openIMIS FHIR R4 Implementation Guide
1.0.0 - ci-build

openIMIS FHIR R4 Implementation Guide - Local Development build (v1.0.0). See the Directory of published versions

Resource Profile: openIMIS Claim

Official URL: https://openimis.github.io/openimis_fhir_r4_ig/StructureDefinition/openimis-claim Version: 1.0.0
Active as of 2022-05-31 Responsible: openIMIS Initiative Computable Name: OpenIMISClaim

Defines a Claim for openIMIS which maps to a Claim.

Usage:

  • Refer to this Resource Profile:
  • Examples for this Resource Profile: Claim/Claim001

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from Claim

Summary

Mandatory: 19 elements (3 nested mandatory elements)
Must-Support: 2 elements
Prohibited: 42 elements

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Slices

This structure defines the following Slices:

  • The element Claim.identifier is sliced based on the value of value:type.coding.code (Closed)
  • The element Claim.supportingInfo is sliced based on the value of value:category.coding.code (Closed)
  • The element Claim.diagnosis.diagnosis[x] is sliced based on the value of type:$this

This structure is derived from Claim

NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim 0..*ClaimClaim, Pre-determination or Pre-authorization
... id 0..1stringClaim UUID
... Slices for identifier S1..2IdentifierBusiness Identifier for claim
Slice: Unordered, Closed by value:type.coding.code
.... identifier:All Slices Content/Rules for all slices
..... type 1..1CodeableConceptDescription of identifier
...... coding
....... code 0..1codeSymbol in syntax defined by the system
Binding: openIMIS Identifiers Value Set (required)
..... value 1..1stringThe value that is unique
.... identifier:Code S1..1IdentifierBusiness Identifier for claim
..... type
...... coding
....... code 1..1codeClaim openIMIS Code
Required Pattern: Code
.... identifier:UUID 0..1IdentifierBusiness Identifier for claim
..... type
...... coding
....... code 1..1codeClaim openIMIS UUID
Required Pattern: UUID
... status 1..1codeFHIR Claim Status
Required Pattern: active
... type
.... coding 0..*CodingVisit type
Binding: Visit Type Codes (Claim) (required)
... subType 0..0
... use 1..1codeClaim Type
Required Pattern: claim
... patient 1..1Reference(openIMIS Patient)The recipient of the products and services
... billablePeriod 1..1PeriodRelevant time frame for the claim
.... start 1..1dateTimeStart date
.... end 0..1dateTimeEnd date
... created 1..1dateTimeClaimed date
... enterer 1..1Reference(openIMIS Claim Administrator Practitioner)Author of the claim
... insurer 0..0
... provider 1..1Reference(openIMIS Health Facility Organization)Health Facility
... priority 1..1CodeableConceptDesired processing ugency
Required Pattern: At least the following
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/processpriority
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: normal
..... display1..1stringRepresentation defined by the system
Fixed Value: Normal
... fundsReserve 0..0
... related 0..0
... prescription 0..0
... originalPrescription 0..0
... payee 0..0
... referral 0..0
... facility 0..0
... careTeam 0..0
... Slices for supportingInfo 0..*BackboneElementSupporting information
Slice: Unordered, Closed by value:category.coding.code
.... supportingInfo:All Slices Content/Rules for all slices
..... category 1..1CodeableConceptClassification of the supplied information
Binding: Category of the supporting info (Claim) (required)
..... code 0..0
..... timing[x] 0..0
..... value[x] 1..1boolean, string, Quantity, Attachment, Reference(Resource)Data to be provided
..... reason 0..0
.... supportingInfo:explanation 0..1BackboneElementExplanation
..... category 1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: https://openimis.github.io/openimis_fhir_r4_ig/CodeSystem/claim-supporting-info-category
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: explanation
..... value[x] 0..1stringData to be provided
.... supportingInfo:guarantee 0..1BackboneElementGuarantee
..... category 1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: https://openimis.github.io/openimis_fhir_r4_ig/CodeSystem/claim-supporting-info-category
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: guarantee
..... value[x] 0..1stringData to be provided
.... supportingInfo:attachment 0..*BackboneElementAttachment
..... category 1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: https://openimis.github.io/openimis_fhir_r4_ig/CodeSystem/claim-supporting-info-category
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: attachment
..... value[x] 0..1AttachmentData to be provided
... diagnosis 1..5BackboneElementDiagnosis
.... diagnosis[x] 1..1CodeableConceptNature of illness or problem
Slice: Unordered, Open by type:$this
.... diagnosisCodeableConcept 1..1CodeableConceptNature of illness or problem
Binding: ICD 10 Level 1 diagnosis (example)
.... type 0..0
.... onAdmission 0..0
.... packageCode 0..0
... procedure 0..0
... insurance 1..1BackboneElementPatient insurance information
.... focal 1..1booleanCoverage to be used for adjudication
Required Pattern: true
.... identifier 0..0
.... coverage 1..1Reference(openIMIS Coverage)Coverage
.... businessArrangement 0..0
.... preAuthRef 0..0
.... claimResponse 0..0
... accident 0..0
... item 1..*BackboneElementProduct or service provided
.... Slices for extension 1..*ExtensionExtension
Slice: Unordered, Open by value:url
.... claim-item-reference 1..1Reference(openIMIS Medication | openIMIS ActivityDefinition)Item Reference
URL: https://openimis.github.io/openimis_fhir_r4_ig/StructureDefinition/claim-item-reference
.... careTeamSequence 0..0
.... diagnosisSequence 0..0
.... procedureSequence 0..0
.... informationSequence 0..0
.... revenue 0..0
.... category 0..1CodeableConceptCategory
Binding: Category of the item (Claim) (required)
.... productOrService 1..1CodeableConceptItem Code
..... coding 0..0
..... text 1..1stringItem/Service Code
.... modifier 0..0
.... programCode 0..0
.... serviced[x] 0..0
.... location[x] 0..0
.... quantity 1..1SimpleQuantityCount of products or services
..... value 1..1decimalNumerical value (with implicit precision)
..... unit 0..0
..... system 0..0
..... code 0..0
.... unitPrice 1..1MoneyFee, charge or cost per item
..... value 1..1decimalNumerical value (with implicit precision)
.... factor 0..0
.... net 0..0
.... udi 0..0
.... bodySite 0..0
.... subSite 0..0
.... encounter 0..0
.... detail 0..0
... total 1..1MoneyTotal claim cost
.... value 1..1decimalNumerical value (with implicit precision)

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim 0..*ClaimClaim, Pre-determination or Pre-authorization
... id Σ0..1stringClaim UUID
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... Slices for identifier S1..2IdentifierBusiness Identifier for claim
Slice: Unordered, Closed by value:type.coding.code
.... identifier:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... type Σ1..1CodeableConceptDescription of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... coding Σ0..*CodingCode defined by a terminology system
....... id 0..1stringUnique id for inter-element referencing
....... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
....... system Σ0..1uriIdentity of the terminology system
....... version Σ0..1stringVersion of the system - if relevant
....... code Σ0..1codeSymbol in syntax defined by the system
Binding: openIMIS Identifiers Value Set (required)
....... display Σ0..1stringRepresentation defined by the system
....... userSelected Σ0..1booleanIf this coding was chosen directly by the user
...... text Σ0..1stringPlain text representation of the concept
..... system Σ0..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value Σ1..1stringThe value that is unique
Example General: 123456
..... period Σ0..1PeriodTime period when id is/was valid for use
..... assigner Σ0..1Reference(Organization)Organization that issued id (may be just text)
.... identifier:Code S1..1IdentifierBusiness Identifier for claim
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... type Σ0..1CodeableConceptDescription of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... coding Σ0..*CodingCode defined by a terminology system
....... id 0..1stringUnique id for inter-element referencing
....... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
....... system Σ0..1uriIdentity of the terminology system
....... version Σ0..1stringVersion of the system - if relevant
....... code Σ1..1codeClaim openIMIS Code
Required Pattern: Code
....... display Σ0..1stringRepresentation defined by the system
....... userSelected Σ0..1booleanIf this coding was chosen directly by the user
...... text Σ0..1stringPlain text representation of the concept
..... system Σ0..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value Σ0..1stringThe value that is unique
Example General: 123456
..... period Σ0..1PeriodTime period when id is/was valid for use
..... assigner Σ0..1Reference(Organization)Organization that issued id (may be just text)
.... identifier:UUID 0..1IdentifierBusiness Identifier for claim
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... type Σ0..1CodeableConceptDescription of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... coding Σ0..*CodingCode defined by a terminology system
....... id 0..1stringUnique id for inter-element referencing
....... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
....... system Σ0..1uriIdentity of the terminology system
....... version Σ0..1stringVersion of the system - if relevant
....... code Σ1..1codeClaim openIMIS UUID
Required Pattern: UUID
....... display Σ0..1stringRepresentation defined by the system
....... userSelected Σ0..1booleanIf this coding was chosen directly by the user
...... text Σ0..1stringPlain text representation of the concept
..... system Σ0..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value Σ0..1stringThe value that is unique
Example General: 123456
..... period Σ0..1PeriodTime period when id is/was valid for use
..... assigner Σ0..1Reference(Organization)Organization that issued id (may be just text)
... status ?!Σ1..1codeFHIR Claim Status
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.


Required Pattern: active
... type Σ1..1CodeableConceptCategory or discipline
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.

.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ0..*CodingVisit type
Binding: Visit Type Codes (Claim) (required)
.... text Σ0..1stringPlain text representation of the concept
... use Σ1..1codeClaim Type
Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim.


Required Pattern: claim
... patient Σ1..1Reference(openIMIS Patient)The recipient of the products and services
... billablePeriod Σ1..1PeriodRelevant time frame for the claim
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... start ΣI1..1dateTimeStart date
.... end ΣI0..1dateTimeEnd date
... created Σ1..1dateTimeClaimed date
... enterer 1..1Reference(openIMIS Claim Administrator Practitioner)Author of the claim
... provider Σ1..1Reference(openIMIS Health Facility Organization)Health Facility
... priority Σ1..1CodeableConceptDesired processing ugency
Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.


Required Pattern: At least the following
.... id0..1stringUnique id for inter-element referencing
.... extension0..*ExtensionAdditional content defined by implementations
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/processpriority
..... version0..1stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: normal
..... display1..1stringRepresentation defined by the system
Fixed Value: Normal
..... userSelected0..1booleanIf this coding was chosen directly by the user
.... text0..1stringPlain text representation of the concept
... Slices for supportingInfo 0..*BackboneElementSupporting information
Slice: Unordered, Closed by value:category.coding.code
.... supportingInfo:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category 1..1CodeableConceptClassification of the supplied information
Binding: Category of the supporting info (Claim) (required)
..... value[x] 1..1Data to be provided
...... valueBooleanboolean
...... valueStringstring
...... valueQuantityQuantity
...... valueAttachmentAttachment
...... valueReferenceReference(Resource)
.... supportingInfo:explanation 0..1BackboneElementExplanation
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category 1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: https://openimis.github.io/openimis_fhir_r4_ig/CodeSystem/claim-supporting-info-category
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: explanation
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code 0..1CodeableConceptType of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... timing[x] 0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] 0..1stringData to be provided
..... reason 0..1CodeableConceptExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:guarantee 0..1BackboneElementGuarantee
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category 1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: https://openimis.github.io/openimis_fhir_r4_ig/CodeSystem/claim-supporting-info-category
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: guarantee
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code 0..1CodeableConceptType of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... timing[x] 0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] 0..1stringData to be provided
..... reason 0..1CodeableConceptExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:attachment 0..*BackboneElementAttachment
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category 1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: https://openimis.github.io/openimis_fhir_r4_ig/CodeSystem/claim-supporting-info-category
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: attachment
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code 0..1CodeableConceptType of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... timing[x] 0..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... value[x] 0..1AttachmentData to be provided
..... reason 0..1CodeableConceptExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

... diagnosis 1..5BackboneElementDiagnosis
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntDiagnosis instance identifier
.... Slices for diagnosis[x] 1..1CodeableConceptNature of illness or problem
Slice: Unordered, Closed by type:$this
Binding: ICD-10Codes (example): Example ICD10 Diagnostic codes.

..... diagnosis[x]:diagnosisCodeableConcept 1..1CodeableConceptNature of illness or problem
Binding: ICD 10 Level 1 diagnosis (example)
... insurance Σ1..1BackboneElementPatient insurance information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence Σ1..1positiveIntInsurance instance identifier
.... focal Σ1..1booleanCoverage to be used for adjudication
Required Pattern: true
.... coverage Σ1..1Reference(openIMIS Coverage)Coverage
... item 1..*BackboneElementProduct or service provided
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 1..*ExtensionExtension
Slice: Unordered, Open by value:url
.... claim-item-reference 1..1Reference(openIMIS Medication | openIMIS ActivityDefinition)Item Reference
URL: https://openimis.github.io/openimis_fhir_r4_ig/StructureDefinition/claim-item-reference
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntItem instance identifier
.... category 0..1CodeableConceptCategory
Binding: Category of the item (Claim) (required)
.... productOrService 1..1CodeableConceptItem Code
Binding: USCLSCodes (example): Allowable service and product codes.

..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... text Σ1..1stringItem/Service Code
.... quantity 1..1SimpleQuantityCount of products or services
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... value Σ1..1decimalNumerical value (with implicit precision)
.... unitPrice 1..1MoneyFee, charge or cost per item
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... value Σ1..1decimalNumerical value (with implicit precision)
..... currency Σ0..1codeISO 4217 Currency Code
Binding: Currencies (required): A code indicating the currency, taken from ISO 4217.

... total 1..1MoneyTotal claim cost
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... value Σ1..1decimalNumerical value (with implicit precision)
.... currency Σ0..1codeISO 4217 Currency Code
Binding: Currencies (required): A code indicating the currency, taken from ISO 4217.


doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim 0..*ClaimClaim, Pre-determination or Pre-authorization
... Slices for identifier 1..2IdentifierBusiness Identifier for claim
Slice: Unordered, Closed by value:type.coding.code
.... identifier:Code 1..1IdentifierBusiness Identifier for claim

doco Documentation for this format

This structure is derived from Claim

Summary

Mandatory: 19 elements (3 nested mandatory elements)
Must-Support: 2 elements
Prohibited: 42 elements

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Slices

This structure defines the following Slices:

  • The element Claim.identifier is sliced based on the value of value:type.coding.code (Closed)
  • The element Claim.supportingInfo is sliced based on the value of value:category.coding.code (Closed)
  • The element Claim.diagnosis.diagnosis[x] is sliced based on the value of type:$this

Differential View

This structure is derived from Claim

NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim 0..*ClaimClaim, Pre-determination or Pre-authorization
... id 0..1stringClaim UUID
... Slices for identifier S1..2IdentifierBusiness Identifier for claim
Slice: Unordered, Closed by value:type.coding.code
.... identifier:All Slices Content/Rules for all slices
..... type 1..1CodeableConceptDescription of identifier
...... coding
....... code 0..1codeSymbol in syntax defined by the system
Binding: openIMIS Identifiers Value Set (required)
..... value 1..1stringThe value that is unique
.... identifier:Code S1..1IdentifierBusiness Identifier for claim
..... type
...... coding
....... code 1..1codeClaim openIMIS Code
Required Pattern: Code
.... identifier:UUID 0..1IdentifierBusiness Identifier for claim
..... type
...... coding
....... code 1..1codeClaim openIMIS UUID
Required Pattern: UUID
... status 1..1codeFHIR Claim Status
Required Pattern: active
... type
.... coding 0..*CodingVisit type
Binding: Visit Type Codes (Claim) (required)
... subType 0..0
... use 1..1codeClaim Type
Required Pattern: claim
... patient 1..1Reference(openIMIS Patient)The recipient of the products and services
... billablePeriod 1..1PeriodRelevant time frame for the claim
.... start 1..1dateTimeStart date
.... end 0..1dateTimeEnd date
... created 1..1dateTimeClaimed date
... enterer 1..1Reference(openIMIS Claim Administrator Practitioner)Author of the claim
... insurer 0..0
... provider 1..1Reference(openIMIS Health Facility Organization)Health Facility
... priority 1..1CodeableConceptDesired processing ugency
Required Pattern: At least the following
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/processpriority
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: normal
..... display1..1stringRepresentation defined by the system
Fixed Value: Normal
... fundsReserve 0..0
... related 0..0
... prescription 0..0
... originalPrescription 0..0
... payee 0..0
... referral 0..0
... facility 0..0
... careTeam 0..0
... Slices for supportingInfo 0..*BackboneElementSupporting information
Slice: Unordered, Closed by value:category.coding.code
.... supportingInfo:All Slices Content/Rules for all slices
..... category 1..1CodeableConceptClassification of the supplied information
Binding: Category of the supporting info (Claim) (required)
..... code 0..0
..... timing[x] 0..0
..... value[x] 1..1boolean, string, Quantity, Attachment, Reference(Resource)Data to be provided
..... reason 0..0
.... supportingInfo:explanation 0..1BackboneElementExplanation
..... category 1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: https://openimis.github.io/openimis_fhir_r4_ig/CodeSystem/claim-supporting-info-category
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: explanation
..... value[x] 0..1stringData to be provided
.... supportingInfo:guarantee 0..1BackboneElementGuarantee
..... category 1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: https://openimis.github.io/openimis_fhir_r4_ig/CodeSystem/claim-supporting-info-category
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: guarantee
..... value[x] 0..1stringData to be provided
.... supportingInfo:attachment 0..*BackboneElementAttachment
..... category 1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: https://openimis.github.io/openimis_fhir_r4_ig/CodeSystem/claim-supporting-info-category
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: attachment
..... value[x] 0..1AttachmentData to be provided
... diagnosis 1..5BackboneElementDiagnosis
.... diagnosis[x] 1..1CodeableConceptNature of illness or problem
Slice: Unordered, Open by type:$this
.... diagnosisCodeableConcept 1..1CodeableConceptNature of illness or problem
Binding: ICD 10 Level 1 diagnosis (example)
.... type 0..0
.... onAdmission 0..0
.... packageCode 0..0
... procedure 0..0
... insurance 1..1BackboneElementPatient insurance information
.... focal 1..1booleanCoverage to be used for adjudication
Required Pattern: true
.... identifier 0..0
.... coverage 1..1Reference(openIMIS Coverage)Coverage
.... businessArrangement 0..0
.... preAuthRef 0..0
.... claimResponse 0..0
... accident 0..0
... item 1..*BackboneElementProduct or service provided
.... Slices for extension 1..*ExtensionExtension
Slice: Unordered, Open by value:url
.... claim-item-reference 1..1Reference(openIMIS Medication | openIMIS ActivityDefinition)Item Reference
URL: https://openimis.github.io/openimis_fhir_r4_ig/StructureDefinition/claim-item-reference
.... careTeamSequence 0..0
.... diagnosisSequence 0..0
.... procedureSequence 0..0
.... informationSequence 0..0
.... revenue 0..0
.... category 0..1CodeableConceptCategory
Binding: Category of the item (Claim) (required)
.... productOrService 1..1CodeableConceptItem Code
..... coding 0..0
..... text 1..1stringItem/Service Code
.... modifier 0..0
.... programCode 0..0
.... serviced[x] 0..0
.... location[x] 0..0
.... quantity 1..1SimpleQuantityCount of products or services
..... value 1..1decimalNumerical value (with implicit precision)
..... unit 0..0
..... system 0..0
..... code 0..0
.... unitPrice 1..1MoneyFee, charge or cost per item
..... value 1..1decimalNumerical value (with implicit precision)
.... factor 0..0
.... net 0..0
.... udi 0..0
.... bodySite 0..0
.... subSite 0..0
.... encounter 0..0
.... detail 0..0
... total 1..1MoneyTotal claim cost
.... value 1..1decimalNumerical value (with implicit precision)

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim 0..*ClaimClaim, Pre-determination or Pre-authorization
... id Σ0..1stringClaim UUID
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... Slices for identifier S1..2IdentifierBusiness Identifier for claim
Slice: Unordered, Closed by value:type.coding.code
.... identifier:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... type Σ1..1CodeableConceptDescription of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... coding Σ0..*CodingCode defined by a terminology system
....... id 0..1stringUnique id for inter-element referencing
....... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
....... system Σ0..1uriIdentity of the terminology system
....... version Σ0..1stringVersion of the system - if relevant
....... code Σ0..1codeSymbol in syntax defined by the system
Binding: openIMIS Identifiers Value Set (required)
....... display Σ0..1stringRepresentation defined by the system
....... userSelected Σ0..1booleanIf this coding was chosen directly by the user
...... text Σ0..1stringPlain text representation of the concept
..... system Σ0..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value Σ1..1stringThe value that is unique
Example General: 123456
..... period Σ0..1PeriodTime period when id is/was valid for use
..... assigner Σ0..1Reference(Organization)Organization that issued id (may be just text)
.... identifier:Code S1..1IdentifierBusiness Identifier for claim
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... type Σ0..1CodeableConceptDescription of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... coding Σ0..*CodingCode defined by a terminology system
....... id 0..1stringUnique id for inter-element referencing
....... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
....... system Σ0..1uriIdentity of the terminology system
....... version Σ0..1stringVersion of the system - if relevant
....... code Σ1..1codeClaim openIMIS Code
Required Pattern: Code
....... display Σ0..1stringRepresentation defined by the system
....... userSelected Σ0..1booleanIf this coding was chosen directly by the user
...... text Σ0..1stringPlain text representation of the concept
..... system Σ0..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value Σ0..1stringThe value that is unique
Example General: 123456
..... period Σ0..1PeriodTime period when id is/was valid for use
..... assigner Σ0..1Reference(Organization)Organization that issued id (may be just text)
.... identifier:UUID 0..1IdentifierBusiness Identifier for claim
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... type Σ0..1CodeableConceptDescription of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... coding Σ0..*CodingCode defined by a terminology system
....... id 0..1stringUnique id for inter-element referencing
....... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
....... system