QI-Core Implementation Guide
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QI-Core Implementation Guide, published by HL7 International / Clinical Quality Information. This guide is not an authorized publication; it is the continuous build for version 7.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-qi-core/ and changes regularly. See the Directory of published versions

Resource Profile: QICore Claim

Official URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-claim Version: 7.0.0
Active as of 2018-08-22 Computable Name: QICoreClaim

Profile of Claim for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.

"Must Have", "QI Elements" and "primary code path" are defined in the QI-Core Must Support section.
QI Elements:
  • Claim: Claim, Pre-determination or Pre-authorization
  • patient: (QI) The recipient of the products and services
  • billablePeriod: (QI) Relevant time frame for the claim
  • created: (QI) Resource creation date
  • provider: (QI) Party responsible for the claim
  • prescription: (QI) Prescription authorizing services and products
  • diagnosis: (QI) Pertinent diagnosis information
  • diagnosis.sequence: (QI) Diagnosis instance identifier
  • diagnosis.diagnosis[x]: (QI) Nature of illness or problem
  • diagnosis.type: (QI) Timing or nature of the diagnosis
  • diagnosis.onAdmission: (QI) Present on admission
  • procedure: (QI) Clinical procedures performed
  • procedure.sequence: (QI) Procedure instance identifier
  • procedure.type: (QI) Category of Procedure
  • procedure.procedure[x]: (QI) Specific clinical procedure
  • item.encounter: (QI) Encounters related to this billed item
Primary code path: type
(PCPath) This element is the primary code path for this resource CQL Retrieve


NOTE TO BALLOT REVIEWERS:
  • US Core 7.0, and thus QI-Core 7.0, has a new approach to USCDI requirements.
    • As noted in the US Core 7.0 Must Support section, US Core 7.0 no longer highlights mandatory (cardinality 1..* or 1..1) and Must Support elements with a (USCDI) indicator as such items must be supported for interoperability.
    • Those USCDI elements that are not mandatory or Must Support now include an indicator (ADDITIONAL USCDI) in US Core. QI-Core 7.0 does not reference USCDI elements; rather, users should access US Core 7.0 to understand its implementation of USCDI version 4.
  • We invite comments about the approach and suggestions for other options that would also avoid unnecessary noise or reading load to the QI-Core profile representation.
  • Further, QI-Core 7.0 does not discuss USCDI+Quality because at the time of ballot preparation, no published version of USCDI+Quality is available. We seek reviewer advice regarding how QI-Core might address future USCDI+Quality.

Usage

See the patterns page for implementation and usage patterns.

Examples

Simple Vision Claim

Usage:

Formal Views of Profile Content

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

NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim 0..* Claim Claim, Pre-determination or Pre-authorization
dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
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
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
dom-6: A resource should have narrative for robust management
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
ele-1: All FHIR elements must have a @value or children
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
... status ?!Σ 1..1 code (QI) active
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.


ele-1: All FHIR elements must have a @value or children
Fixed Value: active
... use Σ 1..1 code (QI) claim | preauthorization | predetermination
Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim.


ele-1: All FHIR elements must have a @value or children
... patient Σ 1..1 Reference(QICore Patient) (QI) The recipient of the products and services
ele-1: All FHIR elements must have a @value or children
... billablePeriod Σ 0..1 Period (QI) Relevant time frame for the claim
ele-1: All FHIR elements must have a @value or children
... created Σ 1..1 dateTime (QI) Resource creation date
ele-1: All FHIR elements must have a @value or children
... provider Σ 1..1 Reference(QICore Practitioner | QICore PractitionerRole | QICore Organization) (QI) Party responsible for the claim
ele-1: All FHIR elements must have a @value or children
... priority Σ 1..1 CodeableConcept Desired processing ugency
Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.


ele-1: All FHIR elements must have a @value or children
... prescription 0..1 Reference(QICore DeviceRequest | QICore MedicationRequest | VisionPrescription) (QI) Prescription authorizing services and products
ele-1: All FHIR elements must have a @value or children
... payee 0..1 BackboneElement Recipient of benefits payable
ele-1: All FHIR elements must have a @value or children
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... type 1..1 CodeableConcept Category of recipient
Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.


ele-1: All FHIR elements must have a @value or children
.... party 0..1 Reference(QICore Practitioner | QICore PractitionerRole | QICore Organization | QICore Patient | QICore RelatedPerson) Recipient reference
ele-1: All FHIR elements must have a @value or children
... referral 0..1 Reference(QICore ServiceRequest) Treatment referral
ele-1: All FHIR elements must have a @value or children
... facility 0..1 Reference(QICore Location) Servicing facility
ele-1: All FHIR elements must have a @value or children
... careTeam 0..* BackboneElement Members of the care team
ele-1: All FHIR elements must have a @value or children
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... sequence 1..1 positiveInt Order of care team
ele-1: All FHIR elements must have a @value or children
.... provider 1..1 Reference(QICore Practitioner | QICore PractitionerRole | QICore Organization) Practitioner or organization
ele-1: All FHIR elements must have a @value or children
... diagnosis 0..* BackboneElement (QI) Pertinent diagnosis information
ele-1: All FHIR elements must have a @value or children
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... sequence 1..1 positiveInt (QI) Diagnosis instance identifier
ele-1: All FHIR elements must have a @value or children
.... diagnosis[x] 1..1 (QI) Nature of illness or problem
Binding: ICD-10Codes (example): Example ICD10 Diagnostic codes.


ele-1: All FHIR elements must have a @value or children
..... diagnosisCodeableConcept CodeableConcept
..... diagnosisReference Reference(QICore Condition Encounter Diagnosis)
.... type 0..* CodeableConcept (QI) Timing or nature of the diagnosis
Binding: http://hl7.org/fhir/R4/valueset-ex-diagnosistype.html (preferred): The type of the diagnosis: admitting, principal, discharge.


ele-1: All FHIR elements must have a @value or children
.... onAdmission 0..1 CodeableConcept (QI) Present on admission
Binding: Present on Admission Indicators (required): Present on admission.


ele-1: All FHIR elements must have a @value or children
... procedure 0..* BackboneElement (QI) Clinical procedures performed
ele-1: All FHIR elements must have a @value or children
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... sequence 1..1 positiveInt (QI) Procedure instance identifier
ele-1: All FHIR elements must have a @value or children
.... type 0..* CodeableConcept (QI) Category of Procedure
Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.


ele-1: All FHIR elements must have a @value or children
.... procedure[x] 1..1 (QI) Specific clinical procedure
Binding: ICD-10ProcedureCodes (example): Example ICD10 Procedure codes.


ele-1: All FHIR elements must have a @value or children
..... procedureCodeableConcept CodeableConcept
..... procedureReference Reference(QICore Procedure)
... insurance Σ 1..* BackboneElement Patient insurance information
ele-1: All FHIR elements must have a @value or children
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... sequence Σ 1..1 positiveInt Insurance instance identifier
ele-1: All FHIR elements must have a @value or children
.... focal Σ 1..1 boolean Coverage to be used for adjudication
ele-1: All FHIR elements must have a @value or children
.... coverage Σ 1..1 Reference(QICore Coverage) Insurance information
ele-1: All FHIR elements must have a @value or children

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Claim.statusrequiredFixed Value: active
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
from the FHIR Standard
Claim.typeextensibleClaimTypeCodes
http://hl7.org/fhir/ValueSet/claim-type
from the FHIR Standard
Claim.userequiredUse
http://hl7.org/fhir/ValueSet/claim-use|4.0.1
from the FHIR Standard
Claim.priorityexampleProcessPriorityCodes
http://hl7.org/fhir/ValueSet/process-priority
from the FHIR Standard
Claim.payee.typeexampleClaim Payee Type Codes
http://hl7.org/fhir/ValueSet/payeetype
from the FHIR Standard
Claim.diagnosis.diagnosis[x]exampleICD-10Codes
http://hl7.org/fhir/ValueSet/icd-10
from the FHIR Standard
Claim.diagnosis.typepreferredhttp://hl7.org/fhir/R4/valueset-ex-diagnosistype.html
http://hl7.org/fhir/R4/valueset-ex-diagnosistype.html
Claim.diagnosis.onAdmissionrequiredPresentOnAdmissionIndicators
http://terminology.hl7.org/ValueSet/POAIndicators
Claim.procedure.typeexampleExampleProcedureTypeCodes
http://hl7.org/fhir/ValueSet/ex-procedure-type
from the FHIR Standard
Claim.procedure.procedure[x]exampleICD-10ProcedureCodes
http://hl7.org/fhir/ValueSet/icd-10-procedures
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorClaimIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorClaimIf 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-4errorClaimIf 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-5errorClaimIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceClaimA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

 

Other representations of profile: CSV, Excel, Schematron