This profile sets minimum expectations for the Claim resource which is used by providers and payors, insurers, to exchange the financial information, and supporting clinical information, regarding the provision of health care services with payors and for reporting to regulatory bodies and firms which provide data analytics. The primary uses of this profile is to support eClaims, the exchange of information relating to the proposed or actual provision of healthcare-related goods and services for patients to their benefit payors, insurers and national health programs, for treatment payment planning and reimbursement.

Examples

• Claim-enhancement-example-01
• Claim-preauthorization-example-01
• Claim-predetermination-example-01
• Claim-settlement-example-01

• Differential Table
• Key Elements Table
• Snapshot Table
• Statistics/References
• All

This structure is derived from Claim

Name	Flags	Card.	Type	Description & Constraints
Claim			Claim
identifier	S	1..1	Identifier	Business Identifier for claim
type		1..1	CodeableConcept	Category or discipline Binding: Claim Type (extensible)
patient		1..1	Reference(Patient)	The recipient of the products and services
enterer		0..1	Reference(Practitioner | PractitionerRole)	Author of the claim
insurer		1..1	Reference(Organization)	Target
provider		1..1	Reference(Practitioner | PractitionerRole | Organization)	Party responsible for the claim
related
claim		0..1	Reference(Claim)	Reference to the related claim
relationship		0..1	CodeableConcept	How the reference claim is related Binding: Related Claim Relationship Code (example)
coding		0..1	Coding	Code defined by a terminology system
system		1..1	uri	Identity of the terminology system
code		1..1	code	Symbol in syntax defined by the system
display		1..1	string	Representation defined by the system
prescription		0..1	Reference(DeviceRequest | VisionPrescription | MedicationRequest)	Prescription authorizing services and products
originalPrescription		0..1	Reference(DeviceRequest | VisionPrescription | MedicationRequest)	Original prescription if superseded by fulfiller
payee
party		0..1	Reference(RelatedPerson | Practitioner | PractitionerRole | Organization | Patient)	Recipient reference
referral		0..1	Reference(ServiceRequest)	Treatment referral
careTeam
provider		1..1	Reference(Practitioner | PractitionerRole | Organization)	Practitioner or organization
role		0..1	CodeableConcept	Function within the team Binding: Care Team Role (example)
coding
system		1..1	uri	Identity of the terminology system
code		1..1	code	Symbol in syntax defined by the system
display		1..1	string	Representation defined by the system
qualification		0..1	CodeableConcept	Practitioner credential or specialization Binding: Care Team Qualification (example)
coding
system		1..1	uri	Identity of the terminology system
code		1..1	code	Symbol in syntax defined by the system
display		1..1	string	Representation defined by the system
supportingInfo	S	0..*	BackboneElement	Supporting information
category		1..1	CodeableConcept	Classification of the supplied information Binding: SupportingInfo Category (preferred): The valueset used for additional information category codes.
coding
system		1..1	uri	Identity of the terminology system
code		1..1	code	Symbol in syntax defined by the system
display		1..1	string	Representation defined by the system
code		1..1	CodeableConcept	Type of information Binding: SupportingInfo Code (preferred): The valueset used for additional information codes.
coding
system		1..1	uri	Identity of the terminology system
code		1..1	code	Symbol in syntax defined by the system
display		1..1	string	Representation defined by the system
diagnosis		1..*	BackboneElement	Pertinent diagnosis information
diagnosis[x]		1..1		Nature of illness or problem Binding: ICD10 Diagnostic codes (example)
diagnosisCodeableConcept			CodeableConcept
diagnosisReference			Reference(Condition)
type		1..*	CodeableConcept	Timing or nature of the diagnosis Binding: Diagnostic Type (example)
coding
system		1..1	uri	Identity of the terminology system
code		1..1	code	Symbol in syntax defined by the system
display		1..1	string	Representation defined by the system
procedure
procedure[x]		1..1		Specific clinical procedure Binding: ProcedureCodes(SNOMEDCT) (example): A code to identify a specific procedure .
procedureCodeableConcept			CodeableConcept
procedureReference			Reference(Procedure)
insurance	S	1..*	BackboneElement	Patient insurance information
coverage		1..1	Reference(Coverage)	Insurance information
claimResponse		0..1	Reference(ClaimResponse)	Adjudication results
item	S	1..*	BackboneElement	Product or service provided
category		0..1	CodeableConcept	Benefit classification Binding: Benefit Category (example)
coding
system		1..1	uri	Identity of the terminology system
code		1..1	code	Symbol in syntax defined by the system
display		1..1	string	Representation defined by the system
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: ProductorService (example): Allowable service and product codes
coding
system		1..1	uri	Identity of the terminology system
code		1..1	code	Symbol in syntax defined by the system
display		1..1	string	Representation defined by the system
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: Program Code (example)
coding
system		1..1	uri	Identity of the terminology system
code		1..1	code	Symbol in syntax defined by the system
display		1..1	string	Representation defined by the system
encounter		0..*	Reference(Encounter)	Encounters related to this billed item
detail
category		0..1	CodeableConcept	Benefit classification Binding: Benefit Category (example): Benefit categories such as: oral-basic, major, glasses
coding
system		1..1	uri	Identity of the terminology system
code		1..1	code	Symbol in syntax defined by the system
display		1..1	string	Representation defined by the system
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: ProductorService (example)
coding
system		1..1	uri	Identity of the terminology system
code		1..1	code	Symbol in syntax defined by the system
display		1..1	string	Representation defined by the system
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: Program Code (example)
coding
system		1..1	uri	Identity of the terminology system
code		1..1	code	Symbol in syntax defined by the system
display		1..1	string	Representation defined by the system
subDetail
category		0..1	CodeableConcept	Benefit classification Binding: Benefit Category (example)
coding
system		1..1	uri	Identity of the terminology system
code		1..1	code	Symbol in syntax defined by the system
display		1..1	string	Representation defined by the system
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: ProductorService (example)
coding
system		1..1	uri	Identity of the terminology system
code		1..1	code	Symbol in syntax defined by the system
display		1..1	string	Representation defined by the system
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: Program Code (example)
coding
system		1..1	uri	Identity of the terminology system
code		1..1	code	Symbol in syntax defined by the system
display		1..1	string	Representation defined by the system
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Claim.type	extensible	ClaimType https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-claim-type from this IG
Claim.related.relationship	example	RelatedClaimRelationshipCode https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-related-claim-relationship-code from this IG
Claim.careTeam.role	example	CareTeamRole https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-care-team-role from this IG
Claim.careTeam.qualification	example	CareTeamQualification https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-care-team-qualification from this IG
Claim.supportingInfo.category	preferred	SupportingInfoCategory (a valid code from SupportingInfo Category) https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-supportinginfo-category from this IG
Claim.supportingInfo.code	preferred	SupportingInfoCode https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-supportinginfo-code from this IG
Claim.diagnosis.diagnosis[x]	example	ICD10Diagnosticcodes https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-diagnostic-code from this IG
Claim.diagnosis.type	example	DiagnosticType https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-diagnostic-type from this IG
Claim.procedure.procedure[x]	example	ProcedureCodes(SNOMEDCT) http://hl7.org/fhir/ValueSet/procedure-code from the FHIR Standard
Claim.item.category	example	BenefitCategory https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-benefitcategory from this IG
Claim.item.productOrService	example	ProductorService https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-productorservice from this IG
Claim.item.programCode	example	ProgramCode (a valid code from Program Code) https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-program-code from this IG
Claim.item.detail.category	example	BenefitCategory https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-benefitcategory from this IG
Claim.item.detail.productOrService	example	ProductorService https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-productorservice from this IG
Claim.item.detail.programCode	example	ProgramCode (a valid code from Program Code) https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-program-code from this IG
Claim.item.detail.subDetail.category	example	BenefitCategory https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-benefitcategory from this IG
Claim.item.detail.subDetail.productOrService	example	ProductorService https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-productorservice from this IG
Claim.item.detail.subDetail.programCode	example	ProgramCode (a valid code from Program Code) https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-program-code from this IG

Name	Flags	Card.	Type	Description & Constraints
Claim		0..*	Claim	Claim, Pre-determination or Pre-authorization
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	S	1..1	Identifier	Business Identifier for claim
status	?!Σ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
type	Σ	1..1	CodeableConcept	Category or discipline Binding: Claim Type (extensible)
use	Σ	1..1	code	claim | preauthorization | predetermination Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim.
patient	Σ	1..1	Reference(Patient)	The recipient of the products and services
created	Σ	1..1	dateTime	Resource creation date
enterer		0..1	Reference(Practitioner | PractitionerRole)	Author of the claim
insurer	Σ	1..1	Reference(Organization)	Target
provider	Σ	1..1	Reference(Practitioner | PractitionerRole | Organization)	Party responsible for the claim
priority	Σ	1..1	CodeableConcept	Desired processing ugency Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.
prescription		0..1	Reference(DeviceRequest | VisionPrescription | MedicationRequest)	Prescription authorizing services and products
originalPrescription		0..1	Reference(DeviceRequest | VisionPrescription | MedicationRequest)	Original prescription if superseded by fulfiller
referral		0..1	Reference(ServiceRequest)	Treatment referral
supportingInfo	S	0..*	BackboneElement	Supporting information
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category		1..1	CodeableConcept	Classification of the supplied information Binding: SupportingInfo Category (preferred): The valueset used for additional information category codes.
code		1..1	CodeableConcept	Type of information Binding: SupportingInfo Code (preferred): The valueset used for additional information codes.
diagnosis		1..*	BackboneElement	Pertinent diagnosis information
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Diagnosis instance identifier
diagnosis[x]		1..1		Nature of illness or problem Binding: ICD10 Diagnostic codes (example)
diagnosisCodeableConcept			CodeableConcept
diagnosisReference			Reference(Condition)
type		1..*	CodeableConcept	Timing or nature of the diagnosis Binding: Diagnostic Type (example)
insurance	SΣ	1..*	BackboneElement	Patient insurance information
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	Σ	1..1	positiveInt	Insurance instance identifier
focal	Σ	1..1	boolean	Coverage to be used for adjudication
coverage	Σ	1..1	Reference(Coverage)	Insurance information
claimResponse		0..1	Reference(ClaimResponse)	Adjudication results
item	S	1..*	BackboneElement	Product or service provided
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Item instance identifier
category		0..1	CodeableConcept	Benefit classification Binding: Benefit Category (example)
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: ProductorService (example): Allowable service and product codes
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: Program Code (example)
encounter		0..*	Reference(Encounter)	Encounters related to this billed item
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Claim.status	required	FinancialResourceStatusCodes http://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard
Claim.type	extensible	ClaimType https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-claim-type from this IG
Claim.use	required	Use http://hl7.org/fhir/ValueSet/claim-use|4.0.1 from the FHIR Standard
Claim.priority	example	ProcessPriorityCodes http://hl7.org/fhir/ValueSet/process-priority from the FHIR Standard
Claim.supportingInfo.category	preferred	SupportingInfoCategory (a valid code from SupportingInfo Category) https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-supportinginfo-category from this IG
Claim.supportingInfo.code	preferred	SupportingInfoCode https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-supportinginfo-code from this IG
Claim.diagnosis.diagnosis[x]	example	ICD10Diagnosticcodes https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-diagnostic-code from this IG
Claim.diagnosis.type	example	DiagnosticType https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-diagnostic-type from this IG
Claim.item.category	example	BenefitCategory https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-benefitcategory from this IG
Claim.item.productOrService	example	ProductorService https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-productorservice from this IG
Claim.item.programCode	example	ProgramCode (a valid code from Program Code) https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-program-code from this IG

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	Claim	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Claim	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	Claim	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	Claim	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Claim	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

Name	Flags	Card.	Type	Description & Constraints
Claim		0..*	Claim	Claim, Pre-determination or Pre-authorization
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	S	1..1	Identifier	Business Identifier for claim
status	?!Σ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
type	Σ	1..1	CodeableConcept	Category or discipline Binding: Claim Type (extensible)
subType		0..1	CodeableConcept	More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
use	Σ	1..1	code	claim | preauthorization | predetermination Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim.
patient	Σ	1..1	Reference(Patient)	The recipient of the products and services
billablePeriod	Σ	0..1	Period	Relevant time frame for the claim
created	Σ	1..1	dateTime	Resource creation date
enterer		0..1	Reference(Practitioner | PractitionerRole)	Author of the claim
insurer	Σ	1..1	Reference(Organization)	Target
provider	Σ	1..1	Reference(Practitioner | PractitionerRole | Organization)	Party responsible for the claim
priority	Σ	1..1	CodeableConcept	Desired processing ugency Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.
fundsReserve		0..1	CodeableConcept	For whom to reserve funds Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
related		0..*	BackboneElement	Prior or corollary claims
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
claim		0..1	Reference(Claim)	Reference to the related claim
relationship		0..1	CodeableConcept	How the reference claim is related Binding: Related Claim Relationship Code (example)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..1	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	1..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
reference		0..1	Identifier	File or case reference
prescription		0..1	Reference(DeviceRequest | VisionPrescription | MedicationRequest)	Prescription authorizing services and products
originalPrescription		0..1	Reference(DeviceRequest | VisionPrescription | MedicationRequest)	Original prescription if superseded by fulfiller
payee		0..1	BackboneElement	Recipient of benefits payable
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Category of recipient Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
party		0..1	Reference(RelatedPerson | Practitioner | PractitionerRole | Organization | Patient)	Recipient reference
referral		0..1	Reference(ServiceRequest)	Treatment referral
facility		0..1	Reference(Location)	Servicing facility
careTeam		0..*	BackboneElement	Members of the care team
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Order of care team
provider		1..1	Reference(Practitioner | PractitionerRole | Organization)	Practitioner or organization
responsible		0..1	boolean	Indicator of the lead practitioner
role		0..1	CodeableConcept	Function within the team Binding: Care Team Role (example)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	1..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
qualification		0..1	CodeableConcept	Practitioner credential or specialization Binding: Care Team Qualification (example)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	1..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
supportingInfo	S	0..*	BackboneElement	Supporting information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category		1..1	CodeableConcept	Classification of the supplied information Binding: SupportingInfo Category (preferred): The valueset used for additional information category codes.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	1..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
code		1..1	CodeableConcept	Type of information Binding: SupportingInfo Code (preferred): The valueset used for additional information codes.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	1..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
timing[x]		0..1		When it occurred
timingDate			date
timingPeriod			Period
value[x]		0..1		Data to be provided
valueBoolean			boolean
valueString			string
valueQuantity			Quantity
valueAttachment			Attachment
valueReference			Reference(Resource)
reason		0..1	CodeableConcept	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
diagnosis		1..*	BackboneElement	Pertinent diagnosis information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Diagnosis instance identifier
diagnosis[x]		1..1		Nature of illness or problem Binding: ICD10 Diagnostic codes (example)
diagnosisCodeableConcept			CodeableConcept
diagnosisReference			Reference(Condition)
type		1..*	CodeableConcept	Timing or nature of the diagnosis Binding: Diagnostic Type (example)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	1..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
onAdmission		0..1	CodeableConcept	Present on admission Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.
packageCode		0..1	CodeableConcept	Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.
procedure		0..*	BackboneElement	Clinical procedures performed
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Procedure instance identifier
type		0..*	CodeableConcept	Category of Procedure Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.
date		0..1	dateTime	When the procedure was performed
procedure[x]		1..1		Specific clinical procedure Binding: ProcedureCodes(SNOMEDCT) (example): A code to identify a specific procedure .
procedureCodeableConcept			CodeableConcept
procedureReference			Reference(Procedure)
udi		0..*	Reference(Device)	Unique device identifier
insurance	SΣ	1..*	BackboneElement	Patient insurance information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	Σ	1..1	positiveInt	Insurance instance identifier
focal	Σ	1..1	boolean	Coverage to be used for adjudication
identifier		0..1	Identifier	Pre-assigned Claim number
coverage	Σ	1..1	Reference(Coverage)	Insurance information
businessArrangement		0..1	string	Additional provider contract number
preAuthRef		0..*	string	Prior authorization reference number
claimResponse		0..1	Reference(ClaimResponse)	Adjudication results
accident		0..1	BackboneElement	Details of the event
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
date		1..1	date	When the incident occurred
type		0..1	CodeableConcept	The nature of the accident Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc.
location[x]		0..1		Where the event occurred
locationAddress			Address
locationReference			Reference(Location)
item	S	1..*	BackboneElement	Product or service provided
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Item instance identifier
careTeamSequence		0..*	positiveInt	Applicable careTeam members
diagnosisSequence		0..*	positiveInt	Applicable diagnoses
procedureSequence		0..*	positiveInt	Applicable procedures
informationSequence		0..*	positiveInt	Applicable exception and supporting information
revenue		0..1	CodeableConcept	Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
category		0..1	CodeableConcept	Benefit classification Binding: Benefit Category (example)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	1..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: ProductorService (example): Allowable service and product codes
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	1..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
modifier		0..*	CodeableConcept	Product or service billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: Program Code (example)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	1..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
serviced[x]		0..1		Date or dates of service or product delivery
servicedDate			date
servicedPeriod			Period
location[x]		0..1		Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.
locationCodeableConcept			CodeableConcept
locationAddress			Address
locationReference			Reference(Location)
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
udi		0..*	Reference(Device)	Unique device identifier
bodySite		0..1	CodeableConcept	Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
subSite		0..*	CodeableConcept	Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
encounter		0..*	Reference(Encounter)	Encounters related to this billed item
detail		0..*	BackboneElement	Product or service provided
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Item instance identifier
revenue		0..1	CodeableConcept	Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
category		0..1	CodeableConcept	Benefit classification Binding: Benefit Category (example): Benefit categories such as: oral-basic, major, glasses
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	1..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: ProductorService (example)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	1..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: Program Code (example)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	1..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
udi		0..*	Reference(Device)	Unique device identifier
subDetail		0..*	BackboneElement	Product or service provided
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Item instance identifier
revenue		0..1	CodeableConcept	Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
category		0..1	CodeableConcept	Benefit classification Binding: Benefit Category (example)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	1..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: ProductorService (example)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	1..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: Program Code (example)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	1..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
udi		0..*	Reference(Device)	Unique device identifier
total		0..1	Money	Total claim cost
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Claim.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
Claim.status	required	FinancialResourceStatusCodes http://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard
Claim.type	extensible	ClaimType https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-claim-type from this IG
Claim.subType	example	ExampleClaimSubTypeCodes http://hl7.org/fhir/ValueSet/claim-subtype from the FHIR Standard
Claim.use	required	Use http://hl7.org/fhir/ValueSet/claim-use|4.0.1 from the FHIR Standard
Claim.priority	example	ProcessPriorityCodes http://hl7.org/fhir/ValueSet/process-priority from the FHIR Standard
Claim.fundsReserve	example	Funds Reservation Codes http://hl7.org/fhir/ValueSet/fundsreserve from the FHIR Standard
Claim.related.relationship	example	RelatedClaimRelationshipCode https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-related-claim-relationship-code from this IG
Claim.payee.type	example	Claim Payee Type Codes http://hl7.org/fhir/ValueSet/payeetype from the FHIR Standard
Claim.careTeam.role	example	CareTeamRole https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-care-team-role from this IG
Claim.careTeam.qualification	example	CareTeamQualification https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-care-team-qualification from this IG
Claim.supportingInfo.category	preferred	SupportingInfoCategory (a valid code from SupportingInfo Category) https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-supportinginfo-category from this IG
Claim.supportingInfo.code	preferred	SupportingInfoCode https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-supportinginfo-code from this IG
Claim.supportingInfo.reason	example	MissingToothReasonCodes http://hl7.org/fhir/ValueSet/missing-tooth-reason from the FHIR Standard
Claim.diagnosis.diagnosis[x]	example	ICD10Diagnosticcodes https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-diagnostic-code from this IG
Claim.diagnosis.type	example	DiagnosticType https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-diagnostic-type from this IG
Claim.diagnosis.onAdmission	example	ExampleDiagnosisOnAdmissionCodes http://hl7.org/fhir/ValueSet/ex-diagnosis-on-admission from the FHIR Standard
Claim.diagnosis.packageCode	example	ExampleDiagnosisRelatedGroupCodes http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup from the FHIR Standard
Claim.procedure.type	example	ExampleProcedureTypeCodes http://hl7.org/fhir/ValueSet/ex-procedure-type from the FHIR Standard
Claim.procedure.procedure[x]	example	ProcedureCodes(SNOMEDCT) http://hl7.org/fhir/ValueSet/procedure-code from the FHIR Standard
Claim.accident.type	extensible	ActIncidentCode http://terminology.hl7.org/ValueSet/v3-ActIncidentCode
Claim.item.revenue	example	ExampleRevenueCenterCodes http://hl7.org/fhir/ValueSet/ex-revenue-center from the FHIR Standard
Claim.item.category	example	BenefitCategory https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-benefitcategory from this IG
Claim.item.productOrService	example	ProductorService https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-productorservice from this IG
Claim.item.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard
Claim.item.programCode	example	ProgramCode (a valid code from Program Code) https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-program-code from this IG
Claim.item.location[x]	example	ExampleServicePlaceCodes http://hl7.org/fhir/ValueSet/service-place from the FHIR Standard
Claim.item.bodySite	example	OralSiteCodes http://hl7.org/fhir/ValueSet/tooth from the FHIR Standard
Claim.item.subSite	example	SurfaceCodes http://hl7.org/fhir/ValueSet/surface from the FHIR Standard
Claim.item.detail.revenue	example	ExampleRevenueCenterCodes http://hl7.org/fhir/ValueSet/ex-revenue-center from the FHIR Standard
Claim.item.detail.category	example	BenefitCategory https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-benefitcategory from this IG
Claim.item.detail.productOrService	example	ProductorService https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-productorservice from this IG
Claim.item.detail.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard
Claim.item.detail.programCode	example	ProgramCode (a valid code from Program Code) https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-program-code from this IG
Claim.item.detail.subDetail.revenue	example	ExampleRevenueCenterCodes http://hl7.org/fhir/ValueSet/ex-revenue-center from the FHIR Standard
Claim.item.detail.subDetail.category	example	BenefitCategory https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-benefitcategory from this IG
Claim.item.detail.subDetail.productOrService	example	ProductorService https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-productorservice from this IG
Claim.item.detail.subDetail.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard
Claim.item.detail.subDetail.programCode	example	ProgramCode (a valid code from Program Code) https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-program-code from this IG

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	Claim	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Claim	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	Claim	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	Claim	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Claim	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()