SIL HIE Implementation Guide, published by Kathurima Kimathi. 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/savannahghi/hie-fhir-ig-profile/ and changes regularly. See the Directory of published versions

• Content
• Detailed Descriptions
• Mappings
• Examples
• XML
• JSON
• TTL

Resource Profile: HIE Claim

R4B Claim constrained for HIE submission and exchange. Emphasizes core administrative data, patient, provider, insurer, billable period, coverage, diagnosis, items, and totals.

Usages:

• Refer to this Profile: HIE Claim and HIE ClaimResponse
• Examples for this Profile: Claim/HIEClaim-example

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.

• Key Elements Table
• Differential Table
• Snapshot Table
• Statistics/References
• All

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Claim		0..*	Claim	Claim, Pre-determination or Pre-authorization
Claim.implicitRules	?! This element is a modifier element. Σ This element is included in summaries.	0..1	uri	A set of rules under which this content was created
Claim.modifierExtension	?! This element is a modifier element.	0..*	Extension	Extensions that cannot be ignored
Claim.identifier	S This element must be supported.	1..*	Identifier	Business Identifier for claim
Claim.identifier.use	?! This element is a modifier element. Σ This element is included in summaries.	1..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required)
Claim.identifier.type	Σ This element is included in summaries. C	1..1	HIECodeableConcept	Description of identifier Binding: Identifier Type Codes (extensible) Constraints: cc-text-or-code
Claim.identifier.system	Σ This element is included in summaries.	1..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
Claim.identifier.value	S This element must be supported. Σ This element is included in summaries.	1..1	string	The value that is unique Example General: 123456
Claim.identifier.assigner	S This element must be supported. Σ This element is included in summaries.	0..1	HIEReference(HIE Organization)	Organization that issued id (may be just text)
Claim.status	?! This element is a modifier element. S This element must be supported. Σ 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	S This element must be supported. Σ This element is included in summaries. C	1..1	HIECodeableConcept	Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. Constraints: cc-text-or-code
Claim.subType	C	0..1	HIECodeableConcept	More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode. Constraints: cc-text-or-code
Claim.use	S This element must be supported. Σ 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	S This element must be supported. Σ This element is included in summaries.	1..1	HIEReference(HIE Patient)	The recipient of the products and services
Claim.billablePeriod	Σ This element is included in summaries.	1..1	Period	Relevant time frame for the claim
Claim.created	S This element must be supported. Σ This element is included in summaries.	1..1	dateTime	Resource creation date
Claim.enterer		0..1	HIEReference(HIE Practitioner | PractitionerRole)	Author of the claim
Claim.insurer	Σ This element is included in summaries.	0..1	HIEReference(HIE Organization)	Target
Claim.provider	S This element must be supported. Σ This element is included in summaries.	1..1	HIEReference(HIE Organization | HIE Practitioner | PractitionerRole)	Party responsible for the claim
Claim.priority	S This element must be supported. Σ This element is included in summaries. C	1..1	HIECodeableConcept	Desired processing ugency Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred. Constraints: cc-text-or-code
Claim.fundsReserve	C	0..1	HIECodeableConcept	For whom to reserve funds Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None). Constraints: cc-text-or-code
Claim.prescription		0..1	HIEReference(DeviceRequest | MedicationRequest | VisionPrescription)	Prescription authorizing services and products
Claim.originalPrescription		0..1	HIEReference(DeviceRequest | MedicationRequest | VisionPrescription)	Original prescription if superseded by fulfiller
Claim.referral		0..1	HIEReference(ServiceRequest)	Treatment referral
Claim.facility		0..1	HIEReference(Location)	Servicing facility
Claim.diagnosis	S This element must be supported.	1..*	BackboneElement	Pertinent diagnosis information
Claim.diagnosis.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Claim.diagnosis.sequence		1..1	positiveInt	Diagnosis instance identifier
Claim.diagnosis.Slices for diagnosis[x]		1..1		Nature of illness or problem Slice: Unordered, Closed by type:$this Binding: ICD-10Codes (example): Example ICD10 Diagnostic codes. Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
Claim.diagnosis.Slices for diagnosis[x].diagnosisCodeableConcept			CodeableConcept
Claim.diagnosis.Slices for diagnosis[x].diagnosisReference			Reference(Condition)
Claim.diagnosis.Slices for diagnosis[x].diagnosis[x]:diagnosisCodeableConcept	C	0..1	HIECodeableConcept	Nature of illness or problem Binding: ICD-10Codes (example): Example ICD10 Diagnostic codes. Constraints: cc-text-or-code
Claim.diagnosis.Slices for diagnosis[x].diagnosis[x]:diagnosisReference		0..1	HIEReference(Condition)	Nature of illness or problem
Claim.diagnosis.type	C	0..*	HIECodeableConcept	Timing or nature of the diagnosis Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge. Constraints: cc-text-or-code
Claim.diagnosis.onAdmission	C	0..1	HIECodeableConcept	Present on admission Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission. Constraints: cc-text-or-code
Claim.diagnosis.packageCode	C	0..1	HIECodeableConcept	Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis. Constraints: cc-text-or-code
Claim.insurance	S This element must be supported. Σ This element is included in summaries.	1..*	BackboneElement	Patient insurance information
Claim.insurance.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Claim.insurance.sequence	Σ This element is included in summaries.	1..1	positiveInt	Insurance instance identifier
Claim.insurance.focal	Σ This element is included in summaries.	1..1	boolean	Coverage to be used for adjudication
Claim.insurance.coverage	Σ This element is included in summaries.	1..1	HIEReference(Coverage)	Insurance information
Claim.insurance.claimResponse		0..1	HIEReference(ClaimResponse)	Adjudication results
Claim.item	S This element must be supported.	1..*	BackboneElement	Product or service provided
Claim.item.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Claim.item.sequence		1..1	positiveInt	Item instance identifier
Claim.item.revenue	C	0..1	HIECodeableConcept	Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. Constraints: cc-text-or-code
Claim.item.category	C	0..1	HIECodeableConcept	Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses. Constraints: cc-text-or-code
Claim.item.productOrService	S This element must be supported. C	1..1	HIECodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. Constraints: cc-text-or-code
Claim.item.modifier	C	0..*	HIECodeableConcept	Product or service billing modifiers Binding: ModifierTypeCodes (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. Constraints: cc-text-or-code
Claim.item.programCode	C	0..*	HIECodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. Constraints: cc-text-or-code
Claim.item.udi		0..*	HIEReference(Device)	Unique device identifier
Claim.item.bodySite	C	0..1	HIECodeableConcept	Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch. Constraints: cc-text-or-code
Claim.item.subSite	C	0..*	HIECodeableConcept	Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations. Constraints: cc-text-or-code
Claim.item.encounter		1..1	HIEReference(HIE Encounter)	Encounters related to this billed item
Claim.total	S This element must be supported.	1..1	Money	Total claim cost
Documentation for this format

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
Claim.identifier.use	Base	required	IdentifierUse	📦4.3.0	FHIR Std.
Claim.identifier.type	Base	extensible	IdentifierType	📦4.3.0	FHIR Std.
Claim.status	Base	required	Financial Resource Status Codes	📍4.3.0	FHIR Std.
Claim.type	Base	extensible	Claim Type Codes	📍4.3.0	FHIR Std.
Claim.subType	Base	example	Example Claim SubType Codes	📍4.3.0	FHIR Std.
Claim.use	Base	required	Use	📍4.3.0	FHIR Std.
Claim.priority	Base	example	Process Priority Codes	📍4.3.0	FHIR Std.
Claim.fundsReserve	Base	example	FundsReserve	📍4.3.0	FHIR Std.
Claim.diagnosis.diagnosis[x]	Base	example	ICD-10 Codes	📍4.3.0	FHIR Std.
Claim.diagnosis.diagnosis[x]:diagnosisCodeableConcept	Base	example	ICD-10 Codes	📍4.3.0	FHIR Std.
Claim.diagnosis.type	Base	example	Example Diagnosis Type Codes	📍4.3.0	FHIR Std.
Claim.diagnosis.onAdmission	Base	example	Example Diagnosis on Admission Codes	📍4.3.0	FHIR Std.
Claim.diagnosis.packageCode	Base	example	Example Diagnosis Related Group Codes	📍4.3.0	FHIR Std.
Claim.item.revenue	Base	example	Example Revenue Center Codes	📍4.3.0	FHIR Std.
Claim.item.category	Base	example	Benefit Category Codes	📍4.3.0	FHIR Std.
Claim.item.productOrService	Base	example	USCLS Codes	📍4.3.0	FHIR Std.
Claim.item.modifier	Base	example	Modifier type Codes	📍4.3.0	FHIR Std.
Claim.item.programCode	Base	example	Example Program Reason Codes	📍4.3.0	FHIR Std.
Claim.item.bodySite	Base	example	Oral Site Codes	📍4.3.0	FHIR Std.
Claim.item.subSite	Base	example	Surface Codes	📍4.3.0	FHIR Std.

Constraints

Id	Grade	Path(s)	Description	Expression
cc-text-or-code	warning	Claim.identifier.type, Claim.type, Claim.subType, Claim.priority, Claim.fundsReserve, Claim.diagnosis.diagnosis[x]:diagnosisCodeableConcept, Claim.diagnosis.type, Claim.diagnosis.onAdmission, Claim.diagnosis.packageCode, Claim.item.revenue, Claim.item.category, Claim.item.productOrService, Claim.item.modifier, Claim.item.programCode, Claim.item.bodySite, Claim.item.subSite	Text is optional, coding is required	coding.exists()
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.exists() and ('#'+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(uri) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	Claim	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated	contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	Claim	If a resource is contained in another resource, it SHALL NOT have a security label	contained.meta.security.empty()
dom-6	best practice	Claim	A resource should have narrative for robust management	text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children	hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both	extension.exists() != value.exists()

This structure is derived from Claim

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Claim		0..*	Claim	Claim, Pre-determination or Pre-authorization
Claim.identifier	S This element must be supported.	1..*	Identifier	Business Identifier for claim
Claim.identifier.use		1..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required)
Claim.identifier.type		1..1	HIECodeableConcept	Description of identifier Binding: Identifier Type Codes (extensible)
Claim.identifier.system		1..1	uri	The namespace for the identifier value
Claim.identifier.value	S This element must be supported.	1..1	string	The value that is unique
Claim.identifier.assigner	S This element must be supported.	0..1	HIEReference(HIE Organization)	Organization that issued id (may be just text)
Claim.status	S This element must be supported.	1..1	code	active | cancelled | draft | entered-in-error
Claim.type	S This element must be supported.	1..1	HIECodeableConcept	Category or discipline
Claim.subType		0..1	HIECodeableConcept	More granular claim type
Claim.use	S This element must be supported.	1..1	code	claim | preauthorization | predetermination
Claim.patient	S This element must be supported.	1..1	HIEReference(HIE Patient)	The recipient of the products and services
Claim.billablePeriod		1..1	Period	Relevant time frame for the claim
Claim.created	S This element must be supported.	1..1	dateTime	Resource creation date
Claim.enterer		0..1	HIEReference(HIE Practitioner | PractitionerRole)	Author of the claim
Claim.insurer		0..1	HIEReference(HIE Organization)	Target
Claim.provider	S This element must be supported.	1..1	HIEReference(HIE Organization | HIE Practitioner | PractitionerRole)	Party responsible for the claim
Claim.priority	S This element must be supported.	1..1	HIECodeableConcept	Desired processing ugency
Claim.fundsReserve		0..1	HIECodeableConcept	For whom to reserve funds
Claim.related
Claim.related.claim		0..1	HIEReference(HIE Claim)	Reference to the related claim
Claim.prescription		0..1	HIEReference(DeviceRequest | MedicationRequest | VisionPrescription)	Prescription authorizing services and products
Claim.originalPrescription		0..1	HIEReference(DeviceRequest | MedicationRequest | VisionPrescription)	Original prescription if superseded by fulfiller
Claim.payee
Claim.payee.type		1..1	HIECodeableConcept	Category of recipient
Claim.payee.party		1..1	HIEReference(HIE Practitioner | PractitionerRole | HIE Organization | HIE Patient | RelatedPerson)	Recipient reference
Claim.referral		0..1	HIEReference(ServiceRequest)	Treatment referral
Claim.facility		0..1	HIEReference(Location)	Servicing facility
Claim.careTeam
Claim.careTeam.provider		1..1	HIEReference(HIE Practitioner | PractitionerRole | HIE Organization)	Practitioner or organization
Claim.careTeam.role		0..1	HIECodeableConcept	Function within the team
Claim.careTeam.qualification		0..1	HIECodeableConcept	Practitioner credential or specialization
Claim.supportingInfo
Claim.supportingInfo.category		1..1	HIECodeableConcept	Classification of the supplied information
Claim.supportingInfo.code		0..1	HIECodeableConcept	Type of information
Claim.supportingInfo.Slices for value[x]		0..1		Data to be provided Slice: Unordered, Open by type:$this Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them Other type slices that contain no new information are not shown in this view
Claim.supportingInfo.Slices for value[x].valueBoolean			boolean
Claim.supportingInfo.Slices for value[x].valueString			string
Claim.supportingInfo.Slices for value[x].valueQuantity			Quantity
Claim.supportingInfo.Slices for value[x].valueAttachment			Attachment
Claim.supportingInfo.Slices for value[x].valueReference			Reference(Resource)
Claim.supportingInfo.Slices for value[x].value[x]:valueReference		0..1	HIEReference(Resource)	Data to be provided
Claim.supportingInfo.reason		0..1	HIECodeableConcept	Explanation for the information
Claim.diagnosis	S This element must be supported.	1..*	BackboneElement	Pertinent diagnosis information
Claim.diagnosis.Slices for diagnosis[x]		1..1		Nature of illness or problem Slice: Unordered, Open by type:$this Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
Claim.diagnosis.Slices for diagnosis[x].diagnosisCodeableConcept			CodeableConcept
Claim.diagnosis.Slices for diagnosis[x].diagnosisReference			Reference(Condition)
Claim.diagnosis.Slices for diagnosis[x].diagnosis[x]:diagnosisCodeableConcept		0..1	HIECodeableConcept	Nature of illness or problem
Claim.diagnosis.Slices for diagnosis[x].diagnosis[x]:diagnosisReference		0..1	HIEReference(Condition)	Nature of illness or problem
Claim.diagnosis.type		0..*	HIECodeableConcept	Timing or nature of the diagnosis
Claim.diagnosis.onAdmission		0..1	HIECodeableConcept	Present on admission
Claim.diagnosis.packageCode		0..1	HIECodeableConcept	Package billing code
Claim.procedure
Claim.procedure.type		0..*	HIECodeableConcept	Category of Procedure
Claim.procedure.Slices for procedure[x]		1..1		Specific clinical procedure Slice: Unordered, Open by type:$this Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
Claim.procedure.Slices for procedure[x].procedureCodeableConcept			CodeableConcept
Claim.procedure.Slices for procedure[x].procedureReference			Reference(Procedure)
Claim.procedure.Slices for procedure[x].procedure[x]:procedureCodeableConcept		0..1	HIECodeableConcept	Specific clinical procedure
Claim.procedure.Slices for procedure[x].procedure[x]:procedureReference		0..1	HIEReference(Procedure)	Specific clinical procedure
Claim.procedure.udi		0..*	HIEReference(Device)	Unique device identifier
Claim.insurance	S This element must be supported.	1..*	BackboneElement	Patient insurance information
Claim.insurance.coverage		1..1	HIEReference(Coverage)	Insurance information
Claim.insurance.claimResponse		0..1	HIEReference(ClaimResponse)	Adjudication results
Claim.accident
Claim.accident.type		0..1	HIECodeableConcept	The nature of the accident
Claim.item	S This element must be supported.	1..*	BackboneElement	Product or service provided
Claim.item.revenue		0..1	HIECodeableConcept	Revenue or cost center code
Claim.item.category		0..1	HIECodeableConcept	Benefit classification
Claim.item.productOrService	S This element must be supported.	1..1	HIECodeableConcept	Billing, service, product, or drug code
Claim.item.modifier		0..*	HIECodeableConcept	Product or service billing modifiers
Claim.item.programCode		0..*	HIECodeableConcept	Program the product or service is provided under
Claim.item.udi		0..*	HIEReference(Device)	Unique device identifier
Claim.item.bodySite		0..1	HIECodeableConcept	Anatomical location
Claim.item.subSite		0..*	HIECodeableConcept	Anatomical sub-location
Claim.item.encounter		1..1	HIEReference(HIE Encounter)	Encounters related to this billed item
Claim.item.detail
Claim.item.detail.revenue		0..1	HIECodeableConcept	Revenue or cost center code
Claim.item.detail.category		0..1	HIECodeableConcept	Benefit classification
Claim.item.detail.productOrService		1..1	HIECodeableConcept	Billing, service, product, or drug code
Claim.item.detail.modifier		0..*	HIECodeableConcept	Service/Product billing modifiers
Claim.item.detail.udi		0..*	HIEReference(Device)	Unique device identifier
Claim.item.detail.subDetail
Claim.item.detail.subDetail.revenue		0..1	HIECodeableConcept	Revenue or cost center code
Claim.item.detail.subDetail.category		0..1	HIECodeableConcept	Benefit classification
Claim.item.detail.subDetail.productOrService		1..1	HIECodeableConcept	Billing, service, product, or drug code
Claim.item.detail.subDetail.modifier		0..*	HIECodeableConcept	Service/Product billing modifiers
Claim.item.detail.subDetail.programCode		0..*	HIECodeableConcept	Program the product or service is provided under
Claim.item.detail.subDetail.udi		0..*	HIEReference(Device)	Unique device identifier
Claim.total	S This element must be supported.	1..1	Money	Total claim cost
Documentation for this format

Terminology Bindings (Differential)

Path	Status	Usage	ValueSet	Version	Source
Claim.identifier.use	Base	required	IdentifierUse	📦4.3.0	FHIR Std.
Claim.identifier.type	Base	extensible	IdentifierType	📦4.3.0	FHIR Std.

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Claim		0..*	Claim	Claim, Pre-determination or Pre-authorization
Claim.id	Σ This element is included in summaries.	0..1	id	Logical id of this artifact
Claim.meta	Σ This element is included in summaries.	0..1	Meta	Metadata about the resource
Claim.implicitRules	?! This element is a modifier element. Σ This element is included in summaries.	0..1	uri	A set of rules under which this content was created
Claim.language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): IETF language tag Additional Bindings Purpose AllLanguages Max Binding
Claim.text		0..1	Narrative	Text 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..*	Resource	Contained, inline Resources Constraints: dom-r4b
Claim.extension		0..*	Extension	Additional content defined by implementations
Claim.modifierExtension	?! This element is a modifier element.	0..*	Extension	Extensions that cannot be ignored
Claim.identifier	S This element must be supported.	1..*	Identifier	Business Identifier for claim
Claim.identifier.id		0..1	id	Unique id for inter-element referencing
Claim.identifier.extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
Claim.identifier.use	?! This element is a modifier element. Σ This element is included in summaries.	1..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required)
Claim.identifier.type	Σ This element is included in summaries. C	1..1	HIECodeableConcept	Description of identifier Binding: Identifier Type Codes (extensible) Constraints: cc-text-or-code
Claim.identifier.system	Σ This element is included in summaries.	1..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
Claim.identifier.value	S This element must be supported. Σ This element is included in summaries.	1..1	string	The value that is unique Example General: 123456
Claim.identifier.period	Σ This element is included in summaries.	0..1	Period	Time period when id is/was valid for use
Claim.identifier.assigner	S This element must be supported. Σ This element is included in summaries.	0..1	HIEReference(HIE Organization)	Organization that issued id (may be just text)
Claim.status	?! This element is a modifier element. S This element must be supported. Σ 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	S This element must be supported. Σ This element is included in summaries. C	1..1	HIECodeableConcept	Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. Constraints: cc-text-or-code
Claim.subType	C	0..1	HIECodeableConcept	More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode. Constraints: cc-text-or-code
Claim.use	S This element must be supported. Σ 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	S This element must be supported. Σ This element is included in summaries.	1..1	HIEReference(HIE Patient)	The recipient of the products and services
Claim.billablePeriod	Σ This element is included in summaries.	1..1	Period	Relevant time frame for the claim
Claim.created	S This element must be supported. Σ This element is included in summaries.	1..1	dateTime	Resource creation date
Claim.enterer		0..1	HIEReference(HIE Practitioner | PractitionerRole)	Author of the claim
Claim.insurer	Σ This element is included in summaries.	0..1	HIEReference(HIE Organization)	Target
Claim.provider	S This element must be supported. Σ This element is included in summaries.	1..1	HIEReference(HIE Organization | HIE Practitioner | PractitionerRole)	Party responsible for the claim
Claim.priority	S This element must be supported. Σ This element is included in summaries. C	1..1	HIECodeableConcept	Desired processing ugency Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred. Constraints: cc-text-or-code
Claim.fundsReserve	C	0..1	HIECodeableConcept	For whom to reserve funds Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None). Constraints: cc-text-or-code
Claim.related		0..*	BackboneElement	Prior or corollary claims
Claim.related.id		0..1	string	Unique id for inter-element referencing
Claim.related.extension		0..*	Extension	Additional content defined by implementations
Claim.related.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Claim.related.claim		0..1	HIEReference(HIE Claim)	Reference to the related claim
Claim.related.relationship		0..1	CodeableConcept	How the reference claim is related Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim.
Claim.related.reference		0..1	Identifier	File or case reference
Claim.prescription		0..1	HIEReference(DeviceRequest | MedicationRequest | VisionPrescription)	Prescription authorizing services and products
Claim.originalPrescription		0..1	HIEReference(DeviceRequest | MedicationRequest | VisionPrescription)	Original prescription if superseded by fulfiller
Claim.payee		0..1	BackboneElement	Recipient of benefits payable
Claim.payee.id		0..1	string	Unique id for inter-element referencing
Claim.payee.extension		0..*	Extension	Additional content defined by implementations
Claim.payee.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Claim.payee.type	C	1..1	HIECodeableConcept	Category of recipient Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed. Constraints: cc-text-or-code
Claim.payee.party		1..1	HIEReference(HIE Practitioner | PractitionerRole | HIE Organization | HIE Patient | RelatedPerson)	Recipient reference
Claim.referral		0..1	HIEReference(ServiceRequest)	Treatment referral
Claim.facility		0..1	HIEReference(Location)	Servicing facility
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. Σ 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	HIEReference(HIE Practitioner | PractitionerRole | HIE Organization)	Practitioner or organization
Claim.careTeam.responsible		0..1	boolean	Indicator of the lead practitioner
Claim.careTeam.role	C	0..1	HIECodeableConcept	Function within the team Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members. Constraints: cc-text-or-code
Claim.careTeam.qualification	C	0..1	HIECodeableConcept	Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications. Constraints: cc-text-or-code
Claim.supportingInfo		0..*	BackboneElement	Supporting information
Claim.supportingInfo.id		0..1	string	Unique id for inter-element referencing
Claim.supportingInfo.extension		0..*	Extension	Additional content defined by implementations
Claim.supportingInfo.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Claim.supportingInfo.sequence		1..1	positiveInt	Information instance identifier
Claim.supportingInfo.category	C	1..1	HIECodeableConcept	Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. Constraints: cc-text-or-code
Claim.supportingInfo.code	C	0..1	HIECodeableConcept	Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes. Constraints: cc-text-or-code
Claim.supportingInfo.timing[x]		0..1		When it occurred
Claim.supportingInfo.timing[x].timingDate			date
Claim.supportingInfo.timing[x].timingPeriod			Period
Claim.supportingInfo.Slices for value[x]		0..1		Data to be provided Slice: Unordered, Closed by type:$this Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them Other type slices that contain no new information are not shown in this view
Claim.supportingInfo.Slices for value[x].valueBoolean			boolean
Claim.supportingInfo.Slices for value[x].valueString			string
Claim.supportingInfo.Slices for value[x].valueQuantity			Quantity
Claim.supportingInfo.Slices for value[x].valueAttachment			Attachment
Claim.supportingInfo.Slices for value[x].valueReference			Reference(Resource)
Claim.supportingInfo.Slices for value[x].value[x]:valueReference		0..1	HIEReference(Resource)	Data to be provided
Claim.supportingInfo.reason	C	0..1	HIECodeableConcept	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth. Constraints: cc-text-or-code
Claim.diagnosis	S This element must be supported.	1..*	BackboneElement	Pertinent diagnosis information
Claim.diagnosis.id		0..1	string	Unique id for inter-element referencing
Claim.diagnosis.extension		0..*	Extension	Additional content defined by implementations
Claim.diagnosis.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Claim.diagnosis.sequence		1..1	positiveInt	Diagnosis instance identifier
Claim.diagnosis.Slices for diagnosis[x]		1..1		Nature of illness or problem Slice: Unordered, Closed by type:$this Binding: ICD-10Codes (example): Example ICD10 Diagnostic codes. Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
Claim.diagnosis.Slices for diagnosis[x].diagnosisCodeableConcept			CodeableConcept
Claim.diagnosis.Slices for diagnosis[x].diagnosisReference			Reference(Condition)
Claim.diagnosis.Slices for diagnosis[x].diagnosis[x]:diagnosisCodeableConcept	C	0..1	HIECodeableConcept	Nature of illness or problem Binding: ICD-10Codes (example): Example ICD10 Diagnostic codes. Constraints: cc-text-or-code
Claim.diagnosis.Slices for diagnosis[x].diagnosis[x]:diagnosisReference		0..1	HIEReference(Condition)	Nature of illness or problem
Claim.diagnosis.type	C	0..*	HIECodeableConcept	Timing or nature of the diagnosis Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge. Constraints: cc-text-or-code
Claim.diagnosis.onAdmission	C	0..1	HIECodeableConcept	Present on admission Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission. Constraints: cc-text-or-code
Claim.diagnosis.packageCode	C	0..1	HIECodeableConcept	Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis. Constraints: cc-text-or-code
Claim.procedure		0..*	BackboneElement	Clinical procedures performed
Claim.procedure.id		0..1	string	Unique id for inter-element referencing
Claim.procedure.extension		0..*	Extension	Additional content defined by implementations
Claim.procedure.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Claim.procedure.sequence		1..1	positiveInt	Procedure instance identifier
Claim.procedure.type	C	0..*	HIECodeableConcept	Category of Procedure Binding: ExampleProcedureTypeCodes (example): Example procedure type codes. Constraints: cc-text-or-code
Claim.procedure.date		0..1	dateTime	When the procedure was performed
Claim.procedure.Slices for procedure[x]		1..1		Specific clinical procedure Slice: Unordered, Closed by type:$this Binding: ICD-10ProcedureCodes (example): Example ICD10 Procedure codes. Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
Claim.procedure.Slices for procedure[x].procedureCodeableConcept			CodeableConcept
Claim.procedure.Slices for procedure[x].procedureReference			Reference(Procedure)
Claim.procedure.Slices for procedure[x].procedure[x]:procedureCodeableConcept	C	0..1	HIECodeableConcept	Specific clinical procedure Binding: ICD-10ProcedureCodes (example): Example ICD10 Procedure codes. Constraints: cc-text-or-code
Claim.procedure.Slices for procedure[x].procedure[x]:procedureReference		0..1	HIEReference(Procedure)	Specific clinical procedure
Claim.procedure.udi		0..*	HIEReference(Device)	Unique device identifier
Claim.insurance	S This element must be supported. Σ This element is included in summaries.	1..*	BackboneElement	Patient insurance information
Claim.insurance.id		0..1	string	Unique id for inter-element referencing
Claim.insurance.extension		0..*	Extension	Additional content defined by implementations
Claim.insurance.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Claim.insurance.sequence	Σ This element is included in summaries.	1..1	positiveInt	Insurance instance identifier
Claim.insurance.focal	Σ This element is included in summaries.	1..1	boolean	Coverage to be used for adjudication
Claim.insurance.identifier		0..1	Identifier	Pre-assigned Claim number
Claim.insurance.coverage	Σ This element is included in summaries.	1..1	HIEReference(Coverage)	Insurance information
Claim.insurance.businessArrangement		0..1	string	Additional provider contract number
Claim.insurance.preAuthRef		0..*	string	Prior authorization reference number
Claim.insurance.claimResponse		0..1	HIEReference(ClaimResponse)	Adjudication results
Claim.accident		0..1	BackboneElement	Details of the event
Claim.accident.id		0..1	string	Unique id for inter-element referencing
Claim.accident.extension		0..*	Extension	Additional content defined by implementations
Claim.accident.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Claim.accident.date		1..1	date	When the incident occurred
Claim.accident.type	C	0..1	HIECodeableConcept	The nature of the accident Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc. Constraints: cc-text-or-code
Claim.accident.location[x]		0..1		Where the event occurred
Claim.accident.location[x].locationAddress			Address
Claim.accident.location[x].locationReference			Reference(Location)
Claim.item	S This element must be supported.	1..*	BackboneElement	Product or service provided
Claim.item.id		0..1	string	Unique id for inter-element referencing
Claim.item.extension		0..*	Extension	Additional content defined by implementations
Claim.item.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Claim.item.sequence		1..1	positiveInt	Item instance identifier
Claim.item.careTeamSequence		0..*	positiveInt	Applicable careTeam members
Claim.item.diagnosisSequence		0..*	positiveInt	Applicable diagnoses
Claim.item.procedureSequence		0..*	positiveInt	Applicable procedures
Claim.item.informationSequence		0..*	positiveInt	Applicable exception and supporting information
Claim.item.revenue	C	0..1	HIECodeableConcept	Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. Constraints: cc-text-or-code
Claim.item.category	C	0..1	HIECodeableConcept	Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses. Constraints: cc-text-or-code
Claim.item.productOrService	S This element must be supported. C	1..1	HIECodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. Constraints: cc-text-or-code
Claim.item.modifier	C	0..*	HIECodeableConcept	Product or service billing modifiers Binding: ModifierTypeCodes (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. Constraints: cc-text-or-code
Claim.item.programCode	C	0..*	HIECodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. Constraints: cc-text-or-code
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.location[x]		0..1		Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.
Claim.item.location[x].locationCodeableConcept			CodeableConcept
Claim.item.location[x].locationAddress			Address
Claim.item.location[x].locationReference			Reference(Location)
Claim.item.quantity	C	0..1	SimpleQuantity(4.3.0)	Count of products or services Constraints: sqty-1
Claim.item.unitPrice		0..1	Money	Fee, charge or cost per item
Claim.item.factor		0..1	decimal	Price scaling factor
Claim.item.net		0..1	Money	Total item cost
Claim.item.udi		0..*	HIEReference(Device)	Unique device identifier
Claim.item.bodySite	C	0..1	HIECodeableConcept	Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch. Constraints: cc-text-or-code
Claim.item.subSite	C	0..*	HIECodeableConcept	Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations. Constraints: cc-text-or-code
Claim.item.encounter		1..1	HIEReference(HIE Encounter)	Encounters related to this billed item
Claim.item.detail		0..*	BackboneElement	Product or service provided
Claim.item.detail.id		0..1	string	Unique id for inter-element referencing
Claim.item.detail.extension		0..*	Extension	Additional content defined by implementations
Claim.item.detail.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Claim.item.detail.sequence		1..1	positiveInt	Item instance identifier
Claim.item.detail.revenue	C	0..1	HIECodeableConcept	Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. Constraints: cc-text-or-code
Claim.item.detail.category	C	0..1	HIECodeableConcept	Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses. Constraints: cc-text-or-code
Claim.item.detail.productOrService	C	1..1	HIECodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. Constraints: cc-text-or-code
Claim.item.detail.modifier	C	0..*	HIECodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (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. Constraints: cc-text-or-code
Claim.item.detail.programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
Claim.item.detail.quantity	C	0..1	SimpleQuantity(4.3.0)	Count of products or services Constraints: sqty-1
Claim.item.detail.unitPrice		0..1	Money	Fee, charge or cost per item
Claim.item.detail.factor		0..1	decimal	Price scaling factor
Claim.item.detail.net		0..1	Money	Total item cost
Claim.item.detail.udi		0..*	HIEReference(Device)	Unique device identifier
Claim.item.detail.subDetail		0..*	BackboneElement	Product or service provided
Claim.item.detail.subDetail.id		0..1	string	Unique id for inter-element referencing
Claim.item.detail.subDetail.extension		0..*	Extension	Additional content defined by implementations
Claim.item.detail.subDetail.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Claim.item.detail.subDetail.sequence		1..1	positiveInt	Item instance identifier
Claim.item.detail.subDetail.revenue	C	0..1	HIECodeableConcept	Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. Constraints: cc-text-or-code
Claim.item.detail.subDetail.category	C	0..1	HIECodeableConcept	Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses. Constraints: cc-text-or-code
Claim.item.detail.subDetail.productOrService	C	1..1	HIECodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. Constraints: cc-text-or-code
Claim.item.detail.subDetail.modifier	C	0..*	HIECodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (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. Constraints: cc-text-or-code
Claim.item.detail.subDetail.programCode	C	0..*	HIECodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. Constraints: cc-text-or-code
Claim.item.detail.subDetail.quantity	C	0..1	SimpleQuantity(4.3.0)	Count of products or services Constraints: sqty-1
Claim.item.detail.subDetail.unitPrice		0..1	Money	Fee, charge or cost per item
Claim.item.detail.subDetail.factor		0..1	decimal	Price scaling factor
Claim.item.detail.subDetail.net		0..1	Money	Total item cost
Claim.item.detail.subDetail.udi		0..*	HIEReference(Device)	Unique device identifier
Claim.total	S This element must be supported.	1..1	Money	Total claim cost
Documentation for this format

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
Claim.language	Base	preferred	Common Languages	📍4.3.0	FHIR Std.
Claim.identifier.use	Base	required	IdentifierUse	📦4.3.0	FHIR Std.
Claim.identifier.type	Base	extensible	IdentifierType	📦4.3.0	FHIR Std.
Claim.status	Base	required	Financial Resource Status Codes	📍4.3.0	FHIR Std.
Claim.type	Base	extensible	Claim Type Codes	📍4.3.0	FHIR Std.
Claim.subType	Base	example	Example Claim SubType Codes	📍4.3.0	FHIR Std.
Claim.use	Base	required	Use	📍4.3.0	FHIR Std.
Claim.priority	Base	example	Process Priority Codes	📍4.3.0	FHIR Std.
Claim.fundsReserve	Base	example	FundsReserve	📍4.3.0	FHIR Std.
Claim.related.relationship	Base	example	Example Related Claim Relationship Codes	📍4.3.0	FHIR Std.
Claim.payee.type	Base	example	PayeeType	📍4.3.0	FHIR Std.
Claim.careTeam.role	Base	example	Claim Care Team Role Codes	📍4.3.0	FHIR Std.
Claim.careTeam.qualification	Base	example	Example Provider Qualification Codes	📍4.3.0	FHIR Std.
Claim.supportingInfo.​category	Base	example	Claim Information Category Codes	📍4.3.0	FHIR Std.
Claim.supportingInfo.​code	Base	example	Exception Codes	📍4.3.0	FHIR Std.
Claim.supportingInfo.​reason	Base	example	Missing Tooth Reason Codes	📍4.3.0	FHIR Std.
Claim.diagnosis.diagnosis[x]	Base	example	ICD-10 Codes	📍4.3.0	FHIR Std.
Claim.diagnosis.diagnosis[x]:diagnosisCodeableConcept	Base	example	ICD-10 Codes	📍4.3.0	FHIR Std.
Claim.diagnosis.type	Base	example	Example Diagnosis Type Codes	📍4.3.0	FHIR Std.
Claim.diagnosis.onAdmission	Base	example	Example Diagnosis on Admission Codes	📍4.3.0	FHIR Std.
Claim.diagnosis.packageCode	Base	example	Example Diagnosis Related Group Codes	📍4.3.0	FHIR Std.
Claim.procedure.type	Base	example	Example Procedure Type Codes	📍4.3.0	FHIR Std.
Claim.procedure.procedure[x]	Base	example	ICD-10 Procedure Codes	📍4.3.0	FHIR Std.
Claim.procedure.procedure[x]:procedureCodeableConcept	Base	example	ICD-10 Procedure Codes	📍4.3.0	FHIR Std.
Claim.accident.type	Base	extensible	ActIncidentCode	📦3.0.0	THO v7.4
Claim.item.revenue	Base	example	Example Revenue Center Codes	📍4.3.0	FHIR Std.
Claim.item.category	Base	example	Benefit Category Codes	📍4.3.0	FHIR Std.
Claim.item.productOrService	Base	example	USCLS Codes	📍4.3.0	FHIR Std.
Claim.item.modifier	Base	example	Modifier type Codes	📍4.3.0	FHIR Std.
Claim.item.programCode	Base	example	Example Program Reason Codes	📍4.3.0	FHIR Std.
Claim.item.location[x]	Base	example	Example Service Place Codes	📍4.3.0	FHIR Std.
Claim.item.bodySite	Base	example	Oral Site Codes	📍4.3.0	FHIR Std.
Claim.item.subSite	Base	example	Surface Codes	📍4.3.0	FHIR Std.
Claim.item.detail.revenue	Base	example	Example Revenue Center Codes	📍4.3.0	FHIR Std.
Claim.item.detail.category	Base	example	Benefit Category Codes	📍4.3.0	FHIR Std.
Claim.item.detail.productOrService	Base	example	USCLS Codes	📍4.3.0	FHIR Std.
Claim.item.detail.modifier	Base	example	Modifier type Codes	📍4.3.0	FHIR Std.
Claim.item.detail.programCode	Base	example	Example Program Reason Codes	📍4.3.0	FHIR Std.
Claim.item.detail.subDetail.​revenue	Base	example	Example Revenue Center Codes	📍4.3.0	FHIR Std.
Claim.item.detail.subDetail.​category	Base	example	Benefit Category Codes	📍4.3.0	FHIR Std.
Claim.item.detail.subDetail.​productOrService	Base	example	USCLS Codes	📍4.3.0	FHIR Std.
Claim.item.detail.subDetail.​modifier	Base	example	Modifier type Codes	📍4.3.0	FHIR Std.
Claim.item.detail.subDetail.​programCode	Base	example	Example Program Reason Codes	📍4.3.0	FHIR Std.

Constraints

Id	Grade	Path(s)	Description	Expression
cc-text-or-code	warning	Claim.identifier.type, Claim.type, Claim.subType, Claim.priority, Claim.fundsReserve, Claim.payee.type, Claim.careTeam.role, Claim.careTeam.qualification, Claim.supportingInfo.category, Claim.supportingInfo.code, Claim.supportingInfo.reason, Claim.diagnosis.diagnosis[x]:diagnosisCodeableConcept, Claim.diagnosis.type, Claim.diagnosis.onAdmission, Claim.diagnosis.packageCode, Claim.procedure.type, Claim.procedure.procedure[x]:procedureCodeableConcept, Claim.accident.type, Claim.item.revenue, Claim.item.category, Claim.item.productOrService, Claim.item.modifier, Claim.item.programCode, Claim.item.bodySite, Claim.item.subSite, Claim.item.detail.revenue, Claim.item.detail.category, Claim.item.detail.productOrService, Claim.item.detail.modifier, Claim.item.detail.subDetail.revenue, Claim.item.detail.subDetail.category, Claim.item.detail.subDetail.productOrService, Claim.item.detail.subDetail.modifier, Claim.item.detail.subDetail.programCode	Text is optional, coding is required	coding.exists()
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.exists() and ('#'+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(uri) = '#').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()
dom-r4b	warning	Claim.contained	Containing new R4B resources within R4 resources may cause interoperability issues if instances are shared with R4 systems	($this is Citation or $this is Evidence or $this is EvidenceReport or $this is EvidenceVariable or $this is MedicinalProductDefinition or $this is PackagedProductDefinition or $this is AdministrableProductDefinition or $this is Ingredient or $this is ClinicalUseDefinition or $this is RegulatedAuthorization or $this is SubstanceDefinition or $this is SubscriptionStatus or $this is SubscriptionTopic) implies (%resource is Citation or %resource is Evidence or %resource is EvidenceReport or %resource is EvidenceVariable or %resource is MedicinalProductDefinition or %resource is PackagedProductDefinition or %resource is AdministrableProductDefinition or %resource is Ingredient or %resource is ClinicalUseDefinition or %resource is RegulatedAuthorization or %resource is SubstanceDefinition or %resource is SubscriptionStatus or %resource is SubscriptionTopic)
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.quantity, Claim.item.detail.subDetail.quantity	The comparator is not used on a SimpleQuantity	comparator.empty()

This structure is derived from Claim

Summary

Mandatory: 10 elements(1 nested mandatory element)
Must-Support: 15 elements

Structures

This structure refers to these other structures:

• HIE CodeableConcept (https://nshr.dha.go.ke/fhir/StructureDefinition/codeable-concept)
• HIE Reference (https://nshr.dha.go.ke/fhir/StructureDefinition/reference)
• HIE Organization (https://nshr.dha.go.ke/fhir/StructureDefinition/organization)
• HIE Patient (https://nshr.dha.go.ke/fhir/StructureDefinition/patient)
• HIE Practitioner (https://nshr.dha.go.ke/fhir/StructureDefinition/practitioner)
• HIE Claim (https://nshr.dha.go.ke/fhir/StructureDefinition/claim)
• HIE Encounter (https://nshr.dha.go.ke/fhir/StructureDefinition/encounter)

Slices

This structure defines the following Slices:

• The element 1 is sliced based on the value of Claim.supportingInfo.value[x]
• The element 1 is sliced based on the value of Claim.diagnosis.diagnosis[x]
• The element 1 is sliced based on the value of Claim.procedure.procedure[x]

Key Elements View

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Claim		0..*	Claim	Claim, Pre-determination or Pre-authorization
Claim.implicitRules	?! This element is a modifier element. Σ This element is included in summaries.	0..1	uri	A set of rules under which this content was created
Claim.modifierExtension	?! This element is a modifier element.	0..*	Extension	Extensions that cannot be ignored
Claim.identifier	S This element must be supported.	1..*	Identifier	Business Identifier for claim
Claim.identifier.use	?! This element is a modifier element. Σ This element is included in summaries.	1..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required)
Claim.identifier.type	Σ This element is included in summaries. C	1..1	HIECodeableConcept	Description of identifier Binding: Identifier Type Codes (extensible) Constraints: cc-text-or-code
Claim.identifier.system	Σ This element is included in summaries.	1..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
Claim.identifier.value	S This element must be supported. Σ This element is included in summaries.	1..1	string	The value that is unique Example General: 123456
Claim.identifier.assigner	S This element must be supported. Σ This element is included in summaries.	0..1	HIEReference(HIE Organization)	Organization that issued id (may be just text)
Claim.status	?! This element is a modifier element. S This element must be supported. Σ 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	S This element must be supported. Σ This element is included in summaries. C	1..1	HIECodeableConcept	Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. Constraints: cc-text-or-code
Claim.subType	C	0..1	HIECodeableConcept	More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode. Constraints: cc-text-or-code
Claim.use	S This element must be supported. Σ 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	S This element must be supported. Σ This element is included in summaries.	1..1	HIEReference(HIE Patient)	The recipient of the products and services
Claim.billablePeriod	Σ This element is included in summaries.	1..1	Period	Relevant time frame for the claim
Claim.created	S This element must be supported. Σ This element is included in summaries.	1..1	dateTime	Resource creation date
Claim.enterer		0..1	HIEReference(HIE Practitioner | PractitionerRole)	Author of the claim
Claim.insurer	Σ This element is included in summaries.	0..1	HIEReference(HIE Organization)	Target
Claim.provider	S This element must be supported. Σ This element is included in summaries.	1..1	HIEReference(HIE Organization | HIE Practitioner | PractitionerRole)	Party responsible for the claim
Claim.priority	S This element must be supported. Σ This element is included in summaries. C	1..1	HIECodeableConcept	Desired processing ugency Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred. Constraints: cc-text-or-code
Claim.fundsReserve	C	0..1	HIECodeableConcept	For whom to reserve funds Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None). Constraints: cc-text-or-code
Claim.prescription		0..1	HIEReference(DeviceRequest | MedicationRequest | VisionPrescription)	Prescription authorizing services and products
Claim.originalPrescription		0..1	HIEReference(DeviceRequest | MedicationRequest | VisionPrescription)	Original prescription if superseded by fulfiller
Claim.referral		0..1	HIEReference(ServiceRequest)	Treatment referral
Claim.facility		0..1	HIEReference(Location)	Servicing facility
Claim.diagnosis	S This element must be supported.	1..*	BackboneElement	Pertinent diagnosis information
Claim.diagnosis.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Claim.diagnosis.sequence		1..1	positiveInt	Diagnosis instance identifier
Claim.diagnosis.Slices for diagnosis[x]		1..1		Nature of illness or problem Slice: Unordered, Closed by type:$this Binding: ICD-10Codes (example): Example ICD10 Diagnostic codes. Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
Claim.diagnosis.Slices for diagnosis[x].diagnosisCodeableConcept			CodeableConcept
Claim.diagnosis.Slices for diagnosis[x].diagnosisReference			Reference(Condition)
Claim.diagnosis.Slices for diagnosis[x].diagnosis[x]:diagnosisCodeableConcept	C	0..1	HIECodeableConcept	Nature of illness or problem Binding: ICD-10Codes (example): Example ICD10 Diagnostic codes. Constraints: cc-text-or-code
Claim.diagnosis.Slices for diagnosis[x].diagnosis[x]:diagnosisReference		0..1	HIEReference(Condition)	Nature of illness or problem
Claim.diagnosis.type	C	0..*	HIECodeableConcept	Timing or nature of the diagnosis Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge. Constraints: cc-text-or-code
Claim.diagnosis.onAdmission	C	0..1	HIECodeableConcept	Present on admission Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission. Constraints: cc-text-or-code
Claim.diagnosis.packageCode	C	0..1	HIECodeableConcept	Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis. Constraints: cc-text-or-code
Claim.insurance	S This element must be supported. Σ This element is included in summaries.	1..*	BackboneElement	Patient insurance information
Claim.insurance.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Claim.insurance.sequence	Σ This element is included in summaries.	1..1	positiveInt	Insurance instance identifier
Claim.insurance.focal	Σ This element is included in summaries.	1..1	boolean	Coverage to be used for adjudication
Claim.insurance.coverage	Σ This element is included in summaries.	1..1	HIEReference(Coverage)	Insurance information
Claim.insurance.claimResponse		0..1	HIEReference(ClaimResponse)	Adjudication results
Claim.item	S This element must be supported.	1..*	BackboneElement	Product or service provided
Claim.item.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Claim.item.sequence		1..1	positiveInt	Item instance identifier
Claim.item.revenue	C	0..1	HIECodeableConcept	Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. Constraints: cc-text-or-code
Claim.item.category	C	0..1	HIECodeableConcept	Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses. Constraints: cc-text-or-code
Claim.item.productOrService	S This element must be supported. C	1..1	HIECodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. Constraints: cc-text-or-code
Claim.item.modifier	C	0..*	HIECodeableConcept	Product or service billing modifiers Binding: ModifierTypeCodes (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. Constraints: cc-text-or-code
Claim.item.programCode	C	0..*	HIECodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. Constraints: cc-text-or-code
Claim.item.udi		0..*	HIEReference(Device)	Unique device identifier
Claim.item.bodySite	C	0..1	HIECodeableConcept	Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch. Constraints: cc-text-or-code
Claim.item.subSite	C	0..*	HIECodeableConcept	Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations. Constraints: cc-text-or-code
Claim.item.encounter		1..1	HIEReference(HIE Encounter)	Encounters related to this billed item
Claim.total	S This element must be supported.	1..1	Money	Total claim cost
Documentation for this format

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
Claim.identifier.use	Base	required	IdentifierUse	📦4.3.0	FHIR Std.
Claim.identifier.type	Base	extensible	IdentifierType	📦4.3.0	FHIR Std.
Claim.status	Base	required	Financial Resource Status Codes	📍4.3.0	FHIR Std.
Claim.type	Base	extensible	Claim Type Codes	📍4.3.0	FHIR Std.
Claim.subType	Base	example	Example Claim SubType Codes	📍4.3.0	FHIR Std.
Claim.use	Base	required	Use	📍4.3.0	FHIR Std.
Claim.priority	Base	example	Process Priority Codes	📍4.3.0	FHIR Std.
Claim.fundsReserve	Base	example	FundsReserve	📍4.3.0	FHIR Std.
Claim.diagnosis.diagnosis[x]	Base	example	ICD-10 Codes	📍4.3.0	FHIR Std.
Claim.diagnosis.diagnosis[x]:diagnosisCodeableConcept	Base	example	ICD-10 Codes	📍4.3.0	FHIR Std.
Claim.diagnosis.type	Base	example	Example Diagnosis Type Codes	📍4.3.0	FHIR Std.
Claim.diagnosis.onAdmission	Base	example	Example Diagnosis on Admission Codes	📍4.3.0	FHIR Std.
Claim.diagnosis.packageCode	Base	example	Example Diagnosis Related Group Codes	📍4.3.0	FHIR Std.
Claim.item.revenue	Base	example	Example Revenue Center Codes	📍4.3.0	FHIR Std.
Claim.item.category	Base	example	Benefit Category Codes	📍4.3.0	FHIR Std.
Claim.item.productOrService	Base	example	USCLS Codes	📍4.3.0	FHIR Std.
Claim.item.modifier	Base	example	Modifier type Codes	📍4.3.0	FHIR Std.
Claim.item.programCode	Base	example	Example Program Reason Codes	📍4.3.0	FHIR Std.
Claim.item.bodySite	Base	example	Oral Site Codes	📍4.3.0	FHIR Std.
Claim.item.subSite	Base	example	Surface Codes	📍4.3.0	FHIR Std.

Constraints

Id	Grade	Path(s)	Description	Expression
cc-text-or-code	warning	Claim.identifier.type, Claim.type, Claim.subType, Claim.priority, Claim.fundsReserve, Claim.diagnosis.diagnosis[x]:diagnosisCodeableConcept, Claim.diagnosis.type, Claim.diagnosis.onAdmission, Claim.diagnosis.packageCode, Claim.item.revenue, Claim.item.category, Claim.item.productOrService, Claim.item.modifier, Claim.item.programCode, Claim.item.bodySite, Claim.item.subSite	Text is optional, coding is required	coding.exists()
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.exists() and ('#'+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(uri) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	Claim	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated	contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	Claim	If a resource is contained in another resource, it SHALL NOT have a security label	contained.meta.security.empty()
dom-6	best practice	Claim	A resource should have narrative for robust management	text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children	hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both	extension.exists() != value.exists()

Differential View

This structure is derived from Claim

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Claim		0..*	Claim	Claim, Pre-determination or Pre-authorization
Claim.identifier	S This element must be supported.	1..*	Identifier	Business Identifier for claim
Claim.identifier.use		1..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required)
Claim.identifier.type		1..1	HIECodeableConcept	Description of identifier Binding: Identifier Type Codes (extensible)
Claim.identifier.system		1..1	uri	The namespace for the identifier value
Claim.identifier.value	S This element must be supported.	1..1	string	The value that is unique
Claim.identifier.assigner	S This element must be supported.	0..1	HIEReference(HIE Organization)	Organization that issued id (may be just text)
Claim.status	S This element must be supported.	1..1	code	active | cancelled | draft | entered-in-error
Claim.type	S This element must be supported.	1..1	HIECodeableConcept	Category or discipline
Claim.subType		0..1	HIECodeableConcept	More granular claim type
Claim.use	S This element must be supported.	1..1	code	claim | preauthorization | predetermination
Claim.patient	S This element must be supported.	1..1	HIEReference(HIE Patient)	The recipient of the products and services
Claim.billablePeriod		1..1	Period	Relevant time frame for the claim
Claim.created	S This element must be supported.	1..1	dateTime	Resource creation date
Claim.enterer		0..1	HIEReference(HIE Practitioner | PractitionerRole)	Author of the claim
Claim.insurer		0..1	HIEReference(HIE Organization)	Target
Claim.provider	S This element must be supported.	1..1	HIEReference(HIE Organization | HIE Practitioner | PractitionerRole)	Party responsible for the claim
Claim.priority	S This element must be supported.	1..1	HIECodeableConcept	Desired processing ugency
Claim.fundsReserve		0..1	HIECodeableConcept	For whom to reserve funds
Claim.related
Claim.related.claim		0..1	HIEReference(HIE Claim)	Reference to the related claim
Claim.prescription		0..1	HIEReference(DeviceRequest | MedicationRequest | VisionPrescription)	Prescription authorizing services and products
Claim.originalPrescription		0..1	HIEReference(DeviceRequest | MedicationRequest | VisionPrescription)	Original prescription if superseded by fulfiller
Claim.payee
Claim.payee.type		1..1	HIECodeableConcept	Category of recipient
Claim.payee.party		1..1	HIEReference(HIE Practitioner | PractitionerRole | HIE Organization | HIE Patient | RelatedPerson)	Recipient reference
Claim.referral		0..1	HIEReference(ServiceRequest)	Treatment referral
Claim.facility		0..1	HIEReference(Location)	Servicing facility
Claim.careTeam
Claim.careTeam.provider		1..1	HIEReference(HIE Practitioner | PractitionerRole | HIE Organization)	Practitioner or organization
Claim.careTeam.role		0..1	HIECodeableConcept	Function within the team
Claim.careTeam.qualification		0..1	HIECodeableConcept	Practitioner credential or specialization
Claim.supportingInfo
Claim.supportingInfo.category		1..1	HIECodeableConcept	Classification of the supplied information
Claim.supportingInfo.code		0..1	HIECodeableConcept	Type of information
Claim.supportingInfo.Slices for value[x]		0..1		Data to be provided Slice: Unordered, Open by type:$this Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them Other type slices that contain no new information are not shown in this view
Claim.supportingInfo.Slices for value[x].valueBoolean			boolean
Claim.supportingInfo.Slices for value[x].valueString			string
Claim.supportingInfo.Slices for value[x].valueQuantity			Quantity
Claim.supportingInfo.Slices for value[x].valueAttachment			Attachment
Claim.supportingInfo.Slices for value[x].valueReference			Reference(Resource)
Claim.supportingInfo.Slices for value[x].value[x]:valueReference		0..1	HIEReference(Resource)	Data to be provided
Claim.supportingInfo.reason		0..1	HIECodeableConcept	Explanation for the information
Claim.diagnosis	S This element must be supported.	1..*	BackboneElement	Pertinent diagnosis information
Claim.diagnosis.Slices for diagnosis[x]		1..1		Nature of illness or problem Slice: Unordered, Open by type:$this Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
Claim.diagnosis.Slices for diagnosis[x].diagnosisCodeableConcept			CodeableConcept
Claim.diagnosis.Slices for diagnosis[x].diagnosisReference			Reference(Condition)
Claim.diagnosis.Slices for diagnosis[x].diagnosis[x]:diagnosisCodeableConcept		0..1	HIECodeableConcept	Nature of illness or problem
Claim.diagnosis.Slices for diagnosis[x].diagnosis[x]:diagnosisReference		0..1	HIEReference(Condition)	Nature of illness or problem
Claim.diagnosis.type		0..*	HIECodeableConcept	Timing or nature of the diagnosis
Claim.diagnosis.onAdmission		0..1	HIECodeableConcept	Present on admission
Claim.diagnosis.packageCode		0..1	HIECodeableConcept	Package billing code
Claim.procedure
Claim.procedure.type		0..*	HIECodeableConcept	Category of Procedure
Claim.procedure.Slices for procedure[x]		1..1		Specific clinical procedure Slice: Unordered, Open by type:$this Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
Claim.procedure.Slices for procedure[x].procedureCodeableConcept			CodeableConcept
Claim.procedure.Slices for procedure[x].procedureReference			Reference(Procedure)
Claim.procedure.Slices for procedure[x].procedure[x]:procedureCodeableConcept		0..1	HIECodeableConcept	Specific clinical procedure
Claim.procedure.Slices for procedure[x].procedure[x]:procedureReference		0..1	HIEReference(Procedure)	Specific clinical procedure
Claim.procedure.udi		0..*	HIEReference(Device)	Unique device identifier
Claim.insurance	S This element must be supported.	1..*	BackboneElement	Patient insurance information
Claim.insurance.coverage		1..1	HIEReference(Coverage)	Insurance information
Claim.insurance.claimResponse		0..1	HIEReference(ClaimResponse)	Adjudication results
Claim.accident
Claim.accident.type		0..1	HIECodeableConcept	The nature of the accident
Claim.item	S This element must be supported.	1..*	BackboneElement	Product or service provided
Claim.item.revenue		0..1	HIECodeableConcept	Revenue or cost center code
Claim.item.category		0..1	HIECodeableConcept	Benefit classification
Claim.item.productOrService	S This element must be supported.	1..1	HIECodeableConcept	Billing, service, product, or drug code
Claim.item.modifier		0..*	HIECodeableConcept	Product or service billing modifiers
Claim.item.programCode		0..*	HIECodeableConcept	Program the product or service is provided under
Claim.item.udi		0..*	HIEReference(Device)	Unique device identifier
Claim.item.bodySite		0..1	HIECodeableConcept	Anatomical location
Claim.item.subSite		0..*	HIECodeableConcept	Anatomical sub-location
Claim.item.encounter		1..1	HIEReference(HIE Encounter)	Encounters related to this billed item
Claim.item.detail
Claim.item.detail.revenue		0..1	HIECodeableConcept	Revenue or cost center code
Claim.item.detail.category		0..1	HIECodeableConcept	Benefit classification
Claim.item.detail.productOrService		1..1	HIECodeableConcept	Billing, service, product, or drug code
Claim.item.detail.modifier		0..*	HIECodeableConcept	Service/Product billing modifiers
Claim.item.detail.udi		0..*	HIEReference(Device)	Unique device identifier
Claim.item.detail.subDetail
Claim.item.detail.subDetail.revenue		0..1	HIECodeableConcept	Revenue or cost center code
Claim.item.detail.subDetail.category		0..1	HIECodeableConcept	Benefit classification
Claim.item.detail.subDetail.productOrService		1..1	HIECodeableConcept	Billing, service, product, or drug code
Claim.item.detail.subDetail.modifier		0..*	HIECodeableConcept	Service/Product billing modifiers
Claim.item.detail.subDetail.programCode		0..*	HIECodeableConcept	Program the product or service is provided under
Claim.item.detail.subDetail.udi		0..*	HIEReference(Device)	Unique device identifier
Claim.total	S This element must be supported.	1..1	Money	Total claim cost
Documentation for this format

Terminology Bindings (Differential)

Path	Status	Usage	ValueSet	Version	Source
Claim.identifier.use	Base	required	IdentifierUse	📦4.3.0	FHIR Std.
Claim.identifier.type	Base	extensible	IdentifierType	📦4.3.0	FHIR Std.

Snapshot View

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Claim		0..*	Claim	Claim, Pre-determination or Pre-authorization
Claim.id	Σ This element is included in summaries.	0..1	id	Logical id of this artifact
Claim.meta	Σ This element is included in summaries.	0..1	Meta	Metadata about the resource
Claim.implicitRules	?! This element is a modifier element. Σ This element is included in summaries.	0..1	uri	A set of rules under which this content was created
Claim.language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): IETF language tag Additional Bindings Purpose AllLanguages Max Binding
Claim.text		0..1	Narrative	Text 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..*	Resource	Contained, inline Resources Constraints: dom-r4b
Claim.extension		0..*	Extension	Additional content defined by implementations
Claim.modifierExtension	?! This element is a modifier element.	0..*	Extension	Extensions that cannot be ignored
Claim.identifier	S This element must be supported.	1..*	Identifier	Business Identifier for claim
Claim.identifier.id		0..1	id	Unique id for inter-element referencing
Claim.identifier.extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
Claim.identifier.use	?! This element is a modifier element. Σ This element is included in summaries.	1..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required)
Claim.identifier.type	Σ This element is included in summaries. C	1..1	HIECodeableConcept	Description of identifier Binding: Identifier Type Codes (extensible) Constraints: cc-text-or-code
Claim.identifier.system	Σ This element is included in summaries.	1..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
Claim.identifier.value	S This element must be supported. Σ This element is included in summaries.	1..1	string	The value that is unique Example General: 123456
Claim.identifier.period	Σ This element is included in summaries.	0..1	Period	Time period when id is/was valid for use
Claim.identifier.assigner	S This element must be supported. Σ This element is included in summaries.	0..1	HIEReference(HIE Organization)	Organization that issued id (may be just text)
Claim.status	?! This element is a modifier element. S This element must be supported. Σ 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	S This element must be supported. Σ This element is included in summaries. C	1..1	HIECodeableConcept	Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. Constraints: cc-text-or-code
Claim.subType	C	0..1	HIECodeableConcept	More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode. Constraints: cc-text-or-code
Claim.use	S This element must be supported. Σ 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	S This element must be supported. Σ This element is included in summaries.	1..1	HIEReference(HIE Patient)	The recipient of the products and services
Claim.billablePeriod	Σ This element is included in summaries.	1..1	Period	Relevant time frame for the claim
Claim.created	S This element must be supported. Σ This element is included in summaries.	1..1	dateTime	Resource creation date
Claim.enterer		0..1	HIEReference(HIE Practitioner | PractitionerRole)	Author of the claim
Claim.insurer	Σ This element is included in summaries.	0..1	HIEReference(HIE Organization)	Target
Claim.provider	S This element must be supported. Σ This element is included in summaries.	1..1	HIEReference(HIE Organization | HIE Practitioner | PractitionerRole)	Party responsible for the claim
Claim.priority	S This element must be supported. Σ This element is included in summaries. C	1..1	HIECodeableConcept	Desired processing ugency Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred. Constraints: cc-text-or-code
Claim.fundsReserve	C	0..1	HIECodeableConcept	For whom to reserve funds Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None). Constraints: cc-text-or-code
Claim.related		0..*	BackboneElement	Prior or corollary claims
Claim.related.id		0..1	string	Unique id for inter-element referencing
Claim.related.extension		0..*	Extension	Additional content defined by implementations
Claim.related.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Claim.related.claim		0..1	HIEReference(HIE Claim)	Reference to the related claim
Claim.related.relationship		0..1	CodeableConcept	How the reference claim is related Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim.
Claim.related.reference		0..1	Identifier	File or case reference
Claim.prescription		0..1	HIEReference(DeviceRequest | MedicationRequest | VisionPrescription)	Prescription authorizing services and products
Claim.originalPrescription		0..1	HIEReference(DeviceRequest | MedicationRequest | VisionPrescription)	Original prescription if superseded by fulfiller
Claim.payee		0..1	BackboneElement	Recipient of benefits payable
Claim.payee.id		0..1	string	Unique id for inter-element referencing
Claim.payee.extension		0..*	Extension	Additional content defined by implementations
Claim.payee.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Claim.payee.type	C	1..1	HIECodeableConcept	Category of recipient Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed. Constraints: cc-text-or-code
Claim.payee.party		1..1	HIEReference(HIE Practitioner | PractitionerRole | HIE Organization | HIE Patient | RelatedPerson)	Recipient reference
Claim.referral		0..1	HIEReference(ServiceRequest)	Treatment referral
Claim.facility		0..1	HIEReference(Location)	Servicing facility
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. Σ 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	HIEReference(HIE Practitioner | PractitionerRole | HIE Organization)	Practitioner or organization
Claim.careTeam.responsible		0..1	boolean	Indicator of the lead practitioner
Claim.careTeam.role	C	0..1	HIECodeableConcept	Function within the team Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members. Constraints: cc-text-or-code
Claim.careTeam.qualification	C	0..1	HIECodeableConcept	Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications. Constraints: cc-text-or-code
Claim.supportingInfo		0..*	BackboneElement	Supporting information
Claim.supportingInfo.id		0..1	string	Unique id for inter-element referencing
Claim.supportingInfo.extension		0..*	Extension	Additional content defined by implementations
Claim.supportingInfo.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Claim.supportingInfo.sequence		1..1	positiveInt	Information instance identifier
Claim.supportingInfo.category	C	1..1	HIECodeableConcept	Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. Constraints: cc-text-or-code
Claim.supportingInfo.code	C	0..1	HIECodeableConcept	Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes. Constraints: cc-text-or-code
Claim.supportingInfo.timing[x]		0..1		When it occurred
Claim.supportingInfo.timing[x].timingDate			date
Claim.supportingInfo.timing[x].timingPeriod			Period
Claim.supportingInfo.Slices for value[x]		0..1		Data to be provided Slice: Unordered, Closed by type:$this Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them Other type slices that contain no new information are not shown in this view
Claim.supportingInfo.Slices for value[x].valueBoolean			boolean
Claim.supportingInfo.Slices for value[x].valueString			string
Claim.supportingInfo.Slices for value[x].valueQuantity			Quantity
Claim.supportingInfo.Slices for value[x].valueAttachment			Attachment
Claim.supportingInfo.Slices for value[x].valueReference			Reference(Resource)
Claim.supportingInfo.Slices for value[x].value[x]:valueReference		0..1	HIEReference(Resource)	Data to be provided
Claim.supportingInfo.reason	C	0..1	HIECodeableConcept	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth. Constraints: cc-text-or-code
Claim.diagnosis	S This element must be supported.	1..*	BackboneElement	Pertinent diagnosis information
Claim.diagnosis.id		0..1	string	Unique id for inter-element referencing
Claim.diagnosis.extension		0..*	Extension	Additional content defined by implementations
Claim.diagnosis.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Claim.diagnosis.sequence		1..1	positiveInt	Diagnosis instance identifier
Claim.diagnosis.Slices for diagnosis[x]		1..1		Nature of illness or problem Slice: Unordered, Closed by type:$this Binding: ICD-10Codes (example): Example ICD10 Diagnostic codes. Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
Claim.diagnosis.Slices for diagnosis[x].diagnosisCodeableConcept			CodeableConcept
Claim.diagnosis.Slices for diagnosis[x].diagnosisReference			Reference(Condition)
Claim.diagnosis.Slices for diagnosis[x].diagnosis[x]:diagnosisCodeableConcept	C	0..1	HIECodeableConcept	Nature of illness or problem Binding: ICD-10Codes (example): Example ICD10 Diagnostic codes. Constraints: cc-text-or-code
Claim.diagnosis.Slices for diagnosis[x].diagnosis[x]:diagnosisReference		0..1	HIEReference(Condition)	Nature of illness or problem
Claim.diagnosis.type	C	0..*	HIECodeableConcept	Timing or nature of the diagnosis Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge. Constraints: cc-text-or-code
Claim.diagnosis.onAdmission	C	0..1	HIECodeableConcept	Present on admission Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission. Constraints: cc-text-or-code
Claim.diagnosis.packageCode	C	0..1	HIECodeableConcept	Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis. Constraints: cc-text-or-code
Claim.procedure		0..*	BackboneElement	Clinical procedures performed
Claim.procedure.id		0..1	string	Unique id for inter-element referencing
Claim.procedure.extension		0..*	Extension	Additional content defined by implementations
Claim.procedure.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Claim.procedure.sequence		1..1	positiveInt	Procedure instance identifier
Claim.procedure.type	C	0..*	HIECodeableConcept	Category of Procedure Binding: ExampleProcedureTypeCodes (example): Example procedure type codes. Constraints: cc-text-or-code
Claim.procedure.date		0..1	dateTime	When the procedure was performed
Claim.procedure.Slices for procedure[x]		1..1		Specific clinical procedure Slice: Unordered, Closed by type:$this Binding: ICD-10ProcedureCodes (example): Example ICD10 Procedure codes. Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
Claim.procedure.Slices for procedure[x].procedureCodeableConcept			CodeableConcept
Claim.procedure.Slices for procedure[x].procedureReference			Reference(Procedure)
Claim.procedure.Slices for procedure[x].procedure[x]:procedureCodeableConcept	C	0..1	HIECodeableConcept	Specific clinical procedure Binding: ICD-10ProcedureCodes (example): Example ICD10 Procedure codes. Constraints: cc-text-or-code
Claim.procedure.Slices for procedure[x].procedure[x]:procedureReference		0..1	HIEReference(Procedure)	Specific clinical procedure
Claim.procedure.udi		0..*	HIEReference(Device)	Unique device identifier
Claim.insurance	S This element must be supported. Σ This element is included in summaries.	1..*	BackboneElement	Patient insurance information
Claim.insurance.id		0..1	string	Unique id for inter-element referencing
Claim.insurance.extension		0..*	Extension	Additional content defined by implementations
Claim.insurance.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Claim.insurance.sequence	Σ This element is included in summaries.	1..1	positiveInt	Insurance instance identifier
Claim.insurance.focal	Σ This element is included in summaries.	1..1	boolean	Coverage to be used for adjudication
Claim.insurance.identifier		0..1	Identifier	Pre-assigned Claim number
Claim.insurance.coverage	Σ This element is included in summaries.	1..1	HIEReference(Coverage)	Insurance information
Claim.insurance.businessArrangement		0..1	string	Additional provider contract number
Claim.insurance.preAuthRef		0..*	string	Prior authorization reference number
Claim.insurance.claimResponse		0..1	HIEReference(ClaimResponse)	Adjudication results
Claim.accident		0..1	BackboneElement	Details of the event
Claim.accident.id		0..1	string	Unique id for inter-element referencing
Claim.accident.extension		0..*	Extension	Additional content defined by implementations
Claim.accident.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Claim.accident.date		1..1	date	When the incident occurred
Claim.accident.type	C	0..1	HIECodeableConcept	The nature of the accident Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc. Constraints: cc-text-or-code
Claim.accident.location[x]		0..1		Where the event occurred
Claim.accident.location[x].locationAddress			Address
Claim.accident.location[x].locationReference			Reference(Location)
Claim.item	S This element must be supported.	1..*	BackboneElement	Product or service provided
Claim.item.id		0..1	string	Unique id for inter-element referencing
Claim.item.extension		0..*	Extension	Additional content defined by implementations
Claim.item.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Claim.item.sequence		1..1	positiveInt	Item instance identifier
Claim.item.careTeamSequence		0..*	positiveInt	Applicable careTeam members
Claim.item.diagnosisSequence		0..*	positiveInt	Applicable diagnoses
Claim.item.procedureSequence		0..*	positiveInt	Applicable procedures
Claim.item.informationSequence		0..*	positiveInt	Applicable exception and supporting information
Claim.item.revenue	C	0..1	HIECodeableConcept	Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. Constraints: cc-text-or-code
Claim.item.category	C	0..1	HIECodeableConcept	Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses. Constraints: cc-text-or-code
Claim.item.productOrService	S This element must be supported. C	1..1	HIECodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. Constraints: cc-text-or-code
Claim.item.modifier	C	0..*	HIECodeableConcept	Product or service billing modifiers Binding: ModifierTypeCodes (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. Constraints: cc-text-or-code
Claim.item.programCode	C	0..*	HIECodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. Constraints: cc-text-or-code
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.location[x]		0..1		Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.
Claim.item.location[x].locationCodeableConcept			CodeableConcept
Claim.item.location[x].locationAddress			Address
Claim.item.location[x].locationReference			Reference(Location)
Claim.item.quantity	C	0..1	SimpleQuantity(4.3.0)	Count of products or services Constraints: sqty-1
Claim.item.unitPrice		0..1	Money	Fee, charge or cost per item
Claim.item.factor		0..1	decimal	Price scaling factor
Claim.item.net		0..1	Money	Total item cost
Claim.item.udi		0..*	HIEReference(Device)	Unique device identifier
Claim.item.bodySite	C	0..1	HIECodeableConcept	Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch. Constraints: cc-text-or-code
Claim.item.subSite	C	0..*	HIECodeableConcept	Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations. Constraints: cc-text-or-code
Claim.item.encounter		1..1	HIEReference(HIE Encounter)	Encounters related to this billed item
Claim.item.detail		0..*	BackboneElement	Product or service provided
Claim.item.detail.id		0..1	string	Unique id for inter-element referencing
Claim.item.detail.extension		0..*	Extension	Additional content defined by implementations
Claim.item.detail.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Claim.item.detail.sequence		1..1	positiveInt	Item instance identifier
Claim.item.detail.revenue	C	0..1	HIECodeableConcept	Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. Constraints: cc-text-or-code
Claim.item.detail.category	C	0..1	HIECodeableConcept	Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses. Constraints: cc-text-or-code
Claim.item.detail.productOrService	C	1..1	HIECodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. Constraints: cc-text-or-code
Claim.item.detail.modifier	C	0..*	HIECodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (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. Constraints: cc-text-or-code
Claim.item.detail.programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
Claim.item.detail.quantity	C	0..1	SimpleQuantity(4.3.0)	Count of products or services Constraints: sqty-1
Claim.item.detail.unitPrice		0..1	Money	Fee, charge or cost per item
Claim.item.detail.factor		0..1	decimal	Price scaling factor
Claim.item.detail.net		0..1	Money	Total item cost
Claim.item.detail.udi		0..*	HIEReference(Device)	Unique device identifier
Claim.item.detail.subDetail		0..*	BackboneElement	Product or service provided
Claim.item.detail.subDetail.id		0..1	string	Unique id for inter-element referencing
Claim.item.detail.subDetail.extension		0..*	Extension	Additional content defined by implementations
Claim.item.detail.subDetail.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Claim.item.detail.subDetail.sequence		1..1	positiveInt	Item instance identifier
Claim.item.detail.subDetail.revenue	C	0..1	HIECodeableConcept	Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. Constraints: cc-text-or-code
Claim.item.detail.subDetail.category	C	0..1	HIECodeableConcept	Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses. Constraints: cc-text-or-code
Claim.item.detail.subDetail.productOrService	C	1..1	HIECodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. Constraints: cc-text-or-code
Claim.item.detail.subDetail.modifier	C	0..*	HIECodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (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. Constraints: cc-text-or-code
Claim.item.detail.subDetail.programCode	C	0..*	HIECodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. Constraints: cc-text-or-code
Claim.item.detail.subDetail.quantity	C	0..1	SimpleQuantity(4.3.0)	Count of products or services Constraints: sqty-1
Claim.item.detail.subDetail.unitPrice		0..1	Money	Fee, charge or cost per item
Claim.item.detail.subDetail.factor		0..1	decimal	Price scaling factor
Claim.item.detail.subDetail.net		0..1	Money	Total item cost
Claim.item.detail.subDetail.udi		0..*	HIEReference(Device)	Unique device identifier
Claim.total	S This element must be supported.	1..1	Money	Total claim cost
Documentation for this format

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
Claim.language	Base	preferred	Common Languages	📍4.3.0	FHIR Std.
Claim.identifier.use	Base	required	IdentifierUse	📦4.3.0	FHIR Std.
Claim.identifier.type	Base	extensible	IdentifierType	📦4.3.0	FHIR Std.
Claim.status	Base	required	Financial Resource Status Codes	📍4.3.0	FHIR Std.
Claim.type	Base	extensible	Claim Type Codes	📍4.3.0	FHIR Std.
Claim.subType	Base	example	Example Claim SubType Codes	📍4.3.0	FHIR Std.
Claim.use	Base	required	Use	📍4.3.0	FHIR Std.
Claim.priority	Base	example	Process Priority Codes	📍4.3.0	FHIR Std.
Claim.fundsReserve	Base	example	FundsReserve	📍4.3.0	FHIR Std.
Claim.related.relationship	Base	example	Example Related Claim Relationship Codes	📍4.3.0	FHIR Std.
Claim.payee.type	Base	example	PayeeType	📍4.3.0	FHIR Std.
Claim.careTeam.role	Base	example	Claim Care Team Role Codes	📍4.3.0	FHIR Std.
Claim.careTeam.qualification	Base	example	Example Provider Qualification Codes	📍4.3.0	FHIR Std.
Claim.supportingInfo.​category	Base	example	Claim Information Category Codes	📍4.3.0	FHIR Std.
Claim.supportingInfo.​code	Base	example	Exception Codes	📍4.3.0	FHIR Std.
Claim.supportingInfo.​reason	Base	example	Missing Tooth Reason Codes	📍4.3.0	FHIR Std.
Claim.diagnosis.diagnosis[x]	Base	example	ICD-10 Codes	📍4.3.0	FHIR Std.
Claim.diagnosis.diagnosis[x]:diagnosisCodeableConcept	Base	example	ICD-10 Codes	📍4.3.0	FHIR Std.
Claim.diagnosis.type	Base	example	Example Diagnosis Type Codes	📍4.3.0	FHIR Std.
Claim.diagnosis.onAdmission	Base	example	Example Diagnosis on Admission Codes	📍4.3.0	FHIR Std.
Claim.diagnosis.packageCode	Base	example	Example Diagnosis Related Group Codes	📍4.3.0	FHIR Std.
Claim.procedure.type	Base	example	Example Procedure Type Codes	📍4.3.0	FHIR Std.
Claim.procedure.procedure[x]	Base	example	ICD-10 Procedure Codes	📍4.3.0	FHIR Std.
Claim.procedure.procedure[x]:procedureCodeableConcept	Base	example	ICD-10 Procedure Codes	📍4.3.0	FHIR Std.
Claim.accident.type	Base	extensible	ActIncidentCode	📦3.0.0	THO v7.4
Claim.item.revenue	Base	example	Example Revenue Center Codes	📍4.3.0	FHIR Std.
Claim.item.category	Base	example	Benefit Category Codes	📍4.3.0	FHIR Std.
Claim.item.productOrService	Base	example	USCLS Codes	📍4.3.0	FHIR Std.
Claim.item.modifier	Base	example	Modifier type Codes	📍4.3.0	FHIR Std.
Claim.item.programCode	Base	example	Example Program Reason Codes	📍4.3.0	FHIR Std.
Claim.item.location[x]	Base	example	Example Service Place Codes	📍4.3.0	FHIR Std.
Claim.item.bodySite	Base	example	Oral Site Codes	📍4.3.0	FHIR Std.
Claim.item.subSite	Base	example	Surface Codes	📍4.3.0	FHIR Std.
Claim.item.detail.revenue	Base	example	Example Revenue Center Codes	📍4.3.0	FHIR Std.
Claim.item.detail.category	Base	example	Benefit Category Codes	📍4.3.0	FHIR Std.
Claim.item.detail.productOrService	Base	example	USCLS Codes	📍4.3.0	FHIR Std.
Claim.item.detail.modifier	Base	example	Modifier type Codes	📍4.3.0	FHIR Std.
Claim.item.detail.programCode	Base	example	Example Program Reason Codes	📍4.3.0	FHIR Std.
Claim.item.detail.subDetail.​revenue	Base	example	Example Revenue Center Codes	📍4.3.0	FHIR Std.
Claim.item.detail.subDetail.​category	Base	example	Benefit Category Codes	📍4.3.0	FHIR Std.
Claim.item.detail.subDetail.​productOrService	Base	example	USCLS Codes	📍4.3.0	FHIR Std.
Claim.item.detail.subDetail.​modifier	Base	example	Modifier type Codes	📍4.3.0	FHIR Std.
Claim.item.detail.subDetail.​programCode	Base	example	Example Program Reason Codes	📍4.3.0	FHIR Std.

Constraints

Id	Grade	Path(s)	Description	Expression
cc-text-or-code	warning	Claim.identifier.type, Claim.type, Claim.subType, Claim.priority, Claim.fundsReserve, Claim.payee.type, Claim.careTeam.role, Claim.careTeam.qualification, Claim.supportingInfo.category, Claim.supportingInfo.code, Claim.supportingInfo.reason, Claim.diagnosis.diagnosis[x]:diagnosisCodeableConcept, Claim.diagnosis.type, Claim.diagnosis.onAdmission, Claim.diagnosis.packageCode, Claim.procedure.type, Claim.procedure.procedure[x]:procedureCodeableConcept, Claim.accident.type, Claim.item.revenue, Claim.item.category, Claim.item.productOrService, Claim.item.modifier, Claim.item.programCode, Claim.item.bodySite, Claim.item.subSite, Claim.item.detail.revenue, Claim.item.detail.category, Claim.item.detail.productOrService, Claim.item.detail.modifier, Claim.item.detail.subDetail.revenue, Claim.item.detail.subDetail.category, Claim.item.detail.subDetail.productOrService, Claim.item.detail.subDetail.modifier, Claim.item.detail.subDetail.programCode	Text is optional, coding is required	coding.exists()
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.exists() and ('#'+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(uri) = '#').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()
dom-r4b	warning	Claim.contained	Containing new R4B resources within R4 resources may cause interoperability issues if instances are shared with R4 systems	($this is Citation or $this is Evidence or $this is EvidenceReport or $this is EvidenceVariable or $this is MedicinalProductDefinition or $this is PackagedProductDefinition or $this is AdministrableProductDefinition or $this is Ingredient or $this is ClinicalUseDefinition or $this is RegulatedAuthorization or $this is SubstanceDefinition or $this is SubscriptionStatus or $this is SubscriptionTopic) implies (%resource is Citation or %resource is Evidence or %resource is EvidenceReport or %resource is EvidenceVariable or %resource is MedicinalProductDefinition or %resource is PackagedProductDefinition or %resource is AdministrableProductDefinition or %resource is Ingredient or %resource is ClinicalUseDefinition or %resource is RegulatedAuthorization or %resource is SubstanceDefinition or %resource is SubscriptionStatus or %resource is SubscriptionTopic)
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.quantity, Claim.item.detail.subDetail.quantity	The comparator is not used on a SimpleQuantity	comparator.empty()

This structure is derived from Claim

Summary

Mandatory: 10 elements(1 nested mandatory element)
Must-Support: 15 elements

Structures

This structure refers to these other structures:

• HIE CodeableConcept (https://nshr.dha.go.ke/fhir/StructureDefinition/codeable-concept)
• HIE Reference (https://nshr.dha.go.ke/fhir/StructureDefinition/reference)
• HIE Organization (https://nshr.dha.go.ke/fhir/StructureDefinition/organization)
• HIE Patient (https://nshr.dha.go.ke/fhir/StructureDefinition/patient)
• HIE Practitioner (https://nshr.dha.go.ke/fhir/StructureDefinition/practitioner)
• HIE Claim (https://nshr.dha.go.ke/fhir/StructureDefinition/claim)
• HIE Encounter (https://nshr.dha.go.ke/fhir/StructureDefinition/encounter)

Slices

This structure defines the following Slices:

• The element 1 is sliced based on the value of Claim.supportingInfo.value[x]
• The element 1 is sliced based on the value of Claim.diagnosis.diagnosis[x]
• The element 1 is sliced based on the value of Claim.procedure.procedure[x]