Health New Zealand Te Whatu Ora Shared Care FHIR API - Local Development build (v0.4.1) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

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Resource Profile: NZ Telehealth Claim

A FHIR resource profile for NZ Telehealth Claims for 24/7 telehealth services.

Note: In 4B insurance, priority and item.productOrService are compulsory fields.

This profile is used to represent telehealth claims in New Zealand for 24/7 telehealth services.

Usages:

• Refer to this Profile: NZ Telehealth Claim Response
• Examples for this Profile: Claim/NzTelehealthClaimExample

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

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

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

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Claim		0..*	Claim	Claim, Pre-determination or Pre-authorization
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:traceNumber		0..*	Identifier	Trace Number URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/trace-number
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier		0..*	Identifier	Business identifier(s) for the 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	Claim type Binding: NZ Claim Types (extensible)
subType		0..1	CodeableConcept	Claim subtype Binding: NZ Claim Subtypes (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)	Patient with NHI
billablePeriod	Σ	0..1	Period	Claim period or billing period
created	Σ	1..1	dateTime	When the claim was created (by the provider)
insurer	Σ	0..1	Reference(Organization)	Payer (i.e. Health NZ)
provider	Σ	1..1	Reference(Organization)	Legal entity who submitted the claim
priority	Σ	1..1	CodeableConcept	Desired processing ugency Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.
payee		0..1	BackboneElement	Who's getting paid - Provider Site in HSAAP
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.
careTeam		0..*	BackboneElement	Practitioner(s) who provided the claimed service(s)
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)	Practitioner or organization
role		0..1	CodeableConcept	Function within the team Binding: Claim Care Team Role Codes (extensible)
qualification		0..1	CodeableConcept	Practitioner credential or specialization Binding: Provider Qualification Codes (extensible)
supportingInfo		0..*	BackboneElement	Additional attributes that may accompany a Claim
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: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes.
insurance	Σ	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
item		0..*	BackboneElement	Each individual product or service being claimed for as part of this claim
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:patientPaid		0..1	Money	Patient Paid Amount URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/patient-paid
extension:itemTax		0..1	Money	Item Tax URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/item-tax
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Referred to by the ClaimResponse.item.itemSequence
productOrService		1..1	CodeableConcept	Purchase unit code for the transaction Binding: USCLSCodes (example): Allowable service and product codes.
Slices for serviced[x]		1..1	Period	Date or dates of service or product delivery Slice: Unordered, Closed by type:$this
serviced[x]:servicedPeriod		1..1	Period	Date or dates of service or product delivery
start	ΣC	1..1	dateTime	When the claimed service started
end	ΣC	1..1	dateTime	When the claimed service ended
Slices for location[x]		0..1		Place of service or where product was supplied Slice: Unordered, Open by type:$this Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.
locationCodeableConcept			CodeableConcept
locationAddress			Address
locationReference			Reference(Location)
location[x]:locationReference		0..1	Reference(Location)	HPI Facility
quantity		0..1	SimpleQuantity	Number of units claimed for product or service
unitPrice		0..1	Money	Claimed unit price of the service
net		0..1	Money	Claimed pre-tax amount
encounter		0..*	Reference(Encounter)	The (e.g. Telehealth) encounter for which this claim is made
detail		0..*	BackboneElement	Additional detail for the claim item
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Item instance identifier
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
total		1..1	Money	Total value of all of the claim items
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	NzClaimTypes(a valid code from https://standards.digital.health.nz/ns/nz-claim-type) https://fhir-ig.digital.health.nz/shared-care/ValueSet/nz-claim-types From this IG
Claim.subType	extensible	NzClaimSubtypes(a valid code from https://standards.digital.health.nz/ns/nz-claim-subtype) https://fhir-ig.digital.health.nz/shared-care/ValueSet/nz-claim-subtypes 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.payee.type	example	Claim Payee Type Codes http://hl7.org/fhir/ValueSet/payeetype From the FHIR Standard
Claim.careTeam.role	extensible	ClaimCareTeamRoleCodes(a valid code from https://standards.digital.health.nz/ns/claim-careteam-role-code) https://fhir-ig.digital.health.nz/shared-care/ValueSet/claim-careteam-role-codes From this IG
Claim.careTeam.qualification	extensible	ProviderQualificationCodes(a valid code from https://standards.digital.health.nz/ns/provider-qualification-codes) https://fhir-ig.digital.health.nz/shared-care/ValueSet/provider-qualification-codes From this IG
Claim.supportingInfo.category	example	ClaimInformationCategoryCodes http://hl7.org/fhir/ValueSet/claim-informationcategory From the FHIR Standard
Claim.item.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls From the FHIR Standard
Claim.item.location[x]	example	ExampleServicePlaceCodes http://hl7.org/fhir/ValueSet/service-place From the FHIR Standard
Claim.item.detail.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls From the FHIR Standard

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()

This structure is derived from Claim

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Claim		0..*	Claim	Claim, Pre-determination or Pre-authorization
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:traceNumber		0..*	Identifier	Trace Number URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/trace-number
identifier		0..*	Identifier	Business identifier(s) for the claim
type		1..1	CodeableConcept	Claim type Binding: NZ Claim Types (extensible)
subType		0..1	CodeableConcept	Claim subtype Binding: NZ Claim Subtypes (extensible)
patient		1..1	Reference(Patient)	Patient with NHI
billablePeriod		0..1	Period	Claim period or billing period
created		1..1	dateTime	When the claim was created (by the provider)
insurer		0..1	Reference(Organization)	Payer (i.e. Health NZ)
provider		1..1	Reference(Organization)	Legal entity who submitted the claim
payee		0..1	BackboneElement	Who's getting paid - Provider Site in HSAAP
careTeam		0..*	BackboneElement	Practitioner(s) who provided the claimed service(s)
provider		1..1	Reference(Practitioner)	Practitioner or organization
role		0..1	CodeableConcept	Function within the team Binding: Claim Care Team Role Codes (extensible)
qualification		0..1	CodeableConcept	Practitioner credential or specialization Binding: Provider Qualification Codes (extensible)
supportingInfo		0..*	BackboneElement	Additional attributes that may accompany a Claim
item		0..*	BackboneElement	Each individual product or service being claimed for as part of this claim
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:patientPaid		0..1	Money	Patient Paid Amount URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/patient-paid
extension:itemTax		0..1	Money	Item Tax URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/item-tax
sequence		1..1	positiveInt	Referred to by the ClaimResponse.item.itemSequence
productOrService		1..1	CodeableConcept	Purchase unit code for the transaction
Slices for serviced[x]		1..1	Period	Date or dates of service or product delivery Slice: Unordered, Open by type:$this
serviced[x]:servicedPeriod		1..1	Period	Date or dates of service or product delivery
start		1..1	dateTime	When the claimed service started
end		1..1	dateTime	When the claimed service ended
Slices for location[x]		0..1	CodeableConcept, Address, Reference(Location)	Place of service or where product was supplied Slice: Unordered, Open by type:$this
location[x]:locationReference		0..1	Reference(Location)	HPI Facility
quantity		0..1	SimpleQuantity	Number of units claimed for product or service
unitPrice		0..1	Money	Claimed unit price of the service
net		0..1	Money	Claimed pre-tax amount
encounter		0..*	Reference(Encounter)	The (e.g. Telehealth) encounter for which this claim is made
detail		0..*	BackboneElement	Additional detail for the claim item
total		1..1	Money	Total value of all of the claim items
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Claim.type	extensible	NzClaimTypes(a valid code from https://standards.digital.health.nz/ns/nz-claim-type) https://fhir-ig.digital.health.nz/shared-care/ValueSet/nz-claim-types From this IG
Claim.subType	extensible	NzClaimSubtypes(a valid code from https://standards.digital.health.nz/ns/nz-claim-subtype) https://fhir-ig.digital.health.nz/shared-care/ValueSet/nz-claim-subtypes From this IG
Claim.careTeam.role	extensible	ClaimCareTeamRoleCodes(a valid code from https://standards.digital.health.nz/ns/claim-careteam-role-code) https://fhir-ig.digital.health.nz/shared-care/ValueSet/claim-careteam-role-codes From this IG
Claim.careTeam.qualification	extensible	ProviderQualificationCodes(a valid code from https://standards.digital.health.nz/ns/provider-qualification-codes) https://fhir-ig.digital.health.nz/shared-care/ValueSet/provider-qualification-codes From this IG

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
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 This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained		0..*	Resource	Contained, inline Resources
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:traceNumber		0..*	Identifier	Trace Number URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/trace-number
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier		0..*	Identifier	Business identifier(s) for the 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	Claim type Binding: NZ Claim Types (extensible)
subType		0..1	CodeableConcept	Claim subtype Binding: NZ Claim Subtypes (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)	Patient with NHI
billablePeriod	Σ	0..1	Period	Claim period or billing period
created	Σ	1..1	dateTime	When the claim was created (by the provider)
enterer		0..1	Reference(Practitioner | PractitionerRole)	Author of the claim
insurer	Σ	0..1	Reference(Organization)	Payer (i.e. Health NZ)
provider	Σ	1..1	Reference(Organization)	Legal entity who submitted 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: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim.
reference		0..1	Identifier	File or case reference
prescription		0..1	Reference(DeviceRequest | MedicationRequest | VisionPrescription)	Prescription authorizing services and products
originalPrescription		0..1	Reference(DeviceRequest | MedicationRequest | VisionPrescription)	Original prescription if superseded by fulfiller
payee		0..1	BackboneElement	Who's getting paid - Provider Site in HSAAP
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(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson)	Recipient reference
referral		0..1	Reference(ServiceRequest)	Treatment referral
facility		0..1	Reference(Location)	Servicing facility
careTeam		0..*	BackboneElement	Practitioner(s) who provided the claimed service(s)
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)	Practitioner or organization
responsible		0..1	boolean	Indicator of the lead practitioner
role		0..1	CodeableConcept	Function within the team Binding: Claim Care Team Role Codes (extensible)
qualification		0..1	CodeableConcept	Practitioner credential or specialization Binding: Provider Qualification Codes (extensible)
supportingInfo		0..*	BackboneElement	Additional attributes that may accompany a Claim
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: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes.
code		0..1	CodeableConcept	Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
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		0..*	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: ICD-10Codes (example): Example ICD10 Diagnostic codes.
diagnosisCodeableConcept			CodeableConcept
diagnosisReference			Reference(Condition)
type		0..*	CodeableConcept	Timing or nature of the diagnosis Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge.
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: ICD-10ProcedureCodes (example): Example ICD10 Procedure codes.
procedureCodeableConcept			CodeableConcept
procedureReference			Reference(Procedure)
udi		0..*	Reference(Device)	Unique device identifier
insurance	Σ	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		0..*	BackboneElement	Each individual product or service being claimed for as part of this claim
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:patientPaid		0..1	Money	Patient Paid Amount URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/patient-paid
extension:itemTax		0..1	Money	Item Tax URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/item-tax
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Referred to by the ClaimResponse.item.itemSequence
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: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.
productOrService		1..1	CodeableConcept	Purchase unit code for the transaction Binding: USCLSCodes (example): Allowable service and product codes.
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: ExampleProgramReasonCodes (example): Program specific reason codes.
Slices for serviced[x]		1..1	Period	Date or dates of service or product delivery Slice: Unordered, Closed by type:$this
serviced[x]:servicedPeriod		1..1	Period	Date or dates of service or product delivery
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
start	ΣC	1..1	dateTime	When the claimed service started
end	ΣC	1..1	dateTime	When the claimed service ended
Slices for location[x]		0..1		Place of service or where product was supplied Slice: Unordered, Open by type:$this Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.
locationCodeableConcept			CodeableConcept
locationAddress			Address
locationReference			Reference(Location)
location[x]:locationReference		0..1	Reference(Location)	HPI Facility
quantity		0..1	SimpleQuantity	Number of units claimed for product or service
unitPrice		0..1	Money	Claimed unit price of the service
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Claimed pre-tax amount
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)	The (e.g. Telehealth) encounter for which this claim is made
detail		0..*	BackboneElement	Additional detail for the claim item
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: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
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: ExampleProgramReasonCodes (example): Program specific reason codes.
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: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
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: ExampleProgramReasonCodes (example): Program specific reason codes.
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		1..1	Money	Total value of all of the claim items
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Claim.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages From the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
Claim.status	required	FinancialResourceStatusCodes http://hl7.org/fhir/ValueSet/fm-status|4.0.1 From the FHIR Standard
Claim.type	extensible	NzClaimTypes(a valid code from https://standards.digital.health.nz/ns/nz-claim-type) https://fhir-ig.digital.health.nz/shared-care/ValueSet/nz-claim-types From this IG
Claim.subType	extensible	NzClaimSubtypes(a valid code from https://standards.digital.health.nz/ns/nz-claim-subtype) https://fhir-ig.digital.health.nz/shared-care/ValueSet/nz-claim-subtypes 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.fundsReserve	example	Funds Reservation Codes http://hl7.org/fhir/ValueSet/fundsreserve From the FHIR Standard
Claim.related.relationship	example	ExampleRelatedClaimRelationshipCodes http://hl7.org/fhir/ValueSet/related-claim-relationship From the FHIR Standard
Claim.payee.type	example	Claim Payee Type Codes http://hl7.org/fhir/ValueSet/payeetype From the FHIR Standard
Claim.careTeam.role	extensible	ClaimCareTeamRoleCodes(a valid code from https://standards.digital.health.nz/ns/claim-careteam-role-code) https://fhir-ig.digital.health.nz/shared-care/ValueSet/claim-careteam-role-codes From this IG
Claim.careTeam.qualification	extensible	ProviderQualificationCodes(a valid code from https://standards.digital.health.nz/ns/provider-qualification-codes) https://fhir-ig.digital.health.nz/shared-care/ValueSet/provider-qualification-codes From this IG
Claim.supportingInfo.category	example	ClaimInformationCategoryCodes http://hl7.org/fhir/ValueSet/claim-informationcategory From the FHIR Standard
Claim.supportingInfo.code	example	ExceptionCodes http://hl7.org/fhir/ValueSet/claim-exception From the FHIR Standard
Claim.supportingInfo.reason	example	MissingToothReasonCodes http://hl7.org/fhir/ValueSet/missing-tooth-reason From the FHIR Standard
Claim.diagnosis.diagnosis[x]	example	ICD-10Codes http://hl7.org/fhir/ValueSet/icd-10 From the FHIR Standard
Claim.diagnosis.type	example	ExampleDiagnosisTypeCodes http://hl7.org/fhir/ValueSet/ex-diagnosistype From the FHIR Standard
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	ICD-10ProcedureCodes http://hl7.org/fhir/ValueSet/icd-10-procedures 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	BenefitCategoryCodes http://hl7.org/fhir/ValueSet/ex-benefitcategory From the FHIR Standard
Claim.item.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls From the FHIR Standard
Claim.item.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers From the FHIR Standard
Claim.item.programCode	example	ExampleProgramReasonCodes http://hl7.org/fhir/ValueSet/ex-program-code From the FHIR Standard
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	BenefitCategoryCodes http://hl7.org/fhir/ValueSet/ex-benefitcategory From the FHIR Standard
Claim.item.detail.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls From the FHIR Standard
Claim.item.detail.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers From the FHIR Standard
Claim.item.detail.programCode	example	ExampleProgramReasonCodes http://hl7.org/fhir/ValueSet/ex-program-code From the FHIR Standard
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	BenefitCategoryCodes http://hl7.org/fhir/ValueSet/ex-benefitcategory From the FHIR Standard
Claim.item.detail.subDetail.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls From the FHIR Standard
Claim.item.detail.subDetail.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers From the FHIR Standard
Claim.item.detail.subDetail.programCode	example	ExampleProgramReasonCodes http://hl7.org/fhir/ValueSet/ex-program-code From the FHIR Standard

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()

This structure is derived from Claim

Summary

Mandatory: 1 element(4 nested mandatory elements)

Extensions

This structure refers to these extensions:

• https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/trace-number
• https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/patient-paid
• https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/item-tax

Slices

This structure defines the following Slices:

• The element 1 is sliced based on the value of Claim.item.serviced[x]
• The element 1 is sliced based on the value of Claim.item.location[x]

Key Elements View

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Claim		0..*	Claim	Claim, Pre-determination or Pre-authorization
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:traceNumber		0..*	Identifier	Trace Number URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/trace-number
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier		0..*	Identifier	Business identifier(s) for the 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	Claim type Binding: NZ Claim Types (extensible)
subType		0..1	CodeableConcept	Claim subtype Binding: NZ Claim Subtypes (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)	Patient with NHI
billablePeriod	Σ	0..1	Period	Claim period or billing period
created	Σ	1..1	dateTime	When the claim was created (by the provider)
insurer	Σ	0..1	Reference(Organization)	Payer (i.e. Health NZ)
provider	Σ	1..1	Reference(Organization)	Legal entity who submitted the claim
priority	Σ	1..1	CodeableConcept	Desired processing ugency Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.
payee		0..1	BackboneElement	Who's getting paid - Provider Site in HSAAP
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.
careTeam		0..*	BackboneElement	Practitioner(s) who provided the claimed service(s)
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)	Practitioner or organization
role		0..1	CodeableConcept	Function within the team Binding: Claim Care Team Role Codes (extensible)
qualification		0..1	CodeableConcept	Practitioner credential or specialization Binding: Provider Qualification Codes (extensible)
supportingInfo		0..*	BackboneElement	Additional attributes that may accompany a Claim
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: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes.
insurance	Σ	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
item		0..*	BackboneElement	Each individual product or service being claimed for as part of this claim
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:patientPaid		0..1	Money	Patient Paid Amount URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/patient-paid
extension:itemTax		0..1	Money	Item Tax URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/item-tax
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Referred to by the ClaimResponse.item.itemSequence
productOrService		1..1	CodeableConcept	Purchase unit code for the transaction Binding: USCLSCodes (example): Allowable service and product codes.
Slices for serviced[x]		1..1	Period	Date or dates of service or product delivery Slice: Unordered, Closed by type:$this
serviced[x]:servicedPeriod		1..1	Period	Date or dates of service or product delivery
start	ΣC	1..1	dateTime	When the claimed service started
end	ΣC	1..1	dateTime	When the claimed service ended
Slices for location[x]		0..1		Place of service or where product was supplied Slice: Unordered, Open by type:$this Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.
locationCodeableConcept			CodeableConcept
locationAddress			Address
locationReference			Reference(Location)
location[x]:locationReference		0..1	Reference(Location)	HPI Facility
quantity		0..1	SimpleQuantity	Number of units claimed for product or service
unitPrice		0..1	Money	Claimed unit price of the service
net		0..1	Money	Claimed pre-tax amount
encounter		0..*	Reference(Encounter)	The (e.g. Telehealth) encounter for which this claim is made
detail		0..*	BackboneElement	Additional detail for the claim item
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Item instance identifier
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
total		1..1	Money	Total value of all of the claim items
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	NzClaimTypes(a valid code from https://standards.digital.health.nz/ns/nz-claim-type) https://fhir-ig.digital.health.nz/shared-care/ValueSet/nz-claim-types From this IG
Claim.subType	extensible	NzClaimSubtypes(a valid code from https://standards.digital.health.nz/ns/nz-claim-subtype) https://fhir-ig.digital.health.nz/shared-care/ValueSet/nz-claim-subtypes 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.payee.type	example	Claim Payee Type Codes http://hl7.org/fhir/ValueSet/payeetype From the FHIR Standard
Claim.careTeam.role	extensible	ClaimCareTeamRoleCodes(a valid code from https://standards.digital.health.nz/ns/claim-careteam-role-code) https://fhir-ig.digital.health.nz/shared-care/ValueSet/claim-careteam-role-codes From this IG
Claim.careTeam.qualification	extensible	ProviderQualificationCodes(a valid code from https://standards.digital.health.nz/ns/provider-qualification-codes) https://fhir-ig.digital.health.nz/shared-care/ValueSet/provider-qualification-codes From this IG
Claim.supportingInfo.category	example	ClaimInformationCategoryCodes http://hl7.org/fhir/ValueSet/claim-informationcategory From the FHIR Standard
Claim.item.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls From the FHIR Standard
Claim.item.location[x]	example	ExampleServicePlaceCodes http://hl7.org/fhir/ValueSet/service-place From the FHIR Standard
Claim.item.detail.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls From the FHIR Standard

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()

Differential View

This structure is derived from Claim

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Claim		0..*	Claim	Claim, Pre-determination or Pre-authorization
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:traceNumber		0..*	Identifier	Trace Number URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/trace-number
identifier		0..*	Identifier	Business identifier(s) for the claim
type		1..1	CodeableConcept	Claim type Binding: NZ Claim Types (extensible)
subType		0..1	CodeableConcept	Claim subtype Binding: NZ Claim Subtypes (extensible)
patient		1..1	Reference(Patient)	Patient with NHI
billablePeriod		0..1	Period	Claim period or billing period
created		1..1	dateTime	When the claim was created (by the provider)
insurer		0..1	Reference(Organization)	Payer (i.e. Health NZ)
provider		1..1	Reference(Organization)	Legal entity who submitted the claim
payee		0..1	BackboneElement	Who's getting paid - Provider Site in HSAAP
careTeam		0..*	BackboneElement	Practitioner(s) who provided the claimed service(s)
provider		1..1	Reference(Practitioner)	Practitioner or organization
role		0..1	CodeableConcept	Function within the team Binding: Claim Care Team Role Codes (extensible)
qualification		0..1	CodeableConcept	Practitioner credential or specialization Binding: Provider Qualification Codes (extensible)
supportingInfo		0..*	BackboneElement	Additional attributes that may accompany a Claim
item		0..*	BackboneElement	Each individual product or service being claimed for as part of this claim
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:patientPaid		0..1	Money	Patient Paid Amount URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/patient-paid
extension:itemTax		0..1	Money	Item Tax URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/item-tax
sequence		1..1	positiveInt	Referred to by the ClaimResponse.item.itemSequence
productOrService		1..1	CodeableConcept	Purchase unit code for the transaction
Slices for serviced[x]		1..1	Period	Date or dates of service or product delivery Slice: Unordered, Open by type:$this
serviced[x]:servicedPeriod		1..1	Period	Date or dates of service or product delivery
start		1..1	dateTime	When the claimed service started
end		1..1	dateTime	When the claimed service ended
Slices for location[x]		0..1	CodeableConcept, Address, Reference(Location)	Place of service or where product was supplied Slice: Unordered, Open by type:$this
location[x]:locationReference		0..1	Reference(Location)	HPI Facility
quantity		0..1	SimpleQuantity	Number of units claimed for product or service
unitPrice		0..1	Money	Claimed unit price of the service
net		0..1	Money	Claimed pre-tax amount
encounter		0..*	Reference(Encounter)	The (e.g. Telehealth) encounter for which this claim is made
detail		0..*	BackboneElement	Additional detail for the claim item
total		1..1	Money	Total value of all of the claim items
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Claim.type	extensible	NzClaimTypes(a valid code from https://standards.digital.health.nz/ns/nz-claim-type) https://fhir-ig.digital.health.nz/shared-care/ValueSet/nz-claim-types From this IG
Claim.subType	extensible	NzClaimSubtypes(a valid code from https://standards.digital.health.nz/ns/nz-claim-subtype) https://fhir-ig.digital.health.nz/shared-care/ValueSet/nz-claim-subtypes From this IG
Claim.careTeam.role	extensible	ClaimCareTeamRoleCodes(a valid code from https://standards.digital.health.nz/ns/claim-careteam-role-code) https://fhir-ig.digital.health.nz/shared-care/ValueSet/claim-careteam-role-codes From this IG
Claim.careTeam.qualification	extensible	ProviderQualificationCodes(a valid code from https://standards.digital.health.nz/ns/provider-qualification-codes) https://fhir-ig.digital.health.nz/shared-care/ValueSet/provider-qualification-codes From this IG

Snapshot View

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
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 This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained		0..*	Resource	Contained, inline Resources
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:traceNumber		0..*	Identifier	Trace Number URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/trace-number
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier		0..*	Identifier	Business identifier(s) for the 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	Claim type Binding: NZ Claim Types (extensible)
subType		0..1	CodeableConcept	Claim subtype Binding: NZ Claim Subtypes (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)	Patient with NHI
billablePeriod	Σ	0..1	Period	Claim period or billing period
created	Σ	1..1	dateTime	When the claim was created (by the provider)
enterer		0..1	Reference(Practitioner | PractitionerRole)	Author of the claim
insurer	Σ	0..1	Reference(Organization)	Payer (i.e. Health NZ)
provider	Σ	1..1	Reference(Organization)	Legal entity who submitted 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: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim.
reference		0..1	Identifier	File or case reference
prescription		0..1	Reference(DeviceRequest | MedicationRequest | VisionPrescription)	Prescription authorizing services and products
originalPrescription		0..1	Reference(DeviceRequest | MedicationRequest | VisionPrescription)	Original prescription if superseded by fulfiller
payee		0..1	BackboneElement	Who's getting paid - Provider Site in HSAAP
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(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson)	Recipient reference
referral		0..1	Reference(ServiceRequest)	Treatment referral
facility		0..1	Reference(Location)	Servicing facility
careTeam		0..*	BackboneElement	Practitioner(s) who provided the claimed service(s)
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)	Practitioner or organization
responsible		0..1	boolean	Indicator of the lead practitioner
role		0..1	CodeableConcept	Function within the team Binding: Claim Care Team Role Codes (extensible)
qualification		0..1	CodeableConcept	Practitioner credential or specialization Binding: Provider Qualification Codes (extensible)
supportingInfo		0..*	BackboneElement	Additional attributes that may accompany a Claim
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: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes.
code		0..1	CodeableConcept	Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
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		0..*	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: ICD-10Codes (example): Example ICD10 Diagnostic codes.
diagnosisCodeableConcept			CodeableConcept
diagnosisReference			Reference(Condition)
type		0..*	CodeableConcept	Timing or nature of the diagnosis Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge.
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: ICD-10ProcedureCodes (example): Example ICD10 Procedure codes.
procedureCodeableConcept			CodeableConcept
procedureReference			Reference(Procedure)
udi		0..*	Reference(Device)	Unique device identifier
insurance	Σ	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		0..*	BackboneElement	Each individual product or service being claimed for as part of this claim
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:patientPaid		0..1	Money	Patient Paid Amount URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/patient-paid
extension:itemTax		0..1	Money	Item Tax URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/item-tax
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Referred to by the ClaimResponse.item.itemSequence
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: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.
productOrService		1..1	CodeableConcept	Purchase unit code for the transaction Binding: USCLSCodes (example): Allowable service and product codes.
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: ExampleProgramReasonCodes (example): Program specific reason codes.
Slices for serviced[x]		1..1	Period	Date or dates of service or product delivery Slice: Unordered, Closed by type:$this
serviced[x]:servicedPeriod		1..1	Period	Date or dates of service or product delivery
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
start	ΣC	1..1	dateTime	When the claimed service started
end	ΣC	1..1	dateTime	When the claimed service ended
Slices for location[x]		0..1		Place of service or where product was supplied Slice: Unordered, Open by type:$this Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.
locationCodeableConcept			CodeableConcept
locationAddress			Address
locationReference			Reference(Location)
location[x]:locationReference		0..1	Reference(Location)	HPI Facility
quantity		0..1	SimpleQuantity	Number of units claimed for product or service
unitPrice		0..1	Money	Claimed unit price of the service
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Claimed pre-tax amount
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)	The (e.g. Telehealth) encounter for which this claim is made
detail		0..*	BackboneElement	Additional detail for the claim item
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: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
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: ExampleProgramReasonCodes (example): Program specific reason codes.
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: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
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: ExampleProgramReasonCodes (example): Program specific reason codes.
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		1..1	Money	Total value of all of the claim items
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Claim.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages From the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
Claim.status	required	FinancialResourceStatusCodes http://hl7.org/fhir/ValueSet/fm-status|4.0.1 From the FHIR Standard
Claim.type	extensible	NzClaimTypes(a valid code from https://standards.digital.health.nz/ns/nz-claim-type) https://fhir-ig.digital.health.nz/shared-care/ValueSet/nz-claim-types From this IG
Claim.subType	extensible	NzClaimSubtypes(a valid code from https://standards.digital.health.nz/ns/nz-claim-subtype) https://fhir-ig.digital.health.nz/shared-care/ValueSet/nz-claim-subtypes 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.fundsReserve	example	Funds Reservation Codes http://hl7.org/fhir/ValueSet/fundsreserve From the FHIR Standard
Claim.related.relationship	example	ExampleRelatedClaimRelationshipCodes http://hl7.org/fhir/ValueSet/related-claim-relationship From the FHIR Standard
Claim.payee.type	example	Claim Payee Type Codes http://hl7.org/fhir/ValueSet/payeetype From the FHIR Standard
Claim.careTeam.role	extensible	ClaimCareTeamRoleCodes(a valid code from https://standards.digital.health.nz/ns/claim-careteam-role-code) https://fhir-ig.digital.health.nz/shared-care/ValueSet/claim-careteam-role-codes From this IG
Claim.careTeam.qualification	extensible	ProviderQualificationCodes(a valid code from https://standards.digital.health.nz/ns/provider-qualification-codes) https://fhir-ig.digital.health.nz/shared-care/ValueSet/provider-qualification-codes From this IG
Claim.supportingInfo.category	example	ClaimInformationCategoryCodes http://hl7.org/fhir/ValueSet/claim-informationcategory From the FHIR Standard
Claim.supportingInfo.code	example	ExceptionCodes http://hl7.org/fhir/ValueSet/claim-exception From the FHIR Standard
Claim.supportingInfo.reason	example	MissingToothReasonCodes http://hl7.org/fhir/ValueSet/missing-tooth-reason From the FHIR Standard
Claim.diagnosis.diagnosis[x]	example	ICD-10Codes http://hl7.org/fhir/ValueSet/icd-10 From the FHIR Standard
Claim.diagnosis.type	example	ExampleDiagnosisTypeCodes http://hl7.org/fhir/ValueSet/ex-diagnosistype From the FHIR Standard
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	ICD-10ProcedureCodes http://hl7.org/fhir/ValueSet/icd-10-procedures 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	BenefitCategoryCodes http://hl7.org/fhir/ValueSet/ex-benefitcategory From the FHIR Standard
Claim.item.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls From the FHIR Standard
Claim.item.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers From the FHIR Standard
Claim.item.programCode	example	ExampleProgramReasonCodes http://hl7.org/fhir/ValueSet/ex-program-code From the FHIR Standard
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	BenefitCategoryCodes http://hl7.org/fhir/ValueSet/ex-benefitcategory From the FHIR Standard
Claim.item.detail.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls From the FHIR Standard
Claim.item.detail.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers From the FHIR Standard
Claim.item.detail.programCode	example	ExampleProgramReasonCodes http://hl7.org/fhir/ValueSet/ex-program-code From the FHIR Standard
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	BenefitCategoryCodes http://hl7.org/fhir/ValueSet/ex-benefitcategory From the FHIR Standard
Claim.item.detail.subDetail.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls From the FHIR Standard
Claim.item.detail.subDetail.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers From the FHIR Standard
Claim.item.detail.subDetail.programCode	example	ExampleProgramReasonCodes http://hl7.org/fhir/ValueSet/ex-program-code From the FHIR Standard

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()

This structure is derived from Claim

Summary

Mandatory: 1 element(4 nested mandatory elements)

Extensions

This structure refers to these extensions:

• https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/trace-number
• https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/patient-paid
• https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/item-tax

Slices

This structure defines the following Slices:

• The element 1 is sliced based on the value of Claim.item.serviced[x]
• The element 1 is sliced based on the value of Claim.item.location[x]