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ElementAliasesCard.Inv.TypeIs ModifierModifier ReasonSummaryBindingExampleDefault ValueMissing MeaningRegexShort NameDefinitionRequirementsCommentsPrior ContentsCMS 1500To DoRIM MappingWorkflow Mappingv2 MappingExisting Standard CDAnet v4w5UMLDisplay HintCommittee Notes
ClaimAdjudication Request; Preauthorization Request; Predetermination RequestDomainResourceClaim, Predetermination or PreauthorizationA provider issued list of professional services and products which have been provided, or to be provided, to a patient which is sent to an insurer for reimbursement.The Claim resource is used by providers to exchange services and products rendered to patients or planned to be rendered with insurers for reimbuserment. It is also used by insurers to exchange claims information with statutory reporting and data analytics firms.The Claim resource fulfills three information request requirements: Claim - a request for ajudication for reimbursement for producst and/or services provided; Preauthorization - a request to authorize the future provision of products and/or servcies including an anticipated adjudication; and, Predetermination - a request for a non-bind adjudication of possible future products and/or services.Requestfinancial.billing360;0
!Identification
Claim.identifier0..*IdentifierBusiness Identifier for claimA unique identifier assigned to this claim.Allows observations to be distinguished and referenced.The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization number.Request.identifierA02|G01id
Claim.status0..1codeYThis 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 validYClaimStatusactive | cancelled | draft | entered-in-errorThe status of the resource instance.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 validHad to change cardinality for a contained version which only had the business identifier.Request.statusstatus
Claim.type0..1CodeableConceptClaimTypeCategory or disciplineThe category of claim, e.g. oral, pharmacy, vision, institutional, professional.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.The category of claim this isclass
Claim.subType0..1CodeableConceptClaimSubTypeMore granular claim typeA 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.classDefer
Claim.use0..1codeYUseclaim | preauthorization | predeterminationA 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.classA claim, a list of completed goods and services; a preauthorization, a list or proposed goods and services; or a predetermination, a set of goods and services being considered, for which insurer adjudication is sought.Make 1..1
!Patient Information
Claim.patient0..1Reference(Patient)The recipient of the Products and ServicesThe party to whom the professional services and/or products have been supplied or are being considered and for whom actual for facast reimburement is sought.The patient must be supplied to the insurer so that confirmation of coverage and service hstory may be considered as part of the authorization and/or adjudiction.Request.subjectC06,C07,C08, C05, C04who.focusMake 1..1
Claim.billablePeriod0..1PeriodRelevant time frame for the claimThe 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 prodeterminations. Typically line item dates of service should fall within the billing period if one is specified. 18when.done
Claim.created0..1dateTimeData capture dateThe date when the information captured in this resource was first created.Some insurers have time limits after the claim creation date for submission and adjudication.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.Request.authoredOnwhen.recorded
Claim.enterer0..1Reference(Practitioner|PractitionerRole)Author of the claimIndividual who created the claim, predetermination or preauthorization.Some jurisdictions require the contact information for personnel completing claims.who.authorConsider adding Patient and RelatedPerios for non-provider filled claims.
Claim.insurer0..1Reference(Organization)Party responsible for reimbursementThe party responsible for authorization, adjudication and reimbursement.To be a valid claim, preauthorization or predetermination there must be a party who is responsible for adjudicating the contents against a policy which provides benefits for the patient.Request.performerMake 1..1
Claim.provider0..1Reference(Practitioner|PractitionerRole|Organization)Party responsible for the claimThe 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.Request.requesterB02who.sourceMake 1..1
Claim.priority0..1CodeableConceptProcessPriorityDesired processing ugencyThe provider-required urgency of processing the request. Typical values include: stat, routine deferred.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.Request.priority
Claim.fundsReserveFund pre-allocation0..1CodeableConceptFundsReserveFor whom to reserve fundsA 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.
Claim.related0..*=RelatedClaimPrior or corollary claimsOther 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.740;150
Claim.related.claim0..1Reference(Claim)Reference to the related claimReference to a related claim.For workplace or other accidents it is common to relate separate claims arising from the same event.11.bRequest.replaces
Claim.related.relationship0..1CodeableConceptRelatedClaimRelationshipHow the reference claim is relatedA code to convey how the claims are related.Some insurers need a declaration of the type of relationship.For example, prior claim or umbrella.11.b
Claim.related.reference0..1IdentifierFile or case referenceAn 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 # .11.b
Claim.prescription0..1Reference(DeviceRequest|MedicationRequest|VisionPrescription)Prescription authorizing services and productsPrescription to support the dispensing of pharmacy, device or vision products.Required to authorize the dispensing of controlled substances and devices.
Claim.originalPrescription0..1Reference(DeviceRequest|MedicationRequest|VisionPrescription)Original prescription if superseded by fulfillerOriginal 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 therefor 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'.
!Payee Information
Claim.payee0..1=PayeeRecipient of benefits payableThe 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 are choose to pay the subscriber instead.0;0
Claim.payee.type1..1CodeableConceptPayeeTypeCategory of recipientType 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.27get codeset from V3
Claim.payee.party0..1Reference(Practitioner|PractitionerRole|Organization|Patient|RelatedPerson)Recipient referenceReference 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'.B03, B04
!Referral Information
Claim.referral0..1Reference(ServiceRequest)Treatment ReferralA 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.B05who.cause
Claim.facility0..1Reference(Location)Servicing FacilityFacility where the services were provided.Insurance adjudication can be dependant on where services were delivered. where
Claim.careTeam0..*=CareTeamMembers of the care teamThe members of the team who provided the products and services. Common to identify the responsible and supporting practitioners40;400
Claim.careTeam.sequence1..1positiveIntOrder of care teamA 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.
Claim.careTeam.provider1..1Reference(Practitioner|PractitionerRole|Organization)Practitioner or organizationMember of the team who provided the product or service.Often a regulatory requirement to specify the responsible provider. 24.I, 24.Jwho.actor
Claim.careTeam.responsible0..1booleanIndicator of the lead practitionerThe 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.TRUE
Claim.careTeam.role0..1CodeableConceptCareTeamRoleFunction within the teamThe 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.
Claim.careTeam.qualification0..1CodeableConceptProviderQualificationPractitioner credential or specializationThe qualification of the practitioner which is applicable for this service.Need to specify which qualification a provider is delivering the product or service under.24.Inot used
Claim.information0..*=SpecialConditionExtra information to be used in performing claimsAdditional 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.Request.supportingInfo740;0Found item: change to supportingInfo to maintain consistency with Request pattern
Claim.information.sequence1..1positiveIntInformation instance identifierA number to uniquely identify supporting information entries.Necessary to maintain the order of the supporting informaton items and provide a mechanism to link to claim details.
Claim.information.category1..1CodeableConceptInformationCategoryClassification of the supplied informationThe 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 treatmentsThis may contain a category for the local bill type codes.
Claim.information.codeException Codes; Occurrence Codes; Occurrence Span Codes; Value Codes0..1CodeableConceptInformationCodeType of informationSystem 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.This may contain the local bill type codes such as the US UB-04 bill type code.10.d F23
Claim.information.timing[x]0..1date|PeriodWhen it occurredThe date when or period to which this information refers.F24
Claim.information.value[x]0..1boolean|string|Quantity|Attachment|Reference(Any)Data to be providedAdditional 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.
Claim.information.reason0..1CodeableConceptMissingReasonExplanation for the informationProvides 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.
!Diagnostic Information
Claim.diagnosis0..*=DiagnosisPertinent diagnosis informationInformation about diagnoses relevant to the claim items. Required for the adjudication by provided context for the services and product listed.Request.reasonReference0;115
Claim.diagnosis.sequence1..1positiveIntDiagnosis instance identifierA 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.
Claim.diagnosis.diagnosis[x]1..1CodeableConcept|Reference(Condition)ICD10Nature of illness or problemThe nature of illness or problem in a coded form or as a reference to an external defined ConditionProvides health context for the evaluation of the products and/or services21.A-LChange binding to ICD10-example
Claim.diagnosis.type0..*CodeableConceptDiagnosisTypeTiming or nature of the diagnosisWhen 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.
Claim.diagnosis.onAdmission0..1CodeableConceptDiagnosisOnAdmissionPresent on admissionIndication 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.
Claim.diagnosis.packageCode0..1CodeableConceptDiagnosisRelatedGroupPackage billing codeA 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 codeFor example DRG (Diagnosis Related Group) or a bundled billing code. A patient may have a diagnosis of a Myocardio-infarction and a DRG for HeartAttack would 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.
!Procedure Information
Claim.procedure0..*=ProcedureClinical procedures performedProcedures 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.0;260
Claim.procedure.sequence1..1positiveIntProcedure instance identifierA number to uniquely identify procedure entries.Necessary to provide a mechanism to link to claim details.
Claim.procedure.date0..1dateTimeWhen the procedure was performed Date and optionally time the procedure was performed.Required for auditing purposes.21.A-LMake into Datetime
Claim.procedure.procedure[x]1..1CodeableConcept|Reference(Procedure)ICD10_ProceduresSpecific clinical procedureThe code or reference to a Procedure resource which identifies the clinical intervention performed.This identifies the actual clinical procedure.21.A-L
!Insurance Information
Claim.insurance0..*=InsurancePatient insurance informationFinancial 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 'subrogation=false', should provide a reference to the ClaimResponse containing the adjudication results of the prior claim. CoverageCoverage790;260
Claim.insurance.sequence1..1positiveIntInsurance instance identifierA number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order.To maintain order of the coverages.Necessary to maintain the order of the supporting informaton items and provide a mechanism to link to claim details.
Claim.insurance.focal1..1booleanCoverage to be used for adjudicationA 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 reimburement 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 woul dbe created to request adjudication against the other listed policies.
Claim.insurance.identifier0..1IdentifierPre-assigned Claim numberThe 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 jursidictions 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'.The business identifier for the instance: invoice number, claim number, pre-determination or pre-authorization number.Request.identifierA02|G01id
Claim.insurance.coverage1..1Reference(Coverage)Insurance informationReference 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.
Claim.insurance.subrogationReimbursement to insurerWhen 'subrogation=true' this insurance instance has been included not for adjudication but to provide insurers with the details to recover costs.See definition for when to be used.Typically, automotive and worker's compensation policies would be flagged with 'subrogation=true' to enable healthcare payors to collect against accident claims.
Claim.insurance.businessArrangement0..1stringAdditional provider contract number 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.
Claim.insurance.preAuthRef0..*stringPrior authorization reference numberReference 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.23F03
Claim.insurance.claimResponse0..1Reference(ClaimResponse)Adjudication resultsThe 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.EOB
!Insurance Exception Information
Claim.accident0..1=AccidentDetails of the eventDetails of a 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. 740;410
Claim.accident.date1..1dateWhen the incident occurredDate 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 preceed the dates of the products and services but within a reasonable timeframe.F02
Claim.accident.type0..1CodeableConceptAccidentTypeThe nature of the accidentThe 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.10.a, 10.b, 10.c
Claim.accident.location[x]0..1Address|Reference(Location)Where the event occurredThe physical location of the accident event.Required for audit purposes and determination of applicable insurance liability.10.b place
!Services Provided
Claim.item0..*=ItemProduct or service providedA claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-details.The items to be processed for adjudication.360;500360;500
Claim.item.sequence1..1positiveIntItem instance identifierA 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.F07
Claim.item.careTeamSequence0..*positiveIntApplicable careTeam membersCareTeam members related to this service or product.Need to identify the individuals and their roles in the provision of the product or service.
Claim.item.diagnosisSequence0..*positiveIntApplicable diagnosesDiagnoses applicable for this service or product.Need to related the product or service to the associated diagnoses.24.E
Claim.item.procedureSequence0..*positiveIntApplicable proceduresProcedures applicable for this service or product.Need to provide any listed specific procedures to support the product or service being claimed.
Claim.item.informationSequence0..*positiveIntApplicable exception and supporting informationExceptions, 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.
Claim.item.revenue0..1CodeableConceptRevenueCenterRevenue or cost center codeThe type of revenue or cost center providing the product and/or service.Needed in the processing of institutional claims.
Claim.item.category0..1CodeableConceptBenefitCategoryBenefit classification Code 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
Claim.item.productOrServiceDrug Code; Bill Code; Service Code0..1CodeableConceptServiceProductBilling, service, product, or drug codeWhen 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'.24.DF06
Claim.item.modifier0..*CodeableConceptModifiersService/Product billing modifiersItem 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.24.C, 24.D modsF16 (required field for Oral) and F05
Claim.item.programCode0..*CodeableConceptProgramCodeProgram the product or service is provided underIdentifies 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 program24.H
Claim.item.serviced[x]0..1date|PeriodDate or dates of service or product deliveryThe 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.24.AF09when.done
Claim.item.location[x]0..1CodeableConcept|Address|Reference(Location)ServicePlacePlace of service or where product was suppliedWhere 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.24.Bwhere
Claim.item.quantity0..1SimpleQuantityCount of products or servicesThe number of repetitions of a service or product.Required when the product or service code does not convey the quantity provided.24.G
Claim.item.unitPrice0..1MoneyFee, charge or cost per itemIf 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.F12
Claim.item.factor0..1decimalPrice scaling factorA 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)F13/F14
Claim.item.net0..1MoneyTotal item costThe 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.24.FF13/F14
Claim.item.udi0..*Reference(Device)Unique device identifierUnique Device Identifiers associated with this line item.The UDI code allows the insurer to obtain device level information on the product supplied.
Claim.item.bodySite0..1CodeableConceptOralSitesAnatomical locationPhysical 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.F10
Claim.item.subSite0..*CodeableConceptSurfaceAnatomical sub-locationA region or surface of the bodySite, e.g. limb region or tooth surface(s).Allows insurer to validate specific procedures.F11
Claim.item.encounter0..*Reference(Encounter)Encounters related to this billed itemA billed item may include goods or services provided in multiple encounters.Used in some jurisdictions to link clinical events to claim items.Request.context
!Additional Charges (lab, expense, materials, components, tax)
Claim.item.detail0..*=DetailProduct or service providedA 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.740;500
Claim.item.detail.sequence1..1positiveIntItem instance identifierA 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.F07
Claim.item.detail.revenue0..1CodeableConceptRevenueCenterRevenue or cost center codeThe type of revenue or cost center providing the product and/or service.Needed in the processing of institutional claims.
Claim.item.detail.category0..1CodeableConceptBenefitCategoryBenefit classification Code 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
Claim.item.detail.productOrServiceDrug Code; Bill Code; Service Code0..1CodeableConceptServiceProductBilling, service, product, or drug codeWhen 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'.F34/F35
Claim.item.detail.modifier0..*CodeableConceptModifiersService/Product billing modifiersItem 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.24.C, 24.D modsF16 (required field for Oral) and F05
Claim.item.detail.programCode0..*CodeableConceptProgramCodeProgram the product or service is provided underIdentifies 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 program24.H
Claim.item.detail.quantity0..1SimpleQuantityCount of products or servicesThe number of repetitions of a service or product.Required when the product or service code does not convey the quantity provided.
Claim.item.detail.unitPrice0..1MoneyFee, charge or cost per itemIf 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.F13/F14
Claim.item.detail.factor0..1decimalPrice scaling factorA 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)F13/F14
Claim.item.detail.net0..1MoneyTotal item costThe 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.F13/F14
Claim.item.detail.udi0..*Reference(Device)Unique device identifierUnique Device Identifiers associated with this line item.The UDI code allows the insurer to obtain device level information on the product supplied.
!Additional Charges (lab, expense, materials, components, tax)
Claim.item.detail.subDetail0..*=SubDetailProduct or service providedA 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.740;740
Claim.item.detail.subDetail.sequence1..1positiveIntItem instance identifierA 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.F07
Claim.item.detail.subDetail.revenue0..1CodeableConceptRevenueCenterRevenue or cost center codeThe type of revenue or cost center providing the product and/or service.Needed in the processing of institutional claims.
Claim.item.detail.subDetail.category0..1CodeableConceptBenefitCategoryBenefit classification Code 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
Claim.item.detail.subDetail.productOrServiceDrug Code; Bill Code; Service Code0..1CodeableConceptServiceProductBilling, service, product, or drug codeWhen 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'.F34/F35
Claim.item.detail.subDetail.modifier0..*CodeableConceptModifiersService/Product billing modifiersItem 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.24.C, 24.D modsF16 (required field for Oral) and F05
Claim.item.detail.subDetail.programCode0..*CodeableConceptProgramCodeProgram the product or service is provided underIdentifies 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 program24.H
Claim.item.detail.subDetail.quantity0..1SimpleQuantityCount of products or servicesThe number of repetitions of a service or product.Required when the product or service code does not convey the quantity provided.
Claim.item.detail.subDetail.unitPrice0..1MoneyFee, charge or cost per itemIf 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.F13/F14
Claim.item.detail.subDetail.factor0..1decimalPrice scaling factorA 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)F13/F14
Claim.item.detail.subDetail.net0..1MoneyTotal item costThe 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.F13/F14
Claim.item.detail.subDetail.udi0..*Reference(Device)Unique device identifierUnique Device Identifiers associated with this line item.The UDI code allows the insurer to obtain device level information on the product supplied.
Claim.total0..1MoneyTotal claim costThe total value of the all the items in the claim.Used for control total purposes.28