STU3 Candidate

This page is part of the FHIR Specification (v1.8.0: STU 3 Draft). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2

Detailed Descriptions for the elements in the Claim resource.

Claim
Definition

A provider issued list of services and products provided, or to be provided, to a patient which is provided to an insurer for payment recovery.

Control1..1
Claim.identifier
Definition

The business identifier for the instance: claim number, pre-determination or pre-authorization number.

NoteThis is a business identifer, not a resource identifier (see discussion)
Control0..*
TypeIdentifier
Claim.status
Definition

The status of the resource instance.

Control0..1
Terminology BindingFinancial Resource Status Codes (Required)
Typecode
Is Modifiertrue
Summarytrue
Claim.type
Definition

The category of claim, eg, oral, pharmacy, vision, insitutional, professional.

Control0..1
Terminology BindingExample Claim Type Codes (Required)
TypeCodeableConcept
Comments

Affects which fields and value sets are used.

Claim.subType
Definition

A finer grained suite of claim subtype codes which may convey Inpatient vs Outpatient and/or a specialty service. In the US the BillType.

Control0..*
Terminology BindingExample Claim SubType Codes (Example)
TypeCodeableConcept
Comments

This may contain the local bill type codes such as the US UB-04 bill type code.

Claim.use
Definition

Complete (Bill or Claim), Proposed (Pre-Authorization), Exploratory (Pre-determination).

Control0..1
Terminology BindingUse (Required)
Typecode
Claim.patient
Definition

Patient Resource.

Control0..1
TypeReference(Patient)
Claim.billablePeriod
Definition

The billable period for which charges are being submitted.

Control0..1
TypePeriod
Claim.created
Definition

The date when the enclosed suite of services were performed or completed.

Control0..1
TypedateTime
Claim.enterer
Definition

Person who created the invoice/claim/pre-determination or pre-authorization.

Control0..1
TypeReference(Practitioner)
Claim.insurer
Definition

The Insurer who is target of the request.

Control0..1
TypeReference(Organization)
Claim.provider
Definition

The provider which is responsible for the bill, claim pre-determination, pre-authorization.

Control0..1
TypeReference(Practitioner)
Claim.organization
Definition

The organization which is responsible for the bill, claim pre-determination, pre-authorization.

Control0..1
TypeReference(Organization)
Claim.priority
Definition

Immediate (STAT), best effort (NORMAL), deferred (DEFER).

Control0..1
Terminology BindingPriority Codes (Example)
TypeCodeableConcept
Claim.fundsReserve
Definition

In the case of a Pre-Determination/Pre-Authorization the provider may request that funds in the amount of the expected Benefit be reserved ('Patient' or 'Provider') to pay for the Benefits determined on the subsequent claim(s). 'None' explicitly indicates no funds reserving is requested.

Control0..1
Terminology BindingFunds Reservation Codes (Example)
TypeCodeableConcept
Claim.related
Definition

Other claims which are related to this claim such as prior claim versions or for related services.

Control0..*
Claim.related.claim
Definition

Other claims which are related to this claim such as prior claim versions or for related services.

Control0..1
TypeReference(Claim)
Comments

Do we need a relationship code?

Claim.related.relationship
Definition

For example prior or umbrella.

Control0..1
Terminology BindingExample Related Claim Relationship Codes (Example)
TypeCodeableConcept
Claim.related.reference
Definition

An alternate organizational reference to the case or file to which this particular claim pertains - eg Property/Casualy insurer claim # or Workers Compensation case # .

Control0..1
TypeIdentifier
Claim.prescription
Definition

Prescription to support the dispensing of Pharmacy or Vision products.

Control0..1
TypeReference(MedicationRequest | VisionPrescription)
Requirements

For type=Pharmacy and Vision only.

Comments

Should we create a group to hold multiple prescriptions and add a sequence number and on the line items a link to the sequence.

Claim.originalPrescription
Definition

Original prescription which has been superceded by this prescription to support the dispensing of pharmacy services, medications or products. For example, a physician may prescribe a medication which the pharmacy determines is contraindicated, or for which the patient has an intolerance, and therefor issues a new precription for an alternate medication which has the same theraputic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription'.

Control0..1
TypeReference(MedicationRequest)
Comments

as above.

Claim.payee
Definition

The party to be reimbursed for the services.

Control0..1
Claim.payee.type
Definition

Type of Party to be reimbursed: Subscriber, provider, other.

Control1..1
Terminology BindingPayee Type Codes (Example)
TypeCodeableConcept
Claim.payee.resourceType
Definition

organization | patient | practitioner | relatedperson.

Control0..1
Terminology BindingPayeeResourceType (Example)
TypeCoding
Claim.payee.party
Definition

Party to be reimbursed: Subscriber, provider, other.

Control0..1
TypeReference(Practitioner | Organization | Patient | RelatedPerson)
Claim.referral
Definition

The referral resource which lists the date, practitioner, reason and other supporting information.

Control0..1
TypeReference(ReferralRequest)
Claim.facility
Definition

Facility where the services were provided.

Control0..1
TypeReference(Location)
Claim.careTeam
Definition

The members of the team who provided the overall service as well as their role and whether responsible and qualifications.

Control0..*
Requirements

Role and Responsible may not be required when there is only a single provider listed.

Claim.careTeam.sequence
Definition

Sequence of the careTeam which serves to order and provide a link.

Control1..1
TypepositiveInt
Requirements

Required to maintain order of the careTeam.

Claim.careTeam.provider
Definition

Member of the team who provided the overall service.

Control1..1
TypeReference(Practitioner | Organization)
Claim.careTeam.responsible
Definition

The party who is billing and responsible for the claimed good or service rendered to the patient.

Control0..1
Typeboolean
Claim.careTeam.role
Definition

The lead, assisting or supervising practitioner and their discipline if a multidisiplinary team.

Control0..1
Terminology BindingClaim Care Team Role Codes (Example)
TypeCodeableConcept
Claim.careTeam.qualification
Definition

The qualification which is applicable for this service.

Control0..1
Terminology BindingExample Provider Qualification Codes (Example)
TypeCodeableConcept
Claim.information
Definition

Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. Often there are mutiple jurisdiction specific valuesets which are required.

Control0..*
Requirements

Typically these information codes are required to support the services rendered or the adjudication of the services rendered.

Claim.information.category
Definition

The general class of the information supplied: information; exception; accident, employment; onset, etc.

Control1..1
Terminology BindingClaim Information Category Codes (Example)
TypeCodeableConcept
Comments

This may contain the local bill type codes such as the US UB-04 bill type code.

Claim.information.code
Definition

System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought which may influence the adjudication.

Control0..1
Terminology BindingException Codes (Example)
TypeCodeableConcept
Comments

This may contain the local bill type codes such as the US UB-04 bill type code.

Claim.information.timing[x]
Definition

The date when or period to which this information refers.

Control0..1
Typedate|Period
[x] NoteSee Choice of Data Types for further information about how to use [x]
Claim.information.value[x]
Definition

Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.

Control0..1
Typestring|Quantity|Attachment|Reference(Any)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Claim.information.reason
Definition

For example, provides the reason for: the additional stay, or missing tooth or any other situation where a reason code is required in addition to the content.

Control0..1
Terminology BindingMissing Tooth Reason Codes (Example)
TypeCodeableConcept
Claim.diagnosis
Definition

Ordered list of patient diagnosis for which care is sought.

Control0..*
Claim.diagnosis.sequence
Definition

Sequence of diagnosis which serves to order and provide a link.

Control1..1
TypepositiveInt
Requirements

Required to maintain order of the diagnoses.

Claim.diagnosis.diagnosis[x]
Definition

The diagnosis.

Control1..1
Terminology BindingICD-10 Codes (Example)
TypeCodeableConcept|Reference(Condition)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

Required to adjudicate services rendered to condition presented.

Claim.diagnosis.type
Definition

The type of the Diagnosis, for example: admitting,.

Control0..*
Terminology BindingExample Diagnosis Type Codes (Example)
TypeCodeableConcept
Requirements

Required to adjudicate services rendered to the mandated diagnosis grouping system.

Comments

Diagnosis are presented in list order to their expected importance: primary, secondary, etc.

Claim.diagnosis.packageCode
Definition

The package billing code, for example DRG, based on the assigned grouping code system.

Control0..1
Terminology BindingExample Diagnosis Related Group Codes (Example)
TypeCodeableConcept
Requirements

Required to adjudicate services rendered to the mandated grouping system.

Claim.procedure
Definition

Ordered list of patient procedures performed to support the adjudication.

Control0..*
Claim.procedure.sequence
Definition

Sequence of procedures which serves to order and provide a link.

Control1..1
TypepositiveInt
Requirements

Required to maintain order of the procudures.

Claim.procedure.date
Definition

Date and optionally time the procedure was performed .

Control0..1
TypedateTime
Requirements

Required to adjudicate services rendered.

Comments

SB DateTime??

Claim.procedure.procedure[x]
Definition

The procedure code.

Control1..1
Terminology BindingICD-10 Procedure Codes (Example)
TypeCodeableConcept|Reference(Procedure)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

Required to adjudicate services rendered.

Claim.insurance
Definition

Financial instrument by which payment information for health care.

Control0..*
Requirements

Health care programs and insurers are significant payors of health service costs.

Claim.insurance.sequence
Definition

A service line item.

Control1..1
TypepositiveInt
Requirements

To maintain order of the coverages.

Claim.insurance.focal
Definition

A flag to indicate that this Coverage is the focus for adjudication. The Coverage against which the claim is to be adjudicated.

Control1..1
Typeboolean
Requirements

To identify which coverage is being adjudicated.

Claim.insurance.coverage
Definition

Reference to the program or plan identification, underwriter or payor.

Control1..1
TypeReference(Coverage)
Requirements

Need to identify the issuer to target for processing and for coordination of benefit processing.

Claim.insurance.businessArrangement
Definition

The contract number of a business agreement which describes the terms and conditions.

Control0..1
Typestring
Claim.insurance.preAuthRef
Definition

A list of references from the Insurer to which these services pertain.

Control0..*
Typestring
Requirements

To provide any pre=determination or prior authorization reference.

Claim.insurance.claimResponse
Definition

The Coverages adjudication details.

Control0..1
TypeReference(ClaimResponse)
Requirements

Used by downstream payers to determine what balance remains and the net payable.

Claim.accident
Definition

An accident which resulted in the need for healthcare services.

Control0..1
Claim.accident.date
Definition

Date of an accident which these services are addressing.

Control1..1
Typedate
Requirements

Coverage may be dependant on accidents.

Claim.accident.type
Definition

Type of accident: work, auto, etc.

Control0..1
Terminology BindingActIncidentCode (Required)
TypeCodeableConcept
Requirements

Coverage may be dependant on the type of accident.

Claim.accident.location[x]
Definition

Accident Place.

Control0..1
TypeAddress|Reference(Location)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Claim.employmentImpacted
Definition

The start and optional end dates of when the patient was precluded from working due to the treatable condition(s).

Control0..1
TypePeriod
Claim.hospitalization
Definition

The start and optional end dates of when the patient was confined to a treatment center.

Control0..1
TypePeriod
Claim.item
Definition

First tier of goods and services.

Control0..*
Claim.item.sequence
Definition

A service line number.

Control1..1
TypepositiveInt
Claim.item.careTeamLinkId
Definition

CareTeam applicable for this service or product line.

Control0..*
TypepositiveInt
Claim.item.diagnosisLinkId
Definition

Diagnosis applicable for this service or product line.

Control0..*
TypepositiveInt
Claim.item.procedureLinkId
Definition

Procedures applicable for this service or product line.

Control0..*
TypepositiveInt
Claim.item.informationLinkId
Definition

Exceptions, special conditions and supporting information pplicable for this service or product line.

Control0..*
TypepositiveInt
Claim.item.revenue
Definition

The type of reveneu or cost center providing the product and/or service.

Control0..1
Terminology BindingExample Revenue Center Codes (Example)
TypeCodeableConcept
Claim.item.category
Definition

Health Care Service Type Codes to identify the classification of service or benefits.

Control0..1
Terminology BindingBenefit SubCategory Codes (Example)
TypeCodeableConcept
Claim.item.service
Definition

If this is an actual service or product line, ie. not a Group, then use code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,RXNorm,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'.

Control0..1
Terminology BindingUSCLS Codes (Example)
TypeCodeableConcept
Claim.item.modifier
Definition

Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.

Control0..*
Terminology BindingModifier type Codes (Example)
TypeCodeableConcept
Requirements

May impact on adjudication.

Claim.item.programCode
Definition

For programs which require reason codes for the inclusion or covering of this billed item under the program or sub-program.

Control0..*
Terminology BindingExample Program Reason Codes (Example)
TypeCodeableConcept
Claim.item.serviced[x]
Definition

The date or dates when the enclosed suite of services were performed or completed.

Control0..1
Typedate|Period
[x] NoteSee Choice of Data Types for further information about how to use [x]
Claim.item.location[x]
Definition

Where the service was provided.

Control0..1
Terminology BindingExample Service Place Codes (Example)
TypeCodeableConcept|Address|Reference(Location)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Claim.item.quantity
Definition

The number of repetitions of a service or product.

Control0..1
TypeSimpleQuantity
Claim.item.unitPrice
Definition

If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group.

Control0..1
TypeMoney
Claim.item.factor
Definition

A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

Control0..1
Typedecimal
Requirements

If a fee is present the associated product/service code must be present.

Claim.item.net
Definition

The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.

Control0..1
TypeMoney
Requirements

If a fee is present the associated product/service code must be present.

Claim.item.udi
Definition

List of Unique Device Identifiers associated with this line item.

Control0..*
TypeReference(Device)
Requirements

The UDI code and issuer if applicable for the supplied product.

Claim.item.bodySite
Definition

Physical service site on the patient (limb, tooth, etc).

Control0..1
Terminology BindingOral Site Codes (Example)
TypeCodeableConcept
Claim.item.subSite
Definition

A region or surface of the site, eg. limb region or tooth surface(s).

Control0..*
Terminology BindingSurface Codes (Example)
TypeCodeableConcept
Claim.item.detail
Definition

Second tier of goods and services.

Control0..*
Claim.item.detail.sequence
Definition

A service line number.

Control1..1
TypepositiveInt
Claim.item.detail.revenue
Definition

The type of reveneu or cost center providing the product and/or service.

Control0..1
Terminology BindingExample Revenue Center Codes (Example)
TypeCodeableConcept
Claim.item.detail.category
Definition

Health Care Service Type Codes to identify the classification of service or benefits.

Control0..1
Terminology BindingBenefit SubCategory Codes (Example)
TypeCodeableConcept
Claim.item.detail.service
Definition

If this is an actual service or product line, ie. not a Group, then use code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI). If a grouping item then use a group code to indicate the type of thing being grouped eg. 'glasses' or 'compound'.

Control0..1
Terminology BindingUSCLS Codes (Example)
TypeCodeableConcept
Claim.item.detail.modifier
Definition

Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.

Control0..*
Terminology BindingModifier type Codes (Example)
TypeCodeableConcept
Requirements

May impact on adjudication.

Claim.item.detail.programCode
Definition

For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program.

Control0..*
Terminology BindingExample Program Reason Codes (Example)
TypeCodeableConcept
Claim.item.detail.quantity
Definition

The number of repetitions of a service or product.

Control0..1
TypeSimpleQuantity
Claim.item.detail.unitPrice
Definition

If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group.

Control0..1
TypeMoney
Requirements

If a fee is present the associated product/service code must be present.

Claim.item.detail.factor
Definition

A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

Control0..1
Typedecimal
Requirements

If a fee is present the associated product/service code must be present.

Claim.item.detail.net
Definition

The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.

Control0..1
TypeMoney
Requirements

If a fee is present the associated product/service code must be present.

Claim.item.detail.udi
Definition

List of Unique Device Identifiers associated with this line item.

Control0..*
TypeReference(Device)
Requirements

The UDI code and issuer if applicable for the supplied product.

Claim.item.detail.subDetail
Definition

Third tier of goods and services.

Control0..*
Claim.item.detail.subDetail.sequence
Definition

A service line number.

Control1..1
TypepositiveInt
Claim.item.detail.subDetail.revenue
Definition

The type of reveneu or cost center providing the product and/or service.

Control0..1
Terminology BindingExample Revenue Center Codes (Example)
TypeCodeableConcept
Claim.item.detail.subDetail.category
Definition

Health Care Service Type Codes to identify the classification of service or benefits.

Control0..1
Terminology BindingBenefit SubCategory Codes (Example)
TypeCodeableConcept
Claim.item.detail.subDetail.service
Definition

A code to indicate the Professional Service or Product supplied (eg. CTP, HCPCS,USCLS,ICD10, NCPDP,DIN,ACHI,CCI).

Control0..1
Terminology BindingUSCLS Codes (Example)
TypeCodeableConcept
Claim.item.detail.subDetail.modifier
Definition

Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.

Control0..*
Terminology BindingModifier type Codes (Example)
TypeCodeableConcept
Requirements

May impact on adjudication.

Claim.item.detail.subDetail.programCode
Definition

For programs which require reson codes for the inclusion, covering, of this billed item under the program or sub-program.

Control0..*
Terminology BindingExample Program Reason Codes (Example)
TypeCodeableConcept
Claim.item.detail.subDetail.quantity
Definition

The number of repetitions of a service or product.

Control0..1
TypeSimpleQuantity
Claim.item.detail.subDetail.unitPrice
Definition

The fee for an addittional service or product or charge.

Control0..1
TypeMoney
Requirements

If a fee is present the associated product/service code must be present.

Claim.item.detail.subDetail.factor
Definition

A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

Control0..1
Typedecimal
Requirements

If a fee is present the associated product/service code must be present.

Claim.item.detail.subDetail.net
Definition

The quantity times the unit price for an addittional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.

Control0..1
TypeMoney
Requirements

If a fee is present the associated product/service code must be present.

Claim.item.detail.subDetail.udi
Definition

List of Unique Device Identifiers associated with this line item.

Control0..*
TypeReference(Device)
Requirements

The UDI code and issuer if applicable for the supplied product.

Claim.item.prosthesis
Definition

The materials and placement date of prior fixed prosthesis.

Control0..1
Claim.item.prosthesis.initial
Definition

Indicates whether this is the initial placement of a fixed prosthesis.

Control0..1
Typeboolean
Requirements

May impact on adjudication.

Claim.item.prosthesis.priorDate
Definition

Date of the initial placement.

Control0..1
Typedate
Requirements

May impact on adjudication.

Claim.item.prosthesis.priorMaterial
Definition

Material of the prior denture or bridge prosthesis. (Oral).

Control0..1
Terminology BindingOral Prostho Material type Codes (Example)
TypeCodeableConcept
Requirements

May impact on adjudication.

Claim.total
Definition

The total value of the claim.

Control0..1
TypeMoney