LinuxForHealth FHIR Implementation Guide
8.0.0 - draft United States of America flag

LinuxForHealth FHIR Implementation Guide - Local Development build (v8.0.0). See the Directory of published versions

Resource Profile: CDM Claim Facility

Official URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/cdm-claim-facility Version: 8.0.0
Active as of 2022-11-10 Computable Name: CDMClaimFacility

The CDMClaimFacility profile extends the base CDMClaim profile with additional details that are specific to facility claims

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from CDMClaim

NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim 0..*CDMClaimClaim, Pre-determination or Pre-authorization
... admitCount 0..1integerUsed to determine which facility claims should be counted as inpatient admissions
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/admit-count

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim 0..*CDMClaimClaim, Pre-determination or Pre-authorization
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... aggregateClaimIndicator 0..1stringIndicates whether this claim record is included in the adjustment processing of the aggregate build logic for admissions, episodes or DCGs
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/aggregate-claim-indicator
... claimSnapshotProviderName 0..1stringOriginal provider name as reported on the claim
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-snapshot-provider-name
... claimSnapshotProviderZipCode 0..1stringOriginal provider postal code, as reported on the claim
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-snapshot-provider-zip-code
... companyCode 0..1CodeableConceptCompany code of the subscriber as reported on the claim
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/company-code
... employeeBusinessUnit 0..1CodeableConceptBusiness unit of the subscriber as reported on the claim
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/employee-business-unit
... employer 0..1CodeableConceptCustomer-specific code for the employer as reported on the claim record
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/employer
... financialSystem 0..1CodeableConceptCustomer-specific code for the financial system
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/financial-system
... claimCategory 0..1CodeableConceptStandard HIPAA code for the category of the claim status
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-category
Binding: https://x12.org/codes/claim-status-category-codes (extensible)
... claimStatus 0..1CodeableConceptStandard HIPAA code for the status of an entire claim
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-status
.... extension 0..0
.... url 1..1uri"http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-status"
.... Slices for value[x] 0..1CodeableConceptValue of extension
Slice: Unordered, Closed by type:$this
..... value[x]:valueCodeableConcept 0..1CodeableConceptValue of extension
Binding: https://x12.org/codes/claim-status-codes (extensible)
... lastClaimIndicator 0..1stringIndicates whether this claim record is the last or most recent claim
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/last-claim-indicator
... participatingPlan 0..1CodeableConceptCustomer-specific code for the participating plan
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/participating-plan
... referralIndicator 0..1stringIndicates whether the service resulted from a referral
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/referral-indicator
... snapshotAgeInYears 0..1unsignedIntThe age of the patient in years at the date of service
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/snapshot-age-in-years
... submissionType 0..1CodeableConceptCustomer-specific code for the type of electronic submission
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/submission-type
... payerPcpResponsibilityIndicator 0..1stringIndicates whether the primary care physician is the physician considered either responsible or accountable for this claim
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/payer-pcp-responsibility-indicator
... admitCount 0..1integerUsed to determine which facility claims should be counted as inpatient admissions
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/admit-count
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier 1..*IdentifierBusiness Identifier for claim
.... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

.... system Σ1..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
.... value Σ1..1stringThe value that is unique
Example General: 123456
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... type Σ1..1CodeableConceptCategory or discipline
Binding: Claim Type Value Set (extensible)
... use Σ1..1codeclaim | preauthorization | predetermination
Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim.

... patient Σ1..1Reference(Patient)The recipient of the products and services
... created Σ1..1dateTimeResource creation date
... provider Σ1..1Reference(Practitioner | PractitionerRole | Organization)Party responsible for the claim
... priority Σ1..1CodeableConceptDesired processing ugency
Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.

... insurance Σ1..*BackboneElementPatient insurance information
.... crossoverIndicator 0..1stringIndicates whether the claim is a crossover claim where a portion is paid by Medicare
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/crossover-indicator
.... lineOfBusiness 0..1CodeableConceptCode for the line of business
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/line-of-business
.... priorAuthorizationIndicator 0..1stringIndicates prior authorization for the claim
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/prior-authorization-indicator
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence Σ1..1positiveIntInsurance instance identifier
.... focal Σ1..1booleanCoverage to be used for adjudication
.... coverage Σ1..1Reference(Coverage)Insurance information

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Claim.extension:claimStatus.value[x]:valueCodeableConceptextensiblehttps://x12.org/codes/claim-status-codes
Claim.identifier.userequiredIdentifierUse
Claim.statusrequiredFinancialResourceStatusCodes
Claim.typeextensibleClaimTypeValueSet (a valid code from Payer Claim Type Codes)
Claim.userequiredUse
Claim.priorityexampleProcessPriorityCodes
NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim 0..*CDMClaimClaim, Pre-determination or Pre-authorization
... id Σ0..1idLogical id of this artifact
... meta 0..1ProcessMetaMetadata about a resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... aggregateClaimIndicator 0..1stringIndicates whether this claim record is included in the adjustment processing of the aggregate build logic for admissions, episodes or DCGs
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/aggregate-claim-indicator
... claimSnapshotProviderName 0..1stringOriginal provider name as reported on the claim
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-snapshot-provider-name
... claimSnapshotProviderZipCode 0..1stringOriginal provider postal code, as reported on the claim
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-snapshot-provider-zip-code
... companyCode 0..1CodeableConceptCompany code of the subscriber as reported on the claim
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/company-code
... employeeBusinessUnit 0..1CodeableConceptBusiness unit of the subscriber as reported on the claim
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/employee-business-unit
... employer 0..1CodeableConceptCustomer-specific code for the employer as reported on the claim record
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/employer
... financialSystem 0..1CodeableConceptCustomer-specific code for the financial system
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/financial-system
... claimCategory 0..1CodeableConceptStandard HIPAA code for the category of the claim status
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-category
Binding: https://x12.org/codes/claim-status-category-codes (extensible)
... claimStatus 0..1CodeableConceptStandard HIPAA code for the status of an entire claim
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-status
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..0
.... url 1..1uri"http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-status"
.... Slices for value[x] 0..1CodeableConceptValue of extension
Slice: Unordered, Closed by type:$this
..... value[x]:valueCodeableConcept 0..1CodeableConceptValue of extension
Binding: https://x12.org/codes/claim-status-codes (extensible)
... lastClaimIndicator 0..1stringIndicates whether this claim record is the last or most recent claim
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/last-claim-indicator
... participatingPlan 0..1CodeableConceptCustomer-specific code for the participating plan
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/participating-plan
... referralIndicator 0..1stringIndicates whether the service resulted from a referral
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/referral-indicator
... snapshotAgeInYears 0..1unsignedIntThe age of the patient in years at the date of service
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/snapshot-age-in-years
... submissionType 0..1CodeableConceptCustomer-specific code for the type of electronic submission
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/submission-type
... payerPcpResponsibilityIndicator 0..1stringIndicates whether the primary care physician is the physician considered either responsible or accountable for this claim
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/payer-pcp-responsibility-indicator
... admitCount 0..1integerUsed to determine which facility claims should be counted as inpatient admissions
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/admit-count
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier 1..*IdentifierBusiness Identifier for claim
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

.... type Σ0..1CodeableConceptDescription of identifier
Binding: Identifier Type Value Set (extensible)
.... system Σ1..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
.... value Σ1..1stringThe value that is unique
Example General: 123456
.... period Σ0..1PeriodTime period when id is/was valid for use
.... assigner Σ0..1Reference(Organization)Organization that issued id (may be just text)
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... type Σ1..1CodeableConceptCategory or discipline
Binding: Claim Type Value Set (extensible)
... subType 0..1CodeableConceptMore granular claim type
Binding: Claim Subtype Value Set (extensible)
... use Σ1..1codeclaim | preauthorization | predetermination
Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim.

... patient Σ1..1Reference(Patient)The recipient of the products and services
... billablePeriod Σ0..1PeriodRelevant time frame for the claim
... created Σ1..1dateTimeResource creation date
... enterer 0..1Reference(Practitioner | PractitionerRole)Author of the claim
... insurer Σ0..1Reference(Organization)Target
... provider Σ1..1Reference(Practitioner | PractitionerRole | Organization)Party responsible for the claim
... priority Σ1..1CodeableConceptDesired processing ugency
Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.

... fundsReserve 0..1CodeableConceptFor whom to reserve funds
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).

... related 0..*BackboneElementPrior or corollary claims
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... claim 0..1Reference(Claim)Reference to the related claim
.... relationship 0..1CodeableConceptHow the reference claim is related
Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim.

.... reference 0..1IdentifierFile or case reference
... prescription 0..1Reference(DeviceRequest | MedicationRequest | VisionPrescription)Prescription authorizing services and products
... originalPrescription 0..1Reference(DeviceRequest | MedicationRequest | VisionPrescription)Original prescription if superseded by fulfiller
... payee 0..1BackboneElementRecipient of benefits payable
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type 1..1CodeableConceptCategory of recipient
Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.

.... party 0..1Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson)Recipient reference
... referral 0..1Reference(ServiceRequest)Treatment referral
... facility 0..1Reference(Location)Servicing facility
... careTeam 0..*BackboneElementMembers of the care team
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntOrder of care team
.... provider 1..1Reference(Practitioner | PractitionerRole | Organization)Practitioner or organization
.... responsible 0..1booleanIndicator of the lead practitioner
.... role 0..1CodeableConceptFunction within the team
Binding: Claim Care Team Role Value Set (extensible)
.... qualification 0..1CodeableConceptPractitioner credential or specialization
Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.

... supportingInfo 0..*BackboneElementSupporting information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntInformation instance identifier
.... category 1..1CodeableConceptClassification of the supplied information
Binding: Claim Supporting Info Category Value Set (extensible)
.... code 0..1CodeableConceptType of information
Binding: Claim Supporting Info Type Value Set (extensible)
.... timing[x] 0..1When it occurred
..... timingDatedate
..... timingPeriodPeriod
.... value[x] 0..1Data to be provided
..... valueBooleanboolean
..... valueStringstring
..... valueQuantityQuantity
..... valueAttachmentAttachment
..... valueReferenceReference(Resource)
.... reason 0..1CodeableConceptExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

... diagnosis 0..*BackboneElementPertinent diagnosis information
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... majorDiagnosticCategory 0..1CodeableConceptThe body system or disease related groupings of clinical conditions, based on diagnosis codes
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/major-diagnostic-category
Binding: Payer Major Diagnostic Category Value Set (extensible)
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntDiagnosis instance identifier
.... diagnosis[x] 1..1Nature of illness or problem
Binding: ICD-10Codes (example): Example ICD10 Diagnostic codes.

..... diagnosisCodeableConceptCodeableConcept
..... diagnosisReferenceReference(Condition)
.... type 0..*CodeableConceptTiming or nature of the diagnosis
Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge.


.... onAdmission 0..1CodeableConceptPresent on admission
Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.

.... packageCode 0..1CodeableConceptPackage billing code
Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.

... procedure 0..*BackboneElementClinical procedures performed
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... procedureGroup 0..1CodeableConceptCode assigned to categorize related procedures
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/procedure-group
Binding: Payer Procedure Group Value Set (extensible)
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntProcedure instance identifier
.... type 0..*CodeableConceptCategory of Procedure
Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.


.... date 0..1dateTimeWhen the procedure was performed
.... procedure[x] 1..1Specific clinical procedure
Binding: ICD-10ProcedureCodes (example): Example ICD10 Procedure codes.

..... procedureCodeableConceptCodeableConcept
..... procedureReferenceReference(Procedure)
.... udi 0..*Reference(Device)Unique device identifier
... insurance Σ1..*BackboneElementPatient insurance information
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... crossoverIndicator 0..1stringIndicates whether the claim is a crossover claim where a portion is paid by Medicare
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/crossover-indicator
.... lineOfBusiness 0..1CodeableConceptCode for the line of business
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/line-of-business
.... priorAuthorizationIndicator 0..1stringIndicates prior authorization for the claim
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/prior-authorization-indicator
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence Σ1..1positiveIntInsurance instance identifier
.... focal Σ1..1booleanCoverage to be used for adjudication
.... identifier 0..1IdentifierPre-assigned Claim number
.... coverage Σ1..1Reference(Coverage)Insurance information
.... businessArrangement 0..1stringAdditional provider contract number
.... preAuthRef 0..*stringPrior authorization reference number
.... claimResponse 0..1Reference(ClaimResponse)Adjudication results
... accident 0..1BackboneElementDetails of the event
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... date 1..1dateWhen the incident occurred
.... type 0..1CodeableConceptThe nature of the accident
Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc.

.... location[x] 0..1Where the event occurred
..... locationAddressAddress
..... locationReferenceReference(Location)
... item 0..*BackboneElementProduct or service provided
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... capitatedServiceIndicator 0..1stringIndicates whether this service (encounter record) was capitated
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/capitated-service-indicator
.... fullyInsuredIndicator 0..1stringIndicates whether the claim was for a fully insured plan
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/fully-insured-indicator
.... nursingHomeIndicator 0..1stringIndicates whether the claim was for a nursing home patient
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/nursing-home-indicator
.... serviceBillDaysCount 0..1unsignedIntNumber of days between the date of service and the date the claim was received
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/service-bill-days-count
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntItem instance identifier
.... careTeamSequence 0..*positiveIntApplicable careTeam members
.... diagnosisSequence 0..*positiveIntApplicable diagnoses
.... procedureSequence 0..*positiveIntApplicable procedures
.... informationSequence 0..*positiveIntApplicable exception and supporting information
.... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

.... category 0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.

.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

.... modifier 0..*CodeableConceptProduct or service billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


.... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


.... serviced[x] 0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.

..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1SimpleQuantityCount of products or services
..... id 0..1stringUnique id for inter-element referencing
..... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... localNumberOfUnitsPerService 0..1QuantityCustomer-specific quantity of either services or units
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/local-number-of-units-per-service
..... value Σ0..1decimalNumerical value (with implicit precision)
..... unit Σ0..1stringUnit representation
..... system ΣC0..1uriSystem that defines coded unit form
..... code Σ0..1codeCoded form of the unit
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... udi 0..*Reference(Device)Unique device identifier
.... bodySite 0..1CodeableConceptAnatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.

.... subSite 0..*CodeableConceptAnatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.


.... encounter 0..*Reference(Encounter)Encounters related to this billed item
.... detail 0..*BackboneElementProduct or service provided
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntItem instance identifier
..... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

..... category 0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.

..... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

..... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


..... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


..... quantity 0..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal item cost
..... udi 0..*Reference(Device)Unique device identifier
..... subDetail 0..*BackboneElementProduct or service provided
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... sequence 1..1positiveIntItem instance identifier
...... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

...... category 0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.

...... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

...... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


...... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


...... quantity 0..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyTotal item cost
...... udi 0..*Reference(Device)Unique device identifier
... total 0..1MoneyTotal claim cost

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Claim.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Claim.extension:claimStatus.value[x]:valueCodeableConceptextensiblehttps://x12.org/codes/claim-status-codes
Claim.identifier.userequiredIdentifierUse
Claim.identifier.typeextensibleIdentifierTypeValueSet
Claim.statusrequiredFinancialResourceStatusCodes
Claim.typeextensibleClaimTypeValueSet (a valid code from Payer Claim Type Codes)
Claim.subTypeextensibleClaimSubtypeValueSet (a valid code from Claim Subtype Codes)
Claim.userequiredUse
Claim.priorityexampleProcessPriorityCodes
Claim.fundsReserveexampleFunds Reservation Codes
Claim.related.relationshipexampleExampleRelatedClaimRelationshipCodes
Claim.payee.typeexampleClaim Payee Type Codes
Claim.careTeam.roleextensibleClaimCareTeamRoleValueSet (a valid code from Claim Care Team Role Codes)
Claim.careTeam.qualificationexampleExampleProviderQualificationCodes
Claim.supportingInfo.categoryextensibleClaimSupportingInfoCategoryValueSet
Claim.supportingInfo.codeextensibleClaimSupportingInfoTypeValueSet (a valid code from Claim Supporting Info Type Codes)
Claim.supportingInfo.reasonexampleMissingToothReasonCodes
Claim.diagnosis.diagnosis[x]exampleICD-10Codes
Claim.diagnosis.typeexampleExampleDiagnosisTypeCodes
Claim.diagnosis.onAdmissionexampleExampleDiagnosisOnAdmissionCodes
Claim.diagnosis.packageCodeexampleExampleDiagnosisRelatedGroupCodes
Claim.procedure.typeexampleExampleProcedureTypeCodes
Claim.procedure.procedure[x]exampleICD-10ProcedureCodes
Claim.accident.typeextensibleActIncidentCode
Claim.item.revenueexampleExampleRevenueCenterCodes
Claim.item.categoryexampleBenefitCategoryCodes
Claim.item.productOrServiceexampleUSCLSCodes
Claim.item.modifierexampleModifierTypeCodes
Claim.item.programCodeexampleExampleProgramReasonCodes
Claim.item.location[x]exampleExampleServicePlaceCodes
Claim.item.bodySiteexampleOralSiteCodes
Claim.item.subSiteexampleSurfaceCodes
Claim.item.detail.revenueexampleExampleRevenueCenterCodes
Claim.item.detail.categoryexampleBenefitCategoryCodes
Claim.item.detail.productOrServiceexampleUSCLSCodes
Claim.item.detail.modifierexampleModifierTypeCodes
Claim.item.detail.programCodeexampleExampleProgramReasonCodes
Claim.item.detail.subDetail.revenueexampleExampleRevenueCenterCodes
Claim.item.detail.subDetail.categoryexampleBenefitCategoryCodes
Claim.item.detail.subDetail.productOrServiceexampleUSCLSCodes
Claim.item.detail.subDetail.modifierexampleModifierTypeCodes
Claim.item.detail.subDetail.programCodeexampleExampleProgramReasonCodes

This structure is derived from CDMClaim

Summary

Extensions

This structure refers to these extensions:

Differential View

This structure is derived from CDMClaim

NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim 0..*CDMClaimClaim, Pre-determination or Pre-authorization
... admitCount 0..1integerUsed to determine which facility claims should be counted as inpatient admissions
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/admit-count

doco Documentation for this format

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim 0..*CDMClaimClaim, Pre-determination or Pre-authorization
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... aggregateClaimIndicator 0..1stringIndicates whether this claim record is included in the adjustment processing of the aggregate build logic for admissions, episodes or DCGs
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/aggregate-claim-indicator
... claimSnapshotProviderName 0..1stringOriginal provider name as reported on the claim
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-snapshot-provider-name
... claimSnapshotProviderZipCode 0..1stringOriginal provider postal code, as reported on the claim
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-snapshot-provider-zip-code
... companyCode 0..1CodeableConceptCompany code of the subscriber as reported on the claim
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/company-code
... employeeBusinessUnit 0..1CodeableConceptBusiness unit of the subscriber as reported on the claim
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/employee-business-unit
... employer 0..1CodeableConceptCustomer-specific code for the employer as reported on the claim record
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/employer
... financialSystem 0..1CodeableConceptCustomer-specific code for the financial system
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/financial-system
... claimCategory 0..1CodeableConceptStandard HIPAA code for the category of the claim status
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-category
Binding: https://x12.org/codes/claim-status-category-codes (extensible)
... claimStatus 0..1CodeableConceptStandard HIPAA code for the status of an entire claim
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-status
.... extension 0..0
.... url 1..1uri"http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-status"
.... Slices for value[x] 0..1CodeableConceptValue of extension
Slice: Unordered, Closed by type:$this
..... value[x]:valueCodeableConcept 0..1CodeableConceptValue of extension
Binding: https://x12.org/codes/claim-status-codes (extensible)
... lastClaimIndicator 0..1stringIndicates whether this claim record is the last or most recent claim
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/last-claim-indicator
... participatingPlan 0..1CodeableConceptCustomer-specific code for the participating plan
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/participating-plan
... referralIndicator 0..1stringIndicates whether the service resulted from a referral
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/referral-indicator
... snapshotAgeInYears 0..1unsignedIntThe age of the patient in years at the date of service
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/snapshot-age-in-years
... submissionType 0..1CodeableConceptCustomer-specific code for the type of electronic submission
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/submission-type
... payerPcpResponsibilityIndicator 0..1stringIndicates whether the primary care physician is the physician considered either responsible or accountable for this claim
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/payer-pcp-responsibility-indicator
... admitCount 0..1integerUsed to determine which facility claims should be counted as inpatient admissions
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/admit-count
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier 1..*IdentifierBusiness Identifier for claim
.... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

.... system Σ1..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
.... value Σ1..1stringThe value that is unique
Example General: 123456
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... type Σ1..1CodeableConceptCategory or discipline
Binding: Claim Type Value Set (extensible)
... use Σ1..1codeclaim | preauthorization | predetermination
Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim.

... patient Σ1..1Reference(Patient)The recipient of the products and services
... created Σ1..1dateTimeResource creation date
... provider Σ1..1Reference(Practitioner | PractitionerRole | Organization)Party responsible for the claim
... priority Σ1..1CodeableConceptDesired processing ugency
Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.

... insurance Σ1..*BackboneElementPatient insurance information
.... crossoverIndicator 0..1stringIndicates whether the claim is a crossover claim where a portion is paid by Medicare
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/crossover-indicator
.... lineOfBusiness 0..1CodeableConceptCode for the line of business
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/line-of-business
.... priorAuthorizationIndicator 0..1stringIndicates prior authorization for the claim
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/prior-authorization-indicator
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence Σ1..1positiveIntInsurance instance identifier
.... focal Σ1..1booleanCoverage to be used for adjudication
.... coverage Σ1..1Reference(Coverage)Insurance information

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Claim.extension:claimStatus.value[x]:valueCodeableConceptextensiblehttps://x12.org/codes/claim-status-codes
Claim.identifier.userequiredIdentifierUse
Claim.statusrequiredFinancialResourceStatusCodes
Claim.typeextensibleClaimTypeValueSet (a valid code from Payer Claim Type Codes)
Claim.userequiredUse
Claim.priorityexampleProcessPriorityCodes

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim 0..*CDMClaimClaim, Pre-determination or Pre-authorization
... id Σ0..1idLogical id of this artifact
... meta 0..1ProcessMetaMetadata about a resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... aggregateClaimIndicator 0..1stringIndicates whether this claim record is included in the adjustment processing of the aggregate build logic for admissions, episodes or DCGs
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/aggregate-claim-indicator
... claimSnapshotProviderName 0..1stringOriginal provider name as reported on the claim
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-snapshot-provider-name
... claimSnapshotProviderZipCode 0..1stringOriginal provider postal code, as reported on the claim
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-snapshot-provider-zip-code
... companyCode 0..1CodeableConceptCompany code of the subscriber as reported on the claim
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/company-code
... employeeBusinessUnit 0..1CodeableConceptBusiness unit of the subscriber as reported on the claim
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/employee-business-unit
... employer 0..1CodeableConceptCustomer-specific code for the employer as reported on the claim record
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/employer
... financialSystem 0..1CodeableConceptCustomer-specific code for the financial system
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/financial-system
... claimCategory 0..1CodeableConceptStandard HIPAA code for the category of the claim status
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-category
Binding: https://x12.org/codes/claim-status-category-codes (extensible)
... claimStatus 0..1CodeableConceptStandard HIPAA code for the status of an entire claim
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-status
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..0
.... url 1..1uri"http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-status"
.... Slices for value[x] 0..1CodeableConceptValue of extension
Slice: Unordered, Closed by type:$this
..... value[x]:valueCodeableConcept 0..1CodeableConceptValue of extension
Binding: https://x12.org/codes/claim-status-codes (extensible)
... lastClaimIndicator 0..1stringIndicates whether this claim record is the last or most recent claim
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/last-claim-indicator
... participatingPlan 0..1CodeableConceptCustomer-specific code for the participating plan
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/participating-plan
... referralIndicator 0..1stringIndicates whether the service resulted from a referral
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/referral-indicator
... snapshotAgeInYears 0..1unsignedIntThe age of the patient in years at the date of service
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/snapshot-age-in-years
... submissionType 0..1CodeableConceptCustomer-specific code for the type of electronic submission
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/submission-type
... payerPcpResponsibilityIndicator 0..1stringIndicates whether the primary care physician is the physician considered either responsible or accountable for this claim
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/payer-pcp-responsibility-indicator
... admitCount 0..1integerUsed to determine which facility claims should be counted as inpatient admissions
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/admit-count
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier 1..*IdentifierBusiness Identifier for claim
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

.... type Σ0..1CodeableConceptDescription of identifier
Binding: Identifier Type Value Set (extensible)
.... system Σ1..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
.... value Σ1..1stringThe value that is unique
Example General: 123456
.... period Σ0..1PeriodTime period when id is/was valid for use
.... assigner Σ0..1Reference(Organization)Organization that issued id (may be just text)
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... type Σ1..1CodeableConceptCategory or discipline
Binding: Claim Type Value Set (extensible)
... subType 0..1CodeableConceptMore granular claim type
Binding: Claim Subtype Value Set (extensible)
... use Σ1..1codeclaim | preauthorization | predetermination
Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim.

... patient Σ1..1Reference(Patient)The recipient of the products and services
... billablePeriod Σ0..1PeriodRelevant time frame for the claim
... created Σ1..1dateTimeResource creation date
... enterer 0..1Reference(Practitioner | PractitionerRole)Author of the claim
... insurer Σ0..1Reference(Organization)Target
... provider Σ1..1Reference(Practitioner | PractitionerRole | Organization)Party responsible for the claim
... priority Σ1..1CodeableConceptDesired processing ugency
Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.

... fundsReserve 0..1CodeableConceptFor whom to reserve funds
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).

... related 0..*BackboneElementPrior or corollary claims
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... claim 0..1Reference(Claim)Reference to the related claim
.... relationship 0..1CodeableConceptHow the reference claim is related
Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim.

.... reference 0..1IdentifierFile or case reference
... prescription 0..1Reference(DeviceRequest | MedicationRequest | VisionPrescription)Prescription authorizing services and products
... originalPrescription 0..1Reference(DeviceRequest | MedicationRequest | VisionPrescription)Original prescription if superseded by fulfiller
... payee 0..1BackboneElementRecipient of benefits payable
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type 1..1CodeableConceptCategory of recipient
Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.

.... party 0..1Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson)Recipient reference
... referral 0..1Reference(ServiceRequest)Treatment referral
... facility 0..1Reference(Location)Servicing facility
... careTeam 0..*BackboneElementMembers of the care team
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntOrder of care team
.... provider 1..1Reference(Practitioner | PractitionerRole | Organization)Practitioner or organization
.... responsible 0..1booleanIndicator of the lead practitioner
.... role 0..1CodeableConceptFunction within the team
Binding: Claim Care Team Role Value Set (extensible)
.... qualification 0..1CodeableConceptPractitioner credential or specialization
Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.

... supportingInfo 0..*BackboneElementSupporting information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntInformation instance identifier
.... category 1..1CodeableConceptClassification of the supplied information
Binding: Claim Supporting Info Category Value Set (extensible)
.... code 0..1CodeableConceptType of information
Binding: Claim Supporting Info Type Value Set (extensible)
.... timing[x] 0..1When it occurred
..... timingDatedate
..... timingPeriodPeriod
.... value[x] 0..1Data to be provided
..... valueBooleanboolean
..... valueStringstring
..... valueQuantityQuantity
..... valueAttachmentAttachment
..... valueReferenceReference(Resource)
.... reason 0..1CodeableConceptExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

... diagnosis 0..*BackboneElementPertinent diagnosis information
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... majorDiagnosticCategory 0..1CodeableConceptThe body system or disease related groupings of clinical conditions, based on diagnosis codes
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/major-diagnostic-category
Binding: Payer Major Diagnostic Category Value Set (extensible)
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntDiagnosis instance identifier
.... diagnosis[x] 1..1Nature of illness or problem
Binding: ICD-10Codes (example): Example ICD10 Diagnostic codes.

..... diagnosisCodeableConceptCodeableConcept
..... diagnosisReferenceReference(Condition)
.... type 0..*CodeableConceptTiming or nature of the diagnosis
Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge.


.... onAdmission 0..1CodeableConceptPresent on admission
Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.

.... packageCode 0..1CodeableConceptPackage billing code
Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.

... procedure 0..*BackboneElementClinical procedures performed
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... procedureGroup 0..1CodeableConceptCode assigned to categorize related procedures
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/procedure-group
Binding: Payer Procedure Group Value Set (extensible)
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntProcedure instance identifier
.... type 0..*CodeableConceptCategory of Procedure
Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.


.... date 0..1dateTimeWhen the procedure was performed
.... procedure[x] 1..1Specific clinical procedure
Binding: ICD-10ProcedureCodes (example): Example ICD10 Procedure codes.

..... procedureCodeableConceptCodeableConcept
..... procedureReferenceReference(Procedure)
.... udi 0..*Reference(Device)Unique device identifier
... insurance Σ1..*BackboneElementPatient insurance information
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... crossoverIndicator 0..1stringIndicates whether the claim is a crossover claim where a portion is paid by Medicare
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/crossover-indicator
.... lineOfBusiness 0..1CodeableConceptCode for the line of business
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/line-of-business
.... priorAuthorizationIndicator 0..1stringIndicates prior authorization for the claim
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/prior-authorization-indicator
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence Σ1..1positiveIntInsurance instance identifier
.... focal Σ1..1booleanCoverage to be used for adjudication
.... identifier 0..1IdentifierPre-assigned Claim number
.... coverage Σ1..1Reference(Coverage)Insurance information
.... businessArrangement 0..1stringAdditional provider contract number
.... preAuthRef 0..*stringPrior authorization reference number
.... claimResponse 0..1Reference(ClaimResponse)Adjudication results
... accident 0..1BackboneElementDetails of the event
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... date 1..1dateWhen the incident occurred
.... type 0..1CodeableConceptThe nature of the accident
Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc.

.... location[x] 0..1Where the event occurred
..... locationAddressAddress
..... locationReferenceReference(Location)
... item 0..*BackboneElementProduct or service provided
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... capitatedServiceIndicator 0..1stringIndicates whether this service (encounter record) was capitated
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/capitated-service-indicator
.... fullyInsuredIndicator 0..1stringIndicates whether the claim was for a fully insured plan
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/fully-insured-indicator
.... nursingHomeIndicator 0..1stringIndicates whether the claim was for a nursing home patient
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/nursing-home-indicator
.... serviceBillDaysCount 0..1unsignedIntNumber of days between the date of service and the date the claim was received
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/service-bill-days-count
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntItem instance identifier
.... careTeamSequence 0..*positiveIntApplicable careTeam members
.... diagnosisSequence 0..*positiveIntApplicable diagnoses
.... procedureSequence 0..*positiveIntApplicable procedures
.... informationSequence 0..*positiveIntApplicable exception and supporting information
.... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

.... category 0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.

.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

.... modifier 0..*CodeableConceptProduct or service billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


.... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


.... serviced[x] 0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.

..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1SimpleQuantityCount of products or services
..... id 0..1stringUnique id for inter-element referencing
..... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... localNumberOfUnitsPerService 0..1QuantityCustomer-specific quantity of either services or units
URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/local-number-of-units-per-service
..... value Σ0..1decimalNumerical value (with implicit precision)
..... unit Σ0..1stringUnit representation
..... system ΣC0..1uriSystem that defines coded unit form
..... code Σ0..1codeCoded form of the unit
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... udi 0..*Reference(Device)Unique device identifier
.... bodySite 0..1CodeableConceptAnatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.

.... subSite 0..*CodeableConceptAnatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.


.... encounter 0..*Reference(Encounter)Encounters related to this billed item
.... detail 0..*BackboneElementProduct or service provided
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntItem instance identifier
..... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

..... category 0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.

..... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

..... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


..... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


..... quantity 0..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal item cost
..... udi 0..*Reference(Device)Unique device identifier
..... subDetail 0..*BackboneElementProduct or service provided
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... sequence 1..1positiveIntItem instance identifier
...... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

...... category 0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.

...... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

...... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


...... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


...... quantity 0..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyTotal item cost
...... udi 0..*Reference(Device)Unique device identifier
... total 0..1MoneyTotal claim cost

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Claim.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Claim.extension:claimStatus.value[x]:valueCodeableConceptextensiblehttps://x12.org/codes/claim-status-codes
Claim.identifier.userequiredIdentifierUse
Claim.identifier.typeextensibleIdentifierTypeValueSet
Claim.statusrequiredFinancialResourceStatusCodes
Claim.typeextensibleClaimTypeValueSet (a valid code from Payer Claim Type Codes)
Claim.subTypeextensibleClaimSubtypeValueSet (a valid code from Claim Subtype Codes)
Claim.userequiredUse
Claim.priorityexampleProcessPriorityCodes
Claim.fundsReserveexampleFunds Reservation Codes
Claim.related.relationshipexampleExampleRelatedClaimRelationshipCodes
Claim.payee.typeexampleClaim Payee Type Codes
Claim.careTeam.roleextensibleClaimCareTeamRoleValueSet (a valid code from Claim Care Team Role Codes)
Claim.careTeam.qualificationexampleExampleProviderQualificationCodes
Claim.supportingInfo.categoryextensibleClaimSupportingInfoCategoryValueSet
Claim.supportingInfo.codeextensibleClaimSupportingInfoTypeValueSet (a valid code from Claim Supporting Info Type Codes)
Claim.supportingInfo.reasonexampleMissingToothReasonCodes
Claim.diagnosis.diagnosis[x]exampleICD-10Codes
Claim.diagnosis.typeexampleExampleDiagnosisTypeCodes
Claim.diagnosis.onAdmissionexampleExampleDiagnosisOnAdmissionCodes
Claim.diagnosis.packageCodeexampleExampleDiagnosisRelatedGroupCodes
Claim.procedure.typeexampleExampleProcedureTypeCodes
Claim.procedure.procedure[x]exampleICD-10ProcedureCodes
Claim.accident.typeextensibleActIncidentCode
Claim.item.revenueexampleExampleRevenueCenterCodes
Claim.item.categoryexampleBenefitCategoryCodes
Claim.item.productOrServiceexampleUSCLSCodes
Claim.item.modifierexampleModifierTypeCodes
Claim.item.programCodeexampleExampleProgramReasonCodes
Claim.item.location[x]exampleExampleServicePlaceCodes
Claim.item.bodySiteexampleOralSiteCodes
Claim.item.subSiteexampleSurfaceCodes
Claim.item.detail.revenueexampleExampleRevenueCenterCodes
Claim.item.detail.categoryexampleBenefitCategoryCodes
Claim.item.detail.productOrServiceexampleUSCLSCodes
Claim.item.detail.modifierexampleModifierTypeCodes
Claim.item.detail.programCodeexampleExampleProgramReasonCodes
Claim.item.detail.subDetail.revenueexampleExampleRevenueCenterCodes
Claim.item.detail.subDetail.categoryexampleBenefitCategoryCodes
Claim.item.detail.subDetail.productOrServiceexampleUSCLSCodes
Claim.item.detail.subDetail.modifierexampleModifierTypeCodes
Claim.item.detail.subDetail.programCodeexampleExampleProgramReasonCodes

This structure is derived from CDMClaim

Summary

Extensions

This structure refers to these extensions:

 

Other representations of profile: CSV, Excel, Schematron