| MII_PR_MTB_Antrag_Kostenuebernahme (Claim) | C | | Claim | There are no (further) constraints on this element Element idClaim Short descriptionClaim, Pre-determination or Pre-authorization Alternate namesAdjudication Request, Preauthorization Request, Predetermination Request 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.
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.
Claim Constraints- dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
contained.contained.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-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-5: If a resource is contained in another resource, it SHALL NOT have a security label
contained.meta.security.empty() - dom-6: A resource should have narrative for robust management
text.`div`.exists()
Mappings- rim: Entity. Role, or Act
- workflow: Request
|
| id | Σ | 0..1 | string | There are no (further) constraints on this element Element idClaim.id Short descriptionLogical id of this artifact DefinitionThe logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
The only time that a resource does not have an id is when it is being submitted to the server using a create operation.
string |
| meta | S Σ | 0..1 | Meta | There are no (further) constraints on this element Element idClaim.meta Short descriptionMetadata about the resource 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.
Meta Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| id | | 0..1 | string | There are no (further) constraints on this element Element idClaim.meta.id Short descriptionUnique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
string Mappings |
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idClaim.meta.extension Short descriptionAdditional content defined by implementations Alternate namesextensions, user content 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.
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.
Extension SlicingUnordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints- 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 |
| versionId | Σ | 0..1 | id | There are no (further) constraints on this element Element idClaim.meta.versionId Short descriptionVersion specific identifier DefinitionThe version specific identifier, as it appears in the version portion of the URL. This value changes when the resource is created, updated, or deleted.
The server assigns this value, and ignores what the client specifies, except in the case that the server is imposing version integrity on updates/deletes.
id Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| lastUpdated | Σ | 0..1 | instant | There are no (further) constraints on this element Element idClaim.meta.lastUpdated Short descriptionWhen the resource version last changed DefinitionWhen the resource last changed - e.g. when the version changed.
This value is always populated except when the resource is first being created. The server / resource manager sets this value; what a client provides is irrelevant. This is equivalent to the HTTP Last-Modified and SHOULD have the same value on a read interaction.
instant Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| source | Σ | 0..1 | uri | There are no (further) constraints on this element Element idClaim.meta.source Short descriptionIdentifies where the resource comes from DefinitionA uri that identifies the source system of the resource. This provides a minimal amount of Provenance information that can be used to track or differentiate the source of information in the resource. The source may identify another FHIR server, document, message, database, etc.
In the provenance resource, this corresponds to Provenance.entity.what[x]. The exact use of the source (and the implied Provenance.entity.role) is left to implementer discretion. Only one nominated source is allowed; for additional provenance details, a full Provenance resource should be used.
This element can be used to indicate where the current master source of a resource that has a canonical URL if the resource is no longer hosted at the canonical URL.
uri Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| profile | S Σ | 0..* | canonical(StructureDefinition) | There are no (further) constraints on this element Element idClaim.meta.profile Short descriptionProfiles this resource claims to conform to DefinitionCommentsIt is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set.
canonical(StructureDefinition) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| security | Σ | 0..* | CodingBinding | There are no (further) constraints on this element Element idClaim.meta.security Short descriptionSecurity Labels applied to this resource DefinitionSecurity labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure.
The security labels can be updated without changing the stated version of the resource. The list of security labels is a set. Uniqueness is based the system/code, and version and display are ignored.
Coding BindingSecurity Labels from the Healthcare Privacy and Security Classification System.
All Security Labels (extensible) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| tag | Σ | 0..* | Coding | There are no (further) constraints on this element Element idClaim.meta.tag Short descriptionTags applied to this resource DefinitionTags applied to this resource. Tags are intended to be used to identify and relate resources to process and workflow, and applications are not required to consider the tags when interpreting the meaning of a resource.
The tags can be updated without changing the stated version of the resource. The list of tags is a set. Uniqueness is based the system/code, and version and display are ignored.
Coding BindingCodes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
CommonTags (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idClaim.implicitRules Short descriptionA set of rules under which this content was created 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.
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.
uri Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| language | | 0..1 | codeBinding | There are no (further) constraints on this element Element idClaim.language Short descriptionLanguage of the resource content DefinitionThe base language in which the resource is written.
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).
code BindingCommonLanguages (preferred) Binding extensionsConstraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| text | | 0..1 | Narrative | There are no (further) constraints on this element Element idClaim.text Short descriptionText summary of the resource, for human interpretation Alternate namesnarrative, html, xhtml, display 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.
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.
Narrative Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings |
| contained | | 0..* | Resource | There are no (further) constraints on this element Element idClaim.contained Short descriptionContained, inline Resources Alternate namesinline resources, anonymous resources, contained resources 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.
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.
Resource Mappings |
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idClaim.extension Short descriptionAdditional content defined by implementations Alternate namesextensions, user content 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.
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.
Extension Constraints- 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 |
| modifierExtension | ?! C | 0..* | Extension | There are no (further) constraints on this element Element idClaim.modifierExtension Short descriptionExtensions that cannot be ignored Alternate namesextensions, user content 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).
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.
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.
Extension Constraints- 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 |
| identifier | | 0..* | Identifier | There are no (further) constraints on this element Element idClaim.identifier Short descriptionBusiness Identifier for claim Alternate namesClaim Number DefinitionA unique identifier assigned to this claim.
Allows claims to be distinguished and referenced.
Identifier Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- workflow: Request.identifier
- w5: FiveWs.identifier
|
| status | S Σ ?! | 1..1 | codeBindingPattern | Element idClaim.status Short descriptionAntrag DefinitionStatus der FHIR-Ressource - statisch auf #active gesetzt
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'.
This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.
code BindingA code specifying the state of the resource instance.
FinancialResourceStatusCodes (required) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Patternactive Mappings- workflow: Request.status
- w5: FiveWs.status
|
| type | S Σ | 1..1 | CodeableConceptBinding | Element idClaim.type Short descriptionKategorie des Antragstellers DefinitionKategorie des Antragstellers - z.B. stationär, ambulant, Apotheke
Claim type determine the general sets of business rules applied for information requirements and adjudication.
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.
CodeableConcept BindingThe type or discipline-style of the claim.
MII_VS_MTB_Antrag_Kostenuebernahme_Type (required) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings |
| subType | | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idClaim.subType Short descriptionMore granular claim type DefinitionA finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.
Some jurisdictions need a finer grained claim type for routing and adjudication.
This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.
CodeableConcept BindingA more granular claim typecode.
ExampleClaimSubTypeCodes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings |
| use | S Σ | 1..1 | codeBinding | Element idClaim.use Short descriptionArt des Kostenerstattungsantrags (claim, predetermination, preauthorization) Definitionfolgt den Definitionen wie im amerikanischen Gesundsheitswesen gebräuchlich. claim: Erstattungsantrag nach erfolgter Therapie; predetermination: unverbindliche Anfrage, insb. zu Anteilen der Kostenübernahme; preauthorization: Anfrage nach möglicher Erstattung für zukünftige Therapie
This element is required to understand the nature of the request for adjudication.
code BindingThe purpose of the Claim: predetermination, preauthorization, claim.
Use (required) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings |
| patient | S Σ | 1..1 | Reference(Patient) | There are no (further) constraints on this element Element idClaim.patient Short descriptionThe recipient of the products and services 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.
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.
Reference(Patient) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- workflow: Request.subject
- w5: FiveWs.subject[x]
- w5: FiveWs.subject
|
| billablePeriod | Σ | 0..1 | Period | There are no (further) constraints on this element Element idClaim.billablePeriod Short descriptionRelevant time frame for the claim DefinitionThe period for which charges are being submitted.
A number jurisdictions required the submission of the billing period when submitting claims for example for hospital stays or long-term care.
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.
Period Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings |
| created | S Σ | 1..1 | dateTime | Element idClaim.created Short descriptionAntragsdatum DefinitionRequirementsNeed to record a timestamp for use by both the recipient and the issuer.
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.
dateTime Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- workflow: Request.authoredOn
- w5: FiveWs.recorded
|
| enterer | | 0..1 | Reference(Practitioner | PractitionerRole) | There are no (further) constraints on this element Element idClaim.enterer Short descriptionAuthor of the claim DefinitionIndividual who created the claim, predetermination or preauthorization.
Some jurisdictions require the contact information for personnel completing claims.
Reference(Practitioner | PractitionerRole) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings |
| insurer | Σ | 0..1 | Reference(Organization) | There are no (further) constraints on this element Element idClaim.insurer Short descriptionTarget DefinitionThe Insurer who is target of the request.
Reference(Organization) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- workflow: Request.performer
|
| provider | S Σ | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Element idClaim.provider Short descriptionAntragstellende Einrichtung / Klinik / Person DefinitionEinrichtung, die den Antrag stellt. In der Regel die Klinik, die den Patienten behandelt
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.
Reference(Practitioner | PractitionerRole | Organization) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- workflow: Request.requester
- w5: FiveWs.source
|
| priority | S Σ | 1..1 | CodeableConceptPattern | Element idClaim.priority Short descriptionPriorität des Antrags DefinitionPriorität des Antrags. Pflichtfeld in FHIR, aber nicht in der MII-Logik relevant
The provider may need to indicate their processing requirements so that the processor can indicate if they are unable to comply.
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.
CodeableConcept BindingThe timeliness with which processing is required: stat, normal, deferred.
ProcessPriorityCodes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Pattern{
"coding": [
{
"code": "normal"
}
]
}Mappings- workflow: Request.priority
|
| fundsReserve | | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idClaim.fundsReserve Short descriptionFor whom to reserve funds Alternate namesFund pre-allocation DefinitionA code to indicate whether and for whom funds are to be reserved for future claims.
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.
This field is only used for preauthorizations.
CodeableConcept BindingFor whom funds are to be reserved: (Patient, Provider, None).
Funds Reservation Codes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| related | S | 0..* | BackboneElement | There are no (further) constraints on this element Element idClaim.related Short descriptionPrior or corollary claims DefinitionOther claims which are related to this claim such as prior submissions or claims for related services or for the same event.
For workplace or other accidents it is common to relate separate claims arising from the same event.
For example, for the original treatment and follow-up exams.
BackboneElement Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| id | | 0..1 | string | There are no (further) constraints on this element Element idClaim.related.id Short descriptionUnique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
string Mappings |
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idClaim.related.extension Short descriptionAdditional content defined by implementations Alternate namesextensions, user content 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.
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.
Extension Constraints- 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 |
| modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idClaim.related.modifierExtension Short descriptionExtensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers 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).
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.
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.
Extension Constraints- 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 |
| claim | S | 0..1 | Reference(MII_PR_MTB_Antrag_Kostenuebernahme) | Element idClaim.related.claim Short descriptionbei Folgeantrag/Widerspruch: Verweis auf ursprünglichen Erstantrag DefinitionVerweis auf ursprünglichen Erstantrag, der zu diesem Folgeantrag oder Widerspruch führt
For workplace or other accidents it is common to relate separate claims arising from the same event.
Reference(MII_PR_MTB_Antrag_Kostenuebernahme) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- workflow: Request.replaces
|
| relationship | S | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idClaim.related.relationship Short descriptionHow the reference claim is related DefinitionA code to convey how the claims are related.
Some insurers need a declaration of the type of relationship.
For example, prior claim or umbrella.
CodeableConcept BindingRelationship of this claim to a related Claim.
ExampleRelatedClaimRelationshipCodes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| id | | 0..1 | string | There are no (further) constraints on this element Element idClaim.related.relationship.id Short descriptionUnique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
string Mappings |
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idClaim.related.relationship.extension Short descriptionAdditional content defined by implementations Alternate namesextensions, user content 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.
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.
Extension SlicingUnordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints- 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 |
| coding | S Σ | 1..* | Coding | Element idClaim.related.relationship.coding Short descriptionAntragsstadium DefinitionStadium des Antrags auf Kostenuebernahme - Erstantrag, Widerspruch, Folgeantrag, Unbekannt. Bei Widerspruch oder Folgeantrag ist der Verweis auf den Erstantrag erforderlich
Allows for alternative encodings within a code system, and translations to other code systems.
Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
Coding Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- v2: C*E.1-8, C*E.10-22
- rim: union(., ./translation)
- orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
|
| id | | 0..1 | string | There are no (further) constraints on this element Element idClaim.related.relationship.coding.id Short descriptionUnique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
string Mappings |
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idClaim.related.relationship.coding.extension Short descriptionAdditional content defined by implementations Alternate namesextensions, user content 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.
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.
Extension SlicingUnordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints- 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 |
| system | Σ | 0..1 | uriPattern | Element idClaim.related.relationship.coding.system Short descriptionIdentity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code.
Need to be unambiguous about the source of the definition of the symbol.
The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
uri Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Patternhttps://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/CodeSystem/mii-cs-mtb-antrag-kostenuebernahme-antragsstadium Mappings- v2: C*E.3
- rim: ./codeSystem
- orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
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| version | Σ | 0..1 | string | There are no (further) constraints on this element Element idClaim.related.relationship.coding.version Short descriptionVersion of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.
Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
string Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- v2: C*E.7
- rim: ./codeSystemVersion
- orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
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| code | S Σ | 1..1 | code | There are no (further) constraints on this element Element idClaim.related.relationship.coding.code Short descriptionSymbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).
Need to refer to a particular code in the system.
code Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- v2: C*E.1
- rim: ./code
- orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
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| display | Σ | 0..1 | string | There are no (further) constraints on this element Element idClaim.related.relationship.coding.display Short descriptionRepresentation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system.
Need to be able to carry a human-readable meaning of the code for readers that do not know the system.
string Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- v2: C*E.2 - but note this is not well followed
- rim: CV.displayName
- orim: fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
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| userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idClaim.related.relationship.coding.userSelected Short descriptionIf this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays).
This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.
Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
boolean Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- v2: Sometimes implied by being first
- rim: CD.codingRationale
- orim: fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
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| text | Σ | 0..1 | string | There are no (further) constraints on this element Element idClaim.related.relationship.text Short descriptionPlain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.
The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.
Very often the text is the same as a displayName of one of the codings.
string Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- v2: C*E.9. But note many systems use C*E.2 for this
- rim: ./originalText[mediaType/code="text/plain"]/data
- orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
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| reference | | 0..1 | Identifier | There are no (further) constraints on this element Element idClaim.related.reference Short descriptionFile or case reference DefinitionAn alternate organizational reference to the case or file to which this particular claim pertains.
In cases where an event-triggered claim is being submitted to an insurer which requires a reference number to be specified on all exchanges.
For example, Property/Casualty insurer claim # or Workers Compensation case # .
Identifier Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
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| prescription | S | 0..1 | Reference(MedicationRequest) | Element idClaim.prescription Short descriptionTherapieempfehlung DefinitionVerweis auf die Therapieempfehlung des MTB, die zu diesem Antrag führt
Required to authorize the dispensing of controlled substances and devices.
Reference(MedicationRequest) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
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| originalPrescription | | 0..1 | Reference(DeviceRequest | MedicationRequest | VisionPrescription) | There are no (further) constraints on this element Element idClaim.originalPrescription Short descriptionOriginal prescription if superseded by fulfiller DefinitionOriginal prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or products.
Often required when a fulfiller varies what is fulfilled from that authorized on the original prescription.
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'.
Reference(DeviceRequest | MedicationRequest | VisionPrescription) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
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| payee | | 0..1 | BackboneElement | There are no (further) constraints on this element Element idClaim.payee Short descriptionRecipient of benefits payable DefinitionThe party to be reimbursed for cost of the products and services according to the terms of the policy.
The provider needs to specify who they wish to be reimbursed and the claims processor needs express who they will reimburse.
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.
BackboneElement Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
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| id | | 0..1 | string | There are no (further) constraints on this element Element idClaim.payee.id Short descriptionUnique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
string Mappings |
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idClaim.payee.extension Short descriptionAdditional content defined by implementations Alternate namesextensions, user content 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.
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.
Extension Constraints- 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 |
| modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idClaim.payee.modifierExtension Short descriptionExtensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers 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).
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.
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.
Extension Constraints- 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 |
| type | | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idClaim.payee.type Short descriptionCategory of recipient DefinitionType of Party to be reimbursed: subscriber, provider, other.
Need to know who should receive payment with the most common situations being the Provider (assignment of benefits) or the Subscriber.
CodeableConcept BindingA code for the party to be reimbursed.
Claim Payee Type Codes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
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| party | | 0..1 | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) | There are no (further) constraints on this element Element idClaim.payee.party Short descriptionRecipient reference DefinitionReference to the individual or organization to whom any payment will be made.
Need to provide demographics if the payee is not 'subscriber' nor 'provider'.
Not required if the payee is 'subscriber' or 'provider'.
Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
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| referral | | 0..1 | Reference(ServiceRequest) | There are no (further) constraints on this element Element idClaim.referral Short descriptionTreatment referral DefinitionA reference to a referral resource.
Some insurers require proof of referral to pay for services or to pay specialist rates for services.
The referral resource which lists the date, practitioner, reason and other supporting information.
Reference(ServiceRequest) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings |
| facility | | 0..1 | Reference(Location) | There are no (further) constraints on this element Element idClaim.facility Short descriptionServicing facility DefinitionFacility where the services were provided.
Insurance adjudication can be dependant on where services were delivered.
Reference(Location) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings |
| careTeam | | 1..* | BackboneElement | Element idClaim.careTeam Short descriptionMembers of the care team DefinitionThe members of the team who provided the products and services.
Common to identify the responsible and supporting practitioners.
BackboneElement SlicingUnordered, Open, by sequence(Type) Slice für Antragsstellung ZPM Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
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| (All Slices) | | | | The requirements in this element apply to all slices |
| id | | 0..1 | string | There are no (further) constraints on this element Element idClaim.careTeam.id Short descriptionUnique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
string Mappings |
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idClaim.careTeam.extension Short descriptionAdditional content defined by implementations Alternate namesextensions, user content 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.
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.
Extension Constraints- 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 |
| modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idClaim.careTeam.modifierExtension Short descriptionExtensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers 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).
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.
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.
Extension Constraints- 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 |
| sequence | | 1..1 | positiveInt | There are no (further) constraints on this element Element idClaim.careTeam.sequence Short descriptionOrder of care team DefinitionA number to uniquely identify care team entries.
Necessary to maintain the order of the care team and provide a mechanism to link individuals to claim details.
positiveInt Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
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| provider | | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | There are no (further) constraints on this element Element idClaim.careTeam.provider Short descriptionPractitioner or organization DefinitionMember of the team who provided the product or service.
Often a regulatory requirement to specify the responsible provider.
Reference(Practitioner | PractitionerRole | Organization) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings |
| responsible | | 0..1 | boolean | There are no (further) constraints on this element Element idClaim.careTeam.responsible Short descriptionIndicator of the lead practitioner DefinitionThe party who is billing and/or responsible for the claimed products or services.
When multiple parties are present it is required to distinguish the lead or responsible individual.
Responsible might not be required when there is only a single provider listed.
boolean Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| role | | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idClaim.careTeam.role Short descriptionFunction within the team DefinitionThe lead, assisting or supervising practitioner and their discipline if a multidisciplinary team.
When multiple parties are present it is required to distinguish the roles performed by each member.
Role might not be required when there is only a single provider listed.
CodeableConcept BindingThe role codes for the care team members.
ClaimCareTeamRoleCodes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
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| qualification | | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idClaim.careTeam.qualification Short descriptionPractitioner credential or specialization DefinitionThe qualification of the practitioner which is applicable for this service.
Need to specify which qualification a provider is delivering the product or service under.
CodeableConcept BindingProvider professional qualifications.
ExampleProviderQualificationCodes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
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| ZPMBeteiligung | S | 1..1 | BackboneElement | Element idClaim.careTeam:ZPMBeteiligung Short descriptionAntragstellung ZPM DefinitionVerweis auf entsprechendes Feld in NGS Bericht und/oder IHC (Verweis auf KDS Molekular-Pathologischer Befundbericht)
Common to identify the responsible and supporting practitioners.
BackboneElement Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| id | | 0..1 | string | There are no (further) constraints on this element Element idClaim.careTeam:ZPMBeteiligung.id Short descriptionUnique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
string Mappings |
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idClaim.careTeam:ZPMBeteiligung.extension Short descriptionAdditional content defined by implementations Alternate namesextensions, user content 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.
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.
Extension Constraints- 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 |
| modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idClaim.careTeam:ZPMBeteiligung.modifierExtension Short descriptionExtensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers 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).
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.
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.
Extension Constraints- 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 |
| sequence | S | 1..1 | positiveIntPattern | Element idClaim.careTeam:ZPMBeteiligung.sequence Short descriptioninterne Variable der beteiligten Einrichtung DefinitionA number to uniquely identify care team entries.
Necessary to maintain the order of the care team and provide a mechanism to link individuals to claim details.
positiveInt Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Pattern1 |
| provider | S | 1..1 | Reference(Organization) | Element idClaim.careTeam:ZPMBeteiligung.provider Short descriptionVerweis auf ZPM DefinitionVerweis auf Antragstellendes ZPM (z.B. ZPM ID)
Often a regulatory requirement to specify the responsible provider.
Reference(Organization) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings |
| responsible | S | 1..1 | boolean | Element idClaim.careTeam:ZPMBeteiligung.responsible Short descriptionBeteiliung ZPM - Ja/Nein DefinitionBeteiliung des ZPM - Ja/Nein
When multiple parties are present it is required to distinguish the lead or responsible individual.
Responsible might not be required when there is only a single provider listed.
boolean Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| role | | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idClaim.careTeam:ZPMBeteiligung.role Short descriptionFunction within the team DefinitionThe lead, assisting or supervising practitioner and their discipline if a multidisciplinary team.
When multiple parties are present it is required to distinguish the roles performed by each member.
Role might not be required when there is only a single provider listed.
CodeableConcept BindingThe role codes for the care team members.
ClaimCareTeamRoleCodes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| qualification | | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idClaim.careTeam:ZPMBeteiligung.qualification Short descriptionPractitioner credential or specialization DefinitionThe qualification of the practitioner which is applicable for this service.
Need to specify which qualification a provider is delivering the product or service under.
CodeableConcept BindingProvider professional qualifications.
ExampleProviderQualificationCodes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
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| supportingInfo | | 0..* | BackboneElement | There are no (further) constraints on this element Element idClaim.supportingInfo Short descriptionSupporting information Alternate namesAttachments
Exception Codes
Occurrence Codes
Value codes DefinitionAdditional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.
Typically these information codes are required to support the services rendered or the adjudication of the services rendered.
Often there are multiple jurisdiction specific valuesets which are required.
BackboneElement Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- workflow: Request.supportingInfo
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| id | | 0..1 | string | There are no (further) constraints on this element Element idClaim.supportingInfo.id Short descriptionUnique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
string Mappings |
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idClaim.supportingInfo.extension Short descriptionAdditional content defined by implementations Alternate namesextensions, user content 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.
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.
Extension Constraints- 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 |
| modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idClaim.supportingInfo.modifierExtension Short descriptionExtensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers 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).
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.
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.
Extension Constraints- 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 |
| sequence | | 1..1 | positiveInt | There are no (further) constraints on this element Element idClaim.supportingInfo.sequence Short descriptionInformation instance identifier DefinitionA number to uniquely identify supporting information entries.
Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details.
positiveInt Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| category | | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idClaim.supportingInfo.category Short descriptionClassification of the supplied information DefinitionThe general class of the information supplied: information; exception; accident, employment; onset, etc.
Required to group or associate information items with common characteristics. For example: admission information or prior treatments.
This may contain a category for the local bill type codes.
CodeableConcept BindingThe valuset used for additional information category codes.
ClaimInformationCategoryCodes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| code | | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idClaim.supportingInfo.code Short descriptionType of information DefinitionSystem and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought.
Required to identify the kind of additional information.
CodeableConcept BindingThe valuset used for additional information codes.
ExceptionCodes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| timing[x] | | 0..1 | | There are no (further) constraints on this element Element idClaim.supportingInfo.timing[x] Short descriptionWhen it occurred DefinitionThe date when or period to which this information refers.
- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| timingDate | | | date | There are no (further) constraints on this element Data typedate |
| timingPeriod | | | Period | There are no (further) constraints on this element Data typePeriod |
| value[x] | | 0..1 | | There are no (further) constraints on this element Element idClaim.supportingInfo.value[x] Short descriptionData to be provided DefinitionAdditional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.
To convey the data content to be provided when the information is more than a simple code or period.
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.
- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| valueBoolean | | | boolean | There are no (further) constraints on this element Data typeboolean |
| valueString | | | string | There are no (further) constraints on this element Data typestring |
| valueQuantity | | | Quantity | There are no (further) constraints on this element Data typeQuantity |
| valueAttachment | | | Attachment | There are no (further) constraints on this element Data typeAttachment |
| valueReference | | | Reference(Resource) | There are no (further) constraints on this element Data typeReference(Resource) |
| reason | | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idClaim.supportingInfo.reason Short descriptionExplanation for the information DefinitionProvides the reason in the situation where a reason code is required in addition to the content.
Needed when the supporting information has both a date and amount/value and requires explanation.
For example: the reason for the additional stay, or why a tooth is missing.
CodeableConcept BindingReason codes for the missing teeth.
MissingToothReasonCodes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| diagnosis | | 0..* | BackboneElement | There are no (further) constraints on this element Element idClaim.diagnosis Short descriptionPertinent diagnosis information DefinitionInformation about diagnoses relevant to the claim items.
Required for the adjudication by provided context for the services and product listed.
BackboneElement Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- workflow: Request.reasonReference
|
| id | | 0..1 | string | There are no (further) constraints on this element Element idClaim.diagnosis.id Short descriptionUnique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
string Mappings |
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idClaim.diagnosis.extension Short descriptionAdditional content defined by implementations Alternate namesextensions, user content 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.
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.
Extension Constraints- 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 |
| modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idClaim.diagnosis.modifierExtension Short descriptionExtensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers 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).
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.
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.
Extension Constraints- 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 |
| sequence | | 1..1 | positiveInt | There are no (further) constraints on this element Element idClaim.diagnosis.sequence Short descriptionDiagnosis instance identifier DefinitionA number to uniquely identify diagnosis entries.
Necessary to maintain the order of the diagnosis items and provide a mechanism to link to claim details.
Diagnosis are presented in list order to their expected importance: primary, secondary, etc.
positiveInt Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| diagnosis[x] | | 1..1 | | There are no (further) constraints on this element Element idClaim.diagnosis.diagnosis[x] Short descriptionNature of illness or problem DefinitionThe nature of illness or problem in a coded form or as a reference to an external defined Condition.
Provides health context for the evaluation of the products and/or services.
Example ICD10 Diagnostic codes.
ICD-10Codes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| diagnosisCodeableConcept | | | CodeableConcept | There are no (further) constraints on this element Data typeCodeableConcept |
| diagnosisReference | | | Reference(Condition) | There are no (further) constraints on this element Data typeReference(Condition) |
| type | | 0..* | CodeableConcept | There are no (further) constraints on this element Element idClaim.diagnosis.type Short descriptionTiming or nature of the diagnosis DefinitionWhen the condition was observed or the relative ranking.
Often required to capture a particular diagnosis, for example: primary or discharge.
For example: admitting, primary, secondary, discharge.
CodeableConcept BindingThe type of the diagnosis: admitting, principal, discharge.
ExampleDiagnosisTypeCodes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| onAdmission | | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idClaim.diagnosis.onAdmission Short descriptionPresent on admission DefinitionIndication of whether the diagnosis was present on admission to a facility.
Many systems need to understand for adjudication if the diagnosis was present a time of admission.
CodeableConcept BindingExampleDiagnosisOnAdmissionCodes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| packageCode | | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idClaim.diagnosis.packageCode Short descriptionPackage billing code 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.
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.
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.
CodeableConcept BindingThe DRG codes associated with the diagnosis.
ExampleDiagnosisRelatedGroupCodes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| procedure | | 0..* | BackboneElement | There are no (further) constraints on this element Element idClaim.procedure Short descriptionClinical procedures performed DefinitionProcedures performed on the patient relevant to the billing items with the claim.
The specific clinical invention are sometimes required to be provided to justify billing a greater than customary amount for a service.
BackboneElement Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| id | | 0..1 | string | There are no (further) constraints on this element Element idClaim.procedure.id Short descriptionUnique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
string Mappings |
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idClaim.procedure.extension Short descriptionAdditional content defined by implementations Alternate namesextensions, user content 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.
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.
Extension Constraints- 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 |
| modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idClaim.procedure.modifierExtension Short descriptionExtensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers 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).
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.
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.
Extension Constraints- 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 |
| sequence | | 1..1 | positiveInt | There are no (further) constraints on this element Element idClaim.procedure.sequence Short descriptionProcedure instance identifier DefinitionA number to uniquely identify procedure entries.
Necessary to provide a mechanism to link to claim details.
positiveInt Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| type | | 0..* | CodeableConcept | There are no (further) constraints on this element Element idClaim.procedure.type Short descriptionCategory of Procedure DefinitionWhen the condition was observed or the relative ranking.
Often required to capture a particular diagnosis, for example: primary or discharge.
For example: primary, secondary.
CodeableConcept BindingExample procedure type codes.
ExampleProcedureTypeCodes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| date | | 0..1 | dateTime | There are no (further) constraints on this element Element idClaim.procedure.date Short descriptionWhen the procedure was performed DefinitionDate and optionally time the procedure was performed.
Required for auditing purposes.
dateTime Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| procedure[x] | | 1..1 | | There are no (further) constraints on this element Element idClaim.procedure.procedure[x] Short descriptionSpecific clinical procedure DefinitionThe code or reference to a Procedure resource which identifies the clinical intervention performed.
This identifies the actual clinical procedure.
Example ICD10 Procedure codes.
ICD-10ProcedureCodes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| procedureCodeableConcept | | | CodeableConcept | There are no (further) constraints on this element Data typeCodeableConcept |
| procedureReference | | | Reference(Procedure) | There are no (further) constraints on this element Data typeReference(Procedure) |
| udi | | 0..* | Reference(Device) | There are no (further) constraints on this element Element idClaim.procedure.udi Short descriptionUnique device identifier DefinitionUnique Device Identifiers associated with this line item.
The UDI code allows the insurer to obtain device level information on the product supplied.
Reference(Device) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| insurance | S Σ | 1..* | BackboneElement | There are no (further) constraints on this element Element idClaim.insurance Short descriptionPatient insurance information DefinitionFinancial instruments for reimbursement for the health care products and services specified on the claim.
At least one insurer is required for a claim to be a claim.
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.
BackboneElement Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings |
| id | | 0..1 | string | There are no (further) constraints on this element Element idClaim.insurance.id Short descriptionUnique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
string Mappings |
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idClaim.insurance.extension Short descriptionAdditional content defined by implementations Alternate namesextensions, user content 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.
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.
Extension Constraints- 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 |
| modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idClaim.insurance.modifierExtension Short descriptionExtensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers 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).
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.
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.
Extension Constraints- 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 |
| sequence | S Σ | 1..1 | positiveInt | Element idClaim.insurance.sequence Short descriptionPriorität der Versicherung DefinitionPriorität der Versicherung. In der Regel 1 für die Hauptkrankenversicherung, und fortlaufend für weitere freiwilligge Zusatzversicherungen. Wird vsl. selten relevant sein.
To maintain order of the coverages.
positiveInt Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| focal | S Σ | 1..1 | booleanPattern | Element idClaim.insurance.focal Short descriptionVersicherung relevant für diesen Antrag DefinitionA flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.
To identify which coverage in the list is being used to adjudicate this claim.
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.
boolean Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Patterntrue |
| identifier | | 0..1 | Identifier | There are no (further) constraints on this element Element idClaim.insurance.identifier Short descriptionPre-assigned Claim number DefinitionThe business identifier to be used when the claim is sent for adjudication against this insurance policy.
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.
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'.
Identifier Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- workflow: Request.identifier
- w5: FiveWs.identifier
|
| coverage | S Σ | 1..1 | Reference(Coverage) | Element idClaim.insurance.coverage Short descriptionVersicherung relevant für diesen Antrag 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.
Required to allow the adjudicator to locate the correct policy and history within their information system.
Reference(Coverage) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| businessArrangement | | 0..1 | string | There are no (further) constraints on this element Element idClaim.insurance.businessArrangement Short descriptionAdditional provider contract number DefinitionA business agreement number established between the provider and the insurer for special business processing purposes.
Providers may have multiple business arrangements with a given insurer and must supply the specific contract number for adjudication.
string Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| preAuthRef | | 0..* | string | There are no (further) constraints on this element Element idClaim.insurance.preAuthRef Short descriptionPrior authorization reference number 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.
Providers must quote previously issued authorization reference numbers in order to obtain adjudication as previously advised on the Preauthorization.
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.
string Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| claimResponse | S | 0..1 | Reference(ClaimResponse) | There are no (further) constraints on this element Element idClaim.insurance.claimResponse Short descriptionAdjudication results DefinitionThe result of the adjudication of the line items for the Coverage specified in this insurance.
An insurer need the adjudication results from prior insurers to determine the outstanding balance remaining by item for the items in the curent claim.
Must not be specified when 'focal=true' for this insurance.
Reference(ClaimResponse) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| accident | | 0..1 | BackboneElement | There are no (further) constraints on this element Element idClaim.accident Short descriptionDetails of the event DefinitionDetails of an accident which resulted in injuries which required the products and services listed in the claim.
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.
BackboneElement Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| id | | 0..1 | string | There are no (further) constraints on this element Element idClaim.accident.id Short descriptionUnique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
string Mappings |
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idClaim.accident.extension Short descriptionAdditional content defined by implementations Alternate namesextensions, user content 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.
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.
Extension Constraints- 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 |
| modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idClaim.accident.modifierExtension Short descriptionExtensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers 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).
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.
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.
Extension Constraints- 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 |
| date | | 1..1 | date | There are no (further) constraints on this element Element idClaim.accident.date Short descriptionWhen the incident occurred DefinitionDate of an accident event related to the products and services contained in the claim.
Required for audit purposes and adjudication.
The date of the accident has to precede the dates of the products and services but within a reasonable timeframe.
date Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| type | | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idClaim.accident.type Short descriptionThe nature of the accident DefinitionThe type or context of the accident event for the purposes of selection of potential insurance coverages and determination of coordination between insurers.
Coverage may be dependant on the type of accident.
CodeableConcept BindingType of accident: work place, auto, etc.
v3.ActIncidentCode (extensible) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| location[x] | | 0..1 | | There are no (further) constraints on this element Element idClaim.accident.location[x] Short descriptionWhere the event occurred DefinitionThe physical location of the accident event.
Required for audit purposes and determination of applicable insurance liability.
- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| locationAddress | | | Address | There are no (further) constraints on this element Data typeAddress |
| locationReference | | | Reference(Location) | There are no (further) constraints on this element Data typeReference(Location) |
| item | | 0..* | BackboneElement | There are no (further) constraints on this element Element idClaim.item Short descriptionProduct or service provided 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.
The items to be processed for adjudication.
BackboneElement Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| id | | 0..1 | string | There are no (further) constraints on this element Element idClaim.item.id Short descriptionUnique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
string Mappings |
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idClaim.item.extension Short descriptionAdditional content defined by implementations Alternate namesextensions, user content 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.
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.
Extension Constraints- 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 |
| modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idClaim.item.modifierExtension Short descriptionExtensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers 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).
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.
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.
Extension Constraints- 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 |
| sequence | | 1..1 | positiveInt | There are no (further) constraints on this element Element idClaim.item.sequence Short descriptionItem instance identifier DefinitionA number to uniquely identify item entries.
Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse.
positiveInt Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| careTeamSequence | | 0..* | positiveInt | There are no (further) constraints on this element Element idClaim.item.careTeamSequence Short descriptionApplicable careTeam members DefinitionCareTeam members related to this service or product.
Need to identify the individuals and their roles in the provision of the product or service.
positiveInt Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| diagnosisSequence | | 0..* | positiveInt | There are no (further) constraints on this element Element idClaim.item.diagnosisSequence Short descriptionApplicable diagnoses DefinitionDiagnosis applicable for this service or product.
Need to related the product or service to the associated diagnoses.
positiveInt Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| procedureSequence | | 0..* | positiveInt | There are no (further) constraints on this element Element idClaim.item.procedureSequence Short descriptionApplicable procedures DefinitionProcedures applicable for this service or product.
Need to provide any listed specific procedures to support the product or service being claimed.
positiveInt Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| informationSequence | | 0..* | positiveInt | There are no (further) constraints on this element Element idClaim.item.informationSequence Short descriptionApplicable exception and supporting information DefinitionExceptions, special conditions and supporting information applicable for this service or product.
Need to reference the supporting information items that relate directly to this product or service.
positiveInt Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| revenue | | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idClaim.item.revenue Short descriptionRevenue or cost center code DefinitionThe type of revenue or cost center providing the product and/or service.
Needed in the processing of institutional claims.
CodeableConcept BindingCodes for the revenue or cost centers supplying the service and/or products.
ExampleRevenueCenterCodes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| category | | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idClaim.item.category Short descriptionBenefit classification DefinitionCode to identify the general type of benefits under which products and services are provided.
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.
Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.
CodeableConcept BindingBenefit categories such as: oral-basic, major, glasses.
BenefitCategoryCodes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| productOrService | | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idClaim.item.productOrService Short descriptionBilling, service, product, or drug code Alternate namesDrug Code, Bill Code, Service Code 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.
Necessary to state what was provided or done.
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'.
CodeableConcept BindingAllowable service and product codes.
USCLSCodes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| modifier | | 0..* | CodeableConcept | There are no (further) constraints on this element Element idClaim.item.modifier Short descriptionProduct or service billing modifiers DefinitionItem typification or modifiers codes to convey additional context for the product or service.
To support inclusion of the item for adjudication or to charge an elevated fee.
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.
CodeableConcept BindingItem 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) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| programCode | | 0..* | CodeableConcept | There are no (further) constraints on this element Element idClaim.item.programCode Short descriptionProgram the product or service is provided under DefinitionIdentifies the program under which this may be recovered.
Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.
For example: Neonatal program, child dental program or drug users recovery program.
CodeableConcept BindingProgram specific reason codes.
ExampleProgramReasonCodes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| serviced[x] | | 0..1 | | There are no (further) constraints on this element Element idClaim.item.serviced[x] Short descriptionDate or dates of service or product delivery DefinitionThe date or dates when the service or product was supplied, performed or completed.
Needed to determine whether the service or product was provided during the term of the insurance coverage.
- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings |
| servicedDate | | | date | There are no (further) constraints on this element Data typedate |
| servicedPeriod | | | Period | There are no (further) constraints on this element Data typePeriod |
| location[x] | | 0..1 | | There are no (further) constraints on this element Element idClaim.item.location[x] Short descriptionPlace of service or where product was supplied DefinitionWhere the product or service was provided.
The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount.
Place of service: pharmacy, school, prison, etc.
ExampleServicePlaceCodes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings |
| locationCodeableConcept | | | CodeableConcept | There are no (further) constraints on this element Data typeCodeableConcept |
| locationAddress | | | Address | There are no (further) constraints on this element Data typeAddress |
| locationReference | | | Reference(Location) | There are no (further) constraints on this element Data typeReference(Location) |
| quantity | | 0..1 | SimpleQuantity | There are no (further) constraints on this element Element idClaim.item.quantity Short descriptionCount of products or services DefinitionThe number of repetitions of a service or product.
Required when the product or service code does not convey the quantity provided.
SimpleQuantity Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| unitPrice | | 0..1 | Money | There are no (further) constraints on this element Element idClaim.item.unitPrice Short descriptionFee, charge or cost per item 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.
The amount charged to the patient by the provider for a single unit.
Money Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| factor | | 0..1 | decimal | There are no (further) constraints on this element Element idClaim.item.factor Short descriptionPrice scaling 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.
When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.
To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
decimal Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| net | | 0..1 | Money | There are no (further) constraints on this element Element idClaim.item.net Short descriptionTotal item cost DefinitionThe quantity times the unit price for an additional service or product or charge.
Provides the total amount claimed for the group (if a grouper) or the line item.
For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
Money Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| udi | | 0..* | Reference(Device) | There are no (further) constraints on this element Element idClaim.item.udi Short descriptionUnique device identifier DefinitionUnique Device Identifiers associated with this line item.
The UDI code allows the insurer to obtain device level information on the product supplied.
Reference(Device) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| bodySite | | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idClaim.item.bodySite Short descriptionAnatomical location DefinitionPhysical service site on the patient (limb, tooth, etc.).
Allows insurer to validate specific procedures.
For example: Providing a tooth code, allows an insurer to identify a provider performing a filling on a tooth that was previously removed.
CodeableConcept BindingThe code for the teeth, quadrant, sextant and arch.
OralSiteCodes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| subSite | | 0..* | CodeableConcept | There are no (further) constraints on this element Element idClaim.item.subSite Short descriptionAnatomical sub-location DefinitionA region or surface of the bodySite, e.g. limb region or tooth surface(s).
Allows insurer to validate specific procedures.
CodeableConcept BindingThe code for the tooth surface and surface combinations.
SurfaceCodes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| encounter | | 0..* | Reference(Encounter) | There are no (further) constraints on this element Element idClaim.item.encounter Short descriptionEncounters related to this billed item DefinitionThe Encounters during which this Claim was created or to which the creation of this record is tightly associated.
Used in some jurisdictions to link clinical events to claim items.
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.
Reference(Encounter) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- workflow: Request.context
|
| detail | | 0..* | BackboneElement | There are no (further) constraints on this element Element idClaim.item.detail Short descriptionProduct or service provided DefinitionA claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.
The items to be processed for adjudication.
BackboneElement Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| id | | 0..1 | string | There are no (further) constraints on this element Element idClaim.item.detail.id Short descriptionUnique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
string Mappings |
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idClaim.item.detail.extension Short descriptionAdditional content defined by implementations Alternate namesextensions, user content 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.
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.
Extension Constraints- 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 |
| modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idClaim.item.detail.modifierExtension Short descriptionExtensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers 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).
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.
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.
Extension Constraints- 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 |
| sequence | | 1..1 | positiveInt | There are no (further) constraints on this element Element idClaim.item.detail.sequence Short descriptionItem instance identifier DefinitionA number to uniquely identify item entries.
Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse.
positiveInt Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| revenue | | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idClaim.item.detail.revenue Short descriptionRevenue or cost center code DefinitionThe type of revenue or cost center providing the product and/or service.
Needed in the processing of institutional claims.
CodeableConcept BindingCodes for the revenue or cost centers supplying the service and/or products.
ExampleRevenueCenterCodes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| category | | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idClaim.item.detail.category Short descriptionBenefit classification DefinitionCode to identify the general type of benefits under which products and services are provided.
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.
Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.
CodeableConcept BindingBenefit categories such as: oral-basic, major, glasses.
BenefitCategoryCodes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| productOrService | | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idClaim.item.detail.productOrService Short descriptionBilling, service, product, or drug code Alternate namesDrug Code, Bill Code, Service Code 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.
Necessary to state what was provided or done.
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'.
CodeableConcept BindingAllowable service and product codes.
USCLSCodes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| modifier | | 0..* | CodeableConcept | There are no (further) constraints on this element Element idClaim.item.detail.modifier Short descriptionService/Product billing modifiers DefinitionItem typification or modifiers codes to convey additional context for the product or service.
To support inclusion of the item for adjudication or to charge an elevated fee.
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.
CodeableConcept BindingItem 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) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| programCode | | 0..* | CodeableConcept | There are no (further) constraints on this element Element idClaim.item.detail.programCode Short descriptionProgram the product or service is provided under DefinitionIdentifies the program under which this may be recovered.
Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.
For example: Neonatal program, child dental program or drug users recovery program.
CodeableConcept BindingProgram specific reason codes.
ExampleProgramReasonCodes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| quantity | | 0..1 | SimpleQuantity | There are no (further) constraints on this element Element idClaim.item.detail.quantity Short descriptionCount of products or services DefinitionThe number of repetitions of a service or product.
Required when the product or service code does not convey the quantity provided.
SimpleQuantity Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| unitPrice | | 0..1 | Money | There are no (further) constraints on this element Element idClaim.item.detail.unitPrice Short descriptionFee, charge or cost per item 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.
The amount charged to the patient by the provider for a single unit.
Money Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| factor | | 0..1 | decimal | There are no (further) constraints on this element Element idClaim.item.detail.factor Short descriptionPrice scaling 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.
When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.
To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
decimal Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| net | | 0..1 | Money | There are no (further) constraints on this element Element idClaim.item.detail.net Short descriptionTotal item cost DefinitionThe quantity times the unit price for an additional service or product or charge.
Provides the total amount claimed for the group (if a grouper) or the line item.
For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
Money Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| udi | | 0..* | Reference(Device) | There are no (further) constraints on this element Element idClaim.item.detail.udi Short descriptionUnique device identifier DefinitionUnique Device Identifiers associated with this line item.
The UDI code allows the insurer to obtain device level information on the product supplied.
Reference(Device) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| subDetail | | 0..* | BackboneElement | There are no (further) constraints on this element Element idClaim.item.detail.subDetail Short descriptionProduct or service provided DefinitionA claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.
The items to be processed for adjudication.
BackboneElement Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| id | | 0..1 | string | There are no (further) constraints on this element Element idClaim.item.detail.subDetail.id Short descriptionUnique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
string Mappings |
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idClaim.item.detail.subDetail.extension Short descriptionAdditional content defined by implementations Alternate namesextensions, user content 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.
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.
Extension Constraints- 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 |
| modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idClaim.item.detail.subDetail.modifierExtension Short descriptionExtensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers 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).
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.
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.
Extension Constraints- 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 |
| sequence | | 1..1 | positiveInt | There are no (further) constraints on this element Element idClaim.item.detail.subDetail.sequence Short descriptionItem instance identifier DefinitionA number to uniquely identify item entries.
Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse.
positiveInt Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| revenue | | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idClaim.item.detail.subDetail.revenue Short descriptionRevenue or cost center code DefinitionThe type of revenue or cost center providing the product and/or service.
Needed in the processing of institutional claims.
CodeableConcept BindingCodes for the revenue or cost centers supplying the service and/or products.
ExampleRevenueCenterCodes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| category | | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idClaim.item.detail.subDetail.category Short descriptionBenefit classification DefinitionCode to identify the general type of benefits under which products and services are provided.
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.
Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.
CodeableConcept BindingBenefit categories such as: oral-basic, major, glasses.
BenefitCategoryCodes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| productOrService | | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idClaim.item.detail.subDetail.productOrService Short descriptionBilling, service, product, or drug code 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.
Necessary to state what was provided or done.
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'.
CodeableConcept BindingAllowable service and product codes.
USCLSCodes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| modifier | | 0..* | CodeableConcept | There are no (further) constraints on this element Element idClaim.item.detail.subDetail.modifier Short descriptionService/Product billing modifiers DefinitionItem typification or modifiers codes to convey additional context for the product or service.
To support inclusion of the item for adjudication or to charge an elevated fee.
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.
CodeableConcept BindingItem 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) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| programCode | | 0..* | CodeableConcept | There are no (further) constraints on this element Element idClaim.item.detail.subDetail.programCode Short descriptionProgram the product or service is provided under DefinitionIdentifies the program under which this may be recovered.
Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.
For example: Neonatal program, child dental program or drug users recovery program.
CodeableConcept BindingProgram specific reason codes.
ExampleProgramReasonCodes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| quantity | | 0..1 | SimpleQuantity | There are no (further) constraints on this element Element idClaim.item.detail.subDetail.quantity Short descriptionCount of products or services DefinitionThe number of repetitions of a service or product.
Required when the product or service code does not convey the quantity provided.
SimpleQuantity Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| unitPrice | | 0..1 | Money | There are no (further) constraints on this element Element idClaim.item.detail.subDetail.unitPrice Short descriptionFee, charge or cost per item 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.
The amount charged to the patient by the provider for a single unit.
Money Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| factor | | 0..1 | decimal | There are no (further) constraints on this element Element idClaim.item.detail.subDetail.factor Short descriptionPrice scaling 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.
When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.
To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
decimal Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| net | | 0..1 | Money | There are no (further) constraints on this element Element idClaim.item.detail.subDetail.net Short descriptionTotal item cost DefinitionThe quantity times the unit price for an additional service or product or charge.
Provides the total amount claimed for the group (if a grouper) or the line item.
For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
Money Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| udi | | 0..* | Reference(Device) | There are no (further) constraints on this element Element idClaim.item.detail.subDetail.udi Short descriptionUnique device identifier DefinitionUnique Device Identifiers associated with this line item.
The UDI code allows the insurer to obtain device level information on the product supplied.
Reference(Device) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| total | | 0..1 | Money | There are no (further) constraints on this element Element idClaim.total Short descriptionTotal claim cost DefinitionThe total value of the all the items in the claim.
Used for control total purposes.
Money Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|