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 Specification

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: doco
Claim 0..* Claim Claim, Pre-determination or Pre-authorization
Claim.Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url

Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
Claim.Slices for extension.extension:encounter 1..* Reference(PH Encounter) Encounter (Extension)
URL: https://nhdr.gov.ph/fhir/StructureDefinition/EncounterExtension
Claim.status This element is a modifier element. This element is included in summaries. 1..1 code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
Claim.type This element is included in summaries. 1..1 CodeableConcept Category or discipline
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
Claim.use This element is included in summaries. 1..1 code claim | preauthorization | predetermination
Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim.
Claim.patient This element is included in summaries. 1..1 Reference(Patient) The recipient of the products and services
Claim.created This element is included in summaries. 1..1 dateTime Resource creation date
Claim.provider This element is included in summaries. 1..1 Reference(Practitioner | PractitionerRole | Organization) Party responsible for the claim
Claim.priority This element is included in summaries. 1..1 CodeableConcept Desired processing ugency
Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.
Claim.insurance This element is included in summaries. 1..* BackboneElement Patient insurance information
Claim.insurance.sequence This element is included in summaries. 1..1 positiveInt Insurance instance identifier
Claim.insurance.focal This element is included in summaries. 1..1 boolean Coverage to be used for adjudication
Claim.insurance.coverage This element is included in summaries. 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: doco
Claim 0..* Claim Claim, Pre-determination or Pre-authorization
Claim.meta
Claim.meta.Slices for extension Content/Rules for all slices
Claim.meta.Slices for extension.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
Claim.meta.Slices for extension.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
Claim.meta.lastUpdated 0..1 instant When the resource was uploaded to the NHDR.
Claim.implicitRules 0..0 A set of rules under which this content was created
Claim.language 0..0 Language of the resource content
Claim.contained 0..0 Contained, inline Resources
Claim.Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url
Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
Claim.Slices for extension.extension:encounter 1..* Reference(PH Encounter) Encounter (Extension)
URL: https://nhdr.gov.ph/fhir/StructureDefinition/EncounterExtension
Claim.modifierExtension 0..0 Extension
Claim.subType 0..0 More granular claim type
Claim.billablePeriod 0..0 Relevant time frame for the claim
Claim.created 1..1 dateTime Resource creation date
Claim.enterer 0..0 Author of the claim
Claim.insurer 0..0 Target
Claim.fundsReserve 0..0 For whom to reserve funds
Claim.related 0..0 Prior or corollary claims
Claim.originalPrescription 0..0 Original prescription if superseded by fulfiller
Claim.payee
Claim.payee.id 0..0 Unique id for inter-element referencing
Claim.payee.extension 0..0 Extension
Claim.payee.modifierExtension 0..0 Extension
Claim.facility 0..0 Servicing facility
Claim.careTeam
Claim.careTeam.responsible 0..0 Indicator of the lead practitioner
Claim.careTeam.role 0..0 Function within the team
Claim.careTeam.qualification 0..0 Practitioner credential or specialization
Claim.supportingInfo
Claim.supportingInfo.id 0..0 Unique id for inter-element referencing
Claim.supportingInfo.extension 0..0 Extension
Claim.supportingInfo.modifierExtension 0..0 Extension
Claim.supportingInfo.code 0..0 Type of information
Claim.supportingInfo.timing[x] 0..0 When it occurred
Claim.supportingInfo.reason 0..0 Explanation for the information
Claim.diagnosis
Claim.diagnosis.id 0..0 Unique id for inter-element referencing
Claim.diagnosis.extension 0..0 Extension
Claim.diagnosis.modifierExtension 0..0 Extension
Claim.diagnosis.type 0..0 Timing or nature of the diagnosis
Claim.diagnosis.onAdmission 0..0 Present on admission
Claim.diagnosis.packageCode 0..0 Package billing code
Claim.procedure
Claim.procedure.id 0..0 Unique id for inter-element referencing
Claim.procedure.extension 0..0 Extension
Claim.procedure.modifierExtension 0..0 Extension
Claim.procedure.type 0..0 Category of Procedure
Claim.procedure.udi 0..0 Unique device identifier
Claim.insurance
Claim.insurance.id 0..0 Unique id for inter-element referencing
Claim.insurance.extension 0..0 Extension
Claim.insurance.modifierExtension 0..0 Extension
Claim.insurance.identifier 0..0 Pre-assigned Claim number
Claim.insurance.businessArrangement 0..0 Additional provider contract number
Claim.insurance.preAuthRef 0..0 Prior authorization reference number
Claim.insurance.claimResponse 0..0 Adjudication results
Claim.accident 0..0 Details of the event
Claim.item
Claim.item.id 0..0 Unique id for inter-element referencing
Claim.item.extension 0..0 Extension
Claim.item.modifierExtension 0..0 Extension
Claim.item.careTeamSequence 0..0 Applicable careTeam members
Claim.item.diagnosisSequence 0..0 Applicable diagnoses
Claim.item.procedureSequence 0..0 Applicable procedures
Claim.item.informationSequence 0..0 Applicable exception and supporting information
Claim.item.revenue 0..0 Revenue or cost center code
Claim.item.category 0..0 Benefit classification
Claim.item.modifier 0..0 Product or service billing modifiers
Claim.item.programCode 0..0 Program the product or service is provided under
Claim.item.location[x] 0..0 Place of service or where product was supplied
Claim.item.unitPrice 0..0 Fee, charge or cost per item
Claim.item.factor 0..0 Price scaling factor
Claim.item.udi 0..0 Unique device identifier
Claim.item.bodySite 0..0 Anatomical location
Claim.item.subSite 0..0 Anatomical sub-location
Claim.item.detail
Claim.item.detail.id 0..0 Unique id for inter-element referencing
Claim.item.detail.extension 0..0 Extension
Claim.item.detail.modifierExtension 0..0 Extension
Claim.item.detail.revenue 0..0 Revenue or cost center code
Claim.item.detail.category 0..0 Benefit classification
Claim.item.detail.modifier 0..0 Service/Product billing modifiers
Claim.item.detail.programCode 0..0 Program the product or service is provided under
Claim.item.detail.quantity 0..0 Count of products or services
Claim.item.detail.unitPrice 0..0 Fee, charge or cost per item
Claim.item.detail.factor 0..0 Price scaling factor
Claim.item.detail.udi 0..0 Unique device identifier
Claim.item.detail.subDetail 0..0 Product or service provided

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraints    Filter: doco
Claim 0..* Claim Claim, Pre-determination or Pre-authorization
Claim.id This element is included in summaries. 0..1 id Logical id of this artifact
Claim.meta This element is included in summaries. 0..1 Meta Metadata about the resource
Claim.meta.id 0..1 string Unique id for inter-element referencing
Claim.meta.Slices for extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
Claim.meta.Slices for extension.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
Claim.meta.Slices for extension.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
Claim.meta.versionId This element is included in summaries. 0..1 id Version specific identifier
Claim.meta.lastUpdated This element is included in summaries. 0..1 instant When the resource was uploaded to the NHDR.
Claim.meta.source This element is included in summaries. 0..1 uri Identifies where the resource comes from
Claim.meta.profile This element is included in summaries. 0..* canonical(StructureDefinition) Profiles this resource claims to conform to
Claim.meta.security This element is included in summaries. 0..* Coding Security Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
Claim.meta.tag This element is included in summaries. 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".
Claim.Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url

Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
Claim.Slices for extension.extension:encounter 1..* Reference(PH Encounter) Encounter (Extension)
URL: https://nhdr.gov.ph/fhir/StructureDefinition/EncounterExtension
Claim.identifier 0..* Identifier Business Identifier for claim
Claim.status This element is a modifier element. This element is included in summaries. 1..1 code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
Claim.type This element is included in summaries. 1..1 CodeableConcept Category or discipline
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
Claim.use This element is included in summaries. 1..1 code claim | preauthorization | predetermination
Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim.
Claim.patient This element is included in summaries. 1..1 Reference(Patient) The recipient of the products and services
Claim.created This element is included in summaries. 1..1 dateTime Resource creation date
Claim.provider This element is included in summaries. 1..1 Reference(Practitioner | PractitionerRole | Organization) Party responsible for the claim
Claim.priority This element is included in summaries. 1..1 CodeableConcept Desired processing ugency
Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.
Claim.prescription 0..1 Reference(DeviceRequest | MedicationRequest | VisionPrescription) Prescription authorizing services and products
Claim.payee 0..1 BackboneElement Recipient of benefits payable
Claim.payee.type 1..1 CodeableConcept Category of recipient
Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
Claim.payee.party 0..1 Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) Recipient reference
Claim.referral 0..1 Reference(ServiceRequest) Treatment referral
Claim.careTeam 0..* BackboneElement Members of the care team
Claim.careTeam.id 0..1 string Unique id for inter-element referencing
Claim.careTeam.extension 0..* Extension Additional content defined by implementations
Claim.careTeam.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
Claim.careTeam.sequence 1..1 positiveInt Order of care team
Claim.careTeam.provider 1..1 Reference(Practitioner | PractitionerRole | Organization) Practitioner or organization
Claim.supportingInfo 0..* BackboneElement Supporting information
Claim.supportingInfo.sequence 1..1 positiveInt Information instance identifier
Claim.supportingInfo.category 1..1 CodeableConcept Classification of the supplied information
Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes.
Claim.supportingInfo.value[x] 0..1 Data to be provided
Claim.supportingInfo.value[x].valueBoolean boolean
Claim.supportingInfo.value[x].valueString string
Claim.supportingInfo.value[x].valueQuantity Quantity
Claim.supportingInfo.value[x].valueAttachment Attachment
Claim.supportingInfo.value[x].valueReference Reference(Resource)
Claim.diagnosis 0..* BackboneElement Pertinent diagnosis information
Claim.diagnosis.sequence 1..1 positiveInt Diagnosis instance identifier
Claim.diagnosis.diagnosis[x] 1..1 Nature of illness or problem
Binding: ICD-10Codes (example): Example ICD10 Diagnostic codes.
Claim.diagnosis.diagnosis[x].diagnosisCodeableConcept CodeableConcept
Claim.diagnosis.diagnosis[x].diagnosisReference Reference(Condition)
Claim.procedure 0..* BackboneElement Clinical procedures performed
Claim.procedure.sequence 1..1 positiveInt Procedure instance identifier
Claim.procedure.date 0..1 dateTime When the procedure was performed
Claim.procedure.procedure[x] 1..1 Specific clinical procedure
Binding: ICD-10ProcedureCodes (example): Example ICD10 Procedure codes.
Claim.procedure.procedure[x].procedureCodeableConcept CodeableConcept
Claim.procedure.procedure[x].procedureReference Reference(Procedure)
Claim.insurance This element is included in summaries. 1..* BackboneElement Patient insurance information
Claim.insurance.sequence This element is included in summaries. 1..1 positiveInt Insurance instance identifier
Claim.insurance.focal This element is included in summaries. 1..1 boolean Coverage to be used for adjudication
Claim.insurance.coverage This element is included in summaries. 1..1 Reference(Coverage) Insurance information
Claim.item 0..* BackboneElement Product or service provided
Claim.item.sequence 1..1 positiveInt Item instance identifier
Claim.item.productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
Claim.item.serviced[x] 0..1 Date or dates of service or product delivery
Claim.item.serviced[x].servicedDate date
Claim.item.serviced[x].servicedPeriod Period
Claim.item.quantity C 0..1 SimpleQuantity(4.0.1) Count of products or services
Constraints: sqty-1
Claim.item.net 0..1 Money Total item cost
Claim.item.encounter 0..* Reference(Encounter) Encounters related to this billed item
Claim.item.detail 0..* BackboneElement Product or service provided
Claim.item.detail.sequence 1..1 positiveInt Item instance identifier
Claim.item.detail.productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
Claim.item.detail.net 0..1 Money Total item cost
Claim.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 v7.4
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()
sqty-1 error Claim.item.quantity, Claim.item.detail.subDetail.quantity The comparator is not used on a SimpleQuantity comparator.empty()

This structure is derived from Claim

Key Elements View

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

Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
Claim.Slices for extension.extension:encounter 1..* Reference(PH Encounter) Encounter (Extension)
URL: https://nhdr.gov.ph/fhir/StructureDefinition/EncounterExtension
Claim.status This element is a modifier element. This element is included in summaries. 1..1 code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
Claim.type This element is included in summaries. 1..1 CodeableConcept Category or discipline
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
Claim.use This element is included in summaries. 1..1 code claim | preauthorization | predetermination
Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim.
Claim.patient This element is included in summaries. 1..1 Reference(Patient) The recipient of the products and services
Claim.created This element is included in summaries. 1..1 dateTime Resource creation date
Claim.provider This element is included in summaries. 1..1 Reference(Practitioner | PractitionerRole | Organization) Party responsible for the claim
Claim.priority This element is included in summaries. 1..1 CodeableConcept Desired processing ugency
Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.
Claim.insurance This element is included in summaries. 1..* BackboneElement Patient insurance information
Claim.insurance.sequence This element is included in summaries. 1..1 positiveInt Insurance instance identifier
Claim.insurance.focal This element is included in summaries. 1..1 boolean Coverage to be used for adjudication
Claim.insurance.coverage This element is included in summaries. 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: doco
Claim 0..* Claim Claim, Pre-determination or Pre-authorization
Claim.meta
Claim.meta.Slices for extension Content/Rules for all slices
Claim.meta.Slices for extension.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
Claim.meta.Slices for extension.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
Claim.meta.lastUpdated 0..1 instant When the resource was uploaded to the NHDR.
Claim.implicitRules 0..0 A set of rules under which this content was created
Claim.language 0..0 Language of the resource content
Claim.text 0..0 Text summary of the resource, for human interpretation
Claim.contained 0..0 Contained, inline Resources
Claim.Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url
Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
Claim.Slices for extension.extension:encounter 1..* Reference(PH Encounter) Encounter (Extension)
URL: https://nhdr.gov.ph/fhir/StructureDefinition/EncounterExtension
Claim.modifierExtension 0..0 Extension
Claim.subType 0..0 More granular claim type
Claim.billablePeriod 0..0 Relevant time frame for the claim
Claim.created 1..1 dateTime Resource creation date
Claim.enterer 0..0 Author of the claim
Claim.insurer 0..0 Target
Claim.fundsReserve 0..0 For whom to reserve funds
Claim.related 0..0 Prior or corollary claims
Claim.originalPrescription 0..0 Original prescription if superseded by fulfiller
Claim.payee
Claim.payee.id 0..0 Unique id for inter-element referencing
Claim.payee.extension 0..0 Extension
Claim.payee.modifierExtension 0..0 Extension
Claim.facility 0..0 Servicing facility
Claim.careTeam
Claim.careTeam.responsible 0..0 Indicator of the lead practitioner
Claim.careTeam.role 0..0 Function within the team
Claim.careTeam.qualification 0..0 Practitioner credential or specialization
Claim.supportingInfo
Claim.supportingInfo.id 0..0 Unique id for inter-element referencing
Claim.supportingInfo.extension 0..0 Extension
Claim.supportingInfo.modifierExtension 0..0 Extension
Claim.supportingInfo.code 0..0 Type of information
Claim.supportingInfo.timing[x] 0..0 When it occurred
Claim.supportingInfo.reason 0..0 Explanation for the information
Claim.diagnosis
Claim.diagnosis.id 0..0 Unique id for inter-element referencing
Claim.diagnosis.extension 0..0 Extension
Claim.diagnosis.modifierExtension 0..0 Extension
Claim.diagnosis.type 0..0 Timing or nature of the diagnosis
Claim.diagnosis.onAdmission 0..0 Present on admission
Claim.diagnosis.packageCode 0..0 Package billing code
Claim.procedure
Claim.procedure.id 0..0 Unique id for inter-element referencing
Claim.procedure.extension 0..0 Extension
Claim.procedure.modifierExtension 0..0 Extension
Claim.procedure.type 0..0 Category of Procedure
Claim.procedure.udi 0..0 Unique device identifier
Claim.insurance
Claim.insurance.id 0..0 Unique id for inter-element referencing
Claim.insurance.extension 0..0 Extension
Claim.insurance.modifierExtension 0..0 Extension
Claim.insurance.identifier 0..0 Pre-assigned Claim number
Claim.insurance.businessArrangement 0..0 Additional provider contract number
Claim.insurance.preAuthRef 0..0 Prior authorization reference number
Claim.insurance.claimResponse 0..0 Adjudication results
Claim.accident 0..0 Details of the event
Claim.item
Claim.item.id 0..0 Unique id for inter-element referencing
Claim.item.extension 0..0 Extension
Claim.item.modifierExtension 0..0 Extension
Claim.item.careTeamSequence 0..0 Applicable careTeam members
Claim.item.diagnosisSequence 0..0 Applicable diagnoses
Claim.item.procedureSequence 0..0 Applicable procedures
Claim.item.informationSequence 0..0 Applicable exception and supporting information
Claim.item.revenue 0..0 Revenue or cost center code
Claim.item.category 0..0 Benefit classification
Claim.item.modifier 0..0 Product or service billing modifiers
Claim.item.programCode 0..0 Program the product or service is provided under
Claim.item.location[x] 0..0 Place of service or where product was supplied
Claim.item.unitPrice 0..0 Fee, charge or cost per item
Claim.item.factor 0..0 Price scaling factor
Claim.item.udi 0..0 Unique device identifier
Claim.item.bodySite 0..0 Anatomical location
Claim.item.subSite 0..0 Anatomical sub-location
Claim.item.detail
Claim.item.detail.id 0..0 Unique id for inter-element referencing
Claim.item.detail.extension 0..0 Extension
Claim.item.detail.modifierExtension 0..0 Extension
Claim.item.detail.revenue 0..0 Revenue or cost center code
Claim.item.detail.category 0..0 Benefit classification
Claim.item.detail.modifier 0..0 Service/Product billing modifiers
Claim.item.detail.programCode 0..0 Program the product or service is provided under
Claim.item.detail.quantity 0..0 Count of products or services
Claim.item.detail.unitPrice 0..0 Fee, charge or cost per item
Claim.item.detail.factor 0..0 Price scaling factor
Claim.item.detail.udi 0..0 Unique device identifier
Claim.item.detail.subDetail 0..0 Product or service provided

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: doco
Claim 0..* Claim Claim, Pre-determination or Pre-authorization
Claim.id This element is included in summaries. 0..1 id Logical id of this artifact
Claim.meta This element is included in summaries. 0..1 Meta Metadata about the resource
Claim.meta.id 0..1 string Unique id for inter-element referencing
Claim.meta.Slices for extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
Claim.meta.Slices for extension.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
Claim.meta.Slices for extension.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
Claim.meta.versionId This element is included in summaries. 0..1 id Version specific identifier
Claim.meta.lastUpdated This element is included in summaries. 0..1 instant When the resource was uploaded to the NHDR.
Claim.meta.source This element is included in summaries. 0..1 uri Identifies where the resource comes from
Claim.meta.profile This element is included in summaries. 0..* canonical(StructureDefinition) Profiles this resource claims to conform to
Claim.meta.security This element is included in summaries. 0..* Coding Security Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
Claim.meta.tag This element is included in summaries. 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".
Claim.Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url

Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
Claim.Slices for extension.extension:encounter 1..* Reference(PH Encounter) Encounter (Extension)
URL: https://nhdr.gov.ph/fhir/StructureDefinition/EncounterExtension
Claim.identifier 0..* Identifier Business Identifier for claim
Claim.status This element is a modifier element. This element is included in summaries. 1..1 code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
Claim.type This element is included in summaries. 1..1 CodeableConcept Category or discipline
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
Claim.use This element is included in summaries. 1..1 code claim | preauthorization | predetermination
Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim.
Claim.patient This element is included in summaries. 1..1 Reference(Patient) The recipient of the products and services
Claim.created This element is included in summaries. 1..1 dateTime Resource creation date
Claim.provider This element is included in summaries. 1..1 Reference(Practitioner | PractitionerRole | Organization) Party responsible for the claim
Claim.priority This element is included in summaries. 1..1 CodeableConcept Desired processing ugency
Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.
Claim.prescription 0..1 Reference(DeviceRequest | MedicationRequest | VisionPrescription) Prescription authorizing services and products
Claim.payee 0..1 BackboneElement Recipient of benefits payable
Claim.payee.type 1..1 CodeableConcept Category of recipient
Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
Claim.payee.party 0..1 Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) Recipient reference
Claim.referral 0..1 Reference(ServiceRequest) Treatment referral
Claim.careTeam 0..* BackboneElement Members of the care team
Claim.careTeam.id 0..1 string Unique id for inter-element referencing
Claim.careTeam.extension 0..* Extension Additional content defined by implementations
Claim.careTeam.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
Claim.careTeam.sequence 1..1 positiveInt Order of care team
Claim.careTeam.provider 1..1 Reference(Practitioner | PractitionerRole | Organization) Practitioner or organization
Claim.supportingInfo 0..* BackboneElement Supporting information
Claim.supportingInfo.sequence 1..1 positiveInt Information instance identifier
Claim.supportingInfo.category 1..1 CodeableConcept Classification of the supplied information
Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes.
Claim.supportingInfo.value[x] 0..1 Data to be provided
Claim.supportingInfo.value[x].valueBoolean boolean
Claim.supportingInfo.value[x].valueString string
Claim.supportingInfo.value[x].valueQuantity Quantity
Claim.supportingInfo.value[x].valueAttachment Attachment
Claim.supportingInfo.value[x].valueReference Reference(Resource)
Claim.diagnosis 0..* BackboneElement Pertinent diagnosis information
Claim.diagnosis.sequence 1..1 positiveInt Diagnosis instance identifier
Claim.diagnosis.diagnosis[x] 1..1 Nature of illness or problem
Binding: ICD-10Codes (example): Example ICD10 Diagnostic codes.
Claim.diagnosis.diagnosis[x].diagnosisCodeableConcept CodeableConcept
Claim.diagnosis.diagnosis[x].diagnosisReference Reference(Condition)
Claim.procedure 0..* BackboneElement Clinical procedures performed
Claim.procedure.sequence 1..1 positiveInt Procedure instance identifier
Claim.procedure.date 0..1 dateTime When the procedure was performed
Claim.procedure.procedure[x] 1..1 Specific clinical procedure
Binding: ICD-10ProcedureCodes (example): Example ICD10 Procedure codes.
Claim.procedure.procedure[x].procedureCodeableConcept CodeableConcept
Claim.procedure.procedure[x].procedureReference Reference(Procedure)
Claim.insurance This element is included in summaries. 1..* BackboneElement Patient insurance information
Claim.insurance.sequence This element is included in summaries. 1..1 positiveInt Insurance instance identifier
Claim.insurance.focal This element is included in summaries. 1..1 boolean Coverage to be used for adjudication
Claim.insurance.coverage This element is included in summaries. 1..1 Reference(Coverage) Insurance information
Claim.item 0..* BackboneElement Product or service provided
Claim.item.sequence 1..1 positiveInt Item instance identifier
Claim.item.productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
Claim.item.serviced[x] 0..1 Date or dates of service or product delivery
Claim.item.serviced[x].servicedDate date
Claim.item.serviced[x].servicedPeriod Period
Claim.item.quantity C 0..1 SimpleQuantity(4.0.1) Count of products or services
Constraints: sqty-1
Claim.item.net 0..1 Money Total item cost
Claim.item.encounter 0..* Reference(Encounter) Encounters related to this billed item
Claim.item.detail 0..* BackboneElement Product or service provided
Claim.item.detail.sequence 1..1 positiveInt Item instance identifier
Claim.item.detail.productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
Claim.item.detail.net 0..1 Money Total item cost
Claim.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 v7.4
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()
sqty-1 error Claim.item.quantity, Claim.item.detail.subDetail.quantity The comparator is not used on a SimpleQuantity comparator.empty()

This structure is derived from Claim

 

Other representations of profile: CSV, Excel, Schematron