Patient Cost Transparency Implementation Guide
2.0.1 - STU 2

Patient Cost Transparency Implementation Guide, published by HL7 International / Financial Management. This guide is not an authorized publication; it is the continuous build for version 2.0.1 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/davinci-pct/ and changes regularly. See the Directory of published versions

## Resource Profile: PCTGFEProfessional - Detailed Descriptions

Page standards status: Trial-use | Maturity Level: 2

Definitions for the davinci-pct-gfe-professional resource profile.

- Key Elements Table
- Differential Elements Table
- Snapshot Elements Table

Guidance on how to interpret the contents of this table can be foundhere

0. Claim
Definition | A provider issued list of professional services and products which have been provided, or are to be provided, to a patient which is sent to an insurer for reimbursement.
Short | Claim, Pre-determination or Pre-authorization
Comments | The Claim resource fulfills three information request requirements: Claim - a request for adjudication for reimbursement for products and/or services provided; Preauthorization - a request to authorize the future provision of products and/or services including an anticipated adjudication; and, Predetermination - a request for a non-bind adjudication of possible future products and/or services.
Control | 0..*
Is Modifier | false
Summary | false
Alternate Names | Adjudication Request, Preauthorization Request, Predetermination Request
Invariants | dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty()) dom-3: 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: 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: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty()) dom-6: A resource should have narrative for robust management (text.`div`.exists())
2. Claim.implicitRules
Definition | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.
Short | A set of rules under which this content was created
Comments | Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
Control | 0..1
Type | uri
Is Modifier | true because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
4. Claim.extension
Definition | An Extension May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | ExtensionAdditional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
Slicing | This element introduces a set of slices on `Claim.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
6. Claim.extension:gfeServiceLinkingInfo
Slice Name | gfeServiceLinkingInfo
Definition | This extension is used to provide the GFE Service Linking Information. This allows implementers to have the same identifier on multiple GFEs that are part of one period of care's services. This would be needed for some of the workflow options that businesses may decide to use.
Short | GFE Service Linking Information
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(GFEServiceLinkingInfo) (Complex Extension)
Is Modifier | false
Must Support | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
8. Claim.extension:providerEventMethodology
Slice Name | providerEventMethodology
Definition | How the provider determined the number of claims and the number and type of billing providers to include in the GFE. Examples include provider episodes of care experience, PACES, order set based on clinical guidelines, payor suggested grouping, or some other method of determination. The extension definition contains additional detail.
Short | Provider event collection methodology
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(ProviderEventMethodology) (Extension Type: string)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
10. Claim.extension:gfeDisclaimer
Slice Name | gfeDisclaimer
Definition | Disclaimers the patient should be made aware of regarding the providers estimate including any additional assumptions and requirements. Noting that that the information provided is only an estimate based on the items and services reasonably expected, at the time of scheduling (or requesting) the item or service, to be furnished and is subject to change.
Short | Disclaimers the patient should be made aware of regarding the providers estimate, e.g. application of sliding scale for self-pay/uninsured patients
Comments | These disclaimers may include, but are not limited to things such as: provider discounts (e.g. application of sliding fee scale), limitations, preconditions, requirements, assumptions (e.g. diagnostic vs. preventative), information known to be missing in the estimate, conditions that may affect the estimate, or anything that may affect the interpretation of the estimate.
Control | 0..* This element is affected by the following invariants: ele-1
Type | Extension(GFEDisclaimer) (Extension Type: string)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
12. Claim.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Summary | false
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
14. Claim.identifier
Definition | A unique identifier assigned to this claim.
Short | Business Identifier for claim
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 10..*
Type | Identifier
Is Modifier | false
Summary | false
Requirements | Allows claims to be distinguished and referenced.
Alternate Names | Claim Number
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
Slicing | This element introduces a set of slices on `Claim.identifier`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ type
16. Claim.identifier:PLAC
Slice Name | PLAC
Definition | A unique identifier assigned to this claim.
Short | Provider Assigned Identifier for GFE ClaimBusiness Identifier for claim
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 10..1*
Type | Identifier
Is Modifier | false
Summary | false
Requirements | Allows claims to be distinguished and referenced.
Alternate Names | Claim Number
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
18. Claim.identifier:PLAC.use
Definition | The purpose of this identifier.
Short | usual | official | temp | secondary | old (If known)
Comments | Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.
Control | 0..1
Binding | The codes SHALL be taken from IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 (required to `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` ) Identifies the purpose for this identifier, if known .
Type | code
Is Modifier | true because This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one.
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
20. Claim.identifier:PLAC.type
Definition | A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.
Short | Description of identifier
Comments | This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type.
Control | 10..1
Binding | Unless not suitable, these codes SHALL be taken from Identifier Type Codes http://hl7.org/fhir/ValueSet/identifier-type|4.0.1 (extensible to `http://hl7.org/fhir/ValueSet/identifier-type|4.0.1` ) A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
Type | CodeableConcept
Is Modifier | false
Summary | true
Requirements | Allows users to make use of identifiers when the identifier system is not known.
Pattern Value | `{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/v2-0203", "code" : "PLAC", "display" : "Placer Identifier" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
22. Claim.identifier:PLAC.system
Definition | Establishes the namespace for the value - that is, a URL that describes a set values that are unique.
Short | The namespace for the identifier value
Comments | Identifier.system is always case sensitive.
Control | 0..1
Type | uri
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Requirements | There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.
Example | General: http://www.acme.com/identifiers/patient
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
24. Claim.identifier:PLAC.value
Definition | The portion of the identifier typically relevant to the user and which is unique within the context of the system.
Short | The value that is unique
Comments | If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.
Control | 10..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Example | General: 123456
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
26. Claim.status
Definition | The status of the resource instance.
Short | active | cancelled | draft | entered-in-error
Comments | This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.
Control | 1..1
Binding | The codes SHALL be taken from FinancialResourceStatusCodes http://hl7.org/fhir/ValueSet/fm-status|4.0.1 (required to `http://hl7.org/fhir/ValueSet/fm-status|4.0.1` ) A code specifying the state of the resource instance.
Type | code
Is Modifier | true because This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
28. Claim.type
Definition | The category of claim, e.g. oral, pharmacy, vision, institutional, professional.
Short | Category or discipline
Comments | The majority of jurisdictions use: oral, pharmacy, vision, professional and institutional, or variants on those terms, as the general styles of claims. The valueset is extensible to accommodate other jurisdictional requirements.
Control | 1..1
Binding | Unless not suitable, these codes SHALL be taken from ClaimTypeCodes http://hl7.org/fhir/ValueSet/claim-type|4.0.1 (extensible to `http://hl7.org/fhir/ValueSet/claim-type|4.0.1` ) The type or discipline-style of the claim.
Type | CodeableConcept
Is Modifier | false
Summary | true
Requirements | Claim type determine the general sets of business rules applied for information requirements and adjudication.
Pattern Value | `{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/claim-type", "code" : "professional" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
30. Claim.use
Definition | A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future.
Short | claim | preauthorization | predetermination
Control | 1..1
Binding | The codes SHALL be taken from Use http://hl7.org/fhir/ValueSet/claim-use|4.0.1 (required to `http://hl7.org/fhir/ValueSet/claim-use|4.0.1` ) The purpose of the Claim: predetermination, preauthorization, claim.
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | This element is required to understand the nature of the request for adjudication.
Pattern Value | `predetermination`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
32. Claim.patient
Definition | The party to whom the professional services and/or products have been supplied or are being considered and for whom actual or forecast reimbursement is sought.
Short | The recipient of the products and services
Control | 1..1
Type | Reference(US Core Patient Profile, Patient)
Is Modifier | false
Summary | true
Requirements | The patient must be supplied to the insurer so that confirmation of coverage and service history may be considered as part of the authorization and/or adjudiction.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
34. Claim.created
Definition | The date this resource was created.
Short | Resource creation date
Comments | This field is independent of the date of creation of the resource as it may reflect the creation date of a source document prior to digitization. Typically for claims all services must be completed as of this date.
Control | 1..1
Type | dateTime
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | Need to record a timestamp for use by both the recipient and the issuer.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
36. Claim.insurer
Definition | The Insurer who is target of the request.
Short | Target
Control | 0..1
Type | Reference(PCT Organization, Organization)
Is Modifier | false
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
38. Claim.provider
Definition | The provider which is responsible for the claim, predetermination or preauthorization.
Short | Billing provider - party responsible for the GFEParty responsible for the claim
Comments | Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below.
Control | 1..1
Type | Reference(PCT Organization, PCT Practitioner, Practitioner, PractitionerRole, Organization)
Is Modifier | false
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
40. Claim.provider.extension
Definition | An Extension May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | ExtensionAdditional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 10..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
Slicing | This element introduces a set of slices on `Claim.provider.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
42. Claim.provider.extension:providerTaxonomy
Slice Name | providerTaxonomy
Definition | This extension is used to indicate the taxonomy code of the provider.
Short | Provider taxonomy codes consisting of NUCC Health Care Provider Taxonomy Code Set for providers
Control | 1..1
Type | Extension(ProviderTaxonomy) (Extension Type: CodeableConcept)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
44. Claim.provider.extension:consentForBalanceBilling
Slice Name | consentForBalanceBilling
Definition | If the provider has received a written consent form indicating a patient has agreed to waive their protections and pay up to the full cost for the out-of-network item or service, this will be “true”. If the provider has not received written consent, this will be “false”. This is an attestation only. The billing provider is legally required to maintain the written notice and consent form.
Short | Extension
Control | 0..1
Type | Extension(GFEConsentForBalanceBilling) (Extension Type: boolean)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
46. Claim.priority
Definition | The provider-required urgency of processing the request. Typical values include: stat, routine deferred.
Short | Desired processing ugency
Comments | If a claim processor is unable to complete the processing as per the priority then they should generate and error and not process the request.
Control | 1..1
Binding | The codes SHALL be taken from For example codes, see ProcessPriorityCodes http://hl7.org/fhir/ValueSet/process-priority|4.0.1 (required to `http://hl7.org/fhir/ValueSet/process-priority` )
Type | CodeableConcept
Is Modifier | false
Summary | true
Requirements | The provider may need to indicate their processing requirements so that the processor can indicate if they are unable to comply.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
48. Claim.payee
Definition | The party to be reimbursed for cost of the products and services according to the terms of the policy.
Short | Recipient of benefits payable
Comments | Often providers agree to receive the benefits payable to reduce the near-term costs to the patient. The insurer may decline to pay the provider and choose to pay the subscriber instead.
Control | 0..1
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Requirements | The provider needs to specify who they wish to be reimbursed and the claims processor needs express who they will reimburse.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
50. Claim.payee.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
52. Claim.payee.type
Definition | Type of Party to be reimbursed: subscriber, provider, other.
Short | Category of recipient
Control | 1..1
Binding | For example codes, see Claim Payee Type Codes http://hl7.org/fhir/ValueSet/payeetype|4.0.1 (example to `http://hl7.org/fhir/ValueSet/payeetype|4.0.1` ) A code for the party to be reimbursed.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Need to know who should receive payment with the most common situations being the Provider (assignment of benefits) or the Subscriber.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
54. Claim.payee.party
Definition | Reference to the individual or organization to whom any payment will be made.
Short | Recipient reference
Comments | Not required if the payee is 'subscriber' or 'provider'.
Control | 0..1
Type | Reference(PCT Practitioner, PCT Organization, Practitioner, PractitionerRole, Organization, Patient, RelatedPerson)
Is Modifier | false
Summary | false
Requirements | Need to provide demographics if the payee is not 'subscriber' nor 'provider'.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
56. Claim.careTeam
Definition | The members of the team who provided the products and services.
Short | Members of the care team
Control | 0..*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Requirements | Common to identify the responsible and supporting practitioners.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
Slicing | This element introduces a set of slices on `Claim.careTeam`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ role
58. Claim.careTeam.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
60. Claim.careTeam.sequence
Definition | A number to uniquely identify care team entries.
Short | Order of care team
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Necessary to maintain the order of the care team and provide a mechanism to link individuals to claim details.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
62. Claim.careTeam.provider
Definition | Member of the team who provided the product or service.
Short | Practitioner or organization
Control | 1..1
Type | Reference(PCT Practitioner, PCT Organization, Practitioner, PractitionerRole, Organization)
Is Modifier | false
Summary | false
Requirements | Often a regulatory requirement to specify the responsible provider.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
64. Claim.careTeam.role
Definition | The lead, assisting or supervising practitioner and their discipline if a multidisciplinary team.
Short | Function within the team
Comments | Role might not be required when there is only a single provider listed.
Control | 10..1
Binding | The codes SHALL be taken from For example codes, see PCT Care Team Role Value Set http://hl7.org/fhir/ValueSet/claim-careteamrole|4.0.1 (required to `http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTCareTeamRoleVS` )
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | When multiple parties are present it is required to distinguish the roles performed by each member.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
66. Claim.careTeam.qualification
Definition | The qualification of the practitioner which is applicable for this service.
Short | Practitioner credential or specialization
Control | 0..1
Binding | The codes SHALL be taken from For example codes, see US Core Provider Role (NUCC)http://hl7.org/fhir/ValueSet/provider-qualification|4.0.1 (required to `http://hl7.org/fhir/us/core/ValueSet/us-core-provider-role` )
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Need to specify which qualification a provider is delivering the product or service under.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
68. Claim.careTeam:rendering
Slice Name | rendering
Definition | The members of the team who provided the products and services.
Short | Members of the care team
Control | 0..*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Requirements | Common to identify the responsible and supporting practitioners.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
70. Claim.careTeam:rendering.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
72. Claim.careTeam:rendering.sequence
Definition | A number to uniquely identify care team entries.
Short | Order of care team
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Necessary to maintain the order of the care team and provide a mechanism to link individuals to claim details.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
74. Claim.careTeam:rendering.provider
Definition | Member of the team who provided the product or service.
Short | Practitioner or organization
Control | 1..1
Type | Reference(PCT Practitioner, PCT Organization, Practitioner, PractitionerRole, Organization)
Is Modifier | false
Summary | false
Requirements | Often a regulatory requirement to specify the responsible provider.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
76. Claim.careTeam:rendering.role
Definition | The lead, assisting or supervising practitioner and their discipline if a multidisciplinary team.
Short | Function within the team
Comments | Role might not be required when there is only a single provider listed.
Control | 10..1
Binding | The codes SHALL be taken from For example codes, see PCT Care Team Role Value Set http://hl7.org/fhir/ValueSet/claim-careteamrole|4.0.1 (required to `http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTCareTeamRoleVS` )
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | When multiple parties are present it is required to distinguish the roles performed by each member.
Pattern Value | `{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "version" : "1.0.1", "code" : "rendering" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
78. Claim.careTeam:rendering.qualification
Definition | The qualification of the practitioner which is applicable for this service.
Short | Practitioner credential or specialization - must provide a taxonomy code for the Professional case
Control | 10..1
Binding | The codes SHALL be taken from For example codes, see US Core Provider Role (NUCC)http://hl7.org/fhir/ValueSet/provider-qualification|4.0.1 (required to `http://hl7.org/fhir/us/core/ValueSet/us-core-provider-role` )
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Need to specify which qualification a provider is delivering the product or service under.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
80. Claim.careTeam:referring
Slice Name | referring
Definition | The members of the team who provided the products and services.
Short | Members of the care team
Control | 0..1*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Requirements | Common to identify the responsible and supporting practitioners.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
82. Claim.careTeam:referring.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
84. Claim.careTeam:referring.sequence
Definition | A number to uniquely identify care team entries.
Short | Order of care team
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Necessary to maintain the order of the care team and provide a mechanism to link individuals to claim details.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
86. Claim.careTeam:referring.provider
Definition | Member of the team who provided the product or service.
Short | Practitioner or organization
Control | 1..1
Type | Reference(PCT Practitioner, PCT Organization, Practitioner, PractitionerRole, Organization)
Is Modifier | false
Summary | false
Requirements | Often a regulatory requirement to specify the responsible provider.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
88. Claim.careTeam:referring.role
Definition | The lead, assisting or supervising practitioner and their discipline if a multidisciplinary team.
Short | Function within the team
Comments | Role might not be required when there is only a single provider listed.
Control | 10..1
Binding | The codes SHALL be taken from For example codes, see PCT Care Team Role Value Set http://hl7.org/fhir/ValueSet/claim-careteamrole|4.0.1 (required to `http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTCareTeamRoleVS` )
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | When multiple parties are present it is required to distinguish the roles performed by each member.
Pattern Value | `{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "version" : "1.0.1", "code" : "referring" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
90. Claim.supportingInfo
Definition | Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.
Short | Supporting information
Comments | Often there are multiple jurisdiction specific valuesets which are required.
Control | 0..*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Requirements | Typically these information codes are required to support the services rendered or the adjudication of the services rendered.
Alternate Names | Attachments Exception Codes Occurrence Codes Value codes
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
Slicing | This element introduces a set of slices on `Claim.supportingInfo`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ category
92. Claim.supportingInfo.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
94. Claim.supportingInfo.sequence
Definition | A number to uniquely identify supporting information entries.
Short | Information instance identifier
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
96. Claim.supportingInfo.category
Definition | The general class of the information supplied: information; exception; accident, employment; onset, etc.
Short | Classification of the supplied information
Comments | This may contain a category for the local bill type codes.
Control | 1..1
Binding | Unless not suitable, these codes SHALL be taken from For example codes, see PCT Supporting Info Type Value Set http://hl7.org/fhir/ValueSet/claim-informationcategory|4.0.1 (extensible to `http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTSupportingInfoTypeVS` )
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Required to group or associate information items with common characteristics. For example: admission information or prior treatments.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
98. Claim.supportingInfo:serviceFacility
Slice Name | serviceFacility
Definition | Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.
Short | Service FacilitySupporting information
Comments | Service Facility Location information conveys the name, full address and identifier of the facility where services were rendered when that is different from the Billing/Performing Provider. Often there are multiple jurisdiction specific valuesets which are required.
Control | 0..1*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Requirements | Typically these information codes are required to support the services rendered or the adjudication of the services rendered.
Alternate Names | Attachments Exception Codes Occurrence Codes Value codes
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
100. Claim.supportingInfo:serviceFacility.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
102. Claim.supportingInfo:serviceFacility.sequence
Definition | A number to uniquely identify supporting information entries.
Short | Information instance identifier
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
104. Claim.supportingInfo:serviceFacility.category
Definition | The general class of the information supplied: information; exception; accident, employment; onset, etc.
Short | Classification of the supplied information
Comments | This may contain a category for the local bill type codes.
Control | 1..1
Binding | Unless not suitable, these codes SHALL be taken from For example codes, see PCT Supporting Info Type Value Set http://hl7.org/fhir/ValueSet/claim-informationcategory|4.0.1 (extensible to `http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTSupportingInfoTypeVS` )
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Required to group or associate information items with common characteristics. For example: admission information or prior treatments.
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType", "code" : "servicefacility" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
106. Claim.supportingInfo:serviceFacility.value[x]
Definition | Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.
Short | Data to be provided
Comments | Could be used to provide references to other resources, document. For example could contain a PDF in an Attachment of the Police Report for an Accident.
Control | 10..1
Type | Reference(Resource), boolean, string, Quantity, Attachment
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Summary | false
Requirements | To convey the data content to be provided when the information is more than a simple code or period.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
Slicing | This element introduces a set of slices on `Claim.supportingInfo.value[x]`. The slices areUnordered and Closed, and can be differentiated using the following discriminators: type @ $this
108. Claim.supportingInfo:serviceFacility.value[x]:valueReference
Slice Name | valueReference
Definition | Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.
Short | Data to be provided
Comments | Could be used to provide references to other resources, document. For example could contain a PDF in an Attachment of the Police Report for an Accident.
Control | 10..1
Type | Reference(PCT Organization, Resource), boolean, string, Quantity, Attachment
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Summary | false
Requirements | To convey the data content to be provided when the information is more than a simple code or period.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
110. Claim.supportingInfo:claimFrequency
Slice Name | claimFrequency
Definition | Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.
Short | Claim Frequency component of the UB-04 Type of Bill Code (4th digit of the UB-04 Type of Bill code).Supporting information
Comments | For the purposes of Patient Cost Transparency Estimates, this field may be used to modify or replace a GFE claim estimate within the same GFE Packet submission. This specification does not support the modification of Claim resources outside of the GFE Packet and client systems SHALL NOT expect the inclusion of the frequency code to affect the use or interpretation of any Claim outside of the GFE Packet. Often there are multiple jurisdiction specific valuesets which are required.
Control | 0..1*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Requirements | Typically these information codes are required to support the services rendered or the adjudication of the services rendered.
Alternate Names | Attachments Exception Codes Occurrence Codes Value codes
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
112. Claim.supportingInfo:claimFrequency.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
114. Claim.supportingInfo:claimFrequency.sequence
Definition | A number to uniquely identify supporting information entries.
Short | Information instance identifier
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
116. Claim.supportingInfo:claimFrequency.category
Definition | The general class of the information supplied: information; exception; accident, employment; onset, etc.
Short | Classification of the supplied information
Comments | This may contain a category for the local bill type codes.
Control | 1..1
Binding | Unless not suitable, these codes SHALL be taken from For example codes, see PCT Supporting Info Type Value Set http://hl7.org/fhir/ValueSet/claim-informationcategory|4.0.1 (extensible to `http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTSupportingInfoTypeVS` )
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Required to group or associate information items with common characteristics. For example: admission information or prior treatments.
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType", "code" : "claimFrequency" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
118. Claim.supportingInfo:claimFrequency.code
Definition | System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought.
Short | Type of information
Control | 10..1
Binding | The codes SHALL be taken from For example codes, see PCT GFE NUBC Uniform Billing (UB-04) Type of Bill Value Set http://hl7.org/fhir/ValueSet/claim-exception|4.0.1 (required to `http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFETypeOfBillVS` )
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Required to identify the kind of additional information.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
120. Claim.diagnosis
Definition | Information about diagnoses relevant to the claim items.
Short | Pertinent diagnosis information
Control | 0..*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Requirements | Required for the adjudication by provided context for the services and product listed.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
Slicing | This element introduces a set of slices on `Claim.diagnosis`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ type
122. Claim.diagnosis.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
124. Claim.diagnosis.sequence
Definition | A number to uniquely identify diagnosis entries.
Short | Diagnosis instance identifier
Comments | Diagnosis are presented in list order to their expected importance: primary, secondary, etc.
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Necessary to maintain the order of the diagnosis items and provide a mechanism to link to claim details.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
126. Claim.diagnosis.diagnosis[x]
Definition | The nature of illness or problem in a coded form or as a reference to an external defined Condition.
Short | Nature of illness or problem
Control | 1..1
Binding | For example codes, see ICD-10Codes http://hl7.org/fhir/ValueSet/icd-10|4.0.1 (example to `http://hl7.org/fhir/ValueSet/icd-10|4.0.1` ) Example ICD10 Diagnostic codes.
Type | Choice of: CodeableConcept, Reference(Condition)
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Summary | false
Requirements | Provides health context for the evaluation of the products and/or services.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
128. Claim.diagnosis.type
Definition | When the condition was observed or the relative ranking.
Short | Timing or nature of the diagnosis
Comments | For example: admitting, primary, secondary, discharge.
Control | 0..*
Binding | The codes SHALL be taken from For example codes, see Diagnosis Type Codes http://hl7.org/fhir/ValueSet/ex-diagnosistype|4.0.1 (required to `http://terminology.hl7.org/ValueSet/diagnosistype` )
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | false
Requirements | Often required to capture a particular diagnosis, for example: primary or discharge.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
130. Claim.diagnosis:principal
Slice Name | principal
Definition | Information about diagnoses relevant to the claim items.
Short | Principal Diagnosis - Must Support means the information source SHALL be capable of populating and SHALL populate if available and permitted.Pertinent diagnosis information
Comments | If the Principal Diagnosis code is known, it is important that it be shared in the GFE, particularly when the GFE is being sent to a payer for an insured patient. Payers very often need the diagnosis to be able to provide an estimate. Without the diagnosis, payers may assume the service is diagnostic and thus the patient responsibility may be higher or not covered at all than the diagnosis, such as for preventative services, would otherwise indicate. It is understood that in certain situations, such as scheduled services or GFE requests prior to orders, diagnosis is not needed or may not yet be known. However, when it is known, it is important that this information be shared to ensure the best possible estimate is provided to the patient.
Control | 0..1*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Requirements | Required for the adjudication by provided context for the services and product listed.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
132. Claim.diagnosis:principal.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
134. Claim.diagnosis:principal.sequence
Definition | A number to uniquely identify diagnosis entries.
Short | Diagnosis instance identifier
Comments | Diagnosis are presented in list order to their expected importance: primary, secondary, etc.
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Necessary to maintain the order of the diagnosis items and provide a mechanism to link to claim details.
Pattern Value | `1`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
136. Claim.diagnosis:principal.diagnosis[x]
Definition | The nature of illness or problem in a coded form or as a reference to an external defined Condition.
Short | Nature of illness or problem
Control | 1..1
Binding | The codes SHALL be taken from For example codes, see PCT ICD-10 Diagnostic Codes http://hl7.org/fhir/ValueSet/icd-10|4.0.1 (required to `http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTDiagnosticCodes` )
Type | CodeableConcept, Reference(Condition)
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Summary | false
Requirements | Provides health context for the evaluation of the products and/or services.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
138. Claim.diagnosis:principal.type
Definition | When the condition was observed or the relative ranking.
Short | Timing or nature of the diagnosis
Comments | For example: admitting, primary, secondary, discharge.
Control | 10..1*
Binding | The codes SHALL be taken from For example codes, see Diagnosis Type Codes http://hl7.org/fhir/ValueSet/ex-diagnosistype|4.0.1 (required to `http://terminology.hl7.org/ValueSet/diagnosistype` )
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | false
Requirements | Often required to capture a particular diagnosis, for example: primary or discharge.
Pattern Value | `{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/diagnosistype", "code" : "principal" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
140. Claim.diagnosis:other
Slice Name | other
Definition | Information about diagnoses relevant to the claim items.
Short | Pertinent diagnosis information
Control | 0..11*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Requirements | Required for the adjudication by provided context for the services and product listed.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
142. Claim.diagnosis:other.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
144. Claim.diagnosis:other.sequence
Definition | A number to uniquely identify diagnosis entries.
Short | Diagnosis instance identifier
Comments | Diagnosis are presented in list order to their expected importance: primary, secondary, etc.
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Necessary to maintain the order of the diagnosis items and provide a mechanism to link to claim details.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
146. Claim.diagnosis:other.diagnosis[x]
Definition | The nature of illness or problem in a coded form or as a reference to an external defined Condition.
Short | Nature of illness or problem
Control | 1..1
Binding | The codes SHALL be taken from For example codes, see PCT ICD-10 Diagnostic Codes http://hl7.org/fhir/ValueSet/icd-10|4.0.1 (required to `http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTDiagnosticCodes` )
Type | CodeableConcept, Reference(Condition)
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Summary | false
Requirements | Provides health context for the evaluation of the products and/or services.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
148. Claim.diagnosis:other.type
Definition | When the condition was observed or the relative ranking.
Short | Timing or nature of the diagnosis
Comments | For example: admitting, primary, secondary, discharge.
Control | 10..1*
Binding | The codes SHALL be taken from For example codes, see Diagnosis Type Codes http://hl7.org/fhir/ValueSet/ex-diagnosistype|4.0.1 (required to `http://terminology.hl7.org/ValueSet/diagnosistype` )
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | false
Requirements | Often required to capture a particular diagnosis, for example: primary or discharge.
Pattern Value | `{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/diagnosistype", "code" : "secondary" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
150. Claim.procedure
Definition | Procedures performed on the patient relevant to the billing items with the claim.
Short | Clinical procedures performed
Control | 0..*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Requirements | The specific clinical invention are sometimes required to be provided to justify billing a greater than customary amount for a service.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
Slicing | This element introduces a set of slices on `Claim.procedure`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ type
152. Claim.procedure.extension
Definition | An Extension May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | ExtensionAdditional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 10..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
Slicing | This element introduces a set of slices on `Claim.procedure.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
154. Claim.procedure.extension:serviceDescription
Slice Name | serviceDescription
Definition | This extension is used to communicate a plain language description of the procedure, product, or service.
Short | Service Description
Control | 1..1 This element is affected by the following invariants: ele-1
Type | Extension(Service Description) (Extension Type: string)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
156. Claim.procedure.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
158. Claim.procedure.sequence
Definition | A number to uniquely identify procedure entries.
Short | Procedure instance identifier
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Necessary to provide a mechanism to link to claim details.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
160. Claim.procedure.type
Definition | When the condition was observed or the relative ranking.
Short | Category of Procedure
Comments | For example: primary, secondary.
Control | 0..*
Binding | The codes SHALL be taken from For example codes, see PCT Procedure Type Value Set http://hl7.org/fhir/ValueSet/ex-procedure-type|4.0.1 (required to `http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTProcedureTypeVS` )
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | false
Requirements | Often required to capture a particular diagnosis, for example: primary or discharge.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
162. Claim.procedure.procedure[x]
Definition | The code or reference to a Procedure resource which identifies the clinical intervention performed.
Short | Specific clinical procedure
Control | 1..1
Binding | For example codes, see ICD-10ProcedureCodes http://hl7.org/fhir/ValueSet/icd-10-procedures|4.0.1 (example to `http://hl7.org/fhir/ValueSet/icd-10-procedures|4.0.1` ) Example ICD10 Procedure codes.
Type | Choice of: CodeableConcept, Reference(Procedure)
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Summary | false
Requirements | This identifies the actual clinical procedure.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
164. Claim.procedure:anesthesiaRelated
Slice Name | anesthesiaRelated
Definition | Procedures performed on the patient relevant to the billing items with the claim.
Short | Clinical procedures performed
Control | 0..2*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Requirements | The specific clinical invention are sometimes required to be provided to justify billing a greater than customary amount for a service.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
166. Claim.procedure:anesthesiaRelated.extension
Definition | An Extension May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | ExtensionAdditional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 10..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
Slicing | This element introduces a set of slices on `Claim.procedure.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
168. Claim.procedure:anesthesiaRelated.extension:serviceDescription
Slice Name | serviceDescription
Definition | This extension is used to communicate a plain language description of the procedure, product, or service.
Short | Service Description
Control | 1..1 This element is affected by the following invariants: ele-1
Type | Extension(Service Description) (Extension Type: string)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
170. Claim.procedure:anesthesiaRelated.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
172. Claim.procedure:anesthesiaRelated.sequence
Definition | A number to uniquely identify procedure entries.
Short | Procedure instance identifier
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Necessary to provide a mechanism to link to claim details.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
174. Claim.procedure:anesthesiaRelated.type
Definition | When the condition was observed or the relative ranking.
Short | Category of Procedure
Comments | For example: primary, secondary.
Control | 10..1*
Binding | The codes SHALL be taken from For example codes, see PCT Procedure Type Value Set http://hl7.org/fhir/ValueSet/ex-procedure-type|4.0.1 (required to `http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTProcedureTypeVS` )
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | false
Requirements | Often required to capture a particular diagnosis, for example: primary or discharge.
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTProcedureType", "code" : "procedureRequiringAnesthesia" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
176. Claim.procedure:anesthesiaRelated.procedure[x]
Definition | The code or reference to a Procedure resource which identifies the clinical intervention performed.
Short | Specific clinical procedure
Control | 1..1
Binding | The codes SHALL be taken from For example codes, see PCT CMS HCPCS and AMA CPT Procedure Surgical Codes http://hl7.org/fhir/ValueSet/icd-10-procedures|4.0.1 (required to `http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTProcedureSurgicalCodes` )
Type | CodeableConcept, Reference(Procedure)
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Summary | false
Requirements | This identifies the actual clinical procedure.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
178. Claim.procedure:other
Slice Name | other
Definition | Procedures performed on the patient relevant to the billing items with the claim.
Short | Clinical procedures performed
Control | 0..24*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Requirements | The specific clinical invention are sometimes required to be provided to justify billing a greater than customary amount for a service.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
180. Claim.procedure:other.extension
Definition | An Extension May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | ExtensionAdditional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 10..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
Slicing | This element introduces a set of slices on `Claim.procedure.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
182. Claim.procedure:other.extension:serviceDescription
Slice Name | serviceDescription
Definition | This extension is used to communicate a plain language description of the procedure, product, or service.
Short | Service Description
Control | 1..1 This element is affected by the following invariants: ele-1
Type | Extension(Service Description) (Extension Type: string)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
184. Claim.procedure:other.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
186. Claim.procedure:other.sequence
Definition | A number to uniquely identify procedure entries.
Short | Procedure instance identifier
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Necessary to provide a mechanism to link to claim details.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
188. Claim.procedure:other.type
Definition | When the condition was observed or the relative ranking.
Short | Category of Procedure
Comments | For example: primary, secondary.
Control | 10..1*
Binding | The codes SHALL be taken from For example codes, see PCT Procedure Type Value Set http://hl7.org/fhir/ValueSet/ex-procedure-type|4.0.1 (required to `http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTProcedureTypeVS` )
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | false
Requirements | Often required to capture a particular diagnosis, for example: primary or discharge.
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTProcedureType", "code" : "other" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
190. Claim.procedure:other.procedure[x]
Definition | The code or reference to a Procedure resource which identifies the clinical intervention performed.
Short | Specific clinical procedure
Control | 1..1
Binding | The codes SHALL be taken from For example codes, see PCT CMS HCPCS and AMA CPT Procedure Surgical Codes http://hl7.org/fhir/ValueSet/icd-10-procedures|4.0.1 (required to `http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTProcedureSurgicalCodes` )
Type | CodeableConcept, Reference(Procedure)
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Summary | false
Requirements | This identifies the actual clinical procedure.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
192. Claim.insurance
Definition | Financial instruments for reimbursement for the health care products and services specified on the claim.
Short | Patient insurance information
Comments | All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. Coverages appearing before the focal Coverage in the list, and where 'Coverage.subrogation=false', should provide a reference to the ClaimResponse containing the adjudication results of the prior claim.
Control | 1..*
Type | BackboneElement
Is Modifier | false
Summary | true
Requirements | At least one insurer is required for a claim to be a claim.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
194. Claim.insurance.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
196. Claim.insurance.sequence
Definition | A number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order.
Short | Insurance instance identifier
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | To maintain order of the coverages.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
198. Claim.insurance.focal
Definition | A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.
Short | Coverage to be used for adjudication
Comments | A patient may (will) have multiple insurance policies which provide reimbursement for healthcare services and products. For example a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for adjudicating this claim. Other claims would be created to request adjudication against the other listed policies.
Control | 1..1
Type | boolean
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | To identify which coverage in the list is being used to adjudicate this claim.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
200. Claim.insurance.coverage
Definition | Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.
Short | Insurance information
Control | 1..1
Type | Reference(PCT Coverage, Coverage)
Is Modifier | false
Summary | true
Requirements | Required to allow the adjudicator to locate the correct policy and history within their information system.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
202. Claim.insurance.coverage.extension:dataAbsentReason
Slice Name | dataAbsentReason
Definition | Provides a reason why the expected value or elements in the element that is extended are missing.
Short | Coverage may be not applicable if estimate is for self-pay or uninsured
Control | 0..1
Type | Extension(Data Absent Reason) (Extension Type: code)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
204. Claim.insurance.preAuthRef
Definition | Reference numbers previously provided by the insurer to the provider to be quoted on subsequent claims containing services or products related to the prior authorization.
Short | Prior authorization reference number
Comments | This value is an alphanumeric string that may be provided over the phone, via text, via paper, or within a ClaimResponse resource and is not a FHIR Identifier.
Control | 0..2*
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Providers must quote previously issued authorization reference numbers in order to obtain adjudication as previously advised on the Preauthorization.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
206. Claim.item
Definition | A claim line. Either a simple product or service or a 'group' of details which can each be a simple items or groups of sub-details.
Short | Product or service provided
Control | 10..50*
Type | BackboneElement
Is Modifier | false
Summary | false
Requirements | The items to be processed for adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
208. Claim.item.extension
Definition | An Extension May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | ExtensionAdditional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 10..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
Slicing | This element introduces a set of slices on `Claim.item.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
210. Claim.item.extension:referralNumber
Slice Name | referralNumber
Definition | This extension is used to provide the Referral Number.
Short | Referral Number
Control | 0..11 This element is affected by the following invariants: ele-1
Type | Extension(ReferralNumber) (Extension Type: string)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
212. Claim.item.extension:gfeBillingProviderLineItemCtrlNum
Slice Name | gfeBillingProviderLineItemCtrlNum
Definition | This extension is used by the provider to assign a unique identifier to this item. The intent of this element is to allow the provider to assign something other than 'line number' for their purposes (e.g. tracking and troubleshooting).
Short | Extension
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(GFEBillingProviderLineItemCtrlNum) (Extension Type: Identifier)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
214. Claim.item.extension:serviceDescription
Slice Name | serviceDescription
Definition | This extension is used to communicate a plain language description of the procedure, product, or service.
Short | Service Description
Control | 1..1 This element is affected by the following invariants: ele-1
Type | Extension(Service Description) (Extension Type: string)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
216. Claim.item.extension:ProviderEventMethodology
Slice Name | ProviderEventMethodology
Definition | This extension is used for indicating the method a provider used to group services, and those providing such services, beyond what may be indicated through DRGs that the payer or patient may find helpful (e.g. grouping services by a standardized episode of care definition). This is provider generated text and should not be modified by the payer.
Short | Provider Event Methodology
Comments | The method a provider used to group services. The extension definition contains additional detail.
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(ProviderEventMethodology) (Extension Type: string)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
218. Claim.item.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
220. Claim.item.sequence
Definition | A number to uniquely identify item entries.
Short | Item instance identifier
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
222. Claim.item.careTeamSequence
Definition | CareTeam members related to this service or product.
Short | Applicable careTeam members
Control | 0..*
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | false
Requirements | Need to identify the individuals and their roles in the provision of the product or service.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
224. Claim.item.productOrService
Definition | When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.
Short | Billing, service, product, or drug code
Comments | If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.
Control | 1..1
Binding | The codes SHALL be taken from For example codes, see Claim Medical Product or Service Value Set http://hl7.org/fhir/ValueSet/service-uscls|4.0.1 (required to `http://hl7.org/fhir/us/davinci-pct/ValueSet/USClaimMedicalProductOrServiceCodes` )
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Necessary to state what was provided or done.
Alternate Names | Drug Code, Bill Code, Service Code
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
226. Claim.item.productOrService.coding
Definition | A reference to a code defined by a terminology system.
Short | Code defined by a terminology system
Comments | Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
Control | 0..*
Type | Coding
Is Modifier | false
Summary | true
Requirements | Allows for alternative encodings within a code system, and translations to other code systems.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) pct-cpt-display: CPT codes require a display value (CPT Consumer Friendly Descriptors recommended) (`system = 'http://www.ama-assn.org/go/cpt' implies display.exists()`)
228. Claim.item.modifier
Definition | Item typification or modifiers codes to convey additional context for the product or service.
Short | Product or service billing modifiers
Comments | For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours.
Control | 0..4*
Binding | The codes SHALL be taken from For example codes, see PCT GFE Item CPT - HCPCS Value Set http://hl7.org/fhir/ValueSet/claim-modifiers|4.0.1 (required to `http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFEItemCptHcpcsVS` )
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | false
Requirements | To support inclusion of the item for adjudication or to charge an elevated fee.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
230. Claim.item.modifier.coding
Definition | A reference to a code defined by a terminology system.
Short | Code defined by a terminology system
Comments | Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
Control | 0..*
Type | Coding
Is Modifier | false
Summary | true
Requirements | Allows for alternative encodings within a code system, and translations to other code systems.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) pct-cpt-display: CPT codes require a display value (CPT Consumer Friendly Descriptors recommended) (`system = 'http://www.ama-assn.org/go/cpt' implies display.exists()`)
232. Claim.item.serviced[x]
Definition | This is the planned or estimated dates of service. Use Revenue code to determine inpatient stays if needed for adjudication The date or dates when the service or product was supplied, performed or completed.
Short | This is the planned or estimated date(s)s of serviceDate or dates of service or product delivery
Control | 10..1
Type | Choice of: date, Period
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Must Support Types | No must-support rules about the choice of types/profiles
Summary | false
Requirements | Needed to determine whether the service or product was provided during the term of the insurance coverage.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
234. Claim.item.location[x]
Definition | Where the product or service was provided.
Short | Place of service or where product was supplied
Control | 10..1
Binding | The codes SHALL be taken from For example codes, see PCT GFE CMS Place of Service Value Set http://hl7.org/fhir/ValueSet/service-place|4.0.1 (required to `http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFECMSPOS` )
Type | CodeableConcept, Address, Reference(Location)
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Summary | false
Requirements | The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
236. Claim.item.quantity
Definition | The number of repetitions of a service or product.
Short | Count of products or services
Control | 10..1
Type | Quantity(SimpleQuantity)
Is Modifier | false
Summary | false
Requirements | Required when the product or service code does not convey the quantity provided.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
238. Claim.item.unitPrice
Definition | If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.
Short | Fee, charge or cost per item
Control | 10..1
Type | Money
Is Modifier | false
Summary | false
Requirements | The amount charged to the patient by the provider for a single unit.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
240. Claim.item.net
Definition | The quantity times the unit price for an additional service or product or charge.
Short | Total charge amount for the service lineTotal item cost
Comments | For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
Control | 10..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Provides the total amount claimed for the group (if a grouper) or the line item.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
242. Claim.item.detail
Definition | A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.
Short | Drug Identification InformationProduct or service provided
Control | 0..*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Requirements | The items to be processed for adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
244. Claim.item.detail.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
246. Claim.item.detail.sequence
Definition | A number to uniquely identify item entries.
Short | Item instance identifier
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
248. Claim.item.detail.productOrService
Definition | When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.
Short | Billing, service, product, or drug code
Comments | If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.
Control | 1..1
Binding | The codes SHALL be taken from For example codes, see Claim Medical Product or Service Value Set http://hl7.org/fhir/ValueSet/service-uscls|4.0.1 (required to `http://hl7.org/fhir/us/davinci-pct/ValueSet/USClaimMedicalProductOrServiceCodes` )
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Necessary to state what was provided or done.
Alternate Names | Drug Code, Bill Code, Service Code
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
250. Claim.item.detail.quantity
Definition | The number of repetitions of a service or product.
Short | Count of products or services
Control | 0..1
Type | Quantity(SimpleQuantity)
Is Modifier | false
Must Support | true
Summary | false
Requirements | Required when the product or service code does not convey the quantity provided.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
252. Claim.total
Definition | The total value of the all the items in the claim.
Short | Total GFE Charges SubmittedTotal claim cost
Control | 10..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Used for control total purposes.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

Guidance on how to interpret the contents of this table can be foundhere

0. Claim
2. Claim.extension
Slicing | This element introduces a set of slices on `Claim.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
Added: 4. Claim.extension:gfeServiceLinkingInfo
Slice Name | gfeServiceLinkingInfo
Short | GFE Service Linking Information
Control | 0..1
Type | Extension(GFEServiceLinkingInfo) (Complex Extension)
Must Support | true
Added: 6. Claim.extension:providerEventMethodology
Slice Name | providerEventMethodology
Definition | Changed: How the provider determined the number of claims and the number and type of billing providers to include in the GFE. Examples include provider episodes of care experience, PACES, order set based on clinical guidelines, payor suggested grouping, or some other method of determination. The extension definition contains additional detail.
Short | Provider event collection methodology
Control | 0..1
Type | Extension(ProviderEventMethodology) (Extension Type: string)
Must Support | true
Added: 8. Claim.extension:gfeDisclaimer
Slice Name | gfeDisclaimer
Definition | Added: Disclaimers the patient should be made aware of regarding the providers estimate including any additional assumptions and requirements. Noting that that the information provided is only an estimate based on the items and services reasonably expected, at the time of scheduling (or requesting) the item or service, to be furnished and is subject to change.
Short | Changed:Disclaimers the patient should be made aware of regarding the providers estimate, e.g. application of sliding scale for self-pay/uninsured patients
Comments | Added: These disclaimers may include, but are not limited to things such as: provider discounts (e.g. application of sliding fee scale), limitations, preconditions, requirements, assumptions (e.g. diagnostic vs. preventative), information known to be missing in the estimate, conditions that may affect the estimate, or anything that may affect the interpretation of the estimate.
Control | 0..*
Type | Extension(GFEDisclaimer) (Extension Type: string)
Must Support | true
10. Claim.identifier
Removed:--. Claim.extension:gfeSubmitter
Slice Name | gfeSubmitter
Short | The scheduling entity that submits the GFE to provide a collection of services to a payer for the creation of an Advanced EOB
Control | 1..1
Type | Extension(`http://hl7.org/fhir/us/davinci-pct/StructureDefinition/gfeSubmitter`)
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 1..?
Slicing | This element introduces a set of slices on `Claim.identifier`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ type
12. Claim.identifier:PLAC
Removed:--. Claim.identifier:INTER
Slice Name | INTER
Short | Intermediary System Identifier
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 0..*
Slice Name | PLAC
Short | Provider Assigned Identifier for GFE Claim
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 1..1
14. Claim.identifier:PLAC.type
Control | 1..?
Pattern Value | `{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/v2-0203", "code" : "PLAC", "display" : "Placer Identifier" }] }`
16. Claim.identifier:PLAC.system
Must Support | true
18. Claim.identifier:PLAC.value
Control | 1..?
20. Claim.type
Pattern Value | `{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/claim-type", "code" : "professional" }] }`
22. Claim.use
Pattern Value | `predetermination`
24. Claim.patient
Type | Reference(US Core Patient Profile)
26. Claim.insurer
Type | Reference(PCT Organization)
28. Claim.provider
Short | Billing provider - party responsible for the GFE
Type | Reference(PCT Organization, PCT Practitioner)
30. Claim.provider.extension
Control | 1..?
32. Claim.provider.extension:providerTaxonomy
Slice Name | providerTaxonomy
Short | Provider taxonomy codes consisting of NUCC Health Care Provider Taxonomy Code Set for providers
Control | 1..1
Type | Extension(ProviderTaxonomy) (Extension Type: CodeableConcept)
34. Claim.provider.extension:consentForBalanceBilling
Slice Name | consentForBalanceBilling
Control | 0..1
Type | Extension(GFEConsentForBalanceBilling) (Extension Type: boolean)
Must Support | true
36. Claim.priority
Binding | The codes SHALL be taken from ProcessPriorityCodes (required to `http://hl7.org/fhir/ValueSet/process-priority` )
38. Claim.payee
Must Support | true
40. Claim.payee.party
Type | Reference(PCT Practitioner, PCT Organization)
42. Claim.referral
Added: 44. Claim.referral.extension
Control | 1..?
46. Claim.referral.extension:referralNumber
Slice Name | referralNumber
Short | Referral Number
Control | 1..1
Type | Extension(ReferralNumber) (Extension Type: string)
48. Claim.careTeam
Must Support | true
Slicing | This element introduces a set of slices on `Claim.careTeam`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ role
50. Claim.careTeam.provider
Type | Reference(PCT Practitioner, PCT Organization)
52. Claim.careTeam.role
Control | 1..?
Binding | The codes SHALL be taken from PCT Care Team Role Value Set (required to `http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTCareTeamRoleVS` )
54. Claim.careTeam.qualification
Binding | The codes SHALL be taken from US Core Provider Role (NUCC) (required to `http://hl7.org/fhir/us/core/ValueSet/us-core-provider-role` )
56. Claim.careTeam:rendering
Slice Name | rendering
Control | 0..*
Must Support | Added:true
58. Claim.careTeam:rendering.role
Pattern Value | Changed:`{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "version" : "1.0.1", "code" : "rendering" }] }`
60. Claim.careTeam:rendering.qualification
Short | Practitioner credential or specialization - must provide a taxonomy code for the Professional case
Control | 1..?
62. Claim.careTeam:referring
Slice Name | referring
Control | 0..1
Must Support | Added:true
64. Claim.careTeam:referring.role
Pattern Value | Changed:`{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "version" : "1.0.1", "code" : "referring" }] }`
66. Claim.supportingInfo
Must Support | true
Slicing | This element introduces a set of slices on `Claim.supportingInfo`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ category
68. Claim.supportingInfo.category
Binding | Unless not suitable, these codes SHALL be taken from PCT Supporting Info Type Value Set (extensible to `http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTSupportingInfoTypeVS` )
70. Claim.supportingInfo:serviceFacility
Slice Name | serviceFacility
Short | Service Facility
Comments | Service Facility Location information conveys the name, full address and identifier of the facility where services were rendered when that is different from the Billing/Performing Provider.
Control | 0..1
Must Support | true
72. Claim.supportingInfo:serviceFacility.category
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType", "code" : "servicefacility" }] }`
74. Claim.supportingInfo:serviceFacility.value[x]
Control | 1..?
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Slicing | This element introduces a set of slices on `Claim.supportingInfo.value[x]`. The slices areUnordered and Open, and can be differentiated using the following discriminators: type @ $this
76. Claim.supportingInfo:serviceFacility.value[x]:valueReference
Slice Name | valueReference
Control | 1..1
Type | Reference(PCT Organization)
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
78. Claim.supportingInfo:claimFrequency
Slice Name | claimFrequency
Short | Changed:Claim Frequency component of the UB-04 Type of Bill Code (4th digit of the UB-04 Type of Bill code).
Comments | Changed: For the purposes of Patient Cost Transparency Estimates, this field may be used to modify or replace a GFE claim estimate within the same GFE Packet submission. This specification does not support the modification of Claim resources outside of the GFE Packet and client systems SHALL NOT expect the inclusion of the frequency code to affect the use or interpretation of any Claim outside of the GFE Packet.
Control | 0..1
Must Support | true
80. Claim.supportingInfo:claimFrequency.category
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType", "code" : "claimFrequency" }] }`
82. Claim.supportingInfo:claimFrequency.code
Control | 1..?
Binding | The codes SHALL be taken from Changed:PCT GFE NUBC Uniform Billing (UB-04) Type of Bill Value Set (required to `http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFETypeOfBillVS` )
84. Claim.diagnosis
Must Support | true
Slicing | This element introduces a set of slices on `Claim.diagnosis`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ type
86. Claim.diagnosis.type
Binding | The codes SHALL be taken from Changed:Diagnosis Type Codes (required to `http://terminology.hl7.org/ValueSet/diagnosistype` )
Must Support | true
88. Claim.diagnosis:principal
Slice Name | principal
Short | Added:Principal Diagnosis - Must Support means the information source SHALL be capable of populating and SHALL populate if available and permitted.
Comments | Added: If the Principal Diagnosis code is known, it is important that it be shared in the GFE, particularly when the GFE is being sent to a payer for an insured patient. Payers very often need the diagnosis to be able to provide an estimate. Without the diagnosis, payers may assume the service is diagnostic and thus the patient responsibility may be higher or not covered at all than the diagnosis, such as for preventative services, would otherwise indicate. It is understood that in certain situations, such as scheduled services or GFE requests prior to orders, diagnosis is not needed or may not yet be known. However, when it is known, it is important that this information be shared to ensure the best possible estimate is provided to the patient.
Control | Changed:0..1
Must Support | Added:true
90. Claim.diagnosis:principal.sequence
Pattern Value | `1`
92. Claim.diagnosis:principal.diagnosis[x]
Binding | The codes SHALL be taken from PCT ICD-10 Diagnostic Codes (required to `http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTDiagnosticCodes` )
Type | CodeableConcept
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
94. Claim.diagnosis:principal.type
Control | 1..1
Pattern Value | Changed:`{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/diagnosistype", "code" : "principal" }] }`
96. Claim.diagnosis:other
Slice Name | other
Control | 0..11
Must Support | true
98. Claim.diagnosis:other.diagnosis[x]
Binding | The codes SHALL be taken from PCT ICD-10 Diagnostic Codes (required to `http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTDiagnosticCodes` )
Type | CodeableConcept
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
100. Claim.diagnosis:other.type
Control | 1..1
Pattern Value | Changed:`{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/diagnosistype", "code" : "secondary" }] }`
102. Claim.procedure
Must Support | true
Slicing | This element introduces a set of slices on `Claim.procedure`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ type
104. Claim.procedure.extension
Control | 1..?
Slicing | This element introduces a set of slices on `Claim.procedure.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
106. Claim.procedure.extension:serviceDescription
Slice Name | serviceDescription
Control | 1..1
Type | Extension(Service Description) (Extension Type: string)
108. Claim.procedure.type
Binding | The codes SHALL be taken from PCT Procedure Type Value Set (required to `http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTProcedureTypeVS` )
Must Support | true
110. Claim.procedure:anesthesiaRelated
Slice Name | anesthesiaRelated
Control | 0..2
Must Support | true
112. Claim.procedure:anesthesiaRelated.extension:serviceDescription
Slice Name | serviceDescription
Control | 1..1
Type | Extension(Service Description) (Extension Type: string)
114. Claim.procedure:anesthesiaRelated.type
Control | 1..1
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTProcedureType", "code" : "procedureRequiringAnesthesia" }] }`
116. Claim.procedure:anesthesiaRelated.procedure[x]
Binding | The codes SHALL be taken from PCT CMS HCPCS and AMA CPT Procedure Surgical Codes (required to `http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTProcedureSurgicalCodes` )
Type | CodeableConcept
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
118. Claim.procedure:other
Slice Name | other
Control | 0..24
Must Support | true
120. Claim.procedure:other.extension:serviceDescription
Slice Name | serviceDescription
Control | 1..1
Type | Extension(Service Description) (Extension Type: string)
Added: 122. Claim.procedure:other.type
Control | 1..1
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTProcedureType", "code" : "other" }] }`
Added: 124. Claim.procedure:other.procedure[x]
Binding | The codes SHALL be taken from PCT CMS HCPCS and AMA CPT Procedure Surgical Codes (required to `http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTProcedureSurgicalCodes` )
Type | CodeableConcept
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
126. Claim.insurance
128. Claim.insurance.coverage
Type | Reference(PCT Coverage)
Added: 130. Claim.insurance.coverage.extension:dataAbsentReason
Slice Name | dataAbsentReason
Short | Coverage may be not applicable if estimate is for self-pay or uninsured
Control | 0..1
Type | Extension(Data Absent Reason) (Extension Type: code)
Must Support | true
132. Claim.insurance.preAuthRef
Control | 0..2
134. Claim.accident
136. Claim.accident.location[x]
Type | Address, Reference(Location)
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
138. Claim.accident.location[x].country
Binding | The codes SHALL be taken from Iso3166-1-2 (required to `http://hl7.org/fhir/ValueSet/iso3166-1-2` )
140. Claim.item
Control | 1..50
142. Claim.item.extension
Control | 1..?
Slicing | This element introduces a set of slices on `Claim.item.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
144. Claim.item.extension:referralNumber
Slice Name | referralNumber
Short | Referral Number
Control | 0..11
Type | Extension(ReferralNumber) (Extension Type: string)
Must Support | true
146. Claim.item.extension:gfeBillingProviderLineItemCtrlNum
Slice Name | gfeBillingProviderLineItemCtrlNum
Control | 0..1
Type | Extension(GFEBillingProviderLineItemCtrlNum) (Extension Type: Identifier)
Must Support | true
148. Claim.item.extension:serviceDescription
Slice Name | serviceDescription
Control | 1..1
Type | Extension(Service Description) (Extension Type: string)
150. Claim.item.extension:ProviderEventMethodology
Slice Name | ProviderEventMethodology
Short | Provider Event Methodology
Comments | Changed: The method a provider used to group services. The extension definition contains additional detail.
Control | 0..1
Type | Extension(ProviderEventMethodology) (Extension Type: string)
Must Support | true
152. Claim.item.careTeamSequence
Must Support | true
154. Claim.item.productOrService
Binding | The codes SHALL be taken from Claim Medical Product or Service Value Set (required to `http://hl7.org/fhir/us/davinci-pct/ValueSet/USClaimMedicalProductOrServiceCodes` )
Added: 156. Claim.item.productOrService.coding
Invariants | pct-cpt-display: CPT codes require a display value (CPT Consumer Friendly Descriptors recommended) (`system = 'http://www.ama-assn.org/go/cpt' implies display.exists()`)
158. Claim.item.modifier
Control | 0..4
Binding | The codes SHALL be taken from PCT GFE Item CPT - HCPCS Value Set (required to `http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFEItemCptHcpcsVS` )
Must Support | true
Added: 160. Claim.item.modifier.coding
Invariants | pct-cpt-display: CPT codes require a display value (CPT Consumer Friendly Descriptors recommended) (`system = 'http://www.ama-assn.org/go/cpt' implies display.exists()`)
162. Claim.item.serviced[x]
Definition | This is the planned or estimated dates of service. Use Revenue code to determine inpatient stays if needed for adjudication
Short | This is the planned or estimated date(s)s of service
Control | 1..?
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Must Support | true
164. Claim.item.location[x]
Control | 1..?
Binding | The codes SHALL be taken from PCT GFE CMS Place of Service Value Set (required to `http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFECMSPOS` )
Type | CodeableConcept, Address, Reference(Location)
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
166. Claim.item.quantity
Control | 1..?
168. Claim.item.unitPrice
Control | 1..?
170. Claim.item.net
Short | Total charge amount for the service line
Control | 1..?
172. Claim.item.detail
Short | Drug Identification Information
Must Support | true
174. Claim.item.detail.productOrService
Binding | The codes SHALL be taken from Claim Medical Product or Service Value Set (required to `http://hl7.org/fhir/us/davinci-pct/ValueSet/USClaimMedicalProductOrServiceCodes` )
176. Claim.item.detail.quantity
Must Support | true
178. Claim.total
Short | Total GFE Charges Submitted
Control | 1..?

Guidance on how to interpret the contents of this table can be foundhere

0. Claim
Definition | A provider issued list of professional services and products which have been provided, or are to be provided, to a patient which is sent to an insurer for reimbursement.
Short | Claim, Pre-determination or Pre-authorization
Comments | The Claim resource fulfills three information request requirements: Claim - a request for adjudication for reimbursement for products and/or services provided; Preauthorization - a request to authorize the future provision of products and/or services including an anticipated adjudication; and, Predetermination - a request for a non-bind adjudication of possible future products and/or services.
Control | 0..*
Is Modifier | false
Summary | false
Alternate Names | Adjudication Request, Preauthorization Request, Predetermination Request
Invariants | dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (`contained.contained.empty()`) dom-3: 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: 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: If a resource is contained in another resource, it SHALL NOT have a security label (`contained.meta.security.empty()`) dom-6: A resource should have narrative for robust management (`text.`div`.exists()`)
2. Claim.id
Definition | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
Short | Logical id of this artifact
Comments | The only time that a resource does not have an id is when it is being submitted to the server using a create operation.
Control | 0..1
Type | id
Is Modifier | false
Summary | true
4. Claim.meta
Definition | The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
Short | Metadata about the resource
Control | 0..1
Type | Meta
Is Modifier | false
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
6. Claim.implicitRules
Definition | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.
Short | A set of rules under which this content was created
Comments | Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
Control | 0..1
Type | uri
Is Modifier | true because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
8. Claim.language
Definition | The base language in which the resource is written.
Short | Language of the resource content
Comments | Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).
Control | 0..1
Binding | The codes SHOULD be taken from CommonLanguages (preferred to `http://hl7.org/fhir/ValueSet/languages|4.0.1` ) A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
10. Claim.text
Definition | A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.
Short | Text summary of the resource, for human interpretation
Comments | Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
Control | 0..1
Type | Narrative
Is Modifier | false
Summary | false
Alternate Names | narrative, html, xhtml, display
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
12. Claim.contained
Definition | These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.
Short | Contained, inline Resources
Comments | This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
Control | 0..*
Type | Resource
Is Modifier | false
Summary | false
Alternate Names | inline resources, anonymous resources, contained resources
14. Claim.extension
Definition | An Extension
Short | Extension
Control | Changed:0..*
Type | Extension
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
Slicing | This element introduces a set of slices on `Claim.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
16. Claim.extension:gfeServiceLinkingInfo
Slice Name | gfeServiceLinkingInfo
Definition | This extension is used to provide the GFE Service Linking Information. This allows implementers to have the same identifier on multiple GFEs that are part of one period of care's services. This would be needed for some of the workflow options that businesses may decide to use.
Short | GFE Service Linking Information
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(GFEServiceLinkingInfo) (Complex Extension)
Is Modifier | false
Must Support | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
18. Claim.extension:providerEventMethodology
Slice Name | providerEventMethodology
Definition | How the provider determined the number of claims and the number and type of billing providers to include in the GFE. Examples include provider episodes of care experience, PACES, order set based on clinical guidelines, payor suggested grouping, or some other method of determination. The extension definition contains additional detail.
Short | Provider event collection methodology
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(ProviderEventMethodology) (Extension Type: string)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
20. Claim.extension:gfeDisclaimer
Slice Name | gfeDisclaimer
Definition | Disclaimers the patient should be made aware of regarding the providers estimate including any additional assumptions and requirements. Noting that that the information provided is only an estimate based on the items and services reasonably expected, at the time of scheduling (or requesting) the item or service, to be furnished and is subject to change.
Short | Disclaimers the patient should be made aware of regarding the providers estimate, e.g. application of sliding scale for self-pay/uninsured patients
Comments | These disclaimers may include, but are not limited to things such as: provider discounts (e.g. application of sliding fee scale), limitations, preconditions, requirements, assumptions (e.g. diagnostic vs. preventative), information known to be missing in the estimate, conditions that may affect the estimate, or anything that may affect the interpretation of the estimate.
Control | 0..* This element is affected by the following invariants: ele-1
Type | Extension(GFEDisclaimer) (Extension Type: string)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
22. Claim.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Summary | false
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
24. Claim.identifier
Definition | A unique identifier assigned to this claim.
Short | Business Identifier for claim
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 1..*
Type | Identifier
Is Modifier | false
Summary | false
Requirements | Allows claims to be distinguished and referenced.
Alternate Names | Claim Number
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
Slicing | This element introduces a set of slices on `Claim.identifier`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ type
26. Claim.identifier:PLAC
Slice Name | PLAC
Definition | A unique identifier assigned to this claim.
Short | Provider Assigned Identifier for GFE Claim
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 1..1
Type | Identifier
Is Modifier | false
Summary | false
Requirements | Allows claims to be distinguished and referenced.
Alternate Names | Claim Number
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
28. Claim.identifier:PLAC.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
30. Claim.identifier:PLAC.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
Slicing | This element introduces a set of slices on `Claim.identifier.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
32. Claim.identifier:PLAC.use
Definition | The purpose of this identifier.
Short | usual | official | temp | secondary | old (If known)
Comments | Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.
Control | 0..1
Binding | The codes SHALL be taken from IdentifierUse (required to `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` ) Identifies the purpose for this identifier, if known .
Type | code
Is Modifier | true because This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one.
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
34. Claim.identifier:PLAC.type
Definition | A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.
Short | Description of identifier
Comments | This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type.
Control | 1..1
Binding | Unless not suitable, these codes SHALL be taken from Identifier Type Codes (extensible to `http://hl7.org/fhir/ValueSet/identifier-type|4.0.1` ) A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
Type | CodeableConcept
Is Modifier | false
Summary | true
Requirements | Allows users to make use of identifiers when the identifier system is not known.
Pattern Value | `{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/v2-0203", "code" : "PLAC", "display" : "Placer Identifier" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
36. Claim.identifier:PLAC.system
Definition | Establishes the namespace for the value - that is, a URL that describes a set values that are unique.
Short | The namespace for the identifier value
Comments | Identifier.system is always case sensitive.
Control | 0..1
Type | uri
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Requirements | There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.
Example | General: http://www.acme.com/identifiers/patient
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
38. Claim.identifier:PLAC.value
Definition | The portion of the identifier typically relevant to the user and which is unique within the context of the system.
Short | The value that is unique
Comments | If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.
Control | 1..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Example | General: 123456
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
40. Claim.identifier:PLAC.period
Definition | Time period during which identifier is/was valid for use.
Short | Time period when id is/was valid for use
Control | 0..1
Type | Period
Is Modifier | false
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
42. Claim.identifier:PLAC.assigner
Definition | Organization that issued/manages the identifier.
Short | Organization that issued id (may be just text)
Comments | The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.
Control | 0..1
Type | Reference(Organization)
Is Modifier | false
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
44. Claim.status
Definition | The status of the resource instance.
Short | active | cancelled | draft | entered-in-error
Comments | This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.
Control | 1..1
Binding | The codes SHALL be taken from FinancialResourceStatusCodes (required to `http://hl7.org/fhir/ValueSet/fm-status|4.0.1` ) A code specifying the state of the resource instance.
Type | code
Is Modifier | true because This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
46. Claim.type
Definition | The category of claim, e.g. oral, pharmacy, vision, institutional, professional.
Short | Category or discipline
Comments | The majority of jurisdictions use: oral, pharmacy, vision, professional and institutional, or variants on those terms, as the general styles of claims. The valueset is extensible to accommodate other jurisdictional requirements.
Control | 1..1
Binding | Unless not suitable, these codes SHALL be taken from ClaimTypeCodes (extensible to `http://hl7.org/fhir/ValueSet/claim-type|4.0.1` ) The type or discipline-style of the claim.
Type | CodeableConcept
Is Modifier | false
Summary | true
Requirements | Claim type determine the general sets of business rules applied for information requirements and adjudication.
Pattern Value | `{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/claim-type", "code" : "professional" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
48. Claim.subType
Definition | A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.
Short | More granular claim type
Comments | This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.
Control | 0..1
Binding | For example codes, see ExampleClaimSubTypeCodes (example to `http://hl7.org/fhir/ValueSet/claim-subtype|4.0.1` ) A more granular claim typecode.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Some jurisdictions need a finer grained claim type for routing and adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
50. Claim.use
Definition | A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future.
Short | claim | preauthorization | predetermination
Control | 1..1
Binding | The codes SHALL be taken from Use (required to `http://hl7.org/fhir/ValueSet/claim-use|4.0.1` ) The purpose of the Claim: predetermination, preauthorization, claim.
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | This element is required to understand the nature of the request for adjudication.
Pattern Value | `predetermination`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
52. Claim.patient
Definition | The party to whom the professional services and/or products have been supplied or are being considered and for whom actual or forecast reimbursement is sought.
Short | The recipient of the products and services
Control | 1..1
Type | Reference(US Core Patient Profile)
Is Modifier | false
Summary | true
Requirements | The patient must be supplied to the insurer so that confirmation of coverage and service history may be considered as part of the authorization and/or adjudiction.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
54. Claim.billablePeriod
Definition | The period for which charges are being submitted.
Short | Relevant time frame for the claim
Comments | Typically this would be today or in the past for a claim, and today or in the future for preauthorizations and predeterminations. Typically line item dates of service should fall within the billing period if one is specified.
Control | 0..1
Type | Period
Is Modifier | false
Summary | true
Requirements | A number jurisdictions required the submission of the billing period when submitting claims for example for hospital stays or long-term care.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
56. Claim.created
Definition | The date this resource was created.
Short | Resource creation date
Comments | This field is independent of the date of creation of the resource as it may reflect the creation date of a source document prior to digitization. Typically for claims all services must be completed as of this date.
Control | 1..1
Type | dateTime
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | Need to record a timestamp for use by both the recipient and the issuer.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
58. Claim.enterer
Definition | Individual who created the claim, predetermination or preauthorization.
Short | Author of the claim
Control | 0..1
Type | Reference(Practitioner, PractitionerRole)
Is Modifier | false
Summary | false
Requirements | Some jurisdictions require the contact information for personnel completing claims.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
60. Claim.insurer
Definition | The Insurer who is target of the request.
Short | Target
Control | Changed:0..1
Type | Reference(PCT Organization)
Is Modifier | false
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
62. Claim.provider
Definition | The provider which is responsible for the claim, predetermination or preauthorization.
Short | Billing provider - party responsible for the GFE
Comments | Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below.
Control | 1..1
Type | Reference(PCT Organization, PCT Practitioner)
Is Modifier | false
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
64. Claim.provider.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
66. Claim.provider.extension
Definition | An Extension
Short | Extension
Control | 1..*
Type | Extension
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
Slicing | This element introduces a set of slices on `Claim.provider.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
68. Claim.provider.extension:providerTaxonomy
Slice Name | providerTaxonomy
Definition | This extension is used to indicate the taxonomy code of the provider.
Short | Provider taxonomy codes consisting of NUCC Health Care Provider Taxonomy Code Set for providers
Control | 1..1
Type | Extension(ProviderTaxonomy) (Extension Type: CodeableConcept)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
70. Claim.provider.extension:consentForBalanceBilling
Slice Name | consentForBalanceBilling
Definition | If the provider has received a written consent form indicating a patient has agreed to waive their protections and pay up to the full cost for the out-of-network item or service, this will be “true”. If the provider has not received written consent, this will be “false”. This is an attestation only. The billing provider is legally required to maintain the written notice and consent form.
Short | Extension
Control | 0..1
Type | Extension(GFEConsentForBalanceBilling) (Extension Type: boolean)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
72. Claim.provider.reference
Definition | A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.
Short | Literal reference, Relative, internal or absolute URL
Comments | Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.
Control | 0..1 This element is affected by the following invariants: ref-1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
74. Claim.provider.type
Definition | The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources).
Short | Type the reference refers to (e.g. "Patient")
Comments | This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified.
Control | 0..1
Binding | Unless not suitable, these codes SHALL be taken from ResourceType (extensible to `http://hl7.org/fhir/ValueSet/resource-types|4.0.1` ) Aa resource (or, for logical models, the URI of the logical model).
Type | uri
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
76. Claim.provider.identifier
Definition | An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.
Short | Logical reference, when literal reference is not known
Comments | When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 0..1
Type | Identifier
Is Modifier | false
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
78. Claim.provider.display
Definition | Plain text narrative that identifies the resource in addition to the resource reference.
Short | Text alternative for the resource
Comments | This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
80. Claim.priority
Definition | The provider-required urgency of processing the request. Typical values include: stat, routine deferred.
Short | Desired processing ugency
Comments | If a claim processor is unable to complete the processing as per the priority then they should generate and error and not process the request.
Control | 1..1
Binding | The codes SHALL be taken from ProcessPriorityCodes (required to `http://hl7.org/fhir/ValueSet/process-priority` )
Type | CodeableConcept
Is Modifier | false
Summary | true
Requirements | The provider may need to indicate their processing requirements so that the processor can indicate if they are unable to comply.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
82. Claim.fundsReserve
Definition | A code to indicate whether and for whom funds are to be reserved for future claims.
Short | For whom to reserve funds
Comments | This field is only used for preauthorizations.
Control | 0..1
Binding | For example codes, see Funds Reservation Codes (example to `http://hl7.org/fhir/ValueSet/fundsreserve|4.0.1` ) For whom funds are to be reserved: (Patient, Provider, None).
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | In the case of a Pre-Determination/Pre-Authorization the provider may request that funds in the amount of the expected Benefit be reserved ('Patient' or 'Provider') to pay for the Benefits determined on the subsequent claim(s). 'None' explicitly indicates no funds reserving is requested.
Alternate Names | Fund pre-allocation
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
84. Claim.related
Definition | Other claims which are related to this claim such as prior submissions or claims for related services or for the same event.
Short | Prior or corollary claims
Comments | For example, for the original treatment and follow-up exams.
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | false
Requirements | For workplace or other accidents it is common to relate separate claims arising from the same event.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
86. Claim.related.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
88. Claim.related.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
90. Claim.related.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
92. Claim.related.claim
Definition | Reference to a related claim.
Short | Reference to the related claim
Control | 0..1
Type | Reference(Claim)
Is Modifier | false
Summary | false
Requirements | For workplace or other accidents it is common to relate separate claims arising from the same event.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
94. Claim.related.relationship
Definition | A code to convey how the claims are related.
Short | How the reference claim is related
Comments | For example, prior claim or umbrella.
Control | 0..1
Binding | For example codes, see ExampleRelatedClaimRelationshipCodes (example to `http://hl7.org/fhir/ValueSet/related-claim-relationship|4.0.1` ) Relationship of this claim to a related Claim.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Some insurers need a declaration of the type of relationship.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
96. Claim.related.reference
Definition | An alternate organizational reference to the case or file to which this particular claim pertains.
Short | File or case reference
Comments | For example, Property/Casualty insurer claim # or Workers Compensation case # .
Control | 0..1
Type | Identifier
Is Modifier | false
Summary | false
Requirements | In cases where an event-triggered claim is being submitted to an insurer which requires a reference number to be specified on all exchanges.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
98. Claim.prescription
Definition | Prescription to support the dispensing of pharmacy, device or vision products.
Short | Prescription authorizing services and products
Control | 0..1
Type | Reference(DeviceRequest, MedicationRequest, VisionPrescription)
Is Modifier | false
Summary | false
Requirements | Required to authorize the dispensing of controlled substances and devices.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
100. Claim.originalPrescription
Definition | Original prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or products.
Short | Original prescription if superseded by fulfiller
Comments | For example, a physician may prescribe a medication which the pharmacy determines is contraindicated, or for which the patient has an intolerance, and therefore issues a new prescription for an alternate medication which has the same therapeutic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription'.
Control | 0..1
Type | Reference(DeviceRequest, MedicationRequest, VisionPrescription)
Is Modifier | false
Summary | false
Requirements | Often required when a fulfiller varies what is fulfilled from that authorized on the original prescription.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
102. Claim.payee
Definition | The party to be reimbursed for cost of the products and services according to the terms of the policy.
Short | Recipient of benefits payable
Comments | Often providers agree to receive the benefits payable to reduce the near-term costs to the patient. The insurer may decline to pay the provider and choose to pay the subscriber instead.
Control | 0..1
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Requirements | The provider needs to specify who they wish to be reimbursed and the claims processor needs express who they will reimburse.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
104. Claim.payee.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
106. Claim.payee.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
108. Claim.payee.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
110. Claim.payee.type
Definition | Type of Party to be reimbursed: subscriber, provider, other.
Short | Category of recipient
Control | 1..1
Binding | For example codes, see Claim Payee Type Codes (example to `http://hl7.org/fhir/ValueSet/payeetype|4.0.1` ) A code for the party to be reimbursed.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Need to know who should receive payment with the most common situations being the Provider (assignment of benefits) or the Subscriber.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
112. Claim.payee.party
Definition | Reference to the individual or organization to whom any payment will be made.
Short | Recipient reference
Comments | Not required if the payee is 'subscriber' or 'provider'.
Control | 0..1
Type | Reference(PCT Practitioner, PCT Organization)
Is Modifier | false
Summary | false
Requirements | Need to provide demographics if the payee is not 'subscriber' nor 'provider'.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
114. Claim.referral
Definition | A reference to a referral resource.
Short | Treatment referral
Comments | The referral resource which lists the date, practitioner, reason and other supporting information.
Control | 0..1
Type | Reference(ServiceRequest)
Is Modifier | false
Summary | false
Requirements | Some insurers require proof of referral to pay for services or to pay specialist rates for services.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
116. Claim.referral.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
118. Claim.referral.extension
Definition | An Extension
Short | Extension
Control | 1..*
Type | Extension
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
Slicing | This element introduces a set of slices on `Claim.referral.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
120. Claim.referral.extension:referralNumber
Slice Name | referralNumber
Definition | This extension is used to provide the Referral Number.
Short | Referral Number
Control | 1..1
Type | Extension(ReferralNumber) (Extension Type: string)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
122. Claim.referral.reference
Definition | A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.
Short | Literal reference, Relative, internal or absolute URL
Comments | Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.
Control | 0..1 This element is affected by the following invariants: ref-1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
124. Claim.referral.type
Definition | The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources).
Short | Type the reference refers to (e.g. "Patient")
Comments | This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified.
Control | 0..1
Binding | Unless not suitable, these codes SHALL be taken from ResourceType (extensible to `http://hl7.org/fhir/ValueSet/resource-types|4.0.1` ) Aa resource (or, for logical models, the URI of the logical model).
Type | uri
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
126. Claim.referral.identifier
Definition | An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.
Short | Logical reference, when literal reference is not known
Comments | When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 0..1
Type | Identifier
Is Modifier | false
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
128. Claim.referral.display
Definition | Plain text narrative that identifies the resource in addition to the resource reference.
Short | Text alternative for the resource
Comments | This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
130. Claim.facility
Definition | Facility where the services were provided.
Short | Servicing facility
Control | 0..1
Type | Reference(Location)
Is Modifier | false
Summary | false
Requirements | Insurance adjudication can be dependant on where services were delivered.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
132. Claim.careTeam
Definition | The members of the team who provided the products and services.
Short | Members of the care team
Control | 0..*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Requirements | Common to identify the responsible and supporting practitioners.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
Slicing | This element introduces a set of slices on `Claim.careTeam`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ role
134. Claim.careTeam.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
136. Claim.careTeam.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
138. Claim.careTeam.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
140. Claim.careTeam.sequence
Definition | A number to uniquely identify care team entries.
Short | Order of care team
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Necessary to maintain the order of the care team and provide a mechanism to link individuals to claim details.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
142. Claim.careTeam.provider
Definition | Member of the team who provided the product or service.
Short | Practitioner or organization
Control | 1..1
Type | Reference(PCT Practitioner, PCT Organization)
Is Modifier | false
Summary | false
Requirements | Often a regulatory requirement to specify the responsible provider.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
144. Claim.careTeam.responsible
Definition | The party who is billing and/or responsible for the claimed products or services.
Short | Indicator of the lead practitioner
Comments | Responsible might not be required when there is only a single provider listed.
Control | 0..1
Type | boolean
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | When multiple parties are present it is required to distinguish the lead or responsible individual.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
146. Claim.careTeam.role
Definition | The lead, assisting or supervising practitioner and their discipline if a multidisciplinary team.
Short | Function within the team
Comments | Role might not be required when there is only a single provider listed.
Control | 1..1
Binding | The codes SHALL be taken from PCT Care Team Role Value Set (required to `http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTCareTeamRoleVS` )
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | When multiple parties are present it is required to distinguish the roles performed by each member.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
148. Claim.careTeam.qualification
Definition | The qualification of the practitioner which is applicable for this service.
Short | Practitioner credential or specialization
Control | 0..1
Binding | The codes SHALL be taken from US Core Provider Role (NUCC) (required to `http://hl7.org/fhir/us/core/ValueSet/us-core-provider-role` )
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Need to specify which qualification a provider is delivering the product or service under.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
150. Claim.careTeam:rendering
Slice Name | rendering
Definition | The members of the team who provided the products and services.
Short | Members of the care team
Control | 0..*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Requirements | Common to identify the responsible and supporting practitioners.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
152. Claim.careTeam:rendering.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
154. Claim.careTeam:rendering.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
156. Claim.careTeam:rendering.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
158. Claim.careTeam:rendering.sequence
Definition | A number to uniquely identify care team entries.
Short | Order of care team
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Necessary to maintain the order of the care team and provide a mechanism to link individuals to claim details.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
160. Claim.careTeam:rendering.provider
Definition | Member of the team who provided the product or service.
Short | Practitioner or organization
Control | 1..1
Type | Reference(PCT Practitioner, PCT Organization)
Is Modifier | false
Summary | false
Requirements | Often a regulatory requirement to specify the responsible provider.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
162. Claim.careTeam:rendering.responsible
Definition | The party who is billing and/or responsible for the claimed products or services.
Short | Indicator of the lead practitioner
Comments | Responsible might not be required when there is only a single provider listed.
Control | 0..1
Type | boolean
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | When multiple parties are present it is required to distinguish the lead or responsible individual.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
164. Claim.careTeam:rendering.role
Definition | The lead, assisting or supervising practitioner and their discipline if a multidisciplinary team.
Short | Function within the team
Comments | Role might not be required when there is only a single provider listed.
Control | 1..1
Binding | The codes SHALL be taken from PCT Care Team Role Value Set (required to `http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTCareTeamRoleVS` )
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | When multiple parties are present it is required to distinguish the roles performed by each member.
Pattern Value | `{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "version" : "1.0.1", "code" : "rendering" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
166. Claim.careTeam:rendering.qualification
Definition | The qualification of the practitioner which is applicable for this service.
Short | Practitioner credential or specialization - must provide a taxonomy code for the Professional case
Control | 1..1
Binding | The codes SHALL be taken from US Core Provider Role (NUCC) (required to `http://hl7.org/fhir/us/core/ValueSet/us-core-provider-role` )
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Need to specify which qualification a provider is delivering the product or service under.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
168. Claim.careTeam:referring
Slice Name | referring
Definition | The members of the team who provided the products and services.
Short | Members of the care team
Control | 0..1
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Requirements | Common to identify the responsible and supporting practitioners.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
170. Claim.careTeam:referring.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
172. Claim.careTeam:referring.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
174. Claim.careTeam:referring.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
176. Claim.careTeam:referring.sequence
Definition | A number to uniquely identify care team entries.
Short | Order of care team
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Necessary to maintain the order of the care team and provide a mechanism to link individuals to claim details.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
178. Claim.careTeam:referring.provider
Definition | Member of the team who provided the product or service.
Short | Practitioner or organization
Control | 1..1
Type | Reference(PCT Practitioner, PCT Organization)
Is Modifier | false
Summary | false
Requirements | Often a regulatory requirement to specify the responsible provider.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
180. Claim.careTeam:referring.responsible
Definition | The party who is billing and/or responsible for the claimed products or services.
Short | Indicator of the lead practitioner
Comments | Responsible might not be required when there is only a single provider listed.
Control | 0..1
Type | boolean
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | When multiple parties are present it is required to distinguish the lead or responsible individual.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
182. Claim.careTeam:referring.role
Definition | The lead, assisting or supervising practitioner and their discipline if a multidisciplinary team.
Short | Function within the team
Comments | Role might not be required when there is only a single provider listed.
Control | 1..1
Binding | The codes SHALL be taken from PCT Care Team Role Value Set (required to `http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTCareTeamRoleVS` )
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | When multiple parties are present it is required to distinguish the roles performed by each member.
Pattern Value | `{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/claimcareteamrole", "version" : "1.0.1", "code" : "referring" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
184. Claim.careTeam:referring.qualification
Definition | The qualification of the practitioner which is applicable for this service.
Short | Practitioner credential or specialization
Control | 0..1
Binding | The codes SHALL be taken from US Core Provider Role (NUCC) (required to `http://hl7.org/fhir/us/core/ValueSet/us-core-provider-role` )
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Need to specify which qualification a provider is delivering the product or service under.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
186. Claim.supportingInfo
Definition | Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.
Short | Supporting information
Comments | Often there are multiple jurisdiction specific valuesets which are required.
Control | 0..*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Requirements | Typically these information codes are required to support the services rendered or the adjudication of the services rendered.
Alternate Names | Attachments Exception Codes Occurrence Codes Value codes
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
Slicing | This element introduces a set of slices on `Claim.supportingInfo`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ category
188. Claim.supportingInfo.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
190. Claim.supportingInfo.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
192. Claim.supportingInfo.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
194. Claim.supportingInfo.sequence
Definition | A number to uniquely identify supporting information entries.
Short | Information instance identifier
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
196. Claim.supportingInfo.category
Definition | The general class of the information supplied: information; exception; accident, employment; onset, etc.
Short | Classification of the supplied information
Comments | This may contain a category for the local bill type codes.
Control | 1..1
Binding | Unless not suitable, these codes SHALL be taken from PCT Supporting Info Type Value Set (extensible to `http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTSupportingInfoTypeVS` )
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Required to group or associate information items with common characteristics. For example: admission information or prior treatments.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
198. Claim.supportingInfo.code
Definition | System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought.
Short | Type of information
Control | 0..1
Binding | For example codes, see ExceptionCodes (example to `http://hl7.org/fhir/ValueSet/claim-exception|4.0.1` ) The valuset used for additional information codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Required to identify the kind of additional information.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
200. Claim.supportingInfo.timing[x]
Definition | The date when or period to which this information refers.
Short | When it occurred
Control | 0..1
Type | Choice of: date, Period
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
202. Claim.supportingInfo.value[x]
Definition | Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.
Short | Data to be provided
Comments | Could be used to provide references to other resources, document. For example could contain a PDF in an Attachment of the Police Report for an Accident.
Control | 0..1
Type | Choice of: boolean, string, Quantity, Attachment, Reference(Resource)
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | To convey the data content to be provided when the information is more than a simple code or period.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
204. Claim.supportingInfo.reason
Definition | Provides the reason in the situation where a reason code is required in addition to the content.
Short | Explanation for the information
Comments | For example: the reason for the additional stay, or why a tooth is missing.
Control | 0..1
Binding | For example codes, see MissingToothReasonCodes (example to `http://hl7.org/fhir/ValueSet/missing-tooth-reason|4.0.1` ) Reason codes for the missing teeth.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Needed when the supporting information has both a date and amount/value and requires explanation.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
206. Claim.supportingInfo:serviceFacility
Slice Name | serviceFacility
Definition | Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.
Short | Service Facility
Comments | Service Facility Location information conveys the name, full address and identifier of the facility where services were rendered when that is different from the Billing/Performing Provider.
Control | 0..1
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Requirements | Typically these information codes are required to support the services rendered or the adjudication of the services rendered.
Alternate Names | Attachments Exception Codes Occurrence Codes Value codes
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
208. Claim.supportingInfo:serviceFacility.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
210. Claim.supportingInfo:serviceFacility.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
212. Claim.supportingInfo:serviceFacility.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
214. Claim.supportingInfo:serviceFacility.sequence
Definition | A number to uniquely identify supporting information entries.
Short | Information instance identifier
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
216. Claim.supportingInfo:serviceFacility.category
Definition | The general class of the information supplied: information; exception; accident, employment; onset, etc.
Short | Classification of the supplied information
Comments | This may contain a category for the local bill type codes.
Control | 1..1
Binding | Unless not suitable, these codes SHALL be taken from PCT Supporting Info Type Value Set (extensible to `http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTSupportingInfoTypeVS` )
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Required to group or associate information items with common characteristics. For example: admission information or prior treatments.
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType", "code" : "servicefacility" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
218. Claim.supportingInfo:serviceFacility.code
Definition | System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought.
Short | Type of information
Control | 0..1
Binding | For example codes, see ExceptionCodes (example to `http://hl7.org/fhir/ValueSet/claim-exception|4.0.1` ) The valuset used for additional information codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Required to identify the kind of additional information.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
220. Claim.supportingInfo:serviceFacility.timing[x]
Definition | The date when or period to which this information refers.
Short | When it occurred
Control | 0..1
Type | Choice of: date, Period
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
222. Claim.supportingInfo:serviceFacility.value[x]
Definition | Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.
Short | Data to be provided
Comments | Could be used to provide references to other resources, document. For example could contain a PDF in an Attachment of the Police Report for an Accident.
Control | 1..1
Type | Reference(Resource)
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Summary | false
Requirements | To convey the data content to be provided when the information is more than a simple code or period.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
Slicing | This element introduces a set of slices on `Claim.supportingInfo.value[x]`. The slices areUnordered and Closed, and can be differentiated using the following discriminators: type @ $this
224. Claim.supportingInfo:serviceFacility.value[x]:valueReference
Slice Name | valueReference
Definition | Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.
Short | Data to be provided
Comments | Could be used to provide references to other resources, document. For example could contain a PDF in an Attachment of the Police Report for an Accident.
Control | 1..1
Type | Reference(PCT Organization)
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Summary | false
Requirements | To convey the data content to be provided when the information is more than a simple code or period.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
226. Claim.supportingInfo:serviceFacility.reason
Definition | Provides the reason in the situation where a reason code is required in addition to the content.
Short | Explanation for the information
Comments | For example: the reason for the additional stay, or why a tooth is missing.
Control | 0..1
Binding | For example codes, see MissingToothReasonCodes (example to `http://hl7.org/fhir/ValueSet/missing-tooth-reason|4.0.1` ) Reason codes for the missing teeth.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Needed when the supporting information has both a date and amount/value and requires explanation.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
228. Claim.supportingInfo:claimFrequency
Slice Name | claimFrequency
Definition | Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.
Short | Claim Frequency component of the UB-04 Type of Bill Code (4th digit of the UB-04 Type of Bill code).
Comments | For the purposes of Patient Cost Transparency Estimates, this field may be used to modify or replace a GFE claim estimate within the same GFE Packet submission. This specification does not support the modification of Claim resources outside of the GFE Packet and client systems SHALL NOT expect the inclusion of the frequency code to affect the use or interpretation of any Claim outside of the GFE Packet.
Control | 0..1
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Requirements | Typically these information codes are required to support the services rendered or the adjudication of the services rendered.
Alternate Names | Attachments Exception Codes Occurrence Codes Value codes
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
230. Claim.supportingInfo:claimFrequency.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
232. Claim.supportingInfo:claimFrequency.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
234. Claim.supportingInfo:claimFrequency.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
236. Claim.supportingInfo:claimFrequency.sequence
Definition | A number to uniquely identify supporting information entries.
Short | Information instance identifier
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
238. Claim.supportingInfo:claimFrequency.category
Definition | The general class of the information supplied: information; exception; accident, employment; onset, etc.
Short | Classification of the supplied information
Comments | This may contain a category for the local bill type codes.
Control | 1..1
Binding | Unless not suitable, these codes SHALL be taken from PCT Supporting Info Type Value Set (extensible to `http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTSupportingInfoTypeVS` )
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Required to group or associate information items with common characteristics. For example: admission information or prior treatments.
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTSupportingInfoType", "code" : "claimFrequency" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
240. Claim.supportingInfo:claimFrequency.code
Definition | System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought.
Short | Type of information
Control | 1..1
Binding | The codes SHALL be taken from PCT GFE NUBC Uniform Billing (UB-04) Type of Bill Value Set (required to `http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFETypeOfBillVS` )
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Required to identify the kind of additional information.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
242. Claim.supportingInfo:claimFrequency.timing[x]
Definition | The date when or period to which this information refers.
Short | When it occurred
Control | 0..1
Type | Choice of: date, Period
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
244. Claim.supportingInfo:claimFrequency.value[x]
Definition | Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.
Short | Data to be provided
Comments | Could be used to provide references to other resources, document. For example could contain a PDF in an Attachment of the Police Report for an Accident.
Control | 0..1
Type | Choice of: boolean, string, Quantity, Attachment, Reference(Resource)
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | To convey the data content to be provided when the information is more than a simple code or period.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
246. Claim.supportingInfo:claimFrequency.reason
Definition | Provides the reason in the situation where a reason code is required in addition to the content.
Short | Explanation for the information
Comments | For example: the reason for the additional stay, or why a tooth is missing.
Control | 0..1
Binding | For example codes, see MissingToothReasonCodes (example to `http://hl7.org/fhir/ValueSet/missing-tooth-reason|4.0.1` ) Reason codes for the missing teeth.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Needed when the supporting information has both a date and amount/value and requires explanation.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
248. Claim.diagnosis
Definition | Information about diagnoses relevant to the claim items.
Short | Pertinent diagnosis information
Control | Changed:0..*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Requirements | Required for the adjudication by provided context for the services and product listed.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
Slicing | This element introduces a set of slices on `Claim.diagnosis`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ type
250. Claim.diagnosis.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
252. Claim.diagnosis.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
254. Claim.diagnosis.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
256. Claim.diagnosis.sequence
Definition | A number to uniquely identify diagnosis entries.
Short | Diagnosis instance identifier
Comments | Diagnosis are presented in list order to their expected importance: primary, secondary, etc.
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Necessary to maintain the order of the diagnosis items and provide a mechanism to link to claim details.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
258. Claim.diagnosis.diagnosis[x]
Definition | The nature of illness or problem in a coded form or as a reference to an external defined Condition.
Short | Nature of illness or problem
Control | 1..1
Binding | For example codes, see ICD-10Codes (example to `http://hl7.org/fhir/ValueSet/icd-10|4.0.1` ) Example ICD10 Diagnostic codes.
Type | Choice of: CodeableConcept, Reference(Condition)
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Summary | false
Requirements | Provides health context for the evaluation of the products and/or services.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
260. Claim.diagnosis.type
Definition | When the condition was observed or the relative ranking.
Short | Timing or nature of the diagnosis
Comments | For example: admitting, primary, secondary, discharge.
Control | 0..*
Binding | The codes SHALL be taken from Diagnosis Type Codes (required to `http://terminology.hl7.org/ValueSet/diagnosistype` )
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | false
Requirements | Often required to capture a particular diagnosis, for example: primary or discharge.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
262. Claim.diagnosis.onAdmission
Definition | Indication of whether the diagnosis was present on admission to a facility.
Short | Present on admission
Control | 0..1
Binding | For example codes, see ExampleDiagnosisOnAdmissionCodes (example to `http://hl7.org/fhir/ValueSet/ex-diagnosis-on-admission|4.0.1` ) Present on admission.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Many systems need to understand for adjudication if the diagnosis was present a time of admission.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
264. Claim.diagnosis.packageCode
Definition | A package billing code or bundle code used to group products and services to a particular health condition (such as heart attack) which is based on a predetermined grouping code system.
Short | Package billing code
Comments | For example DRG (Diagnosis Related Group) or a bundled billing code. A patient may have a diagnosis of a Myocardial Infarction and a DRG for HeartAttack would be assigned. The Claim item (and possible subsequent claims) would refer to the DRG for those line items that were for services related to the heart attack event.
Control | 0..1
Binding | For example codes, see ExampleDiagnosisRelatedGroupCodes (example to `http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup|4.0.1` ) The DRG codes associated with the diagnosis.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Required to relate the current diagnosis to a package billing code that is then referenced on the individual claim items which are specific to the health condition covered by the package code.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
266. Claim.diagnosis:principal
Slice Name | principal
Definition | Information about diagnoses relevant to the claim items.
Short | Principal Diagnosis - Must Support means the information source SHALL be capable of populating and SHALL populate if available and permitted.
Comments | If the Principal Diagnosis code is known, it is important that it be shared in the GFE, particularly when the GFE is being sent to a payer for an insured patient. Payers very often need the diagnosis to be able to provide an estimate. Without the diagnosis, payers may assume the service is diagnostic and thus the patient responsibility may be higher or not covered at all than the diagnosis, such as for preventative services, would otherwise indicate. It is understood that in certain situations, such as scheduled services or GFE requests prior to orders, diagnosis is not needed or may not yet be known. However, when it is known, it is important that this information be shared to ensure the best possible estimate is provided to the patient.
Control | 0..1
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Requirements | Required for the adjudication by provided context for the services and product listed.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
268. Claim.diagnosis:principal.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
270. Claim.diagnosis:principal.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
272. Claim.diagnosis:principal.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
274. Claim.diagnosis:principal.sequence
Definition | A number to uniquely identify diagnosis entries.
Short | Diagnosis instance identifier
Comments | Diagnosis are presented in list order to their expected importance: primary, secondary, etc.
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Necessary to maintain the order of the diagnosis items and provide a mechanism to link to claim details.
Pattern Value | `1`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
276. Claim.diagnosis:principal.diagnosis[x]
Definition | The nature of illness or problem in a coded form or as a reference to an external defined Condition.
Short | Nature of illness or problem
Control | 1..1
Binding | The codes SHALL be taken from PCT ICD-10 Diagnostic Codes (required to `http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTDiagnosticCodes` )
Type | CodeableConcept
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Summary | false
Requirements | Provides health context for the evaluation of the products and/or services.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
278. Claim.diagnosis:principal.type
Definition | When the condition was observed or the relative ranking.
Short | Timing or nature of the diagnosis
Comments | For example: admitting, primary, secondary, discharge.
Control | 1..1
Binding | The codes SHALL be taken from Diagnosis Type Codes (required to `http://terminology.hl7.org/ValueSet/diagnosistype` )
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | false
Requirements | Often required to capture a particular diagnosis, for example: primary or discharge.
Pattern Value | `{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/diagnosistype", "code" : "principal" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
280. Claim.diagnosis:principal.onAdmission
Definition | Indication of whether the diagnosis was present on admission to a facility.
Short | Present on admission
Control | 0..1
Binding | For example codes, see ExampleDiagnosisOnAdmissionCodes (example to `http://hl7.org/fhir/ValueSet/ex-diagnosis-on-admission|4.0.1` ) Present on admission.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Many systems need to understand for adjudication if the diagnosis was present a time of admission.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
282. Claim.diagnosis:principal.packageCode
Definition | A package billing code or bundle code used to group products and services to a particular health condition (such as heart attack) which is based on a predetermined grouping code system.
Short | Package billing code
Comments | For example DRG (Diagnosis Related Group) or a bundled billing code. A patient may have a diagnosis of a Myocardial Infarction and a DRG for HeartAttack would be assigned. The Claim item (and possible subsequent claims) would refer to the DRG for those line items that were for services related to the heart attack event.
Control | 0..1
Binding | For example codes, see ExampleDiagnosisRelatedGroupCodes (example to `http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup|4.0.1` ) The DRG codes associated with the diagnosis.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Required to relate the current diagnosis to a package billing code that is then referenced on the individual claim items which are specific to the health condition covered by the package code.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
284. Claim.diagnosis:other
Slice Name | other
Definition | Information about diagnoses relevant to the claim items.
Short | Pertinent diagnosis information
Control | 0..11
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Requirements | Required for the adjudication by provided context for the services and product listed.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
286. Claim.diagnosis:other.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
288. Claim.diagnosis:other.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
290. Claim.diagnosis:other.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
292. Claim.diagnosis:other.sequence
Definition | A number to uniquely identify diagnosis entries.
Short | Diagnosis instance identifier
Comments | Diagnosis are presented in list order to their expected importance: primary, secondary, etc.
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Necessary to maintain the order of the diagnosis items and provide a mechanism to link to claim details.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
294. Claim.diagnosis:other.diagnosis[x]
Definition | The nature of illness or problem in a coded form or as a reference to an external defined Condition.
Short | Nature of illness or problem
Control | 1..1
Binding | The codes SHALL be taken from PCT ICD-10 Diagnostic Codes (required to `http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTDiagnosticCodes` )
Type | CodeableConcept
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Summary | false
Requirements | Provides health context for the evaluation of the products and/or services.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
296. Claim.diagnosis:other.type
Definition | When the condition was observed or the relative ranking.
Short | Timing or nature of the diagnosis
Comments | For example: admitting, primary, secondary, discharge.
Control | 1..1
Binding | The codes SHALL be taken from Diagnosis Type Codes (required to `http://terminology.hl7.org/ValueSet/diagnosistype` )
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | false
Requirements | Often required to capture a particular diagnosis, for example: primary or discharge.
Pattern Value | `{ "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/diagnosistype", "code" : "secondary" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
298. Claim.diagnosis:other.onAdmission
Definition | Indication of whether the diagnosis was present on admission to a facility.
Short | Present on admission
Control | 0..1
Binding | For example codes, see ExampleDiagnosisOnAdmissionCodes (example to `http://hl7.org/fhir/ValueSet/ex-diagnosis-on-admission|4.0.1` ) Present on admission.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Many systems need to understand for adjudication if the diagnosis was present a time of admission.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
300. Claim.diagnosis:other.packageCode
Definition | A package billing code or bundle code used to group products and services to a particular health condition (such as heart attack) which is based on a predetermined grouping code system.
Short | Package billing code
Comments | For example DRG (Diagnosis Related Group) or a bundled billing code. A patient may have a diagnosis of a Myocardial Infarction and a DRG for HeartAttack would be assigned. The Claim item (and possible subsequent claims) would refer to the DRG for those line items that were for services related to the heart attack event.
Control | 0..1
Binding | For example codes, see ExampleDiagnosisRelatedGroupCodes (example to `http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup|4.0.1` ) The DRG codes associated with the diagnosis.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Required to relate the current diagnosis to a package billing code that is then referenced on the individual claim items which are specific to the health condition covered by the package code.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
302. Claim.procedure
Definition | Procedures performed on the patient relevant to the billing items with the claim.
Short | Clinical procedures performed
Control | 0..*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Requirements | The specific clinical invention are sometimes required to be provided to justify billing a greater than customary amount for a service.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
Slicing | This element introduces a set of slices on `Claim.procedure`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ type
304. Claim.procedure.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
306. Claim.procedure.extension
Definition | An Extension
Short | Extension
Control | 1..*
Type | Extension
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
Slicing | This element introduces a set of slices on `Claim.procedure.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
308. Claim.procedure.extension:serviceDescription
Slice Name | serviceDescription
Definition | This extension is used to communicate a plain language description of the procedure, product, or service.
Short | Service Description
Control | 1..1 This element is affected by the following invariants: ele-1
Type | Extension(Service Description) (Extension Type: string)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
310. Claim.procedure.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
312. Claim.procedure.sequence
Definition | A number to uniquely identify procedure entries.
Short | Procedure instance identifier
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Necessary to provide a mechanism to link to claim details.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
314. Claim.procedure.type
Definition | When the condition was observed or the relative ranking.
Short | Category of Procedure
Comments | For example: primary, secondary.
Control | 0..*
Binding | The codes SHALL be taken from PCT Procedure Type Value Set (required to `http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTProcedureTypeVS` )
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | false
Requirements | Often required to capture a particular diagnosis, for example: primary or discharge.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
316. Claim.procedure.date
Definition | Date and optionally time the procedure was performed.
Short | When the procedure was performed
Control | 0..1
Type | dateTime
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Required for auditing purposes.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
318. Claim.procedure.procedure[x]
Definition | The code or reference to a Procedure resource which identifies the clinical intervention performed.
Short | Specific clinical procedure
Control | 1..1
Binding | For example codes, see ICD-10ProcedureCodes (example to `http://hl7.org/fhir/ValueSet/icd-10-procedures|4.0.1` ) Example ICD10 Procedure codes.
Type | Choice of: CodeableConcept, Reference(Procedure)
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Summary | false
Requirements | This identifies the actual clinical procedure.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
320. Claim.procedure.udi
Definition | Unique Device Identifiers associated with this line item.
Short | Unique device identifier
Control | 0..*
Type | Reference(Device)
Is Modifier | false
Summary | false
Requirements | The UDI code allows the insurer to obtain device level information on the product supplied.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
322. Claim.procedure:anesthesiaRelated
Slice Name | anesthesiaRelated
Definition | Procedures performed on the patient relevant to the billing items with the claim.
Short | Clinical procedures performed
Control | 0..2
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Requirements | The specific clinical invention are sometimes required to be provided to justify billing a greater than customary amount for a service.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
324. Claim.procedure:anesthesiaRelated.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
326. Claim.procedure:anesthesiaRelated.extension
Definition | An Extension
Short | Extension
Control | 1..*
Type | Extension
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
Slicing | This element introduces a set of slices on `Claim.procedure.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
328. Claim.procedure:anesthesiaRelated.extension:serviceDescription
Slice Name | serviceDescription
Definition | This extension is used to communicate a plain language description of the procedure, product, or service.
Short | Service Description
Control | 1..1 This element is affected by the following invariants: ele-1
Type | Extension(Service Description) (Extension Type: string)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
330. Claim.procedure:anesthesiaRelated.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
332. Claim.procedure:anesthesiaRelated.sequence
Definition | A number to uniquely identify procedure entries.
Short | Procedure instance identifier
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Necessary to provide a mechanism to link to claim details.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
334. Claim.procedure:anesthesiaRelated.type
Definition | When the condition was observed or the relative ranking.
Short | Category of Procedure
Comments | For example: primary, secondary.
Control | 1..1
Binding | The codes SHALL be taken from PCT Procedure Type Value Set (required to `http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTProcedureTypeVS` )
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | false
Requirements | Often required to capture a particular diagnosis, for example: primary or discharge.
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTProcedureType", "code" : "procedureRequiringAnesthesia" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
336. Claim.procedure:anesthesiaRelated.date
Definition | Date and optionally time the procedure was performed.
Short | When the procedure was performed
Control | 0..1
Type | dateTime
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Required for auditing purposes.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
338. Claim.procedure:anesthesiaRelated.procedure[x]
Definition | The code or reference to a Procedure resource which identifies the clinical intervention performed.
Short | Specific clinical procedure
Control | 1..1
Binding | The codes SHALL be taken from PCT CMS HCPCS and AMA CPT Procedure Surgical Codes (required to `http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTProcedureSurgicalCodes` )
Type | CodeableConcept
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Summary | false
Requirements | This identifies the actual clinical procedure.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
340. Claim.procedure:anesthesiaRelated.udi
Definition | Unique Device Identifiers associated with this line item.
Short | Unique device identifier
Control | 0..*
Type | Reference(Device)
Is Modifier | false
Summary | false
Requirements | The UDI code allows the insurer to obtain device level information on the product supplied.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
342. Claim.procedure:other
Slice Name | other
Definition | Procedures performed on the patient relevant to the billing items with the claim.
Short | Clinical procedures performed
Control | 0..24
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Requirements | The specific clinical invention are sometimes required to be provided to justify billing a greater than customary amount for a service.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
344. Claim.procedure:other.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
346. Claim.procedure:other.extension
Definition | An Extension
Short | Extension
Control | 1..*
Type | Extension
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
Slicing | This element introduces a set of slices on `Claim.procedure.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
348. Claim.procedure:other.extension:serviceDescription
Slice Name | serviceDescription
Definition | This extension is used to communicate a plain language description of the procedure, product, or service.
Short | Service Description
Control | 1..1 This element is affected by the following invariants: ele-1
Type | Extension(Service Description) (Extension Type: string)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
350. Claim.procedure:other.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
352. Claim.procedure:other.sequence
Definition | A number to uniquely identify procedure entries.
Short | Procedure instance identifier
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Necessary to provide a mechanism to link to claim details.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
354. Claim.procedure:other.type
Definition | When the condition was observed or the relative ranking.
Short | Category of Procedure
Comments | For example: primary, secondary.
Control | 1..1
Binding | The codes SHALL be taken from PCT Procedure Type Value Set (required to `http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTProcedureTypeVS` )
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | false
Requirements | Often required to capture a particular diagnosis, for example: primary or discharge.
Pattern Value | `{ "coding" : [{ "system" : "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTProcedureType", "code" : "other" }] }`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
356. Claim.procedure:other.date
Definition | Date and optionally time the procedure was performed.
Short | When the procedure was performed
Control | 0..1
Type | dateTime
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Required for auditing purposes.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
358. Claim.procedure:other.procedure[x]
Definition | The code or reference to a Procedure resource which identifies the clinical intervention performed.
Short | Specific clinical procedure
Control | 1..1
Binding | The codes SHALL be taken from PCT CMS HCPCS and AMA CPT Procedure Surgical Codes (required to `http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTProcedureSurgicalCodes` )
Type | CodeableConcept
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Summary | false
Requirements | This identifies the actual clinical procedure.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
360. Claim.procedure:other.udi
Definition | Unique Device Identifiers associated with this line item.
Short | Unique device identifier
Control | 0..*
Type | Reference(Device)
Is Modifier | false
Summary | false
Requirements | The UDI code allows the insurer to obtain device level information on the product supplied.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
362. Claim.insurance
Definition | Financial instruments for reimbursement for the health care products and services specified on the claim.
Short | Patient insurance information
Comments | All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. Coverages appearing before the focal Coverage in the list, and where 'Coverage.subrogation=false', should provide a reference to the ClaimResponse containing the adjudication results of the prior claim.
Control | 1..*
Type | BackboneElement
Is Modifier | false
Summary | true
Requirements | At least one insurer is required for a claim to be a claim.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
364. Claim.insurance.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
366. Claim.insurance.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
368. Claim.insurance.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
370. Claim.insurance.sequence
Definition | A number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order.
Short | Insurance instance identifier
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | To maintain order of the coverages.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
372. Claim.insurance.focal
Definition | A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.
Short | Coverage to be used for adjudication
Comments | A patient may (will) have multiple insurance policies which provide reimbursement for healthcare services and products. For example a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for adjudicating this claim. Other claims would be created to request adjudication against the other listed policies.
Control | 1..1
Type | boolean
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | To identify which coverage in the list is being used to adjudicate this claim.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
374. Claim.insurance.identifier
Definition | The business identifier to be used when the claim is sent for adjudication against this insurance policy.
Short | Pre-assigned Claim number
Comments | Only required in jurisdictions where insurers, rather than the provider, are required to send claims to insurers that appear after them in the list. This element is not required when 'subrogation=true'.
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 0..1
Type | Identifier
Is Modifier | false
Summary | false
Requirements | This will be the claim number should it be necessary to create this claim in the future. This is provided so that payors may forward claims to other payors in the Coordination of Benefit for adjudication rather than the provider being required to initiate each adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
376. Claim.insurance.coverage
Definition | Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.
Short | Insurance information
Control | 1..1
Type | Reference(PCT Coverage)
Is Modifier | false
Summary | true
Requirements | Required to allow the adjudicator to locate the correct policy and history within their information system.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
378. Claim.insurance.coverage.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
380. Claim.insurance.coverage.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
Slicing | This element introduces a set of slices on `Claim.insurance.coverage.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
382. Claim.insurance.coverage.extension:dataAbsentReason
Slice Name | dataAbsentReason
Definition | Provides a reason why the expected value or elements in the element that is extended are missing.
Short | Coverage may be not applicable if estimate is for self-pay or uninsured
Control | 0..1
Type | Extension(Data Absent Reason) (Extension Type: code)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
384. Claim.insurance.coverage.reference
Definition | A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.
Short | Literal reference, Relative, internal or absolute URL
Comments | Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.
Control | 0..1 This element is affected by the following invariants: ref-1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
386. Claim.insurance.coverage.type
Definition | The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources).
Short | Type the reference refers to (e.g. "Patient")
Comments | This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified.
Control | 0..1
Binding | Unless not suitable, these codes SHALL be taken from ResourceType (extensible to `http://hl7.org/fhir/ValueSet/resource-types|4.0.1` ) Aa resource (or, for logical models, the URI of the logical model).
Type | uri
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
388. Claim.insurance.coverage.identifier
Definition | An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.
Short | Logical reference, when literal reference is not known
Comments | When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 0..1
Type | Identifier
Is Modifier | false
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
390. Claim.insurance.coverage.display
Definition | Plain text narrative that identifies the resource in addition to the resource reference.
Short | Text alternative for the resource
Comments | This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
392. Claim.insurance.businessArrangement
Definition | A business agreement number established between the provider and the insurer for special business processing purposes.
Short | Additional provider contract number
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Providers may have multiple business arrangements with a given insurer and must supply the specific contract number for adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
394. Claim.insurance.preAuthRef
Definition | Reference numbers previously provided by the insurer to the provider to be quoted on subsequent claims containing services or products related to the prior authorization.
Short | Prior authorization reference number
Comments | This value is an alphanumeric string that may be provided over the phone, via text, via paper, or within a ClaimResponse resource and is not a FHIR Identifier.
Control | 0..2
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Providers must quote previously issued authorization reference numbers in order to obtain adjudication as previously advised on the Preauthorization.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
396. Claim.insurance.claimResponse
Definition | The result of the adjudication of the line items for the Coverage specified in this insurance.
Short | Adjudication results
Comments | Must not be specified when 'focal=true' for this insurance.
Control | 0..1
Type | Reference(ClaimResponse)
Is Modifier | false
Summary | false
Requirements | An insurer need the adjudication results from prior insurers to determine the outstanding balance remaining by item for the items in the curent claim.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
398. Claim.accident
Definition | Details of an accident which resulted in injuries which required the products and services listed in the claim.
Short | Details of the event
Control | 0..1
Type | BackboneElement
Is Modifier | false
Summary | false
Requirements | When healthcare products and services are accident related, benefits may be payable under accident provisions of policies, such as automotive, etc before they are payable under normal health insurance.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
400. Claim.accident.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
402. Claim.accident.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
404. Claim.accident.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
406. Claim.accident.date
Definition | Date of an accident event related to the products and services contained in the claim.
Short | When the incident occurred
Comments | The date of the accident has to precede the dates of the products and services but within a reasonable timeframe.
Control | 1..1
Type | date
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Required for audit purposes and adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
408. Claim.accident.type
Definition | The type or context of the accident event for the purposes of selection of potential insurance coverages and determination of coordination between insurers.
Short | The nature of the accident
Control | 0..1
Binding | Unless not suitable, these codes SHALL be taken from ActIncidentCode (3.0.0) (extensible to `http://terminology.hl7.org/ValueSet/v3-ActIncidentCode|3.0.0` ) Type of accident: work place, auto, etc.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Coverage may be dependant on the type of accident.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
410. Claim.accident.location[x]
Definition | The physical location of the accident event.
Short | Where the event occurred
Control | 0..1
Type | Address
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Summary | false
Requirements | Required for audit purposes and determination of applicable insurance liability.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
412. Claim.accident.location[x].id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
414. Claim.accident.location[x].extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
Slicing | This element introduces a set of slices on `Claim.accident.location[x].extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
416. Claim.accident.location[x].use
Definition | The purpose of this address.
Short | home | work | temp | old | billing - purpose of this address
Comments | Applications can assume that an address is current unless it explicitly says that it is temporary or old.
Control | 0..1
Binding | The codes SHALL be taken from AddressUse (required to `http://hl7.org/fhir/ValueSet/address-use|4.0.1` ) The use of an address.
Type | code
Is Modifier | true because This is labeled as "Is Modifier" because applications should not mistake a temporary or old address etc.for a current/permanent one
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | Allows an appropriate address to be chosen from a list of many.
Example | General: home
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
418. Claim.accident.location[x].type
Definition | Distinguishes between physical addresses (those you can visit) and mailing addresses (e.g. PO Boxes and care-of addresses). Most addresses are both.
Short | postal | physical | both
Comments | Changed: The definition of Address states that "address is intended to describe postal addresses, not physical locations". However, many applications track whether an address has a dual purpose of being a location that can be visited as well as being a valid delivery destination, and Postal addresses are often used as proxies for physical locations (also see the Location resource).
Control | 0..1
Binding | The codes SHALL be taken from AddressType (required to `http://hl7.org/fhir/ValueSet/address-type|4.0.1` ) The type of an address (physical / postal).
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Example | General: both
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
420. Claim.accident.location[x].text
Definition | Specifies the entire address as it should be displayed e.g. on a postal label. This may be provided instead of or as well as the specific parts.
Short | Text representation of the address
Comments | Can provide both a text representation and parts. Applications updating an address SHALL ensure that when both text and parts are present, no content is included in the text that isn't found in a part.
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | A renderable, unencoded form.
Example | General: 137 Nowhere Street, Erewhon 9132
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
422. Claim.accident.location[x].line
Definition | This component contains the house number, apartment number, street name, street direction, P.O. Box number, delivery hints, and similar address information.
Short | Street name, number, direction & P.O. Box etc.
Control | 0..*
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Example | General: 137 Nowhere Street
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
424. Claim.accident.location[x].city
Definition | The name of the city, town, suburb, village or other community or delivery center.
Short | Name of city, town etc.
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Alternate Names | Municpality
Example | General: Erewhon
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
426. Claim.accident.location[x].district
Definition | The name of the administrative area (county).
Short | District name (aka county)
Comments | District is sometimes known as county, but in some regions 'county' is used in place of city (municipality), so county name should be conveyed in city instead.
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Alternate Names | County
Example | General: Madison
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
428. Claim.accident.location[x].state
Definition | Sub-unit of a country with limited sovereignty in a federally organized country. A code may be used if codes are in common use (e.g. US 2 letter state codes).
Short | Sub-unit of country (abbreviations ok)
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Alternate Names | Province, Territory
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
430. Claim.accident.location[x].postalCode
Definition | A postal code designating a region defined by the postal service.
Short | Postal code for area
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Alternate Names | Zip
Example | General: 9132
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
432. Claim.accident.location[x].country
Definition | Country - a nation as commonly understood or generally accepted.
Short | Country (e.g. can be ISO 3166 2 or 3 letter code)
Comments | ISO 3166 3 letter codes can be used in place of a human readable country name.
Control | 0..1
Binding | The codes SHALL be taken from Iso3166-1-2 (required to `http://hl7.org/fhir/ValueSet/iso3166-1-2` )
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
434. Claim.accident.location[x].period
Definition | Time period when address was/is in use.
Short | Time period when address was/is in use
Control | 0..1
Type | Period
Is Modifier | false
Summary | true
Requirements | Allows addresses to be placed in historical context.
Example | General: { "start" : "2010-03-23", "end" : "2010-07-01" }
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
436. Claim.item
Definition | A claim line. Either a simple product or service or a 'group' of details which can each be a simple items or groups of sub-details.
Short | Product or service provided
Control | 1..50
Type | BackboneElement
Is Modifier | false
Summary | false
Requirements | The items to be processed for adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
438. Claim.item.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
440. Claim.item.extension
Definition | An Extension
Short | Extension
Control | 1..*
Type | Extension
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
Slicing | This element introduces a set of slices on `Claim.item.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
442. Claim.item.extension:referralNumber
Slice Name | referralNumber
Definition | This extension is used to provide the Referral Number.
Short | Referral Number
Control | 0..11 This element is affected by the following invariants: ele-1
Type | Extension(ReferralNumber) (Extension Type: string)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
444. Claim.item.extension:gfeBillingProviderLineItemCtrlNum
Slice Name | gfeBillingProviderLineItemCtrlNum
Definition | This extension is used by the provider to assign a unique identifier to this item. The intent of this element is to allow the provider to assign something other than 'line number' for their purposes (e.g. tracking and troubleshooting).
Short | Extension
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(GFEBillingProviderLineItemCtrlNum) (Extension Type: Identifier)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
446. Claim.item.extension:serviceDescription
Slice Name | serviceDescription
Definition | This extension is used to communicate a plain language description of the procedure, product, or service.
Short | Service Description
Control | 1..1 This element is affected by the following invariants: ele-1
Type | Extension(Service Description) (Extension Type: string)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
448. Claim.item.extension:ProviderEventMethodology
Slice Name | ProviderEventMethodology
Definition | This extension is used for indicating the method a provider used to group services, and those providing such services, beyond what may be indicated through DRGs that the payer or patient may find helpful (e.g. grouping services by a standardized episode of care definition). This is provider generated text and should not be modified by the payer.
Short | Provider Event Methodology
Comments | The method a provider used to group services. The extension definition contains additional detail.
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(ProviderEventMethodology) (Extension Type: string)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
450. Claim.item.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
452. Claim.item.sequence
Definition | A number to uniquely identify item entries.
Short | Item instance identifier
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
454. Claim.item.careTeamSequence
Definition | CareTeam members related to this service or product.
Short | Applicable careTeam members
Control | 0..*
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | false
Requirements | Need to identify the individuals and their roles in the provision of the product or service.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
456. Claim.item.diagnosisSequence
Definition | Diagnosis applicable for this service or product.
Short | Applicable diagnoses
Control | 0..*
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Need to related the product or service to the associated diagnoses.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
458. Claim.item.procedureSequence
Definition | Procedures applicable for this service or product.
Short | Applicable procedures
Control | 0..*
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Need to provide any listed specific procedures to support the product or service being claimed.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
460. Claim.item.informationSequence
Definition | Exceptions, special conditions and supporting information applicable for this service or product.
Short | Applicable exception and supporting information
Control | 0..*
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Need to reference the supporting information items that relate directly to this product or service.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
462. Claim.item.revenue
Definition | The type of revenue or cost center providing the product and/or service.
Short | Revenue or cost center code
Control | 0..1
Binding | For example codes, see ExampleRevenueCenterCodes (example to `http://hl7.org/fhir/ValueSet/ex-revenue-center|4.0.1` ) Codes for the revenue or cost centers supplying the service and/or products.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Needed in the processing of institutional claims.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
464. Claim.item.category
Definition | Code to identify the general type of benefits under which products and services are provided.
Short | Benefit classification
Comments | Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.
Control | 0..1
Binding | For example codes, see BenefitCategoryCodes (example to `http://hl7.org/fhir/ValueSet/ex-benefitcategory|4.0.1` ) Benefit categories such as: oral-basic, major, glasses.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
466. Claim.item.productOrService
Definition | When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.
Short | Billing, service, product, or drug code
Comments | If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.
Control | 1..1
Binding | The codes SHALL be taken from Claim Medical Product or Service Value Set (required to `http://hl7.org/fhir/us/davinci-pct/ValueSet/USClaimMedicalProductOrServiceCodes` )
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Necessary to state what was provided or done.
Alternate Names | Drug Code, Bill Code, Service Code
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
468. Claim.item.productOrService.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
470. Claim.item.productOrService.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
Slicing | This element introduces a set of slices on `Claim.item.productOrService.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
472. Claim.item.productOrService.coding
Definition | A reference to a code defined by a terminology system.
Short | Code defined by a terminology system
Comments | Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
Control | 0..*
Type | Coding
Is Modifier | false
Summary | true
Requirements | Allows for alternative encodings within a code system, and translations to other code systems.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) pct-cpt-display: CPT codes require a display value (CPT Consumer Friendly Descriptors recommended) (`system = 'http://www.ama-assn.org/go/cpt' implies display.exists()`)
474. Claim.item.productOrService.text
Definition | A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.
Short | Plain text representation of the concept
Comments | Very often the text is the same as a displayName of one of the codings.
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
476. Claim.item.modifier
Definition | Item typification or modifiers codes to convey additional context for the product or service.
Short | Product or service billing modifiers
Comments | For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours.
Control | 0..4
Binding | The codes SHALL be taken from PCT GFE Item CPT - HCPCS Value Set (required to `http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFEItemCptHcpcsVS` )
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | false
Requirements | To support inclusion of the item for adjudication or to charge an elevated fee.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
478. Claim.item.modifier.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
480. Claim.item.modifier.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
Slicing | This element introduces a set of slices on `Claim.item.modifier.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
482. Claim.item.modifier.coding
Definition | A reference to a code defined by a terminology system.
Short | Code defined by a terminology system
Comments | Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
Control | 0..*
Type | Coding
Is Modifier | false
Summary | true
Requirements | Allows for alternative encodings within a code system, and translations to other code systems.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) pct-cpt-display: CPT codes require a display value (CPT Consumer Friendly Descriptors recommended) (`system = 'http://www.ama-assn.org/go/cpt' implies display.exists()`)
484. Claim.item.modifier.text
Definition | A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.
Short | Plain text representation of the concept
Comments | Very often the text is the same as a displayName of one of the codings.
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
486. Claim.item.programCode
Definition | Identifies the program under which this may be recovered.
Short | Program the product or service is provided under
Comments | For example: Neonatal program, child dental program or drug users recovery program.
Control | 0..*
Binding | For example codes, see ExampleProgramReasonCodes (example to `http://hl7.org/fhir/ValueSet/ex-program-code|4.0.1` ) Program specific reason codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
488. Claim.item.serviced[x]
Definition | This is the planned or estimated dates of service. Use Revenue code to determine inpatient stays if needed for adjudication
Short | This is the planned or estimated date(s)s of service
Control | 1..1
Type | Choice of: date, Period
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Must Support Types | No must-support rules about the choice of types/profiles
Summary | false
Requirements | Needed to determine whether the service or product was provided during the term of the insurance coverage.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
490. Claim.item.location[x]
Definition | Where the product or service was provided.
Short | Place of service or where product was supplied
Control | 1..1
Binding | The codes SHALL be taken from PCT GFE CMS Place of Service Value Set (required to `http://hl7.org/fhir/us/davinci-pct/ValueSet/PCTGFECMSPOS` )
Type | CodeableConcept
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Summary | false
Requirements | The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
492. Claim.item.quantity
Definition | The number of repetitions of a service or product.
Short | Count of products or services
Control | 1..1
Type | Quantity(SimpleQuantity)
Is Modifier | false
Summary | false
Requirements | Required when the product or service code does not convey the quantity provided.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
494. Claim.item.unitPrice
Definition | If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.
Short | Fee, charge or cost per item
Control | 1..1
Type | Money
Is Modifier | false
Summary | false
Requirements | The amount charged to the patient by the provider for a single unit.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
496. Claim.item.factor
Definition | A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.
Short | Price scaling factor
Comments | To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
Control | 0..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
498. Claim.item.net
Definition | The quantity times the unit price for an additional service or product or charge.
Short | Total charge amount for the service line
Comments | For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
Control | 1..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Provides the total amount claimed for the group (if a grouper) or the line item.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
500. Claim.item.udi
Definition | Unique Device Identifiers associated with this line item.
Short | Unique device identifier
Control | 0..*
Type | Reference(Device)
Is Modifier | false
Summary | false
Requirements | The UDI code allows the insurer to obtain device level information on the product supplied.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
502. Claim.item.bodySite
Definition | Physical service site on the patient (limb, tooth, etc.).
Short | Anatomical location
Comments | For example: Providing a tooth code, allows an insurer to identify a provider performing a filling on a tooth that was previously removed.
Control | 0..1
Binding | For example codes, see OralSiteCodes (example to `http://hl7.org/fhir/ValueSet/tooth|4.0.1` ) The code for the teeth, quadrant, sextant and arch.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Allows insurer to validate specific procedures.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
504. Claim.item.subSite
Definition | A region or surface of the bodySite, e.g. limb region or tooth surface(s).
Short | Anatomical sub-location
Control | 0..*
Binding | For example codes, see SurfaceCodes (example to `http://hl7.org/fhir/ValueSet/surface|4.0.1` ) The code for the tooth surface and surface combinations.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Allows insurer to validate specific procedures.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
506. Claim.item.encounter
Definition | The Encounters during which this Claim was created or to which the creation of this record is tightly associated.
Short | Encounters related to this billed item
Comments | This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter.
Control | 0..*
Type | Reference(Encounter)
Is Modifier | false
Summary | false
Requirements | Used in some jurisdictions to link clinical events to claim items.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
508. Claim.item.detail
Definition | A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.
Short | Drug Identification Information
Control | 0..*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Requirements | The items to be processed for adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
510. Claim.item.detail.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
512. Claim.item.detail.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
514. Claim.item.detail.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
516. Claim.item.detail.sequence
Definition | A number to uniquely identify item entries.
Short | Item instance identifier
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
518. Claim.item.detail.revenue
Definition | The type of revenue or cost center providing the product and/or service.
Short | Revenue or cost center code
Control | 0..1
Binding | For example codes, see ExampleRevenueCenterCodes (example to `http://hl7.org/fhir/ValueSet/ex-revenue-center|4.0.1` ) Codes for the revenue or cost centers supplying the service and/or products.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Needed in the processing of institutional claims.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
520. Claim.item.detail.category
Definition | Code to identify the general type of benefits under which products and services are provided.
Short | Benefit classification
Comments | Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.
Control | 0..1
Binding | For example codes, see BenefitCategoryCodes (example to `http://hl7.org/fhir/ValueSet/ex-benefitcategory|4.0.1` ) Benefit categories such as: oral-basic, major, glasses.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
522. Claim.item.detail.productOrService
Definition | When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.
Short | Billing, service, product, or drug code
Comments | If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.
Control | 1..1
Binding | The codes SHALL be taken from Claim Medical Product or Service Value Set (required to `http://hl7.org/fhir/us/davinci-pct/ValueSet/USClaimMedicalProductOrServiceCodes` )
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Necessary to state what was provided or done.
Alternate Names | Drug Code, Bill Code, Service Code
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
524. Claim.item.detail.modifier
Definition | Item typification or modifiers codes to convey additional context for the product or service.
Short | Service/Product billing modifiers
Comments | For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.
Control | 0..*
Binding | For example codes, see ModifierTypeCodes (example to `http://hl7.org/fhir/ValueSet/claim-modifiers|4.0.1` ) Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | To support inclusion of the item for adjudication or to charge an elevated fee.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
526. Claim.item.detail.programCode
Definition | Identifies the program under which this may be recovered.
Short | Program the product or service is provided under
Comments | For example: Neonatal program, child dental program or drug users recovery program.
Control | 0..*
Binding | For example codes, see ExampleProgramReasonCodes (example to `http://hl7.org/fhir/ValueSet/ex-program-code|4.0.1` ) Program specific reason codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
528. Claim.item.detail.quantity
Definition | The number of repetitions of a service or product.
Short | Count of products or services
Control | 0..1
Type | Quantity(SimpleQuantity)
Is Modifier | false
Must Support | true
Summary | false
Requirements | Required when the product or service code does not convey the quantity provided.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
530. Claim.item.detail.unitPrice
Definition | If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.
Short | Fee, charge or cost per item
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | The amount charged to the patient by the provider for a single unit.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
532. Claim.item.detail.factor
Definition | A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.
Short | Price scaling factor
Comments | To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
Control | 0..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
534. Claim.item.detail.net
Definition | The quantity times the unit price for an additional service or product or charge.
Short | Total item cost
Comments | For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Provides the total amount claimed for the group (if a grouper) or the line item.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
536. Claim.item.detail.udi
Definition | Unique Device Identifiers associated with this line item.
Short | Unique device identifier
Control | 0..*
Type | Reference(Device)
Is Modifier | false
Summary | false
Requirements | The UDI code allows the insurer to obtain device level information on the product supplied.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
538. Claim.item.detail.subDetail
Definition | A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.
Short | Product or service provided
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | false
Requirements | The items to be processed for adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
540. Claim.item.detail.subDetail.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
542. Claim.item.detail.subDetail.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
544. Claim.item.detail.subDetail.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
546. Claim.item.detail.subDetail.sequence
Definition | A number to uniquely identify item entries.
Short | Item instance identifier
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
548. Claim.item.detail.subDetail.revenue
Definition | The type of revenue or cost center providing the product and/or service.
Short | Revenue or cost center code
Control | 0..1
Binding | For example codes, see ExampleRevenueCenterCodes (example to `http://hl7.org/fhir/ValueSet/ex-revenue-center|4.0.1` ) Codes for the revenue or cost centers supplying the service and/or products.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Needed in the processing of institutional claims.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
550. Claim.item.detail.subDetail.category
Definition | Code to identify the general type of benefits under which products and services are provided.
Short | Benefit classification
Comments | Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.
Control | 0..1
Binding | For example codes, see BenefitCategoryCodes (example to `http://hl7.org/fhir/ValueSet/ex-benefitcategory|4.0.1` ) Benefit categories such as: oral-basic, major, glasses.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
552. Claim.item.detail.subDetail.productOrService
Definition | When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.
Short | Billing, service, product, or drug code
Comments | If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.
Control | 1..1
Binding | For example codes, see USCLSCodes (example to `http://hl7.org/fhir/ValueSet/service-uscls|4.0.1` ) Allowable service and product codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Necessary to state what was provided or done.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
554. Claim.item.detail.subDetail.modifier
Definition | Item typification or modifiers codes to convey additional context for the product or service.
Short | Service/Product billing modifiers
Comments | For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.
Control | 0..*
Binding | For example codes, see ModifierTypeCodes (example to `http://hl7.org/fhir/ValueSet/claim-modifiers|4.0.1` ) Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | To support inclusion of the item for adjudication or to charge an elevated fee.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
556. Claim.item.detail.subDetail.programCode
Definition | Identifies the program under which this may be recovered.
Short | Program the product or service is provided under
Comments | For example: Neonatal program, child dental program or drug users recovery program.
Control | 0..*
Binding | For example codes, see ExampleProgramReasonCodes (example to `http://hl7.org/fhir/ValueSet/ex-program-code|4.0.1` ) Program specific reason codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
558. Claim.item.detail.subDetail.quantity
Definition | The number of repetitions of a service or product.
Short | Count of products or services
Control | 0..1
Type | Quantity(SimpleQuantity)
Is Modifier | false
Summary | false
Requirements | Required when the product or service code does not convey the quantity provided.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
560. Claim.item.detail.subDetail.unitPrice
Definition | If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.
Short | Fee, charge or cost per item
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | The amount charged to the patient by the provider for a single unit.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
562. Claim.item.detail.subDetail.factor
Definition | A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.
Short | Price scaling factor
Comments | To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
Control | 0..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
564. Claim.item.detail.subDetail.net
Definition | The quantity times the unit price for an additional service or product or charge.
Short | Total item cost
Comments | For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Provides the total amount claimed for the group (if a grouper) or the line item.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
566. Claim.item.detail.subDetail.udi
Definition | Unique Device Identifiers associated with this line item.
Short | Unique device identifier
Control | 0..*
Type | Reference(Device)
Is Modifier | false
Summary | false
Requirements | The UDI code allows the insurer to obtain device level information on the product supplied.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
568. Claim.total
Definition | The total value of the all the items in the claim.
Short | Total GFE Charges Submitted
Control | 1..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Used for control total purposes.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)