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DSTU2

This page is part of the FHIR Specification (v1.0.2: DSTU 2). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2

7.1 Resource Claim - Content

Financial Management Work GroupMaturity Level: 0Compartments: Patient, Practitioner

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

7.1.1 Scope and Usage

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

The Claim is intended to support:

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

The Claim also supports:

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

Todo

This resource is referenced by ClaimResponse and ExplanationOfBenefit

7.1.2 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim ΣDomainResourceClaim, Pre-determination or Pre-authorization
... type Σ1..1codeinstitutional | oral | pharmacy | professional | vision
ClaimType (Required)
... identifier Σ0..*IdentifierClaim number
... ruleset Σ0..1CodingCurrent specification followed
Ruleset Codes (Example)
... originalRuleset Σ0..1CodingOriginal specification followed
Ruleset Codes (Example)
... created Σ0..1dateTimeCreation date
... target Σ0..1Reference(Organization)Insurer
... provider Σ0..1Reference(Practitioner)Responsible provider
... organization Σ0..1Reference(Organization)Responsible organization
... use Σ0..1codecomplete | proposed | exploratory | other
Use (Required)
... priority Σ0..1CodingDesired processing priority
Priority Codes (Example)
... fundsReserve Σ0..1CodingFunds requested to be reserved
Funds Reservation Codes (Example)
... enterer Σ0..1Reference(Practitioner)Author
... facility Σ0..1Reference(Location)Servicing Facility
... prescription Σ0..1Reference(MedicationOrder | VisionPrescription)Prescription
... originalPrescription Σ0..1Reference(MedicationOrder)Original Prescription
... payee Σ0..1BackboneElementPayee
.... type Σ0..1CodingParty to be paid any benefits payable
Payee Type Codes (Example)
.... provider Σ0..1Reference(Practitioner)Provider who is the payee
.... organization Σ0..1Reference(Organization)Organization who is the payee
.... person Σ0..1Reference(Patient)Other person who is the payee
... referral Σ0..1Reference(ReferralRequest)Treatment Referral
... diagnosis Σ0..*BackboneElementDiagnosis
.... sequence Σ1..1positiveIntSequence of diagnosis
.... diagnosis Σ1..1CodingPatient's list of diagnosis
ICD-10 Codes (Example)
... condition Σ0..*CodingList of presenting Conditions
Conditions Codes (Example)
... patient Σ1..1Reference(Patient)The subject of the Products and Services
... coverage Σ0..*BackboneElementInsurance or medical plan
.... sequence Σ1..1positiveIntService instance identifier
.... focal Σ1..1booleanThe focal Coverage
.... coverage Σ1..1Reference(Coverage)Insurance information
.... businessArrangement Σ0..1stringBusiness agreement
.... relationship Σ1..1CodingPatient relationship to subscriber
Surface Codes (Example)
.... preAuthRef Σ0..*stringPre-Authorization/Determination Reference
.... claimResponse Σ0..1Reference(ClaimResponse)Adjudication results
.... originalRuleset Σ0..1CodingOriginal version
Ruleset Codes (Example)
... exception Σ0..*CodingEligibility exceptions
Exception Codes (Example)
... school Σ0..1stringName of School
... accident Σ0..1dateAccident Date
... accidentType Σ0..1CodingAccident Type
ActIncidentCode (Required)
... interventionException Σ0..*CodingIntervention and exception code (Pharma)
Intervention Codes (Example)
... item Σ0..*BackboneElementGoods and Services
.... sequence Σ1..1positiveIntService instance
.... type Σ1..1CodingGroup or type of product or service
ActInvoiceGroupCode (Required)
.... provider Σ0..1Reference(Practitioner)Responsible practitioner
.... diagnosisLinkId Σ0..*positiveIntDiagnosis Link
.... service Σ1..1CodingItem Code
USCLS Codes (Example)
.... serviceDate Σ0..1dateDate of Service
.... quantity Σ0..1SimpleQuantityCount of Products or Services
.... unitPrice Σ0..1MoneyFee, charge or cost per point
.... factor Σ0..1decimalPrice scaling factor
.... points Σ0..1decimalDifficulty scaling factor
.... net Σ0..1MoneyTotal item cost
.... udi Σ0..1CodingUnique Device Identifier
UDI Codes (Example)
.... bodySite Σ0..1CodingService Location
Surface Codes (Example)
.... subSite Σ0..*CodingService Sub-location
Surface Codes (Example)
.... modifier Σ0..*CodingService/Product billing modifiers
Modifier type Codes (Example)
.... detail Σ0..*BackboneElementAdditional items
..... sequence Σ1..1positiveIntService instance
..... type Σ1..1CodingGroup or type of product or service
ActInvoiceGroupCode (Required)
..... service Σ1..1CodingAdditional item codes
USCLS Codes (Example)
..... quantity Σ0..1SimpleQuantityCount of Products or Services
..... unitPrice Σ0..1MoneyFee, charge or cost per point
..... factor Σ0..1decimalPrice scaling factor
..... points Σ0..1decimalDifficulty scaling factor
..... net Σ0..1MoneyTotal additional item cost
..... udi Σ0..1CodingUnique Device Identifier
UDI Codes (Example)
..... subDetail Σ0..*BackboneElementAdditional items
...... sequence Σ1..1positiveIntService instance
...... type Σ1..1CodingType of product or service
ActInvoiceGroupCode (Required)
...... service Σ1..1CodingAdditional item codes
USCLS Codes (Example)
...... quantity Σ0..1SimpleQuantityCount of Products or Services
...... unitPrice Σ0..1MoneyFee, charge or cost per point
...... factor Σ0..1decimalPrice scaling factor
...... points Σ0..1decimalDifficulty scaling factor
...... net Σ0..1MoneyNet additional item cost
...... udi Σ0..1CodingUnique Device Identifier
UDI Codes (Example)
.... prosthesis Σ0..1BackboneElementProsthetic details
..... initial Σ0..1booleanIs this the initial service
..... priorDate Σ0..1dateInitial service Date
..... priorMaterial Σ0..1CodingProsthetic Material
Oral Prostho Material type Codes (Example)
... additionalMaterials Σ0..*CodingAdditional materials, documents, etc.
Additional Material Codes (Example)
... missingTeeth Σ0..*BackboneElementOnly if type = oral
.... tooth Σ1..1CodingTooth Code
Teeth Codes (Example)
.... reason Σ0..1CodingReason for missing
Missing Tooth Reason Codes (Example)
.... extractionDate Σ0..1dateDate of Extraction

doco Documentation for this format

UML Diagram

Claim (DomainResource)The category of claim this istype : code [1..1] « The type or discipline-style of the claim. (Strength=Required)ClaimType! »The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization numberidentifier : Identifier [0..*]The version of the specification on which this instance reliesruleset : Coding [0..1] « The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example)Ruleset ?? »The version of the specification from which the original instance was createdoriginalRuleset : Coding [0..1] « The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example)Ruleset ?? »The date when the enclosed suite of services were performed or completedcreated : dateTime [0..1]Insurer Identifier, typical BIN number (6 digit)target : Reference [0..1] « Organization »The provider which is responsible for the bill, claim pre-determination, pre-authorizationprovider : Reference [0..1] « Practitioner »The organization which is responsible for the bill, claim pre-determination, pre-authorizationorganization : Reference [0..1] « Organization »Complete (Bill or Claim), Proposed (Pre-Authorization), Exploratory (Pre-determination)use : code [0..1] « Complete, proposed, exploratory, other. (Strength=Required)Use! »Immediate (stat), best effort (normal), deferred (deferred)priority : Coding [0..1] « The timeliness with which processing is required: STAT, Normal, Deferred. (Strength=Example)Priority ?? »In the case of a Pre-Determination/Pre-Authorization the provider may request that funds in the amount of the expected Benefit be reserved ('Patient' or 'Provider') to pay for the Benefits determined on the subsequent claim(s). 'None' explicitly indicates no funds reserving is requestedfundsReserve : Coding [0..1] « For whom funds are to be reserved: (Patient, Provider, None). (Strength=Example)Funds Reservation ?? »Person who created the invoice/claim/pre-determination or pre-authorizationenterer : Reference [0..1] « Practitioner »Facility where the services were providedfacility : Reference [0..1] « Location »Prescription to support the dispensing of Pharmacy or Vision productsprescription : Reference [0..1] « MedicationOrder|VisionPrescription »Original prescription to support the dispensing of pharmacy services, medications or productsoriginalPrescription : Reference [0..1] « MedicationOrder »The referral resource which lists the date, practitioner, reason and other supporting informationreferral : Reference [0..1] « ReferralRequest »List of patient conditions for which care is soughtcondition : Coding [0..*] « Patient conditions and symptoms. (Strength=Example)Conditions ?? »Patient Resourcepatient : Reference [1..1] « Patient »Factors which may influence the applicability of coverageexception : Coding [0..*] « The eligibility exception codes. (Strength=Example)Exception ?? »Name of school for over-aged dependentsschool : string [0..1]Date of an accident which these services are addressingaccident : date [0..1]Type of accident: work, auto, etcaccidentType : Coding [0..1] « Type of accident: work place, auto, etc. (Strength=Required)ActIncidentCode! »A list of intervention and exception codes which may influence the adjudication of the claiminterventionException : Coding [0..*] « Intervention and exception codes (Pharm). (Strength=Example)Intervention ?? »Code to indicate that Xrays, images, emails, documents, models or attachments are being sent in support of this submissionadditionalMaterials : Coding [0..*] « Code to indicate that Xrays, images, emails, documents, models or attachments are being sent in support of this submission. (Strength=Example)Additional Material ?? »PayeeParty to be reimbursed: Subscriber, provider, othertype : Coding [0..1] « A code for the party to be reimbursed. (Strength=Example)Payee Type ?? »The provider who is to be reimbursed for the claim (the party to whom any benefit is assigned)provider : Reference [0..1] « Practitioner »The organization who is to be reimbursed for the claim (the party to whom any benefit is assigned)organization : Reference [0..1] « Organization »The person other than the subscriber who is to be reimbursed for the claim (the party to whom any benefit is assigned)person : Reference [0..1] « Patient »DiagnosisSequence of diagnosis which serves to order and provide a linksequence : positiveInt [1..1]The diagnosisdiagnosis : Coding [1..1] « ICD10 diagnostic codes. (Strength=Example)ICD-10 ?? »CoverageA service line itemsequence : positiveInt [1..1]The instance number of the Coverage which is the focus for adjudication. The Coverage against which the claim is to be adjudicatedfocal : boolean [1..1]Reference to the program or plan identification, underwriter or payorcoverage : Reference [1..1] « Coverage »The contract number of a business agreement which describes the terms and conditionsbusinessArrangement : string [0..1]The relationship of the patient to the subscriberrelationship : Coding [1..1] « The code for the relationship of the patient to the subscriber. (Strength=Example)Surface ?? »A list of references from the Insurer to which these services pertainpreAuthRef : string [0..*]The Coverages adjudication detailsclaimResponse : Reference [0..1] « ClaimResponse »The style (standard) and version of the original material which was converted into this resourceoriginalRuleset : Coding [0..1] « The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example)Ruleset ?? »ItemsA service line numbersequence : positiveInt [1..1]The type of product or servicetype : Coding [1..1] « Service, Product, Rx Dispense, Rx Compound etc. (Strength=Required)ActInvoiceGroupCode! »The practitioner who is responsible for the services rendered to the patientprovider : Reference [0..1] « Practitioner »Diagnosis applicable for this service or product linediagnosisLinkId : positiveInt [0..*]If a grouping item then 'GROUP' otherwise it is a node therefore a code to indicate the Professional Service or Product suppliedservice : Coding [1..1] « Allowable service and product codes. (Strength=Example)USCLS ?? »The date when the enclosed suite of services were performed or completedserviceDate : date [0..1]The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the groupunitPrice : Quantity(Money) [0..1]A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amountfactor : decimal [0..1]An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each pointpoints : decimal [0..1]The quantity times the unit price for an additional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not suppliednet : Quantity(Money) [0..1]List of Unique Device Identifiers associated with this line itemudi : Coding [0..1] « The FDA, or other, UDI repository. (Strength=Example)UDI ?? »Physical service site on the patient (limb, tooth, etc.)bodySite : Coding [0..1] « The code for the teeth, quadrant, sextant and arch. (Strength=Example)Surface ?? »A region or surface of the site, e.g. limb region or tooth surface(s)subSite : Coding [0..*] « The code for the tooth surface and surface combinations. (Strength=Example)Surface ?? »Item typification or modifiers codes, e.g. for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolenmodifier : Coding [0..*] « Item type or modifiers codes, e.g. for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)Modifier type ?? »DetailA service line numbersequence : positiveInt [1..1]The type of product or servicetype : Coding [1..1] « Service, Product, Rx Dispense, Rx Compound etc. (Strength=Required)ActInvoiceGroupCode! »If a grouping item then 'GROUP' otherwise it is a node therefore a code to indicate the Professional Service or Product suppliedservice : Coding [1..1] « Allowable service and product codes. (Strength=Example)USCLS ?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the groupunitPrice : Quantity(Money) [0..1]A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amountfactor : decimal [0..1]An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each pointpoints : decimal [0..1]The quantity times the unit price for an additional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not suppliednet : Quantity(Money) [0..1]List of Unique Device Identifiers associated with this line itemudi : Coding [0..1] « The FDA, or other, UDI repository. (Strength=Example)UDI ?? »SubDetailA service line numbersequence : positiveInt [1..1]The type of product or servicetype : Coding [1..1] « Service, Product, Rx Dispense, Rx Compound etc. (Strength=Required)ActInvoiceGroupCode! »The fee for an additional service or product or chargeservice : Coding [1..1] « Allowable service and product codes. (Strength=Example)USCLS ?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]The fee for an additional service or product or chargeunitPrice : Quantity(Money) [0..1]A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amountfactor : decimal [0..1]An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each pointpoints : decimal [0..1]The quantity times the unit price for an additional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not suppliednet : Quantity(Money) [0..1]List of Unique Device Identifiers associated with this line itemudi : Coding [0..1] « The FDA, or other, UDI repository. (Strength=Example)UDI ?? »ProsthesisIndicates whether this is the initial placement of a fixed prosthesisinitial : boolean [0..1]Date of the initial placementpriorDate : date [0..1]Material of the prior denture or bridge prosthesis. (Oral)priorMaterial : Coding [0..1] « Material of the prior denture or bridge prosthesis. (Oral) (Strength=Example)Oral Prostho Material type ?? »MissingTeethThe code identifying which tooth is missingtooth : Coding [1..1] « The codes for the teeth, subset of OralSites. (Strength=Example)Teeth ?? »Missing reason may be: E-extraction, O-otherreason : Coding [0..1] « Reason codes for the missing teeth. (Strength=Example)Missing Tooth Reason ?? »The date of the extraction either known from records or patient reported estimateextractionDate : date [0..1]The party to be reimbursed for the servicespayee[0..1]Ordered list of patient diagnosis for which care is soughtdiagnosis[0..*]Financial instrument by which payment information for health carecoverage[0..*]Third tier of goods and servicessubDetail[0..*]Second tier of goods and servicesdetail[0..*]The materials and placement date of prior fixed prosthesisprosthesis[0..1]First tier of goods and servicesitem[0..*]A list of teeth which would be expected but are not found due to having been previously extracted or for other reasonsmissingTeeth[0..*]

XML Template

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

JSON Template

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

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim ΣDomainResourceClaim, Pre-determination or Pre-authorization
... type Σ1..1codeinstitutional | oral | pharmacy | professional | vision
ClaimType (Required)
... identifier Σ0..*IdentifierClaim number
... ruleset Σ0..1CodingCurrent specification followed
Ruleset Codes (Example)
... originalRuleset Σ0..1CodingOriginal specification followed
Ruleset Codes (Example)
... created Σ0..1dateTimeCreation date
... target Σ0..1Reference(Organization)Insurer
... provider Σ0..1Reference(Practitioner)Responsible provider
... organization Σ0..1Reference(Organization)Responsible organization
... use Σ0..1codecomplete | proposed | exploratory | other
Use (Required)
... priority Σ0..1CodingDesired processing priority
Priority Codes (Example)
... fundsReserve Σ0..1CodingFunds requested to be reserved
Funds Reservation Codes (Example)
... enterer Σ0..1Reference(Practitioner)Author
... facility Σ0..1Reference(Location)Servicing Facility
... prescription Σ0..1Reference(MedicationOrder | VisionPrescription)Prescription
... originalPrescription Σ0..1Reference(MedicationOrder)Original Prescription
... payee Σ0..1BackboneElementPayee
.... type Σ0..1CodingParty to be paid any benefits payable
Payee Type Codes (Example)
.... provider Σ0..1Reference(Practitioner)Provider who is the payee
.... organization Σ0..1Reference(Organization)Organization who is the payee
.... person Σ0..1Reference(Patient)Other person who is the payee
... referral Σ0..1Reference(ReferralRequest)Treatment Referral
... diagnosis Σ0..*BackboneElementDiagnosis
.... sequence Σ1..1positiveIntSequence of diagnosis
.... diagnosis Σ1..1CodingPatient's list of diagnosis
ICD-10 Codes (Example)
... condition Σ0..*CodingList of presenting Conditions
Conditions Codes (Example)
... patient Σ1..1Reference(Patient)The subject of the Products and Services
... coverage Σ0..*BackboneElementInsurance or medical plan
.... sequence Σ1..1positiveIntService instance identifier
.... focal Σ1..1booleanThe focal Coverage
.... coverage Σ1..1Reference(Coverage)Insurance information
.... businessArrangement Σ0..1stringBusiness agreement
.... relationship Σ1..1CodingPatient relationship to subscriber
Surface Codes (Example)
.... preAuthRef Σ0..*stringPre-Authorization/Determination Reference
.... claimResponse Σ0..1Reference(ClaimResponse)Adjudication results
.... originalRuleset Σ0..1CodingOriginal version
Ruleset Codes (Example)
... exception Σ0..*CodingEligibility exceptions
Exception Codes (Example)
... school Σ0..1stringName of School
... accident Σ0..1dateAccident Date
... accidentType Σ0..1CodingAccident Type
ActIncidentCode (Required)
... interventionException Σ0..*CodingIntervention and exception code (Pharma)
Intervention Codes (Example)
... item Σ0..*BackboneElementGoods and Services
.... sequence Σ1..1positiveIntService instance
.... type Σ1..1CodingGroup or type of product or service
ActInvoiceGroupCode (Required)
.... provider Σ0..1Reference(Practitioner)Responsible practitioner
.... diagnosisLinkId Σ0..*positiveIntDiagnosis Link
.... service Σ1..1CodingItem Code
USCLS Codes (Example)
.... serviceDate Σ0..1dateDate of Service
.... quantity Σ0..1SimpleQuantityCount of Products or Services
.... unitPrice Σ0..1MoneyFee, charge or cost per point
.... factor Σ0..1decimalPrice scaling factor
.... points Σ0..1decimalDifficulty scaling factor
.... net Σ0..1MoneyTotal item cost
.... udi Σ0..1CodingUnique Device Identifier
UDI Codes (Example)
.... bodySite Σ0..1CodingService Location
Surface Codes (Example)
.... subSite Σ0..*CodingService Sub-location
Surface Codes (Example)
.... modifier Σ0..*CodingService/Product billing modifiers
Modifier type Codes (Example)
.... detail Σ0..*BackboneElementAdditional items
..... sequence Σ1..1positiveIntService instance
..... type Σ1..1CodingGroup or type of product or service
ActInvoiceGroupCode (Required)
..... service Σ1..1CodingAdditional item codes
USCLS Codes (Example)
..... quantity Σ0..1SimpleQuantityCount of Products or Services
..... unitPrice Σ0..1MoneyFee, charge or cost per point
..... factor Σ0..1decimalPrice scaling factor
..... points Σ0..1decimalDifficulty scaling factor
..... net Σ0..1MoneyTotal additional item cost
..... udi Σ0..1CodingUnique Device Identifier
UDI Codes (Example)
..... subDetail Σ0..*BackboneElementAdditional items
...... sequence Σ1..1positiveIntService instance
...... type Σ1..1CodingType of product or service
ActInvoiceGroupCode (Required)
...... service Σ1..1CodingAdditional item codes
USCLS Codes (Example)
...... quantity Σ0..1SimpleQuantityCount of Products or Services
...... unitPrice Σ0..1MoneyFee, charge or cost per point
...... factor Σ0..1decimalPrice scaling factor
...... points Σ0..1decimalDifficulty scaling factor
...... net Σ0..1MoneyNet additional item cost
...... udi Σ0..1CodingUnique Device Identifier
UDI Codes (Example)
.... prosthesis Σ0..1BackboneElementProsthetic details
..... initial Σ0..1booleanIs this the initial service
..... priorDate Σ0..1dateInitial service Date
..... priorMaterial Σ0..1CodingProsthetic Material
Oral Prostho Material type Codes (Example)
... additionalMaterials Σ0..*CodingAdditional materials, documents, etc.
Additional Material Codes (Example)
... missingTeeth Σ0..*BackboneElementOnly if type = oral
.... tooth Σ1..1CodingTooth Code
Teeth Codes (Example)
.... reason Σ0..1CodingReason for missing
Missing Tooth Reason Codes (Example)
.... extractionDate Σ0..1dateDate of Extraction

doco Documentation for this format

UML Diagram

Claim (DomainResource)The category of claim this istype : code [1..1] « The type or discipline-style of the claim. (Strength=Required)ClaimType! »The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization numberidentifier : Identifier [0..*]The version of the specification on which this instance reliesruleset : Coding [0..1] « The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example)Ruleset ?? »The version of the specification from which the original instance was createdoriginalRuleset : Coding [0..1] « The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example)Ruleset ?? »The date when the enclosed suite of services were performed or completedcreated : dateTime [0..1]Insurer Identifier, typical BIN number (6 digit)target : Reference [0..1] « Organization »The provider which is responsible for the bill, claim pre-determination, pre-authorizationprovider : Reference [0..1] « Practitioner »The organization which is responsible for the bill, claim pre-determination, pre-authorizationorganization : Reference [0..1] « Organization »Complete (Bill or Claim), Proposed (Pre-Authorization), Exploratory (Pre-determination)use : code [0..1] « Complete, proposed, exploratory, other. (Strength=Required)Use! »Immediate (stat), best effort (normal), deferred (deferred)priority : Coding [0..1] « The timeliness with which processing is required: STAT, Normal, Deferred. (Strength=Example)Priority ?? »In the case of a Pre-Determination/Pre-Authorization the provider may request that funds in the amount of the expected Benefit be reserved ('Patient' or 'Provider') to pay for the Benefits determined on the subsequent claim(s). 'None' explicitly indicates no funds reserving is requestedfundsReserve : Coding [0..1] « For whom funds are to be reserved: (Patient, Provider, None). (Strength=Example)Funds Reservation ?? »Person who created the invoice/claim/pre-determination or pre-authorizationenterer : Reference [0..1] « Practitioner »Facility where the services were providedfacility : Reference [0..1] « Location »Prescription to support the dispensing of Pharmacy or Vision productsprescription : Reference [0..1] « MedicationOrder|VisionPrescription »Original prescription to support the dispensing of pharmacy services, medications or productsoriginalPrescription : Reference [0..1] « MedicationOrder »The referral resource which lists the date, practitioner, reason and other supporting informationreferral : Reference [0..1] « ReferralRequest »List of patient conditions for which care is soughtcondition : Coding [0..*] « Patient conditions and symptoms. (Strength=Example)Conditions ?? »Patient Resourcepatient : Reference [1..1] « Patient »Factors which may influence the applicability of coverageexception : Coding [0..*] « The eligibility exception codes. (Strength=Example)Exception ?? »Name of school for over-aged dependentsschool : string [0..1]Date of an accident which these services are addressingaccident : date [0..1]Type of accident: work, auto, etcaccidentType : Coding [0..1] « Type of accident: work place, auto, etc. (Strength=Required)ActIncidentCode! »A list of intervention and exception codes which may influence the adjudication of the claiminterventionException : Coding [0..*] « Intervention and exception codes (Pharm). (Strength=Example)Intervention ?? »Code to indicate that Xrays, images, emails, documents, models or attachments are being sent in support of this submissionadditionalMaterials : Coding [0..*] « Code to indicate that Xrays, images, emails, documents, models or attachments are being sent in support of this submission. (Strength=Example)Additional Material ?? »PayeeParty to be reimbursed: Subscriber, provider, othertype : Coding [0..1] « A code for the party to be reimbursed. (Strength=Example)Payee Type ?? »The provider who is to be reimbursed for the claim (the party to whom any benefit is assigned)provider : Reference [0..1] « Practitioner »The organization who is to be reimbursed for the claim (the party to whom any benefit is assigned)organization : Reference [0..1] « Organization »The person other than the subscriber who is to be reimbursed for the claim (the party to whom any benefit is assigned)person : Reference [0..1] « Patient »DiagnosisSequence of diagnosis which serves to order and provide a linksequence : positiveInt [1..1]The diagnosisdiagnosis : Coding [1..1] « ICD10 diagnostic codes. (Strength=Example)ICD-10 ?? »CoverageA service line itemsequence : positiveInt [1..1]The instance number of the Coverage which is the focus for adjudication. The Coverage against which the claim is to be adjudicatedfocal : boolean [1..1]Reference to the program or plan identification, underwriter or payorcoverage : Reference [1..1] « Coverage »The contract number of a business agreement which describes the terms and conditionsbusinessArrangement : string [0..1]The relationship of the patient to the subscriberrelationship : Coding [1..1] « The code for the relationship of the patient to the subscriber. (Strength=Example)Surface ?? »A list of references from the Insurer to which these services pertainpreAuthRef : string [0..*]The Coverages adjudication detailsclaimResponse : Reference [0..1] « ClaimResponse »The style (standard) and version of the original material which was converted into this resourceoriginalRuleset : Coding [0..1] « The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example)Ruleset ?? »ItemsA service line numbersequence : positiveInt [1..1]The type of product or servicetype : Coding [1..1] « Service, Product, Rx Dispense, Rx Compound etc. (Strength=Required)ActInvoiceGroupCode! »The practitioner who is responsible for the services rendered to the patientprovider : Reference [0..1] « Practitioner »Diagnosis applicable for this service or product linediagnosisLinkId : positiveInt [0..*]If a grouping item then 'GROUP' otherwise it is a node therefore a code to indicate the Professional Service or Product suppliedservice : Coding [1..1] « Allowable service and product codes. (Strength=Example)USCLS ?? »The date when the enclosed suite of services were performed or completedserviceDate : date [0..1]The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the groupunitPrice : Quantity(Money) [0..1]A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amountfactor : decimal [0..1]An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each pointpoints : decimal [0..1]The quantity times the unit price for an additional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not suppliednet : Quantity(Money) [0..1]List of Unique Device Identifiers associated with this line itemudi : Coding [0..1] « The FDA, or other, UDI repository. (Strength=Example)UDI ?? »Physical service site on the patient (limb, tooth, etc.)bodySite : Coding [0..1] « The code for the teeth, quadrant, sextant and arch. (Strength=Example)Surface ?? »A region or surface of the site, e.g. limb region or tooth surface(s)subSite : Coding [0..*] « The code for the tooth surface and surface combinations. (Strength=Example)Surface ?? »Item typification or modifiers codes, e.g. for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolenmodifier : Coding [0..*] « Item type or modifiers codes, e.g. for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)Modifier type ?? »DetailA service line numbersequence : positiveInt [1..1]The type of product or servicetype : Coding [1..1] « Service, Product, Rx Dispense, Rx Compound etc. (Strength=Required)ActInvoiceGroupCode! »If a grouping item then 'GROUP' otherwise it is a node therefore a code to indicate the Professional Service or Product suppliedservice : Coding [1..1] « Allowable service and product codes. (Strength=Example)USCLS ?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the groupunitPrice : Quantity(Money) [0..1]A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amountfactor : decimal [0..1]An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each pointpoints : decimal [0..1]The quantity times the unit price for an additional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not suppliednet : Quantity(Money) [0..1]List of Unique Device Identifiers associated with this line itemudi : Coding [0..1] « The FDA, or other, UDI repository. (Strength=Example)UDI ?? »SubDetailA service line numbersequence : positiveInt [1..1]The type of product or servicetype : Coding [1..1] « Service, Product, Rx Dispense, Rx Compound etc. (Strength=Required)ActInvoiceGroupCode! »The fee for an additional service or product or chargeservice : Coding [1..1] « Allowable service and product codes. (Strength=Example)USCLS ?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]The fee for an additional service or product or chargeunitPrice : Quantity(Money) [0..1]A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amountfactor : decimal [0..1]An amount that expresses the weighting (based on difficulty, cost and/or resource intensiveness) associated with the good or service delivered. The concept of Points allows for assignment of point values for services and/or goods, such that a monetary amount can be assigned to each pointpoints : decimal [0..1]The quantity times the unit price for an additional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not suppliednet : Quantity(Money) [0..1]List of Unique Device Identifiers associated with this line itemudi : Coding [0..1] « The FDA, or other, UDI repository. (Strength=Example)UDI ?? »ProsthesisIndicates whether this is the initial placement of a fixed prosthesisinitial : boolean [0..1]Date of the initial placementpriorDate : date [0..1]Material of the prior denture or bridge prosthesis. (Oral)priorMaterial : Coding [0..1] « Material of the prior denture or bridge prosthesis. (Oral) (Strength=Example)Oral Prostho Material type ?? »MissingTeethThe code identifying which tooth is missingtooth : Coding [1..1] « The codes for the teeth, subset of OralSites. (Strength=Example)Teeth ?? »Missing reason may be: E-extraction, O-otherreason : Coding [0..1] « Reason codes for the missing teeth. (Strength=Example)Missing Tooth Reason ?? »The date of the extraction either known from records or patient reported estimateextractionDate : date [0..1]The party to be reimbursed for the servicespayee[0..1]Ordered list of patient diagnosis for which care is soughtdiagnosis[0..*]Financial instrument by which payment information for health carecoverage[0..*]Third tier of goods and servicessubDetail[0..*]Second tier of goods and servicesdetail[0..*]The materials and placement date of prior fixed prosthesisprosthesis[0..1]First tier of goods and servicesitem[0..*]A list of teeth which would be expected but are not found due to having been previously extracted or for other reasonsmissingTeeth[0..*]

XML Template

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

JSON Template

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

 

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

7.1.2.1 Terminology Bindings

PathDefinitionTypeReference
Claim.type The type or discipline-style of the claim.RequiredClaimType
Claim.ruleset
Claim.originalRuleset
Claim.coverage.originalRuleset 		The static and dynamic model to which contents conform, which may be business version or standard/version.ExampleRuleset Codes
Claim.use Complete, proposed, exploratory, other.RequiredUse
Claim.priority The timeliness with which processing is required: STAT, Normal, Deferred.ExamplePriority Codes
Claim.fundsReserve For whom funds are to be reserved: (Patient, Provider, None).ExampleFunds Reservation Codes
Claim.payee.type A code for the party to be reimbursed.ExamplePayee Type Codes
Claim.diagnosis.diagnosis ICD10 diagnostic codes.ExampleICD-10 Codes
Claim.condition Patient conditions and symptoms.ExampleConditions Codes
Claim.coverage.relationship The code for the relationship of the patient to the subscriber.ExampleSurface Codes
Claim.exception The eligibility exception codes.ExampleException Codes
Claim.accidentType Type of accident: work place, auto, etc.RequiredActIncidentCode
Claim.interventionException Intervention and exception codes (Pharm).ExampleIntervention Codes
Claim.item.type
Claim.item.detail.type
Claim.item.detail.subDetail.type 		Service, Product, Rx Dispense, Rx Compound etc.RequiredActInvoiceGroupCode
Claim.item.service
Claim.item.detail.service
Claim.item.detail.subDetail.service 		Allowable service and product codes.ExampleUSCLS Codes
Claim.item.udi
Claim.item.detail.udi
Claim.item.detail.subDetail.udi 		The FDA, or other, UDI repository.ExampleUDI Codes
Claim.item.bodySite The code for the teeth, quadrant, sextant and arch.ExampleSurface Codes
Claim.item.subSite The code for the tooth surface and surface combinations.ExampleSurface Codes
Claim.item.modifier Item type or modifiers codes, e.g. for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.ExampleModifier type Codes
Claim.item.prosthesis.priorMaterial Material of the prior denture or bridge prosthesis. (Oral)ExampleOral Prostho Material type Codes
Claim.additionalMaterials Code to indicate that Xrays, images, emails, documents, models or attachments are being sent in support of this submission.ExampleAdditional Material Codes
Claim.missingTeeth.tooth The codes for the teeth, subset of OralSites.ExampleTeeth Codes
Claim.missingTeeth.reason Reason codes for the missing teeth.ExampleMissing Tooth Reason Codes

7.1.3 Search Parameters

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

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