharmacy |
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | string | Representation defined by the system Fixed Value: Pharmacy |
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SΣ | 1..1 | code | Processing Mode Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim. Fixed Value: predetermination |
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SΣ | 1..1 | Reference(RTPBC Patient) | Request Patient Information |
![]() ![]() ![]() ![]() |
SΣC | 1..1 | string | Patient Reference |
![]() ![]() ![]() |
SΣ | 1..1 | dateTime | Created DateTime |
![]() ![]() ![]() |
SΣ | 1..1 | Reference(RTPBC Pharmacy Organization) | Preferred Pharmacy |
![]() ![]() ![]() ![]() |
SΣC | 1..1 | string | Reference to Pharmacy Organization |
![]() ![]() ![]() |
SΣ | 1..1 | CodeableConcept | Processing priority Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred. |
![]() ![]() ![]() ![]() |
SΣ | 1..1 | Coding | Code defined by a terminology system |
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/processpriority |
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: normal |
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | string | Representation defined by the system Fixed Value: Normal |
![]() ![]() ![]() |
S | 1..1 | Reference(RTPBC Medication Request) | Prescription Reference |
![]() ![]() ![]() ![]() |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
![]() ![]() ![]() |
S | 1..1 | BackboneElement | Prescriber |
![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
![]() ![]() ![]() ![]() |
S | 1..1 | positiveInt | Order of care team Fixed Value: 1 |
![]() ![]() ![]() ![]() |
S | 1..1 | Reference(US Core Practitioner Profile) | Prescriber |
![]() ![]() ![]() ![]() ![]() |
SΣC | 1..1 | string | Prescriber Reference |
![]() ![]() ![]() |
SΣ | 1..1 | BackboneElement | Pharmacy Coverage |
![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
![]() ![]() ![]() ![]() |
SΣ | 1..1 | positiveInt | Insurance instance identifier Fixed Value: 1 |
![]() ![]() ![]() ![]() |
SΣ | 1..1 | boolean | Coverage to be used for adjudication Fixed Value: true |
![]() ![]() ![]() ![]() |
SΣ | 1..1 | Reference(RTPBC Coverage) | Pharmacy Coverage Reference |
![]() ![]() ![]() ![]() ![]() |
SΣC | 0..1 | string | Pharmacy Coverage Reference |
![]() ![]() ![]() |
S | 1..1 | BackboneElement | Max 1 item per request |
![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
![]() ![]() ![]() ![]() |
S | 1..1 | positiveInt | Item instance identifier Fixed Value: 1 |
![]() ![]() ![]() ![]() |
S | 1..1 | positiveInt | Care Team Sequence ID Reference |
![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Prescribed Product Binding: RTPBC Prescribable Product Code Value Set (extensible): RTPBC prescribable product codes (NDC11 and RxNorm) |
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..* | Coding | Code defined by a terminology system |
![]() ![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | uri | Identity of the terminology system |
![]() ![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | code | Symbol in syntax defined by the system |
![]() ![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | string | Product Description |
![]() ![]() ![]() ![]() |
S | 1..1 | SimpleQuantity | Prescribed Quantity |
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | decimal | Quantity in Billing Units |
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | string | Billing unit of measure Binding: RTPBC Billing Unit Value Set (extensible): Billing quantity unit of measure |
![]() |
Path | Conformance | ValueSet / Code | URI |
Claim.identifier.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 From the FHIR Standard | |
Claim.status | required | Fixed Value: activehttp://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 | Fixed Value: predeterminationhttp://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.item.productOrService | extensible | RTPBCPrescribableProductCodeValueSethttp://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-prescribable-product-code From this IG | |
Claim.item.quantity.unit | extensible | RtbpcBillingUnitValueSethttp://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-billing-unit From this IG |
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() |
Differential View
This structure is derived from Claim
Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() |
---|---|---|---|---|
![]() ![]() |
Claim | |||
![]() ![]() ![]() |
S | 1..1 | id | Unique Claim Resource Identifier |
![]() ![]() ![]() |
S | 1..1 | Identifier | RTPBC request identifier |
![]() ![]() ![]() ![]() |
S | 1..1 | string | Unique RTPBC request ID |
![]() ![]() ![]() |
S | 1..1 | code | Request status Fixed Value: active |
![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Requested Service Type |
![]() ![]() ![]() ![]() |
S | 1..1 | Coding | Code defined by a terminology system |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | code | Symbol in syntax defined by the system Fixed Value: pharmacy |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | Representation defined by the system Fixed Value: Pharmacy |
![]() ![]() ![]() |
S | 1..1 | code | Processing Mode Fixed Value: predetermination |
![]() ![]() ![]() |
S | 1..1 | Reference(RTPBC Patient) | Request Patient Information |
![]() ![]() ![]() ![]() |
S | 1..1 | string | Patient Reference |
![]() ![]() ![]() |
S | 1..1 | dateTime | Created DateTime |
![]() ![]() ![]() |
S | 1..1 | Reference(RTPBC Pharmacy Organization) | Preferred Pharmacy |
![]() ![]() ![]() ![]() |
S | 1..1 | string | Reference to Pharmacy Organization |
![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Processing priority |
![]() ![]() ![]() ![]() |
S | 1..1 | Coding | Code defined by a terminology system |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/processpriority |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | code | Symbol in syntax defined by the system Fixed Value: normal |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | Representation defined by the system Fixed Value: Normal |
![]() ![]() ![]() |
S | 1..1 | Reference(RTPBC Medication Request) | Prescription Reference |
![]() ![]() ![]() ![]() |
S | 1..1 | string | Literal reference, Relative, internal or absolute URL |
![]() ![]() ![]() |
S | 1..1 | BackboneElement | Prescriber |
![]() ![]() ![]() ![]() |
S | 1..1 | positiveInt | Order of care team Fixed Value: 1 |
![]() ![]() ![]() ![]() |
S | 1..1 | Reference(US Core Practitioner Profile) | Prescriber |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | Prescriber Reference |
![]() ![]() ![]() |
S | 1..1 | BackboneElement | Pharmacy Coverage |
![]() ![]() ![]() ![]() |
S | 1..1 | positiveInt | Insurance instance identifier Fixed Value: 1 |
![]() ![]() ![]() ![]() |
S | 1..1 | boolean | Coverage to be used for adjudication Fixed Value: true |
![]() ![]() ![]() ![]() |
S | 1..1 | Reference(RTPBC Coverage) | Pharmacy Coverage Reference |
![]() ![]() ![]() ![]() ![]() |
S | 0..1 | string | Pharmacy Coverage Reference |
![]() ![]() ![]() |
S | 1..1 | BackboneElement | Max 1 item per request |
![]() ![]() ![]() ![]() |
S | 1..1 | positiveInt | Item instance identifier Fixed Value: 1 |
![]() ![]() ![]() ![]() |
S | 1..1 | positiveInt | Care Team Sequence ID Reference |
![]() ![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Prescribed Product Binding: RTPBC Prescribable Product Code Value Set (extensible): RTPBC prescribable product codes (NDC11 and RxNorm) |
![]() ![]() ![]() ![]() ![]() |
S | 1..* | Coding | Code defined by a terminology system |
![]() ![]() ![]() ![]() ![]() ![]() |
S | 1..1 | uri | Identity of the terminology system |
![]() ![]() ![]() ![]() ![]() ![]() |
S | 1..1 | code | Symbol in syntax defined by the system |
![]() ![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | Product Description |
![]() ![]() ![]() ![]() |
S | 1..1 | SimpleQuantity | Prescribed Quantity |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | decimal | Quantity in Billing Units |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | Billing unit of measure Binding: RTPBC Billing Unit Value Set (extensible): Billing quantity unit of measure |
![]() |
Path | Conformance | ValueSet | URI |
Claim.item.productOrService | extensible | RTPBCPrescribableProductCodeValueSethttp://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-prescribable-product-code From this IG | |
Claim.item.quantity.unit | extensible | RtbpcBillingUnitValueSethttp://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-billing-unit From this IG |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() | ||||
---|---|---|---|---|---|---|---|---|
![]() ![]() |
0..* | Claim | Claim, Pre-determination or Pre-authorization | |||||
![]() ![]() ![]() |
SΣ | 1..1 | id | Unique Claim Resource Identifier | ||||
![]() ![]() ![]() |
Σ | 0..1 | Meta | Metadata about the resource | ||||
![]() ![]() ![]() |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
![]() ![]() ![]() |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
![]() ![]() ![]() |
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 | |||||
![]() ![]() ![]() |
0..* | Resource | Contained, inline Resources | |||||
![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
![]() ![]() ![]() |
S | 1..1 | Identifier | RTPBC request identifier | ||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
![]() ![]() ![]() ![]() |
?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
![]() ![]() ![]() ![]() |
Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. | ||||
![]() ![]() ![]() ![]() |
Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
![]() ![]() ![]() ![]() |
SΣ | 1..1 | string | Unique RTPBC request ID Example General: 123456 | ||||
![]() ![]() ![]() ![]() |
Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
![]() ![]() ![]() ![]() |
Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||
![]() ![]() ![]() |
?!SΣ | 1..1 | code | Request status Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Fixed Value: active | ||||
![]() ![]() ![]() |
SΣ | 1..1 | CodeableConcept | Requested Service Type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. | ||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
![]() ![]() ![]() ![]() |
SΣ | 1..1 | Coding | Code defined by a terminology system | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type | ||||
![]() ![]() ![]() ![]() ![]() |
Σ | 0..1 | string | Version of the system - if relevant | ||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: pharmacy | ||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | string | Representation defined by the system Fixed Value: Pharmacy | ||||
![]() ![]() ![]() ![]() ![]() |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
![]() ![]() ![]() ![]() |
Σ | 0..1 | string | Plain text representation of the concept | ||||
![]() ![]() ![]() |
0..1 | CodeableConcept | More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode. | |||||
![]() ![]() ![]() |
SΣ | 1..1 | code | Processing Mode Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim. Fixed Value: predetermination | ||||
![]() ![]() ![]() |
SΣ | 1..1 | Reference(RTPBC Patient) | Request Patient Information | ||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
![]() ![]() ![]() ![]() |
SΣC | 1..1 | string | Patient Reference | ||||
![]() ![]() ![]() ![]() |
Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
![]() ![]() ![]() ![]() |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
![]() ![]() ![]() ![]() |
Σ | 0..1 | string | Text alternative for the resource | ||||
![]() ![]() ![]() |
Σ | 0..1 | Period | Relevant time frame for the claim | ||||
![]() ![]() ![]() |
SΣ | 1..1 | dateTime | Created DateTime | ||||
![]() ![]() ![]() |
0..1 | Reference(Practitioner | PractitionerRole) | Author of the claim | |||||
![]() ![]() ![]() |
Σ | 0..1 | Reference(Organization) | Target | ||||
![]() ![]() ![]() |
SΣ | 1..1 | Reference(RTPBC Pharmacy Organization) | Preferred Pharmacy | ||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
![]() ![]() ![]() ![]() |
SΣC | 1..1 | string | Reference to Pharmacy Organization | ||||
![]() ![]() ![]() ![]() |
Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
![]() ![]() ![]() ![]() |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
![]() ![]() ![]() ![]() |
Σ | 0..1 | string | Text alternative for the resource | ||||
![]() ![]() ![]() |
SΣ | 1..1 | CodeableConcept | Processing priority Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred. | ||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
![]() ![]() ![]() ![]() |
SΣ | 1..1 | Coding | Code defined by a terminology system | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/processpriority | ||||
![]() ![]() ![]() ![]() ![]() |
Σ | 0..1 | string | Version of the system - if relevant | ||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: normal | ||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | string | Representation defined by the system Fixed Value: Normal | ||||
![]() ![]() ![]() ![]() ![]() |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
![]() ![]() ![]() ![]() |
Σ | 0..1 | string | Plain text representation of the concept | ||||
![]() ![]() ![]() |
0..1 | CodeableConcept | For whom to reserve funds Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None). | |||||
![]() ![]() ![]() |
0..* | BackboneElement | Prior or corollary claims | |||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() |
0..1 | Reference(Claim) | Reference to the related claim | |||||
![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | How the reference claim is related Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim. | |||||
![]() ![]() ![]() ![]() |
0..1 | Identifier | File or case reference | |||||
![]() ![]() ![]() |
S | 1..1 | Reference(RTPBC Medication Request) | Prescription Reference | ||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
![]() ![]() ![]() ![]() |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
![]() ![]() ![]() ![]() |
Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
![]() ![]() ![]() ![]() |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
![]() ![]() ![]() ![]() |
Σ | 0..1 | string | Text alternative for the resource | ||||
![]() ![]() ![]() |
0..1 | Reference(DeviceRequest | MedicationRequest | VisionPrescription) | Original prescription if superseded by fulfiller | |||||
![]() ![]() ![]() |
0..1 | BackboneElement | Recipient of benefits payable | |||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() |
1..1 | CodeableConcept | Category of recipient Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed. | |||||
![]() ![]() ![]() ![]() |
0..1 | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) | Recipient reference | |||||
![]() ![]() ![]() |
0..1 | Reference(ServiceRequest) | Treatment referral | |||||
![]() ![]() ![]() |
0..1 | Reference(Location) | Servicing facility | |||||
![]() ![]() ![]() |
S | 1..1 | BackboneElement | Prescriber | ||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() |
S | 1..1 | positiveInt | Order of care team Fixed Value: 1 | ||||
![]() ![]() ![]() ![]() |
S | 1..1 | Reference(US Core Practitioner Profile) | Prescriber | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
![]() ![]() ![]() ![]() ![]() |
SΣC | 1..1 | string | Prescriber Reference | ||||
![]() ![]() ![]() ![]() ![]() |
Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
![]() ![]() ![]() ![]() ![]() |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
![]() ![]() ![]() ![]() ![]() |
Σ | 0..1 | string | Text alternative for the resource | ||||
![]() ![]() ![]() ![]() |
0..1 | boolean | Indicator of the lead practitioner | |||||
![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Function within the team Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members. | |||||
![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications. | |||||
![]() ![]() ![]() |
0..* | BackboneElement | Supporting information | |||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() |
1..1 | positiveInt | Information instance identifier | |||||
![]() ![]() ![]() ![]() |
1..1 | CodeableConcept | Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. | |||||
![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes. | |||||
![]() ![]() ![]() ![]() |
0..1 | When it occurred | ||||||
![]() ![]() ![]() ![]() ![]() |
date | |||||||
![]() ![]() ![]() ![]() ![]() |
Period | |||||||
![]() ![]() ![]() ![]() |
0..1 | Data to be provided | ||||||
![]() ![]() ![]() ![]() ![]() |
boolean | |||||||
![]() ![]() ![]() ![]() ![]() |
string | |||||||
![]() ![]() ![]() ![]() ![]() |
Quantity | |||||||
![]() ![]() ![]() ![]() ![]() |
Attachment | |||||||
![]() ![]() ![]() ![]() ![]() |
Reference(Resource) | |||||||
![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth. | |||||
![]() ![]() ![]() |
0..* | BackboneElement | Pertinent diagnosis information | |||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() |
1..1 | positiveInt | Diagnosis instance identifier | |||||
![]() ![]() ![]() ![]() |
1..1 | Nature of illness or problem Binding: ICD-10Codes (example): Example ICD10 Diagnostic codes. | ||||||
![]() ![]() ![]() ![]() ![]() |
CodeableConcept | |||||||
![]() ![]() ![]() ![]() ![]() |
Reference(Condition) | |||||||
![]() ![]() ![]() ![]() |
0..* | CodeableConcept | Timing or nature of the diagnosis Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge. | |||||
![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Present on admission Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission. | |||||
![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis. | |||||
![]() ![]() ![]() |
0..* | BackboneElement | Clinical procedures performed | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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1..1 | positiveInt | Procedure instance identifier | |||||
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0..* | CodeableConcept | Category of Procedure Binding: ExampleProcedureTypeCodes (example): Example procedure type codes. | |||||
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0..1 | dateTime | When the procedure was performed | |||||
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1..1 | Specific clinical procedure Binding: ICD-10ProcedureCodes (example): Example ICD10 Procedure codes. | ||||||
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CodeableConcept | |||||||
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Reference(Procedure) | |||||||
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0..* | Reference(Device) | Unique device identifier | |||||
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SΣ | 1..1 | BackboneElement | Pharmacy Coverage | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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SΣ | 1..1 | positiveInt | Insurance instance identifier Fixed Value: 1 | ||||
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SΣ | 1..1 | boolean | Coverage to be used for adjudication Fixed Value: true | ||||
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0..1 | Identifier | Pre-assigned Claim number | |||||
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SΣ | 1..1 | Reference(RTPBC Coverage) | Pharmacy Coverage Reference | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
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SΣC | 0..1 | string | Pharmacy Coverage Reference | ||||
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Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
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Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
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Σ | 0..1 | string | Text alternative for the resource | ||||
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0..1 | string | Additional provider contract number | |||||
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0..* | string | Prior authorization reference number | |||||
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0..1 | Reference(ClaimResponse) | Adjudication results | |||||
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0..1 | BackboneElement | Details of the event | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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1..1 | date | When the incident occurred | |||||
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0..1 | CodeableConcept | The nature of the accident Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc. | |||||
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0..1 | Where the event occurred | ||||||
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Address | |||||||
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Reference(Location) | |||||||
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S | 1..1 | BackboneElement | Max 1 item per request | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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S | 1..1 | positiveInt | Item instance identifier Fixed Value: 1 | ||||
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S | 1..1 | positiveInt | Care Team Sequence ID Reference | ||||
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0..* | positiveInt | Applicable diagnoses | |||||
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0..* | positiveInt | Applicable procedures | |||||
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0..* | positiveInt | Applicable exception and supporting information | |||||
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0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |||||
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0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses. | |||||
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S | 1..1 | CodeableConcept | Prescribed Product Binding: RTPBC Prescribable Product Code Value Set (extensible): RTPBC prescribable product codes (NDC11 and RxNorm) | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
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SΣ | 1..* | Coding | Code defined by a terminology system | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
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SΣ | 1..1 | uri | Identity of the terminology system | ||||
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Σ | 0..1 | string | Version of the system - if relevant | ||||
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SΣ | 1..1 | code | Symbol in syntax defined by the system | ||||
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SΣ | 1..1 | string | Product Description | ||||
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Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
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Σ | 0..1 | string | Plain text representation of the concept | ||||
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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. | |||||
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0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||
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0..1 | Date or dates of service or product delivery | ||||||
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date | |||||||
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Period | |||||||
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0..1 | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc. | ||||||
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CodeableConcept | |||||||
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Address | |||||||
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Reference(Location) | |||||||
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S | 1..1 | SimpleQuantity | Prescribed Quantity | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
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SΣ | 1..1 | decimal | Quantity in Billing Units | ||||
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SΣ | 1..1 | string | Billing unit of measure Binding: RTPBC Billing Unit Value Set (extensible): Billing quantity unit of measure | ||||
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ΣC | 0..1 | uri | System that defines coded unit form | ||||
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Σ | 0..1 | code | Coded form of the unit | ||||
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0..1 | Money | Fee, charge or cost per item | |||||
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0..1 | decimal | Price scaling factor | |||||
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0..1 | Money | Total item cost | |||||
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0..* | Reference(Device) | Unique device identifier | |||||
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0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch. | |||||
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0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations. | |||||
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0..* | Reference(Encounter) | Encounters related to this billed item | |||||
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0..* | BackboneElement | Product or service provided | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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1..1 | positiveInt | Item instance identifier | |||||
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0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |||||
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0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses. | |||||
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1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
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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. | |||||
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0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||
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0..1 | SimpleQuantity | Count of products or services | |||||
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0..1 | Money | Fee, charge or cost per item | |||||
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0..1 | decimal | Price scaling factor | |||||
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0..1 | Money | Total item cost | |||||
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0..* | Reference(Device) | Unique device identifier | |||||
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0..* | BackboneElement | Product or service provided | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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1..1 | positiveInt | Item instance identifier | |||||
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0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses. | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
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. | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||
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0..1 | SimpleQuantity | Count of products or services | |||||
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0..1 | Money | Fee, charge or cost per item | |||||
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0..1 | decimal | Price scaling factor | |||||
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0..1 | Money | Total item cost | |||||
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0..* | Reference(Device) | Unique device identifier | |||||
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0..1 | Money | Total claim cost | |||||
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Path | Conformance | ValueSet / Code | URI | |||
Claim.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languages From the FHIR Standard
| ||||
Claim.identifier.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 From the FHIR Standard | ||||
Claim.identifier.type | extensible | Identifier Type Codeshttp://hl7.org/fhir/ValueSet/identifier-type From the FHIR Standard | ||||
Claim.status | required | Fixed Value: activehttp://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 | Fixed Value: predeterminationhttp://hl7.org/fhir/ValueSet/claim-use|4.0.1 From the FHIR Standard | ||||
Claim.patient.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types From the FHIR Standard | ||||
Claim.provider.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types 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.prescription.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types From the FHIR Standard | ||||
Claim.payee.type | example | Claim Payee Type Codeshttp://hl7.org/fhir/ValueSet/payeetype From the FHIR Standard | ||||
Claim.careTeam.provider.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types 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 | example | ExampleDiagnosisOnAdmissionCodeshttp://hl7.org/fhir/ValueSet/ex-diagnosis-on-admission From the FHIR Standard | ||||
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.insurance.coverage.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types 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 | extensible | RTPBCPrescribableProductCodeValueSethttp://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-prescribable-product-code From this IG | ||||
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.quantity.unit | extensible | RtbpcBillingUnitValueSethttp://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-billing-unit From this IG | ||||
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
Mandatory: 26 elements
Must-Support: 42 elements
Fixed: 12 elements
Structures
This structure refers to these other structures:
Maturity: 4
Other representations of profile: CSV, Excel, Schematron