{ "resourceType": "StructureDefinition", "id": "qicore-claim", "text": { "status": "generated", "div": "
\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n
NameFlagsCard.TypeDescription & Constraints\"doco\"
\".\"\".\" Claim 0..*
\".\"\".\"\".\" patient S1..1Reference(QICore-Patient)
\".\"\".\"\".\" created S1..1dateTime
\".\"\".\"\".\" provider S1..1Reference(QICore-Practitioner)
\".\"\".\"\".\" prescription S1..1Reference(QICore-MedicationRequest | VisionPrescription)
\".\"\".\"\".\" payee 0..1BackboneElement
\".\"\".\"\".\"\".\" party 0..1Reference(QICore-Practitioner | QICore-Organization | QICore-Patient | QICore-RelatedPerson)
\".\"\".\"\".\" referral 0..1Reference(QICore-ReferralRequest)
\".\"\".\"\".\" careTeam 0..*BackboneElement
\".\"\".\"\".\"\".\" provider 1..1Reference(QICore-Practitioner | QICore-Organization)
\".\"\".\"\".\" information 0..*BackboneElement
\".\"\".\"\".\"\".\" category S1..1CodeableConceptBinding: Claim Information Category Codes (example)
\".\"\".\"\".\"\".\" code S0..1CodeableConceptBinding: Exception Codes (example)
\".\"\".\"\".\" diagnosis 0..*BackboneElement
\".\"\".\"\".\"\".\" type 0..*CodeableConceptBinding: Example Diagnosis Type Codes (example)
\".\"\".\"\".\" procedure S0..*BackboneElement
\".\"\".\"\".\"\".\" sequence S1..1positiveInt
\".\"\".\"\".\"\".\" date S0..1dateTime
\".\"\".\"\".\"\".\" procedure[x] S1..1CodeableConcept, Reference(Procedure)
\".\"\".\"\".\" hospitalization S0..1Period
\".\"\".\"\".\" item S1..*BackboneElement
\".\"\".\"\".\"\".\" service S1..1CodeableConceptBinding: USCLS Codes (example)
\".\"\".\"\".\"\".\" serviced[x] S1..1date, Period
\".\"\".\"\".\"\".\" locationReference 0..1Reference(QICore-Location)
\".\"\".\"\".\"\".\" udi 0..*Reference(QICore-Device)
\".\"\".\"\".\"\".\" encounter S0..*Reference(QICore-Encounter)
\".\"\".\"\".\"\".\" detail 0..*BackboneElement
\".\"\".\"\".\"\".\"\".\" udi 0..*Reference(QICore-Device)
\".\"\".\"\".\"\".\"\".\" subDetail 0..*BackboneElement
\".\"\".\"\".\"\".\"\".\"\".\" udi 0..1Reference(QICore-Device)

\"doco\" Documentation for this format
" }, "url": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-claim", "version": "3.1.0", "name": "QICore-Claim", "status": "draft", "date": "2018-08-21T14:00:00+00:00", "publisher": "Health Level Seven, Inc. - CQI WG", "contact": [ { "telecom": [ { "system": "url", "value": "http://hl7.org/special/committees/CQI" } ] } ], "description": "Profile of Claim for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.", "fhirVersion": "3.0.1", "mapping": [ { "identity": "workflow", "uri": "http://hl7.org/fhir/workflow", "name": "Workflow Mapping" }, { "identity": "w5", "uri": "http://hl7.org/fhir/w5", "name": "W5 Mapping" }, { "identity": "rim", "uri": "http://hl7.org/v3", "name": "RIM Mapping" } ], "kind": "resource", "abstract": false, "type": "Claim", "baseDefinition": "http://hl7.org/fhir/StructureDefinition/Claim", "derivation": "constraint", "differential": { "element": [ { "id": "Claim", "path": "Claim", "definition": "A provider issued list of services and products provided, or to be provided, to a patient which is provided to an insurer for payment recovery.", "mustSupport": false, "isModifier": false }, { "id": "Claim.patient", "path": "Claim.patient", "definition": "Patient Resource.", "min": 1, "max": "1", "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-patient" } ], "mustSupport": true, "isModifier": false }, { "id": "Claim.created", "path": "Claim.created", "definition": "The date when the enclosed suite of services were performed or completed.", "min": 1, "max": "1", "type": [ { "code": "dateTime" } ], "mustSupport": true, "isModifier": false }, { "id": "Claim.provider", "path": "Claim.provider", "definition": "The provider which is responsible for the bill, claim pre-determination, pre-authorization.", "min": 1, "max": "1", "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-practitioner" } ], "mustSupport": true, "isModifier": false }, { "id": "Claim.prescription", "path": "Claim.prescription", "definition": "Prescription to support the dispensing of Pharmacy or Vision products.", "min": 1, "max": "1", "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-medicationrequest" }, { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/VisionPrescription" } ], "mustSupport": true, "isModifier": false }, { "id": "Claim.payee", "path": "Claim.payee", "definition": "The party to be reimbursed for the services.", "min": 0, "max": "1", "type": [ { "code": "BackboneElement" } ], "mustSupport": false, "isModifier": false }, { "id": "Claim.payee.party", "path": "Claim.payee.party", "definition": "Party to be reimbursed: Subscriber, provider, other.", "min": 0, "max": "1", "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-practitioner" }, { "code": "Reference", "targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-organization" }, { "code": "Reference", "targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-patient" }, { "code": "Reference", "targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-relatedperson" } ], "mustSupport": false, "isModifier": false }, { "id": "Claim.referral", "path": "Claim.referral", "definition": "The referral resource which lists the date, practitioner, reason and other supporting information.", "min": 0, "max": "1", "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-referralrequest" } ], "mustSupport": false, "isModifier": false }, { "id": "Claim.careTeam", "path": "Claim.careTeam", "definition": "The members of the team who provided the overall service as well as their role and whether responsible and qualifications.", "min": 0, "max": "*", "type": [ { "code": "BackboneElement" } ], "mustSupport": false, "isModifier": false }, { "id": "Claim.careTeam.provider", "path": "Claim.careTeam.provider", "definition": "Member of the team who provided the overall service.", "min": 1, "max": "1", "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-practitioner" }, { "code": "Reference", "targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-organization" } ], "mustSupport": false, "isModifier": false }, { "id": "Claim.information", "path": "Claim.information", "definition": "Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues. Often there are mutiple jurisdiction specific valuesets which are required.", "min": 0, "max": "*", "type": [ { "code": "BackboneElement" } ], "mustSupport": false, "isModifier": false }, { "id": "Claim.information.category", "path": "Claim.information.category", "definition": "The general class of the information supplied: information; exception; accident, employment; onset, etc.", "min": 1, "max": "1", "type": [ { "code": "CodeableConcept" } ], "mustSupport": true, "isModifier": false, "binding": { "strength": "example", "description": "This value set includes sample Information Category codes.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/claim-informationcategory" } } }, { "id": "Claim.information.code", "path": "Claim.information.code", "definition": "System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought which may influence the adjudication.", "min": 0, "max": "1", "type": [ { "code": "CodeableConcept" } ], "mustSupport": true, "isModifier": false, "binding": { "strength": "example", "description": "This value set includes sample Exception codes.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/claim-exception" } } }, { "id": "Claim.diagnosis", "path": "Claim.diagnosis", "definition": "List of patient diagnosis for which care is sought.", "min": 0, "max": "*", "type": [ { "code": "BackboneElement" } ], "mustSupport": false, "isModifier": false }, { "id": "Claim.diagnosis.type", "path": "Claim.diagnosis.type", "definition": "The type of the Diagnosis, for example: admitting, primary, secondary, discharge.", "min": 0, "max": "*", "type": [ { "code": "CodeableConcept" } ], "mustSupport": false, "isModifier": false, "binding": { "strength": "example", "description": "This value set includes example Diagnosis Type codes.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/ex-diagnosistype" } } }, { "id": "Claim.procedure", "path": "Claim.procedure", "definition": "Procedures performed.", "min": 0, "max": "*", "type": [ { "code": "BackboneElement" } ], "mustSupport": true, "isModifier": false }, { "id": "Claim.procedure.sequence", "path": "Claim.procedure.sequence", "definition": "Procedure sequence for reference.", "min": 1, "max": "1", "type": [ { "code": "positiveInt" } ], "mustSupport": true, "isModifier": false }, { "id": "Claim.procedure.date", "path": "Claim.procedure.date", "definition": "When the procedure was performed.", "min": 0, "max": "1", "type": [ { "code": "dateTime" } ], "mustSupport": true, "isModifier": false }, { "id": "Claim.procedure.procedure[x]", "path": "Claim.procedure.procedure[x]", "definition": "When the procedure was performed.", "min": 1, "max": "1", "mustSupport": true, "isModifier": false }, { "id": "Claim.hospitalization", "path": "Claim.hospitalization", "definition": "Period in hospital.", "min": 0, "max": "1", "type": [ { "code": "Period" } ], "mustSupport": true, "isModifier": false }, { "id": "Claim.item", "path": "Claim.item", "definition": "First tier of goods and services.", "min": 1, "max": "*", "type": [ { "code": "BackboneElement" } ], "mustSupport": true, "isModifier": false }, { "id": "Claim.item.service", "path": "Claim.item.service", "definition": "If this is an actual service or product line, ie. not a Group, then use code to indicate the Professional Service or Product supplied (eg. 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 eg. \"glasses\" or \"compound\".", "min": 1, "max": "1", "type": [ { "code": "CodeableConcept" } ], "mustSupport": true, "isModifier": false, "binding": { "strength": "example", "description": "This value set includes a smattering of USCLS codes.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/service-uscls" } } }, { "id": "Claim.item.serviced[x]", "path": "Claim.item.serviced[x]", "definition": "The date or dates when the enclosed suite of services were performed or completed.", "min": 1, "max": "1", "mustSupport": true, "isModifier": false }, { "id": "Claim.item.locationReference", "path": "Claim.item.locationReference", "definition": "Where the service was provided.", "min": 0, "max": "1", "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-location" } ], "mustSupport": false, "isModifier": false }, { "id": "Claim.item.udi", "path": "Claim.item.udi", "definition": "List of Unique Device Identifiers associated with this line item.", "min": 0, "max": "*", "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-device" } ], "mustSupport": false, "isModifier": false }, { "id": "Claim.item.encounter", "path": "Claim.item.encounter", "definition": "Encounters related to this billed item.", "min": 0, "max": "*", "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-encounter" } ], "mustSupport": true, "isModifier": false }, { "id": "Claim.item.detail", "path": "Claim.item.detail", "definition": "Second tier of goods and services.", "min": 0, "max": "*", "type": [ { "code": "BackboneElement" } ], "mustSupport": false, "isModifier": false }, { "id": "Claim.item.detail.udi", "path": "Claim.item.detail.udi", "definition": "List of Unique Device Identifiers associated with this line item.", "min": 0, "max": "*", "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-device" } ], "mustSupport": false, "isModifier": false }, { "id": "Claim.item.detail.subDetail", "path": "Claim.item.detail.subDetail", "definition": "Third tier of goods and services.", "min": 0, "max": "*", "type": [ { "code": "BackboneElement" } ], "mustSupport": false, "isModifier": false }, { "id": "Claim.item.detail.subDetail.udi", "path": "Claim.item.detail.subDetail.udi", "definition": "List of Unique Device Identifiers associated with this line item.", "min": 0, "max": "1", "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-device" } ], "mustSupport": false, "isModifier": false } ] } }