---
type: "resource-definitions"
title: "Claim Definitions"
resource: "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](/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](/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](/code)
**Binding:** required:[fm-status](/valueset-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](/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](/CodeableConcept)
**Binding:** extensible:[claim-type](/valueset-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](/CodeableConcept)
**Binding:** example:[claim-subtype](/valueset-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](/code)
**Binding:** required:[claim-use](/valueset-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](/Patient), [Group](/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](/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](/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](/Practitioner), [PractitionerRole](/PractitionerRole), [Patient](/Patient), [RelatedPerson](/RelatedPerson))
**Mappings:** w5=FiveWs.author
## Claim.insurer
Target
**Definition:** The Insurer who is target of the request.
**Cardinality:** 0..1
**Type:** Reference([Organization](/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](/Practitioner), [PractitionerRole](/PractitionerRole), [Organization](/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](/CodeableConcept)
**Binding:** preferred:[process-priority](/valueset-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](/CodeableConcept)
**Binding:** preferred:[fundsreserve](/valueset-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](/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](/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](/CodeableConcept)
**Binding:** example:[related-claim-relationship](/valueset-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](/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](/DeviceRequest), [MedicationRequest](/MedicationRequest), [ServiceRequest](/ServiceRequest), [VisionPrescription](/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](/DeviceRequest), [MedicationRequest](/MedicationRequest), [ServiceRequest](/ServiceRequest), [VisionPrescription](/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](/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](/CodeableConcept)
**Binding:** example:[payeetype](/valueset-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](/Practitioner), [PractitionerRole](/PractitionerRole), [Organization](/Organization), [Patient](/Patient), [RelatedPerson](/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](/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](/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](/Location), [Organization](/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](/CodeableConcept)
**Binding:** example:[ex-diagnosisrelatedgroup](/valueset-ex-diagnosisrelatedgroup)
## Claim.event
Event information
**Definition:** Information code for an event with a corresponding date or period.
**Cardinality:** 0..*
**Type:** [BackboneElement](/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](/CodeableConcept)
**Binding:** example:[datestype](/valueset-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](/dateTime), [Period](/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](/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](/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](/Practitioner), [PractitionerRole](/PractitionerRole), [Organization](/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](/CodeableConcept)
**Binding:** preferred:[claim-careteamrole](/valueset-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](/CodeableConcept)
**Binding:** example:[provider-qualification](/valueset-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](/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](/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](/CodeableConcept)
**Binding:** preferred:[claim-informationcategory](/valueset-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](/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](/CodeableConcept)
**Binding:** example:[claim-exception](/valueset-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](/dateTime), [Period](/Period), [Timing](/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](/CodeableConcept)
**Binding:** example:[missing-tooth-reason](/valueset-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](/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](/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](/CodeableConcept), Reference([Condition](/Condition))
**Binding:** example:[icd-10](/valueset-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](/CodeableConcept)
**Binding:** preferred:[ex-diagnosistype](/valueset-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](/CodeableConcept)
**Binding:** preferred:[ex-diagnosis-on-admission](/valueset-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](/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](/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](/CodeableConcept)
**Binding:** preferred:[ex-procedure-type](/valueset-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](/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](/CodeableConcept), Reference([Procedure](/Procedure))
**Binding:** example:[icd-10-procedures](/valueset-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](/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](/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](/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](/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](/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](/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](/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](/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](/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](/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](/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](/CodeableConcept)
**Binding:** extensible:[v3-ActIncidentCode](/valueset-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](/Address), Reference([Location](/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](/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](/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](/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](/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](/Patient), [Group](/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](/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](/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](/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](/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](/CodeableConcept)
**Binding:** example:[ex-revenue-center](/valueset-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](/CodeableConcept)
**Binding:** example:[ex-benefitcategory](/valueset-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](/CodeableConcept)
**Binding:** example:[service-uscls](/valueset-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](/CodeableConcept)
**Binding:** example:[service-uscls](/valueset-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](/DeviceRequest), [MedicationRequest](/MedicationRequest), [NutritionOrder](/NutritionOrder), [ServiceRequest](/ServiceRequest), [VisionPrescription](/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](/CodeableConcept)
**Binding:** example:[claim-modifiers](/valueset-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](/CodeableConcept)
**Binding:** example:[ex-program-code](/valueset-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](/date), [Period](/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](/CodeableConcept), [Address](/Address), Reference([Location](/Location))
**Binding:** example:[service-place](/valueset-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](/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](/Quantity)([SimpleQuantity](/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](/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](/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](/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](/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](/Device))
## Claim.item.bodySite
Anatomical location
**Definition:** Physical location where the service is performed or applies.
**Cardinality:** 0..*
**Type:** [BackboneElement](/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](/CodeableReference)
**Binding:** example:[tooth](/valueset-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](/CodeableConcept)
**Binding:** example:[surface](/valueset-surface)
## Claim.item.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](/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](/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](/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](/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](/CodeableConcept)
**Binding:** example:[ex-revenue-center](/valueset-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](/CodeableConcept)
**Binding:** example:[ex-benefitcategory](/valueset-ex-benefitcategory)
## Claim.item.detail.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](/CodeableConcept)
**Binding:** example:[service-uscls](/valueset-service-uscls)
## Claim.item.detail.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](/CodeableConcept)
**Binding:** example:[service-uscls](/valueset-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](/CodeableConcept)
**Binding:** example:[claim-modifiers](/valueset-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](/CodeableConcept)
**Binding:** example:[ex-program-code](/valueset-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](/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](/Quantity)([SimpleQuantity](/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](/Money)
## Claim.item.detail.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](/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](/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](/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](/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](/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](/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](/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](/CodeableConcept)
**Binding:** example:[ex-revenue-center](/valueset-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](/CodeableConcept)
**Binding:** example:[ex-benefitcategory](/valueset-ex-benefitcategory)
## Claim.item.detail.subDetail.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.
**Cardinality:** 0..1
**Type:** [CodeableConcept](/CodeableConcept)
**Binding:** example:[service-uscls](/valueset-service-uscls)
## Claim.item.detail.subDetail.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](/CodeableConcept)
**Binding:** example:[service-uscls](/valueset-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](/CodeableConcept)
**Binding:** example:[claim-modifiers](/valueset-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](/CodeableConcept)
**Binding:** example:[ex-program-code](/valueset-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](/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](/Quantity)([SimpleQuantity](/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](/Money)
## Claim.item.detail.subDetail.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](/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](/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](/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](/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](/Money)