LinuxForHealth FHIR Implementation Guide
8.0.0 - draft
LinuxForHealth FHIR Implementation Guide
8.0.0 - draft
LinuxForHealth FHIR Implementation Guide - Local Development build (v8.0.0). See the Directory of published versions
| Official URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/cdm-claim | Version: 8.0.0 | |||
| Active as of 2022-11-10 | Computable Name: CDMClaim | |||
A provider issued list of professional services and products which have been provided, or are to be provided, to a patient which is sent to an insurer for reimbursement. The CDMClaim profile extends the base FHIR Claim resource with additional details.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Claim
| Path | Conformance | ValueSet |
| Claim.extension:claimStatus.valueCodeableConcept | extensible | https://x12.org/codes/claim-status-codes |
| Claim.identifier.type | extensible | IdentifierTypeValueSet |
| Claim.type | extensible | ClaimTypeValueSet (a valid code from Payer Claim Type Codes) |
| Claim.subType | extensible | ClaimSubtypeValueSet (a valid code from Claim Subtype Codes) |
| Claim.careTeam.role | extensible | ClaimCareTeamRoleValueSet (a valid code from Claim Care Team Role Codes) |
| Claim.supportingInfo.category | extensible | ClaimSupportingInfoCategoryValueSet |
| Claim.supportingInfo.code | extensible | ClaimSupportingInfoTypeValueSet (a valid code from Claim Supporting Info Type Codes) |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Claim | 0..* | Claim | Claim, Pre-determination or Pre-authorization | |
  meta | 0..1 | ProcessMeta | Metadata about a resource | |
 implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
 Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
 aggregateClaimIndicator | 0..1 | string | Indicates 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..1 | string | Original provider name as reported on the claim URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-snapshot-provider-name | |
| claimSnapshotProviderZipCode | 0..1 | string | Original provider postal code, as reported on the claim URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-snapshot-provider-zip-code | |
| companyCode | 0..1 | CodeableConcept | Company code of the subscriber as reported on the claim URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/company-code | |
| employeeBusinessUnit | 0..1 | CodeableConcept | Business unit of the subscriber as reported on the claim URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/employee-business-unit | |
| employer | 0..1 | CodeableConcept | Customer-specific code for the employer as reported on the claim record URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/employer | |
| financialSystem | 0..1 | CodeableConcept | Customer-specific code for the financial system URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/financial-system | |
| claimCategory | 0..1 | CodeableConcept | Standard 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..1 | CodeableConcept | Standard HIPAA code for the status of an entire claim URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-status | |
  extension | 0..0 | |||
| url | 1..1 | uri | "http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-status" | |
  Slices for value[x] | 0..1 | CodeableConcept | Value of extension Slice: Unordered, Closed by type:$this | |
  value[x]:valueCodeableConcept | 0..1 | CodeableConcept | Value of extension Binding: https://x12.org/codes/claim-status-codes (extensible) | |
| lastClaimIndicator | 0..1 | string | Indicates whether this claim record is the last or most recent claim URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/last-claim-indicator | |
| participatingPlan | 0..1 | CodeableConcept | Customer-specific code for the participating plan URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/participating-plan | |
| referralIndicator | 0..1 | string | Indicates whether the service resulted from a referral URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/referral-indicator | |
| snapshotAgeInYears | 0..1 | unsignedInt | The age of the patient in years at the date of service URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/snapshot-age-in-years | |
| submissionType | 0..1 | CodeableConcept | Customer-specific code for the type of electronic submission URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/submission-type | |
| payerPcpResponsibilityIndicator | 0..1 | string | Indicates 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 | |
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| identifier | 1..* | Identifier | Business Identifier for claim | |
| use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . |
| type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Value Set (extensible) |
| system | Σ | 1..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient |
 value | Σ | 1..1 | string | The value that is unique Example General: 123456 |
| status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. |
| type | Σ | 1..1 | CodeableConcept | Category or discipline Binding: Claim Type Value Set (extensible) |
| subType | 0..1 | CodeableConcept | More granular claim type Binding: Claim Subtype Value Set (extensible) | |
| use | Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim. |
 patient | Σ | 1..1 | Reference(Patient) | The recipient of the products and services |
| created | Σ | 1..1 | dateTime | Resource creation date |
| provider | Σ | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim |
| priority | Σ | 1..1 | CodeableConcept | Desired processing ugency Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred. |
 insurance | Σ | 1..* | BackboneElement | Patient insurance information |
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| crossoverIndicator | 0..1 | string | Indicates 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..1 | CodeableConcept | Code for the line of business URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/line-of-business | |
| priorAuthorizationIndicator | 0..1 | string | Indicates prior authorization for the claim URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/prior-authorization-indicator | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | Σ | 1..1 | positiveInt | Insurance instance identifier |
| focal | Σ | 1..1 | boolean | Coverage to be used for adjudication |
| coverage | Σ | 1..1 | Reference(Coverage) | Insurance information |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Claim.extension:claimStatus.value[x]:valueCodeableConcept | extensible | https://x12.org/codes/claim-status-codes |
| Claim.identifier.use | required | IdentifierUse |
| Claim.identifier.type | extensible | IdentifierTypeValueSet |
| Claim.status | required | FinancialResourceStatusCodes |
| Claim.type | extensible | ClaimTypeValueSet (a valid code from Payer Claim Type Codes) |
| Claim.subType | extensible | ClaimSubtypeValueSet (a valid code from Claim Subtype Codes) |
| Claim.use | required | Use |
| Claim.priority | example | ProcessPriorityCodes |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Claim | 0..* | Claim | Claim, Pre-determination or Pre-authorization | |||||
| id | Σ | 0..1 | id | Logical id of this artifact | ||||
| meta | 0..1 | ProcessMeta | Metadata about a resource | |||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| aggregateClaimIndicator | 0..1 | string | Indicates 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..1 | string | Original provider name as reported on the claim URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-snapshot-provider-name | |||||
| claimSnapshotProviderZipCode | 0..1 | string | Original provider postal code, as reported on the claim URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-snapshot-provider-zip-code | |||||
| companyCode | 0..1 | CodeableConcept | Company code of the subscriber as reported on the claim URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/company-code | |||||
| employeeBusinessUnit | 0..1 | CodeableConcept | Business unit of the subscriber as reported on the claim URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/employee-business-unit | |||||
| employer | 0..1 | CodeableConcept | Customer-specific code for the employer as reported on the claim record URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/employer | |||||
| financialSystem | 0..1 | CodeableConcept | Customer-specific code for the financial system URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/financial-system | |||||
| claimCategory | 0..1 | CodeableConcept | Standard 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..1 | CodeableConcept | Standard HIPAA code for the status of an entire claim URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-status | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..0 | |||||||
| url | 1..1 | uri | "http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-status" | |||||
| Slices for value[x] | 0..1 | CodeableConcept | Value of extension Slice: Unordered, Closed by type:$this | |||||
| value[x]:valueCodeableConcept | 0..1 | CodeableConcept | Value of extension Binding: https://x12.org/codes/claim-status-codes (extensible) | |||||
| lastClaimIndicator | 0..1 | string | Indicates whether this claim record is the last or most recent claim URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/last-claim-indicator | |||||
| participatingPlan | 0..1 | CodeableConcept | Customer-specific code for the participating plan URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/participating-plan | |||||
| referralIndicator | 0..1 | string | Indicates whether the service resulted from a referral URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/referral-indicator | |||||
| snapshotAgeInYears | 0..1 | unsignedInt | The age of the patient in years at the date of service URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/snapshot-age-in-years | |||||
| submissionType | 0..1 | CodeableConcept | Customer-specific code for the type of electronic submission URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/submission-type | |||||
| payerPcpResponsibilityIndicator | 0..1 | string | Indicates 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 | |||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier | 1..* | Identifier | Business Identifier for claim | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
| type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Value Set (extensible) | ||||
| system | Σ | 1..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
| value | Σ | 1..1 | string | The value that is unique Example General: 123456 | ||||
| period | Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
| assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||
| status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. | ||||
| type | Σ | 1..1 | CodeableConcept | Category or discipline Binding: Claim Type Value Set (extensible) | ||||
| subType | 0..1 | CodeableConcept | More granular claim type Binding: Claim Subtype Value Set (extensible) | |||||
| use | Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim. | ||||
| patient | Σ | 1..1 | Reference(Patient) | The recipient of the products and services | ||||
| billablePeriod | Σ | 0..1 | Period | Relevant time frame for the claim | ||||
| created | Σ | 1..1 | dateTime | Resource creation date | ||||
| enterer | 0..1 | Reference(Practitioner | PractitionerRole) | Author of the claim | |||||
| insurer | Σ | 0..1 | Reference(Organization) | Target | ||||
| provider | Σ | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim | ||||
| priority | Σ | 1..1 | CodeableConcept | Desired processing ugency Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred. | ||||
| fundsReserve | 0..1 | CodeableConcept | For whom to reserve funds Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None). | |||||
| related | 0..* | BackboneElement | Prior or corollary claims | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| claim | 0..1 | Reference(Claim) | Reference to the related claim | |||||
| relationship | 0..1 | CodeableConcept | How the reference claim is related Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim. | |||||
| reference | 0..1 | Identifier | File or case reference | |||||
| prescription | 0..1 | Reference(DeviceRequest | MedicationRequest | VisionPrescription) | Prescription authorizing services and products | |||||
| originalPrescription | 0..1 | Reference(DeviceRequest | MedicationRequest | VisionPrescription) | Original prescription if superseded by fulfiller | |||||
| payee | 0..1 | BackboneElement | Recipient of benefits payable | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| type | 1..1 | CodeableConcept | Category of recipient Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed. | |||||
| party | 0..1 | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) | Recipient reference | |||||
| referral | 0..1 | Reference(ServiceRequest) | Treatment referral | |||||
| facility | 0..1 | Reference(Location) | Servicing facility | |||||
| careTeam | 0..* | BackboneElement | Members of the care team | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| sequence | 1..1 | positiveInt | Order of care team | |||||
| provider | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Practitioner or organization | |||||
| responsible | 0..1 | boolean | Indicator of the lead practitioner | |||||
| role | 0..1 | CodeableConcept | Function within the team Binding: Claim Care Team Role Value Set (extensible) | |||||
| qualification | 0..1 | CodeableConcept | Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications. | |||||
| supportingInfo | 0..* | BackboneElement | Supporting information | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| sequence | 1..1 | positiveInt | Information instance identifier | |||||
| category | 1..1 | CodeableConcept | Classification of the supplied information Binding: Claim Supporting Info Category Value Set (extensible) | |||||
| code | 0..1 | CodeableConcept | Type of information Binding: Claim Supporting Info Type Value Set (extensible) | |||||
 timing[x] | 0..1 | When it occurred | ||||||
| timingDate | date | |||||||
| timingPeriod | Period | |||||||
| value[x] | 0..1 | Data to be provided | ||||||
| valueBoolean | boolean | |||||||
| valueString | string | |||||||
| valueQuantity | Quantity | |||||||
| valueAttachment | Attachment | |||||||
| valueReference | Reference(Resource) | |||||||
| reason | 0..1 | CodeableConcept | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth. | |||||
| diagnosis | 0..* | BackboneElement | Pertinent diagnosis information | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| majorDiagnosticCategory | 0..1 | CodeableConcept | The 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 | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| sequence | 1..1 | positiveInt | Diagnosis instance identifier | |||||
| diagnosis[x] | 1..1 | Nature of illness or problem Binding: ICD-10Codes (example): Example ICD10 Diagnostic codes. | ||||||
| diagnosisCodeableConcept | CodeableConcept | |||||||
| diagnosisReference | Reference(Condition) | |||||||
| type | 0..* | CodeableConcept | Timing or nature of the diagnosis Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge. | |||||
| onAdmission | 0..1 | CodeableConcept | Present on admission Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission. | |||||
| packageCode | 0..1 | CodeableConcept | Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis. | |||||
| procedure | 0..* | BackboneElement | Clinical procedures performed | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| procedureGroup | 0..1 | CodeableConcept | Code assigned to categorize related procedures URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/procedure-group Binding: Payer Procedure Group Value Set (extensible) | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| sequence | 1..1 | positiveInt | Procedure instance identifier | |||||
| type | 0..* | CodeableConcept | Category of Procedure Binding: ExampleProcedureTypeCodes (example): Example procedure type codes. | |||||
| date | 0..1 | dateTime | When the procedure was performed | |||||
| procedure[x] | 1..1 | Specific clinical procedure Binding: ICD-10ProcedureCodes (example): Example ICD10 Procedure codes. | ||||||
| procedureCodeableConcept | CodeableConcept | |||||||
| procedureReference | Reference(Procedure) | |||||||
| udi | 0..* | Reference(Device) | Unique device identifier | |||||
| insurance | Σ | 1..* | BackboneElement | Patient insurance information | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| crossoverIndicator | 0..1 | string | Indicates 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..1 | CodeableConcept | Code for the line of business URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/line-of-business | |||||
| priorAuthorizationIndicator | 0..1 | string | Indicates prior authorization for the claim URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/prior-authorization-indicator | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| sequence | Σ | 1..1 | positiveInt | Insurance instance identifier | ||||
| focal | Σ | 1..1 | boolean | Coverage to be used for adjudication | ||||
| identifier | 0..1 | Identifier | Pre-assigned Claim number | |||||
| coverage | Σ | 1..1 | Reference(Coverage) | Insurance information | ||||
| businessArrangement | 0..1 | string | Additional provider contract number | |||||
| preAuthRef | 0..* | string | Prior authorization reference number | |||||
| claimResponse | 0..1 | Reference(ClaimResponse) | Adjudication results | |||||
| accident | 0..1 | BackboneElement | Details of the event | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| date | 1..1 | date | When the incident occurred | |||||
| type | 0..1 | CodeableConcept | The nature of the accident Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc. | |||||
| location[x] | 0..1 | Where the event occurred | ||||||
| locationAddress | Address | |||||||
| locationReference | Reference(Location) | |||||||
| item | 0..* | BackboneElement | Product or service provided | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| capitatedServiceIndicator | 0..1 | string | Indicates whether this service (encounter record) was capitated URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/capitated-service-indicator | |||||
| fullyInsuredIndicator | 0..1 | string | Indicates whether the claim was for a fully insured plan URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/fully-insured-indicator | |||||
| nursingHomeIndicator | 0..1 | string | Indicates whether the claim was for a nursing home patient URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/nursing-home-indicator | |||||
| serviceBillDaysCount | 0..1 | unsignedInt | Number 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 | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| sequence | 1..1 | positiveInt | Item instance identifier | |||||
| careTeamSequence | 0..* | positiveInt | Applicable careTeam members | |||||
| diagnosisSequence | 0..* | positiveInt | Applicable diagnoses | |||||
| procedureSequence | 0..* | positiveInt | Applicable procedures | |||||
| informationSequence | 0..* | positiveInt | Applicable exception and supporting information | |||||
| revenue | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |||||
| category | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses. | |||||
| productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
| modifier | 0..* | CodeableConcept | Product 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..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||
| serviced[x] | 0..1 | Date or dates of service or product delivery | ||||||
| servicedDate | date | |||||||
| servicedPeriod | Period | |||||||
| location[x] | 0..1 | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc. | ||||||
| locationCodeableConcept | CodeableConcept | |||||||
| locationAddress | Address | |||||||
| locationReference | Reference(Location) | |||||||
| quantity | 0..1 | SimpleQuantity | Count of products or services | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| localNumberOfUnitsPerService | 0..1 | Quantity | Customer-specific quantity of either services or units URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/local-number-of-units-per-service | |||||
| value | Σ | 0..1 | decimal | Numerical value (with implicit precision) | ||||
| unit | Σ | 0..1 | string | Unit representation | ||||
| system | ΣC | 0..1 | uri | System that defines coded unit form | ||||
| code | Σ | 0..1 | code | Coded form of the unit | ||||
| unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||
| factor | 0..1 | decimal | Price scaling factor | |||||
| net | 0..1 | Money | Total item cost | |||||
| udi | 0..* | Reference(Device) | Unique device identifier | |||||
| bodySite | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch. | |||||
| subSite | 0..* | CodeableConcept | Anatomical 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..* | BackboneElement | Product or service provided | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| sequence | 1..1 | positiveInt | Item instance identifier | |||||
| revenue | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |||||
| category | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses. | |||||
| productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
| modifier | 0..* | CodeableConcept | Service/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..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||
| quantity | 0..1 | SimpleQuantity | Count of products or services | |||||
| unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||
| factor | 0..1 | decimal | Price scaling factor | |||||
| net | 0..1 | Money | Total item cost | |||||
| udi | 0..* | Reference(Device) | Unique device identifier | |||||
| subDetail | 0..* | BackboneElement | Product or service provided | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| sequence | 1..1 | positiveInt | Item instance identifier | |||||
| revenue | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |||||
| category | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses. | |||||
| productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
| modifier | 0..* | CodeableConcept | Service/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..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||
| quantity | 0..1 | SimpleQuantity | Count of products or services | |||||
| unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||
| factor | 0..1 | decimal | Price scaling factor | |||||
| net | 0..1 | Money | Total item cost | |||||
| udi | 0..* | Reference(Device) | Unique device identifier | |||||
| total | 0..1 | Money | Total claim cost | |||||
| Documentation for this format | ||||||||
This structure is derived from Claim
Summary
Mandatory: 3 elements
Prohibited: 1 element
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Differential View
This structure is derived from Claim
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Claim | 0..* | Claim | Claim, Pre-determination or Pre-authorization | |
| meta | 0..1 | ProcessMeta | Metadata about a resource | |
 contained | 0..0 | |||
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| aggregateClaimIndicator | 0..1 | string | Indicates 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..1 | string | Original provider name as reported on the claim URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-snapshot-provider-name | |
| claimSnapshotProviderZipCode | 0..1 | string | Original provider postal code, as reported on the claim URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-snapshot-provider-zip-code | |
| companyCode | 0..1 | CodeableConcept | Company code of the subscriber as reported on the claim URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/company-code | |
| employeeBusinessUnit | 0..1 | CodeableConcept | Business unit of the subscriber as reported on the claim URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/employee-business-unit | |
| employer | 0..1 | CodeableConcept | Customer-specific code for the employer as reported on the claim record URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/employer | |
| financialSystem | 0..1 | CodeableConcept | Customer-specific code for the financial system URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/financial-system | |
| claimCategory | 0..1 | CodeableConcept | Standard 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..1 | CodeableConcept | Standard HIPAA code for the status of an entire claim URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-status | |
 valueCodeableConcept | 0..1 | CodeableConcept | Value of extension Binding: https://x12.org/codes/claim-status-codes (extensible) | |
| lastClaimIndicator | 0..1 | string | Indicates whether this claim record is the last or most recent claim URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/last-claim-indicator | |
| participatingPlan | 0..1 | CodeableConcept | Customer-specific code for the participating plan URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/participating-plan | |
| referralIndicator | 0..1 | string | Indicates whether the service resulted from a referral URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/referral-indicator | |
| snapshotAgeInYears | 0..1 | unsignedInt | The age of the patient in years at the date of service URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/snapshot-age-in-years | |
| submissionType | 0..1 | CodeableConcept | Customer-specific code for the type of electronic submission URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/submission-type | |
| payerPcpResponsibilityIndicator | 0..1 | string | Indicates 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 | |
| identifier | 1..* | Identifier | Business Identifier for claim | |
| type | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Value Set (extensible) | |
| system | 1..1 | uri | The namespace for the identifier value | |
| value | 1..1 | string | The value that is unique | |
| type | 1..1 | CodeableConcept | Category or discipline Binding: Claim Type Value Set (extensible) | |
| subType | 0..1 | CodeableConcept | More granular claim type Binding: Claim Subtype Value Set (extensible) | |
| careTeam | ||||
| role | 0..1 | CodeableConcept | Function within the team Binding: Claim Care Team Role Value Set (extensible) | |
| supportingInfo | ||||
| category | 1..1 | CodeableConcept | Classification of the supplied information Binding: Claim Supporting Info Category Value Set (extensible) | |
| code | 0..1 | CodeableConcept | Type of information Binding: Claim Supporting Info Type Value Set (extensible) | |
| diagnosis | ||||
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| majorDiagnosticCategory | 0..1 | CodeableConcept | The 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) | |
| procedure | ||||
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| procedureGroup | 0..1 | CodeableConcept | Code assigned to categorize related procedures URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/procedure-group Binding: Payer Procedure Group Value Set (extensible) | |
| insurance | ||||
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| crossoverIndicator | 0..1 | string | Indicates 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..1 | CodeableConcept | Code for the line of business URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/line-of-business | |
| priorAuthorizationIndicator | 0..1 | string | Indicates prior authorization for the claim URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/prior-authorization-indicator | |
| item | ||||
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| capitatedServiceIndicator | 0..1 | string | Indicates whether this service (encounter record) was capitated URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/capitated-service-indicator | |
| fullyInsuredIndicator | 0..1 | string | Indicates whether the claim was for a fully insured plan URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/fully-insured-indicator | |
| nursingHomeIndicator | 0..1 | string | Indicates whether the claim was for a nursing home patient URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/nursing-home-indicator | |
| serviceBillDaysCount | 0..1 | unsignedInt | Number 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 | |
| quantity | ||||
| localNumberOfUnitsPerService | 0..1 | Quantity | Customer-specific quantity of either services or units URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/local-number-of-units-per-service | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Claim.extension:claimStatus.valueCodeableConcept | extensible | https://x12.org/codes/claim-status-codes |
| Claim.identifier.type | extensible | IdentifierTypeValueSet |
| Claim.type | extensible | ClaimTypeValueSet (a valid code from Payer Claim Type Codes) |
| Claim.subType | extensible | ClaimSubtypeValueSet (a valid code from Claim Subtype Codes) |
| Claim.careTeam.role | extensible | ClaimCareTeamRoleValueSet (a valid code from Claim Care Team Role Codes) |
| Claim.supportingInfo.category | extensible | ClaimSupportingInfoCategoryValueSet |
| Claim.supportingInfo.code | extensible | ClaimSupportingInfoTypeValueSet (a valid code from Claim Supporting Info Type Codes) |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Claim | 0..* | Claim | Claim, Pre-determination or Pre-authorization | |
| meta | 0..1 | ProcessMeta | Metadata about a resource | |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| aggregateClaimIndicator | 0..1 | string | Indicates 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..1 | string | Original provider name as reported on the claim URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-snapshot-provider-name | |
| claimSnapshotProviderZipCode | 0..1 | string | Original provider postal code, as reported on the claim URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-snapshot-provider-zip-code | |
| companyCode | 0..1 | CodeableConcept | Company code of the subscriber as reported on the claim URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/company-code | |
| employeeBusinessUnit | 0..1 | CodeableConcept | Business unit of the subscriber as reported on the claim URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/employee-business-unit | |
| employer | 0..1 | CodeableConcept | Customer-specific code for the employer as reported on the claim record URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/employer | |
| financialSystem | 0..1 | CodeableConcept | Customer-specific code for the financial system URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/financial-system | |
| claimCategory | 0..1 | CodeableConcept | Standard 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..1 | CodeableConcept | Standard HIPAA code for the status of an entire claim URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-status | |
| extension | 0..0 | |||
| url | 1..1 | uri | "http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-status" | |
| Slices for value[x] | 0..1 | CodeableConcept | Value of extension Slice: Unordered, Closed by type:$this | |
| value[x]:valueCodeableConcept | 0..1 | CodeableConcept | Value of extension Binding: https://x12.org/codes/claim-status-codes (extensible) | |
| lastClaimIndicator | 0..1 | string | Indicates whether this claim record is the last or most recent claim URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/last-claim-indicator | |
| participatingPlan | 0..1 | CodeableConcept | Customer-specific code for the participating plan URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/participating-plan | |
| referralIndicator | 0..1 | string | Indicates whether the service resulted from a referral URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/referral-indicator | |
| snapshotAgeInYears | 0..1 | unsignedInt | The age of the patient in years at the date of service URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/snapshot-age-in-years | |
| submissionType | 0..1 | CodeableConcept | Customer-specific code for the type of electronic submission URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/submission-type | |
| payerPcpResponsibilityIndicator | 0..1 | string | Indicates 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 | |
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| identifier | 1..* | Identifier | Business Identifier for claim | |
| use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . |
| type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Value Set (extensible) |
| system | Σ | 1..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient |
| value | Σ | 1..1 | string | The value that is unique Example General: 123456 |
| status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. |
| type | Σ | 1..1 | CodeableConcept | Category or discipline Binding: Claim Type Value Set (extensible) |
| subType | 0..1 | CodeableConcept | More granular claim type Binding: Claim Subtype Value Set (extensible) | |
| use | Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim. |
| patient | Σ | 1..1 | Reference(Patient) | The recipient of the products and services |
| created | Σ | 1..1 | dateTime | Resource creation date |
| provider | Σ | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim |
| priority | Σ | 1..1 | CodeableConcept | Desired processing ugency Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred. |
| insurance | Σ | 1..* | BackboneElement | Patient insurance information |
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| crossoverIndicator | 0..1 | string | Indicates 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..1 | CodeableConcept | Code for the line of business URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/line-of-business | |
| priorAuthorizationIndicator | 0..1 | string | Indicates prior authorization for the claim URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/prior-authorization-indicator | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | Σ | 1..1 | positiveInt | Insurance instance identifier |
| focal | Σ | 1..1 | boolean | Coverage to be used for adjudication |
| coverage | Σ | 1..1 | Reference(Coverage) | Insurance information |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Claim.extension:claimStatus.value[x]:valueCodeableConcept | extensible | https://x12.org/codes/claim-status-codes |
| Claim.identifier.use | required | IdentifierUse |
| Claim.identifier.type | extensible | IdentifierTypeValueSet |
| Claim.status | required | FinancialResourceStatusCodes |
| Claim.type | extensible | ClaimTypeValueSet (a valid code from Payer Claim Type Codes) |
| Claim.subType | extensible | ClaimSubtypeValueSet (a valid code from Claim Subtype Codes) |
| Claim.use | required | Use |
| Claim.priority | example | ProcessPriorityCodes |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Claim | 0..* | Claim | Claim, Pre-determination or Pre-authorization | |||||
| id | Σ | 0..1 | id | Logical id of this artifact | ||||
| meta | 0..1 | ProcessMeta | Metadata about a resource | |||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| aggregateClaimIndicator | 0..1 | string | Indicates 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..1 | string | Original provider name as reported on the claim URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-snapshot-provider-name | |||||
| claimSnapshotProviderZipCode | 0..1 | string | Original provider postal code, as reported on the claim URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-snapshot-provider-zip-code | |||||
| companyCode | 0..1 | CodeableConcept | Company code of the subscriber as reported on the claim URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/company-code | |||||
| employeeBusinessUnit | 0..1 | CodeableConcept | Business unit of the subscriber as reported on the claim URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/employee-business-unit | |||||
| employer | 0..1 | CodeableConcept | Customer-specific code for the employer as reported on the claim record URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/employer | |||||
| financialSystem | 0..1 | CodeableConcept | Customer-specific code for the financial system URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/financial-system | |||||
| claimCategory | 0..1 | CodeableConcept | Standard 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..1 | CodeableConcept | Standard HIPAA code for the status of an entire claim URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-status | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..0 | |||||||
| url | 1..1 | uri | "http://linuxforhealth.org/fhir/cdm/StructureDefinition/claim-status" | |||||
| Slices for value[x] | 0..1 | CodeableConcept | Value of extension Slice: Unordered, Closed by type:$this | |||||
| value[x]:valueCodeableConcept | 0..1 | CodeableConcept | Value of extension Binding: https://x12.org/codes/claim-status-codes (extensible) | |||||
| lastClaimIndicator | 0..1 | string | Indicates whether this claim record is the last or most recent claim URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/last-claim-indicator | |||||
| participatingPlan | 0..1 | CodeableConcept | Customer-specific code for the participating plan URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/participating-plan | |||||
| referralIndicator | 0..1 | string | Indicates whether the service resulted from a referral URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/referral-indicator | |||||
| snapshotAgeInYears | 0..1 | unsignedInt | The age of the patient in years at the date of service URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/snapshot-age-in-years | |||||
| submissionType | 0..1 | CodeableConcept | Customer-specific code for the type of electronic submission URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/submission-type | |||||
| payerPcpResponsibilityIndicator | 0..1 | string | Indicates 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 | |||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier | 1..* | Identifier | Business Identifier for claim | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
| type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Value Set (extensible) | ||||
| system | Σ | 1..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
| value | Σ | 1..1 | string | The value that is unique Example General: 123456 | ||||
| period | Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
| assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||
| status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. | ||||
| type | Σ | 1..1 | CodeableConcept | Category or discipline Binding: Claim Type Value Set (extensible) | ||||
| subType | 0..1 | CodeableConcept | More granular claim type Binding: Claim Subtype Value Set (extensible) | |||||
| use | Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim. | ||||
| patient | Σ | 1..1 | Reference(Patient) | The recipient of the products and services | ||||
| billablePeriod | Σ | 0..1 | Period | Relevant time frame for the claim | ||||
| created | Σ | 1..1 | dateTime | Resource creation date | ||||
| enterer | 0..1 | Reference(Practitioner | PractitionerRole) | Author of the claim | |||||
| insurer | Σ | 0..1 | Reference(Organization) | Target | ||||
| provider | Σ | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim | ||||
| priority | Σ | 1..1 | CodeableConcept | Desired processing ugency Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred. | ||||
| fundsReserve | 0..1 | CodeableConcept | For whom to reserve funds Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None). | |||||
| related | 0..* | BackboneElement | Prior or corollary claims | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| claim | 0..1 | Reference(Claim) | Reference to the related claim | |||||
| relationship | 0..1 | CodeableConcept | How the reference claim is related Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim. | |||||
| reference | 0..1 | Identifier | File or case reference | |||||
| prescription | 0..1 | Reference(DeviceRequest | MedicationRequest | VisionPrescription) | Prescription authorizing services and products | |||||
| originalPrescription | 0..1 | Reference(DeviceRequest | MedicationRequest | VisionPrescription) | Original prescription if superseded by fulfiller | |||||
| payee | 0..1 | BackboneElement | Recipient of benefits payable | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| type | 1..1 | CodeableConcept | Category of recipient Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed. | |||||
| party | 0..1 | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) | Recipient reference | |||||
| referral | 0..1 | Reference(ServiceRequest) | Treatment referral | |||||
| facility | 0..1 | Reference(Location) | Servicing facility | |||||
| careTeam | 0..* | BackboneElement | Members of the care team | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| sequence | 1..1 | positiveInt | Order of care team | |||||
| provider | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Practitioner or organization | |||||
| responsible | 0..1 | boolean | Indicator of the lead practitioner | |||||
| role | 0..1 | CodeableConcept | Function within the team Binding: Claim Care Team Role Value Set (extensible) | |||||
| qualification | 0..1 | CodeableConcept | Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications. | |||||
| supportingInfo | 0..* | BackboneElement | Supporting information | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| sequence | 1..1 | positiveInt | Information instance identifier | |||||
| category | 1..1 | CodeableConcept | Classification of the supplied information Binding: Claim Supporting Info Category Value Set (extensible) | |||||
| code | 0..1 | CodeableConcept | Type of information Binding: Claim Supporting Info Type Value Set (extensible) | |||||
| timing[x] | 0..1 | When it occurred | ||||||
| timingDate | date | |||||||
| timingPeriod | Period | |||||||
| value[x] | 0..1 | Data to be provided | ||||||
| valueBoolean | boolean | |||||||
| valueString | string | |||||||
| valueQuantity | Quantity | |||||||
| valueAttachment | Attachment | |||||||
| valueReference | Reference(Resource) | |||||||
| reason | 0..1 | CodeableConcept | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth. | |||||
| diagnosis | 0..* | BackboneElement | Pertinent diagnosis information | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| majorDiagnosticCategory | 0..1 | CodeableConcept | The 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 | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| sequence | 1..1 | positiveInt | Diagnosis instance identifier | |||||
| diagnosis[x] | 1..1 | Nature of illness or problem Binding: ICD-10Codes (example): Example ICD10 Diagnostic codes. | ||||||
| diagnosisCodeableConcept | CodeableConcept | |||||||
| diagnosisReference | Reference(Condition) | |||||||
| type | 0..* | CodeableConcept | Timing or nature of the diagnosis Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge. | |||||
| onAdmission | 0..1 | CodeableConcept | Present on admission Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission. | |||||
| packageCode | 0..1 | CodeableConcept | Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis. | |||||
| procedure | 0..* | BackboneElement | Clinical procedures performed | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| procedureGroup | 0..1 | CodeableConcept | Code assigned to categorize related procedures URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/procedure-group Binding: Payer Procedure Group Value Set (extensible) | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| sequence | 1..1 | positiveInt | Procedure instance identifier | |||||
| type | 0..* | CodeableConcept | Category of Procedure Binding: ExampleProcedureTypeCodes (example): Example procedure type codes. | |||||
| date | 0..1 | dateTime | When the procedure was performed | |||||
| procedure[x] | 1..1 | Specific clinical procedure Binding: ICD-10ProcedureCodes (example): Example ICD10 Procedure codes. | ||||||
| procedureCodeableConcept | CodeableConcept | |||||||
| procedureReference | Reference(Procedure) | |||||||
| udi | 0..* | Reference(Device) | Unique device identifier | |||||
| insurance | Σ | 1..* | BackboneElement | Patient insurance information | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| crossoverIndicator | 0..1 | string | Indicates 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..1 | CodeableConcept | Code for the line of business URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/line-of-business | |||||
| priorAuthorizationIndicator | 0..1 | string | Indicates prior authorization for the claim URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/prior-authorization-indicator | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| sequence | Σ | 1..1 | positiveInt | Insurance instance identifier | ||||
| focal | Σ | 1..1 | boolean | Coverage to be used for adjudication | ||||
| identifier | 0..1 | Identifier | Pre-assigned Claim number | |||||
| coverage | Σ | 1..1 | Reference(Coverage) | Insurance information | ||||
| businessArrangement | 0..1 | string | Additional provider contract number | |||||
| preAuthRef | 0..* | string | Prior authorization reference number | |||||
| claimResponse | 0..1 | Reference(ClaimResponse) | Adjudication results | |||||
| accident | 0..1 | BackboneElement | Details of the event | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| date | 1..1 | date | When the incident occurred | |||||
| type | 0..1 | CodeableConcept | The nature of the accident Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc. | |||||
| location[x] | 0..1 | Where the event occurred | ||||||
| locationAddress | Address | |||||||
| locationReference | Reference(Location) | |||||||
| item | 0..* | BackboneElement | Product or service provided | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| capitatedServiceIndicator | 0..1 | string | Indicates whether this service (encounter record) was capitated URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/capitated-service-indicator | |||||
| fullyInsuredIndicator | 0..1 | string | Indicates whether the claim was for a fully insured plan URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/fully-insured-indicator | |||||
| nursingHomeIndicator | 0..1 | string | Indicates whether the claim was for a nursing home patient URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/nursing-home-indicator | |||||
| serviceBillDaysCount | 0..1 | unsignedInt | Number 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 | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| sequence | 1..1 | positiveInt | Item instance identifier | |||||
| careTeamSequence | 0..* | positiveInt | Applicable careTeam members | |||||
| diagnosisSequence | 0..* | positiveInt | Applicable diagnoses | |||||
| procedureSequence | 0..* | positiveInt | Applicable procedures | |||||
| informationSequence | 0..* | positiveInt | Applicable exception and supporting information | |||||
| revenue | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |||||
| category | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses. | |||||
| productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
| modifier | 0..* | CodeableConcept | Product 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..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||
| serviced[x] | 0..1 | Date or dates of service or product delivery | ||||||
| servicedDate | date | |||||||
| servicedPeriod | Period | |||||||
| location[x] | 0..1 | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc. | ||||||
| locationCodeableConcept | CodeableConcept | |||||||
| locationAddress | Address | |||||||
| locationReference | Reference(Location) | |||||||
| quantity | 0..1 | SimpleQuantity | Count of products or services | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| localNumberOfUnitsPerService | 0..1 | Quantity | Customer-specific quantity of either services or units URL: http://linuxforhealth.org/fhir/cdm/StructureDefinition/local-number-of-units-per-service | |||||
| value | Σ | 0..1 | decimal | Numerical value (with implicit precision) | ||||
| unit | Σ | 0..1 | string | Unit representation | ||||
| system | ΣC | 0..1 | uri | System that defines coded unit form | ||||
| code | Σ | 0..1 | code | Coded form of the unit | ||||
| unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||
| factor | 0..1 | decimal | Price scaling factor | |||||
| net | 0..1 | Money | Total item cost | |||||
| udi | 0..* | Reference(Device) | Unique device identifier | |||||
| bodySite | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch. | |||||
| subSite | 0..* | CodeableConcept | Anatomical 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..* | BackboneElement | Product or service provided | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| sequence | 1..1 | positiveInt | Item instance identifier | |||||
| revenue | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |||||
| category | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses. | |||||
| productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
| modifier | 0..* | CodeableConcept | Service/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..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||
| quantity | 0..1 | SimpleQuantity | Count of products or services | |||||
| unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||
| factor | 0..1 | decimal | Price scaling factor | |||||
| net | 0..1 | Money | Total item cost | |||||
| udi | 0..* | Reference(Device) | Unique device identifier | |||||
| subDetail | 0..* | BackboneElement | Product or service provided | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| sequence | 1..1 | positiveInt | Item instance identifier | |||||
| revenue | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |||||
| category | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses. | |||||
| productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
| modifier | 0..* | CodeableConcept | Service/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..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||
| quantity | 0..1 | SimpleQuantity | Count of products or services | |||||
| unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||
| factor | 0..1 | decimal | Price scaling factor | |||||
| net | 0..1 | Money | Total item cost | |||||
| udi | 0..* | Reference(Device) | Unique device identifier | |||||
| total | 0..1 | Money | Total claim cost | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | ||||
| Claim.language | preferred | CommonLanguages
| ||||
| Claim.extension:claimStatus.value[x]:valueCodeableConcept | extensible | https://x12.org/codes/claim-status-codes | ||||
| Claim.identifier.use | required | IdentifierUse | ||||
| Claim.identifier.type | extensible | IdentifierTypeValueSet | ||||
| Claim.status | required | FinancialResourceStatusCodes | ||||
| Claim.type | extensible | ClaimTypeValueSet (a valid code from Payer Claim Type Codes) | ||||
| Claim.subType | extensible | ClaimSubtypeValueSet (a valid code from Claim Subtype Codes) | ||||
| Claim.use | required | Use | ||||
| Claim.priority | example | ProcessPriorityCodes | ||||
| Claim.fundsReserve | example | Funds Reservation Codes | ||||
| Claim.related.relationship | example | ExampleRelatedClaimRelationshipCodes | ||||
| Claim.payee.type | example | Claim Payee Type Codes | ||||
| Claim.careTeam.role | extensible | ClaimCareTeamRoleValueSet (a valid code from Claim Care Team Role Codes) | ||||
| Claim.careTeam.qualification | example | ExampleProviderQualificationCodes | ||||
| Claim.supportingInfo.category | extensible | ClaimSupportingInfoCategoryValueSet | ||||
| Claim.supportingInfo.code | extensible | ClaimSupportingInfoTypeValueSet (a valid code from Claim Supporting Info Type Codes) | ||||
| Claim.supportingInfo.reason | example | MissingToothReasonCodes | ||||
| Claim.diagnosis.diagnosis[x] | example | ICD-10Codes | ||||
| Claim.diagnosis.type | example | ExampleDiagnosisTypeCodes | ||||
| Claim.diagnosis.onAdmission | example | ExampleDiagnosisOnAdmissionCodes | ||||
| Claim.diagnosis.packageCode | example | ExampleDiagnosisRelatedGroupCodes | ||||
| Claim.procedure.type | example | ExampleProcedureTypeCodes | ||||
| Claim.procedure.procedure[x] | example | ICD-10ProcedureCodes | ||||
| Claim.accident.type | extensible | ActIncidentCode | ||||
| Claim.item.revenue | example | ExampleRevenueCenterCodes | ||||
| Claim.item.category | example | BenefitCategoryCodes | ||||
| Claim.item.productOrService | example | USCLSCodes | ||||
| Claim.item.modifier | example | ModifierTypeCodes | ||||
| Claim.item.programCode | example | ExampleProgramReasonCodes | ||||
| Claim.item.location[x] | example | ExampleServicePlaceCodes | ||||
| Claim.item.bodySite | example | OralSiteCodes | ||||
| Claim.item.subSite | example | SurfaceCodes | ||||
| Claim.item.detail.revenue | example | ExampleRevenueCenterCodes | ||||
| Claim.item.detail.category | example | BenefitCategoryCodes | ||||
| Claim.item.detail.productOrService | example | USCLSCodes | ||||
| Claim.item.detail.modifier | example | ModifierTypeCodes | ||||
| Claim.item.detail.programCode | example | ExampleProgramReasonCodes | ||||
| Claim.item.detail.subDetail.revenue | example | ExampleRevenueCenterCodes | ||||
| Claim.item.detail.subDetail.category | example | BenefitCategoryCodes | ||||
| Claim.item.detail.subDetail.productOrService | example | USCLSCodes | ||||
| Claim.item.detail.subDetail.modifier | example | ModifierTypeCodes | ||||
| Claim.item.detail.subDetail.programCode | example | ExampleProgramReasonCodes |
This structure is derived from Claim
Summary
Mandatory: 3 elements
Prohibited: 1 element
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Other representations of profile: CSV, Excel, Schematron