---
type: "resource"
title: "Claim"
resource: "Claim"
---
# Claim


## Introduction


## Scope and Usage

The Claim is used by providers and payers, insurers, to exchange the financial information, and supporting clinical information, regarding the provision of health care services with payers and for reporting to regulatory bodies and firms which provide data analytics. The primary uses of this resource is to support eClaims, the exchange of information relating to the proposed or actual provision of healthcare-related goods and services for patients to their benefit payers, insurers and national health programs, for treatment payment planning and reimbursement.

The Claim resource is a "request" resource from a FHIR workflow perspective - see [Workflow Request.](workflow#request)

The Claim resource may be interpreted differently depending on its intended use (and the Claim.use element contains the code to indicate):

-   claim - where the provision of goods and services is **complete** and adjudication under a plan and payment is sought.
-   preauthorization - where the provision of goods and services is **proposed** and authorization and/or the reservation of funds is desired.
-   predetermination - 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.type code system provides oral, pharmacy, vision, professional and institutional claim types. Claim types supported are influenced by the requirements of the implementing jurisdiction. The valueset is extensible to accommodate other types of claims as required by the jurisdiction.

The Claim also supports:

-   Up to a 3-tier hierarchy of Goods, products, and Services, to support simple to complex billing, see [3-Tier Line Item Hierarchy](financial-module#3-tier).
-   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.

**Mapping to other Claim specifications:** Mappings are currently maintained by the Financial Management Work Group to UB04 and CMS1500 and are available at [https://confluence.hl7.org/display/FM/FHIR+Resource+Development](https://confluence.hl7.org/display/FM/FHIR+Resource+Development). Mappings to other specifications may be made available where IP restrictions permit.

### Additional Information

Additional information regarding electronic claims content and usage may be found at:

-   [Financial Resource Status Lifecycle](financial-module#resource-status): how .status is used in the financial resources.
-   [Secondary Use of Resources](financial-module#secondary-use): how resources such as Claim and ExplanationOfBenefit may used for reporting and data exchange for analytics, not just for eClaims exchange between providers and payers.
-   [Subrogation](financial-module#subrogation): how eClaims may handle patient insurance coverages when another insurer rather than the provider will settle the claim and potentially recover costs against specified coverages.
-   [Coordination of Benefit](financial-module#cob): how eClaims may handle multiple patient insurance coverages.
-   [Batches](financial-module#batch): how eClaims may handle batches of eligibility, claims and responses.
-   [Attachments and Supporting Information](financial-module#attachments): how eClaims may handle the provision of supporting information, whether provided by content or reference, within the eClaim resource when submitted to the payer or later in a resource which refers to the subject eClaim resource. This also includes how payers may request additional supporting information from providers.
-   [3-Tier Line Item Hierarchy](financial-module#3-tier): 3-tier hierarchy of Goods, products, and Services, to support simple to complex billing.
-   [Tax](financial-module#tax): Tax handling of Goods, products, and Services.

## Boundaries and Relationships

The Claim resource is used to request the adjudication and/or authorization of a set of healthcare-related goods and services for a patient against the patient's insurance coverages, or to request what the adjudication would be for a supplied set of goods or services should they be actually supplied to the patient.

When requesting whether the patient's coverage is inforce, whether it is valid at this or a specified date, or requesting the benefit details or preauthorization requirements associated with a coverage, then [CoverageEligibilityRequest](coverageeligibilityrequest) should be used instead.

When using the resources for reporting and transferring claims data, which may have originated in some standard other than FHIR, the Claim resource is useful if only the request side of the information exchange is of interest. If, however, both the request and the adjudication information is to be reported then the [ExplanationOfBenefit](explanationofbenefit) should be used instead.

For reporting out to patients or transferring data to patient centered applications, such as Personal Health Record (PHR) application, the [ExplanationOfBenefit](explanationofbenefit) should be used instead of the Claim and ClaimResponse resources as those resources may contain provider and payer specific information which is not appropriate for sharing with the patient.

**The eClaim domain includes a number of related resources**

| Claim | A suite of goods and services and insurances coverages under which adjudication or authorization is requested. |
| --- | --- |
| [CoverageEligibilityRequest](coverageeligibilityrequest) | A request to a payer to: ascertain whether a coverage is in-force at the current or at a specified time; list the table of benefits; determine whether coverage is provided for specified categories or specific services; and whether preauthorization is required, and if so what supporting information would be required. |
| [ClaimResponse](claimresponse) | A payer's adjudication and/or authorization response to the suite of services provided in a Claim. Typically the ClaimResponse references the Claim but does not duplicate the clinical or financial information provided in the claim. |
| [ExplanationOfBenefit](explanationofbenefit) | This resource combines the information from the Claim and the ClaimResponse, stripping out any provider or payer proprietary information, into a unified information model suitable for use for: patient reporting; transferring information to a Patient Health Record system; and, supporting complete claim and adjudication information exchange with regulatory and analytics organizations and other parts of the provider's organization. |

## Notes


## Additional Information

The information presented in different backbone elements, such as **.supportingInfo** or **.adjudication**, has a different context based on the **.category** code presented in each, for example, adjudication occurrence may represent an amount paid by the patient while another may represent the amount paid to the provider.

Additionally, there are several places in the resource which point to other sections of the resource via the use of a **.sequence** number in the referred-to element and an **._element_Sequence** in the referring element. Sequence numbers appear in such element as **.careTeam** referred to by **.careTeamSequence**, **.diagnosis** referred to by **.diagnosisSequence**, **.procedure** referred to by **.procedureSequence**, **.supportingInfo** referred to by **.informationSequence** and **.item** referred to by **.itemSequence**.

## StructureDefinition

### Elements (Simplified)

- **[Claim](/claim-definitions#Claim)** [0..*]: - Claim, Pre-determination or Pre-authorization
- **[Claim.identifier](/claim-definitions#Claim.identifier)** [0..*]: [Identifier](/Identifier) Business Identifier for claim
- **[Claim.traceNumber](/claim-definitions#Claim.traceNumber)** [0..*]: [Identifier](/Identifier) Number for tracking
- **[Claim.status](/claim-definitions#Claim.status)** [1..1]: [code](/code) required:[fm-status](/valueset-fm-status) active | cancelled | draft | entered-in-error
- **[Claim.statusReason](/claim-definitions#Claim.statusReason)** [0..1]: [string](/string) Reason for status change
- **[Claim.type](/claim-definitions#Claim.type)** [1..1]: [CodeableConcept](/CodeableConcept) extensible:[claim-type](/valueset-claim-type) Category or discipline
- **[Claim.subType](/claim-definitions#Claim.subType)** [0..1]: [CodeableConcept](/CodeableConcept) example:[claim-subtype](/valueset-claim-subtype) More granular claim type
- **[Claim.use](/claim-definitions#Claim.use)** [1..1]: [code](/code) required:[claim-use](/valueset-claim-use) claim | preauthorization | predetermination
- **[Claim.subject](/claim-definitions#Claim.subject)** [1..1]: [Reference(Patient](/Reference(Patient), [Group)](/Group)) The recipient(s) of the products and services
- **[Claim.billablePeriod](/claim-definitions#Claim.billablePeriod)** [0..1]: [Period](/Period) Relevant time frame for the claim
- **[Claim.created](/claim-definitions#Claim.created)** [1..1]: [dateTime](/dateTime) Resource creation date
- **[Claim.enterer](/claim-definitions#Claim.enterer)** [0..1]: [Reference(Practitioner](/Reference(Practitioner), [PractitionerRole](/PractitionerRole), [Patient](/Patient), [RelatedPerson)](/RelatedPerson)) Author of the claim
- **[Claim.insurer](/claim-definitions#Claim.insurer)** [0..1]: Reference([Organization](/Organization)) Target
- **[Claim.provider](/claim-definitions#Claim.provider)** [0..1]: [Reference(Practitioner](/Reference(Practitioner), [PractitionerRole](/PractitionerRole), [Organization)](/Organization)) Party responsible for the claim
- **[Claim.priority](/claim-definitions#Claim.priority)** [0..1]: [CodeableConcept](/CodeableConcept) preferred:[process-priority](/valueset-process-priority) Desired processing urgency
- **[Claim.fundsReserve](/claim-definitions#Claim.fundsReserve)** [0..1]: [CodeableConcept](/CodeableConcept) preferred:[fundsreserve](/valueset-fundsreserve) For whom to reserve funds
- **[Claim.related](/claim-definitions#Claim.related)** [0..*]: [BackboneElement](/BackboneElement) Prior or corollary claims
- **[Claim.related.claim](/claim-definitions#Claim.related.claim)** [0..1]: Reference([Claim](/Claim)) Reference to the related claim
- **[Claim.related.relationship](/claim-definitions#Claim.related.relationship)** [0..1]: [CodeableConcept](/CodeableConcept) example:[related-claim-relationship](/valueset-related-claim-relationship) How the reference claim is related
- **[Claim.related.reference](/claim-definitions#Claim.related.reference)** [0..1]: [Identifier](/Identifier) File or case reference
- **[Claim.prescription](/claim-definitions#Claim.prescription)** [0..1]: [Reference(DeviceRequest](/Reference(DeviceRequest), [MedicationRequest](/MedicationRequest), [ServiceRequest](/ServiceRequest), [VisionPrescription)](/VisionPrescription)) Prescription authorizing services and products
- **[Claim.originalPrescription](/claim-definitions#Claim.originalPrescription)** [0..1]: [Reference(DeviceRequest](/Reference(DeviceRequest), [MedicationRequest](/MedicationRequest), [ServiceRequest](/ServiceRequest), [VisionPrescription)](/VisionPrescription)) Original prescription if superseded by fulfiller
- **[Claim.payee](/claim-definitions#Claim.payee)** [0..1]: [BackboneElement](/BackboneElement) Recipient of benefits payable
- **[Claim.payee.type](/claim-definitions#Claim.payee.type)** [1..1]: [CodeableConcept](/CodeableConcept) example:[payeetype](/valueset-payeetype) Category of recipient
- **[Claim.payee.party](/claim-definitions#Claim.payee.party)** [0..1]: [Reference(Practitioner](/Reference(Practitioner), [PractitionerRole](/PractitionerRole), [Organization](/Organization), [Patient](/Patient), [RelatedPerson)](/RelatedPerson)) Recipient reference
- **[Claim.referral](/claim-definitions#Claim.referral)** [0..1]: Reference([ServiceRequest](/ServiceRequest)) Treatment referral
- **[Claim.encounter](/claim-definitions#Claim.encounter)** [0..*]: Reference([Encounter](/Encounter)) Encounters associated with the listed treatments
- **[Claim.facility](/claim-definitions#Claim.facility)** [0..1]: [Reference(Location](/Reference(Location), [Organization)](/Organization)) Servicing facility
- **[Claim.diagnosisRelatedGroup](/claim-definitions#Claim.diagnosisRelatedGroup)** [0..1]: [CodeableConcept](/CodeableConcept) example:[ex-diagnosisrelatedgroup](/valueset-ex-diagnosisrelatedgroup) Package billing code
- **[Claim.event](/claim-definitions#Claim.event)** [0..*]: [BackboneElement](/BackboneElement) Event information
- **[Claim.event.type](/claim-definitions#Claim.event.type)** [1..1]: [CodeableConcept](/CodeableConcept) example:[datestype](/valueset-datestype) Specific event
- **[Claim.event.when[x]](/claim-definitions#Claim.event.when%5Bx%5D)** [1..1]: [dateTime](/dateTime), [Period](/Period) Occurance date or period
- **[Claim.careTeam](/claim-definitions#Claim.careTeam)** [0..*]: [BackboneElement](/BackboneElement) Members of the care team
- **[Claim.careTeam.sequence](/claim-definitions#Claim.careTeam.sequence)** [1..1]: [positiveInt](/positiveInt) Order of care team
- **[Claim.careTeam.provider](/claim-definitions#Claim.careTeam.provider)** [1..1]: [Reference(Practitioner](/Reference(Practitioner), [PractitionerRole](/PractitionerRole), [Organization)](/Organization)) Practitioner or organization
- **[Claim.careTeam.role](/claim-definitions#Claim.careTeam.role)** [0..1]: [CodeableConcept](/CodeableConcept) preferred:[claim-careteamrole](/valueset-claim-careteamrole) Function within the team
- **[Claim.careTeam.specialty](/claim-definitions#Claim.careTeam.specialty)** [0..1]: [CodeableConcept](/CodeableConcept) example:[provider-qualification](/valueset-provider-qualification) Practitioner or provider specialization
- **[Claim.supportingInfo](/claim-definitions#Claim.supportingInfo)** [0..*]: [BackboneElement](/BackboneElement) Supporting information
- **[Claim.supportingInfo.sequence](/claim-definitions#Claim.supportingInfo.sequence)** [1..1]: [positiveInt](/positiveInt) Information instance identifier
- **[Claim.supportingInfo.category](/claim-definitions#Claim.supportingInfo.category)** [1..1]: [CodeableConcept](/CodeableConcept) preferred:[claim-informationcategory](/valueset-claim-informationcategory) Classification of the supplied information
- **[Claim.supportingInfo.subCategory](/claim-definitions#Claim.supportingInfo.subCategory)** [0..1]: [CodeableConcept](/CodeableConcept) Finer-grained classification of the supplied information
- **[Claim.supportingInfo.code](/claim-definitions#Claim.supportingInfo.code)** [0..1]: [CodeableConcept](/CodeableConcept) example:[claim-exception](/valueset-claim-exception) Type of information
- **[Claim.supportingInfo.timing[x]](/claim-definitions#Claim.supportingInfo.timing%5Bx%5D)** [0..1]: [dateTime](/dateTime), [Period](/Period), [Timing](/Timing) When it occurred
- **[Claim.supportingInfo.value[x]](/claim-definitions#Claim.supportingInfo.value%5Bx%5D)** [0..1]: [*](/*) Data to be provided
- **[Claim.supportingInfo.reason](/claim-definitions#Claim.supportingInfo.reason)** [0..1]: [CodeableConcept](/CodeableConcept) example:[missing-tooth-reason](/valueset-missing-tooth-reason) Explanation for the information
- **[Claim.diagnosis](/claim-definitions#Claim.diagnosis)** [0..*]: [BackboneElement](/BackboneElement) Pertinent diagnosis information
- **[Claim.diagnosis.sequence](/claim-definitions#Claim.diagnosis.sequence)** [1..1]: [positiveInt](/positiveInt) Diagnosis instance identifier
- **[Claim.diagnosis.diagnosis[x]](/claim-definitions#Claim.diagnosis.diagnosis%5Bx%5D)** [1..1]: [CodeableConcept](/CodeableConcept), Reference([Condition](/Condition)) example:[icd-10](/valueset-icd-10) Nature of illness or problem
- **[Claim.diagnosis.type](/claim-definitions#Claim.diagnosis.type)** [0..*]: [CodeableConcept](/CodeableConcept) preferred:[ex-diagnosistype](/valueset-ex-diagnosistype) Timing or nature of the diagnosis
- **[Claim.diagnosis.onAdmission](/claim-definitions#Claim.diagnosis.onAdmission)** [0..1]: [CodeableConcept](/CodeableConcept) preferred:[ex-diagnosis-on-admission](/valueset-ex-diagnosis-on-admission) Present on admission
- **[Claim.procedure](/claim-definitions#Claim.procedure)** [0..*]: [BackboneElement](/BackboneElement) Clinical procedures performed
- **[Claim.procedure.sequence](/claim-definitions#Claim.procedure.sequence)** [1..1]: [positiveInt](/positiveInt) Procedure instance identifier
- **[Claim.procedure.type](/claim-definitions#Claim.procedure.type)** [0..*]: [CodeableConcept](/CodeableConcept) preferred:[ex-procedure-type](/valueset-ex-procedure-type) Category of Procedure
- **[Claim.procedure.date](/claim-definitions#Claim.procedure.date)** [0..1]: [dateTime](/dateTime) When the procedure was performed
- **[Claim.procedure.procedure[x]](/claim-definitions#Claim.procedure.procedure%5Bx%5D)** [1..1]: [CodeableConcept](/CodeableConcept), Reference([Procedure](/Procedure)) example:[icd-10-procedures](/valueset-icd-10-procedures) Specific clinical procedure
- **[Claim.procedure.udi](/claim-definitions#Claim.procedure.udi)** [0..*]: Reference([Device](/Device)) Unique device identifier
- **[Claim.insurance](/claim-definitions#Claim.insurance)** [0..*]: [BackboneElement](/BackboneElement) Patient insurance information
- **[Claim.insurance.sequence](/claim-definitions#Claim.insurance.sequence)** [1..1]: [positiveInt](/positiveInt) Insurance instance identifier
- **[Claim.insurance.focal](/claim-definitions#Claim.insurance.focal)** [1..1]: [boolean](/boolean) Coverage to be used for adjudication
- **[Claim.insurance.identifier](/claim-definitions#Claim.insurance.identifier)** [0..1]: [Identifier](/Identifier) Pre-assigned Claim number
- **[Claim.insurance.coverage](/claim-definitions#Claim.insurance.coverage)** [1..1]: Reference([Coverage](/Coverage)) Insurance information
- **[Claim.insurance.businessArrangement](/claim-definitions#Claim.insurance.businessArrangement)** [0..1]: [string](/string) Additional provider contract number
- **[Claim.insurance.preAuthRef](/claim-definitions#Claim.insurance.preAuthRef)** [0..*]: [string](/string) Prior authorization reference number
- **[Claim.insurance.claimResponse](/claim-definitions#Claim.insurance.claimResponse)** [0..1]: Reference([ClaimResponse](/ClaimResponse)) Adjudication results
- **[Claim.accident](/claim-definitions#Claim.accident)** [0..1]: [BackboneElement](/BackboneElement) Details of the event
- **[Claim.accident.date](/claim-definitions#Claim.accident.date)** [1..1]: [date](/date) When the incident occurred
- **[Claim.accident.type](/claim-definitions#Claim.accident.type)** [0..1]: [CodeableConcept](/CodeableConcept) extensible:[v3-ActIncidentCode](/valueset-v3-ActIncidentCode) The nature of the accident
- **[Claim.accident.location[x]](/claim-definitions#Claim.accident.location%5Bx%5D)** [0..1]: [Address](/Address), Reference([Location](/Location)) Where the event occurred
- **[Claim.patientPaid](/claim-definitions#Claim.patientPaid)** [0..1]: [Money](/Money) Paid by the patient
- **[Claim.item](/claim-definitions#Claim.item)** [0..*]: [BackboneElement](/BackboneElement) Product or service provided
- **[Claim.item.sequence](/claim-definitions#Claim.item.sequence)** [1..1]: [positiveInt](/positiveInt) Item instance identifier
- **[Claim.item.traceNumber](/claim-definitions#Claim.item.traceNumber)** [0..*]: [Identifier](/Identifier) Number for tracking
- **[Claim.item.subject](/claim-definitions#Claim.item.subject)** [0..1]: [Reference(Patient](/Reference(Patient), [Group)](/Group)) The recipient of the products and services
- **[Claim.item.careTeamSequence](/claim-definitions#Claim.item.careTeamSequence)** [0..*]: [positiveInt](/positiveInt) Applicable careTeam members
- **[Claim.item.diagnosisSequence](/claim-definitions#Claim.item.diagnosisSequence)** [0..*]: [positiveInt](/positiveInt) Applicable diagnoses
- **[Claim.item.procedureSequence](/claim-definitions#Claim.item.procedureSequence)** [0..*]: [positiveInt](/positiveInt) Applicable procedures
- **[Claim.item.informationSequence](/claim-definitions#Claim.item.informationSequence)** [0..*]: [positiveInt](/positiveInt) Applicable exception and supporting information
- **[Claim.item.revenue](/claim-definitions#Claim.item.revenue)** [0..1]: [CodeableConcept](/CodeableConcept) example:[ex-revenue-center](/valueset-ex-revenue-center) Revenue or cost center code
- **[Claim.item.category](/claim-definitions#Claim.item.category)** [0..1]: [CodeableConcept](/CodeableConcept) example:[ex-benefitcategory](/valueset-ex-benefitcategory) Benefit classification
- **[Claim.item.productOrService](/claim-definitions#Claim.item.productOrService)** [0..1]: [CodeableConcept](/CodeableConcept) example:[service-uscls](/valueset-service-uscls) Billing, service, product, or drug code
- **[Claim.item.productOrServiceEnd](/claim-definitions#Claim.item.productOrServiceEnd)** [0..1]: [CodeableConcept](/CodeableConcept) example:[service-uscls](/valueset-service-uscls) End of a range of codes
- **[Claim.item.request](/claim-definitions#Claim.item.request)** [0..*]: [Reference(DeviceRequest](/Reference(DeviceRequest), [MedicationRequest](/MedicationRequest), [NutritionOrder](/NutritionOrder), [ServiceRequest](/ServiceRequest), [VisionPrescription)](/VisionPrescription)) Request or Referral for Service
- **[Claim.item.modifier](/claim-definitions#Claim.item.modifier)** [0..*]: [CodeableConcept](/CodeableConcept) example:[claim-modifiers](/valueset-claim-modifiers) Product or service billing modifiers
- **[Claim.item.programCode](/claim-definitions#Claim.item.programCode)** [0..*]: [CodeableConcept](/CodeableConcept) example:[ex-program-code](/valueset-ex-program-code) Program the product or service is provided under
- **[Claim.item.serviced[x]](/claim-definitions#Claim.item.serviced%5Bx%5D)** [0..1]: [date](/date), [Period](/Period) Date or dates of service or product delivery
- **[Claim.item.location[x]](/claim-definitions#Claim.item.location%5Bx%5D)** [0..1]: [CodeableConcept](/CodeableConcept), [Address](/Address), Reference([Location](/Location)) example:[service-place](/valueset-service-place) Place of service or where product was supplied
- **[Claim.item.patientPaid](/claim-definitions#Claim.item.patientPaid)** [0..1]: [Money](/Money) Paid by the patient
- **[Claim.item.quantity](/claim-definitions#Claim.item.quantity)** [0..1]: [Quantity](/Quantity)([SimpleQuantity](/SimpleQuantity)) Count of products or services
- **[Claim.item.unitPrice](/claim-definitions#Claim.item.unitPrice)** [0..1]: [Money](/Money) Fee, charge or cost per item
- **[Claim.item.factor](/claim-definitions#Claim.item.factor)** [0..1]: [decimal](/decimal) Price scaling factor
- **[Claim.item.tax](/claim-definitions#Claim.item.tax)** [0..1]: [Money](/Money) Total tax
- **[Claim.item.net](/claim-definitions#Claim.item.net)** [0..1]: [Money](/Money) Total item cost
- **[Claim.item.udi](/claim-definitions#Claim.item.udi)** [0..*]: Reference([Device](/Device)) Unique device identifier
- **[Claim.item.bodySite](/claim-definitions#Claim.item.bodySite)** [0..*]: [BackboneElement](/BackboneElement) Anatomical location
- **[Claim.item.bodySite.site](/claim-definitions#Claim.item.bodySite.site)** [1..*]: [CodeableReference](/CodeableReference) example:[tooth](/valueset-tooth) Location
- **[Claim.item.bodySite.subSite](/claim-definitions#Claim.item.bodySite.subSite)** [0..*]: [CodeableConcept](/CodeableConcept) example:[surface](/valueset-surface) Sub-location
- **[Claim.item.encounter](/claim-definitions#Claim.item.encounter)** [0..*]: Reference([Encounter](/Encounter)) Encounters associated with the listed treatments
- **[Claim.item.detail](/claim-definitions#Claim.item.detail)** [0..*]: [BackboneElement](/BackboneElement) Product or service provided
- **[Claim.item.detail.sequence](/claim-definitions#Claim.item.detail.sequence)** [1..1]: [positiveInt](/positiveInt) Item instance identifier
- **[Claim.item.detail.traceNumber](/claim-definitions#Claim.item.detail.traceNumber)** [0..*]: [Identifier](/Identifier) Number for tracking
- **[Claim.item.detail.revenue](/claim-definitions#Claim.item.detail.revenue)** [0..1]: [CodeableConcept](/CodeableConcept) example:[ex-revenue-center](/valueset-ex-revenue-center) Revenue or cost center code
- **[Claim.item.detail.category](/claim-definitions#Claim.item.detail.category)** [0..1]: [CodeableConcept](/CodeableConcept) example:[ex-benefitcategory](/valueset-ex-benefitcategory) Benefit classification
- **[Claim.item.detail.productOrService](/claim-definitions#Claim.item.detail.productOrService)** [0..1]: [CodeableConcept](/CodeableConcept) example:[service-uscls](/valueset-service-uscls) Billing, service, product, or drug code
- **[Claim.item.detail.productOrServiceEnd](/claim-definitions#Claim.item.detail.productOrServiceEnd)** [0..1]: [CodeableConcept](/CodeableConcept) example:[service-uscls](/valueset-service-uscls) End of a range of codes
- **[Claim.item.detail.modifier](/claim-definitions#Claim.item.detail.modifier)** [0..*]: [CodeableConcept](/CodeableConcept) example:[claim-modifiers](/valueset-claim-modifiers) Service/Product billing modifiers
- **[Claim.item.detail.programCode](/claim-definitions#Claim.item.detail.programCode)** [0..*]: [CodeableConcept](/CodeableConcept) example:[ex-program-code](/valueset-ex-program-code) Program the product or service is provided under
- **[Claim.item.detail.patientPaid](/claim-definitions#Claim.item.detail.patientPaid)** [0..1]: [Money](/Money) Paid by the patient
- **[Claim.item.detail.quantity](/claim-definitions#Claim.item.detail.quantity)** [0..1]: [Quantity](/Quantity)([SimpleQuantity](/SimpleQuantity)) Count of products or services
- **[Claim.item.detail.unitPrice](/claim-definitions#Claim.item.detail.unitPrice)** [0..1]: [Money](/Money) Fee, charge or cost per item
- **[Claim.item.detail.factor](/claim-definitions#Claim.item.detail.factor)** [0..1]: [decimal](/decimal) Price scaling factor
- **[Claim.item.detail.tax](/claim-definitions#Claim.item.detail.tax)** [0..1]: [Money](/Money) Total tax
- **[Claim.item.detail.net](/claim-definitions#Claim.item.detail.net)** [0..1]: [Money](/Money) Total item cost
- **[Claim.item.detail.udi](/claim-definitions#Claim.item.detail.udi)** [0..*]: Reference([Device](/Device)) Unique device identifier
- **[Claim.item.detail.subDetail](/claim-definitions#Claim.item.detail.subDetail)** [0..*]: [BackboneElement](/BackboneElement) Product or service provided
- **[Claim.item.detail.subDetail.sequence](/claim-definitions#Claim.item.detail.subDetail.sequence)** [1..1]: [positiveInt](/positiveInt) Item instance identifier
- **[Claim.item.detail.subDetail.traceNumber](/claim-definitions#Claim.item.detail.subDetail.traceNumber)** [0..*]: [Identifier](/Identifier) Number for tracking
- **[Claim.item.detail.subDetail.revenue](/claim-definitions#Claim.item.detail.subDetail.revenue)** [0..1]: [CodeableConcept](/CodeableConcept) example:[ex-revenue-center](/valueset-ex-revenue-center) Revenue or cost center code
- **[Claim.item.detail.subDetail.category](/claim-definitions#Claim.item.detail.subDetail.category)** [0..1]: [CodeableConcept](/CodeableConcept) example:[ex-benefitcategory](/valueset-ex-benefitcategory) Benefit classification
- **[Claim.item.detail.subDetail.productOrService](/claim-definitions#Claim.item.detail.subDetail.productOrService)** [0..1]: [CodeableConcept](/CodeableConcept) example:[service-uscls](/valueset-service-uscls) Billing, service, product, or drug code
- **[Claim.item.detail.subDetail.productOrServiceEnd](/claim-definitions#Claim.item.detail.subDetail.productOrServiceEnd)** [0..1]: [CodeableConcept](/CodeableConcept) example:[service-uscls](/valueset-service-uscls) End of a range of codes
- **[Claim.item.detail.subDetail.modifier](/claim-definitions#Claim.item.detail.subDetail.modifier)** [0..*]: [CodeableConcept](/CodeableConcept) example:[claim-modifiers](/valueset-claim-modifiers) Service/Product billing modifiers
- **[Claim.item.detail.subDetail.programCode](/claim-definitions#Claim.item.detail.subDetail.programCode)** [0..*]: [CodeableConcept](/CodeableConcept) example:[ex-program-code](/valueset-ex-program-code) Program the product or service is provided under
- **[Claim.item.detail.subDetail.patientPaid](/claim-definitions#Claim.item.detail.subDetail.patientPaid)** [0..1]: [Money](/Money) Paid by the patient
- **[Claim.item.detail.subDetail.quantity](/claim-definitions#Claim.item.detail.subDetail.quantity)** [0..1]: [Quantity](/Quantity)([SimpleQuantity](/SimpleQuantity)) Count of products or services
- **[Claim.item.detail.subDetail.unitPrice](/claim-definitions#Claim.item.detail.subDetail.unitPrice)** [0..1]: [Money](/Money) Fee, charge or cost per item
- **[Claim.item.detail.subDetail.factor](/claim-definitions#Claim.item.detail.subDetail.factor)** [0..1]: [decimal](/decimal) Price scaling factor
- **[Claim.item.detail.subDetail.tax](/claim-definitions#Claim.item.detail.subDetail.tax)** [0..1]: [Money](/Money) Total tax
- **[Claim.item.detail.subDetail.net](/claim-definitions#Claim.item.detail.subDetail.net)** [0..1]: [Money](/Money) Total item cost
- **[Claim.item.detail.subDetail.udi](/claim-definitions#Claim.item.detail.subDetail.udi)** [0..*]: Reference([Device](/Device)) Unique device identifier
- **[Claim.total](/claim-definitions#Claim.total)** [0..1]: [Money](/Money) Total claim cost

## Mappings

- [Claim Mappings](/claim-mappings) — 31 mapping entries

## Operations

- [submit](/claim-operation-submit) — Submit a Claim resource for adjudication — This operation is used to submit a Claim, Pre-Authorization or Pre-Determination (all instances of Claim resources) for adjudication either as a single Claim resource instance or as a Bundle containing the Claim and other referenced resources, or Bundle containing a batch of Claim resources, either as single Claims resources or Bundle resources, for processing.

[Full Operations](/claim-operations)

## Resource Packs


### list-Claim-packs.xml



```xml
<?xml version="1.0" encoding="UTF-8"?>

<List xmlns="http://hl7.org/fhir" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:schemaLocation="http://hl7.org/fhir ../../publish/List.xsd">
  <id value="Claim-packs"/>
  <status value="current"/>
  <mode value="working"/>
</List>
```


## Search Parameters

- [care-team](/claim-search#care-team) — **reference** — Member of the CareTeam — `Claim.careTeam.provider`
- [created](/claim-search#created) — **date** — The creation date for the Claim — `Claim.created`
- [detail-udi](/claim-search#detail-udi) — **reference** — UDI associated with a line item, detail product or service — `Claim.item.detail.udi`
- [encounter](/claim-search#encounter) — **reference** — Encounters associated with a billed line item — `Claim.item.encounter`
- [enterer](/claim-search#enterer) — **reference** — The party responsible for the entry of the Claim — `Claim.enterer`
- [facility](/claim-search#facility) — **reference** — Facility where the products or services have been or will be provided — `Claim.facility`
- [group](/claim-search#group) — **reference** — Group receiving the products or services — `Claim.subject.where(resolve() is Group) | Claim.item.subject.where(resolve() is Group)`
- [identifier](/claim-search#identifier) — **token** — The primary identifier of the financial resource — `Claim.identifier`
- [insurer](/claim-search#insurer) — **reference** — The target payer/insurer for the Claim — `Claim.insurer`
- [item-udi](/claim-search#item-udi) — **reference** — UDI associated with a line item product or service — `Claim.item.udi`
- [patient](/claim-search#patient) — **reference** — Patient receiving the products or services — `Claim.subject.where(resolve() is Patient) | Claim.item.subject.where(resolve() is Patient)`
- [payee](/claim-search#payee) — **reference** — The party receiving any payment for the Claim — `Claim.payee.party`
- [priority](/claim-search#priority) — **token** — Processing priority requested — `Claim.priority`
- [subject](/claim-search#subject) — **reference** — Subject receiving the products or services — `Claim.subject | Claim.item.subject`
- [procedure-udi](/claim-search#procedure-udi) — **reference** — UDI associated with a procedure — `Claim.procedure.udi`
- [provider](/claim-search#provider) — **reference** — Provider responsible for the Claim — `Claim.provider`
- [status](/claim-search#status) — **token** — The status of the Claim instance. — `Claim.status`
- [subdetail-udi](/claim-search#subdetail-udi) — **reference** — UDI associated with a line item, detail, subdetail product or service — `Claim.item.detail.subDetail.udi`
- [use](/claim-search#use) — **token** — The kind of financial resource — `Claim.use`

[Full Search Parameters](/claim-search)

## Examples

- [100150](/claim-example-100150) — claim-example — Simple dental Claim
- [100151](/claim-example-100151) — claim-example-oral-average — Average dental Claim with Information (Missing Teeth and Student)
- [100152](/claim-example-100152) — claim-example-oral-contained — SOA Dental Claim (Contained)
- [100153](/claim-example-100153) — claim-example-oral-orthoplan — PreAuthorization with Orthodontic Treatment Plan
- [100154](/claim-example-100154) — claim-example-oral-identifier — SOA Dental Claim using identifiers
- [100155](/claim-example-100155) — claim-example-oral-contained-identifier — SOA Dental Claim using identifiers and Contained
- [100156](/claim-example-100156) — claim-example-oral-bridge — PreAuthorization with Bridge and Crown
- [660150](/claim-example-660150) — claim-example-vision — Simple Vision Claim
- [660151](/claim-example-660151) — claim-example-vision-glasses — Glasses Claim
- [660152](/claim-example-660152) — claim-example-vision-glasses-3tier — Glasses Claim, 3 Tier, Secondary Coverage
- [760150](/claim-example-760150) — claim-example-pharmacy — Simple Pharmacy Service Claim
- [760151](/claim-example-760151) — claim-example-pharmacy-medication — Simple Pharmacy Medication Claim
- [760152](/claim-example-760152) — claim-example-pharmacy-compound — Simple Pharmacy Compound Claim
- [860150](/claim-example-860150) — claim-example-professional — Simple Professional Service Claim
- [960150](/claim-example-960150) — claim-example-institutional — Simple Institutional Service Claim
- [960151](/claim-example-960151) — claim-example-institutional-rich — Rich Institutional Service Claim
- [claim-example](/claim-example-claim-example) — claim-example
- [claim-example-cms1500-medical](/claim-example-claim-example-cms1500-medical) — claim-example-cms1500-medical
- [claim-example-institutional](/claim-example-claim-example-institutional) — claim-example-institutional
- [claim-example-institutional-rich](/claim-example-claim-example-institutional-rich) — claim-example-institutional-rich
- [claim-example-oral-average](/claim-example-claim-example-oral-average) — claim-example-oral-average
- [claim-example-oral-bridge](/claim-example-claim-example-oral-bridge) — claim-example-oral-bridge
- [claim-example-oral-contained](/claim-example-claim-example-oral-contained) — claim-example-oral-contained
- [claim-example-oral-contained-identifier](/claim-example-claim-example-oral-contained-identifier) — claim-example-oral-contained-identifier
- [claim-example-oral-identifier](/claim-example-claim-example-oral-identifier) — claim-example-oral-identifier
- [claim-example-oral-orthoplan](/claim-example-claim-example-oral-orthoplan) — claim-example-oral-orthoplan
- [claim-example-pharmacy](/claim-example-claim-example-pharmacy) — claim-example-pharmacy
- [claim-example-pharmacy-compound](/claim-example-claim-example-pharmacy-compound) — claim-example-pharmacy-compound
- [claim-example-pharmacy-medication](/claim-example-claim-example-pharmacy-medication) — claim-example-pharmacy-medication
- [claim-example-professional](/claim-example-claim-example-professional) — claim-example-professional
- [claim-example-vision](/claim-example-claim-example-vision) — claim-example-vision
- [claim-example-vision-glasses](/claim-example-claim-example-vision-glasses) — claim-example-vision-glasses
- [claim-example-vision-glasses-3tier](/claim-example-claim-example-vision-glasses-3tier) — claim-example-vision-glasses-3tier
- [claim-examples-header](/claim-example-claim-examples-header) — claim-examples-header
- [MED-00050](/claim-example-MED-00050) — claim-example-cms1500-medical — Simple US Medical Surgery Claim

[Full Examples](/claim-examples)

## Mapping Exceptions


### claim-fivews-mapping-exceptions.xml

### Unmapped Elements
- **FiveWs.what** — Unknown
- **FiveWs.version** — Unknown
- **FiveWs.witness** — Unknown
- **FiveWs.context** — Unknown
- **FiveWs.init** — Unknown
- **FiveWs.why** — Unknown
- **FiveWs.who** — Unknown
- **FiveWs.grade** — Unknown
- **FiveWs.planned** — Unknown

### claim-request-mapping-exceptions.xml

### Divergent Elements
- **Request.identifier** → **Claim.identifier**
  - summary | reason=Unknown | pattern=true
  - definitionUnmatched | reason=Unknown | pattern=Business identifiers assigned to this claim by the author and/or other systems.  These identifiers remain constant as the resource is updated and propagates from server to server. | resource=A unique identifier assigned to this claim.
  - commentsUnmatched | reason=Unknown | pattern=The identifier.type element is used to distinguish between the identifiers assigned by the requester/placer and the performer/filler.

Note: This is a business identifier, not a resource identifier (see [discussion](resource.html#identifiers)).  It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types.  For example, multiple Patient and a Person resource instance might share the same social insurance number.
  - requirementsUnmatched | reason=Unknown | pattern=Allows identification of the claim as it is known by various participating systems and in a way that remains consistent across servers. | resource=Allows claims to be distinguished and referenced.
- **Request.identifier** → **Claim.insurance.identifier**
  - summary | reason=Unknown | pattern=true
  - shortUnmatched | reason=Unknown | pattern=Business Identifier for claim | resource=Pre-assigned Claim number
  - definitionUnmatched | reason=Unknown | pattern=Business identifiers assigned to this claim by the author and/or other systems.  These identifiers remain constant as the resource is updated and propagates from server to server. | resource=The business identifier to be used when the claim is sent for adjudication against this insurance policy.
  - commentsUnmatched | reason=Unknown | pattern=The identifier.type element is used to distinguish between the identifiers assigned by the requester/placer and the performer/filler.

Note: This is a business identifier, not a resource identifier (see [discussion](resource.html#identifiers)).  It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types.  For example, multiple Patient and a Person resource instance might share the same social insurance number. | resource=Only required in jurisdictions where insurers, rather than the provider, are required to send claims to  insurers that appear after them in the list. This element is not required when 'subrogation=true'.
  - requirementsUnmatched | reason=Unknown | pattern=Allows identification of the claim as it is known by various participating systems and in a way that remains consistent across servers. | resource=This will be the claim number should it be necessary to create this claim in the future. This is provided so that payers may forward claims to other payers in the Coordination of Benefit for adjudication rather than the provider being required to initiate each adjudication.
- **Request.replaces** → **Claim.related.claim**
  - missingTypes | reason=Unknown | pattern=Reference(Request)
  - extraTypes | reason=Unknown
  - summary | reason=Unknown | pattern=true
  - shortUnmatched | reason=Unknown | pattern=Request(s) replaced by this claim | resource=Reference to the related claim
  - definitionUnmatched | reason=Unknown | pattern=Completed or terminated request(s) whose function is taken by this new claim. | resource=Reference to a related claim.
  - commentsUnmatched | reason=Unknown | pattern=The replacement could be because the initial request was immediately rejected (due to an issue) or because the previous request was completed, but the need for the action described by the request remains ongoing.
  - requirementsUnmatched | reason=Unknown | pattern=Allows tracing the continuation of a therapy or administrative process instantiated through multiple requests. | resource=For workplace or other accidents it is common to relate separate claims arising from the same event.
- **Request.status** → **Claim.status**
  - shortUnmatched | reason=Unknown | pattern=draft | active | on-hold | revoked | completed | entered-in-error | unknown | resource=active | cancelled | draft | entered-in-error
  - definitionUnmatched | reason=Unknown | pattern=The current state of the claim. | resource=The status of the resource instance.
  - commentsUnmatched | reason=Unknown | pattern=The status is generally fully in the control of the requester - they determine whether the order is draft or active and, after it has been activated, completed, cancelled or suspended. States relating to the activities of the performer are reflected on either the corresponding]](s) or using the]] resource.  A nominal state-transition diagram can be found in the] documentation  Unknown does not represent "other" - one of the defined statuses must apply.  Unknown is used when the authoring system is not sure what the current status is.  A status of 'active' when doNotPerform is true means that the request to not perform is currently in force.

A status of completed for a "doNotPerform" request indicates that the period of non-performance is now satisfied and the request no longer holds. | resource=This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.
- **Request.priority** → **Claim.priority**
  - missingTypes | reason=Unknown | pattern=code
  - extraTypes | reason=Unknown
  - bindingStrength | reason=Unknown | pattern=required
  - shortUnmatched | reason=Unknown | pattern=routine | urgent | asap | stat | resource=Desired processing urgency
  - definitionUnmatched | reason=Unknown | pattern=Indicates how quickly the claim should be addressed with respect to other requests. | resource=The provider-required urgency of processing the request. Typical values include: stat, normal, deferred.
- **Request.subject** → **Claim.subject**
  - shortUnmatched | reason=Unknown | pattern=Individual the service is ordered/prohibited for | resource=The recipient(s) of the products and services
  - definitionUnmatched | reason=Unknown | pattern=The individual or set of individuals the action is to be performed/not performed on or for. | resource=The party/group to whom the professional services and/or products have been supplied or are being considered and for whom actual or forecast reimbursement is sought.
  - requirementsUnmatched | reason=Unknown | pattern=Links the request to the Patient context. | resource=The patient must be supplied to the insurer so that confirmation of coverage and service history may be considered as part of the authorization and/or adjudiction.
- **Request.authoredOn** → **Claim.created**
  - shortUnmatched | reason=Unknown | pattern=When request was created/transitioned to active | resource=Resource creation date
  - definitionUnmatched | reason=Unknown | pattern=For draft claims, indicates the date of initial creation.  For requests with other statuses, indicates the date of activation. | resource=The date this resource was created.
- **Request.requester** → **Claim.provider**
  - missingTypes | reason=Unknown | pattern=Reference(Patient, RelatedPerson, Device)
  - shortUnmatched | reason=Unknown | pattern=Who/what is requesting service | resource=Party responsible for the claim
  - definitionUnmatched | reason=Unknown | pattern=Who initiated the {{request}} and has responsibility for its activation. | resource=The provider which is responsible for the claim, predetermination or preauthorization.
- **Request.performer** → **Claim.insurer**
  - missingTypes | reason=Unknown | pattern=Reference(Practitioner, PractitionerRole, CareTeam, HealthcareService, Patient, Device, RelatedPerson)
  - shortUnmatched | reason=Unknown | pattern=Specific desired (non)performer | resource=Target
  - definitionUnmatched | reason=Unknown | pattern=Indicates who or what is being asked to perform (or not perform) the {{request}}. | resource=The Insurer who is target of the request.
- **Request.supportingInfo** → **Claim.supportingInfo**
  - missingTypes | reason=Unknown | pattern=Reference(Any)
  - extraTypes | reason=Unknown
  - shortUnmatched | reason=Unknown | pattern=Extra information to use in performing request | resource=Supporting information
  - definitionUnmatched | reason=Unknown | pattern=Information that may be needed by/relevant to the performer in their execution of this claim. | resource=Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.
  - commentsUnmatched | reason=Unknown | pattern=See guidance on [notes vs. supportingInfo](request.html#notes). | resource=Often there are multiple jurisdiction specific valuesets which are required.

### Unmapped Elements
- **Request.intent** — Unknown
- **Request.insurance** — Unknown
- **Request.occurrence** — Unknown
- **Request.groupIdentifier** — Unknown
- **Request.deliverTo** — Unknown
- **Request.note** — Unknown
- **Request.basedOn** — Unknown
- **Request.encounter** — Unknown
- **Request.category** — Unknown
- **Request.reason** — Unknown
- **Request.reported** — Unknown
- **Request.relevantHistory** — Unknown
- **Request.code** — Unknown
- **Request.statusReason** — Unknown
- **Request.performerType** — Unknown
- **Request.doNotPerform** — Unknown
- **Request.product** — Unknown