Path | Short | Definition | Comments |
---|---|---|---|
Claim, Pre-determination or Pre-authorization | A provider issued list of professional services and products which have been provided, or to be provided, to a patient which is sent to an insurer for reimbursement. | The Claim resource fulfills three information request requirements: Claim - a request for ajudication for reimbursement for producst and/or services provided; Preauthorization - a request to authorize the future provision of products and/or servcies including an anticipated adjudication; and, Predetermination - a request for a non-bind adjudication of possible future products and/or services. | |
identifier | Business Identifier for claim | A unique identifier assigned to this claim. | |
status | active | cancelled | draft | entered-in-error | The status of the resource instance. | This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. |
type | Category or discipline | The category of claim, e.g. oral, pharmacy, vision, institutional, professional. | The majority of jurisdictions use: oral, pharmacy, vision, professional and institutional, or variants on those terms, as the general styles of claims. The valueset is extensible to accommodate other jurisdictional requirements. |
subType | More granular claim type | A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service. | This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type. |
use | claim | preauthorization | predetermination | A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future. | |
patient | The recipient of the products and services | The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for forecast reimburement is sought. | |
billablePeriod | Relevant time frame for the claim | The period for which charges are being submitted. | Typically this would be today or in the past for a claim, and today or in the future for preauthorizations and prodeterminations. Typically line item dates of service should fall within the billing period if one is specified. |
created | Resource creation date | The date this resource was created. | 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. |
enterer | Author of the claim | Individual who created the claim, predetermination or preauthorization. | |
insurer | Target | The Insurer who is target of the request. | |
provider | Party responsible for the claim | The provider which is responsible for the claim, predetermination or preauthorization. | Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below. |
priority | Desired processing ugency | The provider-required urgency of processing the request. Typical values include: stat, routine deferred. | If a claim processor is unable to complete the processing as per the priority then they should generate and error and not process the request. |
fundsReserve | For whom to reserve funds | A code to indicate whether and for whom funds are to be reserved for future claims. | This field is only used for preauthorizations. |
related | Prior or corollary claims | Other claims which are related to this claim such as prior submissions or claims for related services or for the same event. | For example, for the original treatment and follow-up exams. |
related.id | Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | |
related.extension | Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
related.modifierExtension | Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
related.claim | Reference to the related claim | Reference to a related claim. | |
related.relationship | How the reference claim is related | A code to convey how the claims are related. | For example, prior claim or umbrella. |
related.reference | File or case reference | An alternate organizational reference to the case or file to which this particular claim pertains. | For example, Property/Casualty insurer claim # or Workers Compensation case # . |
prescription | Prescription authorizing services and products | Prescription to support the dispensing of pharmacy, device or vision products. | |
originalPrescription | Original prescription if superseded by fulfiller | Original prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or products. | For example, a physician may prescribe a medication which the pharmacy determines is contraindicated, or for which the patient has an intolerance, and therefor 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'. |
payee | Recipient of benefits payable | The party to be reimbursed for cost of the products and services according to the terms of the policy. | Often providers agree to receive the benefits payable to reduce the near-term costs to the patient. The insurer may decline to pay the provider are choose to pay the subscriber instead. |
payee.id | Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | |
payee.extension | Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
payee.modifierExtension | Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
payee.type | Category of recipient | Type of Party to be reimbursed: subscriber, provider, other. | |
payee.party | Recipient reference | Reference to the individual or organization to whom any payment will be made. | Not required if the payee is 'subscriber' or 'provider'. |
referral | Treatment referral | A reference to a referral resource. | The referral resource which lists the date, practitioner, reason and other supporting information. |
facility | Servicing facility | Facility where the services were provided. | |
careTeam | Members of the care team | The members of the team who provided the products and services. | |
careTeam.id | Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | |
careTeam.extension | Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
careTeam.modifierExtension | Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
careTeam.sequence | Order of care team | A number to uniquely identify care team entries. | |
careTeam.provider | Practitioner or organization | Member of the team who provided the product or service. | |
careTeam.responsible | Indicator of the lead practitioner | The party who is billing and/or responsible for the claimed products or services. | Responsible might not be required when there is only a single provider listed. |
careTeam.role | Function within the team | The lead, assisting or supervising practitioner and their discipline if a multidisciplinary team. | Role might not be required when there is only a single provider listed. |
careTeam.qualification | Practitioner credential or specialization | The qualification of the practitioner which is applicable for this service. | |
supportingInfo | Supporting information | Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. | Often there are multiple jurisdiction specific valuesets which are required. |
supportingInfo.id | Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | |
supportingInfo.extension | Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
supportingInfo.modifierExtension | Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
supportingInfo.sequence | Information instance identifier | A number to uniquely identify supporting information entries. | |
supportingInfo.category | Classification of the supplied information | The general class of the information supplied: information; exception; accident, employment; onset, etc. | This may contain a category for the local bill type codes. |
supportingInfo.code | Type of information | System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought. | |
supportingInfo.timing[x] | When it occurred | The date when or period to which this information refers. | |
supportingInfo.value[x] | Data to be provided | Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data. | 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. |
supportingInfo.reason | Explanation for the information | Provides the reason in the situation where a reason code is required in addition to the content. | For example: the reason for the additional stay, or why a tooth is missing. |
diagnosis | Pertinent diagnosis information | Information about diagnoses relevant to the claim items. | |
diagnosis.id | Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | |
diagnosis.extension | Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
diagnosis.modifierExtension | Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
diagnosis.sequence | Diagnosis instance identifier | A number to uniquely identify diagnosis entries. | Diagnosis are presented in list order to their expected importance: primary, secondary, etc. |
diagnosis.diagnosis[x] | Nature of illness or problem | The nature of illness or problem in a coded form or as a reference to an external defined Condition. | |
diagnosis.type | Timing or nature of the diagnosis | When the condition was observed or the relative ranking. | For example: admitting, primary, secondary, discharge. |
diagnosis.onAdmission | Present on admission | Indication of whether the diagnosis was present on admission to a facility. | |
diagnosis.packageCode | Package billing code | 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. | For example DRG (Diagnosis Related Group) or a bundled billing code. A patient may have a diagnosis of a Myocardio-infarction and a DRG for HeartAttack would 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. |
procedure | Clinical procedures performed | Procedures performed on the patient relevant to the billing items with the claim. | |
procedure.id | Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | |
procedure.extension | Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
procedure.modifierExtension | Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
procedure.sequence | Procedure instance identifier | A number to uniquely identify procedure entries. | |
procedure.type | Category of Procedure | When the condition was observed or the relative ranking. | For example: primary, secondary. |
procedure.date | When the procedure was performed | Date and optionally time the procedure was performed. | |
procedure.procedure[x] | Specific clinical procedure | The code or reference to a Procedure resource which identifies the clinical intervention performed. | |
procedure.udi | Unique device identifier | Unique Device Identifiers associated with this line item. | |
insurance | Patient insurance information | Financial instruments for reimbursement for the health care products and services specified on the claim. | 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. |
insurance.id | Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | |
insurance.extension | Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
insurance.modifierExtension | Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
insurance.sequence | Insurance instance identifier | A number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order. | |
insurance.focal | Coverage to be used for adjudication | A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true. | A patient may (will) have multiple insurance policies which provide reimburement 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. |
insurance.identifier | Pre-assigned Claim number | The business identifier to be used when the claim is sent for adjudication against this insurance policy. | Only required in jursidictions 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'. |
insurance.coverage | Insurance information | 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. | |
insurance.businessArrangement | Additional provider contract number | A business agreement number established between the provider and the insurer for special business processing purposes. | |
insurance.preAuthRef | Prior authorization reference number | 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. | 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. |
insurance.claimResponse | Adjudication results | The result of the adjudication of the line items for the Coverage specified in this insurance. | Must not be specified when 'focal=true' for this insurance. |
accident | Details of the event | Details of a accident which resulted in injuries which required the products and services listed in the claim. | |
accident.id | Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | |
accident.extension | Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
accident.modifierExtension | Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
accident.date | When the incident occurred | Date of an accident event related to the products and services contained in the claim. | The date of the accident has to preceed the dates of the products and services but within a reasonable timeframe. |
accident.type | The nature of the accident | The type or context of the accident event for the purposes of selection of potential insurance coverages and determination of coordination between insurers. | |
accident.location[x] | Where the event occurred | The physical location of the accident event. | |
item | Product or service provided | A claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-details. | |
item.id | Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | |
item.extension | Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
item.modifierExtension | Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
item.sequence | Item instance identifier | A number to uniquely identify item entries. | |
item.careTeamSequence | Applicable careTeam members | CareTeam members related to this service or product. | |
item.diagnosisSequence | Applicable diagnoses | Diagnoses applicable for this service or product. | |
item.procedureSequence | Applicable procedures | Procedures applicable for this service or product. | |
item.informationSequence | Applicable exception and supporting information | Exceptions, special conditions and supporting information applicable for this service or product. | |
item.revenue | Revenue or cost center code | The type of revenue or cost center providing the product and/or service. | |
item.category | Benefit classification | Code to identify the general type of benefits under which products and services are provided. | Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage. |
item.productOrService | Billing, service, product, or drug code | When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item. | 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'. |
item.modifier | Product or service billing modifiers | Item typification or modifiers codes to convey additional context for the product or service. | 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. |
item.programCode | Program the product or service is provided under | Identifies the program under which this may be recovered. | For example: Neonatal program, child dental program or drug users recovery program. |
item.serviced[x] | Date or dates of service or product delivery | The date or dates when the service or product was supplied, performed or completed. | |
item.location[x] | Place of service or where product was supplied | Where the product or service was provided. | |
item.quantity | Count of products or services | The number of repetitions of a service or product. | |
item.unitPrice | Fee, charge or cost per item | 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. | |
item.factor | Price scaling factor | 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. | To show a 10% Senior's discount, the value entered is: 0.90 (1.00 - 0.10). |
item.net | Total item cost | The quantity times the unit price for an additional service or product or charge. | For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied. |
item.udi | Unique device identifier | Unique Device Identifiers associated with this line item. | |
item.bodySite | Anatomical location | Physical service site on the patient (limb, tooth, etc.). | For example: Providing a tooth code, allows an insurer to identify a provider performing a filling on a tooth that was previously removed. |
item.subSite | Anatomical sub-location | A region or surface of the bodySite, e.g. limb region or tooth surface(s). | |
item.encounter | Encounters related to this billed item | The Encounters during which this Claim was created or to which the creation of this record is tightly associated. | 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. |
item.detail | Product or service provided | A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items. | |
item.detail.id | Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | |
item.detail.extension | Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
item.detail.modifierExtension | Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
item.detail.sequence | Item instance identifier | A number to uniquely identify item entries. | |
item.detail.revenue | Revenue or cost center code | The type of revenue or cost center providing the product and/or service. | |
item.detail.category | Benefit classification | Code to identify the general type of benefits under which products and services are provided. | Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage. |
item.detail.productOrService | Billing, service, product, or drug code | When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item. | 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'. |
item.detail.modifier | Service/Product billing modifiers | Item typification or modifiers codes to convey additional context for the product or service. | 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. |
item.detail.programCode | Program the product or service is provided under | Identifies the program under which this may be recovered. | For example: Neonatal program, child dental program or drug users recovery program. |
item.detail.quantity | Count of products or services | The number of repetitions of a service or product. | |
item.detail.unitPrice | Fee, charge or cost per item | 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. | |
item.detail.factor | Price scaling factor | 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. | To show a 10% Senior's discount, the value entered is: 0.90 (1.00 - 0.10). |
item.detail.net | Total item cost | The quantity times the unit price for an additional service or product or charge. | For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied. |
item.detail.udi | Unique device identifier | Unique Device Identifiers associated with this line item. | |
item.detail.subDetail | Product or service provided | A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items. | |
item.detail.subDetail.id | Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | |
item.detail.subDetail.extension | Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
item.detail.subDetail.modifierExtension | Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
item.detail.subDetail.sequence | Item instance identifier | A number to uniquely identify item entries. | |
item.detail.subDetail.revenue | Revenue or cost center code | The type of revenue or cost center providing the product and/or service. | |
item.detail.subDetail.category | Benefit classification | Code to identify the general type of benefits under which products and services are provided. | Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage. |
item.detail.subDetail.productOrService | Billing, service, product, or drug code | When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item. | 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'. |
item.detail.subDetail.modifier | Service/Product billing modifiers | Item typification or modifiers codes to convey additional context for the product or service. | 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. |
item.detail.subDetail.programCode | Program the product or service is provided under | Identifies the program under which this may be recovered. | For example: Neonatal program, child dental program or drug users recovery program. |
item.detail.subDetail.quantity | Count of products or services | The number of repetitions of a service or product. | |
item.detail.subDetail.unitPrice | Fee, charge or cost per item | 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. | |
item.detail.subDetail.factor | Price scaling factor | 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. | To show a 10% Senior's discount, the value entered is: 0.90 (1.00 - 0.10). |
item.detail.subDetail.net | Total item cost | The quantity times the unit price for an additional service or product or charge. | For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied. |
item.detail.subDetail.udi | Unique device identifier | Unique Device Identifiers associated with this line item. | |
total | Total claim cost | The total value of the all the items in the claim. |
The Claim is used by providers and payors, insurers, to exchange the financial information, and supporting clinical information, regarding the provision of health care services with payors and for reporting to regulatory bodies and firms which provide data analytics. The primary uses of this resource is to support eClaims, the exchange of information relating to the proposed or actual provision of healthcare-related goods and services for patients to their benefit payors, insurers and national health programs, for treatment payment planning and reimbursement.
The Claim resource is a "request" resource from a FHIR workflow perspective - see Workflow Request.
The Claim resource may be interpreted differently depending on its intended use (and the Claim.use element contains the code to indicate):
The Claim also supports:
Mapping to other Claim specifications: Mappings are currently maintained by the Financial Management Work Group to UB04 and CMS1500 and are available at https://confluence.hl7.org/display/FM/FHIR+Resource+Development. Mappings to other specifications may be made available where IP restrictions permit.
Additional information regarding electronic claims content and usage may be found at:
The Claim resource is used to request the adjudication and/or authorization of a set of healthcare-related goods and services for a patient against the patient's insurance coverages, or to request what the adjudication would be for a supplied set of goods or services should they be actually supplied to the patient.
When requesting whether the patient's coverage is inforce, whether it is valid at this or a specified date, or requesting the benefit details or preauthorization requirements associated with a coverage CoverageEligibilityRequest should be used instead.
When using the resources for reporting and transferring claims data, which may have originated in some standard other than FHIR, the Claim resource is useful if only the request side of the information exchange is of interest. If, however, both the request and the adjudication information is to be reported then the ExplanationOfBenefit should be used instead.
For reporting out to patients or transferring data to patient centered applications, such as patient health Record (PHR) application, the ExplanationOfBenefit should be used instead of the Claim and ClaimResponse resources as those resources may contain provider and payer specific information which is not appropriate for sharing with the patient.
The eClaim domain includes a number of related resources
Claim | A suite of goods and services and insurances coverages under which adjudication or authorization is requested. |
CoverageEligibilityRequest | A request to a payor to: ascertain whether a coverage is in-force at the current or at a specified time; list the table of benefits; determine whether coverage is provided for specified categories or specific services; and whether preauthorization is required, and if so what supporting information would be required. |
ClaimResponse | A payor's adjudication and/or authorization response to the suite of services provided in a Claim. Typically the ClaimResponse references the Claim but does not duplicate the clinical or financial information provided in the claim. |
ExplanationOfBenefit | This resource combines the information from the Claim and the ClaimResponse, stripping out any provider or payor proprietary information, into a unified information model suitable for use for: patient reporting; transferring information to a Patient Health Record system; and, supporting complete claim and adjudication information exchange with regulatory and analytics organizations and other parts of the provider's organization. |
care-team | Member of the CareTeam | Claim.careTeam.provider |
created | The creation date for the Claim | Claim.created |
detail-udi | UDI associated with a line item detail product or service | Claim.item.detail.udi |
encounter | Encounters associated with a billed line item | Claim.item.encounter |
enterer | The party responsible for the entry of the Claim | Claim.enterer |
facility | Facility where the products or services were/are to be provided | Claim.facility |
identifier | The primary identifier of the financial resource | Claim.identifier |
insurer | The target payor/insurer for the Claim | Claim.insurer |
item-udi | UDI associated with a line item product or service | Claim.item.udi |
patient | Patient receiving the products or services | Claim.patient |
payee | The party receiving any payment for the Claim | Claim.payee.party |
priority | Processing priority requested | Claim.priority |
procedure-udi | UDI associated with a procedure | Claim.procedure.udi |
provider | Provider responsible for the Claim | Claim.provider |
status | The status of the Claim instance. | Claim.status |
subdetail-udi | UDI associated with a line item detail subdetail product or service | Claim.item.detail.subDetail.udi |
use | The kind of financial resource | Claim.use |