NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim DomainResourceClaim, Pre-determination or Pre-authorization
... identifier 0..*IdentifierClaim number
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
ClaimStatus (Required)
... type 1..1CodingType or discipline
Example Claim Type Codes (Required)
... subType 0..*CodingFiner grained claim type information
Example Claim SubType Codes (Example)
... ruleset 0..1CodingCurrent specification followed
Ruleset Codes (Example)
... originalRuleset 0..1CodingOriginal specification followed
Ruleset Codes (Example)
... created 0..1dateTimeCreation date
... billablePeriod 0..1PeriodPeriod for charge submission
... insurer[x] 0..1Target
.... insurerIdentifierIdentifier
.... insurerReferenceReference(Organization)
... provider[x] 0..1Responsible provider
.... providerIdentifierIdentifier
.... providerReferenceReference(Practitioner)
... organization[x] 0..1Responsible organization
.... organizationIdentifierIdentifier
.... organizationReferenceReference(Organization)
... use 0..1codecomplete | proposed | exploratory | other
Use (Required)
... priority 0..1CodingDesired processing priority
Priority Codes (Example)
... fundsReserve 0..1CodingFunds requested to be reserved
Funds Reservation Codes (Example)
... enterer[x] 0..1Author
.... entererIdentifierIdentifier
.... entererReferenceReference(Practitioner)
... facility[x] 0..1Servicing Facility
.... facilityIdentifierIdentifier
.... facilityReferenceReference(Location)
... related 0..*BackboneElementRelated Claims which may be revelant to processing this claimn
.... claim[x] 0..1Reference to the related claim
..... claimIdentifierIdentifier
..... claimReferenceReference(Claim)
.... relationship 0..1CodingHow the reference claim is related
Example Related Claim Relationship Codes (Example)
.... reference 0..1IdentifierRelated file or case reference
... prescription[x] 0..1Prescription
.... prescriptionIdentifierIdentifier
.... prescriptionReferenceReference(MedicationOrder | VisionPrescription)
... originalPrescription[x] 0..1Original Prescription
.... originalPrescriptionIdentifierIdentifier
.... originalPrescriptionReferenceReference(MedicationOrder)
... payee 0..1BackboneElementParty to be paid any benefits payable
.... type 1..1CodingType of party: Subscriber, Provider, other
Payee Type Codes (Example)
.... resourceType 0..1Codingorganization | patient | practitioner | relatedperson
PayeeResourceType (Example)
.... party[x] 0..1Party to receive the payable
..... partyIdentifierIdentifier
..... partyReferenceReference(Practitioner | Organization | Patient | RelatedPerson)
... referral[x] 0..1Treatment Referral
.... referralIdentifierIdentifier
.... referralReferenceReference(ReferralRequest)
... information 0..*BackboneElement
.... category 1..1CodingCategory of information
Claim Information Category Codes (Example)
.... code 0..1CodingType of information
Exception Codes (Example)
.... timing[x] 0..1When it occurred
..... timingDatedate
..... timingPeriodPeriod
.... value[x] 0..1Additional Data
..... valueStringstring
..... valueQuantityQuantity
... diagnosis 0..*BackboneElementDiagnosis
.... sequence 1..1positiveIntNumber to covey order of diagnosis
.... diagnosis 1..1CodingPatient's diagnosis
ICD-10 Codes (Example)
.... type 0..*CodingType of Diagnosis
Example Diagnosis Type Codes (Example)
.... drg 0..1CodingDiagnosis Related Group
Example Diagnosis Related Group Codes (Example)
... procedure 0..*BackboneElementProcedures performed
.... sequence 1..1positiveIntProcedure sequence for reference
.... date 0..1dateTimeWhen the procedure was performed
.... procedure[x] 1..1Patient's list of procedures performed
ICD-10 Procedure Codes (Example)
..... procedureCodingCoding
..... procedureReferenceReference(Procedure)
... patient[x] 1..1The subject of the Products and Services
.... patientIdentifierIdentifier
.... patientReferenceReference(Patient)
... coverage 0..*BackboneElementInsurance or medical plan
.... sequence 1..1positiveIntService instance identifier
.... focal 1..1booleanIs the focal Coverage
.... coverage[x] 1..1Insurance information
..... coverageIdentifierIdentifier
..... coverageReferenceReference(Coverage)
.... businessArrangement 0..1stringBusiness agreement
.... preAuthRef 0..*stringPre-Authorization/Determination Reference
.... claimResponse 0..1Reference(ClaimResponse)Adjudication results
.... originalRuleset 0..1CodingOriginal version
Ruleset Codes (Example)
... accident 0..1BackboneElement
.... date 1..1dateWhen the accident occurred see information codes see information codes
.... type 0..1CodingThe nature of the accident
ActIncidentCode (Required)
.... location[x] 0..1Accident Place
..... locationAddressAddress
..... locationReferenceReference(Location)
... employmentImpacted 0..1PeriodPeriod unable to work
... hospitalization 0..1PeriodPeriod in hospital
... item 0..*BackboneElementGoods and Services
.... sequence 1..1positiveIntService instance
.... careTeam 0..*BackboneElement
..... provider[x] 1..1Provider individual or organization
...... providerIdentifierIdentifier
...... providerReferenceReference(Practitioner | Organization)
..... responsible 0..1booleanBilling provider
..... role 0..1CodingRole on the team
Claim Care Team Role Codes (Example)
..... qualification 0..1CodingType, classification or Specialization
Example Provider Qualification Codes (Example)
.... diagnosisLinkId 0..*positiveIntApplicable diagnoses
.... revenue 0..1CodingRevenue or cost center code
Example Revenue Center Codes (Example)
.... category 0..1CodingType of service or product
Benefit SubCategory Codes (Example)
.... service 0..1CodingBilling Code
USCLS Codes (Example)
.... modifier 0..*CodingService/Product billing modifiers
Modifier type Codes (Example)
.... programCode 0..*CodingProgram specific reason for item inclusion
Example Program Reason Codes (Example)
.... serviced[x] 0..1Date or dates of Service
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service
Example Service Place Codes (Example)
..... locationCodingCoding
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1SimpleQuantityCount of Products or Services
.... unitPrice 0..1MoneyFee, charge or cost per point
.... factor 0..1decimalPrice scaling factor
.... points 0..1decimalDifficulty scaling factor
.... net 0..1MoneyTotal item cost
.... udi 0..*Reference(Device)Unique Device Identifier
.... bodySite 0..1CodingService Location
Oral Site Codes (Example)
.... subSite 0..*CodingService Sub-location
Surface Codes (Example)
.... detail 0..*BackboneElementAdditional items
..... sequence 1..1positiveIntService instance
..... revenue 0..1CodingRevenue or cost center code
Example Revenue Center Codes (Example)
..... category 0..1CodingType of service or product
Benefit SubCategory Codes (Example)
..... service 0..1CodingBilling Code
USCLS Codes (Example)
..... modifier 0..*CodingService/Product billing modifiers
Modifier type Codes (Example)
..... programCode 0..*CodingProgram specific reason for item inclusion
Example Program Reason Codes (Example)
..... quantity 0..1SimpleQuantityCount of Products or Services
..... unitPrice 0..1MoneyFee, charge or cost per point
..... factor 0..1decimalPrice scaling factor
..... points 0..1decimalDifficulty scaling factor
..... net 0..1MoneyTotal additional item cost
..... udi 0..*Reference(Device)Unique Device Identifier
..... subDetail 0..*BackboneElementAdditional items
...... sequence 1..1positiveIntService instance
...... revenue 0..1CodingRevenue or cost center code
Example Revenue Center Codes (Example)
...... category 0..1CodingType of service or product
Benefit SubCategory Codes (Example)
...... service 0..1CodingBilling Code
USCLS Codes (Example)
...... modifier 0..*CodingService/Product billing modifiers
Modifier type Codes (Example)
...... programCode 0..*CodingProgram specific reason for item inclusion
Example Program Reason Codes (Example)
...... quantity 0..1SimpleQuantityCount of Products or Services
...... unitPrice 0..1MoneyFee, charge or cost per point
...... factor 0..1decimalPrice scaling factor
...... points 0..1decimalDifficulty scaling factor
...... net 0..1MoneyNet additional item cost
...... udi 0..*Reference(Device)Unique Device Identifier
.... prosthesis 0..1BackboneElementProsthetic details
..... initial 0..1booleanIs this the initial service
..... priorDate 0..1dateInitial service Date
..... priorMaterial 0..1CodingProsthetic Material
Oral Prostho Material type Codes (Example)
... total 0..1MoneyTotal claim cost
... missingTeeth 0..*BackboneElementOnly if type = oral
.... tooth 1..1CodingTooth Code
Teeth Codes (Example)
.... reason 0..1CodingIndicates whether it was extracted or other reason
Missing Tooth Reason Codes (Example)
.... extractionDate 0..1dateDate tooth was extracted if known

doco Documentation for this format