| Name | Flags | Card. | Type | Description & Constraints![]() |
|---|---|---|---|---|
| DomainResource | Claim, Pre-determination or Pre-authorization | |||
| 0..* | Identifier | Claim number | ||
| ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error ClaimStatus (Required) | |
| 1..1 | Coding | Type or discipline Example Claim Type Codes (Required) | ||
| 0..* | Coding | Finer grained claim type information Example Claim SubType Codes (Example) | ||
| 0..1 | Coding | Current specification followed Ruleset Codes (Example) | ||
| 0..1 | Coding | Original specification followed Ruleset Codes (Example) | ||
| 0..1 | dateTime | Creation date | ||
| 0..1 | Period | Period for charge submission | ||
| 0..1 | Target | |||
| Identifier | ||||
| Reference(Organization) | ||||
| 0..1 | Responsible provider | |||
| Identifier | ||||
| Reference(Practitioner) | ||||
| 0..1 | Responsible organization | |||
| Identifier | ||||
| Reference(Organization) | ||||
| 0..1 | code | complete | proposed | exploratory | other Use (Required) | ||
| 0..1 | Coding | Desired processing priority Priority Codes (Example) | ||
| 0..1 | Coding | Funds requested to be reserved Funds Reservation Codes (Example) | ||
| 0..1 | Author | |||
| Identifier | ||||
| Reference(Practitioner) | ||||
| 0..1 | Servicing Facility | |||
| Identifier | ||||
| Reference(Location) | ||||
| 0..* | BackboneElement | Related Claims which may be revelant to processing this claimn | ||
| 0..1 | Reference to the related claim | |||
| Identifier | ||||
| Reference(Claim) | ||||
| 0..1 | Coding | How the reference claim is related Example Related Claim Relationship Codes (Example) | ||
| 0..1 | Identifier | Related file or case reference | ||
| 0..1 | Prescription | |||
| Identifier | ||||
| Reference(MedicationOrder | VisionPrescription) | ||||
| 0..1 | Original Prescription | |||
| Identifier | ||||
| Reference(MedicationOrder) | ||||
| 0..1 | BackboneElement | Party to be paid any benefits payable | ||
| 1..1 | Coding | Type of party: Subscriber, Provider, other Payee Type Codes (Example) | ||
| 0..1 | Coding | organization | patient | practitioner | relatedperson PayeeResourceType (Example) | ||
| 0..1 | Party to receive the payable | |||
| Identifier | ||||
| Reference(Practitioner | Organization | Patient | RelatedPerson) | ||||
| 0..1 | Treatment Referral | |||
| Identifier | ||||
| Reference(ReferralRequest) | ||||
| 0..* | BackboneElement | |||
| 1..1 | Coding | Category of information Claim Information Category Codes (Example) | ||
| 0..1 | Coding | Type of information Exception Codes (Example) | ||
| 0..1 | When it occurred | |||
| date | ||||
| Period | ||||
| 0..1 | Additional Data | |||
| string | ||||
| Quantity | ||||
| 0..* | BackboneElement | Diagnosis | ||
| 1..1 | positiveInt | Number to covey order of diagnosis | ||
| 1..1 | Coding | Patient's diagnosis ICD-10 Codes (Example) | ||
| 0..* | Coding | Type of Diagnosis Example Diagnosis Type Codes (Example) | ||
| 0..1 | Coding | Diagnosis Related Group Example Diagnosis Related Group Codes (Example) | ||
| 0..* | BackboneElement | Procedures performed | ||
| 1..1 | positiveInt | Procedure sequence for reference | ||
| 0..1 | dateTime | When the procedure was performed | ||
| 1..1 | Patient's list of procedures performed ICD-10 Procedure Codes (Example) | |||
| Coding | ||||
| Reference(Procedure) | ||||
| 1..1 | The subject of the Products and Services | |||
| Identifier | ||||
| Reference(Patient) | ||||
| 0..* | BackboneElement | Insurance or medical plan | ||
| 1..1 | positiveInt | Service instance identifier | ||
| 1..1 | boolean | Is the focal Coverage | ||
| 1..1 | Insurance information | |||
| Identifier | ||||
| Reference(Coverage) | ||||
| 0..1 | string | Business agreement | ||
| 0..* | string | Pre-Authorization/Determination Reference | ||
| 0..1 | Reference(ClaimResponse) | Adjudication results | ||
| 0..1 | Coding | Original version Ruleset Codes (Example) | ||
| 0..1 | BackboneElement | |||
| 1..1 | date | When the accident occurred see information codes see information codes | ||
| 0..1 | Coding | The nature of the accident ActIncidentCode (Required) | ||
| 0..1 | Accident Place | |||
| Address | ||||
| Reference(Location) | ||||
| 0..1 | Period | Period unable to work | ||
| 0..1 | Period | Period in hospital | ||
| 0..* | BackboneElement | Goods and Services | ||
| 1..1 | positiveInt | Service instance | ||
| 0..* | BackboneElement | |||
| 1..1 | Provider individual or organization | |||
| Identifier | ||||
| Reference(Practitioner | Organization) | ||||
| 0..1 | boolean | Billing provider | ||
| 0..1 | Coding | Role on the team Claim Care Team Role Codes (Example) | ||
| 0..1 | Coding | Type, classification or Specialization Example Provider Qualification Codes (Example) | ||
| 0..* | positiveInt | Applicable diagnoses | ||
| 0..1 | Coding | Revenue or cost center code Example Revenue Center Codes (Example) | ||
| 0..1 | Coding | Type of service or product Benefit SubCategory Codes (Example) | ||
| 0..1 | Coding | Billing Code USCLS Codes (Example) | ||
| 0..* | Coding | Service/Product billing modifiers Modifier type Codes (Example) | ||
| 0..* | Coding | Program specific reason for item inclusion Example Program Reason Codes (Example) | ||
| 0..1 | Date or dates of Service | |||
| date | ||||
| Period | ||||
| 0..1 | Place of service Example Service Place Codes (Example) | |||
| Coding | ||||
| Address | ||||
| Reference(Location) | ||||
| 0..1 | SimpleQuantity | Count of Products or Services | ||
| 0..1 | Money | Fee, charge or cost per point | ||
| 0..1 | decimal | Price scaling factor | ||
| 0..1 | decimal | Difficulty scaling factor | ||
| 0..1 | Money | Total item cost | ||
| 0..* | Reference(Device) | Unique Device Identifier | ||
| 0..1 | Coding | Service Location Oral Site Codes (Example) | ||
| 0..* | Coding | Service Sub-location Surface Codes (Example) | ||
| 0..* | BackboneElement | Additional items | ||
| 1..1 | positiveInt | Service instance | ||
| 0..1 | Coding | Revenue or cost center code Example Revenue Center Codes (Example) | ||
| 0..1 | Coding | Type of service or product Benefit SubCategory Codes (Example) | ||
| 0..1 | Coding | Billing Code USCLS Codes (Example) | ||
| 0..* | Coding | Service/Product billing modifiers Modifier type Codes (Example) | ||
| 0..* | Coding | Program specific reason for item inclusion Example Program Reason Codes (Example) | ||
| 0..1 | SimpleQuantity | Count of Products or Services | ||
| 0..1 | Money | Fee, charge or cost per point | ||
| 0..1 | decimal | Price scaling factor | ||
| 0..1 | decimal | Difficulty scaling factor | ||
| 0..1 | Money | Total additional item cost | ||
| 0..* | Reference(Device) | Unique Device Identifier | ||
| 0..* | BackboneElement | Additional items | ||
| 1..1 | positiveInt | Service instance | ||
| 0..1 | Coding | Revenue or cost center code Example Revenue Center Codes (Example) | ||
| 0..1 | Coding | Type of service or product Benefit SubCategory Codes (Example) | ||
| 0..1 | Coding | Billing Code USCLS Codes (Example) | ||
| 0..* | Coding | Service/Product billing modifiers Modifier type Codes (Example) | ||
| 0..* | Coding | Program specific reason for item inclusion Example Program Reason Codes (Example) | ||
| 0..1 | SimpleQuantity | Count of Products or Services | ||
| 0..1 | Money | Fee, charge or cost per point | ||
| 0..1 | decimal | Price scaling factor | ||
| 0..1 | decimal | Difficulty scaling factor | ||
| 0..1 | Money | Net additional item cost | ||
| 0..* | Reference(Device) | Unique Device Identifier | ||
| 0..1 | BackboneElement | Prosthetic details | ||
| 0..1 | boolean | Is this the initial service | ||
| 0..1 | date | Initial service Date | ||
| 0..1 | Coding | Prosthetic Material Oral Prostho Material type Codes (Example) | ||
| 0..1 | Money | Total claim cost | ||
| 0..* | BackboneElement | Only if type = oral | ||
| 1..1 | Coding | Tooth Code Teeth Codes (Example) | ||
| 0..1 | Coding | Indicates whether it was extracted or other reason Missing Tooth Reason Codes (Example) | ||
| 0..1 | date | Date tooth was extracted if known | ||
Documentation for this format | ||||