http://hl7.org/fhir/StructureDefinition/Claim|4.0.1
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.
| Name | Flags | Card | Type | Description & Constraints |
|---|---|---|---|---|
Claim | 0..* | Claim, Pre-determination or Pre-authorization | ||
| 0..* | Identifier | Business Identifier for claim | ||
?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error ClaimStatus (required) | |
Σ | 1..1 | CodeableConcept | Category or discipline ClaimType (extensible) | |
| 0..1 | CodeableConcept | More granular claim type ClaimSubType (example) | ||
Σ | 1..1 | code | claim | preauthorization | predetermination Use (required) | |
Σ | 1..1 | Reference | The recipient of the products and services | |
Σ | 0..1 | Period | Relevant time frame for the claim | |
Σ | 1..1 | dateTime | Resource creation date | |
| 0..1 | Reference | Author of the claim | ||
Σ | 0..1 | Reference | Target | |
Σ | 1..1 | Reference | Party responsible for the claim | |
Σ | 1..1 | CodeableConcept | Desired processing ugency ProcessPriority (example) | |
| 0..1 | CodeableConcept | For whom to reserve funds FundsReserve (example) | ||
| 0..* | BackboneElement | Prior or corollary claims | ||
| 0..1 | Reference | Reference to the related claim | ||
| 0..1 | CodeableConcept | How the reference claim is related RelatedClaimRelationship (example) | ||
| 0..1 | Identifier | File or case reference | ||
| 0..1 | Reference | Prescription authorizing services and products | ||
| 0..1 | Reference | Original prescription if superseded by fulfiller | ||
| 0..1 | BackboneElement | Recipient of benefits payable | ||
| 1..1 | CodeableConcept | Category of recipient PayeeType (example) | ||
| 0..1 | Reference | Recipient reference | ||
| 0..1 | Reference | Treatment referral | ||
| 0..1 | Reference | Servicing facility | ||
| 0..* | BackboneElement | Members of the care team | ||
| 1..1 | positiveInt | Order of care team | ||
| 1..1 | Reference | Practitioner or organization | ||
| 0..1 | boolean | Indicator of the lead practitioner | ||
| 0..1 | CodeableConcept | Function within the team CareTeamRole (example) | ||
| 0..1 | CodeableConcept | Practitioner credential or specialization ProviderQualification (example) | ||
| 0..* | BackboneElement | Supporting information | ||
| 1..1 | positiveInt | Information instance identifier | ||
| 1..1 | CodeableConcept | Classification of the supplied information InformationCategory (example) | ||
| 0..1 | CodeableConcept | Type of information InformationCode (example) | ||
| 0..1 | When it occurred | |||
| 0..1 | date | |||
| 0..1 | Period | |||
| 0..1 | Data to be provided | |||
| 0..1 | boolean | |||
| 0..1 | string | |||
| 0..1 | Quantity | |||
| 0..1 | Attachment | |||
| 0..1 | Reference | |||
| 0..1 | CodeableConcept | Explanation for the information MissingReason (example) | ||
| 0..* | BackboneElement | Pertinent diagnosis information | ||
| 1..1 | positiveInt | Diagnosis instance identifier | ||
| 1..1 | Nature of illness or problem ICD10 (example) | |||
| 1..1 | CodeableConcept | ICD10 (example) | ||
| 1..1 | Reference | ICD10 (example) | ||
| 0..* | CodeableConcept | Timing or nature of the diagnosis DiagnosisType (example) | ||
| 0..1 | CodeableConcept | Present on admission DiagnosisOnAdmission (example) | ||
| 0..1 | CodeableConcept | Package billing code DiagnosisRelatedGroup (example) | ||
| 0..* | BackboneElement | Clinical procedures performed | ||
| 1..1 | positiveInt | Procedure instance identifier | ||
| 0..* | CodeableConcept | Category of Procedure ProcedureType (example) | ||
| 0..1 | dateTime | When the procedure was performed | ||
| 1..1 | Specific clinical procedure ICD10_Procedures (example) | |||
| 1..1 | CodeableConcept | ICD10_Procedures (example) | ||
| 1..1 | Reference | ICD10_Procedures (example) | ||
| 0..* | Reference | Unique device identifier | ||
Σ | 1..* | BackboneElement | Patient insurance information | |
Σ | 1..1 | positiveInt | Insurance instance identifier | |
Σ | 1..1 | boolean | Coverage to be used for adjudication | |
| 0..1 | Identifier | Pre-assigned Claim number | ||
Σ | 1..1 | Reference | Insurance information | |
| 0..1 | string | Additional provider contract number | ||
| 0..* | string | Prior authorization reference number | ||
| 0..1 | Reference | Adjudication results | ||
| 0..1 | BackboneElement | Details of the event | ||
| 1..1 | date | When the incident occurred | ||
| 0..1 | CodeableConcept | The nature of the accident AccidentType (extensible) | ||
| 0..1 | Where the event occurred | |||
| 0..1 | Address | |||
| 0..1 | Reference | |||
| 0..* | BackboneElement | Product or service provided | ||
| 1..1 | positiveInt | Item instance identifier | ||
| 0..* | positiveInt | Applicable careTeam members | ||
| 0..* | positiveInt | Applicable diagnoses | ||
| 0..* | positiveInt | Applicable procedures | ||
| 0..* | positiveInt | Applicable exception and supporting information | ||
| 0..1 | CodeableConcept | Revenue or cost center code RevenueCenter (example) | ||
| 0..1 | CodeableConcept | Benefit classification BenefitCategory (example) | ||
| 1..1 | CodeableConcept | Billing, service, product, or drug code ServiceProduct (example) | ||
| 0..* | CodeableConcept | Product or service billing modifiers Modifiers (example) | ||
| 0..* | CodeableConcept | Program the product or service is provided under ProgramCode (example) | ||
| 0..1 | Date or dates of service or product delivery | |||
| 0..1 | date | |||
| 0..1 | Period | |||
| 0..1 | Place of service or where product was supplied ServicePlace (example) | |||
| 0..1 | CodeableConcept | ServicePlace (example) | ||
| 0..1 | Address | ServicePlace (example) | ||
| 0..1 | Reference | ServicePlace (example) | ||
| 0..1 | Quantity | Count of products or services | ||
| 0..1 | Money | Fee, charge or cost per item | ||
| 0..1 | decimal | Price scaling factor | ||
| 0..1 | Money | Total item cost | ||
| 0..* | Reference | Unique device identifier | ||
| 0..1 | CodeableConcept | Anatomical location OralSites (example) | ||
| 0..* | CodeableConcept | Anatomical sub-location Surface (example) | ||
| 0..* | Reference | Encounters related to this billed item | ||
| 0..* | BackboneElement | Product or service provided | ||
| 1..1 | positiveInt | Item instance identifier | ||
| 0..1 | CodeableConcept | Revenue or cost center code RevenueCenter (example) | ||
| 0..1 | CodeableConcept | Benefit classification BenefitCategory (example) | ||
| 1..1 | CodeableConcept | Billing, service, product, or drug code ServiceProduct (example) | ||
| 0..* | CodeableConcept | Service/Product billing modifiers Modifiers (example) | ||
| 0..* | CodeableConcept | Program the product or service is provided under ProgramCode (example) | ||
| 0..1 | Quantity | Count of products or services | ||
| 0..1 | Money | Fee, charge or cost per item | ||
| 0..1 | decimal | Price scaling factor | ||
| 0..1 | Money | Total item cost | ||
| 0..* | Reference | Unique device identifier | ||
| 0..* | BackboneElement | Product or service provided | ||
| 1..1 | positiveInt | Item instance identifier | ||
| 0..1 | CodeableConcept | Revenue or cost center code RevenueCenter (example) | ||
| 0..1 | CodeableConcept | Benefit classification BenefitCategory (example) | ||
| 1..1 | CodeableConcept | Billing, service, product, or drug code ServiceProduct (example) | ||
| 0..* | CodeableConcept | Service/Product billing modifiers Modifiers (example) | ||
| 0..* | CodeableConcept | Program the product or service is provided under ProgramCode (example) | ||
| 0..1 | Quantity | Count of products or services | ||
| 0..1 | Money | Fee, charge or cost per item | ||
| 0..1 | decimal | Price scaling factor | ||
| 0..1 | Money | Total item cost | ||
| 0..* | Reference | Unique device identifier | ||
| 0..1 | Money | Total claim cost |