PATIENT ADMINISTRTAION (PA) Workgroup Development Draft

7.1 Resource Claim - Content

This resource maintained by the Financial Management Work Group

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.

7.1.1 Scope and Usage

The OralHealthClaim is one of a suite of similar resources (VisionClaim, PharmacyClaim, ProfessionalClaim, InstitutionalClaim) which are used by providers to exchange the financial information, and supporting clinical information, regarding the provision of healthcare services. The primary uses of this resource is to support eClaims, the exchange of proposed or actual services to benefit payors, insurers and national health programs, for treatment payment planning and reimbursement.

The Claim is intended to support:

  • Claims - where the provision of goods and services is complete and reimbursement is sought.
  • Pre-Authorization - where the provision of goods and services is proposed and either authorization and/or the reservation of funds is desired.
  • Pre-Determination - where the provision of goods and services is explored to determine what services may be covered and to what amount. Essentially a 'what if' claim.

The Claim also supports:

  • Up to a 3 tier hierarchy of Goods, products, and Services, to support simple to complex billing.
  • Multiple insurance programs arranged in a Coordination of Benefit sequence to enable exchange with primary, secondary, tertiary etc. insurance coverages.
  • Assignment of benefit - the benefit may be requested to be directed to the subscriber, the provider or another party.

Todo

This resource is referenced by ClaimResponse and ExplanationOfBenefit

7.1.2 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim DomainResourceClaim, Pre-determination or Pre-authorization
... type 1..1codeinstitutional | oral | pharmacy | professional | vision
ClaimType (Required)
... identifier 0..*IdentifierClaim number
... ruleset 0..1CodingCurrent specification followed
Ruleset Codes (Example)
... originalRuleset 0..1CodingOriginal specification followed
Ruleset Codes (Example)
... created 0..1dateTimeCreation date
... target 0..1OrganizationInsurer
... provider 0..1PractitionerResponsible provider
... organization 0..1OrganizationResponsible 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 0..1PractitionerAuthor
... facility 0..1LocationServicing Facility
... prescription 0..1MedicationPrescription | VisionPrescriptionPrescription
... originalPrescription 0..1MedicationPrescriptionOriginal Prescription
... payee 0..1ElementPayee
.... type 0..1CodingParty to be paid any benefits payable
Payee type Codes (Example)
.... provider 0..1PractitionerProvider who is the payee
.... organization 0..1OrganizationOrganization who is the payee
.... person 0..1PatientOther person who is the payee
... referral 0..1ReferralRequestTreatment Referral
... diagnosis 0..*ElementDiagnosis
.... sequence 1..1positiveIntSequence of diagnosis
.... diagnosis 1..1CodingPatient's list of diagnosis
ICD-10 Codes (Example)
... condition 0..*CodingList of presenting Conditions
Conditions Codes (Example)
... patient 1..1PatientThe subject of the Products and Services
... coverage 0..*ElementInsurance or medical plan
.... sequence 1..1positiveIntService instance identifier
.... focal 1..1booleanIs the focal Coverage
.... coverage 1..1CoverageInsurance information
.... businessArrangement 0..1stringBusiness agreement
.... relationship 1..1CodingPatient relationship to subscriber
Surface Codes (Example)
.... preAuthRef 0..*stringPre-Authorization/Determination Reference
.... claimResponse 0..1ClaimResponseAdjudication results
.... originalRuleset 0..1CodingOriginal version
Ruleset Codes (Example)
... exception 0..*CodingEligibility exceptions
Exception Codes (Example)
... school 0..1stringName of School
... accident 0..1dateAccident Date
... accidentType 0..1CodingAccident Type
ActIncidentCode Codes (Example)
... interventionException 0..*CodingIntervention and exception code (Pharma)
Intervention Codes (Example)
... item 0..*ElementGoods and Services
.... sequence 1..1positiveIntService instance
.... type 1..1CodingGroup or type of product or service
ActInvoiceGroupCode Codes (Example)
.... provider 0..1PractitionerResponsible practitioner
.... diagnosisLinkId 0..*positiveIntDiagnosis Link
.... service 1..1CodingItem Code
USCLS Codes (Example)
.... serviceDate 0..1dateDate of Service
.... quantity 0..1QuantityCount 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..1CodingUnique Device Identifier
UDI Codes (Example)
.... bodySite 0..1CodingService Location
Surface Codes (Example)
.... subSite 0..*CodingService Sub-location
Surface Codes (Example)
.... modifier 0..*CodingService/Product billing modifiers
Modifier type Codes (Example)
.... detail 0..*ElementAdditional items
..... sequence 1..1positiveIntService instance
..... type 1..1CodingGroup or type of product or service
ActInvoiceGroupCode Codes (Example)
..... service 1..1CodingAdditional item codes
USCLS Codes (Example)
..... quantity 0..1QuantityCount 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..1CodingUnique Device Identifier
UDI Codes (Example)
..... subDetail 0..*ElementAdditional items
...... sequence 1..1positiveIntService instance
...... type 1..1CodingType of product or service
ActInvoiceGroupCode Codes (Example)
...... service 1..1CodingAdditional item codes
USCLS Codes (Example)
...... quantity 0..1QuantityCount 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..1CodingUnique Device Identifier
UDI Codes (Example)
.... prosthesis 0..1ElementProsthetic details
..... initial 0..1booleanIs this the initial service
..... priorDate 0..1dateInitial service Date
..... priorMaterial 0..1CodingProsthetic Material
Oral Prostho Material type Codes (Example)
... additionalMaterials 0..*CodingAdditional materials, documents, etc.
Additional Material Codes (Example)
... missingTeeth 0..*ElementOnly if type = oral
.... tooth 1..1CodingTooth Code
Teeth Codes (Example)
.... reason 0..1CodingReason for missing
Missing Tooth Reason Codes (Example)
.... extractionDate 0..1dateDate of Extraction

UML Diagram

Claim (DomainResource)The category of claim this istype : code 1..1 « The type or discipline-style of the claimClaimType »The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization numberidentifier : Identifier 0..*The version of the specification on which this instance reliesruleset : Coding 0..1 « (The static and dynamic model to which contents conform, may be business version or standard and version.Ruleset Codes) »The version of the specification from which the original instance was createdoriginalRuleset : Coding 0..1 « (The static and dynamic model to which contents conform, may be business version or standard and version.Ruleset Codes) »The date when the enclosed suite of services were performed or completedcreated : dateTime 0..1Insurer Identifier, typical BIN number (6 digit)target : Reference(Organization) 0..1The provider which is responsible for the bill, claim pre-determination, pre-authorizationprovider : Reference(Practitioner) 0..1The organization which is responsible for the bill, claim pre-determination, pre-authorizationorganization : Reference(Organization) 0..1Complete (Bill or Claim), Proposed (Pre-Authorization), Exploratory (Pre-determination)use : code 0..1 « Complete, proposed, exploratory, otherUse »Immediate (STAT), best effort (NORMAL), deferred (DEFER)priority : Coding 0..1 « (The timeliness with which processing is required: STAT, normal, DeferredPriority Codes) »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 requestedfundsReserve : Coding 0..1 « (For whom funds are to be reserved: (Patient, Provider, None)Funds Reservation Codes) »Person who created the invoice/claim/pre-determination or pre-authorizationenterer : Reference(Practitioner) 0..1Facility where the services were providedfacility : Reference(Location) 0..1Prescription to support the dispensing of Pharmacy or Vision productsprescription : Reference(MedicationPrescription| VisionPrescription) 0..1Original prescription to support the dispensing of pharmacy services, medications or productsoriginalPrescription : Reference(MedicationPrescription) 0..1The referral resource which lists the date, practitioner, reason and other supporting informationreferral : Reference(ReferralRequest) 0..1List of patient conditions for which care is soughtcondition : Coding 0..* « (Patient conditions and symptomsConditions Codes) »Patient Resourcepatient : Reference(Patient) 1..1Factors which may influence the applicability of coverageexception : Coding 0..* « (The eligibility exception codes.Exception Codes) »Name of school for over-aged dependantsschool : string 0..1Date of an accident which these services are addressingaccident : date 0..1Type of accident: work, auto, etcaccidentType : Coding 0..1 « (Type of accident: work place, auto, etc.ActIncidentCode Codes) »A list of intervention and exception codes which may influence the adjudication of the claiminterventionException : Coding 0..* « (Intervention and exception codes (Pharm)Intervention Codes) »Code to indicate that Xrays, images, emails, documents, models or attachments are being sent in support of this submissionadditionalMaterials : Coding 0..* « (Code to indicate that Xrays, images, emails, documents, models or attachments are being sent in support of this submission.Additional Material Codes) »PayeeParty to be reimbursed: Subscriber, provider, othertype : Coding 0..1 « (A code for the party to be reimbursed.Payee type Codes) »The provider who is to be reimbursed for the claim (the party to whom any benefit is assigned)provider : Reference(Practitioner) 0..1The organization who is to be reimbursed for the claim (the party to whom any benefit is assigned)organization : Reference(Organization) 0..1The person other than the subscriber who is to be reimbursed for the claim (the party to whom any benefit is assigned)person : Reference(Patient) 0..1DiagnosisSequence of diagnosis which serves to order and provide a linksequence : positiveInt 1..1The diagnosisdiagnosis : Coding 1..1 « (ICD10 Diagnostic codesICD-10 Codes) »CoverageA service line itemsequence : positiveInt 1..1The instance number of the Coverage which is the focus for adjudication. The Coverage against which the claim is to be adjudicatedfocal : boolean 1..1Reference to the program or plan identification, underwriter or payorcoverage : Reference(Coverage) 1..1The contract number of a business agreement which describes the terms and conditionsbusinessArrangement : string 0..1The relationship of the patient to the subscriberrelationship : Coding 1..1 « (The code for the relationship of the patient to the subscriberSurface Codes) »A list of references from the Insurer to which these services pertainpreAuthRef : string 0..*The Coverages adjudication detailsclaimResponse : Reference(ClaimResponse) 0..1The style (standard) and version of the original material which was converted into this resourceoriginalRuleset : Coding 0..1 « (The static and dynamic model to which contents conform, may be business version or standard and version.Ruleset Codes) »ItemsA service line numbersequence : positiveInt 1..1The type of product or servicetype : Coding 1..1 « (Service, Product, Rx Dispense, Rx Compound etc.ActInvoiceGroupCode Codes) »The practitioner who is responsible for the services rendered to the patientprovider : Reference(Practitioner) 0..1Diagnosis applicable for this service or product linediagnosisLinkId : positiveInt 0..*If a grouping item then 'GROUP' otherwise it is a node therefore a code to indicate the Professional Service or Product suppliedservice : Coding 1..1 « (Allowable service and product codesUSCLS Codes) »The date when the enclosed suite of services were performed or completedserviceDate : date 0..1The number of repetitions of a service or productquantity : Quantity 0..1If 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 groupunitPrice : Money 0..1A 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 amountfactor : decimal 0..1An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each pointpoints : decimal 0..1The 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 suppliednet : Money 0..1List of Unique Device Identifiers associated with this line itemudi : Coding 0..1 « (The FDA, or other, UDI repository.UDI Codes) »Physical service site on the patient (limb, tooth, etc)bodySite : Coding 0..1 « (The code for the teeth, quadrant, sextant and archSurface Codes) »A region or surface of the site, eg. limb region or tooth surface(s)subSite : Coding 0..* « (The code for the tooth surface and surface combinationsSurface Codes) »Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolenmodifier : Coding 0..* « (Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.Modifier type Codes) »DetailA service line numbersequence : positiveInt 1..1The type of product or servicetype : Coding 1..1 « (Service, Product, Rx Dispense, Rx Compound etc.ActInvoiceGroupCode Codes) »If a grouping item then 'GROUP' otherwise it is a node therefore a code to indicate the Professional Service or Product suppliedservice : Coding 1..1 « (Allowable service and product codesUSCLS Codes) »The number of repetitions of a service or productquantity : Quantity 0..1If 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 groupunitPrice : Money 0..1A 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 amountfactor : decimal 0..1An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each pointpoints : decimal 0..1The 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 suppliednet : Money 0..1List of Unique Device Identifiers associated with this line itemudi : Coding 0..1 « (The FDA, or other, UDI repository.UDI Codes) »SubDetailA service line numbersequence : positiveInt 1..1The type of product or servicetype : Coding 1..1 « (Service, Product, Rx Dispense, Rx Compound etc.ActInvoiceGroupCode Codes) »The fee for an addittional service or product or chargeservice : Coding 1..1 « (Allowable service and product codesUSCLS Codes) »The number of repetitions of a service or productquantity : Quantity 0..1The fee for an addittional service or product or chargeunitPrice : Money 0..1A 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 amountfactor : decimal 0..1An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each pointpoints : decimal 0..1The 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 suppliednet : Money 0..1List of Unique Device Identifiers associated with this line itemudi : Coding 0..1 « (The FDA, or other, UDI repository.UDI Codes) »ProsthesisIndicates whether this is the initial placement of a fixed prosthesisinitial : boolean 0..1Date of the initial placementpriorDate : date 0..1Material of the prior denture or bridge prosthesis. (Oral)priorMaterial : Coding 0..1 « (Material of the prior denture or bridge prosthesis. (Oral)Oral Prostho Material type Codes) »MissingTeethThe code identifying which tooth is missingtooth : Coding 1..1 « (The codes for the teeth, subset of OralSitesTeeth Codes) »Missing reason may be: E-extraction, O-otherreason : Coding 0..1 « (Reason codes for the missing teethMissing Tooth Reason Codes) »The date of the extraction either known from records or patient reported estimateextractionDate : date 0..1The party to be reimbursed for the servicespayee0..1Ordered list of patient diagnosis for which care is soughtdiagnosis0..*Financial instrument by which payment information for health carecoverage0..*Third tier of goods and servicessubDetail0..*Second tier of goods and servicesdetail0..*The materials and placement date of prior fixed prosthesisprosthesis0..1First tier of goods and servicesitem0..*A list of teeth which would be expected but are not found due to having been previously extracted or for other reasonsmissingTeeth0..*

XML Template

<Claim xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <type value="[code]"/><!-- 1..1 institutional | oral | pharmacy | professional | vision -->
 <identifier><!-- 0..* Identifier Claim number --></identifier>
 <ruleset><!-- 0..1 Coding Current specification followed --></ruleset>
 <originalRuleset><!-- 0..1 Coding Original specification followed --></originalRuleset>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <target><!-- 0..1 Reference(Organization) Insurer --></target>
 <provider><!-- 0..1 Reference(Practitioner) Responsible provider --></provider>
 <organization><!-- 0..1 Reference(Organization) Responsible organization --></organization>
 <use value="[code]"/><!-- 0..1 complete | proposed | exploratory | other -->
 <priority><!-- 0..1 Coding Desired processing priority --></priority>
 <fundsReserve><!-- 0..1 Coding Funds requested to be reserved --></fundsReserve>
 <enterer><!-- 0..1 Reference(Practitioner) Author --></enterer>
 <facility><!-- 0..1 Reference(Location) Servicing Facility --></facility>
 <prescription><!-- 0..1 Reference(MedicationPrescription|VisionPrescription) Prescription --></prescription>
 <originalPrescription><!-- 0..1 Reference(MedicationPrescription) Original Prescription --></originalPrescription>
 <payee>  <!-- 0..1 Payee -->
  <type><!-- 0..1 Coding Party to be paid any benefits payable --></type>
  <provider><!-- 0..1 Reference(Practitioner) Provider who is the payee --></provider>
  <organization><!-- 0..1 Reference(Organization) Organization who is the payee --></organization>
  <person><!-- 0..1 Reference(Patient) Other person who is the payee --></person>
 </payee>
 <referral><!-- 0..1 Reference(ReferralRequest) Treatment Referral --></referral>
 <diagnosis>  <!-- 0..* Diagnosis -->
  <sequence value="[positiveInt]"/><!-- 1..1 Sequence of diagnosis -->
  <diagnosis><!-- 1..1 Coding Patient's list of diagnosis --></diagnosis>
 </diagnosis>
 <condition><!-- 0..* Coding List of presenting Conditions --></condition>
 <patient><!-- 1..1 Reference(Patient) The subject of the Products and Services --></patient>
 <coverage>  <!-- 0..* Insurance or medical plan -->
  <sequence value="[positiveInt]"/><!-- 1..1 Service instance identifier -->
  <focal value="[boolean]"/><!-- 1..1 Is the focal Coverage -->
  <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage>
  <businessArrangement value="[string]"/><!-- 0..1 Business agreement -->
  <relationship><!-- 1..1 Coding Patient relationship to subscriber --></relationship>
  <preAuthRef value="[string]"/><!-- 0..* Pre-Authorization/Determination Reference -->
  <claimResponse><!-- 0..1 Reference(ClaimResponse) Adjudication results --></claimResponse>
  <originalRuleset><!-- 0..1 Coding Original version --></originalRuleset>
 </coverage>
 <exception><!-- 0..* Coding Eligibility exceptions --></exception>
 <school value="[string]"/><!-- 0..1 Name of School -->
 <accident value="[date]"/><!-- 0..1 Accident Date -->
 <accidentType><!-- 0..1 Coding Accident Type --></accidentType>
 <interventionException><!-- 0..* Coding Intervention and exception code (Pharma) --></interventionException>
 <item>  <!-- 0..* Goods and Services -->
  <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
  <type><!-- 1..1 Coding Group or type of product or service --></type>
  <provider><!-- 0..1 Reference(Practitioner) Responsible practitioner --></provider>
  <diagnosisLinkId value="[positiveInt]"/><!-- 0..* Diagnosis Link -->
  <service><!-- 1..1 Coding Item Code --></service>
  <serviceDate value="[date]"/><!-- 0..1 Date of Service -->
  <quantity><!-- 0..1 Quantity Count of Products or Services --></quantity>
  <unitPrice><!-- 0..1 Money Fee, charge or cost per point --></unitPrice>
  <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
  <points value="[decimal]"/><!-- 0..1 Difficulty scaling factor -->
  <net><!-- 0..1 Money Total item cost --></net>
  <udi><!-- 0..1 Coding Unique Device Identifier --></udi>
  <bodySite><!-- 0..1 Coding Service Location --></bodySite>
  <subSite><!-- 0..* Coding Service Sub-location --></subSite>
  <modifier><!-- 0..* Coding Service/Product billing modifiers --></modifier>
  <detail>  <!-- 0..* Additional items -->
   <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
   <type><!-- 1..1 Coding Group or type of product or service --></type>
   <service><!-- 1..1 Coding Additional item codes --></service>
   <quantity><!-- 0..1 Quantity Count of Products or Services --></quantity>
   <unitPrice><!-- 0..1 Money Fee, charge or cost per point --></unitPrice>
   <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
   <points value="[decimal]"/><!-- 0..1 Difficulty scaling factor -->
   <net><!-- 0..1 Money Total additional item cost --></net>
   <udi><!-- 0..1 Coding Unique Device Identifier --></udi>
   <subDetail>  <!-- 0..* Additional items -->
    <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
    <type><!-- 1..1 Coding Type of product or service --></type>
    <service><!-- 1..1 Coding Additional item codes --></service>
    <quantity><!-- 0..1 Quantity Count of Products or Services --></quantity>
    <unitPrice><!-- 0..1 Money Fee, charge or cost per point --></unitPrice>
    <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
    <points value="[decimal]"/><!-- 0..1 Difficulty scaling factor -->
    <net><!-- 0..1 Money Net additional item cost --></net>
    <udi><!-- 0..1 Coding Unique Device Identifier --></udi>
   </subDetail>
  </detail>
  <prosthesis>  <!-- 0..1 Prosthetic details -->
   <initial value="[boolean]"/><!-- 0..1 Is this the initial service -->
   <priorDate value="[date]"/><!-- 0..1 Initial service Date -->
   <priorMaterial><!-- 0..1 Coding Prosthetic Material --></priorMaterial>
  </prosthesis>
 </item>
 <additionalMaterials><!-- 0..* Coding Additional materials, documents, etc. --></additionalMaterials>
 <missingTeeth>  <!-- 0..* Only if type = oral -->
  <tooth><!-- 1..1 Coding Tooth Code --></tooth>
  <reason><!-- 0..1 Coding Reason for missing --></reason>
  <extractionDate value="[date]"/><!-- 0..1 Date of Extraction -->
 </missingTeeth>
</Claim>

JSON Template

{doco
  "resourceType" : "Claim",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "type" : "<code>", // R!  institutional | oral | pharmacy | professional | vision
  "identifier" : [{ Identifier }], // Claim number
  "ruleset" : { Coding }, // Current specification followed
  "originalRuleset" : { Coding }, // Original specification followed
  "created" : "<dateTime>", // Creation date
  "target" : { Reference(Organization) }, // Insurer
  "provider" : { Reference(Practitioner) }, // Responsible provider
  "organization" : { Reference(Organization) }, // Responsible organization
  "use" : "<code>", // complete | proposed | exploratory | other
  "priority" : { Coding }, // Desired processing priority
  "fundsReserve" : { Coding }, // Funds requested to be reserved
  "enterer" : { Reference(Practitioner) }, // Author
  "facility" : { Reference(Location) }, // Servicing Facility
  "prescription" : { Reference(MedicationPrescription|VisionPrescription) }, // Prescription
  "originalPrescription" : { Reference(MedicationPrescription) }, // Original Prescription
  "payee" : { // Payee
    "type" : { Coding }, // Party to be paid any benefits payable
    "provider" : { Reference(Practitioner) }, // Provider who is the payee
    "organization" : { Reference(Organization) }, // Organization who is the payee
    "person" : { Reference(Patient) } // Other person who is the payee
  },
  "referral" : { Reference(ReferralRequest) }, // Treatment Referral
  "diagnosis" : [{ // Diagnosis
    "sequence" : "<positiveInt>", // R!  Sequence of diagnosis
    "diagnosis" : { Coding } // R!  Patient's list of diagnosis
  }],
  "condition" : [{ Coding }], // List of presenting Conditions
  "patient" : { Reference(Patient) }, // R!  The subject of the Products and Services
  "coverage" : [{ // Insurance or medical plan
    "sequence" : "<positiveInt>", // R!  Service instance identifier
    "focal" : <boolean>, // R!  Is the focal Coverage
    "coverage" : { Reference(Coverage) }, // R!  Insurance information
    "businessArrangement" : "<string>", // Business agreement
    "relationship" : { Coding }, // R!  Patient relationship to subscriber
    "preAuthRef" : ["<string>"], // Pre-Authorization/Determination Reference
    "claimResponse" : { Reference(ClaimResponse) }, // Adjudication results
    "originalRuleset" : { Coding } // Original version
  }],
  "exception" : [{ Coding }], // Eligibility exceptions
  "school" : "<string>", // Name of School
  "accident" : "<date>", // Accident Date
  "accidentType" : { Coding }, // Accident Type
  "interventionException" : [{ Coding }], // Intervention and exception code (Pharma)
  "item" : [{ // Goods and Services
    "sequence" : "<positiveInt>", // R!  Service instance
    "type" : { Coding }, // R!  Group or type of product or service
    "provider" : { Reference(Practitioner) }, // Responsible practitioner
    "diagnosisLinkId" : ["<positiveInt>"], // Diagnosis Link
    "service" : { Coding }, // R!  Item Code
    "serviceDate" : "<date>", // Date of Service
    "quantity" : { Quantity }, // Count of Products or Services
    "unitPrice" : { Money }, // Fee, charge or cost per point
    "factor" : <decimal>, // Price scaling factor
    "points" : <decimal>, // Difficulty scaling factor
    "net" : { Money }, // Total item cost
    "udi" : { Coding }, // Unique Device Identifier
    "bodySite" : { Coding }, // Service Location
    "subSite" : [{ Coding }], // Service Sub-location
    "modifier" : [{ Coding }], // Service/Product billing modifiers
    "detail" : [{ // Additional items
      "sequence" : "<positiveInt>", // R!  Service instance
      "type" : { Coding }, // R!  Group or type of product or service
      "service" : { Coding }, // R!  Additional item codes
      "quantity" : { Quantity }, // Count of Products or Services
      "unitPrice" : { Money }, // Fee, charge or cost per point
      "factor" : <decimal>, // Price scaling factor
      "points" : <decimal>, // Difficulty scaling factor
      "net" : { Money }, // Total additional item cost
      "udi" : { Coding }, // Unique Device Identifier
      "subDetail" : [{ // Additional items
        "sequence" : "<positiveInt>", // R!  Service instance
        "type" : { Coding }, // R!  Type of product or service
        "service" : { Coding }, // R!  Additional item codes
        "quantity" : { Quantity }, // Count of Products or Services
        "unitPrice" : { Money }, // Fee, charge or cost per point
        "factor" : <decimal>, // Price scaling factor
        "points" : <decimal>, // Difficulty scaling factor
        "net" : { Money }, // Net additional item cost
        "udi" : { Coding } // Unique Device Identifier
      }]
    }],
    "prosthesis" : { // Prosthetic details
      "initial" : <boolean>, // Is this the initial service
      "priorDate" : "<date>", // Initial service Date
      "priorMaterial" : { Coding } // Prosthetic Material
    }
  }],
  "additionalMaterials" : [{ Coding }], // Additional materials, documents, etc.
  "missingTeeth" : [{ // Only if type = oral
    "tooth" : { Coding }, // R!  Tooth Code
    "reason" : { Coding }, // Reason for missing
    "extractionDate" : "<date>" // Date of Extraction
  }]
}

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim DomainResourceClaim, Pre-determination or Pre-authorization
... type 1..1codeinstitutional | oral | pharmacy | professional | vision
ClaimType (Required)
... identifier 0..*IdentifierClaim number
... ruleset 0..1CodingCurrent specification followed
Ruleset Codes (Example)
... originalRuleset 0..1CodingOriginal specification followed
Ruleset Codes (Example)
... created 0..1dateTimeCreation date
... target 0..1OrganizationInsurer
... provider 0..1PractitionerResponsible provider
... organization 0..1OrganizationResponsible 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 0..1PractitionerAuthor
... facility 0..1LocationServicing Facility
... prescription 0..1MedicationPrescription | VisionPrescriptionPrescription
... originalPrescription 0..1MedicationPrescriptionOriginal Prescription
... payee 0..1ElementPayee
.... type 0..1CodingParty to be paid any benefits payable
Payee type Codes (Example)
.... provider 0..1PractitionerProvider who is the payee
.... organization 0..1OrganizationOrganization who is the payee
.... person 0..1PatientOther person who is the payee
... referral 0..1ReferralRequestTreatment Referral
... diagnosis 0..*ElementDiagnosis
.... sequence 1..1positiveIntSequence of diagnosis
.... diagnosis 1..1CodingPatient's list of diagnosis
ICD-10 Codes (Example)
... condition 0..*CodingList of presenting Conditions
Conditions Codes (Example)
... patient 1..1PatientThe subject of the Products and Services
... coverage 0..*ElementInsurance or medical plan
.... sequence 1..1positiveIntService instance identifier
.... focal 1..1booleanIs the focal Coverage
.... coverage 1..1CoverageInsurance information
.... businessArrangement 0..1stringBusiness agreement
.... relationship 1..1CodingPatient relationship to subscriber
Surface Codes (Example)
.... preAuthRef 0..*stringPre-Authorization/Determination Reference
.... claimResponse 0..1ClaimResponseAdjudication results
.... originalRuleset 0..1CodingOriginal version
Ruleset Codes (Example)
... exception 0..*CodingEligibility exceptions
Exception Codes (Example)
... school 0..1stringName of School
... accident 0..1dateAccident Date
... accidentType 0..1CodingAccident Type
ActIncidentCode Codes (Example)
... interventionException 0..*CodingIntervention and exception code (Pharma)
Intervention Codes (Example)
... item 0..*ElementGoods and Services
.... sequence 1..1positiveIntService instance
.... type 1..1CodingGroup or type of product or service
ActInvoiceGroupCode Codes (Example)
.... provider 0..1PractitionerResponsible practitioner
.... diagnosisLinkId 0..*positiveIntDiagnosis Link
.... service 1..1CodingItem Code
USCLS Codes (Example)
.... serviceDate 0..1dateDate of Service
.... quantity 0..1QuantityCount 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..1CodingUnique Device Identifier
UDI Codes (Example)
.... bodySite 0..1CodingService Location
Surface Codes (Example)
.... subSite 0..*CodingService Sub-location
Surface Codes (Example)
.... modifier 0..*CodingService/Product billing modifiers
Modifier type Codes (Example)
.... detail 0..*ElementAdditional items
..... sequence 1..1positiveIntService instance
..... type 1..1CodingGroup or type of product or service
ActInvoiceGroupCode Codes (Example)
..... service 1..1CodingAdditional item codes
USCLS Codes (Example)
..... quantity 0..1QuantityCount 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..1CodingUnique Device Identifier
UDI Codes (Example)
..... subDetail 0..*ElementAdditional items
...... sequence 1..1positiveIntService instance
...... type 1..1CodingType of product or service
ActInvoiceGroupCode Codes (Example)
...... service 1..1CodingAdditional item codes
USCLS Codes (Example)
...... quantity 0..1QuantityCount 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..1CodingUnique Device Identifier
UDI Codes (Example)
.... prosthesis 0..1ElementProsthetic details
..... initial 0..1booleanIs this the initial service
..... priorDate 0..1dateInitial service Date
..... priorMaterial 0..1CodingProsthetic Material
Oral Prostho Material type Codes (Example)
... additionalMaterials 0..*CodingAdditional materials, documents, etc.
Additional Material Codes (Example)
... missingTeeth 0..*ElementOnly if type = oral
.... tooth 1..1CodingTooth Code
Teeth Codes (Example)
.... reason 0..1CodingReason for missing
Missing Tooth Reason Codes (Example)
.... extractionDate 0..1dateDate of Extraction

UML Diagram

Claim (DomainResource)The category of claim this istype : code 1..1 « The type or discipline-style of the claimClaimType »The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization numberidentifier : Identifier 0..*The version of the specification on which this instance reliesruleset : Coding 0..1 « (The static and dynamic model to which contents conform, may be business version or standard and version.Ruleset Codes) »The version of the specification from which the original instance was createdoriginalRuleset : Coding 0..1 « (The static and dynamic model to which contents conform, may be business version or standard and version.Ruleset Codes) »The date when the enclosed suite of services were performed or completedcreated : dateTime 0..1Insurer Identifier, typical BIN number (6 digit)target : Reference(Organization) 0..1The provider which is responsible for the bill, claim pre-determination, pre-authorizationprovider : Reference(Practitioner) 0..1The organization which is responsible for the bill, claim pre-determination, pre-authorizationorganization : Reference(Organization) 0..1Complete (Bill or Claim), Proposed (Pre-Authorization), Exploratory (Pre-determination)use : code 0..1 « Complete, proposed, exploratory, otherUse »Immediate (STAT), best effort (NORMAL), deferred (DEFER)priority : Coding 0..1 « (The timeliness with which processing is required: STAT, normal, DeferredPriority Codes) »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 requestedfundsReserve : Coding 0..1 « (For whom funds are to be reserved: (Patient, Provider, None)Funds Reservation Codes) »Person who created the invoice/claim/pre-determination or pre-authorizationenterer : Reference(Practitioner) 0..1Facility where the services were providedfacility : Reference(Location) 0..1Prescription to support the dispensing of Pharmacy or Vision productsprescription : Reference(MedicationPrescription| VisionPrescription) 0..1Original prescription to support the dispensing of pharmacy services, medications or productsoriginalPrescription : Reference(MedicationPrescription) 0..1The referral resource which lists the date, practitioner, reason and other supporting informationreferral : Reference(ReferralRequest) 0..1List of patient conditions for which care is soughtcondition : Coding 0..* « (Patient conditions and symptomsConditions Codes) »Patient Resourcepatient : Reference(Patient) 1..1Factors which may influence the applicability of coverageexception : Coding 0..* « (The eligibility exception codes.Exception Codes) »Name of school for over-aged dependantsschool : string 0..1Date of an accident which these services are addressingaccident : date 0..1Type of accident: work, auto, etcaccidentType : Coding 0..1 « (Type of accident: work place, auto, etc.ActIncidentCode Codes) »A list of intervention and exception codes which may influence the adjudication of the claiminterventionException : Coding 0..* « (Intervention and exception codes (Pharm)Intervention Codes) »Code to indicate that Xrays, images, emails, documents, models or attachments are being sent in support of this submissionadditionalMaterials : Coding 0..* « (Code to indicate that Xrays, images, emails, documents, models or attachments are being sent in support of this submission.Additional Material Codes) »PayeeParty to be reimbursed: Subscriber, provider, othertype : Coding 0..1 « (A code for the party to be reimbursed.Payee type Codes) »The provider who is to be reimbursed for the claim (the party to whom any benefit is assigned)provider : Reference(Practitioner) 0..1The organization who is to be reimbursed for the claim (the party to whom any benefit is assigned)organization : Reference(Organization) 0..1The person other than the subscriber who is to be reimbursed for the claim (the party to whom any benefit is assigned)person : Reference(Patient) 0..1DiagnosisSequence of diagnosis which serves to order and provide a linksequence : positiveInt 1..1The diagnosisdiagnosis : Coding 1..1 « (ICD10 Diagnostic codesICD-10 Codes) »CoverageA service line itemsequence : positiveInt 1..1The instance number of the Coverage which is the focus for adjudication. The Coverage against which the claim is to be adjudicatedfocal : boolean 1..1Reference to the program or plan identification, underwriter or payorcoverage : Reference(Coverage) 1..1The contract number of a business agreement which describes the terms and conditionsbusinessArrangement : string 0..1The relationship of the patient to the subscriberrelationship : Coding 1..1 « (The code for the relationship of the patient to the subscriberSurface Codes) »A list of references from the Insurer to which these services pertainpreAuthRef : string 0..*The Coverages adjudication detailsclaimResponse : Reference(ClaimResponse) 0..1The style (standard) and version of the original material which was converted into this resourceoriginalRuleset : Coding 0..1 « (The static and dynamic model to which contents conform, may be business version or standard and version.Ruleset Codes) »ItemsA service line numbersequence : positiveInt 1..1The type of product or servicetype : Coding 1..1 « (Service, Product, Rx Dispense, Rx Compound etc.ActInvoiceGroupCode Codes) »The practitioner who is responsible for the services rendered to the patientprovider : Reference(Practitioner) 0..1Diagnosis applicable for this service or product linediagnosisLinkId : positiveInt 0..*If a grouping item then 'GROUP' otherwise it is a node therefore a code to indicate the Professional Service or Product suppliedservice : Coding 1..1 « (Allowable service and product codesUSCLS Codes) »The date when the enclosed suite of services were performed or completedserviceDate : date 0..1The number of repetitions of a service or productquantity : Quantity 0..1If 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 groupunitPrice : Money 0..1A 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 amountfactor : decimal 0..1An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each pointpoints : decimal 0..1The 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 suppliednet : Money 0..1List of Unique Device Identifiers associated with this line itemudi : Coding 0..1 « (The FDA, or other, UDI repository.UDI Codes) »Physical service site on the patient (limb, tooth, etc)bodySite : Coding 0..1 « (The code for the teeth, quadrant, sextant and archSurface Codes) »A region or surface of the site, eg. limb region or tooth surface(s)subSite : Coding 0..* « (The code for the tooth surface and surface combinationsSurface Codes) »Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolenmodifier : Coding 0..* « (Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.Modifier type Codes) »DetailA service line numbersequence : positiveInt 1..1The type of product or servicetype : Coding 1..1 « (Service, Product, Rx Dispense, Rx Compound etc.ActInvoiceGroupCode Codes) »If a grouping item then 'GROUP' otherwise it is a node therefore a code to indicate the Professional Service or Product suppliedservice : Coding 1..1 « (Allowable service and product codesUSCLS Codes) »The number of repetitions of a service or productquantity : Quantity 0..1If 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 groupunitPrice : Money 0..1A 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 amountfactor : decimal 0..1An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each pointpoints : decimal 0..1The 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 suppliednet : Money 0..1List of Unique Device Identifiers associated with this line itemudi : Coding 0..1 « (The FDA, or other, UDI repository.UDI Codes) »SubDetailA service line numbersequence : positiveInt 1..1The type of product or servicetype : Coding 1..1 « (Service, Product, Rx Dispense, Rx Compound etc.ActInvoiceGroupCode Codes) »The fee for an addittional service or product or chargeservice : Coding 1..1 « (Allowable service and product codesUSCLS Codes) »The number of repetitions of a service or productquantity : Quantity 0..1The fee for an addittional service or product or chargeunitPrice : Money 0..1A 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 amountfactor : decimal 0..1An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each pointpoints : decimal 0..1The 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 suppliednet : Money 0..1List of Unique Device Identifiers associated with this line itemudi : Coding 0..1 « (The FDA, or other, UDI repository.UDI Codes) »ProsthesisIndicates whether this is the initial placement of a fixed prosthesisinitial : boolean 0..1Date of the initial placementpriorDate : date 0..1Material of the prior denture or bridge prosthesis. (Oral)priorMaterial : Coding 0..1 « (Material of the prior denture or bridge prosthesis. (Oral)Oral Prostho Material type Codes) »MissingTeethThe code identifying which tooth is missingtooth : Coding 1..1 « (The codes for the teeth, subset of OralSitesTeeth Codes) »Missing reason may be: E-extraction, O-otherreason : Coding 0..1 « (Reason codes for the missing teethMissing Tooth Reason Codes) »The date of the extraction either known from records or patient reported estimateextractionDate : date 0..1The party to be reimbursed for the servicespayee0..1Ordered list of patient diagnosis for which care is soughtdiagnosis0..*Financial instrument by which payment information for health carecoverage0..*Third tier of goods and servicessubDetail0..*Second tier of goods and servicesdetail0..*The materials and placement date of prior fixed prosthesisprosthesis0..1First tier of goods and servicesitem0..*A list of teeth which would be expected but are not found due to having been previously extracted or for other reasonsmissingTeeth0..*

XML Template

<Claim xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <type value="[code]"/><!-- 1..1 institutional | oral | pharmacy | professional | vision -->
 <identifier><!-- 0..* Identifier Claim number --></identifier>
 <ruleset><!-- 0..1 Coding Current specification followed --></ruleset>
 <originalRuleset><!-- 0..1 Coding Original specification followed --></originalRuleset>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <target><!-- 0..1 Reference(Organization) Insurer --></target>
 <provider><!-- 0..1 Reference(Practitioner) Responsible provider --></provider>
 <organization><!-- 0..1 Reference(Organization) Responsible organization --></organization>
 <use value="[code]"/><!-- 0..1 complete | proposed | exploratory | other -->
 <priority><!-- 0..1 Coding Desired processing priority --></priority>
 <fundsReserve><!-- 0..1 Coding Funds requested to be reserved --></fundsReserve>
 <enterer><!-- 0..1 Reference(Practitioner) Author --></enterer>
 <facility><!-- 0..1 Reference(Location) Servicing Facility --></facility>
 <prescription><!-- 0..1 Reference(MedicationPrescription|VisionPrescription) Prescription --></prescription>
 <originalPrescription><!-- 0..1 Reference(MedicationPrescription) Original Prescription --></originalPrescription>
 <payee>  <!-- 0..1 Payee -->
  <type><!-- 0..1 Coding Party to be paid any benefits payable --></type>
  <provider><!-- 0..1 Reference(Practitioner) Provider who is the payee --></provider>
  <organization><!-- 0..1 Reference(Organization) Organization who is the payee --></organization>
  <person><!-- 0..1 Reference(Patient) Other person who is the payee --></person>
 </payee>
 <referral><!-- 0..1 Reference(ReferralRequest) Treatment Referral --></referral>
 <diagnosis>  <!-- 0..* Diagnosis -->
  <sequence value="[positiveInt]"/><!-- 1..1 Sequence of diagnosis -->
  <diagnosis><!-- 1..1 Coding Patient's list of diagnosis --></diagnosis>
 </diagnosis>
 <condition><!-- 0..* Coding List of presenting Conditions --></condition>
 <patient><!-- 1..1 Reference(Patient) The subject of the Products and Services --></patient>
 <coverage>  <!-- 0..* Insurance or medical plan -->
  <sequence value="[positiveInt]"/><!-- 1..1 Service instance identifier -->
  <focal value="[boolean]"/><!-- 1..1 Is the focal Coverage -->
  <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage>
  <businessArrangement value="[string]"/><!-- 0..1 Business agreement -->
  <relationship><!-- 1..1 Coding Patient relationship to subscriber --></relationship>
  <preAuthRef value="[string]"/><!-- 0..* Pre-Authorization/Determination Reference -->
  <claimResponse><!-- 0..1 Reference(ClaimResponse) Adjudication results --></claimResponse>
  <originalRuleset><!-- 0..1 Coding Original version --></originalRuleset>
 </coverage>
 <exception><!-- 0..* Coding Eligibility exceptions --></exception>
 <school value="[string]"/><!-- 0..1 Name of School -->
 <accident value="[date]"/><!-- 0..1 Accident Date -->
 <accidentType><!-- 0..1 Coding Accident Type --></accidentType>
 <interventionException><!-- 0..* Coding Intervention and exception code (Pharma) --></interventionException>
 <item>  <!-- 0..* Goods and Services -->
  <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
  <type><!-- 1..1 Coding Group or type of product or service --></type>
  <provider><!-- 0..1 Reference(Practitioner) Responsible practitioner --></provider>
  <diagnosisLinkId value="[positiveInt]"/><!-- 0..* Diagnosis Link -->
  <service><!-- 1..1 Coding Item Code --></service>
  <serviceDate value="[date]"/><!-- 0..1 Date of Service -->
  <quantity><!-- 0..1 Quantity Count of Products or Services --></quantity>
  <unitPrice><!-- 0..1 Money Fee, charge or cost per point --></unitPrice>
  <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
  <points value="[decimal]"/><!-- 0..1 Difficulty scaling factor -->
  <net><!-- 0..1 Money Total item cost --></net>
  <udi><!-- 0..1 Coding Unique Device Identifier --></udi>
  <bodySite><!-- 0..1 Coding Service Location --></bodySite>
  <subSite><!-- 0..* Coding Service Sub-location --></subSite>
  <modifier><!-- 0..* Coding Service/Product billing modifiers --></modifier>
  <detail>  <!-- 0..* Additional items -->
   <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
   <type><!-- 1..1 Coding Group or type of product or service --></type>
   <service><!-- 1..1 Coding Additional item codes --></service>
   <quantity><!-- 0..1 Quantity Count of Products or Services --></quantity>
   <unitPrice><!-- 0..1 Money Fee, charge or cost per point --></unitPrice>
   <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
   <points value="[decimal]"/><!-- 0..1 Difficulty scaling factor -->
   <net><!-- 0..1 Money Total additional item cost --></net>
   <udi><!-- 0..1 Coding Unique Device Identifier --></udi>
   <subDetail>  <!-- 0..* Additional items -->
    <sequence value="[positiveInt]"/><!-- 1..1 Service instance -->
    <type><!-- 1..1 Coding Type of product or service --></type>
    <service><!-- 1..1 Coding Additional item codes --></service>
    <quantity><!-- 0..1 Quantity Count of Products or Services --></quantity>
    <unitPrice><!-- 0..1 Money Fee, charge or cost per point --></unitPrice>
    <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
    <points value="[decimal]"/><!-- 0..1 Difficulty scaling factor -->
    <net><!-- 0..1 Money Net additional item cost --></net>
    <udi><!-- 0..1 Coding Unique Device Identifier --></udi>
   </subDetail>
  </detail>
  <prosthesis>  <!-- 0..1 Prosthetic details -->
   <initial value="[boolean]"/><!-- 0..1 Is this the initial service -->
   <priorDate value="[date]"/><!-- 0..1 Initial service Date -->
   <priorMaterial><!-- 0..1 Coding Prosthetic Material --></priorMaterial>
  </prosthesis>
 </item>
 <additionalMaterials><!-- 0..* Coding Additional materials, documents, etc. --></additionalMaterials>
 <missingTeeth>  <!-- 0..* Only if type = oral -->
  <tooth><!-- 1..1 Coding Tooth Code --></tooth>
  <reason><!-- 0..1 Coding Reason for missing --></reason>
  <extractionDate value="[date]"/><!-- 0..1 Date of Extraction -->
 </missingTeeth>
</Claim>

JSON Template

{doco
  "resourceType" : "Claim",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "type" : "<code>", // R!  institutional | oral | pharmacy | professional | vision
  "identifier" : [{ Identifier }], // Claim number
  "ruleset" : { Coding }, // Current specification followed
  "originalRuleset" : { Coding }, // Original specification followed
  "created" : "<dateTime>", // Creation date
  "target" : { Reference(Organization) }, // Insurer
  "provider" : { Reference(Practitioner) }, // Responsible provider
  "organization" : { Reference(Organization) }, // Responsible organization
  "use" : "<code>", // complete | proposed | exploratory | other
  "priority" : { Coding }, // Desired processing priority
  "fundsReserve" : { Coding }, // Funds requested to be reserved
  "enterer" : { Reference(Practitioner) }, // Author
  "facility" : { Reference(Location) }, // Servicing Facility
  "prescription" : { Reference(MedicationPrescription|VisionPrescription) }, // Prescription
  "originalPrescription" : { Reference(MedicationPrescription) }, // Original Prescription
  "payee" : { // Payee
    "type" : { Coding }, // Party to be paid any benefits payable
    "provider" : { Reference(Practitioner) }, // Provider who is the payee
    "organization" : { Reference(Organization) }, // Organization who is the payee
    "person" : { Reference(Patient) } // Other person who is the payee
  },
  "referral" : { Reference(ReferralRequest) }, // Treatment Referral
  "diagnosis" : [{ // Diagnosis
    "sequence" : "<positiveInt>", // R!  Sequence of diagnosis
    "diagnosis" : { Coding } // R!  Patient's list of diagnosis
  }],
  "condition" : [{ Coding }], // List of presenting Conditions
  "patient" : { Reference(Patient) }, // R!  The subject of the Products and Services
  "coverage" : [{ // Insurance or medical plan
    "sequence" : "<positiveInt>", // R!  Service instance identifier
    "focal" : <boolean>, // R!  Is the focal Coverage
    "coverage" : { Reference(Coverage) }, // R!  Insurance information
    "businessArrangement" : "<string>", // Business agreement
    "relationship" : { Coding }, // R!  Patient relationship to subscriber
    "preAuthRef" : ["<string>"], // Pre-Authorization/Determination Reference
    "claimResponse" : { Reference(ClaimResponse) }, // Adjudication results
    "originalRuleset" : { Coding } // Original version
  }],
  "exception" : [{ Coding }], // Eligibility exceptions
  "school" : "<string>", // Name of School
  "accident" : "<date>", // Accident Date
  "accidentType" : { Coding }, // Accident Type
  "interventionException" : [{ Coding }], // Intervention and exception code (Pharma)
  "item" : [{ // Goods and Services
    "sequence" : "<positiveInt>", // R!  Service instance
    "type" : { Coding }, // R!  Group or type of product or service
    "provider" : { Reference(Practitioner) }, // Responsible practitioner
    "diagnosisLinkId" : ["<positiveInt>"], // Diagnosis Link
    "service" : { Coding }, // R!  Item Code
    "serviceDate" : "<date>", // Date of Service
    "quantity" : { Quantity }, // Count of Products or Services
    "unitPrice" : { Money }, // Fee, charge or cost per point
    "factor" : <decimal>, // Price scaling factor
    "points" : <decimal>, // Difficulty scaling factor
    "net" : { Money }, // Total item cost
    "udi" : { Coding }, // Unique Device Identifier
    "bodySite" : { Coding }, // Service Location
    "subSite" : [{ Coding }], // Service Sub-location
    "modifier" : [{ Coding }], // Service/Product billing modifiers
    "detail" : [{ // Additional items
      "sequence" : "<positiveInt>", // R!  Service instance
      "type" : { Coding }, // R!  Group or type of product or service
      "service" : { Coding }, // R!  Additional item codes
      "quantity" : { Quantity }, // Count of Products or Services
      "unitPrice" : { Money }, // Fee, charge or cost per point
      "factor" : <decimal>, // Price scaling factor
      "points" : <decimal>, // Difficulty scaling factor
      "net" : { Money }, // Total additional item cost
      "udi" : { Coding }, // Unique Device Identifier
      "subDetail" : [{ // Additional items
        "sequence" : "<positiveInt>", // R!  Service instance
        "type" : { Coding }, // R!  Type of product or service
        "service" : { Coding }, // R!  Additional item codes
        "quantity" : { Quantity }, // Count of Products or Services
        "unitPrice" : { Money }, // Fee, charge or cost per point
        "factor" : <decimal>, // Price scaling factor
        "points" : <decimal>, // Difficulty scaling factor
        "net" : { Money }, // Net additional item cost
        "udi" : { Coding } // Unique Device Identifier
      }]
    }],
    "prosthesis" : { // Prosthetic details
      "initial" : <boolean>, // Is this the initial service
      "priorDate" : "<date>", // Initial service Date
      "priorMaterial" : { Coding } // Prosthetic Material
    }
  }],
  "additionalMaterials" : [{ Coding }], // Additional materials, documents, etc.
  "missingTeeth" : [{ // Only if type = oral
    "tooth" : { Coding }, // R!  Tooth Code
    "reason" : { Coding }, // Reason for missing
    "extractionDate" : "<date>" // Date of Extraction
  }]
}

 

Alternate definitions: Schema/Schematron, Resource Profile (XML, JSON)

7.1.2.1 Terminology Bindings

PathDefinitionTypeReference
Claim.type The type or discipline-style of the claimRequiredhttp://hl7.org/fhir/type-link
Claim.ruleset
Claim.originalRuleset
Claim.coverage.originalRuleset
The static and dynamic model to which contents conform, may be business version or standard and version.Examplehttp://hl7.org/fhir/vs/ruleset
Claim.use Complete, proposed, exploratory, otherRequiredhttp://hl7.org/fhir/use-link
Claim.priority The timeliness with which processing is required: STAT, normal, DeferredExamplehttp://hl7.org/fhir/vs/process-priority
Claim.fundsReserve For whom funds are to be reserved: (Patient, Provider, None)Examplehttp://hl7.org/fhir/vs/fundsreserve
Claim.payee.type A code for the party to be reimbursed.Examplehttp://hl7.org/fhir/vs/payeetype
Claim.diagnosis.diagnosis ICD10 Diagnostic codesExamplehttp://hl7.org/fhir/vs/icd-10
Claim.condition Patient conditions and symptomsExamplehttp://hl7.org/fhir/vs/fm-conditions
Claim.coverage.relationship The code for the relationship of the patient to the subscriberExamplehttp://hl7.org/fhir/vs/relationship
Claim.exception The eligibility exception codes.Examplehttp://hl7.org/fhir/vs/exception
Claim.accidentType Type of accident: work place, auto, etc.Examplehttp://hl7.org/fhir/vs/ActIncidentCode
Claim.interventionException Intervention and exception codes (Pharm)Examplehttp://hl7.org/fhir/vs/intervention
Claim.item.type
Claim.item.detail.type
Claim.item.detail.subDetail.type
Service, Product, Rx Dispense, Rx Compound etc.Examplehttp://hl7.org/fhir/vs/ActInvoiceGroupCode
Claim.item.service
Claim.item.detail.service
Claim.item.detail.subDetail.service
Allowable service and product codesExamplehttp://hl7.org/fhir/vs/service-uscls
Claim.item.udi
Claim.item.detail.udi
Claim.item.detail.subDetail.udi
The FDA, or other, UDI repository.Examplehttp://hl7.org/fhir/vs/udi
Claim.item.bodySite The code for the teeth, quadrant, sextant and archExamplehttp://hl7.org/fhir/vs/tooth
Claim.item.subSite The code for the tooth surface and surface combinationsExamplehttp://hl7.org/fhir/vs/surface
Claim.item.modifier Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.Examplehttp://hl7.org/fhir/vs/modifiers
Claim.item.prosthesis.priorMaterial Material of the prior denture or bridge prosthesis. (Oral)Examplehttp://hl7.org/fhir/vs/oral-prosthodontic-material
Claim.additionalMaterials Code to indicate that Xrays, images, emails, documents, models or attachments are being sent in support of this submission.Examplehttp://hl7.org/fhir/vs/additionalmaterials
Claim.missingTeeth.tooth The codes for the teeth, subset of OralSitesExamplehttp://hl7.org/fhir/vs/teeth
Claim.missingTeeth.reason Reason codes for the missing teethExamplehttp://hl7.org/fhir/vs/missing-tooth-reason

7.1.3 Search Parameters

Search parameters for this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.

NameTypeDescriptionPaths
identifiertokenThe primary identifier of the financial resourceClaim.identifier
patientreferencePatientClaim.patient
(Patient)
prioritytokenProcessing priority requestedClaim.priority
providerreferenceProvider responsible for the claimClaim.provider
(Practitioner)
usetokenThe kind of financial resourceClaim.use