NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim ΣDomainResourceClaim, Pre-determination or Pre-authorization
... type Σ1..1codeinstitutional | oral | pharmacy | professional | vision
ClaimType (Required)
... identifier Σ0..*IdentifierClaim number
... ruleset Σ0..1CodingCurrent specification followed
Ruleset Codes (Example)
... originalRuleset Σ0..1CodingOriginal specification followed
Ruleset Codes (Example)
... created Σ0..1dateTimeCreation date
... billablePeriod Σ0..1PeriodPeriod for charge submission
... target Σ0..1Reference(Organization)Insurer
... provider Σ0..1Reference(Practitioner)Responsible provider
... organization Σ0..1Reference(Organization)Responsible organization
... use Σ0..1codecomplete | proposed | exploratory | other
Use (Required)
... priority Σ0..1CodingDesired processing priority
Priority Codes (Example)
... fundsReserve Σ0..1CodingFunds requested to be reserved
Funds Reservation Codes (Example)
... enterer Σ0..1Reference(Practitioner)Author
... facility Σ0..1Reference(Location)Servicing Facility
... relatedClaim Σ0..*Reference(Claim)Related Claims
... prescription Σ0..1Reference(MedicationOrder | VisionPrescription)Prescription
... originalPrescription Σ0..1Reference(MedicationOrder)Original Prescription
... payee Σ0..1BackboneElementPayee
.... type Σ0..1CodingParty to be paid any benefits payable
Payee Type Codes (Example)
.... provider Σ0..1Reference(Practitioner)Provider who is the payee
.... organization Σ0..1Reference(Organization)Organization who is the payee
.... person Σ0..1Reference(Patient)Other person who is the payee
... referral Σ0..1Reference(ReferralRequest)Treatment Referral
... diagnosis Σ0..*BackboneElementDiagnosis
.... sequence Σ1..1positiveIntSequence of diagnosis
.... diagnosis Σ1..1CodingPatient's list of diagnosis
ICD-10 Codes (Example)
... specialCondition Σ0..*CodingList of special Conditions
Conditions Codes (Example)
... patient Σ1..1Reference(Patient)The subject of the Products and Services
... coverage Σ0..*BackboneElementInsurance or medical plan
.... sequence Σ1..1positiveIntService instance identifier
.... focal Σ1..1booleanIs the focal Coverage
.... coverage Σ1..1Reference(Coverage)Insurance information
.... businessArrangement Σ0..1stringBusiness agreement
.... relationship Σ1..1CodingPatient relationship to subscriber
Surface Codes (Example)
.... preAuthRef Σ0..*stringPre-Authorization/Determination Reference
.... claimResponse Σ0..1Reference(ClaimResponse)Adjudication results
.... originalRuleset Σ0..1CodingOriginal version
Ruleset Codes (Example)
... exception Σ0..*CodingEligibility exceptions
Exception Codes (Example)
... school Σ0..1stringName of School
... accidentDate Σ0..1dateAccident Date
... accidentType Σ0..1CodingAccident Type
ActIncidentCode (Required)
... accidentLocation[x] Σ0..1Accident Place
.... accidentLocationStringstring
.... accidentLocationAddressAddress
.... accidentLocationReferenceReference(Location)
... interventionException Σ0..*CodingIntervention and exception code (Pharma)
Intervention Codes (Example)
... onset[x] Σ0..1Illness, injury or treatable condition date
.... onsetDatedate
.... onsetPeriodPeriod
... employmentImpacted Σ0..1PeriodPeriod unable to work
... hospitalization Σ0..1PeriodPeriod in hospital
... item Σ0..*BackboneElementGoods and Services
.... sequence Σ1..1positiveIntService instance
.... type Σ1..1CodingGroup or type of product or service
ActInvoiceGroupCode (Required)
.... provider Σ0..1Reference(Practitioner)Responsible practitioner
.... diagnosisLinkId Σ0..*positiveIntDiagnosis Link
.... service Σ1..1CodingItem Code
USCLS Codes (Example)
.... serviced[x] Σ0..1Date or dates of Service
..... servicedDatedate
..... servicedPeriodPeriod
.... place Σ0..1CodingPlace of service
Example Service Place Codes (Example)
.... quantity Σ0..1SimpleQuantityCount of Products or Services
.... unitPrice Σ0..1MoneyFee, charge or cost per point
.... factor Σ0..1decimalPrice scaling factor
.... points Σ0..1decimalDifficulty scaling factor
.... net Σ0..1MoneyTotal item cost
.... udi Σ0..1CodingUnique Device Identifier
UDI Codes (Example)
.... bodySite Σ0..1CodingService Location
Surface Codes (Example)
.... subSite Σ0..*CodingService Sub-location
Surface Codes (Example)
.... modifier Σ0..*CodingService/Product billing modifiers
Modifier type Codes (Example)
.... detail Σ0..*BackboneElementAdditional items
..... sequence Σ1..1positiveIntService instance
..... type Σ1..1CodingGroup or type of product or service
ActInvoiceGroupCode (Required)
..... service Σ1..1CodingAdditional item codes
USCLS Codes (Example)
..... quantity Σ0..1SimpleQuantityCount of Products or Services
..... unitPrice Σ0..1MoneyFee, charge or cost per point
..... factor Σ0..1decimalPrice scaling factor
..... points Σ0..1decimalDifficulty scaling factor
..... net Σ0..1MoneyTotal additional item cost
..... udi Σ0..1CodingUnique Device Identifier
UDI Codes (Example)
..... subDetail Σ0..*BackboneElementAdditional items
...... sequence Σ1..1positiveIntService instance
...... type Σ1..1CodingType of product or service
ActInvoiceGroupCode (Required)
...... service Σ1..1CodingAdditional item codes
USCLS Codes (Example)
...... quantity Σ0..1SimpleQuantityCount of Products or Services
...... unitPrice Σ0..1MoneyFee, charge or cost per point
...... factor Σ0..1decimalPrice scaling factor
...... points Σ0..1decimalDifficulty scaling factor
...... net Σ0..1MoneyNet additional item cost
...... udi Σ0..1CodingUnique Device Identifier
UDI Codes (Example)
.... prosthesis Σ0..1BackboneElementProsthetic details
..... initial Σ0..1booleanIs this the initial service
..... priorDate Σ0..1dateInitial service Date
..... priorMaterial Σ0..1CodingProsthetic Material
Oral Prostho Material type Codes (Example)
... total Σ0..1MoneyTotal claim cost
... additionalMaterials Σ0..*CodingAdditional materials, documents, etc.
Additional Material Codes (Example)
... missingTeeth Σ0..*BackboneElementOnly if type = oral
.... tooth Σ1..1CodingTooth Code
Teeth Codes (Example)
.... reason Σ0..1CodingReason for missing
Missing Tooth Reason Codes (Example)
.... extractionDate Σ0..1dateDate of Extraction

doco Documentation for this format