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Financial Management Work GroupMaturity Level: 2 Trial Use Compartments: Device, Encounter, Patient, Practitioner, RelatedPerson

Подробное описание элементов ресурса Claim.

Claim
Element IdClaim
Definition

A provider issued list of professional services and products which have been provided, or to be provided, to a patient which is sent to an insurer for reimbursement.

Control0..*
TypeDomainResource
Requirements

The Claim resource is used by providers to exchange services and products rendered to patients or planned to be rendered with insurers for reimbuserment. It is also used by insurers to exchange claims information with statutory reporting and data analytics firms.

Alternate NamesAdjudication Request; Preauthorization Request; Predetermination Request
Comments

The Claim resource fulfills three information request requirements: Claim - a request for ajudication for reimbursement for producst and/or services provided; Preauthorization - a request to authorize the future provision of products and/or servcies including an anticipated adjudication; and, Predetermination - a request for a non-bind adjudication of possible future products and/or services.

Claim.identifier
Element IdClaim.identifier
Definition

A unique identifier assigned to this claim.

NoteThis is a business identifer, not a resource identifier (see discussion)
Control0..*
TypeIdentifier
Requirements

Allows claims to be distinguished and referenced.

Alternate NamesНомер требования о страховом возмещении
Claim.status
Element IdClaim.status
Definition

The status of the resource instance.

Control1..1
Terminology BindingFinancial Resource Status Codes (Required)
Typecode
Is Modifiertrue (Reason: This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid)
Requirements

Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.

Summarytrue
Comments

This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

Claim.type
Element IdClaim.type
Definition

Категория требования о страховом возмещении, например стоматология, фармацевтика, офтальмология, институциональная, профессиональная.

Control1..1
Terminology BindingClaim Type Codes (Extensible)
TypeCodeableConcept
Requirements

Claim type determine the general sets of business rules applied for information requirements and adjudication.

Summarytrue
Comments

The majority of jurisdictions use: oral, pharmacy, vision, professional and institutional, or variants on those terms, as the general styles of claims. The valueset is extensible to accommodate other jurisdictional requirements.

Claim.subType
Element IdClaim.subType
Definition

A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.

Control0..1
Terminology BindingExample Claim SubType Codes (Example)
TypeCodeableConcept
Requirements

Some jurisdictions need a finer grained claim type for routing and adjudication.

Comments

This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.

Claim.use
Element IdClaim.use
Definition

A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future.

Control1..1
Terminology BindingUse (Required)
Typecode
Requirements

This element is required to understand the nature of the request for adjudication.

Summarytrue
Claim.patient
Element IdClaim.patient
Definition

The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for forecast reimburement is sought.

Control1..1
TypeReference(Patient)
Requirements

The patient must be supplied to the insurer so that confirmation of coverage and service history may be considered as part of the authorization and/or adjudiction.

Summarytrue
Claim.billablePeriod
Element IdClaim.billablePeriod
Definition

The period for which charges are being submitted.

Control0..1
TypePeriod
Requirements

A number jurisdictions required the submission of the billing period when submitting claims for example for hospital stays or long-term care.

Summarytrue
Comments

Typically this would be today or in the past for a claim, and today or in the future for preauthorizations and prodeterminations. Typically line item dates of service should fall within the billing period if one is specified.

Claim.created
Element IdClaim.created
Definition

The date this resource was created.

Control1..1
TypedateTime
Requirements

Need to record a timestamp for use by both the recipient and the issuer.

Summarytrue
Comments

This field is independent of the date of creation of the resource as it may reflect the creation date of a source document prior to digitization. Typically for claims all services must be completed as of this date.

Claim.enterer
Element IdClaim.enterer
Definition

Individual who created the claim, predetermination or preauthorization.

Control0..1
TypeReference(Practitioner | PractitionerRole)
Requirements

Some jurisdictions require the contact information for personnel completing claims.

Claim.insurer
Element IdClaim.insurer
Definition

Страховщик, который является объектом запроса.

Control0..1
TypeReference(Organization)
Summarytrue
Claim.provider
Element IdClaim.provider
Definition

Поставщик, который несет ответственность за предварительное определение, предварительное разрешение счёта, требования о страховом возмещении.

Control1..1
TypeReference(Practitioner | PractitionerRole | Organization)
Summarytrue
Comments

Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below.

Claim.priority
Element IdClaim.priority
Definition

The provider-required urgency of processing the request. Typical values include: stat, routine deferred.

Control1..1
Terminology BindingProcess Priority Codes (Example)
TypeCodeableConcept
Requirements

The provider may need to indicate their processing requirements so that the processor can indicate if they are unable to comply.

Summarytrue
Comments

If a claim processor is unable to complete the processing as per the priority then they should generate and error and not process the request.

Claim.fundsReserve
Element IdClaim.fundsReserve
Definition

A code to indicate whether and for whom funds are to be reserved for future claims.

Control0..1
Terminology BindingFundsReserve (Example)
TypeCodeableConcept
Requirements

В случае предварительного определения / предварительного разрешения поставщик может потребовать, чтобы средства в размере ожидаемых выплат были зарезервированы ('Patient' или 'Provider') для оплаты выплат, определенных в последующих требованиях о страховом возмещении. "None" явно указывает на то, что резервирование средств не запрашивается.

Alternate NamesFund pre-allocation
Comments

This field is only used for preauthorizations.

Claim.related
Element IdClaim.related
Definition

Other claims which are related to this claim such as prior submissions or claims for related services or for the same event.

Control0..*
Requirements

For workplace or other accidents it is common to relate separate claims arising from the same event.

Comments

For example, for the original treatment and follow-up exams.

Claim.related.claim
Element IdClaim.related.claim
Definition

Reference to a related claim.

Control0..1
TypeReference(Claim)
Requirements

For workplace or other accidents it is common to relate separate claims arising from the same event.

Claim.related.relationship
Element IdClaim.related.relationship
Definition

A code to convey how the claims are related.

Control0..1
Terminology BindingExample Related Claim Relationship Codes (Example)
TypeCodeableConcept
Requirements

Some insurers need a declaration of the type of relationship.

Comments

For example, prior claim or umbrella.

Claim.related.reference
Element IdClaim.related.reference
Definition

An alternate organizational reference to the case or file to which this particular claim pertains.

Control0..1
TypeIdentifier
Requirements

In cases where an event-triggered claim is being submitted to an insurer which requires a reference number to be specified on all exchanges.

Comments

For example, Property/Casualty insurer claim # or Workers Compensation case # .

Claim.prescription
Element IdClaim.prescription
Definition

Предписание для поддержки распределения продуктов коррекции зрения или медикаментов.

Control0..1
TypeReference(DeviceRequest | MedicationRequest | VisionPrescription)
Requirements

Required to authorize the dispensing of controlled substances and devices.

Claim.originalPrescription
Element IdClaim.originalPrescription
Definition

Original prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or products.

Control0..1
TypeReference(DeviceRequest | MedicationRequest | VisionPrescription)
Requirements

Often required when a fulfiller varies what is fulfilled from that authorized on the original prescription.

Comments

For example, a physician may prescribe a medication which the pharmacy determines is contraindicated, or for which the patient has an intolerance, and therefor issues a new prescription for an alternate medication which has the same therapeutic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription'.

Claim.payee
Element IdClaim.payee
Definition

The party to be reimbursed for cost of the products and services according to the terms of the policy.

Control0..1
Requirements

The provider needs to specify who they wish to be reimbursed and the claims processor needs express who they will reimburse.

Comments

Often providers agree to receive the benefits payable to reduce the near-term costs to the patient. The insurer may decline to pay the provider are choose to pay the subscriber instead.

Claim.payee.type
Element IdClaim.payee.type
Definition

Тип стороны, которой возмещаются затраты: подписчик, поставщик, другое.

Control1..1
Terminology BindingPayeeType (Example)
TypeCodeableConcept
Requirements

Need to know who should receive payment with the most common situations being the Provider (assignment of benefits) or the Subscriber.

Claim.payee.party
Element IdClaim.payee.party
Definition

Reference to the individual or organization to whom any payment will be made.

Control0..1
TypeReference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson)
Requirements

Need to provide demographics if the payee is not 'subscriber' nor 'provider'.

Comments

Not required if the payee is 'subscriber' or 'provider'.

Claim.referral
Element IdClaim.referral
Definition

A reference to a referral resource.

Control0..1
TypeReference(ServiceRequest)
Requirements

Some insurers require proof of referral to pay for services or to pay specialist rates for services.

Comments

Ресурс ReferralRequest, в котором перечислены дата, специалист, причина и другая вспомогательная информация.

Claim.facility
Element IdClaim.facility
Definition

Объект, где были представлены услуги.

Control0..1
TypeReference(Location)
Requirements

Insurance adjudication can be dependant on where services were delivered.

Claim.careTeam
Element IdClaim.careTeam
Definition

The members of the team who provided the products and services.

Control0..*
Requirements

Common to identify the responsible and supporting practitioners.

Claim.careTeam.sequence
Element IdClaim.careTeam.sequence
Definition

A number to uniquely identify care team entries.

Control1..1
TypepositiveInt
Requirements

Necessary to maintain the order of the care team and provide a mechanism to link individuals to claim details.

Claim.careTeam.provider
Element IdClaim.careTeam.provider
Definition

Член команды, предоставившей услугу.

Control1..1
TypeReference(Practitioner | PractitionerRole | Organization)
Requirements

Often a regulatory requirement to specify the Ответственный поставщик.

Claim.careTeam.responsible
Element IdClaim.careTeam.responsible
Definition

The party who is billing and/or responsible for the claimed products or services.

Control0..1
Typeboolean
Requirements

When multiple parties are present it is required to distinguish the lead or responsible individual.

Comments

Responsible might not be required when there is only a single provider listed.

Claim.careTeam.role
Element IdClaim.careTeam.role
Definition

The lead, assisting or supervising practitioner and their discipline if a multidisciplinary team.

Control0..1
Terminology BindingClaim Care Team Role Codes (Example)
TypeCodeableConcept
Requirements

When multiple parties are present it is required to distinguish the roles performed by each member.

Comments

Role might not be required when there is only a single provider listed.

Claim.careTeam.qualification
Element IdClaim.careTeam.qualification
Definition

The qualification of the practitioner which is applicable for this service.

Control0..1
Terminology BindingExample Provider Qualification Codes (Example)
TypeCodeableConcept
Requirements

Need to specify which qualification a provider is delivering the product or service under.

Claim.supportingInfo
Element IdClaim.supportingInfo
Definition

Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.

Control0..*
Requirements

Typically these information codes are required to support the services rendered or the adjudication of the services rendered.

Alternate NamesAttachments Exception Codes Occurrence Codes Value codes
Comments

Often there are multiple jurisdiction specific valuesets which are required.

Claim.supportingInfo.sequence
Element IdClaim.supportingInfo.sequence
Definition

A number to uniquely identify supporting information entries.

Control1..1
TypepositiveInt
Requirements

Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details.

Claim.supportingInfo.category
Element IdClaim.supportingInfo.category
Definition

The general class of the information supplied: information; exception; accident, employment; onset, etc.

Control1..1
Terminology BindingClaim Information Category Codes (Example)
TypeCodeableConcept
Requirements

Required to group or associate information items with common characteristics. For example: admission information or prior treatments.

Comments

This may contain a category for the local bill type codes.

Claim.supportingInfo.code
Element IdClaim.supportingInfo.code
Definition

System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought.

Control0..1
Terminology BindingException Codes (Example)
TypeCodeableConcept
Requirements

Required to identify the kind of additional information.

Claim.supportingInfo.timing[x]
Element IdClaim.supportingInfo.timing[x]
Definition

The date when or period to which this information refers.

Control0..1
Typedate|Period
[x] NoteSee Choice of Data Types for further information about how to use [x]
Claim.supportingInfo.value[x]
Element IdClaim.supportingInfo.value[x]
Definition

Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.

Control0..1
Typeboolean|string|Quantity|Attachment|Reference(Any)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

To convey the data content to be provided when the information is more than a simple code or period.

Comments

Could be used to provide references to other resources, document. For example could contain a PDF in an Attachment of the Police Report for an Accident.

Claim.supportingInfo.reason
Element IdClaim.supportingInfo.reason
Definition

Provides the reason in the situation where a reason code is required in addition to the content.

Control0..1
Terminology BindingMissing Tooth Reason Codes (Example)
TypeCodeableConcept
Requirements

Needed when the supporting information has both a date and amount/value and requires explanation.

Comments

For example: the reason for the additional stay, or why a tooth is missing.

Claim.diagnosis
Element IdClaim.diagnosis
Definition

Information about diagnoses relevant to the claim items.

Control0..*
Requirements

Required for the adjudication by provided context for the services and product listed.

Claim.diagnosis.sequence
Element IdClaim.diagnosis.sequence
Definition

A number to uniquely identify diagnosis entries.

Control1..1
TypepositiveInt
Requirements

Necessary to maintain the order of the diagnosis items and provide a mechanism to link to claim details.

Comments

Diagnosis are presented in list order to their expected importance: primary, secondary, etc.

Claim.diagnosis.diagnosis[x]
Element IdClaim.diagnosis.diagnosis[x]
Definition

The nature of illness or problem in a coded form or as a reference to an external defined Condition.

Control1..1
Terminology BindingICD-10 Codes (Example)
TypeCodeableConcept|Reference(Condition)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

Provides health context for the evaluation of the products and/or services.

Claim.diagnosis.type
Element IdClaim.diagnosis.type
Definition

When the condition was observed or the relative ranking.

Control0..*
Terminology BindingExample Diagnosis Type Codes (Example)
TypeCodeableConcept
Requirements

Often required to capture a particular diagnosis, for example: primary or discharge.

Comments

For example: admitting, primary, secondary, discharge.

Claim.diagnosis.onAdmission
Element IdClaim.diagnosis.onAdmission
Definition

Indication of whether the diagnosis was present on admission to a facility.

Control0..1
Terminology BindingExample Diagnosis on Admission Codes (Example)
TypeCodeableConcept
Requirements

Many systems need to understand for adjudication if the diagnosis was present a time of admission.

Claim.diagnosis.packageCode
Element IdClaim.diagnosis.packageCode
Definition

A package billing code or bundle code used to group products and services to a particular health condition (such as heart attack) which is based on a predetermined grouping code system.

Control0..1
Terminology BindingExample Diagnosis Related Group Codes (Example)
TypeCodeableConcept
Requirements

Required to relate the current diagnosis to a package billing code that is then referenced on the individual claim items which are specific to the health condition covered by the package code.

Comments

For example DRG (Diagnosis Related Group) or a bundled billing code. A patient may have a diagnosis of a Myocardio-infarction and a DRG for HeartAttack would assigned. The Claim item (and possible subsequent claims) would refer to the DRG for those line items that were for services related to the heart attack event.

Claim.procedure
Element IdClaim.procedure
Definition

Procedures performed on the patient relevant to the billing items with the claim.

Control0..*
Requirements

The specific clinical invention are sometimes required to be provided to justify billing a greater than customary amount for a service.

Claim.procedure.sequence
Element IdClaim.procedure.sequence
Definition

A number to uniquely identify procedure entries.

Control1..1
TypepositiveInt
Requirements

Necessary to provide a mechanism to link to claim details.

Claim.procedure.type
Element IdClaim.procedure.type
Definition

When the condition was observed or the relative ranking.

Control0..*
Terminology BindingExample Procedure Type Codes (Example)
TypeCodeableConcept
Requirements

Often required to capture a particular diagnosis, for example: primary or discharge.

Comments

For example: primary, secondary.

Claim.procedure.date
Element IdClaim.procedure.date
Definition

Дата и, необязательно, время, когда была выполнена процедура.

Control0..1
TypedateTime
Requirements

Required for auditing purposes.

Claim.procedure.procedure[x]
Element IdClaim.procedure.procedure[x]
Definition

The code or reference to a Procedure resource which identifies the clinical intervention performed.

Control1..1
Terminology BindingICD-10 Procedure Codes (Example)
TypeCodeableConcept|Reference(Procedure)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

This identifies the actual clinical procedure.

Claim.procedure.udi
Element IdClaim.procedure.udi
Definition

Unique Device Identifiers associated with this line item.

Control0..*
TypeReference(Device)
Requirements

The UDI code allows the insurer to obtain device level information on the product supplied.

Claim.insurance
Element IdClaim.insurance
Definition

Financial instruments for reimbursement for the health care products and services specified on the claim.

Control1..*
Requirements

At least one insurer is required for a claim to be a claim.

Summarytrue
Comments

All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. Coverages appearing before the focal Coverage in the list, and where 'Coverage.subrogation=false', should provide a reference to the ClaimResponse containing the adjudication results of the prior claim.

Claim.insurance.sequence
Element IdClaim.insurance.sequence
Definition

A number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order.

Control1..1
TypepositiveInt
Requirements

Для упорядочивания пунктов в страховых покрытиях.

Summarytrue
Claim.insurance.focal
Element IdClaim.insurance.focal
Definition

A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.

Control1..1
Typeboolean
Requirements

To identify which coverage in the list is being used to adjudicate this claim.

Summarytrue
Comments

A patient may (will) have multiple insurance policies which provide reimburement for healthcare services and products. For example a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for adjudicating this claim. Other claims would be created to request adjudication against the other listed policies.

Claim.insurance.identifier
Element IdClaim.insurance.identifier
Definition

The business identifier to be used when the claim is sent for adjudication against this insurance policy.

NoteThis is a business identifer, not a resource identifier (see discussion)
Control0..1
TypeIdentifier
Requirements

This will be the claim number should it be necessary to create this claim in the future. This is provided so that payors may forward claims to other payors in the Coordination of Benefit for adjudication rather than the provider being required to initiate each adjudication.

Comments

Only required in jursidictions where insurers, rather than the provider, are required to send claims to insurers that appear after them in the list. This element is not required when 'subrogation=true'.

Claim.insurance.coverage
Element IdClaim.insurance.coverage
Definition

Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.

Control1..1
TypeReference(Coverage)
Requirements

Required to allow the adjudicator to locate the correct policy and history within their information system.

Summarytrue
Claim.insurance.businessArrangement
Element IdClaim.insurance.businessArrangement
Definition

A Деловое соглашениеnumber established between the provider and the insurer for special business processing purposes.

Control0..1
Typestring
Requirements

Providers may have multiple business arrangements with a given insurer and must supply the specific contract number for adjudication.

Claim.insurance.preAuthRef
Element IdClaim.insurance.preAuthRef
Definition

Reference numbers previously provided by the insurer to the provider to be quoted on subsequent claims containing services or products related to the prior authorization.

Control0..*
Typestring
Requirements

Providers must quote previously issued authorization reference numbers in order to obtain adjudication as previously advised on the Preauthorization.

Comments

This value is an alphanumeric string that may be provided over the phone, via text, via paper, or within a ClaimResponse resource and is not a FHIR Identifier.

Claim.insurance.claimResponse
Element IdClaim.insurance.claimResponse
Definition

The result of the adjudication of the line items for the Coverage specified in this insurance.

Control0..1
TypeReference(ClaimResponse)
Requirements

An insurer need the adjudication results from prior insurers to determine the outstanding balance remaining by item for the items in the curent claim.

Comments

Must not be specified when 'focal=true' for this insurance.

Claim.accident
Element IdClaim.accident
Definition

Details of a accident which resulted in injuries which required the products and services listed in the claim.

Control0..1
Requirements

When healthcare products and services are accident related, benefits may be payable under accident provisions of policies, such as automotive, etc before they are payable under normal health insurance.

Claim.accident.date
Element IdClaim.accident.date
Definition

Date of an accident event related to the products and services contained in the claim.

Control1..1
Typedate
Requirements

Required for audit purposes and adjudication.

Comments

The date of the accident has to preceed the dates of the products and services but within a reasonable timeframe.

Claim.accident.type
Element IdClaim.accident.type
Definition

The type or context of the accident event for the purposes of selection of potential insurance coverages and determination of coordination between insurers.

Control0..1
Terminology BindingV3 Value SetActIncidentCode (Extensible)
TypeCodeableConcept
Requirements

Страховое покрытие может зависеть от типа несчастного случая.

Claim.accident.location[x]
Element IdClaim.accident.location[x]
Definition

The physical location of the accident event.

Control0..1
TypeAddress|Reference(Location)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

Required for audit purposes and determination of applicable insurance liability.

Claim.item
Element IdClaim.item
Definition

A claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-details.

Control0..*
Requirements

The items to be processed for adjudication.

Claim.item.sequence
Element IdClaim.item.sequence
Definition

A number to uniquely identify item entries.

Control1..1
TypepositiveInt
Requirements

Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse.

Claim.item.careTeamSequence
Element IdClaim.item.careTeamSequence
Definition

CareTeam members related to this service or product.

Control0..*
TypepositiveInt
Requirements

Need to identify the individuals and their roles in the provision of the product or service.

Claim.item.diagnosisSequence
Element IdClaim.item.diagnosisSequence
Definition

Diagnoses applicable for this service or product.

Control0..*
TypepositiveInt
Requirements

Need to related the product or service to the associated diagnoses.

Claim.item.procedureSequence
Element IdClaim.item.procedureSequence
Definition

Procedures applicable for this service or product.

Control0..*
TypepositiveInt
Requirements

Need to provide any listed specific procedures to support the product or service being claimed.

Claim.item.informationSequence
Element IdClaim.item.informationSequence
Definition

Exceptions, special conditions and supporting information applicable for this service or product.

Control0..*
TypepositiveInt
Requirements

Need to reference the supporting information items that relate directly to this product or service.

Claim.item.revenue
Element IdClaim.item.revenue
Definition

The type of revenue or cost center providing the product and/or service.

Control0..1
Terminology BindingExample Revenue Center Codes (Example)
TypeCodeableConcept
Requirements

Needed in the processing of institutional claims.

Claim.item.category
Element IdClaim.item.category
Definition

Code to identify the general type of benefits under which products and services are provided.

Control0..1
Terminology BindingBenefit Category Codes (Example)
TypeCodeableConcept
Requirements

Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.

Comments

Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

Claim.item.productOrService
Element IdClaim.item.productOrService
Definition

When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

Control1..1
Terminology BindingUSCLS Codes (Example)
TypeCodeableConcept
Requirements

Necessary to state what was provided or done.

Alternate NamesDrug Code; Bill Code; Service Code
Comments

If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

Claim.item.modifier
Element IdClaim.item.modifier
Definition

Item typification or modifiers codes to convey additional context for the product or service.

Control0..*
Terminology BindingModifier type Codes (Example)
TypeCodeableConcept
Requirements

To support inclusion of the item for adjudication or to charge an elevated fee.

Comments

For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.

Claim.item.programCode
Element IdClaim.item.programCode
Definition

Identifies the program under which this may be recovered.

Control0..*
Terminology BindingExample Program Reason Codes (Example)
TypeCodeableConcept
Requirements

Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.

Comments

For example: Neonatal program, child dental program or drug users recovery program.

Claim.item.serviced[x]
Element IdClaim.item.serviced[x]
Definition

The date or dates when the service or product was supplied, performed or completed.

Control0..1
Typedate|Period
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

Needed to determine whether the service or product was provided during the term of the insurance coverage.

Claim.item.location[x]
Element IdClaim.item.location[x]
Definition

Where the product or service was provided.

Control0..1
Terminology BindingExample Service Place Codes (Example)
TypeCodeableConcept|Address|Reference(Location)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount.

Claim.item.quantity
Element IdClaim.item.quantity
Definition

Число повторений услуги или продукта.

Control0..1
TypeSimpleQuantity
Requirements

Required when the product or service code does not convey the quantity provided.

Claim.item.unitPrice
Element IdClaim.item.unitPrice
Definition

Если этот пункт является конечным элементом, тогда это плата за продукт или услугу, иначе это общая сумма плат за все пункты из этой группы.

Control0..1
TypeMoney
Requirements

The amount charged to the patient by the provider for a single unit.

Claim.item.factor
Element IdClaim.item.factor
Definition

Действительное число, которое представляет собой множитель, используемый при определении общей стоимости предоставляемых услуг и/или полученных товаров. Понятие "коэффициент" позволяет применять к денежной сумме множитель скидки или надбавки.

Control0..1
Typedecimal
Requirements

When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

Comments

To show a 10% Senior's discount, the value entered is: 0.90 (1.00 - 0.10).

Claim.item.net
Element IdClaim.item.net
Definition

The quantity times the unit price for an additional service or product or charge.

Control0..1
TypeMoney
Requirements

Provides the total amount claimed for the group (if a grouper) or the line item.

Comments

For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

Claim.item.udi
Element IdClaim.item.udi
Definition

Unique Device Identifiers associated with this line item.

Control0..*
TypeReference(Device)
Requirements

The UDI code allows the insurer to obtain device level information on the product supplied.

Claim.item.bodySite
Element IdClaim.item.bodySite
Definition

Физическое расположение на пациенте места оказания услуги (конечность, зуб и т. п.).

Control0..1
Terminology BindingOral Site Codes (Example)
TypeCodeableConcept
Requirements

Allows insurer to validate specific procedures.

Comments

For example: Providing a tooth code, allows an insurer to identify a provider performing a filling on a tooth that was previously removed.

Claim.item.subSite
Element IdClaim.item.subSite
Definition

Участок или поверхность тела, например область конечности или поверхности зуба.

Control0..*
Terminology BindingSurface Codes (Example)
TypeCodeableConcept
Requirements

Allows insurer to validate specific procedures.

Claim.item.encounter
Element IdClaim.item.encounter
Definition

The Encounters during which this Claim was created or to which the creation of this record is tightly associated.

Control0..*
TypeReference(Encounter)
Requirements

Used in some jurisdictions to link clinical events to claim items.

Comments

This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter.

Claim.item.detail
Element IdClaim.item.detail
Definition

A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.

Control0..*
Requirements

The items to be processed for adjudication.

Claim.item.detail.sequence
Element IdClaim.item.detail.sequence
Definition

A number to uniquely identify item entries.

Control1..1
TypepositiveInt
Requirements

Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse.

Claim.item.detail.revenue
Element IdClaim.item.detail.revenue
Definition

The type of revenue or cost center providing the product and/or service.

Control0..1
Terminology BindingExample Revenue Center Codes (Example)
TypeCodeableConcept
Requirements

Needed in the processing of institutional claims.

Claim.item.detail.category
Element IdClaim.item.detail.category
Definition

Code to identify the general type of benefits under which products and services are provided.

Control0..1
Terminology BindingBenefit Category Codes (Example)
TypeCodeableConcept
Requirements

Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.

Comments

Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

Claim.item.detail.productOrService
Element IdClaim.item.detail.productOrService
Definition

When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

Control1..1
Terminology BindingUSCLS Codes (Example)
TypeCodeableConcept
Requirements

Necessary to state what was provided or done.

Alternate NamesDrug Code; Bill Code; Service Code
Comments

If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

Claim.item.detail.modifier
Element IdClaim.item.detail.modifier
Definition

Item typification or modifiers codes to convey additional context for the product or service.

Control0..*
Terminology BindingModifier type Codes (Example)
TypeCodeableConcept
Requirements

To support inclusion of the item for adjudication or to charge an elevated fee.

Comments

For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.

Claim.item.detail.programCode
Element IdClaim.item.detail.programCode
Definition

Identifies the program under which this may be recovered.

Control0..*
Terminology BindingExample Program Reason Codes (Example)
TypeCodeableConcept
Requirements

Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.

Comments

For example: Neonatal program, child dental program or drug users recovery program.

Claim.item.detail.quantity
Element IdClaim.item.detail.quantity
Definition

Число повторений услуги или продукта.

Control0..1
TypeSimpleQuantity
Requirements

Required when the product or service code does not convey the quantity provided.

Claim.item.detail.unitPrice
Element IdClaim.item.detail.unitPrice
Definition

Если этот пункт является конечным элементом, тогда это плата за продукт или услугу, иначе это общая сумма плат за все пункты из этой группы.

Control0..1
TypeMoney
Requirements

The amount charged to the patient by the provider for a single unit.

Claim.item.detail.factor
Element IdClaim.item.detail.factor
Definition

Действительное число, которое представляет собой множитель, используемый при определении общей стоимости предоставляемых услуг и/или полученных товаров. Понятие "коэффициент" позволяет применять к денежной сумме множитель скидки или надбавки.

Control0..1
Typedecimal
Requirements

When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

Comments

To show a 10% Senior's discount, the value entered is: 0.90 (1.00 - 0.10).

Claim.item.detail.net
Element IdClaim.item.detail.net
Definition

The quantity times the unit price for an additional service or product or charge.

Control0..1
TypeMoney
Requirements

Provides the total amount claimed for the group (if a grouper) or the line item.

Comments

For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

Claim.item.detail.udi
Element IdClaim.item.detail.udi
Definition

Unique Device Identifiers associated with this line item.

Control0..*
TypeReference(Device)
Requirements

The UDI code allows the insurer to obtain device level information on the product supplied.

Claim.item.detail.subDetail
Element IdClaim.item.detail.subDetail
Definition

A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.

Control0..*
Requirements

The items to be processed for adjudication.

Claim.item.detail.subDetail.sequence
Element IdClaim.item.detail.subDetail.sequence
Definition

A number to uniquely identify item entries.

Control1..1
TypepositiveInt
Requirements

Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse.

Claim.item.detail.subDetail.revenue
Element IdClaim.item.detail.subDetail.revenue
Definition

The type of revenue or cost center providing the product and/or service.

Control0..1
Terminology BindingExample Revenue Center Codes (Example)
TypeCodeableConcept
Requirements

Needed in the processing of institutional claims.

Claim.item.detail.subDetail.category
Element IdClaim.item.detail.subDetail.category
Definition

Code to identify the general type of benefits under which products and services are provided.

Control0..1
Terminology BindingBenefit Category Codes (Example)
TypeCodeableConcept
Requirements

Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.

Comments

Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

Claim.item.detail.subDetail.productOrService
Element IdClaim.item.detail.subDetail.productOrService
Definition

When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

Control1..1
Terminology BindingUSCLS Codes (Example)
TypeCodeableConcept
Requirements

Necessary to state what was provided or done.

Comments

If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

Claim.item.detail.subDetail.modifier
Element IdClaim.item.detail.subDetail.modifier
Definition

Item typification or modifiers codes to convey additional context for the product or service.

Control0..*
Terminology BindingModifier type Codes (Example)
TypeCodeableConcept
Requirements

To support inclusion of the item for adjudication or to charge an elevated fee.

Comments

For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.

Claim.item.detail.subDetail.programCode
Element IdClaim.item.detail.subDetail.programCode
Definition

Identifies the program under which this may be recovered.

Control0..*
Terminology BindingExample Program Reason Codes (Example)
TypeCodeableConcept
Requirements

Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.

Comments

For example: Neonatal program, child dental program or drug users recovery program.

Claim.item.detail.subDetail.quantity
Element IdClaim.item.detail.subDetail.quantity
Definition

Число повторений услуги или продукта.

Control0..1
TypeSimpleQuantity
Requirements

Required when the product or service code does not convey the quantity provided.

Claim.item.detail.subDetail.unitPrice
Element IdClaim.item.detail.subDetail.unitPrice
Definition

Если этот пункт является конечным элементом, тогда это плата за продукт или услугу, иначе это общая сумма плат за все пункты из этой группы.

Control0..1
TypeMoney
Requirements

The amount charged to the patient by the provider for a single unit.

Claim.item.detail.subDetail.factor
Element IdClaim.item.detail.subDetail.factor
Definition

Действительное число, которое представляет собой множитель, используемый при определении общей стоимости предоставляемых услуг и/или полученных товаров. Понятие "коэффициент" позволяет применять к денежной сумме множитель скидки или надбавки.

Control0..1
Typedecimal
Requirements

When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

Comments

To show a 10% Senior's discount, the value entered is: 0.90 (1.00 - 0.10).

Claim.item.detail.subDetail.net
Element IdClaim.item.detail.subDetail.net
Definition

The quantity times the unit price for an additional service or product or charge.

Control0..1
TypeMoney
Requirements

Provides the total amount claimed for the group (if a grouper) or the line item.

Comments

For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

Claim.item.detail.subDetail.udi
Element IdClaim.item.detail.subDetail.udi
Definition

Unique Device Identifiers associated with this line item.

Control0..*
TypeReference(Device)
Requirements

The UDI code allows the insurer to obtain device level information on the product supplied.

Claim.total
Element IdClaim.total
Definition

The total value of the all the items in the claim.

Control0..1
TypeMoney
Requirements

Used for control total purposes.