NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim DomainResourceClaim, Pre-determination or Pre-authorization
... identifier 0..*IdentifierClaim number
... status ?!Σ0..1codeactive | cancelled | draft | entered-in-error
Financial Resource Status Codes (Required)
... type 0..1CodeableConceptType or discipline
Example Claim Type Codes (Required)
... subType 0..*CodeableConceptFiner grained claim type information
Example Claim SubType Codes (Example)
... use 0..1codecomplete | proposed | exploratory | other
Use (Required)
... patient 0..1Reference(Patient)The subject of the Products and Services
... billablePeriod 0..1PeriodPeriod for charge submission
... created 0..1dateTimeCreation date
... enterer 0..1Reference(Practitioner)Author
... insurer 0..1Reference(Organization)Target
... provider 0..1Reference(Practitioner)Responsible provider
... organization 0..1Reference(Organization)Responsible organization
... priority 0..1CodeableConceptDesired processing priority
Priority Codes (Example)
... fundsReserve 0..1CodeableConceptFunds requested to be reserved
Funds Reservation Codes (Example)
... related 0..*BackboneElementRelated Claims which may be revelant to processing this claimn
.... claim 0..1Reference(Claim)Reference to the related claim
.... relationship 0..1CodeableConceptHow the reference claim is related
Example Related Claim Relationship Codes (Example)
.... reference 0..1IdentifierRelated file or case reference
... prescription 0..1Reference(MedicationRequest | VisionPrescription)Prescription
... originalPrescription 0..1Reference(MedicationRequest)Original Prescription
... payee 0..1BackboneElementParty to be paid any benefits payable
.... type 1..1CodeableConceptType of party: Subscriber, Provider, other
Payee Type Codes (Example)
.... resourceType 0..1Codingorganization | patient | practitioner | relatedperson
PayeeResourceType (Example)
.... party 0..1Reference(Practitioner | Organization | Patient | RelatedPerson)Party to receive the payable
... referral 0..1Reference(ReferralRequest)Treatment Referral
... facility 0..1Reference(Location)Servicing Facility
... careTeam 0..*BackboneElementMembers of the care team
.... sequence 1..1positiveIntNumber to covey order of careTeam
.... provider 1..1Reference(Practitioner | Organization)Provider individual or organization
.... responsible 0..1booleanBilling provider
.... role 0..1CodeableConceptRole on the team
Claim Care Team Role Codes (Example)
.... qualification 0..1CodeableConceptType, classification or Specialization
Example Provider Qualification Codes (Example)
... information 0..*BackboneElementExceptions, special considerations, the condition, situation, prior or concurrent issues
.... category 1..1CodeableConceptCategory of information
Claim Information Category Codes (Example)
.... code 0..1CodeableConceptType of information
Exception Codes (Example)
.... timing[x] 0..1When it occurred
..... timingDatedate
..... timingPeriodPeriod
.... value[x] 0..1Additional Data or supporting information
..... valueStringstring
..... valueQuantityQuantity
..... valueAttachmentAttachment
..... valueReferenceReference(Any)
.... reason 0..1CodeableConceptReason associated with the information
Missing Tooth Reason Codes (Example)
... diagnosis 0..*BackboneElementDiagnosis
.... sequence 1..1positiveIntNumber to covey order of diagnosis
.... diagnosis[x] 1..1Patient's diagnosis
ICD-10 Codes (Example)
..... diagnosisCodeableConceptCodeableConcept
..... diagnosisReferenceReference(Condition)
.... type 0..*CodeableConceptType of Diagnosis
Example Diagnosis Type Codes (Example)
.... packageCode 0..1CodeableConceptPackage billing code
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)
..... procedureCodeableConceptCodeableConcept
..... procedureReferenceReference(Procedure)
... insurance 0..*BackboneElementInsurance or medical plan
.... sequence 1..1positiveIntService instance identifier
.... focal 1..1booleanIs the focal Coverage
.... coverage 1..1Reference(Coverage)Insurance information
.... businessArrangement 0..1stringBusiness agreement
.... preAuthRef 0..*stringPre-Authorization/Determination Reference
.... claimResponse 0..1Reference(ClaimResponse)Adjudication results
... accident 0..1BackboneElementDetails about an accident
.... date 1..1dateWhen the accident occurred see information codes see information codes
.... type 0..1CodeableConceptThe 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
.... careTeamLinkId 0..*positiveIntApplicable careTeam members
.... diagnosisLinkId 0..*positiveIntApplicable diagnoses
.... procedureLinkId 0..*positiveIntApplicable procedures
.... informationLinkId 0..*positiveIntApplicable exception and supporting information
.... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
.... category 0..1CodeableConceptType of service or product
Benefit SubCategory Codes (Example)
.... service 0..1CodeableConceptBilling Code
USCLS Codes (Example)
.... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
.... programCode 0..*CodeableConceptProgram 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)
..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1SimpleQuantityCount of Products or Services
.... unitPrice 0..1MoneyFee, charge or cost per point
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... udi 0..*Reference(Device)Unique Device Identifier
.... bodySite 0..1CodeableConceptService Location
Oral Site Codes (Example)
.... subSite 0..*CodeableConceptService Sub-location
Surface Codes (Example)
.... detail 0..*BackboneElementAdditional items
..... sequence 1..1positiveIntService instance
..... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
..... category 0..1CodeableConceptType of service or product
Benefit SubCategory Codes (Example)
..... service 0..1CodeableConceptBilling Code
USCLS Codes (Example)
..... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
..... programCode 0..*CodeableConceptProgram 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
..... net 0..1MoneyTotal additional item cost
..... udi 0..*Reference(Device)Unique Device Identifier
..... subDetail 0..*BackboneElementAdditional items
...... sequence 1..1positiveIntService instance
...... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
...... category 0..1CodeableConceptType of service or product
Benefit SubCategory Codes (Example)
...... service 0..1CodeableConceptBilling Code
USCLS Codes (Example)
...... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
...... programCode 0..*CodeableConceptProgram 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
...... 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..1CodeableConceptProsthetic Material
Oral Prostho Material type Codes (Example)
... total 0..1MoneyTotal claim cost

doco Documentation for this format