http://hl7.org/fhir/StructureDefinition/Claim|4.0.1

description: 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.
derivation: specialization
name: Claim
type: Claim
elements:
  patient: {short: The recipient of the products and services, isSummary: true, index: 5}
  insurance:
    min: 1
    short: Patient insurance information
    array: true
    isSummary: true
    index: 53
    elements:
      sequence: {short: Insurance instance identifier, isSummary: true, index: 54}
      focal: {short: Coverage to be used for adjudication, isSummary: true, index: 55}
      identifier: {short: Pre-assigned Claim number, index: 56}
      coverage: {short: Insurance information, isSummary: true, index: 57}
      businessArrangement: {short: Additional provider contract number, index: 58}
      preAuthRef: {short: Prior authorization reference number, array: true, index: 59}
      claimResponse: {short: Adjudication results, index: 60}
    required: [coverage, focal, sequence]
  facility: {short: Servicing facility, index: 23}
  diagnosis:
    short: Pertinent diagnosis information
    array: true
    index: 39
    elements:
      sequence: {short: Diagnosis instance identifier, index: 40}
      diagnosis:
        short: Nature of illness or problem
        choices: []
        index: 42
      type:
        short: Timing or nature of the diagnosis
        array: true
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-diagnosistype'}
        index: 43
      onAdmission:
        short: Present on admission
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-diagnosis-on-admission'}
        index: 44
      packageCode:
        short: Package billing code
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup'}
        index: 45
    required: [diagnosis, sequence]
  enterer: {short: Author of the claim, index: 8}
  supportingInfo:
    short: Supporting information
    array: true
    index: 30
    elements:
      sequence: {short: Information instance identifier, index: 31}
      category:
        short: Classification of the supplied information
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-informationcategory'}
        index: 32
      code:
        short: Type of information
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-exception'}
        index: 33
      timing:
        short: When it occurred
        choices: []
        index: 35
      value:
        short: Data to be provided
        choices: []
        index: 37
      reason:
        short: Explanation for the information
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/missing-tooth-reason'}
        index: 38
    required: [sequence, category]
  use:
    short: claim | preauthorization | predetermination
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/claim-use|4.0.1'}
    isSummary: true
    index: 4
  item:
    short: Product or service provided
    array: true
    index: 66
    elements:
      category:
        short: Benefit classification
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-benefitcategory'}
        index: 73
      diagnosisSequence: {short: Applicable diagnoses, array: true, index: 69}
      procedureSequence: {short: Applicable procedures, array: true, index: 70}
      modifier:
        short: Product or service billing modifiers
        array: true
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-modifiers'}
        index: 75
      revenue:
        short: Revenue or cost center code
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-revenue-center'}
        index: 72
      encounter: {short: Encounters related to this billed item, array: true, index: 88}
      net: {short: Total item cost, index: 84}
      serviced:
        short: Date or dates of service or product delivery
        choices: []
        index: 78
      subSite:
        short: Anatomical sub-location
        array: true
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/surface'}
        index: 87
      careTeamSequence: {short: Applicable careTeam members, array: true, index: 68}
      productOrService:
        short: Billing, service, product, or drug code
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
        index: 74
      udi: {short: Unique device identifier, array: true, index: 85}
      informationSequence: {short: Applicable exception and supporting information, array: true, index: 71}
      programCode:
        short: Program the product or service is provided under
        array: true
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-program-code'}
        index: 76
      factor: {short: Price scaling factor, index: 83}
      sequence: {short: Item instance identifier, index: 67}
      bodySite:
        short: Anatomical location
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/tooth'}
        index: 86
      quantity: {short: Count of products or services, index: 81}
      location:
        short: Place of service or where product was supplied
        choices: []
        index: 80
      unitPrice: {short: 'Fee, charge or cost per item', index: 82}
      detail:
        short: Product or service provided
        array: true
        index: 89
        elements:
          category:
            short: Benefit classification
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-benefitcategory'}
            index: 92
          modifier:
            short: Service/Product billing modifiers
            array: true
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-modifiers'}
            index: 94
          revenue:
            short: Revenue or cost center code
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-revenue-center'}
            index: 91
          net: {short: Total item cost, index: 99}
          productOrService:
            short: Billing, service, product, or drug code
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
            index: 93
          udi: {short: Unique device identifier, array: true, index: 100}
          programCode:
            short: Program the product or service is provided under
            array: true
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-program-code'}
            index: 95
          factor: {short: Price scaling factor, index: 98}
          sequence: {short: Item instance identifier, index: 90}
          subDetail:
            short: Product or service provided
            array: true
            index: 101
            elements:
              category:
                short: Benefit classification
                binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-benefitcategory'}
                index: 104
              modifier:
                short: Service/Product billing modifiers
                array: true
                binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-modifiers'}
                index: 106
              revenue:
                short: Revenue or cost center code
                binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-revenue-center'}
                index: 103
              net: {short: Total item cost, index: 111}
              productOrService:
                short: Billing, service, product, or drug code
                binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
                index: 105
              udi: {short: Unique device identifier, array: true, index: 112}
              programCode:
                short: Program the product or service is provided under
                array: true
                binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-program-code'}
                index: 107
              factor: {short: Price scaling factor, index: 110}
              sequence: {short: Item instance identifier, index: 102}
              quantity: {short: Count of products or services, index: 108}
              unitPrice: {short: 'Fee, charge or cost per item', index: 109}
            required: [sequence, productOrService]
          quantity: {short: Count of products or services, index: 96}
          unitPrice: {short: 'Fee, charge or cost per item', index: 97}
        required: [sequence, productOrService]
    required: [sequence, productOrService]
  type:
    short: Category or discipline
    binding: {strength: extensible, valueSet: 'http://hl7.org/fhir/ValueSet/claim-type'}
    isSummary: true
    index: 2
  created: {short: Resource creation date, isSummary: true, index: 7}
  procedure:
    short: Clinical procedures performed
    array: true
    index: 46
    elements:
      sequence: {short: Procedure instance identifier, index: 47}
      type:
        short: Category of Procedure
        array: true
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-procedure-type'}
        index: 48
      date: {short: When the procedure was performed, index: 49}
      procedure:
        short: Specific clinical procedure
        choices: []
        index: 51
      udi: {short: Unique device identifier, array: true, index: 52}
    required: [sequence, procedure]
  related:
    short: Prior or corollary claims
    array: true
    index: 13
    elements:
      claim: {short: Reference to the related claim, index: 14}
      relationship:
        short: How the reference claim is related
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/related-claim-relationship'}
        index: 15
      reference: {short: File or case reference, index: 16}
  referral: {short: Treatment referral, index: 22}
  total: {short: Total claim cost, index: 113}
  insurer: {short: Target, isSummary: true, index: 9}
  fundsReserve:
    short: For whom to reserve funds
    binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/fundsreserve'}
    index: 12
  priority:
    short: Desired processing ugency
    binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/process-priority'}
    isSummary: true
    index: 11
  accident:
    short: Details of the event
    index: 61
    elements:
      date: {short: When the incident occurred, index: 62}
      type:
        short: The nature of the accident
        binding: {strength: extensible, valueSet: 'http://terminology.hl7.org/ValueSet/v3-ActIncidentCode'}
        index: 63
      location:
        short: Where the event occurred
        choices: []
        index: 65
    required: [date]
  status:
    isModifier: true
    short: active | cancelled | draft | entered-in-error
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/fm-status|4.0.1'}
    isModifierReason: This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
    isSummary: true
    index: 1
  payee:
    short: Recipient of benefits payable
    index: 19
    elements:
      type:
        short: Category of recipient
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/payeetype'}
        index: 20
      party: {short: Recipient reference, index: 21}
    required: [type]
  prescription: {short: Prescription authorizing services and products, index: 17}
  billablePeriod: {short: Relevant time frame for the claim, isSummary: true, index: 6}
  identifier: {short: Business Identifier for claim, array: true, index: 0}
  subType:
    short: More granular claim type
    binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-subtype'}
    index: 3
  provider: {short: Party responsible for the claim, isSummary: true, index: 10}
  originalPrescription: {short: Original prescription if superseded by fulfiller, index: 18}
  careTeam:
    short: Members of the care team
    array: true
    index: 24
    elements:
      sequence: {short: Order of care team, index: 25}
      provider: {short: Practitioner or organization, index: 26}
      responsible: {short: Indicator of the lead practitioner, index: 27}
      role:
        short: Function within the team
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-careteamrole'}
        index: 28
      qualification:
        short: Practitioner credential or specialization
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/provider-qualification'}
        index: 29
    required: [provider, sequence]
class: resource
kind: resource
url: http://hl7.org/fhir/StructureDefinition/Claim
base: http://hl7.org/fhir/StructureDefinition/DomainResource
version: 4.0.1
required: [created, priority, provider, status, insurance, type, patient, use]