NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim ΣDomainResourceClaim, Pre-determination or Pre-authorization
... type Σ1..1codeinstitutional | oral | pharmacy | professional | vision
ClaimType (Required)
... subType Σ0..*CodingFiner grained claim type information
Example Claim SubType Codes (Example)
... 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[x] Σ0..1Insurer
.... targetIdentifierIdentifier
.... targetReferenceReference(Organization)
... provider[x] Σ0..1Responsible provider
.... providerIdentifierIdentifier
.... providerReferenceReference(Practitioner)
... organization[x] Σ0..1Responsible organization
.... organizationIdentifierIdentifier
.... organizationReferenceReference(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[x] Σ0..1Author
.... entererIdentifierIdentifier
.... entererReferenceReference(Practitioner)
... facility[x] Σ0..1Servicing Facility
.... facilityIdentifierIdentifier
.... facilityReferenceReference(Location)
... related Σ0..*BackboneElementRelated Claims which may be revelant to processing this claimn
.... claim[x] Σ0..1Reference to the related claim
..... claimIdentifierIdentifier
..... claimReferenceReference(Claim)
.... relationship Σ0..1CodingHow the reference claim is related
Example Related Claim Relationship Codes (Example)
.... reference Σ0..1IdentifierRelated file or case reference
... prescription[x] Σ0..1Prescription
.... prescriptionIdentifierIdentifier
.... prescriptionReferenceReference(MedicationOrder | VisionPrescription)
... originalPrescription[x] Σ0..1Original Prescription
.... originalPrescriptionIdentifierIdentifier
.... originalPrescriptionReferenceReference(MedicationOrder)
... payee Σ0..1BackboneElementParty to be paid any benefits payable
.... type Σ1..1CodingType of party: Subscriber, Provider, other
Payee Type Codes (Example)
.... party[x] Σ0..1Party to receive the payable
..... partyIdentifierIdentifier
..... partyReferenceReference(Practitioner | Organization | Patient | RelatedPerson)
... referral[x] Σ0..1Treatment Referral
.... referralIdentifierIdentifier
.... referralReferenceReference(ReferralRequest)
... occurrenceCode Σ0..*CodingOccurrence Codes
Example Occurrance Codes (Example)
... occurenceSpanCode Σ0..*CodingOccurrence Span Codes
Example Occurrance Span Codes (Example)
... valueCode Σ0..*CodingValue Codes
Example Value Codes (Example)
... diagnosis Σ0..*BackboneElementDiagnosis
.... sequence Σ1..1positiveIntNumber to covey order of diagnosis
.... diagnosis Σ1..1CodingPatient's list of diagnosis
ICD-10 Codes (Example)
... procedure Σ0..*BackboneElementProcedures performed
.... sequence Σ1..1positiveIntProcedure sequence for reference
.... date Σ0..1dateTimeWhen the procedure was performed
.... procedure[x] Σ1..1Patient's list of procedures performed
ICD-10 Procedure Codes (Example)
..... procedureCodingCoding
..... procedureReferenceReference(Procedure)
... specialCondition Σ0..*CodingList of special Conditions
Conditions Codes (Example)
... patient[x] Σ1..1The subject of the Products and Services
.... patientIdentifierIdentifier
.... patientReferenceReference(Patient)
... coverage Σ0..*BackboneElementInsurance or medical plan
.... sequence Σ1..1positiveIntService instance identifier
.... focal Σ1..1booleanIs the focal Coverage
.... coverage[x] Σ1..1Insurance information
..... coverageIdentifierIdentifier
..... coverageReferenceReference(Coverage)
.... businessArrangement Σ0..1stringBusiness agreement
.... preAuthRef Σ0..*stringPre-Authorization/Determination Reference
.... claimResponse Σ0..1Reference(ClaimResponse)Adjudication results
.... originalRuleset Σ0..1CodingOriginal version
Ruleset Codes (Example)
... accidentDate Σ0..1dateWhen the accident occurred
... accidentType Σ0..1CodingThe nature of the accident
ActIncidentCode (Required)
... accidentLocation[x] Σ0..1Accident Place
.... accidentLocationAddressAddress
.... accidentLocationReferenceReference(Location)
... interventionException Σ0..*CodingIntervention and exception code (Pharma)
Intervention Codes (Example)
... onset Σ0..*BackboneElementCondition related Onset related dates and codes
.... time[x] Σ0..1Illness, injury or treatable condition date
..... timeDatedate
..... timePeriodPeriod
.... type Σ0..1CodingOnset of what
Example Onset Type (Reason) Codes (Example)
... 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
Exception Codes (Required)
.... provider[x] Σ0..1Responsible practitioner
..... providerIdentifierIdentifier
..... providerReferenceReference(Practitioner)
.... supervisor[x] Σ0..1Supervising Practitioner
..... supervisorIdentifierIdentifier
..... supervisorReferenceReference(Practitioner)
.... providerQualification Σ0..1CodingType, classification or Specialization
Example Provider Qualification Codes (Example)
.... diagnosisLinkId Σ0..*positiveIntApplicable diagnoses
.... service Σ1..1CodingItem Code
USCLS Codes (Example)
.... serviceModifier Σ0..*CodingService/Product modifiers
Example Service Modifier Codes (Example)
.... modifier Σ0..*CodingService/Product billing modifiers
Modifier type Codes (Example)
.... programCode Σ0..*CodingProgram specific reason for item inclusion
Example Program Reason 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..*Reference(Device)Unique Device Identifier
.... bodySite Σ0..1CodingService Location
Oral Site Codes (Example)
.... subSite Σ0..*CodingService Sub-location
Surface Codes (Example)
.... detail Σ0..*BackboneElementAdditional items
..... sequence Σ1..1positiveIntService instance
..... type Σ1..1CodingGroup or type of product or service
Exception Codes (Required)
..... service Σ1..1CodingAdditional item codes
USCLS Codes (Example)
..... programCode Σ0..*CodingProgram specific reason for item inclusion
Example Program Reason 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..*Reference(Device)Unique Device Identifier
..... subDetail Σ0..*BackboneElementAdditional items
...... sequence Σ1..1positiveIntService instance
...... type Σ1..1CodingType of product or service
Exception Codes (Required)
...... service Σ1..1CodingAdditional item codes
USCLS Codes (Example)
...... programCode Σ0..*CodingProgram specific reason for item inclusion
Example Program Reason 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..*Reference(Device)Unique Device Identifier
.... 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
... additionalMaterial Σ0..*CodingAdditional supporting materials and documents
Additional Material Codes (Example)
... missingTeeth Σ0..*BackboneElementOnly if type = oral
.... tooth Σ1..1CodingTooth Code
Teeth Codes (Example)
.... reason Σ0..1CodingIndicates whether it was extracted or other reason
Missing Tooth Reason Codes (Example)
.... extractionDate Σ0..1dateDate tooth was extracted if known

doco Documentation for this format