Claim R5 (FHIR) at fhirtruck

Path

Claim

Id

Claim

Cardinality

0 - *

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.

Comment

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.

Constraint

dom-2 [error]

If the resource is contained in another resource, it SHALL NOT contain nested Resources

dom-3 [error]

If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource

dom-4 [error]

If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated

dom-5 [error]

If a resource is contained in another resource, it SHALL NOT have a security label

dom-6 [warning]

A resource should have narrative for robust management

Path

Claim.identifier

Id

Claim.identifier

Type

Identifier

Cardinality

0 - *

Definition

A unique identifier assigned to this claim.

Comment

Requirements

Allows claims to be distinguished and referenced.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

use

Summary: The element appears in the summary view

code

usual | official | temp | secondary | old (If known)

type

CodeableConcept

Description of identifier

coding

List: This element is a list and more than one value can be provided

Coding

Code defined by a terminology system

system

uri

Identity of the terminology system

version

string

Version of the system - if relevant

code

Symbol in syntax defined by the system

display

string

Representation defined by the system

userSelected

boolean

If this coding was chosen directly by the user

system

uri

The namespace for the identifier value

value

string

The value that is unique

period

Period

Time period when id is/was valid for use

start

dateTime

Starting time with inclusive boundary

end

dateTime

End time with inclusive boundary, if not ongoing

assigner

Reference

Organization that issued id (may be just text)

reference

string

Literal reference, Relative, internal or absolute URL

type

uri

Type the reference refers to (e.g. "Patient") - must be a resource in resources

identifier

Identifier

Logical reference, when literal reference is not known

Path

Claim.identifier.Identifier.assigner.Reference.identifier

Id

Reference.identifier

Type

Identifier

Cardinality

0 - 1

Definition

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

Comment

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). This element only allows for a single identifier. In the case where additional identifers are required, use the [http://hl7.org/fhir/StructureDefinition/additionalIdentifier](http://hl7.org/fhir/extensions/StructureDefinition-additionalIdentifier.html) extension.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Condition

ref-2

use

code

usual | official | temp | secondary | old (If known)

type

CodeableConcept

Description of identifier

system

uri

The namespace for the identifier value

value

string

The value that is unique

period

Period

Time period when id is/was valid for use

assigner

Reference

Organization that issued id (may be just text)

display

string

Text alternative for the resource

Path

Claim.traceNumber

Id

Claim.traceNumber

Type

Identifier

Cardinality

0 - *

Definition

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

Comment

Requirements

Allows partners to uniquely identify components for tracking.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

use

code

usual | official | temp | secondary | old (If known)

type

CodeableConcept

Description of identifier

coding

Coding

Code defined by a terminology system

system

uri

Identity of the terminology system

version

string

Version of the system - if relevant

code

Symbol in syntax defined by the system

display

string

Representation defined by the system

userSelected

boolean

If this coding was chosen directly by the user

system

uri

The namespace for the identifier value

value

string

The value that is unique

period

Period

Time period when id is/was valid for use

start

dateTime

Starting time with inclusive boundary

end

dateTime

End time with inclusive boundary, if not ongoing

assigner

Reference

Organization that issued id (may be just text)

reference

string

Literal reference, Relative, internal or absolute URL

type

uri

Type the reference refers to (e.g. "Patient") - must be a resource in resources

identifier

Identifier

Logical reference, when literal reference is not known

Path

Claim.traceNumber.Identifier.assigner.Reference.identifier

Id

Reference.identifier

Type

Identifier

Cardinality

0 - 1

Definition

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

Comment

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). This element only allows for a single identifier. In the case where additional identifers are required, use the [http://hl7.org/fhir/StructureDefinition/additionalIdentifier](http://hl7.org/fhir/extensions/StructureDefinition-additionalIdentifier.html) extension.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Condition

ref-2

use

code

usual | official | temp | secondary | old (If known)

type

CodeableConcept

Description of identifier

system

uri

The namespace for the identifier value

value

string

The value that is unique

period

Period

Time period when id is/was valid for use

assigner

Reference

Organization that issued id (may be just text)

display

string

Text alternative for the resource

Path

Claim.status

Id

Claim.status

Type

code

Cardinality

1 - 1

Definition

The status of the resource instance.

Comment

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'.

Binding

Strength

required

Description

A code specifying the state of the resource instance.

ValueSet

http://hl7.org/fhir/ValueSet/fm-status|5.0.0

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.type

Id

Claim.type

Type

CodeableConcept

Cardinality

1 - 1

Definition

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

Comment

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.

Binding

Strength

extensible

Description

The type or discipline-style of the claim.

ValueSet

http://hl7.org/fhir/ValueSet/claim-type

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

coding

Coding

Code defined by a terminology system

system

uri

Identity of the terminology system

version

string

Version of the system - if relevant

code

Symbol in syntax defined by the system

display

string

Representation defined by the system

userSelected

boolean

If this coding was chosen directly by the user

Path

Claim.subType

Id

Claim.subType

Type

CodeableConcept

Cardinality

0 - 1

Definition

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

Comment

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.

Binding

Strength

example

Description

A more granular claim typecode.

ValueSet

http://hl7.org/fhir/ValueSet/claim-subtype

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

coding

Coding

Code defined by a terminology system

system

uri

Identity of the terminology system

version

string

Version of the system - if relevant

code

Symbol in syntax defined by the system

display

string

Representation defined by the system

userSelected

boolean

If this coding was chosen directly by the user

Path

Claim.use

Id

Claim.use

Type

code

Cardinality

1 - 1

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.

Comment

Requirements

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

Binding

Strength

required

Description

The purpose of the Claim: predetermination, preauthorization, claim.

ValueSet

http://hl7.org/fhir/ValueSet/claim-use|5.0.0

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.patient

Id

Claim.patient

Type

Reference

Cardinality

1 - 1

Definition

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

Comment

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.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

reference

string

Literal reference, Relative, internal or absolute URL

type

uri

Type the reference refers to (e.g. "Patient") - must be a resource in resources

identifier

Identifier

Logical reference, when literal reference is not known

Path

Claim.patient.Reference.identifier

Id

Reference.identifier

Type

Identifier

Cardinality

0 - 1

Definition

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

Comment

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). This element only allows for a single identifier. In the case where additional identifers are required, use the [http://hl7.org/fhir/StructureDefinition/additionalIdentifier](http://hl7.org/fhir/extensions/StructureDefinition-additionalIdentifier.html) extension.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Condition

ref-2

use

code

usual | official | temp | secondary | old (If known)

type

CodeableConcept

Description of identifier

system

uri

The namespace for the identifier value

value

string

The value that is unique

period

Period

Time period when id is/was valid for use

start

dateTime

Starting time with inclusive boundary

end

dateTime

End time with inclusive boundary, if not ongoing

assigner

Reference

Organization that issued id (may be just text)

reference

string

Literal reference, Relative, internal or absolute URL

type

uri

Type the reference refers to (e.g. "Patient") - must be a resource in resources

identifier

Identifier

Logical reference, when literal reference is not known

Path

Claim.patient.Reference.identifier.Identifier.assigner.Reference.identifier

Id

Reference.identifier

Type

Identifier

Cardinality

0 - 1

Definition

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

Comment

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). This element only allows for a single identifier. In the case where additional identifers are required, use the [http://hl7.org/fhir/StructureDefinition/additionalIdentifier](http://hl7.org/fhir/extensions/StructureDefinition-additionalIdentifier.html) extension.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Condition

ref-2

display

string

Text alternative for the resource

display

string

Text alternative for the resource

Path

Claim.billablePeriod

Id

Claim.billablePeriod

Type

Period

Cardinality

0 - 1

Definition

The period for which charges are being submitted.

Comment

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.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

start

dateTime

Starting time with inclusive boundary

end

dateTime

End time with inclusive boundary, if not ongoing

Path

Claim.created

Id

Claim.created

Type

dateTime

Cardinality

1 - 1

Definition

The date this resource was created.

Comment

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.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.enterer

Id

Claim.enterer

Type

Reference

Cardinality

0 - 1

Definition

Individual who created the claim, predetermination or preauthorization.

Comment

Requirements

Some jurisdictions require the contact information for personnel completing claims.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

reference

string

Literal reference, Relative, internal or absolute URL

type

uri

Type the reference refers to (e.g. "Patient") - must be a resource in resources

identifier

Identifier

Logical reference, when literal reference is not known

Path

Claim.enterer.Reference.identifier

Id

Reference.identifier

Type

Identifier

Cardinality

0 - 1

Definition

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

Comment

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). This element only allows for a single identifier. In the case where additional identifers are required, use the [http://hl7.org/fhir/StructureDefinition/additionalIdentifier](http://hl7.org/fhir/extensions/StructureDefinition-additionalIdentifier.html) extension.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Condition

ref-2

use

code

usual | official | temp | secondary | old (If known)

type

CodeableConcept

Description of identifier

system

uri

The namespace for the identifier value

value

string

The value that is unique

period

Period

Time period when id is/was valid for use

start

dateTime

Starting time with inclusive boundary

end

dateTime

End time with inclusive boundary, if not ongoing

assigner

Reference

Organization that issued id (may be just text)

reference

string

Literal reference, Relative, internal or absolute URL

type

uri

Type the reference refers to (e.g. "Patient") - must be a resource in resources

identifier

Identifier

Logical reference, when literal reference is not known

Path

Claim.enterer.Reference.identifier.Identifier.assigner.Reference.identifier

Id

Reference.identifier

Type

Identifier

Cardinality

0 - 1

Definition

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

Comment

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). This element only allows for a single identifier. In the case where additional identifers are required, use the [http://hl7.org/fhir/StructureDefinition/additionalIdentifier](http://hl7.org/fhir/extensions/StructureDefinition-additionalIdentifier.html) extension.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Condition

ref-2

display

string

Text alternative for the resource

display

string

Text alternative for the resource

Path

Claim.insurer

Id

Claim.insurer

Type

Reference

Cardinality

0 - 1

Definition

The Insurer who is target of the request.

Comment

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

reference

string

Literal reference, Relative, internal or absolute URL

type

uri

Type the reference refers to (e.g. "Patient") - must be a resource in resources

identifier

Identifier

Logical reference, when literal reference is not known

Path

Claim.insurer.Reference.identifier

Id

Reference.identifier

Type

Identifier

Cardinality

0 - 1

Definition

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

Comment

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). This element only allows for a single identifier. In the case where additional identifers are required, use the [http://hl7.org/fhir/StructureDefinition/additionalIdentifier](http://hl7.org/fhir/extensions/StructureDefinition-additionalIdentifier.html) extension.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Condition

ref-2

use

code

usual | official | temp | secondary | old (If known)

type

CodeableConcept

Description of identifier

system

uri

The namespace for the identifier value

value

string

The value that is unique

period

Period

Time period when id is/was valid for use

start

dateTime

Starting time with inclusive boundary

end

dateTime

End time with inclusive boundary, if not ongoing

assigner

Reference

Organization that issued id (may be just text)

reference

string

Literal reference, Relative, internal or absolute URL

type

uri

Type the reference refers to (e.g. "Patient") - must be a resource in resources

identifier

Identifier

Logical reference, when literal reference is not known

Path

Claim.insurer.Reference.identifier.Identifier.assigner.Reference.identifier

Id

Reference.identifier

Type

Identifier

Cardinality

0 - 1

Definition

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

Comment

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). This element only allows for a single identifier. In the case where additional identifers are required, use the [http://hl7.org/fhir/StructureDefinition/additionalIdentifier](http://hl7.org/fhir/extensions/StructureDefinition-additionalIdentifier.html) extension.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Condition

ref-2

display

string

Text alternative for the resource

display

string

Text alternative for the resource

Path

Claim.provider

Id

Claim.provider

Type

Reference

Cardinality

0 - 1

Definition

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

Comment

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.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

reference

string

Literal reference, Relative, internal or absolute URL

type

uri

Type the reference refers to (e.g. "Patient") - must be a resource in resources

identifier

Identifier

Logical reference, when literal reference is not known

Path

Claim.provider.Reference.identifier

Id

Reference.identifier

Type

Identifier

Cardinality

0 - 1

Definition

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

Comment

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). This element only allows for a single identifier. In the case where additional identifers are required, use the [http://hl7.org/fhir/StructureDefinition/additionalIdentifier](http://hl7.org/fhir/extensions/StructureDefinition-additionalIdentifier.html) extension.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Condition

ref-2

use

code

usual | official | temp | secondary | old (If known)

type

CodeableConcept

Description of identifier

system

uri

The namespace for the identifier value

value

string

The value that is unique

period

Period

Time period when id is/was valid for use

start

dateTime

Starting time with inclusive boundary

end

dateTime

End time with inclusive boundary, if not ongoing

assigner

Reference

Organization that issued id (may be just text)

reference

string

Literal reference, Relative, internal or absolute URL

type

uri

Type the reference refers to (e.g. "Patient") - must be a resource in resources

identifier

Identifier

Logical reference, when literal reference is not known

Path

Claim.provider.Reference.identifier.Identifier.assigner.Reference.identifier

Id

Reference.identifier

Type

Identifier

Cardinality

0 - 1

Definition

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

Comment

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). This element only allows for a single identifier. In the case where additional identifers are required, use the [http://hl7.org/fhir/StructureDefinition/additionalIdentifier](http://hl7.org/fhir/extensions/StructureDefinition-additionalIdentifier.html) extension.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Condition

ref-2

display

string

Text alternative for the resource

display

string

Text alternative for the resource

Path

Claim.priority

Id

Claim.priority

Type

CodeableConcept

Cardinality

0 - 1

Definition

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

Comment

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.

Binding

Strength

example

Description

The timeliness with which processing is required: stat, normal, deferred.

ValueSet

http://hl7.org/fhir/ValueSet/process-priority

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

coding

Coding

Code defined by a terminology system

system

uri

Identity of the terminology system

version

string

Version of the system - if relevant

code

Symbol in syntax defined by the system

display

string

Representation defined by the system

userSelected

boolean

If this coding was chosen directly by the user

Path

Claim.fundsReserve

Id

Claim.fundsReserve

Type

CodeableConcept

Cardinality

0 - 1

Definition

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

Comment

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.

Binding

Strength

example

Description

For whom funds are to be reserved: (Patient, Provider, None).

ValueSet

http://hl7.org/fhir/ValueSet/fundsreserve

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

coding

Coding

Code defined by a terminology system

system

uri

Identity of the terminology system

version

string

Version of the system - if relevant

code

Symbol in syntax defined by the system

display

string

Representation defined by the system

userSelected

boolean

If this coding was chosen directly by the user

Path

Claim.related

Id

Claim.related

Type

BackboneElement

Cardinality

0 - *

Definition

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

Comment

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.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.related.claim

Id

Claim.related.claim

Type

Reference

Cardinality

0 - 1

Definition

Reference to a related claim.

Comment

Requirements

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

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.related.claim.Reference.identifier

Id

Reference.identifier

Type

Identifier

Cardinality

0 - 1

Definition

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

Comment

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). This element only allows for a single identifier. In the case where additional identifers are required, use the [http://hl7.org/fhir/StructureDefinition/additionalIdentifier](http://hl7.org/fhir/extensions/StructureDefinition-additionalIdentifier.html) extension.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Condition

ref-2

Path

Claim.related.relationship

Id

Claim.related.relationship

Type

CodeableConcept

Cardinality

0 - 1

Definition

A code to convey how the claims are related.

Comment

For example, prior claim or umbrella.

Requirements

Some insurers need a declaration of the type of relationship.

Binding

Strength

example

Description

Relationship of this claim to a related Claim.

ValueSet

http://hl7.org/fhir/ValueSet/related-claim-relationship

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.related.reference

Id

Claim.related.reference

Type

Identifier

Cardinality

0 - 1

Definition

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

Comment

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.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.prescription

Id

Claim.prescription

Type

Reference

Cardinality

0 - 1

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.

Comment

Requirements

Required to authorize the dispensing of controlled substances and devices.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

reference

string

Literal reference, Relative, internal or absolute URL

type

uri

Type the reference refers to (e.g. "Patient") - must be a resource in resources

identifier

Identifier

Logical reference, when literal reference is not known

Path

Claim.prescription.Reference.identifier

Id

Reference.identifier

Type

Identifier

Cardinality

0 - 1

Definition

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

Comment

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). This element only allows for a single identifier. In the case where additional identifers are required, use the [http://hl7.org/fhir/StructureDefinition/additionalIdentifier](http://hl7.org/fhir/extensions/StructureDefinition-additionalIdentifier.html) extension.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Condition

ref-2

use

code

usual | official | temp | secondary | old (If known)

type

CodeableConcept

Description of identifier

system

uri

The namespace for the identifier value

value

string

The value that is unique

period

Period

Time period when id is/was valid for use

start

dateTime

Starting time with inclusive boundary

end

dateTime

End time with inclusive boundary, if not ongoing

assigner

Reference

Organization that issued id (may be just text)

reference

string

Literal reference, Relative, internal or absolute URL

type

uri

Type the reference refers to (e.g. "Patient") - must be a resource in resources

identifier

Identifier

Logical reference, when literal reference is not known

Path

Claim.prescription.Reference.identifier.Identifier.assigner.Reference.identifier

Id

Reference.identifier

Type

Identifier

Cardinality

0 - 1

Definition

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

Comment

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). This element only allows for a single identifier. In the case where additional identifers are required, use the [http://hl7.org/fhir/StructureDefinition/additionalIdentifier](http://hl7.org/fhir/extensions/StructureDefinition-additionalIdentifier.html) extension.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Condition

ref-2

display

string

Text alternative for the resource

display

string

Text alternative for the resource

Path

Claim.originalPrescription

Id

Claim.originalPrescription

Type

Reference

Cardinality

0 - 1

Definition

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

Comment

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.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

reference

string

Literal reference, Relative, internal or absolute URL

type

uri

Type the reference refers to (e.g. "Patient") - must be a resource in resources

identifier

Identifier

Logical reference, when literal reference is not known

Path

Claim.originalPrescription.Reference.identifier

Id

Reference.identifier

Type

Identifier

Cardinality

0 - 1

Definition

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

Comment

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). This element only allows for a single identifier. In the case where additional identifers are required, use the [http://hl7.org/fhir/StructureDefinition/additionalIdentifier](http://hl7.org/fhir/extensions/StructureDefinition-additionalIdentifier.html) extension.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Condition

ref-2

use

code

usual | official | temp | secondary | old (If known)

type

CodeableConcept

Description of identifier

system

uri

The namespace for the identifier value

value

string

The value that is unique

period

Period

Time period when id is/was valid for use

start

dateTime

Starting time with inclusive boundary

end

dateTime

End time with inclusive boundary, if not ongoing

assigner

Reference

Organization that issued id (may be just text)

reference

string

Literal reference, Relative, internal or absolute URL

type

uri

Type the reference refers to (e.g. "Patient") - must be a resource in resources

identifier

Identifier

Logical reference, when literal reference is not known

Path

Claim.originalPrescription.Reference.identifier.Identifier.assigner.Reference.identifier

Id

Reference.identifier

Type

Identifier

Cardinality

0 - 1

Definition

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

Comment

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). This element only allows for a single identifier. In the case where additional identifers are required, use the [http://hl7.org/fhir/StructureDefinition/additionalIdentifier](http://hl7.org/fhir/extensions/StructureDefinition-additionalIdentifier.html) extension.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Condition

ref-2

display

string

Text alternative for the resource

display

string

Text alternative for the resource

Path

Claim.payee

Id

Claim.payee

Type

BackboneElement

Cardinality

0 - 1

Definition

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

Comment

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 and choose to pay the subscriber instead.

Requirements

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

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.payee.type

Id

Claim.payee.type

Type

CodeableConcept

Cardinality

1 - 1

Definition

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

Comment

Requirements

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

Binding

Strength

example

Description

A code for the party to be reimbursed.

ValueSet

http://hl7.org/fhir/ValueSet/payeetype

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

coding

Coding

Code defined by a terminology system

system

uri

Identity of the terminology system

version

string

Version of the system - if relevant

code

Symbol in syntax defined by the system

display

string

Representation defined by the system

userSelected

boolean

If this coding was chosen directly by the user

Path

Claim.payee.party

Id

Claim.payee.party

Type

Reference

Cardinality

0 - 1

Definition

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

Comment

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

Requirements

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

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

reference

string

Literal reference, Relative, internal or absolute URL

type

uri

Type the reference refers to (e.g. "Patient") - must be a resource in resources

identifier

Identifier

Logical reference, when literal reference is not known

Path

Claim.payee.party.Reference.identifier

Id

Reference.identifier

Type

Identifier

Cardinality

0 - 1

Definition

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

Comment

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). This element only allows for a single identifier. In the case where additional identifers are required, use the [http://hl7.org/fhir/StructureDefinition/additionalIdentifier](http://hl7.org/fhir/extensions/StructureDefinition-additionalIdentifier.html) extension.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Condition

ref-2

use

code

usual | official | temp | secondary | old (If known)

type

CodeableConcept

Description of identifier

system

uri

The namespace for the identifier value

value

string

The value that is unique

period

Period

Time period when id is/was valid for use

assigner

Reference

Organization that issued id (may be just text)

display

string

Text alternative for the resource

Path

Claim.referral

Id

Claim.referral

Type

Reference

Cardinality

0 - 1

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.

Comment

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.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

reference

string

Literal reference, Relative, internal or absolute URL

type

uri

Type the reference refers to (e.g. "Patient") - must be a resource in resources

identifier

Identifier

Logical reference, when literal reference is not known

Path

Claim.referral.Reference.identifier

Id

Reference.identifier

Type

Identifier

Cardinality

0 - 1

Definition

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

Comment

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). This element only allows for a single identifier. In the case where additional identifers are required, use the [http://hl7.org/fhir/StructureDefinition/additionalIdentifier](http://hl7.org/fhir/extensions/StructureDefinition-additionalIdentifier.html) extension.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Condition

ref-2

use

code

usual | official | temp | secondary | old (If known)

type

CodeableConcept

Description of identifier

system

uri

The namespace for the identifier value

value

string

The value that is unique

period

Period

Time period when id is/was valid for use

start

dateTime

Starting time with inclusive boundary

end

dateTime

End time with inclusive boundary, if not ongoing

assigner

Reference

Organization that issued id (may be just text)

reference

string

Literal reference, Relative, internal or absolute URL

type

uri

Type the reference refers to (e.g. "Patient") - must be a resource in resources

identifier

Identifier

Logical reference, when literal reference is not known

Path

Claim.referral.Reference.identifier.Identifier.assigner.Reference.identifier

Id

Reference.identifier

Type

Identifier

Cardinality

0 - 1

Definition

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

Comment

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). This element only allows for a single identifier. In the case where additional identifers are required, use the [http://hl7.org/fhir/StructureDefinition/additionalIdentifier](http://hl7.org/fhir/extensions/StructureDefinition-additionalIdentifier.html) extension.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Condition

ref-2

display

string

Text alternative for the resource

display

string

Text alternative for the resource

Path

Claim.encounter

Id

Claim.encounter

Type

Reference

Cardinality

0 - *

Definition

Healthcare encounters related to this claim.

Comment

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.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

reference

string

Literal reference, Relative, internal or absolute URL

type

uri

Type the reference refers to (e.g. "Patient") - must be a resource in resources

identifier

Identifier

Logical reference, when literal reference is not known

Path

Claim.encounter.Reference.identifier

Id

Reference.identifier

Type

Identifier

Cardinality

0 - 1

Definition

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

Comment

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). This element only allows for a single identifier. In the case where additional identifers are required, use the [http://hl7.org/fhir/StructureDefinition/additionalIdentifier](http://hl7.org/fhir/extensions/StructureDefinition-additionalIdentifier.html) extension.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Condition

ref-2

use

code

usual | official | temp | secondary | old (If known)

type

CodeableConcept

Description of identifier

system

uri

The namespace for the identifier value

value

string

The value that is unique

period

Period

Time period when id is/was valid for use

start

dateTime

Starting time with inclusive boundary

end

dateTime

End time with inclusive boundary, if not ongoing

assigner

Reference

Organization that issued id (may be just text)

reference

string

Literal reference, Relative, internal or absolute URL

type

uri

Type the reference refers to (e.g. "Patient") - must be a resource in resources

identifier

Identifier

Logical reference, when literal reference is not known

Path

Claim.encounter.Reference.identifier.Identifier.assigner.Reference.identifier

Id

Reference.identifier

Type

Identifier

Cardinality

0 - 1

Definition

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

Comment

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). This element only allows for a single identifier. In the case where additional identifers are required, use the [http://hl7.org/fhir/StructureDefinition/additionalIdentifier](http://hl7.org/fhir/extensions/StructureDefinition-additionalIdentifier.html) extension.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Condition

ref-2

display

string

Text alternative for the resource

display

string

Text alternative for the resource

Path

Claim.facility

Id

Claim.facility

Type

Reference

Cardinality

0 - 1

Definition

Facility where the services were provided.

Comment

Requirements

Insurance adjudication can be dependant on where services were delivered.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

reference

string

Literal reference, Relative, internal or absolute URL

type

uri

Type the reference refers to (e.g. "Patient") - must be a resource in resources

identifier

Identifier

Logical reference, when literal reference is not known

Path

Claim.facility.Reference.identifier

Id

Reference.identifier

Type

Identifier

Cardinality

0 - 1

Definition

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

Comment

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). This element only allows for a single identifier. In the case where additional identifers are required, use the [http://hl7.org/fhir/StructureDefinition/additionalIdentifier](http://hl7.org/fhir/extensions/StructureDefinition-additionalIdentifier.html) extension.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Condition

ref-2

use

code

usual | official | temp | secondary | old (If known)

type

CodeableConcept

Description of identifier

system

uri

The namespace for the identifier value

value

string

The value that is unique

period

Period

Time period when id is/was valid for use

start

dateTime

Starting time with inclusive boundary

end

dateTime

End time with inclusive boundary, if not ongoing

assigner

Reference

Organization that issued id (may be just text)

reference

string

Literal reference, Relative, internal or absolute URL

type

uri

Type the reference refers to (e.g. "Patient") - must be a resource in resources

identifier

Identifier

Logical reference, when literal reference is not known

Path

Claim.facility.Reference.identifier.Identifier.assigner.Reference.identifier

Id

Reference.identifier

Type

Identifier

Cardinality

0 - 1

Definition

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

Comment

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). This element only allows for a single identifier. In the case where additional identifers are required, use the [http://hl7.org/fhir/StructureDefinition/additionalIdentifier](http://hl7.org/fhir/extensions/StructureDefinition-additionalIdentifier.html) extension.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Condition

ref-2

display

string

Text alternative for the resource

display

string

Text alternative for the resource

Path

Claim.diagnosisRelatedGroup

Id

Claim.diagnosisRelatedGroup

Type

CodeableConcept

Cardinality

0 - 1

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.

Comment

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.

Binding

Strength

example

Description

ValueSet

http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

coding

Coding

Code defined by a terminology system

system

uri

Identity of the terminology system

version

string

Version of the system - if relevant

code

Symbol in syntax defined by the system

display

string

Representation defined by the system

userSelected

boolean

If this coding was chosen directly by the user

Path

Claim.event

Id

Claim.event

Type

BackboneElement

Cardinality

0 - *

Definition

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

Comment

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.event.type

Id

Claim.event.type

Type

CodeableConcept

Cardinality

1 - 1

Definition

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

Comment

Binding

Strength

example

Description

ValueSet

http://hl7.org/fhir/ValueSet/datestype

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

coding

Coding

Code defined by a terminology system

system

uri

Identity of the terminology system

version

string

Version of the system - if relevant

code

Symbol in syntax defined by the system

display

string

Representation defined by the system

userSelected

boolean

If this coding was chosen directly by the user

Path

Claim.event.when[x]

Id

Claim.event.when[x]

Type

dateTime

Cardinality

1 - 1

Definition

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

Comment

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.careTeam

Id

Claim.careTeam

Type

BackboneElement

Cardinality

0 - *

Definition

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

Comment

Requirements

Common to identify the responsible and supporting practitioners.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.careTeam.sequence

Id

Claim.careTeam.sequence

Type

positiveInt

Cardinality

1 - 1

Definition

A number to uniquely identify care team entries.

Comment

Requirements

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

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.careTeam.provider

Id

Claim.careTeam.provider

Type

Reference

Cardinality

1 - 1

Definition

Member of the team who provided the product or service.

Comment

Requirements

Often a regulatory requirement to specify the responsible provider.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

reference

string

Literal reference, Relative, internal or absolute URL

type

uri

Type the reference refers to (e.g. "Patient") - must be a resource in resources

identifier

Identifier

Logical reference, when literal reference is not known

Path

Claim.careTeam.provider.Reference.identifier

Id

Reference.identifier

Type

Identifier

Cardinality

0 - 1

Definition

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

Comment

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). This element only allows for a single identifier. In the case where additional identifers are required, use the [http://hl7.org/fhir/StructureDefinition/additionalIdentifier](http://hl7.org/fhir/extensions/StructureDefinition-additionalIdentifier.html) extension.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Condition

ref-2

use

code

usual | official | temp | secondary | old (If known)

type

CodeableConcept

Description of identifier

system

uri

The namespace for the identifier value

value

string

The value that is unique

period

Period

Time period when id is/was valid for use

assigner

Reference

Organization that issued id (may be just text)

display

string

Text alternative for the resource

Path

Claim.careTeam.responsible

Id

Claim.careTeam.responsible

Type

boolean

Cardinality

0 - 1

Definition

The party who is billing and/or responsible for the claimed products or services.

Comment

Responsible might not be required when there is only a single provider listed.

Requirements

When multiple parties are present it is required to distinguish the lead or responsible individual.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.careTeam.role

Id

Claim.careTeam.role

Type

CodeableConcept

Cardinality

0 - 1

Definition

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

Comment

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.

Binding

Strength

example

Description

The role codes for the care team members.

ValueSet

http://hl7.org/fhir/ValueSet/claim-careteamrole

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

coding

Coding

Code defined by a terminology system

system

uri

Identity of the terminology system

version

string

Version of the system - if relevant

code

Symbol in syntax defined by the system

display

string

Representation defined by the system

userSelected

boolean

If this coding was chosen directly by the user

Path

Claim.careTeam.specialty

Id

Claim.careTeam.specialty

Type

CodeableConcept

Cardinality

0 - 1

Definition

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

Comment

Requirements

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

Binding

Strength

example

Description

ValueSet

http://hl7.org/fhir/ValueSet/provider-qualification

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

coding

Coding

Code defined by a terminology system

system

uri

Identity of the terminology system

version

string

Version of the system - if relevant

code

Symbol in syntax defined by the system

display

string

Representation defined by the system

userSelected

boolean

If this coding was chosen directly by the user

Path

Claim.supportingInfo

Id

Claim.supportingInfo

Type

BackboneElement

Cardinality

0 - *

Definition

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

Comment

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.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.supportingInfo.sequence

Id

Claim.supportingInfo.sequence

Type

positiveInt

Cardinality

1 - 1

Definition

A number to uniquely identify supporting information entries.

Comment

Requirements

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

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.supportingInfo.category

Id

Claim.supportingInfo.category

Type

CodeableConcept

Cardinality

1 - 1

Definition

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

Comment

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.

Binding

Strength

example

Description

The valuset used for additional information category codes.

ValueSet

http://hl7.org/fhir/ValueSet/claim-informationcategory

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

coding

Coding

Code defined by a terminology system

system

uri

Identity of the terminology system

version

string

Version of the system - if relevant

code

Symbol in syntax defined by the system

display

string

Representation defined by the system

userSelected

boolean

If this coding was chosen directly by the user

Path

Claim.supportingInfo.code

Id

Claim.supportingInfo.code

Type

CodeableConcept

Cardinality

0 - 1

Definition

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

Comment

Requirements

Required to identify the kind of additional information.

Binding

Strength

example

Description

The valuset used for additional information codes.

ValueSet

http://hl7.org/fhir/ValueSet/claim-exception

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

coding

Coding

Code defined by a terminology system

system

uri

Identity of the terminology system

version

string

Version of the system - if relevant

code

Symbol in syntax defined by the system

display

string

Representation defined by the system

userSelected

boolean

If this coding was chosen directly by the user

Path

Claim.supportingInfo.timing[x]

Id

Claim.supportingInfo.timing[x]

Type

date

Cardinality

0 - 1

Definition

The date when or period to which this information refers.

Comment

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.supportingInfo.value[x]

Id

Claim.supportingInfo.value[x]

Type

boolean

Cardinality

0 - 1

Definition

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

Comment

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.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.supportingInfo.reason

Id

Claim.supportingInfo.reason

Type

CodeableConcept

Cardinality

0 - 1

Definition

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

Comment

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.

Binding

Strength

example

Description

Reason codes for the missing teeth.

ValueSet

http://hl7.org/fhir/ValueSet/missing-tooth-reason

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

coding

Coding

Code defined by a terminology system

system

uri

Identity of the terminology system

version

string

Version of the system - if relevant

code

Symbol in syntax defined by the system

display

string

Representation defined by the system

userSelected

boolean

If this coding was chosen directly by the user

Path

Claim.diagnosis

Id

Claim.diagnosis

Type

BackboneElement

Cardinality

0 - *

Definition

Information about diagnoses relevant to the claim items.

Comment

Requirements

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

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.diagnosis.sequence

Id

Claim.diagnosis.sequence

Type

positiveInt

Cardinality

1 - 1

Definition

A number to uniquely identify diagnosis entries.

Comment

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.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.diagnosis.diagnosis[x]

Id

Claim.diagnosis.diagnosis[x]

Type

CodeableConcept

Cardinality

1 - 1

Definition

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

Comment

Requirements

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

Binding

Strength

example

Description

Example ICD10 Diagnostic codes.

ValueSet

http://hl7.org/fhir/ValueSet/icd-10

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

coding

Coding

Code defined by a terminology system

system

uri

Identity of the terminology system

version

string

Version of the system - if relevant

code

Symbol in syntax defined by the system

display

string

Representation defined by the system

userSelected

boolean

If this coding was chosen directly by the user

Path

Claim.diagnosis.type

Id

Claim.diagnosis.type

Type

CodeableConcept

Cardinality

0 - *

Definition

When the condition was observed or the relative ranking.

Comment

For example: admitting, primary, secondary, discharge.

Requirements

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

Binding

Strength

example

Description

The type of the diagnosis: admitting, principal, discharge.

ValueSet

http://hl7.org/fhir/ValueSet/ex-diagnosistype

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

coding

Coding

Code defined by a terminology system

system

uri

Identity of the terminology system

version

string

Version of the system - if relevant

code

Symbol in syntax defined by the system

display

string

Representation defined by the system

userSelected

boolean

If this coding was chosen directly by the user

Path

Claim.diagnosis.onAdmission

Id

Claim.diagnosis.onAdmission

Type

CodeableConcept

Cardinality

0 - 1

Definition

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

Comment

Requirements

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

Binding

Strength

example

Description

Present on admission.

ValueSet

http://hl7.org/fhir/ValueSet/ex-diagnosis-on-admission

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

coding

Coding

Code defined by a terminology system

system

uri

Identity of the terminology system

version

string

Version of the system - if relevant

code

Symbol in syntax defined by the system

display

string

Representation defined by the system

userSelected

boolean

If this coding was chosen directly by the user

Path

Claim.procedure

Id

Claim.procedure

Type

BackboneElement

Cardinality

0 - *

Definition

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

Comment

Requirements

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

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.procedure.sequence

Id

Claim.procedure.sequence

Type

positiveInt

Cardinality

1 - 1

Definition

A number to uniquely identify procedure entries.

Comment

Requirements

Necessary to provide a mechanism to link to claim details.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.procedure.type

Id

Claim.procedure.type

Type

CodeableConcept

Cardinality

0 - *

Definition

When the condition was observed or the relative ranking.

Comment

For example: primary, secondary.

Requirements

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

Binding

Strength

example

Description

Example procedure type codes.

ValueSet

http://hl7.org/fhir/ValueSet/ex-procedure-type

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

coding

Coding

Code defined by a terminology system

system

uri

Identity of the terminology system

version

string

Version of the system - if relevant

code

Symbol in syntax defined by the system

display

string

Representation defined by the system

userSelected

boolean

If this coding was chosen directly by the user

Path

Claim.procedure.date

Id

Claim.procedure.date

Type

dateTime

Cardinality

0 - 1

Definition

Date and optionally time the procedure was performed.

Comment

Requirements

Required for auditing purposes.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.procedure.procedure[x]

Id

Claim.procedure.procedure[x]

Type

CodeableConcept

Cardinality

1 - 1

Definition

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

Comment

Requirements

This identifies the actual clinical procedure.

Binding

Strength

example

Description

Example ICD10 Procedure codes.

ValueSet

http://hl7.org/fhir/ValueSet/icd-10-procedures

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

coding

Coding

Code defined by a terminology system

system

uri

Identity of the terminology system

version

string

Version of the system - if relevant

code

Symbol in syntax defined by the system

display

string

Representation defined by the system

userSelected

boolean

If this coding was chosen directly by the user

Path

Claim.procedure.udi

Id

Claim.procedure.udi

Type

Reference

Cardinality

0 - *

Definition

Unique Device Identifiers associated with this line item.

Comment

Requirements

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

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

reference

string

Literal reference, Relative, internal or absolute URL

type

uri

Type the reference refers to (e.g. "Patient") - must be a resource in resources

identifier

Identifier

Logical reference, when literal reference is not known

Path

Claim.procedure.udi.Reference.identifier

Id

Reference.identifier

Type

Identifier

Cardinality

0 - 1

Definition

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

Comment

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). This element only allows for a single identifier. In the case where additional identifers are required, use the [http://hl7.org/fhir/StructureDefinition/additionalIdentifier](http://hl7.org/fhir/extensions/StructureDefinition-additionalIdentifier.html) extension.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Condition

ref-2

use

code

usual | official | temp | secondary | old (If known)

type

CodeableConcept

Description of identifier

system

uri

The namespace for the identifier value

value

string

The value that is unique

period

Period

Time period when id is/was valid for use

assigner

Reference

Organization that issued id (may be just text)

display

string

Text alternative for the resource

Path

Claim.insurance

Id

Claim.insurance

Type

BackboneElement

Cardinality

0 - *

Definition

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

Comment

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.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.insurance.sequence

Id

Claim.insurance.sequence

Type

positiveInt

Cardinality

1 - 1

Definition

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

Comment

Requirements

To maintain order of the coverages.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.insurance.focal

Id

Claim.insurance.focal

Type

boolean

Cardinality

1 - 1

Definition

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

Comment

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.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.insurance.identifier

Id

Claim.insurance.identifier

Type

Identifier

Cardinality

0 - 1

Definition

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

Comment

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 payors may forward claims to other payors in the Coordination of Benefit for adjudication rather than the provider being required to initiate each adjudication.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

use

code

usual | official | temp | secondary | old (If known)

type

CodeableConcept

Description of identifier

system

uri

The namespace for the identifier value

value

string

The value that is unique

period

Period

Time period when id is/was valid for use

start

dateTime

Starting time with inclusive boundary

end

dateTime

End time with inclusive boundary, if not ongoing

assigner

Reference

Organization that issued id (may be just text)

reference

string

Literal reference, Relative, internal or absolute URL

type

uri

Type the reference refers to (e.g. "Patient") - must be a resource in resources

identifier

Identifier

Logical reference, when literal reference is not known

Path

Claim.insurance.identifier.Identifier.assigner.Reference.identifier

Id

Reference.identifier

Type

Identifier

Cardinality

0 - 1

Definition

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

Comment

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). This element only allows for a single identifier. In the case where additional identifers are required, use the [http://hl7.org/fhir/StructureDefinition/additionalIdentifier](http://hl7.org/fhir/extensions/StructureDefinition-additionalIdentifier.html) extension.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Condition

ref-2

display

string

Text alternative for the resource

Path

Claim.insurance.coverage

Id

Claim.insurance.coverage

Type

Reference

Cardinality

1 - 1

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.

Comment

Requirements

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

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

reference

string

Literal reference, Relative, internal or absolute URL

type

uri

Type the reference refers to (e.g. "Patient") - must be a resource in resources

identifier

Identifier

Logical reference, when literal reference is not known

Path

Claim.insurance.coverage.Reference.identifier

Id

Reference.identifier

Type

Identifier

Cardinality

0 - 1

Definition

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

Comment

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). This element only allows for a single identifier. In the case where additional identifers are required, use the [http://hl7.org/fhir/StructureDefinition/additionalIdentifier](http://hl7.org/fhir/extensions/StructureDefinition-additionalIdentifier.html) extension.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Condition

ref-2

use

code

usual | official | temp | secondary | old (If known)

type

CodeableConcept

Description of identifier

system

uri

The namespace for the identifier value

value

string

The value that is unique

period

Period

Time period when id is/was valid for use

assigner

Reference

Organization that issued id (may be just text)

display

string

Text alternative for the resource

Path

Claim.insurance.businessArrangement

Id

Claim.insurance.businessArrangement

Type

string

Cardinality

0 - 1

Definition

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

Comment

Requirements

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

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.insurance.preAuthRef

Id

Claim.insurance.preAuthRef

Type

string

Cardinality

0 - *

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.

Comment

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.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.insurance.claimResponse

Id

Claim.insurance.claimResponse

Type

Reference

Cardinality

0 - 1

Definition

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

Comment

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.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

reference

string

Literal reference, Relative, internal or absolute URL

type

uri

Type the reference refers to (e.g. "Patient") - must be a resource in resources

identifier

Identifier

Logical reference, when literal reference is not known

Path

Claim.insurance.claimResponse.Reference.identifier

Id

Reference.identifier

Type

Identifier

Cardinality

0 - 1

Definition

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

Comment

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). This element only allows for a single identifier. In the case where additional identifers are required, use the [http://hl7.org/fhir/StructureDefinition/additionalIdentifier](http://hl7.org/fhir/extensions/StructureDefinition-additionalIdentifier.html) extension.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Condition

ref-2

use

code

usual | official | temp | secondary | old (If known)

type

CodeableConcept

Description of identifier

system

uri

The namespace for the identifier value

value

string

The value that is unique

period

Period

Time period when id is/was valid for use

assigner

Reference

Organization that issued id (may be just text)

display

string

Text alternative for the resource

Path

Claim.accident

Id

Claim.accident

Type

BackboneElement

Cardinality

0 - 1

Definition

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

Comment

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.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.accident.date

Id

Claim.accident.date

Type

date

Cardinality

1 - 1

Definition

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

Comment

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.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.accident.type

Id

Claim.accident.type

Type

CodeableConcept

Cardinality

0 - 1

Definition

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

Comment

Requirements

Coverage may be dependant on the type of accident.

Binding

Strength

extensible

Description

Type of accident: work place, auto, etc.

ValueSet

http://terminology.hl7.org/ValueSet/v3-ActIncidentCode

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

coding

Coding

Code defined by a terminology system

system

uri

Identity of the terminology system

version

string

Version of the system - if relevant

code

Symbol in syntax defined by the system

display

string

Representation defined by the system

userSelected

boolean

If this coding was chosen directly by the user

Path

Claim.accident.location[x]

Id

Claim.accident.location[x]

Type

Address

Cardinality

0 - 1

Definition

The physical location of the accident event.

Comment

Requirements

Required for audit purposes and determination of applicable insurance liability.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

use

code

home | work | temp | old | billing - purpose of this address

type

code

postal | physical | both

line

string

Street name, number, direction & P.O. Box etc.

city

string

Name of city, town etc.

district

string

District name (aka county)

state

string

Sub-unit of country (abbreviations ok)

postalCode

string

Postal code for area

country

string

Country (e.g. may be ISO 3166 2 or 3 letter code)

period

Period

Time period when address was/is in use

start

dateTime

Starting time with inclusive boundary

end

dateTime

End time with inclusive boundary, if not ongoing

Path

Claim.patientPaid

Id

Claim.patientPaid

Type

Money

Cardinality

0 - 1

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.

Comment

Requirements

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

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

value

decimal

Numerical value (with implicit precision)

currency

code

ISO 4217 Currency Code

Path

Claim.item

Id

Claim.item

Type

BackboneElement

Cardinality

0 - *

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.

Comment

Requirements

The items to be processed for adjudication.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.item.sequence

Id

Claim.item.sequence

Type

positiveInt

Cardinality

1 - 1

Definition

A number to uniquely identify item entries.

Comment

Requirements

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

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.item.traceNumber

Id

Claim.item.traceNumber

Type

Identifier

Cardinality

0 - *

Definition

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

Comment

Requirements

Allows partners to uniquely identify components for tracking.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

use

code

usual | official | temp | secondary | old (If known)

type

CodeableConcept

Description of identifier

system

uri

The namespace for the identifier value

value

string

The value that is unique

period

Period

Time period when id is/was valid for use

start

dateTime

Starting time with inclusive boundary

end

dateTime

End time with inclusive boundary, if not ongoing

assigner

Reference

Organization that issued id (may be just text)

reference

string

Literal reference, Relative, internal or absolute URL

type

uri

Type the reference refers to (e.g. "Patient") - must be a resource in resources

identifier

Identifier

Logical reference, when literal reference is not known

Path

Claim.item.traceNumber.Identifier.assigner.Reference.identifier

Id

Reference.identifier

Type

Identifier

Cardinality

0 - 1

Definition

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

Comment

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). This element only allows for a single identifier. In the case where additional identifers are required, use the [http://hl7.org/fhir/StructureDefinition/additionalIdentifier](http://hl7.org/fhir/extensions/StructureDefinition-additionalIdentifier.html) extension.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Condition

ref-2

display

string

Text alternative for the resource

Path

Claim.item.careTeamSequence

Id

Claim.item.careTeamSequence

Type

positiveInt

Cardinality

0 - *

Definition

CareTeam members related to this service or product.

Comment

Requirements

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

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.item.diagnosisSequence

Id

Claim.item.diagnosisSequence

Type

positiveInt

Cardinality

0 - *

Definition

Diagnosis applicable for this service or product.

Comment

Requirements

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

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.item.procedureSequence

Id

Claim.item.procedureSequence

Type

positiveInt

Cardinality

0 - *

Definition

Procedures applicable for this service or product.

Comment

Requirements

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

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.item.informationSequence

Id

Claim.item.informationSequence

Type

positiveInt

Cardinality

0 - *

Definition

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

Comment

Requirements

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

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.item.revenue

Id

Claim.item.revenue

Type

CodeableConcept

Cardinality

0 - 1

Definition

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

Comment

Requirements

Needed in the processing of institutional claims.

Binding

Strength

example

Description

Codes for the revenue or cost centers supplying the service and/or products.

ValueSet

http://hl7.org/fhir/ValueSet/ex-revenue-center

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

coding

Coding

Code defined by a terminology system

system

uri

Identity of the terminology system

version

string

Version of the system - if relevant

code

Symbol in syntax defined by the system

display

string

Representation defined by the system

userSelected

boolean

If this coding was chosen directly by the user

Path

Claim.item.category

Id

Claim.item.category

Type

CodeableConcept

Cardinality

0 - 1

Definition

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

Comment

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.

Binding

Strength

example

Description

Benefit categories such as: oral-basic, major, glasses.

ValueSet

http://hl7.org/fhir/ValueSet/ex-benefitcategory

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

coding

Coding

Code defined by a terminology system

system

uri

Identity of the terminology system

version

string

Version of the system - if relevant

code

Symbol in syntax defined by the system

display

string

Representation defined by the system

userSelected

boolean

If this coding was chosen directly by the user

Path

Claim.item.productOrService

Id

Claim.item.productOrService

Type

CodeableConcept

Cardinality

0 - 1

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.

Comment

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.

Binding

Strength

example

Description

Allowable service and product codes.

ValueSet

http://hl7.org/fhir/ValueSet/service-uscls

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

coding

Coding

Code defined by a terminology system

system

uri

Identity of the terminology system

version

string

Version of the system - if relevant

code

Symbol in syntax defined by the system

display

string

Representation defined by the system

userSelected

boolean

If this coding was chosen directly by the user

Path

Claim.item.productOrServiceEnd

Id

Claim.item.productOrServiceEnd

Type

CodeableConcept

Cardinality

0 - 1

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.

Comment

Binding

Strength

example

Description

ValueSet

http://hl7.org/fhir/ValueSet/service-uscls

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

coding

Coding

Code defined by a terminology system

system

uri

Identity of the terminology system

version

string

Version of the system - if relevant

code

Symbol in syntax defined by the system

display

string

Representation defined by the system

userSelected

boolean

If this coding was chosen directly by the user

Path

Claim.item.request

Id

Claim.item.request

Type

Reference

Cardinality

0 - *

Definition

Request or Referral for Goods or Service to be rendered.

Comment

Requirements

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

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

reference

string

Literal reference, Relative, internal or absolute URL

type

uri

Type the reference refers to (e.g. "Patient") - must be a resource in resources

identifier

Identifier

Logical reference, when literal reference is not known

Path

Claim.item.request.Reference.identifier

Id

Reference.identifier

Type

Identifier

Cardinality

0 - 1

Definition

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

Comment

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). This element only allows for a single identifier. In the case where additional identifers are required, use the [http://hl7.org/fhir/StructureDefinition/additionalIdentifier](http://hl7.org/fhir/extensions/StructureDefinition-additionalIdentifier.html) extension.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Condition

ref-2

use

code

usual | official | temp | secondary | old (If known)

type

CodeableConcept

Description of identifier

system

uri

The namespace for the identifier value

value

string

The value that is unique

period

Period

Time period when id is/was valid for use

assigner

Reference

Organization that issued id (may be just text)

display

string

Text alternative for the resource

Path

Claim.item.modifier

Id

Claim.item.modifier

Type

CodeableConcept

Cardinality

0 - *

Definition

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

Comment

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.

Binding

Strength

example

Description

Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.

ValueSet

http://hl7.org/fhir/ValueSet/claim-modifiers

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

coding

Coding

Code defined by a terminology system

system

uri

Identity of the terminology system

version

string

Version of the system - if relevant

code

Symbol in syntax defined by the system

display

string

Representation defined by the system

userSelected

boolean

If this coding was chosen directly by the user

Path

Claim.item.programCode

Id

Claim.item.programCode

Type

CodeableConcept

Cardinality

0 - *

Definition

Identifies the program under which this may be recovered.

Comment

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.

Binding

Strength

example

Description

Program specific reason codes.

ValueSet

http://hl7.org/fhir/ValueSet/ex-program-code

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

coding

Coding

Code defined by a terminology system

system

uri

Identity of the terminology system

version

string

Version of the system - if relevant

code

Symbol in syntax defined by the system

display

string

Representation defined by the system

userSelected

boolean

If this coding was chosen directly by the user

Path

Claim.item.serviced[x]

Id

Claim.item.serviced[x]

Type

date

Cardinality

0 - 1

Definition

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

Comment

Requirements

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

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.item.location[x]

Id

Claim.item.location[x]

Type

CodeableConcept

Cardinality

0 - 1

Definition

Where the product or service was provided.

Comment

Requirements

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

Binding

Strength

example

Description

Place of service: pharmacy, school, prison, etc.

ValueSet

http://hl7.org/fhir/ValueSet/service-place

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

coding

Coding

Code defined by a terminology system

system

uri

Identity of the terminology system

version

string

Version of the system - if relevant

code

Symbol in syntax defined by the system

display

string

Representation defined by the system

userSelected

boolean

If this coding was chosen directly by the user

Path

Claim.item.patientPaid

Id

Claim.item.patientPaid

Type

Money

Cardinality

0 - 1

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.

Comment

Requirements

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

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

value

decimal

Numerical value (with implicit precision)

currency

code

ISO 4217 Currency Code

Path

Claim.item.quantity

Id

Claim.item.quantity

Type

Quantity

Cardinality

0 - 1

Definition

The number of repetitions of a service or product.

Comment

Requirements

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

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

value

decimal

Numerical value (with implicit precision)

comparator

code

< | <= | >= | > | ad - how to understand the value

unit

string

Unit representation

system

uri

System that defines coded unit form

code

Coded form of the unit

Path

Claim.item.unitPrice

Id

Claim.item.unitPrice

Type

Money

Cardinality

0 - 1

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.

Comment

Requirements

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

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

value

decimal

Numerical value (with implicit precision)

currency

code

ISO 4217 Currency Code

Path

Claim.item.factor

Id

Claim.item.factor

Type

decimal

Cardinality

0 - 1

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.

Comment

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.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.item.tax

Id

Claim.item.tax

Type

Money

Cardinality

0 - 1

Definition

The total of taxes applicable for this product or service.

Comment

Requirements

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

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

value

decimal

Numerical value (with implicit precision)

currency

code

ISO 4217 Currency Code

Path

Claim.item.net

Id

Claim.item.net

Type

Money

Cardinality

0 - 1

Definition

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

Comment

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.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

value

decimal

Numerical value (with implicit precision)

currency

code

ISO 4217 Currency Code

Path

Claim.item.udi

Id

Claim.item.udi

Type

Reference

Cardinality

0 - *

Definition

Unique Device Identifiers associated with this line item.

Comment

Requirements

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

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

reference

string

Literal reference, Relative, internal or absolute URL

type

uri

Type the reference refers to (e.g. "Patient") - must be a resource in resources

identifier

Identifier

Logical reference, when literal reference is not known

Path

Claim.item.udi.Reference.identifier

Id

Reference.identifier

Type

Identifier

Cardinality

0 - 1

Definition

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

Comment

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). This element only allows for a single identifier. In the case where additional identifers are required, use the [http://hl7.org/fhir/StructureDefinition/additionalIdentifier](http://hl7.org/fhir/extensions/StructureDefinition-additionalIdentifier.html) extension.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Condition

ref-2

use

code

usual | official | temp | secondary | old (If known)

type

CodeableConcept

Description of identifier

system

uri

The namespace for the identifier value

value

string

The value that is unique

period

Period

Time period when id is/was valid for use

assigner

Reference

Organization that issued id (may be just text)

display

string

Text alternative for the resource

Path

Claim.item.bodySite

Id

Claim.item.bodySite

Type

BackboneElement

Cardinality

0 - *

Definition

Physical location where the service is performed or applies.

Comment

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.item.bodySite.site

Id

Claim.item.bodySite.site

Type

CodeableReference

Cardinality

1 - *

Definition

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

Comment

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.

Binding

Strength

example

Description

ValueSet

http://hl7.org/fhir/ValueSet/tooth

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

concept

CodeableConcept

Reference to a concept (by class)

reference

Reference

Reference to a resource (by instance)

Path

Claim.item.bodySite.subSite

Id

Claim.item.bodySite.subSite

Type

CodeableConcept

Cardinality

0 - *

Definition

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

Comment

Requirements

Allows insurer to validate specific procedures.

Binding

Strength

example

Description

ValueSet

http://hl7.org/fhir/ValueSet/surface

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

coding

Coding

Code defined by a terminology system

Path

Claim.item.encounter

Id

Claim.item.encounter

Type

Reference

Cardinality

0 - *

Definition

Healthcare encounters related to this claim.

Comment

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.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

reference

string

Literal reference, Relative, internal or absolute URL

type

uri

Type the reference refers to (e.g. "Patient") - must be a resource in resources

identifier

Identifier

Logical reference, when literal reference is not known

Path

Claim.item.encounter.Reference.identifier

Id

Reference.identifier

Type

Identifier

Cardinality

0 - 1

Definition

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

Comment

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). This element only allows for a single identifier. In the case where additional identifers are required, use the [http://hl7.org/fhir/StructureDefinition/additionalIdentifier](http://hl7.org/fhir/extensions/StructureDefinition-additionalIdentifier.html) extension.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Condition

ref-2

use

code

usual | official | temp | secondary | old (If known)

type

CodeableConcept

Description of identifier

system

uri

The namespace for the identifier value

value

string

The value that is unique

period

Period

Time period when id is/was valid for use

assigner

Reference

Organization that issued id (may be just text)

display

string

Text alternative for the resource

Path

Claim.item.detail

Id

Claim.item.detail

Type

BackboneElement

Cardinality

0 - *

Definition

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

Comment

Requirements

The items to be processed for adjudication.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.item.detail.sequence

Id

Claim.item.detail.sequence

Type

positiveInt

Cardinality

1 - 1

Definition

A number to uniquely identify item entries.

Comment

Requirements

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

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.item.detail.traceNumber

Id

Claim.item.detail.traceNumber

Type

Identifier

Cardinality

0 - *

Definition

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

Comment

Requirements

Allows partners to uniquely identify components for tracking.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

use

code

usual | official | temp | secondary | old (If known)

type

CodeableConcept

Description of identifier

system

uri

The namespace for the identifier value

value

string

The value that is unique

period

Period

Time period when id is/was valid for use

assigner

Reference

Organization that issued id (may be just text)

Path

Claim.item.detail.revenue

Id

Claim.item.detail.revenue

Type

CodeableConcept

Cardinality

0 - 1

Definition

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

Comment

Requirements

Needed in the processing of institutional claims.

Binding

Strength

example

Description

Codes for the revenue or cost centers supplying the service and/or products.

ValueSet

http://hl7.org/fhir/ValueSet/ex-revenue-center

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

coding

Coding

Code defined by a terminology system

Path

Claim.item.detail.category

Id

Claim.item.detail.category

Type

CodeableConcept

Cardinality

0 - 1

Definition

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

Comment

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.

Binding

Strength

example

Description

Benefit categories such as: oral-basic, major, glasses.

ValueSet

http://hl7.org/fhir/ValueSet/ex-benefitcategory

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

coding

Coding

Code defined by a terminology system

Path

Claim.item.detail.productOrService

Id

Claim.item.detail.productOrService

Type

CodeableConcept

Cardinality

0 - 1

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.

Comment

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.

Binding

Strength

example

Description

Allowable service and product codes.

ValueSet

http://hl7.org/fhir/ValueSet/service-uscls

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

coding

Coding

Code defined by a terminology system

Path

Claim.item.detail.productOrServiceEnd

Id

Claim.item.detail.productOrServiceEnd

Type

CodeableConcept

Cardinality

0 - 1

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.

Comment

Binding

Strength

example

Description

ValueSet

http://hl7.org/fhir/ValueSet/service-uscls

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

coding

Coding

Code defined by a terminology system

Path

Claim.item.detail.modifier

Id

Claim.item.detail.modifier

Type

CodeableConcept

Cardinality

0 - *

Definition

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

Comment

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.

Binding

Strength

example

Description

Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.

ValueSet

http://hl7.org/fhir/ValueSet/claim-modifiers

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

coding

Coding

Code defined by a terminology system

Path

Claim.item.detail.programCode

Id

Claim.item.detail.programCode

Type

CodeableConcept

Cardinality

0 - *

Definition

Identifies the program under which this may be recovered.

Comment

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.

Binding

Strength

example

Description

Program specific reason codes.

ValueSet

http://hl7.org/fhir/ValueSet/ex-program-code

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

coding

Coding

Code defined by a terminology system

Path

Claim.item.detail.patientPaid

Id

Claim.item.detail.patientPaid

Type

Money

Cardinality

0 - 1

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.

Comment

Requirements

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

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

value

decimal

Numerical value (with implicit precision)

currency

code

ISO 4217 Currency Code

Path

Claim.item.detail.quantity

Id

Claim.item.detail.quantity

Type

Quantity

Cardinality

0 - 1

Definition

The number of repetitions of a service or product.

Comment

Requirements

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

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

value

decimal

Numerical value (with implicit precision)

comparator

code

< | <= | >= | > | ad - how to understand the value

unit

string

Unit representation

system

uri

System that defines coded unit form

code

Coded form of the unit

Path

Claim.item.detail.unitPrice

Id

Claim.item.detail.unitPrice

Type

Money

Cardinality

0 - 1

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.

Comment

Requirements

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

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

value

decimal

Numerical value (with implicit precision)

currency

code

ISO 4217 Currency Code

Path

Claim.item.detail.factor

Id

Claim.item.detail.factor

Type

decimal

Cardinality

0 - 1

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.

Comment

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.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.item.detail.tax

Id

Claim.item.detail.tax

Type

Money

Cardinality

0 - 1

Definition

The total of taxes applicable for this product or service.

Comment

Requirements

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

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

value

decimal

Numerical value (with implicit precision)

currency

code

ISO 4217 Currency Code

Path

Claim.item.detail.net

Id

Claim.item.detail.net

Type

Money

Cardinality

0 - 1

Definition

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

Comment

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.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

value

decimal

Numerical value (with implicit precision)

currency

code

ISO 4217 Currency Code

Path

Claim.item.detail.udi

Id

Claim.item.detail.udi

Type

Reference

Cardinality

0 - *

Definition

Unique Device Identifiers associated with this line item.

Comment

Requirements

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

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

reference

string

Literal reference, Relative, internal or absolute URL

type

uri

Type the reference refers to (e.g. "Patient") - must be a resource in resources

identifier

Identifier

Logical reference, when literal reference is not known

Path

Claim.item.detail.udi.Reference.identifier

Id

Reference.identifier

Type

Identifier

Cardinality

0 - 1

Definition

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

Comment

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). This element only allows for a single identifier. In the case where additional identifers are required, use the [http://hl7.org/fhir/StructureDefinition/additionalIdentifier](http://hl7.org/fhir/extensions/StructureDefinition-additionalIdentifier.html) extension.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Condition

ref-2

display

string

Text alternative for the resource

Path

Claim.item.detail.subDetail

Id

Claim.item.detail.subDetail

Type

BackboneElement

Cardinality

0 - *

Definition

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

Comment

Requirements

The items to be processed for adjudication.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.item.detail.subDetail.sequence

Id

Claim.item.detail.subDetail.sequence

Type

positiveInt

Cardinality

1 - 1

Definition

A number to uniquely identify item entries.

Comment

Requirements

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

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.item.detail.subDetail.traceNumber

Id

Claim.item.detail.subDetail.traceNumber

Type

Identifier

Cardinality

0 - *

Definition

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

Comment

Requirements

Allows partners to uniquely identify components for tracking.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.item.detail.subDetail.revenue

Id

Claim.item.detail.subDetail.revenue

Type

CodeableConcept

Cardinality

0 - 1

Definition

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

Comment

Requirements

Needed in the processing of institutional claims.

Binding

Strength

example

Description

Codes for the revenue or cost centers supplying the service and/or products.

ValueSet

http://hl7.org/fhir/ValueSet/ex-revenue-center

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.item.detail.subDetail.category

Id

Claim.item.detail.subDetail.category

Type

CodeableConcept

Cardinality

0 - 1

Definition

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

Comment

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.

Binding

Strength

example

Description

Benefit categories such as: oral-basic, major, glasses.

ValueSet

http://hl7.org/fhir/ValueSet/ex-benefitcategory

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.item.detail.subDetail.productOrService

Id

Claim.item.detail.subDetail.productOrService

Type

CodeableConcept

Cardinality

0 - 1

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.

Comment

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.

Binding

Strength

example

Description

Allowable service and product codes.

ValueSet

http://hl7.org/fhir/ValueSet/service-uscls

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.item.detail.subDetail.productOrServiceEnd

Id

Claim.item.detail.subDetail.productOrServiceEnd

Type

CodeableConcept

Cardinality

0 - 1

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.

Comment

Binding

Strength

example

Description

ValueSet

http://hl7.org/fhir/ValueSet/service-uscls

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.item.detail.subDetail.modifier

Id

Claim.item.detail.subDetail.modifier

Type

CodeableConcept

Cardinality

0 - *

Definition

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

Comment

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.

Binding

Strength

example

Description

Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.

ValueSet

http://hl7.org/fhir/ValueSet/claim-modifiers

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.item.detail.subDetail.programCode

Id

Claim.item.detail.subDetail.programCode

Type

CodeableConcept

Cardinality

0 - *

Definition

Identifies the program under which this may be recovered.

Comment

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.

Binding

Strength

example

Description

Program specific reason codes.

ValueSet

http://hl7.org/fhir/ValueSet/ex-program-code

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.item.detail.subDetail.patientPaid

Id

Claim.item.detail.subDetail.patientPaid

Type

Money

Cardinality

0 - 1

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.

Comment

Requirements

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

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.item.detail.subDetail.quantity

Id

Claim.item.detail.subDetail.quantity

Type

Quantity

Cardinality

0 - 1

Definition

The number of repetitions of a service or product.

Comment

Requirements

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

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.item.detail.subDetail.unitPrice

Id

Claim.item.detail.subDetail.unitPrice

Type

Money

Cardinality

0 - 1

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.

Comment

Requirements

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

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.item.detail.subDetail.factor

Id

Claim.item.detail.subDetail.factor

Type

decimal

Cardinality

0 - 1

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.

Comment

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.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.item.detail.subDetail.tax

Id

Claim.item.detail.subDetail.tax

Type

Money

Cardinality

0 - 1

Definition

The total of taxes applicable for this product or service.

Comment

Requirements

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

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.item.detail.subDetail.net

Id

Claim.item.detail.subDetail.net

Type

Money

Cardinality

0 - 1

Definition

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

Comment

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.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.item.detail.subDetail.udi

Id

Claim.item.detail.subDetail.udi

Type

Reference

Cardinality

0 - *

Definition

Unique Device Identifiers associated with this line item.

Comment

Requirements

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

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

Claim.total

Id

Claim.total

Type

Money

Cardinality

0 - 1

Definition

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

Comment

Requirements

Used for control total purposes.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

value

decimal

Numerical value (with implicit precision)

currency

code

ISO 4217 Currency Code