NHDR Implementation Guide Release 1.0, published by NHDR. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/PROJ-PHILHEALTH-EA-NHDR/PhilHealth-NHDR-IG-Review/ and changes regularly. See the Directory of published versions
Resource Profile: PH Claim
| Official URL: https://nhdr.gov.ph/fhir/StructureDefinition/PH-Claim | Version: 0.1.0 | |||
| Standards status: Draft | Computable Name: PH_Claim | |||
Copyright/Legal: Used by permission of HL7 International, all rights reserved Creative Commons License |
||||
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.
Usages:
- This Profile is not used by any profiles in this Implementation Guide
You can also check for usages in the FHIR IG Statistics
Formal Views of Profile Content
Description of Profiles, Differentials, Snapshots and how the different presentations work.
| Name | Flags | Card. | Type | Description & Constraints Filter:   |
|---|---|---|---|---|
  Claim |
0..* | Claim | Claim, Pre-determination or Pre-authorization | |
  Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
   extension:claimEncounter |
0..* | Reference(PH Encounter) | Encounter (Extension) URL: https://nhdr.gov.ph/fhir/StructureDefinition/EncounterExtension | |
  status |
?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. |
 type |
Σ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. |
| use |
Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim. |
 patient |
Σ | 1..1 | Reference(Patient) | The recipient of the products and services |
| created |
Σ | 1..1 | dateTime | Resource creation date |
| provider |
Σ | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim |
| priority |
Σ | 1..1 | CodeableConcept | Desired processing ugency Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred. |
 insurance |
Σ | 1..* | BackboneElement | Patient insurance information |
 sequence |
Σ | 1..1 | positiveInt | Insurance instance identifier |
| focal |
Σ | 1..1 | boolean | Coverage to be used for adjudication |
 coverage |
Σ | 1..1 | Reference(Coverage) | Insurance information |
| Documentation for this format | ||||
Terminology Bindings
| Path | Conformance | ValueSet | URI |
| Claim.status | required | FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|4.0.1From the FHIR Standard | |
| Claim.type | extensible | ClaimTypeCodeshttp://hl7.org/fhir/ValueSet/claim-type|4.0.1From the FHIR Standard | |
| Claim.use | required | Usehttp://hl7.org/fhir/ValueSet/claim-use|4.0.1From the FHIR Standard | |
| Claim.priority | example | ProcessPriorityCodeshttp://hl7.org/fhir/ValueSet/process-priority|4.0.1From the FHIR Standard |
Constraints
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Claim | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Claim | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Claim | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Claim | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Claim | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from Claim
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| Claim |
0..* | Claim | Claim, Pre-determination or Pre-authorization | |
 implicitRules |
0..0 | |||
| language |
0..0 | |||
| text |
0..0 | |||
| contained |
0..0 | |||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| extension:claimEncounter |
0..* | Reference(PH Encounter) | Encounter (Extension) URL: https://nhdr.gov.ph/fhir/StructureDefinition/EncounterExtension | |
 modifierExtension |
0..0 | |||
| subType |
0..0 | |||
| billablePeriod |
0..0 | |||
| enterer |
0..0 | |||
| insurer |
0..0 | |||
| fundsReserve |
0..0 | |||
| related |
0..0 | |||
| originalPrescription |
0..0 | |||
| payee |
||||
| id |
0..0 | |||
| extension |
0..0 | |||
| modifierExtension |
0..0 | |||
| facility |
0..0 | |||
| careTeam |
0..0 | |||
| supportingInfo |
||||
| id |
0..0 | |||
| extension |
0..0 | |||
| modifierExtension |
0..0 | |||
| code |
0..0 | |||
| timing[x] |
0..0 | |||
| reason |
0..0 | |||
| diagnosis |
||||
| id |
0..0 | |||
| extension |
0..0 | |||
| modifierExtension |
0..0 | |||
| type |
0..0 | |||
| onAdmission |
0..0 | |||
| packageCode |
0..0 | |||
| procedure |
||||
| id |
0..0 | |||
| extension |
0..0 | |||
| modifierExtension |
0..0 | |||
| type |
0..0 | |||
| udi |
0..0 | |||
| insurance |
||||
| id |
0..0 | |||
| extension |
0..0 | |||
| modifierExtension |
0..0 | |||
| identifier |
0..0 | |||
| businessArrangement |
0..0 | |||
| preAuthRef |
0..0 | |||
| claimResponse |
0..0 | |||
| accident |
0..0 | |||
| item |
||||
| id |
0..0 | |||
| extension |
0..0 | |||
| modifierExtension |
0..0 | |||
| careTeamSequence |
0..0 | |||
| diagnosisSequence |
0..0 | |||
| procedureSequence |
0..0 | |||
| informationSequence |
0..0 | |||
| revenue |
0..0 | |||
| category |
0..0 | |||
| modifier |
0..0 | |||
| programCode |
0..0 | |||
| location[x] |
0..0 | |||
| quantity |
0..0 | |||
| unitPrice |
0..0 | |||
| factor |
0..0 | |||
| udi |
0..0 | |||
| bodySite |
0..0 | |||
| subSite |
0..0 | |||
| detail |
||||
| id |
0..0 | |||
| extension |
0..0 | |||
| modifierExtension |
0..0 | |||
| revenue |
0..0 | |||
| category |
0..0 | |||
| modifier |
0..0 | |||
| programCode |
0..0 | |||
| quantity |
0..0 | |||
| unitPrice |
0..0 | |||
| factor |
0..0 | |||
| udi |
0..0 | |||
| subDetail |
||||
| id |
0..0 | |||
| extension |
0..0 | |||
| modifierExtension |
0..0 | |||
| revenue |
0..0 | |||
| category |
0..0 | |||
| modifier |
0..0 | |||
| programCode |
0..0 | |||
| quantity |
0..0 | |||
| unitPrice |
0..0 | |||
| factor |
0..0 | |||
| net |
0..0 | |||
| udi |
0..0 | |||
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| Claim |
0..* | Claim | Claim, Pre-determination or Pre-authorization | |
| id |
Σ | 0..1 | id | Logical id of this artifact |
| meta |
Σ | 0..1 | Meta | Metadata about the resource |
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| extension:claimEncounter |
0..* | Reference(PH Encounter) | Encounter (Extension) URL: https://nhdr.gov.ph/fhir/StructureDefinition/EncounterExtension | |
| identifier |
0..* | Identifier | Business Identifier for claim | |
| status |
?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. |
| type |
Σ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. |
| use |
Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim. |
| patient |
Σ | 1..1 | Reference(Patient) | The recipient of the products and services |
| created |
Σ | 1..1 | dateTime | Resource creation date |
| provider |
Σ | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim |
| priority |
Σ | 1..1 | CodeableConcept | Desired processing ugency Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred. |
| prescription |
0..1 | Reference(DeviceRequest | MedicationRequest | VisionPrescription) | Prescription authorizing services and products | |
| payee |
0..1 | BackboneElement | Recipient of benefits payable | |
| type |
1..1 | CodeableConcept | Category of recipient Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed. | |
| party |
0..1 | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) | Recipient reference | |
| referral |
0..1 | Reference(ServiceRequest) | Treatment referral | |
| supportingInfo |
0..* | BackboneElement | Supporting information | |
| sequence |
1..1 | positiveInt | Information instance identifier | |
| category |
1..1 | CodeableConcept | Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. | |
 value[x] |
0..1 | Data to be provided | ||
| valueBoolean |
boolean | |||
| valueString |
string | |||
| valueQuantity |
Quantity | |||
| valueAttachment |
Attachment | |||
| valueReference |
Reference(Resource) | |||
| diagnosis |
0..* | BackboneElement | Pertinent diagnosis information | |
| sequence |
1..1 | positiveInt | Diagnosis instance identifier | |
| diagnosis[x] |
1..1 | Nature of illness or problem Binding: ICD-10Codes (example): Example ICD10 Diagnostic codes. | ||
| diagnosisCodeableConcept |
CodeableConcept | |||
| diagnosisReference |
Reference(Condition) | |||
| procedure |
0..* | BackboneElement | Clinical procedures performed | |
| sequence |
1..1 | positiveInt | Procedure instance identifier | |
| date |
0..1 | dateTime | When the procedure was performed | |
| procedure[x] |
1..1 | Specific clinical procedure Binding: ICD-10ProcedureCodes (example): Example ICD10 Procedure codes. | ||
| procedureCodeableConcept |
CodeableConcept | |||
| procedureReference |
Reference(Procedure) | |||
| insurance |
Σ | 1..* | BackboneElement | Patient insurance information |
| sequence |
Σ | 1..1 | positiveInt | Insurance instance identifier |
| focal |
Σ | 1..1 | boolean | Coverage to be used for adjudication |
| coverage |
Σ | 1..1 | Reference(Coverage) | Insurance information |
| item |
0..* | BackboneElement | Product or service provided | |
| sequence |
1..1 | positiveInt | Item instance identifier | |
| productOrService |
1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |
| serviced[x] |
0..1 | Date or dates of service or product delivery | ||
| servicedDate |
date | |||
| servicedPeriod |
Period | |||
| net |
0..1 | Money | Total item cost | |
| encounter |
0..* | Reference(Encounter) | Encounters related to this billed item | |
| detail |
0..* | BackboneElement | Product or service provided | |
| sequence |
1..1 | positiveInt | Item instance identifier | |
| productOrService |
1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |
| net |
0..1 | Money | Total item cost | |
| subDetail |
0..* | BackboneElement | Product or service provided | |
| sequence |
1..1 | positiveInt | Item instance identifier | |
| productOrService |
1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |
| total |
0..1 | Money | Total claim cost | |
| Documentation for this format | ||||
Terminology Bindings
| Path | Conformance | ValueSet | URI |
| Claim.status | required | FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|4.0.1From the FHIR Standard | |
| Claim.type | extensible | ClaimTypeCodeshttp://hl7.org/fhir/ValueSet/claim-type|4.0.1From the FHIR Standard | |
| Claim.use | required | Usehttp://hl7.org/fhir/ValueSet/claim-use|4.0.1From the FHIR Standard | |
| Claim.priority | example | ProcessPriorityCodeshttp://hl7.org/fhir/ValueSet/process-priority|4.0.1From the FHIR Standard | |
| Claim.related.relationship | example | ExampleRelatedClaimRelationshipCodeshttp://hl7.org/fhir/ValueSet/related-claim-relationship|4.0.1From the FHIR Standard | |
| Claim.payee.type | example | Claim Payee Type Codeshttp://hl7.org/fhir/ValueSet/payeetype|4.0.1From the FHIR Standard | |
| Claim.careTeam.role | example | ClaimCareTeamRoleCodeshttp://hl7.org/fhir/ValueSet/claim-careteamrole|4.0.1From the FHIR Standard | |
| Claim.careTeam.qualification | example | ExampleProviderQualificationCodeshttp://hl7.org/fhir/ValueSet/provider-qualification|4.0.1From the FHIR Standard | |
| Claim.supportingInfo.category | example | ClaimInformationCategoryCodeshttp://hl7.org/fhir/ValueSet/claim-informationcategory|4.0.1From the FHIR Standard | |
| Claim.diagnosis.diagnosis[x] | example | ICD-10Codeshttp://hl7.org/fhir/ValueSet/icd-10|4.0.1From the FHIR Standard | |
| Claim.procedure.procedure[x] | example | ICD-10ProcedureCodeshttp://hl7.org/fhir/ValueSet/icd-10-procedures|4.0.1From the FHIR Standard | |
| Claim.accident.type | extensible | ActIncidentCodehttp://terminology.hl7.org/ValueSet/v3-ActIncidentCode | |
| Claim.item.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls|4.0.1From the FHIR Standard | |
| Claim.item.detail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls|4.0.1From the FHIR Standard | |
| Claim.item.detail.subDetail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls|4.0.1From the FHIR Standard |
Constraints
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Claim | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Claim | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Claim | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Claim | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Claim | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from Claim
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| Claim |
0..* | Claim | Claim, Pre-determination or Pre-authorization | |
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| extension:claimEncounter |
0..* | Reference(PH Encounter) | Encounter (Extension) URL: https://nhdr.gov.ph/fhir/StructureDefinition/EncounterExtension | |
| status |
?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. |
| type |
Σ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. |
| use |
Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim. |
| patient |
Σ | 1..1 | Reference(Patient) | The recipient of the products and services |
| created |
Σ | 1..1 | dateTime | Resource creation date |
| provider |
Σ | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim |
| priority |
Σ | 1..1 | CodeableConcept | Desired processing ugency Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred. |
| insurance |
Σ | 1..* | BackboneElement | Patient insurance information |
| sequence |
Σ | 1..1 | positiveInt | Insurance instance identifier |
| focal |
Σ | 1..1 | boolean | Coverage to be used for adjudication |
| coverage |
Σ | 1..1 | Reference(Coverage) | Insurance information |
| Documentation for this format | ||||
Terminology Bindings
| Path | Conformance | ValueSet | URI |
| Claim.status | required | FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|4.0.1From the FHIR Standard | |
| Claim.type | extensible | ClaimTypeCodeshttp://hl7.org/fhir/ValueSet/claim-type|4.0.1From the FHIR Standard | |
| Claim.use | required | Usehttp://hl7.org/fhir/ValueSet/claim-use|4.0.1From the FHIR Standard | |
| Claim.priority | example | ProcessPriorityCodeshttp://hl7.org/fhir/ValueSet/process-priority|4.0.1From the FHIR Standard |
Constraints
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Claim | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Claim | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Claim | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Claim | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Claim | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Differential View
This structure is derived from Claim
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| Claim |
0..* | Claim | Claim, Pre-determination or Pre-authorization | |
| implicitRules |
0..0 | |||
| language |
0..0 | |||
| text |
0..0 | |||
| contained |
0..0 | |||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| extension:claimEncounter |
0..* | Reference(PH Encounter) | Encounter (Extension) URL: https://nhdr.gov.ph/fhir/StructureDefinition/EncounterExtension | |
| modifierExtension |
0..0 | |||
| subType |
0..0 | |||
| billablePeriod |
0..0 | |||
| enterer |
0..0 | |||
| insurer |
0..0 | |||
| fundsReserve |
0..0 | |||
| related |
0..0 | |||
| originalPrescription |
0..0 | |||
| payee |
||||
| id |
0..0 | |||
| extension |
0..0 | |||
| modifierExtension |
0..0 | |||
| facility |
0..0 | |||
| careTeam |
0..0 | |||
| supportingInfo |
||||
| id |
0..0 | |||
| extension |
0..0 | |||
| modifierExtension |
0..0 | |||
| code |
0..0 | |||
| timing[x] |
0..0 | |||
| reason |
0..0 | |||
| diagnosis |
||||
| id |
0..0 | |||
| extension |
0..0 | |||
| modifierExtension |
0..0 | |||
| type |
0..0 | |||
| onAdmission |
0..0 | |||
| packageCode |
0..0 | |||
| procedure |
||||
| id |
0..0 | |||
| extension |
0..0 | |||
| modifierExtension |
0..0 | |||
| type |
0..0 | |||
| udi |
0..0 | |||
| insurance |
||||
| id |
0..0 | |||
| extension |
0..0 | |||
| modifierExtension |
0..0 | |||
| identifier |
0..0 | |||
| businessArrangement |
0..0 | |||
| preAuthRef |
0..0 | |||
| claimResponse |
0..0 | |||
| accident |
0..0 | |||
| item |
||||
| id |
0..0 | |||
| extension |
0..0 | |||
| modifierExtension |
0..0 | |||
| careTeamSequence |
0..0 | |||
| diagnosisSequence |
0..0 | |||
| procedureSequence |
0..0 | |||
| informationSequence |
0..0 | |||
| revenue |
0..0 | |||
| category |
0..0 | |||
| modifier |
0..0 | |||
| programCode |
0..0 | |||
| location[x] |
0..0 | |||
| quantity |
0..0 | |||
| unitPrice |
0..0 | |||
| factor |
0..0 | |||
| udi |
0..0 | |||
| bodySite |
0..0 | |||
| subSite |
0..0 | |||
| detail |
||||
| id |
0..0 | |||
| extension |
0..0 | |||
| modifierExtension |
0..0 | |||
| revenue |
0..0 | |||
| category |
0..0 | |||
| modifier |
0..0 | |||
| programCode |
0..0 | |||
| quantity |
0..0 | |||
| unitPrice |
0..0 | |||
| factor |
0..0 | |||
| udi |
0..0 | |||
| subDetail |
||||
| id |
0..0 | |||
| extension |
0..0 | |||
| modifierExtension |
0..0 | |||
| revenue |
0..0 | |||
| category |
0..0 | |||
| modifier |
0..0 | |||
| programCode |
0..0 | |||
| quantity |
0..0 | |||
| unitPrice |
0..0 | |||
| factor |
0..0 | |||
| net |
0..0 | |||
| udi |
0..0 | |||
| Documentation for this format | ||||
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| Claim |
0..* | Claim | Claim, Pre-determination or Pre-authorization | |
| id |
Σ | 0..1 | id | Logical id of this artifact |
| meta |
Σ | 0..1 | Meta | Metadata about the resource |
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| extension:claimEncounter |
0..* | Reference(PH Encounter) | Encounter (Extension) URL: https://nhdr.gov.ph/fhir/StructureDefinition/EncounterExtension | |
| identifier |
0..* | Identifier | Business Identifier for claim | |
| status |
?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. |
| type |
Σ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. |
| use |
Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim. |
| patient |
Σ | 1..1 | Reference(Patient) | The recipient of the products and services |
| created |
Σ | 1..1 | dateTime | Resource creation date |
| provider |
Σ | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim |
| priority |
Σ | 1..1 | CodeableConcept | Desired processing ugency Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred. |
| prescription |
0..1 | Reference(DeviceRequest | MedicationRequest | VisionPrescription) | Prescription authorizing services and products | |
| payee |
0..1 | BackboneElement | Recipient of benefits payable | |
| type |
1..1 | CodeableConcept | Category of recipient Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed. | |
| party |
0..1 | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) | Recipient reference | |
| referral |
0..1 | Reference(ServiceRequest) | Treatment referral | |
| supportingInfo |
0..* | BackboneElement | Supporting information | |
| sequence |
1..1 | positiveInt | Information instance identifier | |
| category |
1..1 | CodeableConcept | Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. | |
| value[x] |
0..1 | Data to be provided | ||
| valueBoolean |
boolean | |||
| valueString |
string | |||
| valueQuantity |
Quantity | |||
| valueAttachment |
Attachment | |||
| valueReference |
Reference(Resource) | |||
| diagnosis |
0..* | BackboneElement | Pertinent diagnosis information | |
| sequence |
1..1 | positiveInt | Diagnosis instance identifier | |
| diagnosis[x] |
1..1 | Nature of illness or problem Binding: ICD-10Codes (example): Example ICD10 Diagnostic codes. | ||
| diagnosisCodeableConcept |
CodeableConcept | |||
| diagnosisReference |
Reference(Condition) | |||
| procedure |
0..* | BackboneElement | Clinical procedures performed | |
| sequence |
1..1 | positiveInt | Procedure instance identifier | |
| date |
0..1 | dateTime | When the procedure was performed | |
| procedure[x] |
1..1 | Specific clinical procedure Binding: ICD-10ProcedureCodes (example): Example ICD10 Procedure codes. | ||
| procedureCodeableConcept |
CodeableConcept | |||
| procedureReference |
Reference(Procedure) | |||
| insurance |
Σ | 1..* | BackboneElement | Patient insurance information |
| sequence |
Σ | 1..1 | positiveInt | Insurance instance identifier |
| focal |
Σ | 1..1 | boolean | Coverage to be used for adjudication |
| coverage |
Σ | 1..1 | Reference(Coverage) | Insurance information |
| item |
0..* | BackboneElement | Product or service provided | |
| sequence |
1..1 | positiveInt | Item instance identifier | |
| productOrService |
1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |
| serviced[x] |
0..1 | Date or dates of service or product delivery | ||
| servicedDate |
date | |||
| servicedPeriod |
Period | |||
| net |
0..1 | Money | Total item cost | |
| encounter |
0..* | Reference(Encounter) | Encounters related to this billed item | |
| detail |
0..* | BackboneElement | Product or service provided | |
| sequence |
1..1 | positiveInt | Item instance identifier | |
| productOrService |
1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |
| net |
0..1 | Money | Total item cost | |
| subDetail |
0..* | BackboneElement | Product or service provided | |
| sequence |
1..1 | positiveInt | Item instance identifier | |
| productOrService |
1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |
| total |
0..1 | Money | Total claim cost | |
| Documentation for this format | ||||
Terminology Bindings
| Path | Conformance | ValueSet | URI |
| Claim.status | required | FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|4.0.1From the FHIR Standard | |
| Claim.type | extensible | ClaimTypeCodeshttp://hl7.org/fhir/ValueSet/claim-type|4.0.1From the FHIR Standard | |
| Claim.use | required | Usehttp://hl7.org/fhir/ValueSet/claim-use|4.0.1From the FHIR Standard | |
| Claim.priority | example | ProcessPriorityCodeshttp://hl7.org/fhir/ValueSet/process-priority|4.0.1From the FHIR Standard | |
| Claim.related.relationship | example | ExampleRelatedClaimRelationshipCodeshttp://hl7.org/fhir/ValueSet/related-claim-relationship|4.0.1From the FHIR Standard | |
| Claim.payee.type | example | Claim Payee Type Codeshttp://hl7.org/fhir/ValueSet/payeetype|4.0.1From the FHIR Standard | |
| Claim.careTeam.role | example | ClaimCareTeamRoleCodeshttp://hl7.org/fhir/ValueSet/claim-careteamrole|4.0.1From the FHIR Standard | |
| Claim.careTeam.qualification | example | ExampleProviderQualificationCodeshttp://hl7.org/fhir/ValueSet/provider-qualification|4.0.1From the FHIR Standard | |
| Claim.supportingInfo.category | example | ClaimInformationCategoryCodeshttp://hl7.org/fhir/ValueSet/claim-informationcategory|4.0.1From the FHIR Standard | |
| Claim.diagnosis.diagnosis[x] | example | ICD-10Codeshttp://hl7.org/fhir/ValueSet/icd-10|4.0.1From the FHIR Standard | |
| Claim.procedure.procedure[x] | example | ICD-10ProcedureCodeshttp://hl7.org/fhir/ValueSet/icd-10-procedures|4.0.1From the FHIR Standard | |
| Claim.accident.type | extensible | ActIncidentCodehttp://terminology.hl7.org/ValueSet/v3-ActIncidentCode | |
| Claim.item.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls|4.0.1From the FHIR Standard | |
| Claim.item.detail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls|4.0.1From the FHIR Standard | |
| Claim.item.detail.subDetail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls|4.0.1From the FHIR Standard |
Constraints
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Claim | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Claim | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Claim | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Claim | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Claim | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from Claim
Other representations of profile: CSV, Excel, Schematron