Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Claim | TU | DomainResource | Claim, Pre-determination or Pre-authorization Элементы, определённые в родительском элементе: id, meta, implicitRules, language, text, contained, extension, modifierExtension | |
identifier | 0..* | Identifier | Business Identifier for claim | |
status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Financial Resource Status Codes (Required) |
type | Σ | 1..1 | CodeableConcept | Category or discipline Claim Type Codes (Extensible) |
subType | 0..1 | CodeableConcept | More granular claim type Example Claim SubType Codes (Example) | |
use | Σ | 1..1 | code | claim | preauthorization | predetermination Use (Required) |
patient | Σ | 1..1 | Reference(Patient) | The recipient of the products and services |
billablePeriod | Σ | 0..1 | Period | Relevant time frame for the claim |
created | Σ | 1..1 | dateTime | Resource creation date |
enterer | 0..1 | Reference(Practitioner | PractitionerRole) | Author of the claim | |
insurer | Σ | 0..1 | Reference(Organization) | Target |
provider | Σ | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim |
priority | Σ | 1..1 | CodeableConcept | Desired processing ugency Process Priority Codes (Example) |
fundsReserve | 0..1 | CodeableConcept | For whom to reserve funds FundsReserve (Example) | |
related | 0..* | BackboneElement | Prior or corollary claims | |
claim | 0..1 | Reference(Claim) | Reference to the related claim | |
relationship | 0..1 | CodeableConcept | How the reference claim is related Example Related Claim Relationship Codes (Example) | |
reference | 0..1 | Identifier | File or case reference | |
prescription | 0..1 | Reference(DeviceRequest | MedicationRequest | VisionPrescription) | Prescription authorizing services and products | |
originalPrescription | 0..1 | Reference(DeviceRequest | MedicationRequest | VisionPrescription) | Original prescription if superseded by fulfiller | |
payee | 0..1 | BackboneElement | Recipient of benefits payable | |
type | 1..1 | CodeableConcept | Category of recipient PayeeType (Example) | |
party | 0..1 | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) | Recipient reference | |
referral | 0..1 | Reference(ServiceRequest) | Treatment referral | |
facility | 0..1 | Reference(Location) | Servicing facility | |
careTeam | 0..* | BackboneElement | Members of the care team | |
sequence | 1..1 | positiveInt | Order of care team | |
provider | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Practitioner or organization | |
responsible | 0..1 | boolean | Indicator of the lead practitioner | |
role | 0..1 | CodeableConcept | Function within the team Claim Care Team Role Codes (Example) | |
qualification | 0..1 | CodeableConcept | Practitioner credential or specialization Example Provider Qualification Codes (Example) | |
supportingInfo | 0..* | BackboneElement | Supporting information | |
sequence | 1..1 | positiveInt | Information instance identifier | |
category | 1..1 | CodeableConcept | Classification of the supplied information Claim Information Category Codes (Example) | |
code | 0..1 | CodeableConcept | Type of information Exception Codes (Example) | |
timing[x] | 0..1 | When it occurred | ||
timingDate | date | |||
timingPeriod | Period | |||
value[x] | 0..1 | Data to be provided | ||
valueBoolean | boolean | |||
valueString | string | |||
valueQuantity | Quantity | |||
valueAttachment | Attachment | |||
valueReference | Reference(Any) | |||
reason | 0..1 | CodeableConcept | Explanation for the information Missing Tooth Reason Codes (Example) | |
diagnosis | 0..* | BackboneElement | Pertinent diagnosis information | |
sequence | 1..1 | positiveInt | Diagnosis instance identifier | |
diagnosis[x] | 1..1 | Nature of illness or problem ICD-10 Codes (Example) | ||
diagnosisCodeableConcept | CodeableConcept | |||
diagnosisReference | Reference(Condition) | |||
type | 0..* | CodeableConcept | Timing or nature of the diagnosis Example Diagnosis Type Codes (Example) | |
onAdmission | 0..1 | CodeableConcept | Present on admission Example Diagnosis on Admission Codes (Example) | |
packageCode | 0..1 | CodeableConcept | Package billing code Example Diagnosis Related Group Codes (Example) | |
procedure | 0..* | BackboneElement | Clinical procedures performed | |
sequence | 1..1 | positiveInt | Procedure instance identifier | |
type | 0..* | CodeableConcept | Category of Procedure Example Procedure Type Codes (Example) | |
date | 0..1 | dateTime | When the procedure was performed | |
procedure[x] | 1..1 | Specific clinical procedure ICD-10 Procedure Codes (Example) | ||
procedureCodeableConcept | CodeableConcept | |||
procedureReference | Reference(Procedure) | |||
udi | 0..* | Reference(Device) | Unique device identifier | |
insurance | Σ | 1..* | BackboneElement | Patient insurance information |
sequence | Σ | 1..1 | positiveInt | Insurance instance identifier |
focal | Σ | 1..1 | boolean | Coverage to be used for adjudication |
identifier | 0..1 | Identifier | Pre-assigned Claim number | |
coverage | Σ | 1..1 | Reference(Coverage) | Insurance information |
businessArrangement | 0..1 | string | Additional provider contract number | |
preAuthRef | 0..* | string | Prior authorization reference number | |
claimResponse | 0..1 | Reference(ClaimResponse) | Adjudication results | |
accident | 0..1 | BackboneElement | Details of the event | |
date | 1..1 | date | When the incident occurred | |
type | 0..1 | CodeableConcept | The nature of the accident V3 Value SetActIncidentCode (Extensible) | |
location[x] | 0..1 | Where the event occurred | ||
locationAddress | Address | |||
locationReference | Reference(Location) | |||
item | 0..* | BackboneElement | Product or service provided | |
sequence | 1..1 | positiveInt | Item instance identifier | |
careTeamSequence | 0..* | positiveInt | Applicable careTeam members | |
diagnosisSequence | 0..* | positiveInt | Applicable diagnoses | |
procedureSequence | 0..* | positiveInt | Applicable procedures | |
informationSequence | 0..* | positiveInt | Applicable exception and supporting information | |
revenue | 0..1 | CodeableConcept | Revenue or cost center code Example Revenue Center Codes (Example) | |
category | 0..1 | CodeableConcept | Benefit classification Benefit Category Codes (Example) | |
productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code USCLS Codes (Example) | |
modifier | 0..* | CodeableConcept | Product or service billing modifiers Modifier type Codes (Example) | |
programCode | 0..* | CodeableConcept | Program the product or service is provided under Example Program Reason Codes (Example) | |
serviced[x] | 0..1 | Date or dates of service or product delivery | ||
servicedDate | date | |||
servicedPeriod | Period | |||
location[x] | 0..1 | Place of service or where product was supplied Example Service Place Codes (Example) | ||
locationCodeableConcept | CodeableConcept | |||
locationAddress | Address | |||
locationReference | Reference(Location) | |||
quantity | 0..1 | SimpleQuantity | Count of products or services | |
unitPrice | 0..1 | Money | Fee, charge or cost per item | |
factor | 0..1 | decimal | Price scaling factor | |
net | 0..1 | Money | Total item cost | |
udi | 0..* | Reference(Device) | Unique device identifier | |
bodySite | 0..1 | CodeableConcept | Anatomical location Oral Site Codes (Example) | |
subSite | 0..* | CodeableConcept | Anatomical sub-location Surface Codes (Example) | |
encounter | 0..* | Reference(Encounter) | Encounters related to this billed item | |
detail | 0..* | BackboneElement | Product or service provided | |
sequence | 1..1 | positiveInt | Item instance identifier | |
revenue | 0..1 | CodeableConcept | Revenue or cost center code Example Revenue Center Codes (Example) | |
category | 0..1 | CodeableConcept | Benefit classification Benefit Category Codes (Example) | |
productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code USCLS Codes (Example) | |
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Modifier type Codes (Example) | |
programCode | 0..* | CodeableConcept | Program the product or service is provided under Example Program Reason Codes (Example) | |
quantity | 0..1 | SimpleQuantity | Count of products or services | |
unitPrice | 0..1 | Money | Fee, charge or cost per item | |
factor | 0..1 | decimal | Price scaling factor | |
net | 0..1 | Money | Total item cost | |
udi | 0..* | Reference(Device) | Unique device identifier | |
subDetail | 0..* | BackboneElement | Product or service provided | |
sequence | 1..1 | positiveInt | Item instance identifier | |
revenue | 0..1 | CodeableConcept | Revenue or cost center code Example Revenue Center Codes (Example) | |
category | 0..1 | CodeableConcept | Benefit classification Benefit Category Codes (Example) | |
productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code USCLS Codes (Example) | |
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Modifier type Codes (Example) | |
programCode | 0..* | CodeableConcept | Program the product or service is provided under Example Program Reason Codes (Example) | |
quantity | 0..1 | SimpleQuantity | Count of products or services | |
unitPrice | 0..1 | Money | Fee, charge or cost per item | |
factor | 0..1 | decimal | Price scaling factor | |
net | 0..1 | Money | Total item cost | |
udi | 0..* | Reference(Device) | Unique device identifier | |
total | 0..1 | Money | Total claim cost | |
Documentation for this format |