Claim

Defines the ID Core constraints and extensions on the Claim resource for the minimal set of data to query and retrieve claim information.

Usage

This profile is used by providers and payors, insurers, to exchange the financial information, and supporting clinical information, regarding the provision of health care services with payors and for reporting to regulatory bodies and firms which provide data analytics.

The primary uses of this resource is to support electronic claims, the exchange of information relating to the proposed or actual provision of healthcare-related goods and services for patients to their benefit payors, insurers and national health programs, for treatment payment planning and reimbursement.

URL

Type URL
Canonical https://fhir.kemkes.go.id/r4/StructureDefinition/Claim

Structure

Snapshot

identifier0..*Identifier
statusΣ ?!1..1codeBinding
typeΣ1..1CodeableConceptBinding
subType0..1CodeableConcept
useΣ1..1codeBinding
patientΣ I1..1Reference(Patient)
billablePeriodΣ I0..1Period
createdΣ1..1dateTime
entererI0..1Reference(Practitioner | PractitionerRole)
insurerΣ I0..1Reference(Organization)
providerΣ I1..1Reference(Practitioner | PractitionerRole | Organization)
priorityΣ1..1CodeableConcept
fundsReserve0..1CodeableConcept
claimI0..1Reference(Claim)
relationship0..1CodeableConcept
reference0..1Identifier
prescriptionI0..1Reference(DeviceRequest | MedicationRequest | VisionPrescription)
originalPrescriptionI0..1Reference(DeviceRequest | MedicationRequest | VisionPrescription)
type1..1CodeableConcept
partyI0..1Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson)
referralI0..1Reference(ServiceRequest)
facilityI0..1Reference(Location)
sequence1..1positiveInt
providerI1..1Reference(Practitioner | PractitionerRole | Organization)
responsible0..1boolean
role0..1CodeableConcept
qualification0..1CodeableConcept
sequence1..1positiveInt
category1..1CodeableConcept
code0..1CodeableConcept
timingDatedate
timingPeriodPeriod
valueBooleanboolean
valueStringstring
valueQuantityQuantity
valueAttachmentAttachment
valueReferenceReference(Resource)
reason0..1CodeableConcept
sequence1..1positiveInt
diagnosisCodeableConceptCodeableConcept
diagnosisReferenceReference(Condition)
type0..*CodeableConcept
onAdmission0..1CodeableConcept
packageCode0..1CodeableConcept
sequence1..1positiveInt
type0..*CodeableConcept
date0..1dateTime
procedureCodeableConceptCodeableConcept
procedureReferenceReference(Procedure)
udiI0..*Reference(Device)
sequenceΣ1..1positiveInt
focalΣ1..1boolean
identifier0..1Identifier
coverageΣ I1..1Reference(Coverage)
businessArrangement0..1string
preAuthRef0..*string
claimResponseI0..1Reference(ClaimResponse)
date1..1date
type0..1CodeableConceptBinding
locationAddressAddress
locationReferenceReference(Location)
sequence1..1positiveInt
careTeamSequence0..*positiveInt
diagnosisSequence0..*positiveInt
procedureSequence0..*positiveInt
informationSequence0..*positiveInt
revenue0..1CodeableConcept
category0..1CodeableConcept
productOrService1..1CodeableConcept
modifier0..*CodeableConcept
programCode0..*CodeableConcept
servicedDatedate
servicedPeriodPeriod
locationCodeableConceptCodeableConcept
locationAddressAddress
locationReferenceReference(Location)
quantityI0..1SimpleQuantity
unitPrice0..1Money
factor0..1decimal
net0..1Money
udiI0..*Reference(Device)
bodySite0..1CodeableConcept
subSite0..*CodeableConcept
encounterI0..*Reference(Encounter)
sequence1..1positiveInt
revenue0..1CodeableConcept
category0..1CodeableConcept
productOrService1..1CodeableConcept
modifier0..*CodeableConcept
programCode0..*CodeableConcept
quantityI0..1SimpleQuantity
unitPrice0..1Money
factor0..1decimal
net0..1Money
udiI0..*Reference(Device)
sequence1..1positiveInt
revenue0..1CodeableConcept
category0..1CodeableConcept
productOrService1..1CodeableConcept
modifier0..*CodeableConcept
programCode0..*CodeableConcept
quantityI0..1SimpleQuantity
unitPrice0..1Money
factor0..1decimal
net0..1Money
udiI0..*Reference(Device)
total0..1Money

Examples

Dictionary

Claim
DefinitionA 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.
Cardinality0...*
AliasAdjudication Request, Preauthorization Request, Predetermination Request
Comments

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.

Invariants
  • dom-2:If the resource is contained in another resource, it SHALL NOT contain nested Resources
    contained.contained.empty()
  • dom-4:If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
    contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
  • dom-3: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
    contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
  • dom-6:A resource should have narrative for robust management
    text.`div`.exists()
  • dom-5:If a resource is contained in another resource, it SHALL NOT have a security label
    contained.meta.security.empty()
Mappings
  • rim:Entity. Role, or Act
  • workflow:Request
Claim.id
DefinitionThe logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
Cardinality0...1
TypeSystem.String
SummaryTrue
Comments

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

Claim.meta
DefinitionThe metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
Cardinality0...1
TypeMeta
SummaryTrue
Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • rim:N/A
Claim.implicitRules
DefinitionA reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.
Cardinality0...1
Typeuri
ModifierTrue
SummaryTrue
Comments

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
Claim.language
DefinitionThe base language in which the resource is written.
Cardinality0...1
Typecode
Binding

A human language.

CommonLanguages (preferred)
Comments

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
Claim.text
DefinitionA human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.
Cardinality0...1
TypeNarrative
Aliasnarrative, html, xhtml, display
Comments

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • rim:N/A
  • rim:Act.text?
Claim.contained
DefinitionThese resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.
Cardinality0...*
TypeResource
Aliasinline resources, anonymous resources, contained resources
Comments

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.

Mappings
  • rim:Entity. Role, or Act
  • rim:N/A
Claim.extension
DefinitionMay be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Cardinality0...*
TypeExtension
Aliasextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

SlicingUnordered, Open, by url(Value)
Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1:Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim:n/a
  • rim:N/A
Claim.modifierExtension
DefinitionMay be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Cardinality0...*
TypeExtension
ModifierTrue
Aliasextensions, user content
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

SlicingUnordered, Open, by url(Value)
Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1:Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim:n/a
  • rim:N/A
Claim.identifier
DefinitionA unique identifier assigned to this claim.
Cardinality0...*
TypeIdentifier
AliasClaim Number
Requirements

Allows claims to be distinguished and referenced.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • v2:CX / EI (occasionally, more often EI maps to a resource id or a URL)
  • rim:II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]
  • servd:Identifier
  • workflow:Request.identifier
  • w5:FiveWs.identifier
Claim.status
DefinitionThe status of the resource instance.
Cardinality1...1
Typecode
Binding

A code specifying the state of the resource instance.

FinancialResourceStatusCodes (required)
ModifierTrue
SummaryTrue
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'.

Comments

This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • workflow:Request.status
  • w5:FiveWs.status
Claim.type
DefinitionThe category of claim, e.g. oral, pharmacy, vision, institutional, professional.
Cardinality1...1
TypeCodeableConcept
Binding

The type or discipline-style of the claim.

ClaimTypeCodes (extensible)
SummaryTrue
Requirements

Claim type determine the general sets of business rules applied for information requirements and adjudication.

Comments

The majority of jurisdictions use: oral, pharmacy, vision, professional and institutional, or variants on those terms, as the general styles of claims. The valueset is extensible to accommodate other jurisdictional requirements.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • v2:CE/CNE/CWE
  • rim:CD
  • orim:fhir:CodeableConcept rdfs:subClassOf dt:CD
  • w5:FiveWs.class
Claim.subType
DefinitionA finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.
Cardinality0...1
TypeCodeableConcept
Binding

A more granular claim typecode.

ExampleClaimSubTypeCodes (example)
Requirements

Some jurisdictions need a finer grained claim type for routing and adjudication.

Comments

This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • v2:CE/CNE/CWE
  • rim:CD
  • orim:fhir:CodeableConcept rdfs:subClassOf dt:CD
  • w5:FiveWs.class
Claim.use
DefinitionA code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future.
Cardinality1...1
Typecode
Binding

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

Use (required)
SummaryTrue
Requirements

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

Comments

Note that FHIR strings SHALL NOT exceed 1MB in size

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • w5:FiveWs.class
Claim.patient
DefinitionThe 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.
Cardinality1...1
TypeReference(Patient)
SummaryTrue
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.

Comments

References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1:SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim:n/a
  • rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • workflow:Request.subject
  • w5:FiveWs.subject[x]
  • w5:FiveWs.subject
Claim.billablePeriod
DefinitionThe period for which charges are being submitted.
Cardinality0...1
TypePeriod
SummaryTrue
Requirements

A number jurisdictions required the submission of the billing period when submitting claims for example for hospital stays or long-term care.

Comments

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.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • per-1:If present, start SHALL have a lower value than end
    start.hasValue().not() or end.hasValue().not() or (start <= end)
Mappings
  • rim:n/a
  • v2:DR
  • rim:IVL<TS>[lowClosed="true" and highClosed="true"] or URG<TS>[lowClosed="true" and highClosed="true"]
  • w5:FiveWs.done[x]
Claim.created
DefinitionThe date this resource was created.
Cardinality1...1
TypedateTime
SummaryTrue
Requirements

Need to record a timestamp for use by both the recipient and the issuer.

Comments

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.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • workflow:Request.authoredOn
  • w5:FiveWs.recorded
Claim.enterer
DefinitionIndividual who created the claim, predetermination or preauthorization.
Cardinality0...1
TypeReference(Practitioner | PractitionerRole)
Requirements

Some jurisdictions require the contact information for personnel completing claims.

Comments

References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1:SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim:n/a
  • rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • w5:FiveWs.author
Claim.insurer
DefinitionThe Insurer who is target of the request.
Cardinality0...1
TypeReference(Organization)
SummaryTrue
Comments

References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1:SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim:n/a
  • rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • workflow:Request.performer
Claim.provider
DefinitionThe provider which is responsible for the claim, predetermination or preauthorization.
Cardinality1...1
TypeReference(Practitioner | PractitionerRole | Organization)
SummaryTrue
Comments

Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1:SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim:n/a
  • rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • workflow:Request.requester
  • w5:FiveWs.source
Claim.priority
DefinitionThe provider-required urgency of processing the request. Typical values include: stat, routine deferred.
Cardinality1...1
TypeCodeableConcept
Binding

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

ProcessPriorityCodes (example)
SummaryTrue
Requirements

The provider may need to indicate their processing requirements so that the processor can indicate if they are unable to comply.

Comments

If a claim processor is unable to complete the processing as per the priority then they should generate and error and not process the request.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • v2:CE/CNE/CWE
  • rim:CD
  • orim:fhir:CodeableConcept rdfs:subClassOf dt:CD
  • workflow:Request.priority
Claim.fundsReserve
DefinitionA code to indicate whether and for whom funds are to be reserved for future claims.
Cardinality0...1
TypeCodeableConcept
Binding

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

Funds Reservation Codes (example)
AliasFund pre-allocation
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.

Comments

This field is only used for preauthorizations.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • v2:CE/CNE/CWE
  • rim:CD
  • orim:fhir:CodeableConcept rdfs:subClassOf dt:CD
Claim.related
DefinitionOther claims which are related to this claim such as prior submissions or claims for related services or for the same event.
Cardinality0...*
TypeBackboneElement
Requirements

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

Comments

For example, for the original treatment and follow-up exams.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
Claim.related.id
DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality0...1
TypeSystem.String
Mappings
  • rim:n/a
Claim.related.extension
DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Cardinality0...*
TypeExtension
Aliasextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

SlicingUnordered, Open, by url(Value)
Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1:Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim:n/a
  • rim:N/A
Claim.related.modifierExtension
DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Cardinality0...*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1:Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim:n/a
  • rim:N/A
Claim.related.claim
DefinitionReference to a related claim.
Cardinality0...1
TypeReference(Claim)
Requirements

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

Comments

References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1:SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim:n/a
  • rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • workflow:Request.replaces
Claim.related.relationship
DefinitionA code to convey how the claims are related.
Cardinality0...1
TypeCodeableConcept
Binding

Relationship of this claim to a related Claim.

ExampleRelatedClaimRelationshipCodes (example)
Requirements

Some insurers need a declaration of the type of relationship.

Comments

For example, prior claim or umbrella.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • v2:CE/CNE/CWE
  • rim:CD
  • orim:fhir:CodeableConcept rdfs:subClassOf dt:CD
Claim.related.reference
DefinitionAn alternate organizational reference to the case or file to which this particular claim pertains.
Cardinality0...1
TypeIdentifier
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.

Comments

For example, Property/Casualty insurer claim # or Workers Compensation case # .

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • v2:CX / EI (occasionally, more often EI maps to a resource id or a URL)
  • rim:II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]
  • servd:Identifier
Claim.prescription
DefinitionPrescription to support the dispensing of pharmacy, device or vision products.
Cardinality0...1
TypeReference(DeviceRequest | MedicationRequest | VisionPrescription)
Requirements

Required to authorize the dispensing of controlled substances and devices.

Comments

References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1:SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim:n/a
  • rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity)
Claim.originalPrescription
DefinitionOriginal prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or products.
Cardinality0...1
TypeReference(DeviceRequest | MedicationRequest | VisionPrescription)
Requirements

Often required when a fulfiller varies what is fulfilled from that authorized on the original prescription.

Comments

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'.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1:SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim:n/a
  • rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity)
Claim.payee
DefinitionThe party to be reimbursed for cost of the products and services according to the terms of the policy.
Cardinality0...1
TypeBackboneElement
Requirements

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

Comments

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.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
Claim.payee.id
DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality0...1
TypeSystem.String
Mappings
  • rim:n/a
Claim.payee.extension
DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Cardinality0...*
TypeExtension
Aliasextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

SlicingUnordered, Open, by url(Value)
Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1:Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim:n/a
  • rim:N/A
Claim.payee.modifierExtension
DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Cardinality0...*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1:Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim:n/a
  • rim:N/A
Claim.payee.type
DefinitionType of Party to be reimbursed: subscriber, provider, other.
Cardinality1...1
TypeCodeableConcept
Binding

A code for the party to be reimbursed.

Claim Payee Type Codes (example)
Requirements

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

Comments

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • v2:CE/CNE/CWE
  • rim:CD
  • orim:fhir:CodeableConcept rdfs:subClassOf dt:CD
Claim.payee.party
DefinitionReference to the individual or organization to whom any payment will be made.
Cardinality0...1
TypeReference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson)
Requirements

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

Comments

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

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1:SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim:n/a
  • rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity)
Claim.referral
DefinitionA reference to a referral resource.
Cardinality0...1
TypeReference(ServiceRequest)
Requirements

Some insurers require proof of referral to pay for services or to pay specialist rates for services.

Comments

The referral resource which lists the date, practitioner, reason and other supporting information.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1:SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim:n/a
  • rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • w5:FiveWs.cause
Claim.facility
DefinitionFacility where the services were provided.
Cardinality0...1
TypeReference(Location)
Requirements

Insurance adjudication can be dependant on where services were delivered.

Comments

References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1:SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim:n/a
  • rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • w5:FiveWs.where[x]
Claim.careTeam
DefinitionThe members of the team who provided the products and services.
Cardinality0...*
TypeBackboneElement
Requirements

Common to identify the responsible and supporting practitioners.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
Claim.careTeam.id
DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality0...1
TypeSystem.String
Mappings
  • rim:n/a
Claim.careTeam.extension
DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Cardinality0...*
TypeExtension
Aliasextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

SlicingUnordered, Open, by url(Value)
Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1:Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim:n/a
  • rim:N/A
Claim.careTeam.modifierExtension
DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Cardinality0...*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1:Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim:n/a
  • rim:N/A
Claim.careTeam.sequence
DefinitionA number to uniquely identify care team entries.
Cardinality1...1
TypepositiveInt
Requirements

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

Comments

32 bit number; for values larger than this, use decimal

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
Claim.careTeam.provider
DefinitionMember of the team who provided the product or service.
Cardinality1...1
TypeReference(Practitioner | PractitionerRole | Organization)
Requirements

Often a regulatory requirement to specify the responsible provider.

Comments

References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1:SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim:n/a
  • rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • w5:FiveWs.actor
Claim.careTeam.responsible
DefinitionThe party who is billing and/or responsible for the claimed products or services.
Cardinality0...1
Typeboolean
Requirements

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

Comments

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

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
Claim.careTeam.role
DefinitionThe lead, assisting or supervising practitioner and their discipline if a multidisciplinary team.
Cardinality0...1
TypeCodeableConcept
Binding

The role codes for the care team members.

ClaimCareTeamRoleCodes (example)
Requirements

When multiple parties are present it is required to distinguish the roles performed by each member.

Comments

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

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • v2:CE/CNE/CWE
  • rim:CD
  • orim:fhir:CodeableConcept rdfs:subClassOf dt:CD
Claim.careTeam.qualification
DefinitionThe qualification of the practitioner which is applicable for this service.
Cardinality0...1
TypeCodeableConcept
Binding

Provider professional qualifications.

ExampleProviderQualificationCodes (example)
Requirements

Need to specify which qualification a provider is delivering the product or service under.

Comments

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • v2:CE/CNE/CWE
  • rim:CD
  • orim:fhir:CodeableConcept rdfs:subClassOf dt:CD
Claim.supportingInfo
DefinitionAdditional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.
Cardinality0...*
TypeBackboneElement
AliasAttachments Exception Codes Occurrence Codes Value codes
Requirements

Typically these information codes are required to support the services rendered or the adjudication of the services rendered.

Comments

Often there are multiple jurisdiction specific valuesets which are required.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • workflow:Request.supportingInfo
Claim.supportingInfo.id
DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality0...1
TypeSystem.String
Mappings
  • rim:n/a
Claim.supportingInfo.extension
DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Cardinality0...*
TypeExtension
Aliasextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

SlicingUnordered, Open, by url(Value)
Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1:Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim:n/a
  • rim:N/A
Claim.supportingInfo.modifierExtension
DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Cardinality0...*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1:Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim:n/a
  • rim:N/A
Claim.supportingInfo.sequence
DefinitionA number to uniquely identify supporting information entries.
Cardinality1...1
TypepositiveInt
Requirements

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

Comments

32 bit number; for values larger than this, use decimal

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
Claim.supportingInfo.category
DefinitionThe general class of the information supplied: information; exception; accident, employment; onset, etc.
Cardinality1...1
TypeCodeableConcept
Binding

The valuset used for additional information category codes.

ClaimInformationCategoryCodes (example)
Requirements

Required to group or associate information items with common characteristics. For example: admission information or prior treatments.

Comments

This may contain a category for the local bill type codes.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • v2:CE/CNE/CWE
  • rim:CD
  • orim:fhir:CodeableConcept rdfs:subClassOf dt:CD
Claim.supportingInfo.code
DefinitionSystem and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought.
Cardinality0...1
TypeCodeableConcept
Binding

The valuset used for additional information codes.

ExceptionCodes (example)
Requirements

Required to identify the kind of additional information.

Comments

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • v2:CE/CNE/CWE
  • rim:CD
  • orim:fhir:CodeableConcept rdfs:subClassOf dt:CD
Claim.supportingInfo.timing[x]
DefinitionThe date when or period to which this information refers.
Cardinality0...1
Typedate
Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
Claim.supportingInfo.value[x]
DefinitionAdditional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.
Cardinality0...1
Typeboolean
Requirements

To convey the data content to be provided when the information is more than a simple code or period.

Comments

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.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
Claim.supportingInfo.reason
DefinitionProvides the reason in the situation where a reason code is required in addition to the content.
Cardinality0...1
TypeCodeableConcept
Binding

Reason codes for the missing teeth.

MissingToothReasonCodes (example)
Requirements

Needed when the supporting information has both a date and amount/value and requires explanation.

Comments

For example: the reason for the additional stay, or why a tooth is missing.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • v2:CE/CNE/CWE
  • rim:CD
  • orim:fhir:CodeableConcept rdfs:subClassOf dt:CD
Claim.diagnosis
DefinitionInformation about diagnoses relevant to the claim items.
Cardinality0...*
TypeBackboneElement
Requirements

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

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • workflow:Request.reasonReference
Claim.diagnosis.id
DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality0...1
TypeSystem.String
Mappings
  • rim:n/a
Claim.diagnosis.extension
DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Cardinality0...*
TypeExtension
Aliasextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

SlicingUnordered, Open, by url(Value)
Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1:Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim:n/a
  • rim:N/A
Claim.diagnosis.modifierExtension
DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Cardinality0...*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1:Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim:n/a
  • rim:N/A
Claim.diagnosis.sequence
DefinitionA number to uniquely identify diagnosis entries.
Cardinality1...1
TypepositiveInt
Requirements

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

Comments

Diagnosis are presented in list order to their expected importance: primary, secondary, etc.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
Claim.diagnosis.diagnosis[x]
DefinitionThe nature of illness or problem in a coded form or as a reference to an external defined Condition.
Cardinality1...1
TypeCodeableConcept
Binding

Example ICD10 Diagnostic codes.

ICD-10Codes (example)
Requirements

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

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
Claim.diagnosis.type
DefinitionWhen the condition was observed or the relative ranking.
Cardinality0...*
TypeCodeableConcept
Binding

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

ExampleDiagnosisTypeCodes (example)
Requirements

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

Comments

For example: admitting, primary, secondary, discharge.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • v2:CE/CNE/CWE
  • rim:CD
  • orim:fhir:CodeableConcept rdfs:subClassOf dt:CD
Claim.diagnosis.onAdmission
DefinitionIndication of whether the diagnosis was present on admission to a facility.
Cardinality0...1
TypeCodeableConcept
Binding

Present on admission.

ExampleDiagnosisOnAdmissionCodes (example)
Requirements

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

Comments

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • v2:CE/CNE/CWE
  • rim:CD
  • orim:fhir:CodeableConcept rdfs:subClassOf dt:CD
Claim.diagnosis.packageCode
DefinitionA 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.
Cardinality0...1
TypeCodeableConcept
Binding

The DRG codes associated with the diagnosis.

ExampleDiagnosisRelatedGroupCodes (example)
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.

Comments

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.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • v2:CE/CNE/CWE
  • rim:CD
  • orim:fhir:CodeableConcept rdfs:subClassOf dt:CD
Claim.procedure
DefinitionProcedures performed on the patient relevant to the billing items with the claim.
Cardinality0...*
TypeBackboneElement
Requirements

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

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
Claim.procedure.id
DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality0...1
TypeSystem.String
Mappings
  • rim:n/a
Claim.procedure.extension
DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Cardinality0...*
TypeExtension
Aliasextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

SlicingUnordered, Open, by url(Value)
Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1:Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim:n/a
  • rim:N/A
Claim.procedure.modifierExtension
DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Cardinality0...*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1:Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim:n/a
  • rim:N/A
Claim.procedure.sequence
DefinitionA number to uniquely identify procedure entries.
Cardinality1...1
TypepositiveInt
Requirements

Necessary to provide a mechanism to link to claim details.

Comments

32 bit number; for values larger than this, use decimal

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
Claim.procedure.type
DefinitionWhen the condition was observed or the relative ranking.
Cardinality0...*
TypeCodeableConcept
Binding

Example procedure type codes.

ExampleProcedureTypeCodes (example)
Requirements

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

Comments

For example: primary, secondary.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • v2:CE/CNE/CWE
  • rim:CD
  • orim:fhir:CodeableConcept rdfs:subClassOf dt:CD
Claim.procedure.date
DefinitionDate and optionally time the procedure was performed.
Cardinality0...1
TypedateTime
Requirements

Required for auditing purposes.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
Claim.procedure.procedure[x]
DefinitionThe code or reference to a Procedure resource which identifies the clinical intervention performed.
Cardinality1...1
TypeCodeableConcept
Binding

Example ICD10 Procedure codes.

ICD-10ProcedureCodes (example)
Requirements

This identifies the actual clinical procedure.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
Claim.procedure.udi
DefinitionUnique Device Identifiers associated with this line item.
Cardinality0...*
TypeReference(Device)
Requirements

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

Comments

References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1:SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim:n/a
  • rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity)
Claim.insurance
DefinitionFinancial instruments for reimbursement for the health care products and services specified on the claim.
Cardinality1...*
TypeBackboneElement
SummaryTrue
Requirements

At least one insurer is required for a claim to be a claim.

Comments

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.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • rim:Coverage
Claim.insurance.id
DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality0...1
TypeSystem.String
Mappings
  • rim:n/a
Claim.insurance.extension
DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Cardinality0...*
TypeExtension
Aliasextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

SlicingUnordered, Open, by url(Value)
Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1:Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim:n/a
  • rim:N/A
Claim.insurance.modifierExtension
DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Cardinality0...*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1:Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim:n/a
  • rim:N/A
Claim.insurance.sequence
DefinitionA number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order.
Cardinality1...1
TypepositiveInt
SummaryTrue
Requirements

To maintain order of the coverages.

Comments

32 bit number; for values larger than this, use decimal

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
Claim.insurance.focal
DefinitionA flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.
Cardinality1...1
Typeboolean
SummaryTrue
Requirements

To identify which coverage in the list is being used to adjudicate this claim.

Comments

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.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
Claim.insurance.identifier
DefinitionThe business identifier to be used when the claim is sent for adjudication against this insurance policy.
Cardinality0...1
TypeIdentifier
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.

Comments

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'.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • v2:CX / EI (occasionally, more often EI maps to a resource id or a URL)
  • rim:II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]
  • servd:Identifier
  • workflow:Request.identifier
  • w5:FiveWs.identifier
Claim.insurance.coverage
DefinitionReference 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.
Cardinality1...1
TypeReference(Coverage)
SummaryTrue
Requirements

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

Comments

References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1:SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim:n/a
  • rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity)
Claim.insurance.businessArrangement
DefinitionA business agreement number established between the provider and the insurer for special business processing purposes.
Cardinality0...1
Typestring
Requirements

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

Comments

Note that FHIR strings SHALL NOT exceed 1MB in size

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
Claim.insurance.preAuthRef
DefinitionReference numbers previously provided by the insurer to the provider to be quoted on subsequent claims containing services or products related to the prior authorization.
Cardinality0...*
Typestring
Requirements

Providers must quote previously issued authorization reference numbers in order to obtain adjudication as previously advised on the Preauthorization.

Comments

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.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
Claim.insurance.claimResponse
DefinitionThe result of the adjudication of the line items for the Coverage specified in this insurance.
Cardinality0...1
TypeReference(ClaimResponse)
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.

Comments

Must not be specified when 'focal=true' for this insurance.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1:SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim:n/a
  • rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity)
Claim.accident
DefinitionDetails of an accident which resulted in injuries which required the products and services listed in the claim.
Cardinality0...1
TypeBackboneElement
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.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
Claim.accident.id
DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality0...1
TypeSystem.String
Mappings
  • rim:n/a
Claim.accident.extension
DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Cardinality0...*
TypeExtension
Aliasextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

SlicingUnordered, Open, by url(Value)
Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1:Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim:n/a
  • rim:N/A
Claim.accident.modifierExtension
DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Cardinality0...*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1:Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim:n/a
  • rim:N/A
Claim.accident.date
DefinitionDate of an accident event related to the products and services contained in the claim.
Cardinality1...1
Typedate
Requirements

Required for audit purposes and adjudication.

Comments

The date of the accident has to precede the dates of the products and services but within a reasonable timeframe.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
Claim.accident.type
DefinitionThe type or context of the accident event for the purposes of selection of potential insurance coverages and determination of coordination between insurers.
Cardinality0...1
TypeCodeableConcept
Binding

Type of accident: work place, auto, etc.

ActIncidentCode (extensible)
Requirements

Coverage may be dependant on the type of accident.

Comments

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • v2:CE/CNE/CWE
  • rim:CD
  • orim:fhir:CodeableConcept rdfs:subClassOf dt:CD
Claim.accident.location[x]
DefinitionThe physical location of the accident event.
Cardinality0...1
TypeAddress
Requirements

Required for audit purposes and determination of applicable insurance liability.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
Claim.item
DefinitionA 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.
Cardinality0...*
TypeBackboneElement
Requirements

The items to be processed for adjudication.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
Claim.item.id
DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality0...1
TypeSystem.String
Mappings
  • rim:n/a
Claim.item.extension
DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Cardinality0...*
TypeExtension
Aliasextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

SlicingUnordered, Open, by url(Value)
Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1:Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim:n/a
  • rim:N/A
Claim.item.modifierExtension
DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Cardinality0...*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1:Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim:n/a
  • rim:N/A
Claim.item.sequence
DefinitionA number to uniquely identify item entries.
Cardinality1...1
TypepositiveInt
Requirements

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

Comments

32 bit number; for values larger than this, use decimal

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
Claim.item.careTeamSequence
DefinitionCareTeam members related to this service or product.
Cardinality0...*
TypepositiveInt
Requirements

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

Comments

32 bit number; for values larger than this, use decimal

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
Claim.item.diagnosisSequence
DefinitionDiagnosis applicable for this service or product.
Cardinality0...*
TypepositiveInt
Requirements

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

Comments

32 bit number; for values larger than this, use decimal

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
Claim.item.procedureSequence
DefinitionProcedures applicable for this service or product.
Cardinality0...*
TypepositiveInt
Requirements

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

Comments

32 bit number; for values larger than this, use decimal

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
Claim.item.informationSequence
DefinitionExceptions, special conditions and supporting information applicable for this service or product.
Cardinality0...*
TypepositiveInt
Requirements

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

Comments

32 bit number; for values larger than this, use decimal

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
Claim.item.revenue
DefinitionThe type of revenue or cost center providing the product and/or service.
Cardinality0...1
TypeCodeableConcept
Binding

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

ExampleRevenueCenterCodes (example)
Requirements

Needed in the processing of institutional claims.

Comments

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • v2:CE/CNE/CWE
  • rim:CD
  • orim:fhir:CodeableConcept rdfs:subClassOf dt:CD
Claim.item.category
DefinitionCode to identify the general type of benefits under which products and services are provided.
Cardinality0...1
TypeCodeableConcept
Binding

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

BenefitCategoryCodes (example)
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.

Comments

Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • v2:CE/CNE/CWE
  • rim:CD
  • orim:fhir:CodeableConcept rdfs:subClassOf dt:CD
Claim.item.productOrService
DefinitionWhen the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.
Cardinality1...1
TypeCodeableConcept
Binding

Allowable service and product codes.

USCLSCodes (example)
AliasDrug Code, Bill Code, Service Code
Requirements

Necessary to state what was provided or done.

Comments

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'.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • v2:CE/CNE/CWE
  • rim:CD
  • orim:fhir:CodeableConcept rdfs:subClassOf dt:CD
Claim.item.modifier
DefinitionItem typification or modifiers codes to convey additional context for the product or service.
Cardinality0...*
TypeCodeableConcept
Binding

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

ModifierTypeCodes (example)
Requirements

To support inclusion of the item for adjudication or to charge an elevated fee.

Comments

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.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • v2:CE/CNE/CWE
  • rim:CD
  • orim:fhir:CodeableConcept rdfs:subClassOf dt:CD
Claim.item.programCode
DefinitionIdentifies the program under which this may be recovered.
Cardinality0...*
TypeCodeableConcept
Binding

Program specific reason codes.

ExampleProgramReasonCodes (example)
Requirements

Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.

Comments

For example: Neonatal program, child dental program or drug users recovery program.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • v2:CE/CNE/CWE
  • rim:CD
  • orim:fhir:CodeableConcept rdfs:subClassOf dt:CD
Claim.item.serviced[x]
DefinitionThe date or dates when the service or product was supplied, performed or completed.
Cardinality0...1
Typedate
Requirements

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

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • w5:FiveWs.done[x]
Claim.item.location[x]
DefinitionWhere the product or service was provided.
Cardinality0...1
TypeCodeableConcept
Binding

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

ExampleServicePlaceCodes (example)
Requirements

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

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • w5:FiveWs.where[x]
Claim.item.quantity
DefinitionThe number of repetitions of a service or product.
Cardinality0...1
TypeSimpleQuantity
Requirements

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

Comments

The context of use may frequently define what kind of quantity this is and therefore what kind of units can be used. The context of use may also restrict the values for the comparator.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • qty-3:If a code for the unit is present, the system SHALL also be present
    code.empty() or system.exists()
  • sqty-1:The comparator is not used on a SimpleQuantity
    comparator.empty()
Mappings
  • rim:n/a
  • v2:SN (see also Range) or CQ
  • rim:PQ, IVL<PQ>, MO, CO, depending on the values
Claim.item.unitPrice
DefinitionIf 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.
Cardinality0...1
TypeMoney
Requirements

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

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • rim:MO
Claim.item.factor
DefinitionA 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.
Cardinality0...1
Typedecimal
Requirements

When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

Comments

To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
Claim.item.net
DefinitionThe quantity times the unit price for an additional service or product or charge.
Cardinality0...1
TypeMoney
Requirements

Provides the total amount claimed for the group (if a grouper) or the line item.

Comments

For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • rim:MO
Claim.item.udi
DefinitionUnique Device Identifiers associated with this line item.
Cardinality0...*
TypeReference(Device)
Requirements

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

Comments

References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1:SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim:n/a
  • rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity)
Claim.item.bodySite
DefinitionPhysical service site on the patient (limb, tooth, etc.).
Cardinality0...1
TypeCodeableConcept
Binding

The code for the teeth, quadrant, sextant and arch.

OralSiteCodes (example)
Requirements

Allows insurer to validate specific procedures.

Comments

For example: Providing a tooth code, allows an insurer to identify a provider performing a filling on a tooth that was previously removed.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • v2:CE/CNE/CWE
  • rim:CD
  • orim:fhir:CodeableConcept rdfs:subClassOf dt:CD
Claim.item.subSite
DefinitionA region or surface of the bodySite, e.g. limb region or tooth surface(s).
Cardinality0...*
TypeCodeableConcept
Binding

The code for the tooth surface and surface combinations.

SurfaceCodes (example)
Requirements

Allows insurer to validate specific procedures.

Comments

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • v2:CE/CNE/CWE
  • rim:CD
  • orim:fhir:CodeableConcept rdfs:subClassOf dt:CD
Claim.item.encounter
DefinitionThe Encounters during which this Claim was created or to which the creation of this record is tightly associated.
Cardinality0...*
TypeReference(Encounter)
Requirements

Used in some jurisdictions to link clinical events to claim items.

Comments

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.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1:SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim:n/a
  • rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • workflow:Request.context
Claim.item.detail
DefinitionA claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.
Cardinality0...*
TypeBackboneElement
Requirements

The items to be processed for adjudication.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
Claim.item.detail.id
DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality0...1
TypeSystem.String
Mappings
  • rim:n/a
Claim.item.detail.extension
DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Cardinality0...*
TypeExtension
Aliasextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

SlicingUnordered, Open, by url(Value)
Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1:Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim:n/a
  • rim:N/A
Claim.item.detail.modifierExtension
DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Cardinality0...*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1:Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim:n/a
  • rim:N/A
Claim.item.detail.sequence
DefinitionA number to uniquely identify item entries.
Cardinality1...1
TypepositiveInt
Requirements

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

Comments

32 bit number; for values larger than this, use decimal

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
Claim.item.detail.revenue
DefinitionThe type of revenue or cost center providing the product and/or service.
Cardinality0...1
TypeCodeableConcept
Binding

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

ExampleRevenueCenterCodes (example)
Requirements

Needed in the processing of institutional claims.

Comments

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • v2:CE/CNE/CWE
  • rim:CD
  • orim:fhir:CodeableConcept rdfs:subClassOf dt:CD
Claim.item.detail.category
DefinitionCode to identify the general type of benefits under which products and services are provided.
Cardinality0...1
TypeCodeableConcept
Binding

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

BenefitCategoryCodes (example)
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.

Comments

Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • v2:CE/CNE/CWE
  • rim:CD
  • orim:fhir:CodeableConcept rdfs:subClassOf dt:CD
Claim.item.detail.productOrService
DefinitionWhen the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.
Cardinality1...1
TypeCodeableConcept
Binding

Allowable service and product codes.

USCLSCodes (example)
AliasDrug Code, Bill Code, Service Code
Requirements

Necessary to state what was provided or done.

Comments

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'.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • v2:CE/CNE/CWE
  • rim:CD
  • orim:fhir:CodeableConcept rdfs:subClassOf dt:CD
Claim.item.detail.modifier
DefinitionItem typification or modifiers codes to convey additional context for the product or service.
Cardinality0...*
TypeCodeableConcept
Binding

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

ModifierTypeCodes (example)
Requirements

To support inclusion of the item for adjudication or to charge an elevated fee.

Comments

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.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • v2:CE/CNE/CWE
  • rim:CD
  • orim:fhir:CodeableConcept rdfs:subClassOf dt:CD
Claim.item.detail.programCode
DefinitionIdentifies the program under which this may be recovered.
Cardinality0...*
TypeCodeableConcept
Binding

Program specific reason codes.

ExampleProgramReasonCodes (example)
Requirements

Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.

Comments

For example: Neonatal program, child dental program or drug users recovery program.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • v2:CE/CNE/CWE
  • rim:CD
  • orim:fhir:CodeableConcept rdfs:subClassOf dt:CD
Claim.item.detail.quantity
DefinitionThe number of repetitions of a service or product.
Cardinality0...1
TypeSimpleQuantity
Requirements

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

Comments

The context of use may frequently define what kind of quantity this is and therefore what kind of units can be used. The context of use may also restrict the values for the comparator.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • qty-3:If a code for the unit is present, the system SHALL also be present
    code.empty() or system.exists()
  • sqty-1:The comparator is not used on a SimpleQuantity
    comparator.empty()
Mappings
  • rim:n/a
  • v2:SN (see also Range) or CQ
  • rim:PQ, IVL<PQ>, MO, CO, depending on the values
Claim.item.detail.unitPrice
DefinitionIf 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.
Cardinality0...1
TypeMoney
Requirements

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

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • rim:MO
Claim.item.detail.factor
DefinitionA 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.
Cardinality0...1
Typedecimal
Requirements

When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

Comments

To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
Claim.item.detail.net
DefinitionThe quantity times the unit price for an additional service or product or charge.
Cardinality0...1
TypeMoney
Requirements

Provides the total amount claimed for the group (if a grouper) or the line item.

Comments

For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • rim:MO
Claim.item.detail.udi
DefinitionUnique Device Identifiers associated with this line item.
Cardinality0...*
TypeReference(Device)
Requirements

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

Comments

References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1:SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim:n/a
  • rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity)
Claim.item.detail.subDetail
DefinitionA claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.
Cardinality0...*
TypeBackboneElement
Requirements

The items to be processed for adjudication.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
Claim.item.detail.subDetail.id
DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality0...1
TypeSystem.String
Mappings
  • rim:n/a
Claim.item.detail.subDetail.extension
DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Cardinality0...*
TypeExtension
Aliasextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

SlicingUnordered, Open, by url(Value)
Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1:Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim:n/a
  • rim:N/A
Claim.item.detail.subDetail.modifierExtension
DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Cardinality0...*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1:Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim:n/a
  • rim:N/A
Claim.item.detail.subDetail.sequence
DefinitionA number to uniquely identify item entries.
Cardinality1...1
TypepositiveInt
Requirements

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

Comments

32 bit number; for values larger than this, use decimal

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
Claim.item.detail.subDetail.revenue
DefinitionThe type of revenue or cost center providing the product and/or service.
Cardinality0...1
TypeCodeableConcept
Binding

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

ExampleRevenueCenterCodes (example)
Requirements

Needed in the processing of institutional claims.

Comments

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • v2:CE/CNE/CWE
  • rim:CD
  • orim:fhir:CodeableConcept rdfs:subClassOf dt:CD
Claim.item.detail.subDetail.category
DefinitionCode to identify the general type of benefits under which products and services are provided.
Cardinality0...1
TypeCodeableConcept
Binding

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

BenefitCategoryCodes (example)
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.

Comments

Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • v2:CE/CNE/CWE
  • rim:CD
  • orim:fhir:CodeableConcept rdfs:subClassOf dt:CD
Claim.item.detail.subDetail.productOrService
DefinitionWhen the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.
Cardinality1...1
TypeCodeableConcept
Binding

Allowable service and product codes.

USCLSCodes (example)
Requirements

Necessary to state what was provided or done.

Comments

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'.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • v2:CE/CNE/CWE
  • rim:CD
  • orim:fhir:CodeableConcept rdfs:subClassOf dt:CD
Claim.item.detail.subDetail.modifier
DefinitionItem typification or modifiers codes to convey additional context for the product or service.
Cardinality0...*
TypeCodeableConcept
Binding

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

ModifierTypeCodes (example)
Requirements

To support inclusion of the item for adjudication or to charge an elevated fee.

Comments

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.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • v2:CE/CNE/CWE
  • rim:CD
  • orim:fhir:CodeableConcept rdfs:subClassOf dt:CD
Claim.item.detail.subDetail.programCode
DefinitionIdentifies the program under which this may be recovered.
Cardinality0...*
TypeCodeableConcept
Binding

Program specific reason codes.

ExampleProgramReasonCodes (example)
Requirements

Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.

Comments

For example: Neonatal program, child dental program or drug users recovery program.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • v2:CE/CNE/CWE
  • rim:CD
  • orim:fhir:CodeableConcept rdfs:subClassOf dt:CD
Claim.item.detail.subDetail.quantity
DefinitionThe number of repetitions of a service or product.
Cardinality0...1
TypeSimpleQuantity
Requirements

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

Comments

The context of use may frequently define what kind of quantity this is and therefore what kind of units can be used. The context of use may also restrict the values for the comparator.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • qty-3:If a code for the unit is present, the system SHALL also be present
    code.empty() or system.exists()
  • sqty-1:The comparator is not used on a SimpleQuantity
    comparator.empty()
Mappings
  • rim:n/a
  • v2:SN (see also Range) or CQ
  • rim:PQ, IVL<PQ>, MO, CO, depending on the values
Claim.item.detail.subDetail.unitPrice
DefinitionIf 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.
Cardinality0...1
TypeMoney
Requirements

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

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • rim:MO
Claim.item.detail.subDetail.factor
DefinitionA 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.
Cardinality0...1
Typedecimal
Requirements

When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

Comments

To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
Claim.item.detail.subDetail.net
DefinitionThe quantity times the unit price for an additional service or product or charge.
Cardinality0...1
TypeMoney
Requirements

Provides the total amount claimed for the group (if a grouper) or the line item.

Comments

For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • rim:MO
Claim.item.detail.subDetail.udi
DefinitionUnique Device Identifiers associated with this line item.
Cardinality0...*
TypeReference(Device)
Requirements

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

Comments

References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1:SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim:n/a
  • rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity)
Claim.total
DefinitionThe total value of the all the items in the claim.
Cardinality0...1
TypeMoney
Requirements

Used for control total purposes.

Invariants
  • ele-1:All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim:n/a
  • rim:MO