Generated Narrative: StructureDefinition ke-eclaims-claim Name Flags Card. Type Description & Constraints Claim 0..* Claim Claim, Pre-determination or Pre-authorization #xD; id S 1..1 id Logical id of this artifact #xD; meta S 1..1 Meta Metadata about the resource #xD; profile S 1..* canonical(StructureDefinition) Profiles this resource claims to conform to #xD; identifier S 1..1 Identifier Business Identifier for claim #xD; status S 1..1 code active | cancelled | draft | entered-in-error #xD; type S 1..1 CodeableConcept Category or discipline #xD; coding S 1..* Coding Code defined by a terminology system #xD; system S 1..1 uri Identity of the terminology system #xD; code S 1..1 code Symbol in syntax defined by the system #xD; display S 1..1 string Representation defined by the system #xD; text S 0..1 string Plain text representation of the concept #xD; subType S 0..1 CodeableConcept More granular claim type #xD; coding S 1..* Coding Code defined by a terminology system #xD; system S 1..1 uri Identity of the terminology system #xD; code S 1..1 code Symbol in syntax defined by the system #xD; display S 1..1 string Representation defined by the system #xD; text S 0..1 string Plain text representation of the concept #xD; use S 1..1 code claim | preauthorization | predetermination #xD; patient S 1..1 Reference(Patient) The recipient of the products and services #xD; billablePeriod S 0..1 Period Relevant time frame for the claim #xD; created S 1..1 dateTime Resource creation date #xD; insurer S 1..1 Reference(Organization) Target #xD; provider S 1..1 Reference(Organization) Party responsible for the claim #xD; priority S 1..1 CodeableConcept Desired processing ugency #xD; coding S 1..* Coding Code defined by a terminology system #xD; system S 1..1 uri Identity of the terminology system #xD; code S 1..1 code Symbol in syntax defined by the system #xD; display S 1..1 string Representation defined by the system #xD; text S 0..1 string Plain text representation of the concept #xD; related S 0..* BackboneElement Prior or corollary claims #xD; claim S 1..1 Reference(Claim) Reference to the related claim #xD; relationship S 1..1 CodeableConcept How the reference claim is related #xD; coding S 1..* Coding Code defined by a terminology system #xD; system S 1..1 uri Identity of the terminology system #xD; code S 1..1 code Symbol in syntax defined by the system #xD; display S 1..1 string Representation defined by the system #xD; text S 0..1 string Plain text representation of the concept #xD; prescription S 0..1 Reference(MedicationRequest | DeviceRequest | VisionPrescription) Prescription authorizing services and products #xD; originalPrescription S 1..1 Reference(MedicationRequest) Original prescription if superseded by fulfiller #xD; payee S 1..1 BackboneElement Recipient of benefits payable #xD; type S 1..1 CodeableConcept Category of recipient #xD; coding S 1..* Coding Code defined by a terminology system #xD; system S 1..1 uri Identity of the terminology system #xD; code S 1..1 code Symbol in syntax defined by the system #xD; display S 1..1 string Representation defined by the system #xD; text S 0..1 string Plain text representation of the concept #xD; party S 0..1 Reference(Patient | Organization) Recipient reference #xD; referral S 1..1 Reference(ServiceRequest) Treatment referral #xD; facility S 1..1 Reference(Location) Servicing facility #xD; careTeam S 1..* BackboneElement Members of the care team #xD; sequence S 1..1 positiveInt Order of care team #xD; provider S 1..1 Reference(Practitioner) Practitioner or organization #xD; role S 1..1 CodeableConcept Function within the team #xD; coding S 1..* Coding Code defined by a terminology system #xD; system S 1..1 uri Identity of the terminology system #xD; code S 1..1 code Symbol in syntax defined by the system #xD; display S 1..1 string Representation defined by the system #xD; text S 0..1 string Plain text representation of the concept #xD; qualification S 1..1 CodeableConcept Practitioner credential or specialization #xD; coding S 1..* Coding Code defined by a terminology system #xD; system S 1..1 uri Identity of the terminology system #xD; code S 1..1 code Symbol in syntax defined by the system #xD; display S 1..1 string Representation defined by the system #xD; text S 0..1 string Plain text representation of the concept #xD; supportingInfo S 0..* BackboneElement Supporting information #xD; sequence S 1..1 positiveInt Information instance identifier #xD; category S 1..1 CodeableConcept Classification of the supplied information #xD; code S 0..1 CodeableConcept Type of information #xD; timing[x] S 0..1 date, Period When it occurred #xD; value[x] S 0..1 boolean, string, Quantity, Attachment, Reference(Resource) Data to be provided #xD; reason S 0..1 CodeableConcept Explanation for the information #xD; diagnosis S 1..* BackboneElement Pertinent diagnosis information #xD; sequence S 1..1 positiveInt Diagnosis instance identifier #xD; diagnosis[x] S 1..1 CodeableConcept Nature of illness or problem #xD; type S 1..1 CodeableConcept Timing or nature of the diagnosis #xD; coding S 1..* Coding Code defined by a terminology system #xD; system S 1..1 uri Identity of the terminology system #xD; code S 1..1 code Symbol in syntax defined by the system #xD; display S 1..1 string Representation defined by the system #xD; text S 0..1 string Plain text representation of the concept #xD; onAdmission S 0..1 CodeableConcept Present on admission #xD; coding S 1..* Coding Code defined by a terminology system #xD; system S 1..1 uri Identity of the terminology system #xD; code S 1..1 code Symbol in syntax defined by the system #xD; display S 1..1 string Representation defined by the system #xD; text S 0..1 string Plain text representation of the concept #xD; insurance S 1..* BackboneElement Patient insurance information #xD; sequence S 1..1 positiveInt Insurance instance identifier #xD; focal S 1..1 boolean Coverage to be used for adjudication #xD; coverage S 1..1 Reference(Coverage) Insurance information #xD; preAuthRef S 0..* string Prior authorization reference number #xD; claimResponse S 0..1 Reference(ClaimResponse) Adjudication results #xD; accident S 0..1 BackboneElement Details of the event #xD; date S 1..1 date When the incident occurred #xD; type S 1..1 CodeableConcept The nature of the accident #xD; location[x] S 0..1 Address, Reference(Location) Where the event occurred #xD; item S 1..* BackboneElement Product or service provided #xD; sequence S 1..1 positiveInt Item instance identifier #xD; careTeamSequence S 1..* positiveInt Applicable careTeam members #xD; diagnosisSequence S 0..* positiveInt Applicable diagnoses #xD; informationSequence S 0..* positiveInt Applicable exception and supporting information #xD; productOrService S 1..1 CodeableConcept Billing, service, product, or drug code #xD; coding S 1..* Coding Code defined by a terminology system #xD; system S 1..1 uri Identity of the terminology system #xD; code S 1..1 code Symbol in syntax defined by the system #xD; display S 1..1 string Representation defined by the system #xD; text S 0..1 string Plain text representation of the concept #xD; serviced[x] S 0..1 date, Period Date or dates of service or product delivery #xD; quantity S 1..1 SimpleQuantity(4.0.1) Count of products or services #xD; unitPrice S 1..1 Money Fee, charge or cost per item #xD; factor S 0..1 decimal Price scaling factor #xD; net S 1..1 Money Total item cost #xD; udi S 0..* Reference(Device) Unique device identifier #xD; bodySite S 0..1 CodeableConcept Anatomical location #xD; coding S 1..* Coding Code defined by a terminology system #xD; system S 1..1 uri Identity of the terminology system #xD; code S 1..1 code Symbol in syntax defined by the system #xD; display S 1..1 string Representation defined by the system #xD; text S 0..1 string Plain text representation of the concept #xD; subSite S 0..1 CodeableConcept Anatomical sub-location #xD; coding S 1..* Coding Code defined by a terminology system #xD; system S 1..1 uri Identity of the terminology system #xD; code S 1..1 code Symbol in syntax defined by the system #xD; display S 1..1 string Representation defined by the system #xD; text S 0..1 string Plain text representation of the concept #xD; detail S 0..* BackboneElement Product or service provided #xD; sequence S 1..1 positiveInt Item instance identifier #xD; productOrService S 1..1 CodeableConcept Billing, service, product, or drug code #xD; coding S 1..* Coding Code defined by a terminology system #xD; system S 1..1 uri Identity of the terminology system #xD; code S 1..1 code Symbol in syntax defined by the system #xD; display S 1..1 string Representation defined by the system #xD; text S 0..1 string Plain text representation of the concept #xD; quantity S 1..1 SimpleQuantity(4.0.1) Count of products or services #xD; unitPrice S 1..1 Money Fee, charge or cost per item #xD; net S 1..1 Money Total item cost #xD; udi S 0..* Reference(Device) Unique device identifier #xD; subDetail S 0..* BackboneElement Product or service provided #xD; sequence S 1..1 positiveInt Item instance identifier #xD; productOrService S 1..1 CodeableConcept Billing, service, product, or drug code #xD; coding S 1..* Coding Code defined by a terminology system #xD; system S 1..1 uri Identity of the terminology system #xD; code S 1..1 code Symbol in syntax defined by the system #xD; display S 1..1 string Representation defined by the system #xD; text S 0..1 string Plain text representation of the concept #xD; quantity S 1..1 SimpleQuantity(4.0.1) Count of products or services #xD; unitPrice S 1..1 Money Fee, charge or cost per item #xD; net S 1..1 Money Total item cost #xD; udi S 0..* Reference(Device) Unique device identifier #xD; total S 1..1 Money Total claim cost #xD; Documentation for this format
This profile defines constraints on the Claim resource for use within the Kenya eClaims Implementation Guide. It supports institutional claims with detailed clinical, financial, insurance, and adjudication metadata.
Claim, Pre-determination or Pre-authorization
A provider issued list of professional services and products which have been provided, or are to be provided, to a patient which is sent to an insurer for reimbursement.
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.
If the resource is contained in another resource, it SHALL NOT contain nested Resources
not(parent::f:contained and f:contained)
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()
not(exists(for $id in f:contained/*/f:id/@value return $contained[not(parent::*/descendant::f:reference/@value=concat('#', $contained/*/id/@value) or descendant::f:reference[@value='#'])]))
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()
not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))
If a resource is contained in another resource, it SHALL NOT have a security label
When a resource has no narrative, only systems that fully understand the data can display the resource to a human safely. Including a human readable representation in the resource makes for a much more robust eco-system and cheaper handling of resources by intermediary systems. Some ecosystems restrict distribution of resources to only those systems that do fully understand the resources, and as a consequence implementers may believe that the narrative is superfluous. However experience shows that such eco-systems often open up to new participants over time.
A resource should have narrative for robust management
The 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.
The 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.
All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Extensions are always sliced by (at least) url
Additional content defined by implementations
May 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.
Must have either extensions or value[x], not both
exists(f:extension)!=exists(f:*[starts-with(local-name(.), "value")])
The 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.
When 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](http://hl7.org/fhir/R4/http.html#read) interaction.
Identifies where the resource comes from
A uri that identifies the source system of the resource. This provides a minimal amount of [Provenance](http://hl7.org/fhir/R4/provenance.html#) 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.
Profiles this resource claims to conform to
A list of profiles (references to [StructureDefinition](http://hl7.org/fhir/R4/structuredefinition.html#) resources) that this resource claims to conform to. The URL is a reference to [StructureDefinition.url](http://hl7.org/fhir/R4/structuredefinition-definitions.html#StructureDefinition.url).
It 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.
Security Labels applied to this resource
Security 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.
Security Labels from the Healthcare Privacy and Security Classification System.
Tags 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.
Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
A set of rules under which this content was created
A 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.
This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
The 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).
Text summary of the resource, for human interpretation
A 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.
These 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.
May 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.
May 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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).
Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
A unique identifier assigned to this claim.
Allows claims to be distinguished and referenced.
active | cancelled | draft | entered-in-error
This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.
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 it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
A code specifying the state of the resource instance.
The category of claim, e.g. oral, pharmacy, vision, institutional, professional.
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.
Claim type determine the general sets of business rules applied for information requirements and adjudication.
The type or discipline-style of the claim.
A reference to a code defined by a terminology system.
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.
Allows for alternative encodings within a code system, and translations to other code systems.
fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
The identification of the code system that defines the meaning of the symbol in the code.
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.
Need to be unambiguous about the source of the definition of the symbol.
fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
The 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.
fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
A 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.
fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
A 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.
C*E.2 - but note this is not well followed
fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
If this coding was chosen directly by the user
Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays).
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.
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.
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 ]
Plain text representation of the concept
A 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.
Very often the text is the same as a displayName of one of the codings.
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.
C*E.9. But note many systems use C*E.2 for this
fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.
This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.
Some jurisdictions need a finer grained claim type for routing and adjudication.
claim | preauthorization | predetermination
A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future.
This element is required to understand the nature of the request for adjudication.
The purpose of the Claim: predetermination, preauthorization, claim.
The recipient of the products and services
The 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.
The period for which charges are being submitted.
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.
A number jurisdictions required the submission of the billing period when submitting claims for example for hospital stays or long-term care.
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.
Need to record a timestamp for use by both the recipient and the issuer.
Individual who created the claim, predetermination or preauthorization.
Some jurisdictions require the contact information for personnel completing claims.
The Insurer who is target of the request.
The provider which is responsible for the claim, predetermination or preauthorization.
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.
The provider-required urgency of processing the request. Typical values include: stat, routine deferred.
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.
The provider may need to indicate their processing requirements so that the processor can indicate if they are unable to comply.
The timeliness with which processing is required: stat, normal, deferred.
A code to indicate whether and for whom funds are to be reserved for future claims.
This field is only used for preauthorizations.
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.
For whom funds are to be reserved: (Patient, Provider, None).
Other claims which are related to this claim such as prior submissions or claims for related services or for the same event.
For example, for the original treatment and follow-up exams.
For workplace or other accidents it is common to relate separate claims arising from the same event.
Extensions that cannot be ignored even if unrecognized
May 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 are expected to modify the meaning or interpretation of the element that contains them
A code to convey how the claims are related.
Some insurers need a declaration of the type of relationship.
Relationship of this claim to a related Claim.
An alternate organizational reference to the case or file to which this particular claim pertains.
For example, Property/Casualty insurer claim # or Workers Compensation case # .
In cases where an event-triggered claim is being submitted to an insurer which requires a reference number to be specified on all exchanges.
Prescription authorizing services and products
Prescription to support the dispensing of pharmacy, device or vision products.
Required to authorize the dispensing of controlled substances and devices.
Original prescription if superseded by fulfiller
Original prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or products.
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'.
Often required when a fulfiller varies what is fulfilled from that authorized on the original prescription.
The party to be reimbursed for cost of the products and services according to the terms of the policy.
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.
The provider needs to specify who they wish to be reimbursed and the claims processor needs express who they will reimburse.
Type 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.
Reference to the individual or organization to whom any payment will be made.
Not required if the payee is 'subscriber' or 'provider'.
Need to provide demographics if the payee is not 'subscriber' nor 'provider'.
The referral resource which lists the date, practitioner, reason and other supporting information.
Some insurers require proof of referral to pay for services or to pay specialist rates for services.
Facility where the services were provided.
Insurance adjudication can be dependant on where services were delivered.
The members of the team who provided the products and services.
Common to identify the responsible and supporting practitioners.
A 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.
Member of the team who provided the product or service.
Often a regulatory requirement to specify the responsible provider.
The party who is billing and/or responsible for the claimed products or services.
Responsible might not be required when there is only a single provider listed.
When multiple parties are present it is required to distinguish the lead or responsible individual.
The lead, assisting or supervising practitioner and their discipline if a multidisciplinary team.
Role might not be required when there is only a single provider listed.
When multiple parties are present it is required to distinguish the roles performed by each member.
The role codes for the care team members.
Practitioner credential or specialization
The qualification of the practitioner which is applicable for this service.
Need to specify which qualification a provider is delivering the product or service under.
Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.
Often there are multiple jurisdiction specific valuesets which are required.
Typically these information codes are required to support the services rendered or the adjudication of the services rendered.
Attachments Exception Codes Occurrence Codes Value codes
A 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.
Classification of the supplied information
The general class of the information supplied: information; exception; accident, employment; onset, etc.
This may contain a category for the local bill type codes.
Required to group or associate information items with common characteristics. For example: admission information or prior treatments.
The valuset used for additional information category codes.
System 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.
The valuset used for additional information codes.
The date when or period to which this information refers.
Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.
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.
To convey the data content to be provided when the information is more than a simple code or period.
Provides the reason in the situation where a reason code is required in addition to the content.
For example: the reason for the additional stay, or why a tooth is missing.
Needed when the supporting information has both a date and amount/value and requires explanation.
Information about diagnoses relevant to the claim items.
Required for the adjudication by provided context for the services and product listed.
A number to uniquely identify diagnosis entries.
Diagnosis are presented in list order to their expected importance: primary, secondary, etc.
Necessary to maintain the order of the diagnosis items and provide a mechanism to link to claim details.
The 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.
When the condition was observed or the relative ranking.
For example: admitting, primary, secondary, discharge.
Often required to capture a particular diagnosis, for example: primary or discharge.
The type of the diagnosis: admitting, principal, discharge.
Indication 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.
A 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.
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.
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.
The DRG codes associated with the diagnosis.
Procedures 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.
A number to uniquely identify procedure entries.
Necessary to provide a mechanism to link to claim details.
Date and optionally time the procedure was performed.
The code or reference to a Procedure resource which identifies the clinical intervention performed.
This identifies the actual clinical procedure.
Unique Device Identifiers associated with this line item.
The UDI code allows the insurer to obtain device level information on the product supplied.
Financial instruments for reimbursement for the health care products and services specified on the 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.
At least one insurer is required for a claim to be a claim.
A number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order.
A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.
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.
To identify which coverage in the list is being used to adjudicate this claim.
The business identifier to be used when the claim is sent for adjudication against this insurance policy.
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'.
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.
Reference 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.
A 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.
Reference numbers previously provided by the insurer to the provider to be quoted on subsequent claims containing services or products related to the prior authorization.
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.
Providers must quote previously issued authorization reference numbers in order to obtain adjudication as previously advised on the Preauthorization.
The result of the adjudication of the line items for the Coverage specified in this insurance.
Must not be specified when 'focal=true' for 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.
Details 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.
Date of an accident event related to the products and services contained in the claim.
The date of the accident has to precede the dates of the products and services but within a reasonable timeframe.
Required for audit purposes and adjudication.
The 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.
Type of accident: work place, auto, etc.
The physical location of the accident event.
Required for audit purposes and determination of applicable insurance liability.
A 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.
A 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.
CareTeam members related to this service or product.
Need to identify the individuals and their roles in the provision of the product or service.
Diagnosis applicable for this service or product.
Need to related the product or service to the associated diagnoses.
Procedures applicable for this service or product.
Need to provide any listed specific procedures to support the product or service being claimed.
Applicable exception and supporting information
Exceptions, 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.
The type of revenue or cost center providing the product and/or service.
Needed in the processing of institutional claims.
Codes for the revenue or cost centers supplying the service and/or products.
Code to identify the general type of benefits under which products and services are provided.
Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.
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.
Benefit categories such as: oral-basic, major, glasses.
When 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.
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'.
Necessary to state what was provided or done.
Item typification or modifiers codes to convey additional context for the product or service.
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.
To support inclusion of the item for adjudication or to charge an elevated fee.
Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
Program the product or service is provided under
Identifies the program under which this may be recovered.
For example: Neonatal program, child dental program or drug users recovery program.
Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.
Date or dates of service or product delivery
The 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.
Place of service or where product was supplied
Where 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.
The number of repetitions of a service or product.
Required when the product or service code does not convey the quantity provided.
If 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.
A 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.
To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.
The quantity times the unit price for an additional service or product or charge.
For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
Provides the total amount claimed for the group (if a grouper) or the line item.
Physical service site on the patient (limb, tooth, etc.).
For example: Providing a tooth code, allows an insurer to identify a provider performing a filling on a tooth that was previously removed.
Allows insurer to validate specific procedures.
The code for the teeth, quadrant, sextant and arch.
A region or surface of the bodySite, e.g. limb region or tooth surface(s).
The code for the tooth surface and surface combinations.
The Encounters during which this Claim was created or to which the creation of this record is tightly associated.
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.
Used in some jurisdictions to link clinical events to claim items.
A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.
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.
The total value of the all the items in the claim.