Claim
FinancialA 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.
| Path | Card. | Type | Description & Constraints |
|---|---|---|---|
| Claim | 0..* | — | Claim, Pre-determination or Pre-authorization |
| .idΣ | 0..1 | String | Logical id of this artifact |
| .metaΣ | 0..1 | Meta | Metadata about the resource |
| .implicitRules?!Σ | 0..1 | uri | A set of rules under which this content was created |
| .language | 0..1 | code | Language of the resource content Bindinglanguages(preferred) |
| .text | 0..1 | Narrative | Text summary of the resource, for human interpretation |
| .contained | 0..* | Resource | Contained, inline Resources |
| .extension | 0..* | Extension | Additional content defined by implementations |
| .modifierExtension?! | 0..* | Extension | Extensions that cannot be ignored |
| .identifier | 0..* | Identifier | Business Identifier for claim |
| .status?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Bindingfm-status(required) |
| .typeΣ | 1..1 | CodeableConcept | Category or discipline Bindingclaim-type(extensible) |
| .subType | 0..1 | CodeableConcept | More granular claim type Bindingclaim-subtype(example) |
| .useΣ | 1..1 | code | claim | preauthorization | predetermination Bindingclaim-use(required) |
| .patientΣ | 1..1 | Reference(Patient) | The recipient of the products and services |
| .billablePeriodΣ | 0..1 | Period | Relevant time frame for the claim |
| .createdΣ | 1..1 | dateTime | Resource creation date |
| .enterer | 0..1 | Reference(Practitioner | PractitionerRole) | Author of the claim |
| .insurerΣ | 0..1 | Reference(Organization) | Target |
| .providerΣ | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim |
| .priorityΣ | 1..1 | CodeableConcept | Desired processing ugency Bindingprocess-priority(example) |
| .fundsReserve | 0..1 | CodeableConcept | For whom to reserve funds Bindingfundsreserve(example) |
| .related | 0..* | BackboneElement | Prior or corollary claims |
| .id | 0..1 | String | Unique id for inter-element referencing |
| .extension | 0..* | Extension | Additional content defined by implementations |
| .modifierExtension?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| .claim | 0..1 | Reference(Claim) | Reference to the related claim |
| .relationship | 0..1 | CodeableConcept | How the reference claim is related Bindingrelated-claim-relationship(example) |
| .reference | 0..1 | Identifier | File or case reference |
| .prescription | 0..1 | Reference(DeviceRequest | MedicationRequest | VisionPrescription) | Prescription authorizing services and products |
| .originalPrescription | 0..1 | Reference(DeviceRequest | MedicationRequest | VisionPrescription) | Original prescription if superseded by fulfiller |
| .payee | 0..1 | BackboneElement | Recipient of benefits payable |
| .id | 0..1 | String | Unique id for inter-element referencing |
| .extension | 0..* | Extension | Additional content defined by implementations |
| .modifierExtension?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| .type | 1..1 | CodeableConcept | Category of recipient Bindingpayeetype(example) |
| .party | 0..1 | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) | Recipient reference |
| .referral | 0..1 | Reference(ServiceRequest) | Treatment referral |
| .facility | 0..1 | Reference(Location) | Servicing facility |
| .careTeam | 0..* | BackboneElement | Members of the care team |
| .id | 0..1 | String | Unique id for inter-element referencing |
| .extension | 0..* | Extension | Additional content defined by implementations |
| .modifierExtension?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| .sequence | 1..1 | positiveInt | Order of care team |
| .provider | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Practitioner or organization |
| .responsible | 0..1 | boolean | Indicator of the lead practitioner |
| .role | 0..1 | CodeableConcept | Function within the team Bindingclaim-careteamrole(example) |
| .qualification | 0..1 | CodeableConcept | Practitioner credential or specialization Bindingprovider-qualification(example) |
| .supportingInfo | 0..* | BackboneElement | Supporting information |
| .id | 0..1 | String | Unique id for inter-element referencing |
| .extension | 0..* | Extension | Additional content defined by implementations |
| .modifierExtension?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| .sequence | 1..1 | positiveInt | Information instance identifier |
| .category | 1..1 | CodeableConcept | Classification of the supplied information Bindingclaim-informationcategory(example) |
| .code | 0..1 | CodeableConcept | Type of information Bindingclaim-exception(example) |
| .timing[x] | 0..1 | date | Period | When it occurred |
| .value[x] | 0..1 | boolean | string | Quantity | Attachment | Reference(Resource) | Data to be provided |
| .reason | 0..1 | CodeableConcept | Explanation for the information Bindingmissing-tooth-reason(example) |
| .diagnosis | 0..* | BackboneElement | Pertinent diagnosis information |
| .id | 0..1 | String | Unique id for inter-element referencing |
| .extension | 0..* | Extension | Additional content defined by implementations |
| .modifierExtension?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| .sequence | 1..1 | positiveInt | Diagnosis instance identifier |
| .diagnosis[x] | 1..1 | CodeableConcept | Reference(Condition) | Nature of illness or problem Bindingicd-10(example) |
| .type | 0..* | CodeableConcept | Timing or nature of the diagnosis Bindingex-diagnosistype(example) |
| .onAdmission | 0..1 | CodeableConcept | Present on admission Bindingex-diagnosis-on-admission(example) |
| .packageCode | 0..1 | CodeableConcept | Package billing code Bindingex-diagnosisrelatedgroup(example) |
| .procedure | 0..* | BackboneElement | Clinical procedures performed |
| .id | 0..1 | String | Unique id for inter-element referencing |
| .extension | 0..* | Extension | Additional content defined by implementations |
| .modifierExtension?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| .sequence | 1..1 | positiveInt | Procedure instance identifier |
| .type | 0..* | CodeableConcept | Category of Procedure Bindingex-procedure-type(example) |
| .date | 0..1 | dateTime | When the procedure was performed |
| .procedure[x] | 1..1 | CodeableConcept | Reference(Procedure) | Specific clinical procedure Bindingicd-10-procedures(example) |
| .udi | 0..* | Reference(Device) | Unique device identifier |
| .insuranceΣ | 1..* | BackboneElement | Patient insurance information |
| .id | 0..1 | String | Unique id for inter-element referencing |
| .extension | 0..* | Extension | Additional content defined by implementations |
| .modifierExtension?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| .sequenceΣ | 1..1 | positiveInt | Insurance instance identifier |
| .focalΣ | 1..1 | boolean | Coverage to be used for adjudication |
| .identifier | 0..1 | Identifier | Pre-assigned Claim number |
| .coverageΣ | 1..1 | Reference(Coverage) | Insurance information |
| .businessArrangement | 0..1 | string | Additional provider contract number |
| .preAuthRef | 0..* | string | Prior authorization reference number |
| .claimResponse | 0..1 | Reference(ClaimResponse) | Adjudication results |
| .accident | 0..1 | BackboneElement | Details of the event |
| .id | 0..1 | String | Unique id for inter-element referencing |
| .extension | 0..* | Extension | Additional content defined by implementations |
| .modifierExtension?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| .date | 1..1 | date | When the incident occurred |
| .type | 0..1 | CodeableConcept | The nature of the accident Bindingv3-ActIncidentCode(extensible) |
| .location[x] | 0..1 | Address | Reference(Location) | Where the event occurred |
| .item | 0..* | BackboneElement | Product or service provided |
| .id | 0..1 | String | Unique id for inter-element referencing |
| .extension | 0..* | Extension | Additional content defined by implementations |
| .modifierExtension?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| .sequence | 1..1 | positiveInt | Item instance identifier |
| .careTeamSequence | 0..* | positiveInt | Applicable careTeam members |
| .diagnosisSequence | 0..* | positiveInt | Applicable diagnoses |
| .procedureSequence | 0..* | positiveInt | Applicable procedures |
| .informationSequence | 0..* | positiveInt | Applicable exception and supporting information |
| .revenue | 0..1 | CodeableConcept | Revenue or cost center code Bindingex-revenue-center(example) |
| .category | 0..1 | CodeableConcept | Benefit classification Bindingex-benefitcategory(example) |
| .productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Bindingservice-uscls(example) |
| .modifier | 0..* | CodeableConcept | Product or service billing modifiers Bindingclaim-modifiers(example) |
| .programCode | 0..* | CodeableConcept | Program the product or service is provided under Bindingex-program-code(example) |
| .serviced[x] | 0..1 | date | Period | Date or dates of service or product delivery |
| .location[x] | 0..1 | CodeableConcept | Address | Reference(Location) | Place of service or where product was supplied Bindingservice-place(example) |
| .quantity | 0..1 | Quantity | Count of products or services |
| .unitPrice | 0..1 | Money | Fee, charge or cost per item |
| .factor | 0..1 | decimal | Price scaling factor |
| .net | 0..1 | Money | Total item cost |
| .udi | 0..* | Reference(Device) | Unique device identifier |
| .bodySite | 0..1 | CodeableConcept | Anatomical location Bindingtooth(example) |
| .subSite | 0..* | CodeableConcept | Anatomical sub-location Bindingsurface(example) |
| .encounter | 0..* | Reference(Encounter) | Encounters related to this billed item |
| .detail | 0..* | BackboneElement | Product or service provided |
| .id | 0..1 | String | Unique id for inter-element referencing |
| .extension | 0..* | Extension | Additional content defined by implementations |
| .modifierExtension?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| .sequence | 1..1 | positiveInt | Item instance identifier |
| .revenue | 0..1 | CodeableConcept | Revenue or cost center code Bindingex-revenue-center(example) |
| .category | 0..1 | CodeableConcept | Benefit classification Bindingex-benefitcategory(example) |
| .productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Bindingservice-uscls(example) |
| .modifier | 0..* | CodeableConcept | Service/Product billing modifiers Bindingclaim-modifiers(example) |
| .programCode | 0..* | CodeableConcept | Program the product or service is provided under Bindingex-program-code(example) |
| .quantity | 0..1 | Quantity | Count of products or services |
| .unitPrice | 0..1 | Money | Fee, charge or cost per item |
| .factor | 0..1 | decimal | Price scaling factor |
| .net | 0..1 | Money | Total item cost |
| .udi | 0..* | Reference(Device) | Unique device identifier |
| .subDetail | 0..* | BackboneElement | Product or service provided |
| .id | 0..1 | String | Unique id for inter-element referencing |
| .extension | 0..* | Extension | Additional content defined by implementations |
| .modifierExtension?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| .sequence | 1..1 | positiveInt | Item instance identifier |
| .revenue | 0..1 | CodeableConcept | Revenue or cost center code Bindingex-revenue-center(example) |
| .category | 0..1 | CodeableConcept | Benefit classification Bindingex-benefitcategory(example) |
| .productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Bindingservice-uscls(example) |
| .modifier | 0..* | CodeableConcept | Service/Product billing modifiers Bindingclaim-modifiers(example) |
| .programCode | 0..* | CodeableConcept | Program the product or service is provided under Bindingex-program-code(example) |
| .quantity | 0..1 | Quantity | Count of products or services |
| .unitPrice | 0..1 | Money | Fee, charge or cost per item |
| .factor | 0..1 | decimal | Price scaling factor |
| .net | 0..1 | Money | Total item cost |
| .udi | 0..* | Reference(Device) | Unique device identifier |
| .total | 0..1 | Money | Total claim cost |