http://hl7.org/fhir/StructureDefinition/Claim|5.0.0

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.
Structure JSON Dependencies FHIRSchema Other Versions Dependant (0)Elements Summary
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: {isModifier: false, short: The recipient of the products and services, mustSupport: false, isSummary: true, index: 6}
  insurance:
    isModifier: false
    short: Patient insurance information
    mustSupport: false
    array: true
    isSummary: true
    index: 59
    elements:
      sequence: {isModifier: false, short: Insurance instance identifier, mustSupport: false, isSummary: true, index: 60}
      focal: {isModifier: false, short: Coverage to be used for adjudication, mustSupport: false, isSummary: true, index: 61}
      identifier: {isModifier: false, short: Pre-assigned Claim number, mustSupport: false, isSummary: false, index: 62}
      coverage: {isModifier: false, short: Insurance information, mustSupport: false, isSummary: true, index: 63}
      businessArrangement: {isModifier: false, short: Additional provider contract number, mustSupport: false, isSummary: false, index: 64}
      preAuthRef: {isModifier: false, short: Prior authorization reference number, mustSupport: false, array: true, isSummary: false, index: 65}
      claimResponse: {isModifier: false, short: Adjudication results, mustSupport: false, isSummary: false, index: 66}
    required: [coverage, focal, sequence]
  facility: {isModifier: false, short: Servicing facility, mustSupport: false, isSummary: false, index: 25}
  diagnosis:
    isModifier: false
    short: Pertinent diagnosis information
    mustSupport: false
    array: true
    isSummary: false
    index: 46
    elements:
      sequence: {isModifier: false, short: Diagnosis instance identifier, mustSupport: false, isSummary: false, index: 47}
      diagnosis:
        isModifier: false
        short: Nature of illness or problem
        mustSupport: false
        choices: []
        isSummary: false
        index: 49
      type:
        isModifier: false
        short: Timing or nature of the diagnosis
        mustSupport: false
        array: true
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-diagnosistype'}
        isSummary: false
        index: 50
      onAdmission:
        isModifier: false
        short: Present on admission
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-diagnosis-on-admission'}
        isSummary: false
        index: 51
    required: [diagnosis, sequence]
  enterer: {isModifier: false, short: Author of the claim, mustSupport: false, isSummary: false, index: 9}
  supportingInfo:
    isModifier: false
    short: Supporting information
    mustSupport: false
    array: true
    isSummary: false
    index: 37
    elements:
      sequence: {isModifier: false, short: Information instance identifier, mustSupport: false, isSummary: false, index: 38}
      category:
        isModifier: false
        short: Classification of the supplied information
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-informationcategory'}
        isSummary: false
        index: 39
      code:
        isModifier: false
        short: Type of information
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-exception'}
        isSummary: false
        index: 40
      timing:
        isModifier: false
        short: When it occurred
        mustSupport: false
        choices: []
        isSummary: false
        index: 42
      value:
        isModifier: false
        short: Data to be provided
        mustSupport: false
        choices: []
        isSummary: false
        index: 44
      reason:
        isModifier: false
        short: Explanation for the information
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/missing-tooth-reason'}
        isSummary: false
        index: 45
    required: [sequence, category]
  encounter: {isModifier: false, short: Encounters associated with the listed treatments, mustSupport: false, array: true, isSummary: false, index: 24}
  use:
    isModifier: false
    short: claim | preauthorization | predetermination
    mustSupport: false
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/claim-use|5.0.0'}
    isSummary: true
    index: 5
  traceNumber: {isModifier: false, short: Number for tracking, mustSupport: false, array: true, isSummary: false, index: 1}
  item:
    isModifier: false
    short: Product or service provided
    mustSupport: false
    array: true
    isSummary: false
    index: 73
    elements:
      category:
        isModifier: false
        short: Benefit classification
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-benefitcategory'}
        isSummary: false
        index: 81
      diagnosisSequence: {isModifier: false, short: Applicable diagnoses, mustSupport: false, array: true, isSummary: false, index: 77}
      procedureSequence: {isModifier: false, short: Applicable procedures, mustSupport: false, array: true, isSummary: false, index: 78}
      request: {isModifier: false, short: Request or Referral for Service, mustSupport: false, array: true, isSummary: false, index: 84}
      modifier:
        isModifier: false
        short: Product or service billing modifiers
        mustSupport: false
        array: true
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-modifiers'}
        isSummary: false
        index: 85
      revenue:
        isModifier: false
        short: Revenue or cost center code
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-revenue-center'}
        isSummary: false
        index: 80
      encounter: {isModifier: false, short: Encounters associated with the listed treatments, mustSupport: false, array: true, isSummary: false, index: 101}
      productOrServiceEnd:
        isModifier: false
        short: End of a range of codes
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
        isSummary: false
        index: 83
      traceNumber: {isModifier: false, short: Number for tracking, mustSupport: false, array: true, isSummary: false, index: 75}
      net: {isModifier: false, short: Total item cost, mustSupport: false, isSummary: false, index: 96}
      serviced:
        isModifier: false
        short: Date or dates of service or product delivery
        mustSupport: false
        choices: []
        isSummary: false
        index: 88
      tax: {isModifier: false, short: Total tax, mustSupport: false, isSummary: false, index: 95}
      careTeamSequence: {isModifier: false, short: Applicable careTeam members, mustSupport: false, array: true, isSummary: false, index: 76}
      productOrService:
        isModifier: false
        short: Billing, service, product, or drug code
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
        isSummary: false
        index: 82
      udi: {isModifier: false, short: Unique device identifier, mustSupport: false, array: true, isSummary: false, index: 97}
      informationSequence: {isModifier: false, short: Applicable exception and supporting information, mustSupport: false, array: true, isSummary: false, index: 79}
      programCode:
        isModifier: false
        short: Program the product or service is provided under
        mustSupport: false
        array: true
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-program-code'}
        isSummary: false
        index: 86
      factor: {isModifier: false, short: Price scaling factor, mustSupport: false, isSummary: false, index: 94}
      sequence: {isModifier: false, short: Item instance identifier, mustSupport: false, isSummary: false, index: 74}
      bodySite:
        isModifier: false
        short: Anatomical location
        mustSupport: false
        array: true
        isSummary: false
        index: 98
        elements:
          site:
            min: 1
            isModifier: false
            short: Location
            index: 99
            mustSupport: false
            array: true
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/tooth'}
            isSummary: false
          subSite:
            isModifier: false
            short: Sub-location
            mustSupport: false
            array: true
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/surface'}
            isSummary: false
            index: 100
        required: [site]
      quantity: {isModifier: false, short: Count of products or services, mustSupport: false, isSummary: false, index: 92}
      location:
        isModifier: false
        short: Place of service or where product was supplied
        mustSupport: false
        choices: []
        isSummary: false
        index: 90
      patientPaid: {isModifier: false, short: Paid by the patient, mustSupport: false, isSummary: false, index: 91}
      unitPrice: {isModifier: false, short: 'Fee, charge or cost per item', mustSupport: false, isSummary: false, index: 93}
      detail:
        isModifier: false
        short: Product or service provided
        mustSupport: false
        array: true
        isSummary: false
        index: 102
        elements:
          category:
            isModifier: false
            short: Benefit classification
            mustSupport: false
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-benefitcategory'}
            isSummary: false
            index: 106
          modifier:
            isModifier: false
            short: Service/Product billing modifiers
            mustSupport: false
            array: true
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-modifiers'}
            isSummary: false
            index: 109
          revenue:
            isModifier: false
            short: Revenue or cost center code
            mustSupport: false
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-revenue-center'}
            isSummary: false
            index: 105
          productOrServiceEnd:
            isModifier: false
            short: End of a range of codes
            mustSupport: false
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
            isSummary: false
            index: 108
          traceNumber: {isModifier: false, short: Number for tracking, mustSupport: false, array: true, isSummary: false, index: 104}
          net: {isModifier: false, short: Total item cost, mustSupport: false, isSummary: false, index: 116}
          tax: {isModifier: false, short: Total tax, mustSupport: false, isSummary: false, index: 115}
          productOrService:
            isModifier: false
            short: Billing, service, product, or drug code
            mustSupport: false
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
            isSummary: false
            index: 107
          udi: {isModifier: false, short: Unique device identifier, mustSupport: false, array: true, isSummary: false, index: 117}
          programCode:
            isModifier: false
            short: Program the product or service is provided under
            mustSupport: false
            array: true
            binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-program-code'}
            isSummary: false
            index: 110
          factor: {isModifier: false, short: Price scaling factor, mustSupport: false, isSummary: false, index: 114}
          sequence: {isModifier: false, short: Item instance identifier, mustSupport: false, isSummary: false, index: 103}
          subDetail:
            isModifier: false
            short: Product or service provided
            mustSupport: false
            array: true
            isSummary: false
            index: 118
            elements:
              category:
                isModifier: false
                short: Benefit classification
                mustSupport: false
                binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-benefitcategory'}
                isSummary: false
                index: 122
              modifier:
                isModifier: false
                short: Service/Product billing modifiers
                mustSupport: false
                array: true
                binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-modifiers'}
                isSummary: false
                index: 125
              revenue:
                isModifier: false
                short: Revenue or cost center code
                mustSupport: false
                binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-revenue-center'}
                isSummary: false
                index: 121
              productOrServiceEnd:
                isModifier: false
                short: End of a range of codes
                mustSupport: false
                binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
                isSummary: false
                index: 124
              traceNumber: {isModifier: false, short: Number for tracking, mustSupport: false, array: true, isSummary: false, index: 120}
              net: {isModifier: false, short: Total item cost, mustSupport: false, isSummary: false, index: 132}
              tax: {isModifier: false, short: Total tax, mustSupport: false, isSummary: false, index: 131}
              productOrService:
                isModifier: false
                short: Billing, service, product, or drug code
                mustSupport: false
                binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/service-uscls'}
                isSummary: false
                index: 123
              udi: {isModifier: false, short: Unique device identifier, mustSupport: false, array: true, isSummary: false, index: 133}
              programCode:
                isModifier: false
                short: Program the product or service is provided under
                mustSupport: false
                array: true
                binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-program-code'}
                isSummary: false
                index: 126
              factor: {isModifier: false, short: Price scaling factor, mustSupport: false, isSummary: false, index: 130}
              sequence: {isModifier: false, short: Item instance identifier, mustSupport: false, isSummary: false, index: 119}
              quantity: {isModifier: false, short: Count of products or services, mustSupport: false, isSummary: false, index: 128}
              patientPaid: {isModifier: false, short: Paid by the patient, mustSupport: false, isSummary: false, index: 127}
              unitPrice: {isModifier: false, short: 'Fee, charge or cost per item', mustSupport: false, isSummary: false, index: 129}
            required: [sequence]
          quantity: {isModifier: false, short: Count of products or services, mustSupport: false, isSummary: false, index: 112}
          patientPaid: {isModifier: false, short: Paid by the patient, mustSupport: false, isSummary: false, index: 111}
          unitPrice: {isModifier: false, short: 'Fee, charge or cost per item', mustSupport: false, isSummary: false, index: 113}
        required: [sequence]
    required: [sequence]
  type:
    isModifier: false
    short: Category or discipline
    mustSupport: false
    binding: {strength: extensible, valueSet: 'http://hl7.org/fhir/ValueSet/claim-type'}
    isSummary: true
    index: 3
  created: {isModifier: false, short: Resource creation date, mustSupport: false, isSummary: true, index: 8}
  procedure:
    isModifier: false
    short: Clinical procedures performed
    mustSupport: false
    array: true
    isSummary: false
    index: 52
    elements:
      sequence: {isModifier: false, short: Procedure instance identifier, mustSupport: false, isSummary: false, index: 53}
      type:
        isModifier: false
        short: Category of Procedure
        mustSupport: false
        array: true
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-procedure-type'}
        isSummary: false
        index: 54
      date: {isModifier: false, short: When the procedure was performed, mustSupport: false, isSummary: false, index: 55}
      procedure:
        isModifier: false
        short: Specific clinical procedure
        mustSupport: false
        choices: []
        isSummary: false
        index: 57
      udi: {isModifier: false, short: Unique device identifier, mustSupport: false, array: true, isSummary: false, index: 58}
    required: [sequence, procedure]
  related:
    isModifier: false
    short: Prior or corollary claims
    mustSupport: false
    array: true
    isSummary: false
    index: 14
    elements:
      claim: {isModifier: false, short: Reference to the related claim, mustSupport: false, isSummary: false, index: 15}
      relationship:
        isModifier: false
        short: How the reference claim is related
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/related-claim-relationship'}
        isSummary: false
        index: 16
      reference: {isModifier: false, short: File or case reference, mustSupport: false, isSummary: false, index: 17}
  referral: {isModifier: false, short: Treatment referral, mustSupport: false, isSummary: false, index: 23}
  diagnosisRelatedGroup:
    isModifier: false
    short: Package billing code
    mustSupport: false
    binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup'}
    isSummary: false
    index: 26
  total: {isModifier: false, short: Total claim cost, mustSupport: false, isSummary: false, index: 134}
  event:
    isModifier: false
    short: Event information
    mustSupport: false
    array: true
    isSummary: false
    index: 27
    elements:
      type:
        isModifier: false
        short: Specific event
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/datestype'}
        isSummary: false
        index: 28
      when:
        isModifier: false
        short: Occurance date or period
        mustSupport: false
        choices: []
        isSummary: false
        index: 30
    required: [when, type]
  insurer: {isModifier: false, short: Target, mustSupport: false, isSummary: true, index: 10}
  fundsReserve:
    isModifier: false
    short: For whom to reserve funds
    mustSupport: false
    binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/fundsreserve'}
    isSummary: false
    index: 13
  priority:
    isModifier: false
    short: Desired processing urgency
    mustSupport: false
    binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/process-priority'}
    isSummary: true
    index: 12
  accident:
    isModifier: false
    short: Details of the event
    mustSupport: false
    isSummary: false
    index: 67
    elements:
      date: {isModifier: false, short: When the incident occurred, mustSupport: false, isSummary: false, index: 68}
      type:
        isModifier: false
        short: The nature of the accident
        mustSupport: false
        binding: {strength: extensible, valueSet: 'http://terminology.hl7.org/ValueSet/v3-ActIncidentCode'}
        isSummary: false
        index: 69
      location:
        isModifier: false
        short: Where the event occurred
        mustSupport: false
        choices: []
        isSummary: false
        index: 71
    required: [date]
  status:
    isModifier: true
    short: active | cancelled | draft | entered-in-error
    mustSupport: false
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/fm-status|5.0.0'}
    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: 2
  payee:
    isModifier: false
    short: Recipient of benefits payable
    mustSupport: false
    isSummary: false
    index: 20
    elements:
      type:
        isModifier: false
        short: Category of recipient
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/payeetype'}
        isSummary: false
        index: 21
      party: {isModifier: false, short: Recipient reference, mustSupport: false, isSummary: false, index: 22}
    required: [type]
  prescription: {isModifier: false, short: Prescription authorizing services and products, mustSupport: false, isSummary: false, index: 18}
  billablePeriod: {isModifier: false, short: Relevant time frame for the claim, mustSupport: false, isSummary: true, index: 7}
  identifier: {isModifier: false, short: Business Identifier for claim, mustSupport: false, array: true, isSummary: false, index: 0}
  subType:
    isModifier: false
    short: More granular claim type
    mustSupport: false
    binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-subtype'}
    isSummary: false
    index: 4
  provider: {isModifier: false, short: Party responsible for the claim, mustSupport: false, isSummary: true, index: 11}
  patientPaid: {isModifier: false, short: Paid by the patient, mustSupport: false, isSummary: false, index: 72}
  originalPrescription: {isModifier: false, short: Original prescription if superseded by fulfiller, mustSupport: false, isSummary: false, index: 19}
  careTeam:
    isModifier: false
    short: Members of the care team
    mustSupport: false
    array: true
    isSummary: false
    index: 31
    elements:
      sequence: {isModifier: false, short: Order of care team, mustSupport: false, isSummary: false, index: 32}
      provider: {isModifier: false, short: Practitioner or organization, mustSupport: false, isSummary: false, index: 33}
      responsible: {isModifier: false, short: Indicator of the lead practitioner, mustSupport: false, isSummary: false, index: 34}
      role:
        isModifier: false
        short: Function within the team
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/claim-careteamrole'}
        isSummary: false
        index: 35
      specialty:
        isModifier: false
        short: Practitioner or provider specialization
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/provider-qualification'}
        isSummary: false
        index: 36
    required: [provider, sequence]
class: resource
kind: resource
url: http://hl7.org/fhir/StructureDefinition/Claim
base: http://hl7.org/fhir/StructureDefinition/DomainResource
version: 5.0.0
required: [created, status, type, patient, use]