NHDR Implementation Guide Release 1.0
0.1.0 - ci-build

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/UP-Manila-SILab/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.

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Claim 0..* Claim Claim, Pre-determination or Pre-authorization
... Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:encounter 1..* 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.
... 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

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Claim.status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
Claim.type Base extensible Claim Type Codes 📍4.0.1 FHIR Std.
Claim.use Base required Use 📍4.0.1 FHIR Std.
Claim.priority Base example Process Priority Codes 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
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

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Claim 0..* Claim Claim, Pre-determination or Pre-authorization
... meta
.... Slices for extension Content/Rules for all slices
..... extension:hfRecordedDate 0..1 dateTime The recorded date indicating when the record was uploaded by the health facility.
URL: https://nhdr.gov.ph/fhir/StructureDefinition/HFRecordedDate
..... extension:hfLastUpdated 0..* dateTime The date indicating when the record was last updated by the health facility.
URL: https://nhdr.gov.ph/fhir/StructureDefinition/HFLastUpdated
.... lastUpdated 0..1 instant When the resource was uploaded to the NHDR.
... implicitRules 0..0
... language 0..0
... contained 0..0
... Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:encounter 1..* Reference(PH Encounter) Encounter (Extension)
URL: https://nhdr.gov.ph/fhir/StructureDefinition/EncounterExtension
... modifierExtension 0..0
... subType 0..0
... billablePeriod 0..0
... created 1..1 dateTime Resource creation date
... 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
.... responsible 0..0
.... role 0..0
.... qualification 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
.... 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 0..0

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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
.... id 0..1 string Unique id for inter-element referencing
.... Slices for extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... extension:hfRecordedDate 0..1 dateTime The recorded date indicating when the record was uploaded by the health facility.
URL: https://nhdr.gov.ph/fhir/StructureDefinition/HFRecordedDate
..... extension:hfLastUpdated 0..* dateTime The date indicating when the record was last updated by the health facility.
URL: https://nhdr.gov.ph/fhir/StructureDefinition/HFLastUpdated
.... versionId Σ 0..1 id Version specific identifier
.... lastUpdated Σ 0..1 instant When the resource was uploaded to the NHDR.
.... source Σ 0..1 uri Identifies where the resource comes from
.... profile Σ 0..* canonical(StructureDefinition) Profiles this resource claims to conform to
.... security Σ 0..* Coding Security Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
.... tag Σ 0..* Coding Tags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
... Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:encounter 1..* 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.
... 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
... careTeam 0..* BackboneElement Members of the care team
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Order of care team
.... provider 1..1 Reference(Practitioner | PractitionerRole | Organization) Practitioner or organization
... 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
.... quantity 0..1 SimpleQuantity(4.0.1) Count of products or services
.... 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
... total 0..1 Money Total claim cost

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Claim.meta.security Base extensible SecurityLabels 📍4.0.1 FHIR Std.
Claim.meta.tag Base example Common Tags 📍4.0.1 FHIR Std.
Claim.status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
Claim.type Base extensible Claim Type Codes 📍4.0.1 FHIR Std.
Claim.use Base required Use 📍4.0.1 FHIR Std.
Claim.priority Base example Process Priority Codes 📍4.0.1 FHIR Std.
Claim.related.relationship Base example Example Related Claim Relationship Codes 📍4.0.1 FHIR Std.
Claim.payee.type Base example PayeeType 📍4.0.1 FHIR Std.
Claim.supportingInfo.​category Base example Claim Information Category Codes 📍4.0.1 FHIR Std.
Claim.diagnosis.diagnosis[x] Base example ICD-10 Codes 📍4.0.1 FHIR Std.
Claim.procedure.procedure[x] Base example ICD-10 Procedure Codes 📍4.0.1 FHIR Std.
Claim.accident.type Base extensible ActIncidentCode 📦3.0.0 THO v6.5
Claim.item.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
Claim.item.detail.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
Claim.item.detail.subDetail.​revenue Base example Example Revenue Center Codes 📍4.0.1 FHIR Std.
Claim.item.detail.subDetail.​category Base example Benefit Category Codes 📍4.0.1 FHIR Std.
Claim.item.detail.subDetail.​productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
Claim.item.detail.subDetail.​modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
Claim.item.detail.subDetail.​programCode Base example Example Program Reason Codes 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
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

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Claim 0..* Claim Claim, Pre-determination or Pre-authorization
... Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:encounter 1..* 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.
... 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

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Claim.status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
Claim.type Base extensible Claim Type Codes 📍4.0.1 FHIR Std.
Claim.use Base required Use 📍4.0.1 FHIR Std.
Claim.priority Base example Process Priority Codes 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
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

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Claim 0..* Claim Claim, Pre-determination or Pre-authorization
... meta
.... Slices for extension Content/Rules for all slices
..... extension:hfRecordedDate 0..1 dateTime The recorded date indicating when the record was uploaded by the health facility.
URL: https://nhdr.gov.ph/fhir/StructureDefinition/HFRecordedDate
..... extension:hfLastUpdated 0..* dateTime The date indicating when the record was last updated by the health facility.
URL: https://nhdr.gov.ph/fhir/StructureDefinition/HFLastUpdated
.... lastUpdated 0..1 instant When the resource was uploaded to the NHDR.
... implicitRules 0..0
... language 0..0
... contained 0..0
... Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:encounter 1..* Reference(PH Encounter) Encounter (Extension)
URL: https://nhdr.gov.ph/fhir/StructureDefinition/EncounterExtension
... modifierExtension 0..0
... subType 0..0
... billablePeriod 0..0
... created 1..1 dateTime Resource creation date
... 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
.... responsible 0..0
.... role 0..0
.... qualification 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
.... 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 0..0

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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
.... id 0..1 string Unique id for inter-element referencing
.... Slices for extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... extension:hfRecordedDate 0..1 dateTime The recorded date indicating when the record was uploaded by the health facility.
URL: https://nhdr.gov.ph/fhir/StructureDefinition/HFRecordedDate
..... extension:hfLastUpdated 0..* dateTime The date indicating when the record was last updated by the health facility.
URL: https://nhdr.gov.ph/fhir/StructureDefinition/HFLastUpdated
.... versionId Σ 0..1 id Version specific identifier
.... lastUpdated Σ 0..1 instant When the resource was uploaded to the NHDR.
.... source Σ 0..1 uri Identifies where the resource comes from
.... profile Σ 0..* canonical(StructureDefinition) Profiles this resource claims to conform to
.... security Σ 0..* Coding Security Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
.... tag Σ 0..* Coding Tags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
... Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:encounter 1..* 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.
... 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
... careTeam 0..* BackboneElement Members of the care team
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Order of care team
.... provider 1..1 Reference(Practitioner | PractitionerRole | Organization) Practitioner or organization
... 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
.... quantity 0..1 SimpleQuantity(4.0.1) Count of products or services
.... 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
... total 0..1 Money Total claim cost

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Claim.meta.security Base extensible SecurityLabels 📍4.0.1 FHIR Std.
Claim.meta.tag Base example Common Tags 📍4.0.1 FHIR Std.
Claim.status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
Claim.type Base extensible Claim Type Codes 📍4.0.1 FHIR Std.
Claim.use Base required Use 📍4.0.1 FHIR Std.
Claim.priority Base example Process Priority Codes 📍4.0.1 FHIR Std.
Claim.related.relationship Base example Example Related Claim Relationship Codes 📍4.0.1 FHIR Std.
Claim.payee.type Base example PayeeType 📍4.0.1 FHIR Std.
Claim.supportingInfo.​category Base example Claim Information Category Codes 📍4.0.1 FHIR Std.
Claim.diagnosis.diagnosis[x] Base example ICD-10 Codes 📍4.0.1 FHIR Std.
Claim.procedure.procedure[x] Base example ICD-10 Procedure Codes 📍4.0.1 FHIR Std.
Claim.accident.type Base extensible ActIncidentCode 📦3.0.0 THO v6.5
Claim.item.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
Claim.item.detail.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
Claim.item.detail.subDetail.​revenue Base example Example Revenue Center Codes 📍4.0.1 FHIR Std.
Claim.item.detail.subDetail.​category Base example Benefit Category Codes 📍4.0.1 FHIR Std.
Claim.item.detail.subDetail.​productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
Claim.item.detail.subDetail.​modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
Claim.item.detail.subDetail.​programCode Base example Example Program Reason Codes 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
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

 

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