Intersection of https://nhicore.nhi.gov.tw/pas/StructureDefinition/Claim-twpas and https://nhicore.nhi.gov.tw/pas/StructureDefinition/Claim-twpas

This is the set of resources that conform to both 癌藥事前審查-Claim TWPAS (https://nhicore.nhi.gov.tw/pas/StructureDefinition/Claim-twpas) and 癌藥事前審查-Claim TWPAS (https://nhicore.nhi.gov.tw/pas/StructureDefinition/Claim-twpas).

Structure

NameFlagsCard.TypeDescription & Constraints    Filter: doco
Claim C0..*Claim, Pre-determination or Pre-authorization
Constraints: sequence-1, applType, supportingInfo, supportingInfo-tests, supportingInfo-c90-c91-c92
Claim.meta This element is included in summaries. 1..1MetaMetadata about the resource
Claim.meta.extension 0..*ExtensionAdditional content defined by implementations
Claim.meta.versionId This element is included in summaries. 0..1idVersion specific identifier
Claim.meta.lastUpdated This element is included in summaries. 0..1instant上傳日期時間。供案件追蹤與識別使用，醫院上傳時無須填寫。
Claim.meta.source This element is included in summaries. 0..1uriIdentifies where the resource comes from
Claim.meta.profile This element is included in summaries. 1..1canonical(StructureDefinition)Profiles this resource claims to conform to
Claim.meta.security This element is included in summaries. 0..*CodingSecurity Labels applied to this resource
Binding: ?? (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
Claim.meta.tag This element is included in summaries. 0..*CodingTags applied to this resource
Binding: ?? (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
Claim.implicitRules This element is a modifier element. This element is included in summaries. 0..1uriA set of rules under which this content was created
Claim.language 0..1codeLanguage of the resource content
Binding: ?? (preferred): A human language.
Additional BindingsPurpose
??Max Binding
Claim.text 0..1NarrativeText summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Claim.contained 0..*ResourceContained, inline Resources
Claim.extension 1..*ExtensionExtension
Claim.modifierExtension This element is a modifier element. 0..*ExtensionExtensions that cannot be ignored
Claim.identifier This element must be supported. 0..*IdentifierBusiness Identifier for claim
Claim.status This element is a modifier element. This element is included in summaries. 1..1codeactive | cancelled | draft | entered-in-error
Binding: ?? (required): A code specifying the state of the resource instance.
Claim.type This element is included in summaries. 1..1CodeableConceptCategory or discipline
Binding: ?? (extensible): The type or discipline-style of the claim.
Claim.subType This element must be supported. 1..1CodeableConcept申報類別，1:送核 | 2:送核補件 | 3:申復 | 4:爭議審議 | 5:申復補件 。院所上傳送核(subType = #1)案件時，不需填寫「原受理編號」資訊，受理成功後會由系統自動產生受理編號。當Claim.subType(申報類別)為2(送核補件)、3(申復)、4(爭議審議)或5(申復補件)時，院所才需於Claim.identifier填寫原送核案件之受理編號。
Binding: ?? (required)
Claim.subType.extension 0..*ExtensionAdditional content defined by implementations
Claim.subType.coding This element is included in summaries. 1..1CodingCode defined by a terminology system
Claim.subType.coding.extension 0..*ExtensionAdditional content defined by implementations
Claim.subType.coding.system This element is included in summaries. 1..1uriIdentity of the terminology system
Claim.subType.coding.version This element is included in summaries. 0..1stringVersion of the system - if relevant
Claim.subType.coding.code This element is included in summaries. 1..1code申報類別，1:送核 | 2:送核補件 | 3:申復 | 4:爭議審議 | 5:申復補件 。當申報類別為2(送核補件)、3(申復)、4(爭議審議)、5(申復補件)時，院所才需於Claim.identifier:old_acpt_no填寫原送核案件之受理編號。
Claim.subType.coding.display This element is included in summaries. 0..1stringRepresentation defined by the system
Claim.subType.coding.userSelected This element is included in summaries. 0..1booleanIf this coding was chosen directly by the user
Claim.subType.text This element is included in summaries. 0..1stringPlain text representation of the concept
Claim.use This element is included in summaries. 1..1codeclaim | preauthorization | predetermination
Binding: ?? (required): The purpose of the Claim: predetermination, preauthorization, claim.
Claim.patient This element must be supported. This element is included in summaries. 1..1Reference(病人資訊-Patient TWPAS | #sd-25-Patient-twpas-Patient-twpas)病人資訊
Claim.billablePeriod This element is included in summaries. 0..1PeriodRelevant time frame for the claim
Claim.created This element must be supported. This element is included in summaries. 1..1dateTime申請日期，YYYY-MM-DD，機構自填。健保署收案後另建受理日期，將呈現在ClaimResponse的disposition和created欄位。
Claim.enterer This element must be supported. 1..1Reference(醫事人員-Practitioner TWPAS | #sd-27-Practitioner-twpas-Practitioner-twpas)申請醫師，必須存在於醫事人員基本資料檔內，並於合約生效起迄日內。
Claim.insurer This element is included in summaries. 0..1Reference(Organization)Target
Claim.provider This element must be supported. This element is included in summaries. 1..1Reference(醫事機構-Organization TWPAS | #sd-36-Organization-twpas-Organization-twpas)醫事機構代碼，必須存在於醫事機構基本資料檔內。
Claim.priority This element must be supported. This element is included in summaries. 1..1CodeableConcept申請案件類別，1:一般事前審查申請 | 3:自主審查 | 4:緊急報備；專審系統識別用，對應PXXT_CODE(TMHB,001)。
Binding: ?? (required)
Claim.fundsReserve 0..1CodeableConceptFor whom to reserve funds
Binding: ?? (example): For whom funds are to be reserved: (Patient, Provider, None).
Claim.related 0..*BackboneElementPrior or corollary claims
Claim.related.extension 0..*ExtensionAdditional content defined by implementations
Claim.related.modifierExtension This element is a modifier element. This element is included in summaries. 0..*ExtensionExtensions that cannot be ignored even if unrecognized
Claim.related.claim 0..1Reference(Claim)Reference to the related claim
Claim.related.relationship 0..1CodeableConceptHow the reference claim is related
Binding: ?? (example): Relationship of this claim to a related Claim.
Claim.related.reference 0..1IdentifierFile or case reference
Claim.prescription 0..1Reference(DeviceRequest | MedicationRequest | VisionPrescription)Prescription authorizing services and products
Claim.originalPrescription 0..1Reference(DeviceRequest | MedicationRequest | VisionPrescription)Original prescription if superseded by fulfiller
Claim.payee 0..1BackboneElementRecipient of benefits payable
Claim.payee.extension 0..*ExtensionAdditional content defined by implementations
Claim.payee.modifierExtension This element is a modifier element. This element is included in summaries. 0..*ExtensionExtensions that cannot be ignored even if unrecognized
Claim.payee.type 1..1CodeableConceptCategory of recipient
Binding: ?? (example): A code for the party to be reimbursed.
Claim.payee.party 0..1Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson)Recipient reference
Claim.referral 0..1Reference(ServiceRequest)Treatment referral
Claim.facility 0..1Reference(Location)Servicing facility
Claim.careTeam 0..*BackboneElementMembers of the care team
Claim.careTeam.extension 0..*ExtensionAdditional content defined by implementations
Claim.careTeam.modifierExtension This element is a modifier element. This element is included in summaries. 0..*ExtensionExtensions that cannot be ignored even if unrecognized
Claim.careTeam.sequence 1..1positiveIntOrder of care team
Claim.careTeam.provider 1..1Reference(Practitioner | PractitionerRole | Organization)Practitioner or organization
Claim.careTeam.responsible 0..1booleanIndicator of the lead practitioner
Claim.careTeam.role 0..1CodeableConceptFunction within the team
Binding: ?? (example): The role codes for the care team members.
Claim.careTeam.qualification 0..1CodeableConceptPractitioner credential or specialization
Binding: ?? (example): Provider professional qualifications.
Claim.supportingInfo 2..*BackboneElementSupporting information
Claim.supportingInfo.extension 0..*ExtensionAdditional content defined by implementations
Claim.supportingInfo.modifierExtension This element is a modifier element. This element is included in summaries. 0..*ExtensionExtensions that cannot be ignored even if unrecognized
Claim.supportingInfo.sequence 1..1positiveInt因FHIR設計而必填、自動流水號（建議每次加1）、不得重複，作為每筆supportingInfo的唯一識別碼。最後一筆sequence號碼即表示總筆數。
Claim.supportingInfo.category 1..1CodeableConceptClassification of the supplied information
Binding: ?? (required)
Claim.supportingInfo.code 0..1CodeableConceptType of information
Binding: ?? (example): The valuset used for additional information codes.
Claim.supportingInfo.timing[x] 0..1When it occurred
Claim.supportingInfo.timing[x].timingDatedate
Claim.supportingInfo.timing[x].timingPeriodPeriod
Claim.supportingInfo.value[x] 0..1Data to be provided
Claim.supportingInfo.value[x].valueBooleanboolean
Claim.supportingInfo.value[x].valueStringstring
Claim.supportingInfo.value[x].valueQuantityQuantity
Claim.supportingInfo.value[x].valueAttachmentAttachment
Claim.supportingInfo.value[x].valueReferenceReference(Resource)
Claim.supportingInfo.reason 0..1CodeableConceptExplanation for the information
Binding: ?? (example): Reason codes for the missing teeth.
Claim.diagnosis This element must be supported. C1..*BackboneElementsequence=1時為主要疾病；sequence>=2代表共病。
Constraints: diagnosis
Claim.diagnosis.extension 0..*ExtensionExtension
Claim.diagnosis.modifierExtension This element is a modifier element. This element is included in summaries. 0..*ExtensionExtensions that cannot be ignored even if unrecognized
Claim.diagnosis.sequence 1..1positiveIntsequence=1時為主要疾病；sequence>=2代表共病。
Claim.diagnosis.diagnosis[x] This element must be supported. 1..1CodeableConcept國際疾病分類代碼(含共病)，當前疾病狀態。ICD-10-CM。
Binding: ?? (preferred)
Claim.diagnosis.diagnosis[x].extension 0..*ExtensionAdditional content defined by implementations
Claim.diagnosis.diagnosis[x].coding This element is included in summaries. 0..*CodingCode defined by a terminology system
Claim.diagnosis.diagnosis[x].text This element is included in summaries. 0..1stringPlain text representation of the concept
Claim.diagnosis.type 0..1CodeableConceptTiming or nature of the diagnosis
Binding: ?? (example): The type of the diagnosis: admitting, principal, discharge.
Claim.diagnosis.type.extension 0..*ExtensionAdditional content defined by implementations
Claim.diagnosis.type.coding This element is included in summaries. 0..*CodingCode defined by a terminology system
Claim.diagnosis.type.text This element must be supported. This element is included in summaries. C0..1string簡要病摘(申請理由)。連結院內HIS系統之簡要病摘，或填寫原事前審查之申請理由。請勿將醫事機構名稱、病人及醫師姓名等資訊列入結果中上傳，且不得包含HTML或XML等語法。
Constraints: pas-2
Claim.diagnosis.onAdmission 0..1CodeableConceptPresent on admission
Binding: ?? (example): Present on admission.
Claim.diagnosis.packageCode 0..1CodeableConceptPackage billing code
Binding: ?? (example): The DRG codes associated with the diagnosis.
Claim.procedure 0..*BackboneElementClinical procedures performed
Claim.procedure.extension 0..*ExtensionAdditional content defined by implementations
Claim.procedure.modifierExtension This element is a modifier element. This element is included in summaries. 0..*ExtensionExtensions that cannot be ignored even if unrecognized
Claim.procedure.sequence 1..1positiveIntProcedure instance identifier
Claim.procedure.type 0..*CodeableConceptCategory of Procedure
Binding: ?? (example): Example procedure type codes.
Claim.procedure.date This element must be supported. 1..1dateTime手術(或其他處置)日期
Claim.procedure.procedure[x] This element must be supported. 1..1CodeableConcept手術(或其他處置)項目，經動脈導管肝臟腫瘤化學栓塞術(TACE)及冷凍療法等非屬手術。ICD-10-PCS 或 健保代碼 或 其他。
Binding: ?? (preferred)
Claim.procedure.procedure[x].extension 0..*ExtensionAdditional content defined by implementations
Claim.procedure.procedure[x].coding This element is included in summaries. 1..1CodingCode defined by a terminology system
Claim.procedure.procedure[x].text This element is included in summaries. 0..1stringPlain text representation of the concept
Claim.procedure.udi 0..*Reference(Device)Unique device identifier
Claim.insurance This element is included in summaries. 1..*BackboneElementPatient insurance information
Claim.insurance.extension 0..*ExtensionAdditional content defined by implementations
Claim.insurance.modifierExtension This element is a modifier element. This element is included in summaries. 0..*ExtensionExtensions that cannot be ignored even if unrecognized
Claim.insurance.sequence This element is included in summaries. 1..1positiveIntInsurance instance identifier
Claim.insurance.focal This element is included in summaries. 1..1booleanCoverage to be used for adjudication
Claim.insurance.identifier 0..1IdentifierPre-assigned Claim number
Claim.insurance.coverage This element is included in summaries. 1..1Reference(健保事前審查計畫-Coverage TWPAS | #sd-39-Coverage-twpas-Coverage-twpas)Insurance information
Claim.insurance.businessArrangement 0..1stringAdditional provider contract number
Claim.insurance.preAuthRef 0..*stringPrior authorization reference number
Claim.insurance.claimResponse 0..1Reference(ClaimResponse)Adjudication results
Claim.accident 0..1BackboneElementDetails of the event
Claim.accident.extension 0..*ExtensionAdditional content defined by implementations
Claim.accident.modifierExtension This element is a modifier element. This element is included in summaries. 0..*ExtensionExtensions that cannot be ignored even if unrecognized
Claim.accident.date 1..1dateWhen the incident occurred
Claim.accident.type 0..1CodeableConceptThe nature of the accident
Binding: ?? (extensible): Type of accident: work place, auto, etc.
Claim.accident.location[x] 0..1Where the event occurred
Claim.accident.location[x].locationAddressAddress
Claim.accident.location[x].locationReferenceReference(Location)
Claim.item 1..*BackboneElementProduct or service provided
Claim.item.extension 1..*ExtensionExtension
Claim.item.modifierExtension This element is a modifier element. This element is included in summaries. 0..*ExtensionExtensions that cannot be ignored even if unrecognized
Claim.item.sequence 1..1positiveIntItem instance identifier
Claim.item.careTeamSequence 0..*positiveIntApplicable careTeam members
Claim.item.diagnosisSequence 0..*positiveIntApplicable diagnoses
Claim.item.procedureSequence 0..*positiveIntApplicable procedures
Claim.item.informationSequence 0..*positiveIntApplicable exception and supporting information
Claim.item.revenue 0..1CodeableConceptRevenue or cost center code
Binding: ?? (example): Codes for the revenue or cost centers supplying the service and/or products.
Claim.item.category 0..1CodeableConceptBenefit classification
Binding: ?? (example): Benefit categories such as: oral-basic, major, glasses.
Claim.item.productOrService This element must be supported. 1..1CodeableConcept醫令類別
Binding: ?? (required)
Claim.item.modifier 1..2CodeableConceptProduct or service billing modifiers
Binding: ?? (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
Claim.item.programCode This element must be supported. C1..1CodeableConcept給付適應症條件，藥品給付規定內所規範之適應症或條件，若有特定事前審查品項代碼應以代碼填報。
Binding: ?? (example): Program specific reason codes.
Constraints: pas-1
Claim.item.programCode.extension 0..*ExtensionAdditional content defined by implementations
Claim.item.programCode.coding This element is included in summaries. 0..1Coding給付適應症條件，當事前審查品項代碼為KC009612B5、KC010892B5、KC011112DE、KC011162B5、KC011362B5、KC01013229、KC01013230、KC01025219、KC01050238、KC01085229、KC00958229、JC00154261、KC01088229、KC01233224時，才可填寫。
Binding: ?? (required)
Claim.item.programCode.text This element is included in summaries. 0..1string給付適應症條件，事前審查品項代碼不為KC009612B5、KC010892B5、KC011112DE、KC011162B5、KC011362B5、KC01013229、KC01013230、KC01025219、KC01050238、KC01085229、KC00958229、JC00154261、KC01088229、KC01233224時，請自行輸入文字。
Claim.item.serviced[x] 0..1Date or dates of service or product delivery
Claim.item.serviced[x].servicedDatedate
Claim.item.serviced[x].servicedPeriodPeriod
Claim.item.location[x] 0..1Place of service or where product was supplied
Binding: ?? (example): Place of service: pharmacy, school, prison, etc.
Claim.item.location[x].locationCodeableConceptCodeableConcept
Claim.item.location[x].locationAddressAddress
Claim.item.location[x].locationReferenceReference(Location)
Claim.item.quantity This element must be supported. 1..1?? The snapshot does not say whether the constraints on the root of this type profile have been applied to this element, so assume they have not. Check the type profile directly as well, ?? The snapshot does not say whether the constraints on the root of this type profile have been applied to this element, so assume they have not. Check the type profile directly as wellCount of products or services
Binding: ?? (required): 事前審查申請數量單位及包裝類型。
Claim.item.quantity.extension 0..*ExtensionAdditional content defined by implementations
Claim.item.quantity.value This element must be supported. This element is included in summaries. 1..1decimal事前審查申請數量
Claim.item.quantity.unit This element is included in summaries. 0..1stringUnit representation
Claim.item.quantity.system This element is included in summaries. 1..1uri事前審查申請數量單位及包裝類型之代碼系統
Claim.item.quantity.code This element must be supported. This element is included in summaries. 1..1code事前審查申請數量單位及包裝類型
Claim.item.unitPrice 0..1MoneyFee, charge or cost per item
Claim.item.factor 0..1decimalPrice scaling factor
Claim.item.net 0..1MoneyTotal item cost
Claim.item.udi 0..*Reference(Device)Unique device identifier
Claim.item.bodySite 0..1CodeableConcept申請部位，R:右側 | L:左側 | B:兩側。(此專案暫不檢核，未來待確認)
Binding: ?? (required)
Claim.item.subSite 0..*CodeableConceptAnatomical sub-location
Binding: ?? (example): The code for the tooth surface and surface combinations.
Claim.item.encounter 0..*Reference(Encounter)Encounters related to this billed item
Claim.item.detail 0..*BackboneElementProduct or service provided
Claim.item.detail.extension 0..*ExtensionAdditional content defined by implementations
Claim.item.detail.modifierExtension This element is a modifier element. This element is included in summaries. 0..*ExtensionExtensions that cannot be ignored even if unrecognized
Claim.item.detail.sequence 1..1positiveIntItem instance identifier
Claim.item.detail.revenue 0..1CodeableConceptRevenue or cost center code
Binding: ?? (example): Codes for the revenue or cost centers supplying the service and/or products.
Claim.item.detail.category 0..1CodeableConceptBenefit classification
Binding: ?? (example): Benefit categories such as: oral-basic, major, glasses.
Claim.item.detail.productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: ?? (example): Allowable service and product codes.
Claim.item.detail.modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ?? (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
Claim.item.detail.programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: ?? (example): Program specific reason codes.
Claim.item.detail.quantity 0..1?? The snapshot does not say whether the constraints on the root of this type profile have been applied to this element, so assume they have not. Check the type profile directly as well, ?? The snapshot does not say whether the constraints on the root of this type profile have been applied to this element, so assume they have not. Check the type profile directly as wellCount of products or services
Claim.item.detail.unitPrice 0..1MoneyFee, charge or cost per item
Claim.item.detail.factor 0..1decimalPrice scaling factor
Claim.item.detail.net 0..1MoneyTotal item cost
Claim.item.detail.udi 0..*Reference(Device)Unique device identifier
Claim.item.detail.subDetail 0..*BackboneElementProduct or service provided
Claim.item.detail.subDetail.extension 0..*ExtensionAdditional content defined by implementations
Claim.item.detail.subDetail.modifierExtension This element is a modifier element. This element is included in summaries. 0..*ExtensionExtensions that cannot be ignored even if unrecognized
Claim.item.detail.subDetail.sequence 1..1positiveIntItem instance identifier
Claim.item.detail.subDetail.revenue 0..1CodeableConceptRevenue or cost center code
Binding: ?? (example): Codes for the revenue or cost centers supplying the service and/or products.
Claim.item.detail.subDetail.category 0..1CodeableConceptBenefit classification
Binding: ?? (example): Benefit categories such as: oral-basic, major, glasses.
Claim.item.detail.subDetail.productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: ?? (example): Allowable service and product codes.
Claim.item.detail.subDetail.modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ?? (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
Claim.item.detail.subDetail.programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: ?? (example): Program specific reason codes.
Claim.item.detail.subDetail.quantity 0..1?? The snapshot does not say whether the constraints on the root of this type profile have been applied to this element, so assume they have not. Check the type profile directly as well, ?? The snapshot does not say whether the constraints on the root of this type profile have been applied to this element, so assume they have not. Check the type profile directly as wellCount of products or services
Claim.item.detail.subDetail.unitPrice 0..1MoneyFee, charge or cost per item
Claim.item.detail.subDetail.factor 0..1decimalPrice scaling factor
Claim.item.detail.subDetail.net 0..1MoneyTotal item cost
Claim.item.detail.subDetail.udi 0..*Reference(Device)Unique device identifier
Claim.total 0..1MoneyTotal claim cost

doco Documentation for this format