type: resource-definitionsresource: Claim

Claim Definitions

Claim

Claim, Pre-determination or Pre-authorization

Definition: A provider issued list of professional services and products which have been provided, or are to be provided, to a patient which is sent to an insurer for reimbursement.

Comments: The Claim resource fulfills three information request requirements: Claim - a request for adjudication for reimbursement for products and/or services provided; Preauthorization - a request to authorize the future provision of products and/or services including an anticipated adjudication; and, Predetermination - a request for a non-bind adjudication of possible future products and/or services.

Aliases: Adjudication Request, Preauthorization Request, Predetermination Request

Cardinality: 0..*

Mappings: workflow=Request; w5=financial.billing

Claim.identifier

Business Identifier for claim

Definition: A unique identifier assigned to this claim.

Requirements: Allows claims to be distinguished and referenced.

Aliases: Claim Number

Cardinality: 0..*

Type: Identifier

Mappings: workflow=Request.identifier; w5=FiveWs.identifier

Claim.traceNumber

Number for tracking

Definition: Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners.

Requirements: Allows partners to uniquely identify components for tracking.

Cardinality: 0..*

Type: Identifier

Claim.status

active | cancelled | draft | entered-in-error

Definition: The status of the resource instance.

Comments: This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

Requirements: Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.

Cardinality: 1..1

Type: code

Binding: required:fm-status

Summary: true

Is Modifier: true (Reason: This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid)

Mappings: workflow=Request.status; w5=FiveWs.status

Claim.statusReason

Reason for status change

Definition: Used to indicate why the status has changed.

Comments: Implementation guides may consider adding invariants such that if status = cancelled, statusReason SHALL be supplied.

Requirements: This is used to implement conformance on other elements.

Cardinality: 0..1

Type: string

Summary: true

Claim.type

Category or discipline

Definition: The category of claim, e.g. oral, pharmacy, vision, institutional, professional.

Comments: The code system provides oral, pharmacy, vision, professional and institutional claim types. Those supported depends on the requirements of the jurisdiction. The valueset is extensible to accommodate other types of claims as required by the jurisdiction.

Requirements: Claim type determine the general sets of business rules applied for information requirements and adjudication.

Cardinality: 1..1

Type: CodeableConcept

Binding: extensible:claim-type

Summary: true

Mappings: w5=FiveWs.class

Claim.subType

More granular claim type

Definition: A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.

Comments: This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.

Requirements: Some jurisdictions need a finer grained claim type for routing and adjudication.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:claim-subtype

Mappings: w5=FiveWs.class

Claim.use

claim | preauthorization | predetermination

Definition: A code to indicate whether the nature of the request is: Claim - A request to an Insurer to adjudicate the supplied charges for health care goods and services under the identified policy and to pay the determined Benefit amount, if any; Preauthorization - A request to an Insurer to adjudicate the supplied proposed future charges for health care goods and services under the identified policy and to approve the services and provide the expected benefit amounts and potentially to reserve funds to pay the benefits when Claims for the indicated services are later submitted; or, Pre-determination - A request to an Insurer to adjudicate the supplied 'what if' charges for health care goods and services under the identified policy and report back what the Benefit payable would be had the services actually been provided.

Requirements: This element is required to understand the nature of the request for adjudication.

Cardinality: 1..1

Type: code

Binding: required:claim-use

Summary: true

Mappings: w5=FiveWs.class

Claim.subject

The recipient(s) of the products and services

Definition: 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.

Requirements: 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.

Aliases: patient

Cardinality: 1..1

Type: Reference(Patient, Group)

Summary: true

Mappings: workflow=Request.subject; w5=FiveWs.subject

Claim.billablePeriod

Relevant time frame for the claim

Definition: The period for which charges are being submitted.

Comments: Typically this would be today or in the past for a claim, and today or in the future for preauthorizations and predeterminations. Typically line item dates of service should fall within the billing period if one is specified.

Requirements: A number jurisdictions required the submission of the billing period when submitting claims for example for hospital stays or long-term care.

Cardinality: 0..1

Type: Period

Summary: true

Mappings: w5=FiveWs.done[x]

Claim.created

Resource creation date

Definition: The date this resource was created.

Comments: This field is independent of the date of creation of the resource as it may reflect the creation date of a source document prior to digitization. Typically for claims all services must be completed as of this date.

Requirements: Need to record a timestamp for use by both the recipient and the issuer.

Cardinality: 1..1

Type: dateTime

Summary: true

Mappings: workflow=Request.authoredOn; w5=FiveWs.recorded

Claim.enterer

Author of the claim

Definition: Individual who created the claim, predetermination or preauthorization.

Requirements: Some jurisdictions require the contact information for personnel completing claims.

Cardinality: 0..1

Type: Reference(Practitioner, PractitionerRole, Patient, RelatedPerson)

Mappings: w5=FiveWs.author

Claim.insurer

Target

Definition: The Insurer who is target of the request.

Cardinality: 0..1

Type: Reference(Organization)

Summary: true

Mappings: workflow=Request.performer

Claim.provider

Party responsible for the claim

Definition: The provider which is responsible for the claim, predetermination or preauthorization.

Comments: Typically this field would be 1..1 where this party is accountable for the data content within the claim but is not necessarily the facility, provider group or practitioner who provided the products and services listed within this claim resource. This field is the Billing Provider, for example, a facility, provider group, lab or practitioner.

Cardinality: 0..1

Type: Reference(Practitioner, PractitionerRole, Organization)

Summary: true

Mappings: workflow=Request.requester; w5=FiveWs.source

Claim.priority

Desired processing urgency

Definition: The provider-required urgency of processing the request. Typical values include: stat, normal, deferred.

Comments: If a claim processor is unable to complete the processing as per the priority then they should generate an error and not process the request.

Requirements: The provider may need to indicate their processing requirements so that the processor can indicate if they are unable to comply.

Cardinality: 0..1

Type: CodeableConcept

Binding: preferred:process-priority

Summary: true

Mappings: workflow=Request.priority

Claim.fundsReserve

For whom to reserve funds

Definition: A code to indicate whether and for whom funds are to be reserved for future claims.

Comments: This field is only used for preauthorizations.

Requirements: 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 requested.

Aliases: Fund pre-allocation

Cardinality: 0..1

Type: CodeableConcept

Binding: preferred:fundsreserve

Claim.related

Prior or corollary claims

Definition: Other claims which are related to this claim such as prior submissions or claims for related services or for the same event.

Comments: For example, for the original treatment and follow-up exams.

Requirements: For workplace or other accidents it is common to relate separate claims arising from the same event.

Cardinality: 0..*

Type: BackboneElement

Claim.related.claim

Reference to the related claim

Definition: Reference to a related claim.

Requirements: For workplace or other accidents it is common to relate separate claims arising from the same event.

Cardinality: 0..1

Type: Reference(Claim)

Mappings: workflow=Request.replaces

Claim.related.relationship

How the reference claim is related

Definition: A code to convey how the claims are related.

Comments: For example, prior claim or umbrella.

Requirements: Some insurers need a declaration of the type of relationship.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:related-claim-relationship

Claim.related.reference

File or case reference

Definition: An alternate organizational reference to the case or file to which this particular claim pertains.

Comments: For example, Property/Casualty insurer claim # or Workers Compensation case # .

Requirements: In cases where an event-triggered claim is being submitted to an insurer which requires a reference number to be specified on all exchanges.

Cardinality: 0..1

Type: Identifier

Claim.prescription

Prescription authorizing services and products

Definition: Prescription is the document/authorization given to the claim author for them to provide products and services for which consideration (reimbursement) is sought. Could be a RX for medications, an 'order' for oxygen or wheelchair or physiotherapy treatments.

Requirements: Required to authorize the dispensing of controlled substances and devices.

Cardinality: 0..1

Type: Reference(DeviceRequest, MedicationRequest, ServiceRequest, VisionPrescription)

Claim.originalPrescription

Original prescription if superseded by fulfiller

Definition: Original prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or products.

Comments: For example, a physician may prescribe a medication which the pharmacy determines is contraindicated, or for which the patient has an intolerance, and therefore issues a new prescription for an alternate medication which has the same therapeutic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription'.

Requirements: Often required when a fulfiller varies what is fulfilled from that authorized on the original prescription.

Cardinality: 0..1

Type: Reference(DeviceRequest, MedicationRequest, ServiceRequest, VisionPrescription)

Claim.payee

Recipient of benefits payable

Definition: The party to be reimbursed for cost of the products and services according to the terms of the policy.

Comments: Often billing providers agree to receive the benefits payable to reduce the near-term costs to the patient. The insurer may decline to pay the provider and choose to pay the subscriber instead.

Requirements: The billing provider needs to specify who they wish to be reimbursed and the claims processor needs express who they will reimburse.

Cardinality: 0..1

Type: BackboneElement

Claim.payee.type

Category of recipient

Definition: Type of Party to be reimbursed: subscriber, provider, other.

Requirements: Need to know who should receive payment with the most common situations being the billing Provider (assignment of benefits) or the Subscriber.

Cardinality: 1..1

Type: CodeableConcept

Binding: example:payeetype

Claim.payee.party

Recipient reference

Definition: Reference to the individual or organization to whom any payment will be made.

Comments: Not required if the payee is 'subscriber' or 'provider'.

Requirements: Need to provide demographics if the payee is not 'subscriber' nor 'provider'.

Cardinality: 0..1

Type: Reference(Practitioner, PractitionerRole, Organization, Patient, RelatedPerson)

Claim.referral

Treatment referral

Definition: The referral information received by the claim author, it is not to be used when the author generates a referral for a patient. A copy of that referral may be provided as supporting information. Some insurers require proof of referral to pay for services or to pay specialist rates for services.

Comments: The referral resource which lists the date, practitioner, reason and other supporting information.

Requirements: Some insurers require proof of referral to pay for services or to pay specialist rates for services.

Cardinality: 0..1

Type: Reference(ServiceRequest)

Mappings: w5=FiveWs.cause

Claim.encounter

Encounters associated with the listed treatments

Definition: Healthcare encounters related to this claim.

Comments: This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter.

Requirements: Used in some jurisdictions to link clinical events to claim items.

Cardinality: 0..*

Type: Reference(Encounter)

Claim.facility

Servicing facility

Definition: Facility where the services were provided.

Requirements: Insurance adjudication can be dependant on where services were delivered.

Cardinality: 0..1

Type: Reference(Location, Organization)

Mappings: w5=FiveWs.where[x]

Claim.diagnosisRelatedGroup

Package billing code

Definition: A package billing code or bundle code used to group products and services to a particular health condition (such as heart attack) which is based on a predetermined grouping code system.

Comments: For example DRG (Diagnosis Related Group) or a bundled billing code. A patient may have a diagnosis of a Myocardial Infarction and a DRG for HeartAttack would be assigned. The Claim item (and possible subsequent claims) would refer to the DRG for those line items that were for services related to the heart attack event.

Requirements: Required to relate the current diagnosis to a package billing code that is then referenced on the individual claim items which are specific to the health condition covered by the package code.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:ex-diagnosisrelatedgroup

Claim.event

Event information

Definition: Information code for an event with a corresponding date or period.

Cardinality: 0..*

Type: BackboneElement

Claim.event.type

Specific event

Definition: A coded event such as when a service is expected or a card printed.

Cardinality: 1..1

Type: CodeableConcept

Binding: example:datestype

Claim.event.when[x]

Occurance date or period

Definition: A date or period in the past or future indicating when the event occurred or is expectd to occur.

Cardinality: 1..1

Type: dateTime, Period

Claim.careTeam

Members of the care team

Definition: The members of the team who provided the products and services.

Requirements: Common to identify the responsible and supporting practitioners.

Cardinality: 0..*

Type: BackboneElement

Claim.careTeam.sequence

Order of care team

Definition: A number to uniquely identify care team entries.

Requirements: Necessary to maintain the order of the care team and provide a mechanism to link individuals to claim details.

Cardinality: 1..1

Type: positiveInt

Claim.careTeam.provider

Practitioner or organization

Definition: Member of the team who provided the product or service.

Requirements: Often a regulatory requirement to specify the responsible provider.

Cardinality: 1..1

Type: Reference(Practitioner, PractitionerRole, Organization)

Mappings: w5=FiveWs.actor

Claim.careTeam.role

Function within the team

Definition: The lead, assisting or supervising practitioner and their discipline if a multidisciplinary team.

Comments: Role might not be required when there is only a single provider listed.

Requirements: When multiple parties are present it is required to distinguish the roles performed by each member.

Cardinality: 0..1

Type: CodeableConcept

Binding: preferred:claim-careteamrole

Claim.careTeam.specialty

Practitioner or provider specialization

Definition: The specialization of the practitioner or provider which is applicable for this service.

Requirements: Need to specify which specialization a practitioner or provider acting under when delivering the product or service.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:provider-qualification

Claim.supportingInfo

Supporting information

Definition: Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.

Comments: Often there are multiple jurisdiction specific valuesets which are required.

Requirements: Typically these information codes are required to support the services rendered or the adjudication of the services rendered.

Aliases: Attachments Exception Codes Occurrence Codes Value codes

Cardinality: 0..*

Type: BackboneElement

Mappings: workflow=Request.supportingInfo

Claim.supportingInfo.sequence

Information instance identifier

Definition: A number to uniquely identify supporting information entries.

Requirements: Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details.

Cardinality: 1..1

Type: positiveInt

Claim.supportingInfo.category

Classification of the supplied information

Definition: The general class of the information supplied: information; exception; accident, employment; onset, etc.

Comments: This may contain a category for the local bill type codes.

Requirements: Required to group or associate information items with common characteristics. For example: admission information or prior treatments.

Cardinality: 1..1

Type: CodeableConcept

Binding: preferred:claim-informationcategory

Claim.supportingInfo.subCategory

Finer-grained classification of the supplied information

Definition: A finer classification within the more general category.

Requirements: Required to provide more detailed categorization, for example lab-test grouping: blood, tissue etc.

Cardinality: 0..1

Type: CodeableConcept

Binding: example

Claim.supportingInfo.code

Type of information

Definition: System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought.

Requirements: Required to identify the kind of additional information.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:claim-exception

Claim.supportingInfo.timing[x]

When it occurred

Definition: The date when or period to which this information refers.

Cardinality: 0..1

Type: dateTime, Period, Timing

Claim.supportingInfo.value[x]

Data to be provided

Definition: Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.

Comments: Could be used to provide references to other resources, document. For example could contain a PDF in an Attachment of the Police Report for an Accident.

Requirements: To convey the data content to be provided when the information is more than a simple code or period.

Cardinality: 0..1

Type: *

Claim.supportingInfo.reason

Explanation for the information

Definition: Provides the reason in the situation where a reason code is required in addition to the content.

Comments: For example: the reason for the additional stay, or why a tooth is missing.

Requirements: Needed when the supporting information has both a date and amount/value and requires explanation.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:missing-tooth-reason

Claim.diagnosis

Pertinent diagnosis information

Definition: Information about diagnoses relevant to the claim items.

Requirements: Required for the adjudication by provided context for the services and product listed.

Cardinality: 0..*

Type: BackboneElement

Mappings: workflow=Request.reasonReference

Claim.diagnosis.sequence

Diagnosis instance identifier

Definition: A number to uniquely identify diagnosis entries.

Comments: Diagnosis are presented in list order to their expected importance: primary, secondary, etc.

Requirements: Necessary to maintain the order of the diagnosis items and provide a mechanism to link to claim details.

Cardinality: 1..1

Type: positiveInt

Claim.diagnosis.diagnosis[x]

Nature of illness or problem

Definition: The nature of illness or problem in a coded form or as a reference to an external defined Condition.

Requirements: Provides health context for the evaluation of the products and/or services.

Cardinality: 1..1

Type: CodeableConcept, Reference(Condition)

Binding: example:icd-10

Claim.diagnosis.type

Timing or nature of the diagnosis

Definition: When the condition was observed or the relative ranking.

Comments: For example: admitting, primary, secondary, discharge.

Requirements: Often required to capture a particular diagnosis, for example: primary or discharge.

Cardinality: 0..*

Type: CodeableConcept

Binding: preferred:ex-diagnosistype

Claim.diagnosis.onAdmission

Present on admission

Definition: Indication of whether the diagnosis was present on admission to a facility.

Requirements: Many systems need to understand for adjudication if the diagnosis was present a time of admission.

Cardinality: 0..1

Type: CodeableConcept

Binding: preferred:ex-diagnosis-on-admission

Claim.procedure

Clinical procedures performed

Definition: Procedures performed on the patient relevant to the billing items with the claim.

Requirements: The specific clinical invention are sometimes required to be provided to justify billing a greater than customary amount for a service.

Cardinality: 0..*

Type: BackboneElement

Claim.procedure.sequence

Procedure instance identifier

Definition: A number to uniquely identify procedure entries.

Requirements: Necessary to provide a mechanism to link to claim details.

Cardinality: 1..1

Type: positiveInt

Claim.procedure.type

Category of Procedure

Definition: When the condition was observed or the relative ranking.

Comments: For example: primary, secondary.

Requirements: Often required to capture a particular diagnosis, for example: primary or discharge.

Cardinality: 0..*

Type: CodeableConcept

Binding: preferred:ex-procedure-type

Claim.procedure.date

When the procedure was performed

Definition: Date and optionally time the procedure was performed.

Requirements: Required for auditing purposes.

Cardinality: 0..1

Type: dateTime

Claim.procedure.procedure[x]

Specific clinical procedure

Definition: The code or reference to a Procedure resource which identifies the clinical intervention performed.

Requirements: This identifies the actual clinical procedure.

Cardinality: 1..1

Type: CodeableConcept, Reference(Procedure)

Binding: example:icd-10-procedures

Claim.procedure.udi

Unique device identifier

Definition: Unique Device Identifiers associated with this line item.

Requirements: The UDI code allows the insurer to obtain device level information on the product supplied.

Cardinality: 0..*

Type: Reference(Device)

Claim.insurance

Patient insurance information

Definition: Financial instruments for reimbursement for the health care products and services specified on the claim.

Comments: All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. Coverages appearing before the focal Coverage in the list, and where 'Coverage.subrogation=false', should provide a reference to the ClaimResponse containing the adjudication results of the prior claim.

Requirements: At least one insurer is required for a claim to be a claim.

Cardinality: 0..*

Type: BackboneElement

Summary: true

Mappings: rim=Coverage

Claim.insurance.sequence

Insurance instance identifier

Definition: A number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order.

Requirements: To maintain order of the coverages.

Cardinality: 1..1

Type: positiveInt

Summary: true

Claim.insurance.focal

Coverage to be used for adjudication

Definition: A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.

Comments: A patient may (will) have multiple insurance policies which provide reimbursement for healthcare services and products. For example a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for adjudicating this claim. Other claims would be created to request adjudication against the other listed policies.

Requirements: To identify which coverage in the list is being used to adjudicate this claim.

Cardinality: 1..1

Type: boolean

Summary: true

Claim.insurance.identifier

Pre-assigned Claim number

Definition: The business identifier to be used when the claim is sent for adjudication against this insurance policy.

Comments: 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'.

Requirements: 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.

Cardinality: 0..1

Type: Identifier

Mappings: workflow=Request.identifier; w5=FiveWs.identifier

Claim.insurance.coverage

Insurance information

Definition: Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.

Requirements: Required to allow the adjudicator to locate the correct policy and history within their information system.

Cardinality: 1..1

Type: Reference(Coverage)

Summary: true

Claim.insurance.businessArrangement

Additional provider contract number

Definition: A business agreement number established between the provider and the insurer for special business processing purposes.

Requirements: Providers may have multiple business arrangements with a given insurer and must supply the specific contract number for adjudication.

Cardinality: 0..1

Type: string

Claim.insurance.preAuthRef

Prior authorization reference number

Definition: Reference numbers previously provided by the insurer to the provider to be quoted on subsequent claims containing services or products related to the prior authorization.

Comments: This value is an alphanumeric string that may be provided over the phone, via text, via paper, or within a ClaimResponse resource and is not a FHIR Identifier.

Requirements: Providers must quote previously issued authorization reference numbers in order to obtain adjudication as previously advised on the Preauthorization.

Cardinality: 0..*

Type: string

Claim.insurance.claimResponse

Adjudication results

Definition: The result of the adjudication of the line items for the Coverage specified in this insurance.

Comments: Must not be specified when 'focal=true' for this insurance.

Requirements: An insurer need the adjudication results from prior insurers to determine the outstanding balance remaining by item for the items in the curent claim.

Cardinality: 0..1

Type: Reference(ClaimResponse)

Claim.accident

Details of the event

Definition: Details of an accident which resulted in injuries which required the products and services listed in the claim.

Requirements: When healthcare products and services are accident related, benefits may be payable under accident provisions of policies, such as automotive, etc before they are payable under normal health insurance.

Cardinality: 0..1

Type: BackboneElement

Claim.accident.date

When the incident occurred

Definition: Date of an accident event related to the products and services contained in the claim.

Comments: The date of the accident has to precede the dates of the products and services but within a reasonable timeframe.

Requirements: Required for audit purposes and adjudication.

Cardinality: 1..1

Type: date

Claim.accident.type

The nature of the accident

Definition: The type or context of the accident event for the purposes of selection of potential insurance coverages and determination of coordination between insurers.

Requirements: Coverage may be dependant on the type of accident.

Cardinality: 0..1

Type: CodeableConcept

Binding: extensible:v3-ActIncidentCode

Claim.accident.location[x]

Where the event occurred

Definition: The physical location of the accident event.

Requirements: Required for audit purposes and determination of applicable insurance liability.

Cardinality: 0..1

Type: Address, Reference(Location)

Claim.patientPaid

Paid by the patient

Definition: The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services.

Requirements: Necessary to demonstrate that copayments, co-insurance and similar patient payments have been made or accounted for.

Cardinality: 0..1

Type: Money

Claim.item

Product or service provided

Definition: A claim line. Either a simple product or service or a 'group' of details which can each be a simple items or groups of sub-details.

Requirements: The items to be processed for adjudication.

Cardinality: 0..*

Type: BackboneElement

Claim.item.sequence

Item instance identifier

Definition: A number to uniquely identify item entries.

Requirements: Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse.

Cardinality: 1..1

Type: positiveInt

Claim.item.traceNumber

Number for tracking

Definition: Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners.

Requirements: Allows partners to uniquely identify components for tracking.

Cardinality: 0..*

Type: Identifier

Claim.item.subject

The recipient of the products and services

Definition: The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for facast reimbursement is sought.

Comments: Profilers should consider making this element required when the backbone .subject is a group.

Cardinality: 0..1

Type: Reference(Patient, Group)

Claim.item.careTeamSequence

Applicable careTeam members

Definition: CareTeam members related to this service or product.

Requirements: Need to identify the individuals and their roles in the provision of the product or service.

Cardinality: 0..*

Type: positiveInt

Claim.item.diagnosisSequence

Applicable diagnoses

Definition: Diagnosis applicable for this service or product.

Requirements: Need to related the product or service to the associated diagnoses.

Cardinality: 0..*

Type: positiveInt

Claim.item.procedureSequence

Applicable procedures

Definition: Procedures applicable for this service or product.

Requirements: Need to provide any listed specific procedures to support the product or service being claimed.

Cardinality: 0..*

Type: positiveInt

Claim.item.informationSequence

Applicable exception and supporting information

Definition: Exceptions, special conditions and supporting information applicable for this service or product.

Requirements: Need to reference the supporting information items that relate directly to this product or service.

Cardinality: 0..*

Type: positiveInt

Claim.item.revenue

Revenue or cost center code

Definition: The type of revenue or cost center providing the product and/or service.

Requirements: Needed in the processing of institutional claims.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:ex-revenue-center

Claim.item.category

Benefit classification

Definition: Code to identify the general type of benefits under which products and services are provided.

Comments: Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

Requirements: Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:ex-benefitcategory

Claim.item.productOrService

Billing, service, product, or drug code

Definition: When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used.

Comments: If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

Requirements: Necessary to state what was provided or done.

Aliases: Drug Code, Bill Code, Service Code

Cardinality: 0..1

Type: CodeableConcept

Binding: example:service-uscls

Claim.item.productOrServiceEnd

End of a range of codes

Definition: This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claims.

Aliases: End of a range of Drug Code; Bill Code; Service Code

Cardinality: 0..1

Type: CodeableConcept

Binding: example:service-uscls

Claim.item.request

Request or Referral for Service

Definition: Request or Referral for Goods or Service to be rendered.

Requirements: May identify the service to be provided or provider authorization for the service.

Cardinality: 0..*

Type: Reference(DeviceRequest, MedicationRequest, NutritionOrder, ServiceRequest, VisionPrescription)

Claim.item.modifier

Product or service billing modifiers

Definition: Item typification or modifiers codes to convey additional context for the product or service.

Comments: For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours.

Requirements: To support inclusion of the item for adjudication or to charge an elevated fee.

Cardinality: 0..*

Type: CodeableConcept

Binding: example:claim-modifiers

Claim.item.programCode

Program the product or service is provided under

Definition: Identifies the program under which this may be recovered.

Comments: For example: Neonatal program, child dental program or drug users recovery program.

Requirements: Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.

Cardinality: 0..*

Type: CodeableConcept

Binding: example:ex-program-code

Claim.item.serviced[x]

Date or dates of service or product delivery

Definition: The date or dates when the service or product was supplied, performed or completed.

Requirements: Needed to determine whether the service or product was provided during the term of the insurance coverage.

Cardinality: 0..1

Type: date, Period

Mappings: w5=FiveWs.done[x]

Claim.item.location[x]

Place of service or where product was supplied

Definition: Where the product or service was provided.

Requirements: The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount.

Cardinality: 0..1

Type: CodeableConcept, Address, Reference(Location)

Binding: example:service-place

Mappings: w5=FiveWs.where[x]

Claim.item.patientPaid

Paid by the patient

Definition: The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services.

Requirements: Necessary to demonstrate that copayments, co-insurance and similar patient payments have been made or accounted for.

Cardinality: 0..1

Type: Money

Claim.item.quantity

Count of products or services

Definition: The number of repetitions of a service or product.

Requirements: Required when the product or service code does not convey the quantity provided.

Cardinality: 0..1

Type: Quantity(SimpleQuantity)

Claim.item.unitPrice

Fee, charge or cost per item

Definition: If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

Requirements: The amount charged to the patient by the provider for a single unit.

Cardinality: 0..1

Type: Money

Claim.item.factor

Price scaling factor

Definition: 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 amount.

Comments: To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

Requirements: When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

Cardinality: 0..1

Type: decimal

Claim.item.tax

Total tax

Definition: The total of taxes applicable for this product or service.

Requirements: Required when taxes are not embedded in the unit price or provided as a separate service.

Cardinality: 0..1

Type: Money

Claim.item.net

Total item cost

Definition: The total amount claimed for the group (if a grouper) or the line item. Net = unit price * quantity * factor.

Comments: For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

Requirements: Provides the total amount claimed for the group (if a grouper) or the line item.

Cardinality: 0..1

Type: Money

Claim.item.udi

Unique device identifier

Definition: Unique Device Identifiers associated with this line item.

Requirements: The UDI code allows the insurer to obtain device level information on the product supplied.

Cardinality: 0..*

Type: Reference(Device)

Claim.item.bodySite

Anatomical location

Definition: Physical location where the service is performed or applies.

Cardinality: 0..*

Type: BackboneElement

Claim.item.bodySite.site

Location

Definition: Physical service site on the patient (limb, tooth, etc.).

Comments: For example: Providing a tooth code, allows an insurer to identify a provider performing a filling on a tooth that was previously removed.

Requirements: Allows insurer to validate specific procedures.

Cardinality: 1..*

Type: CodeableReference

Binding: example:tooth

Claim.item.bodySite.subSite

Sub-location

Definition: A region or surface of the bodySite, e.g. limb region or tooth surface(s).

Requirements: Allows insurer to validate specific procedures.

Cardinality: 0..*

Type: CodeableConcept

Binding: example:surface

Claim.item.encounter

Encounters associated with the listed treatments

Definition: Healthcare encounters related to this claim.

Requirements: Used in some jurisdictions to link clinical events to claim items.

Cardinality: 0..*

Type: Reference(Encounter)

Mappings: workflow=Request.context

Claim.item.detail

Product or service provided

Definition: A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.

Requirements: The items to be processed for adjudication.

Cardinality: 0..*

Type: BackboneElement

Claim.item.detail.sequence

Item instance identifier

Definition: A number to uniquely identify item entries.

Requirements: Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse.

Cardinality: 1..1

Type: positiveInt

Claim.item.detail.traceNumber

Number for tracking

Definition: Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners.

Requirements: Allows partners to uniquely identify components for tracking.

Cardinality: 0..*

Type: Identifier

Claim.item.detail.revenue

Revenue or cost center code

Definition: The type of revenue or cost center providing the product and/or service.

Requirements: Needed in the processing of institutional claims.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:ex-revenue-center

Claim.item.detail.category

Benefit classification

Definition: Code to identify the general type of benefits under which products and services are provided.

Comments: Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

Requirements: Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:ex-benefitcategory

Claim.item.detail.productOrService

Billing, service, product, or drug code

Requirements: Necessary to state what was provided or done.

Aliases: Drug Code, Bill Code, Service Code

Cardinality: 0..1

Type: CodeableConcept

Binding: example:service-uscls

Claim.item.detail.productOrServiceEnd

End of a range of codes

Aliases: End of a range of Drug Code; Bill Code; Service Code

Cardinality: 0..1

Type: CodeableConcept

Binding: example:service-uscls

Claim.item.detail.modifier

Service/Product billing modifiers

Definition: Item typification or modifiers codes to convey additional context for the product or service.

Comments: For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.

Requirements: To support inclusion of the item for adjudication or to charge an elevated fee.

Cardinality: 0..*

Type: CodeableConcept

Binding: example:claim-modifiers

Claim.item.detail.programCode

Program the product or service is provided under

Definition: Identifies the program under which this may be recovered.

Comments: For example: Neonatal program, child dental program or drug users recovery program.

Requirements: Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.

Cardinality: 0..*

Type: CodeableConcept

Binding: example:ex-program-code

Claim.item.detail.patientPaid

Paid by the patient

Definition: The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services.

Requirements: Necessary to demonstrate that copayments, co-insurance and similar patient payments have been made or accounted for.

Cardinality: 0..1

Type: Money

Claim.item.detail.quantity

Count of products or services

Definition: The number of repetitions of a service or product.

Requirements: Required when the product or service code does not convey the quantity provided.

Cardinality: 0..1

Type: Quantity(SimpleQuantity)

Claim.item.detail.unitPrice

Fee, charge or cost per item

Definition: If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

Requirements: The amount charged to the patient by the provider for a single unit.

Cardinality: 0..1

Type: Money

Claim.item.detail.factor

Price scaling factor

Comments: To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

Requirements: When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

Cardinality: 0..1

Type: decimal

Claim.item.detail.tax

Total tax

Definition: The total of taxes applicable for this product or service.

Requirements: Required when taxes are not embedded in the unit price or provided as a separate service.

Cardinality: 0..1

Type: Money

Claim.item.detail.net

Total item cost

Definition: The total amount claimed for the group (if a grouper) or the line item.detail. Net = unit price * quantity * factor.

Comments: For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

Requirements: Provides the total amount claimed for the group (if a grouper) or the line item.

Cardinality: 0..1

Type: Money

Claim.item.detail.udi

Unique device identifier

Definition: Unique Device Identifiers associated with this line item.

Requirements: The UDI code allows the insurer to obtain device level information on the product supplied.

Cardinality: 0..*

Type: Reference(Device)

Claim.item.detail.subDetail

Product or service provided

Definition: A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.

Requirements: The items to be processed for adjudication.

Cardinality: 0..*

Type: BackboneElement

Claim.item.detail.subDetail.sequence

Item instance identifier

Definition: A number to uniquely identify item entries.

Requirements: Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse.

Cardinality: 1..1

Type: positiveInt

Claim.item.detail.subDetail.traceNumber

Number for tracking

Definition: Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners.

Requirements: Allows partners to uniquely identify components for tracking.

Cardinality: 0..*

Type: Identifier

Claim.item.detail.subDetail.revenue

Revenue or cost center code

Definition: The type of revenue or cost center providing the product and/or service.

Requirements: Needed in the processing of institutional claims.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:ex-revenue-center

Claim.item.detail.subDetail.category

Benefit classification

Definition: Code to identify the general type of benefits under which products and services are provided.

Comments: Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

Requirements: Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:ex-benefitcategory

Claim.item.detail.subDetail.productOrService

Billing, service, product, or drug code

Requirements: Necessary to state what was provided or done.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:service-uscls

Claim.item.detail.subDetail.productOrServiceEnd

End of a range of codes

Aliases: End of a range of Drug Code; Bill Code; Service Code

Cardinality: 0..1

Type: CodeableConcept

Binding: example:service-uscls

Claim.item.detail.subDetail.modifier

Service/Product billing modifiers

Definition: Item typification or modifiers codes to convey additional context for the product or service.

Comments: For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.

Requirements: To support inclusion of the item for adjudication or to charge an elevated fee.

Cardinality: 0..*

Type: CodeableConcept

Binding: example:claim-modifiers

Claim.item.detail.subDetail.programCode

Program the product or service is provided under

Definition: Identifies the program under which this may be recovered.

Comments: For example: Neonatal program, child dental program or drug users recovery program.

Requirements: Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.

Cardinality: 0..*

Type: CodeableConcept

Binding: example:ex-program-code

Claim.item.detail.subDetail.patientPaid

Paid by the patient

Definition: The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services.

Requirements: Necessary to demonstrate that copayments, co-insurance and similar patient payments have been made or accounted for.

Cardinality: 0..1

Type: Money

Claim.item.detail.subDetail.quantity

Count of products or services

Definition: The number of repetitions of a service or product.

Requirements: Required when the product or service code does not convey the quantity provided.

Cardinality: 0..1

Type: Quantity(SimpleQuantity)

Claim.item.detail.subDetail.unitPrice

Fee, charge or cost per item

Definition: If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

Requirements: The amount charged to the patient by the provider for a single unit.

Cardinality: 0..1

Type: Money

Claim.item.detail.subDetail.factor

Price scaling factor

Comments: To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

Requirements: When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

Cardinality: 0..1

Type: decimal

Claim.item.detail.subDetail.tax

Total tax

Definition: The total of taxes applicable for this product or service.

Requirements: Required when taxes are not embedded in the unit price or provided as a separate service.

Cardinality: 0..1

Type: Money

Claim.item.detail.subDetail.net

Total item cost

Definition: The total amount claimed for line item.detail.subDetail. Net = unit price * quantity * factor.

Comments: For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

Requirements: Provides the total amount claimed for the group (if a grouper) or the line item.

Cardinality: 0..1

Type: Money

Claim.item.detail.subDetail.udi

Unique device identifier

Definition: Unique Device Identifiers associated with this line item.

Requirements: The UDI code allows the insurer to obtain device level information on the product supplied.

Cardinality: 0..*

Type: Reference(Device)

Claim.total

Total claim cost

Definition: The total value of the all the items in the claim.

Requirements: Used for control total purposes.

Cardinality: 0..1

Type: Money