Health New Zealand Te Whatu Ora Shared Care FHIR API
0.4.2 - release New Zealand flag

Health New Zealand Te Whatu Ora Shared Care FHIR API - Local Development build (v0.4.2) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Resource Profile: NZ SharedCare Claim

Official URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/SharedCareClaim Version: 0.0.1
Draft as of 2025-09-24 Computable Name: SharedCareClaim

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:

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.

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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 Shared Care Claim Trace Number
URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/shared-care-trace-number
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... 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 Shared Care Patient Copayment
URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/shared-care-patient-copayment
..... extension:itemTax 0..1 Money Shared Care Item Tax
URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/shared-care-item-tax
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence S 1..1 positiveInt Referred to by the ClaimResponse.item.itemSequence
.... productOrService S 1..1 CodeableConcept Purchase unit code for the transaction
Binding: USCLSCodes (example): Allowable service and product codes.
.... 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Claim.statusrequiredFinancialResourceStatusCodes
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
From the FHIR Standard
Claim.typeextensibleNzClaimTypes(a valid code from NZ Claim Type Code System)
https://fhir-ig.digital.health.nz/shared-care/ValueSet/nz-claim-types
From this IG
Claim.subTypeextensibleNzClaimSubtypes(a valid code from NZ Claim Subtype Code System)
https://fhir-ig.digital.health.nz/shared-care/ValueSet/nz-claim-subtypes
From this IG
Claim.userequiredUse
http://hl7.org/fhir/ValueSet/claim-use|4.0.1
From the FHIR Standard
Claim.priorityexampleProcessPriorityCodes
http://hl7.org/fhir/ValueSet/process-priority
From the FHIR Standard
Claim.payee.typeexampleClaim Payee Type Codes
http://hl7.org/fhir/ValueSet/payeetype
From the FHIR Standard
Claim.careTeam.roleextensibleClaimCareTeamRoleCodes(a valid code from Claim Care Team Role Code System)
https://fhir-ig.digital.health.nz/shared-care/ValueSet/claim-careteam-role-codes
From this IG
Claim.careTeam.qualificationextensibleProviderQualificationCodes(a valid code from Provider Qualification Code System)
https://fhir-ig.digital.health.nz/shared-care/ValueSet/provider-qualification-codes
From this IG
Claim.supportingInfo.categoryexampleClaimInformationCategoryCodes
http://hl7.org/fhir/ValueSet/claim-informationcategory
From the FHIR Standard
Claim.item.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
From the FHIR Standard
Claim.item.location[x]exampleExampleServicePlaceCodes
http://hl7.org/fhir/ValueSet/service-place
From the FHIR Standard
Claim.item.detail.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
From the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorClaimIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorClaimIf 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-4errorClaimIf 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-5errorClaimIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceClaimA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

This structure is derived from Claim

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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 Shared Care Claim Trace Number
URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/shared-care-trace-number
... identifier 0..* Identifier Business identifier(s) for the claim
... type 1..1 CodeableConcept Claim type
Binding: NZ Claim Types (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 Shared Care Patient Copayment
URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/shared-care-patient-copayment
..... extension:itemTax 0..1 Money Shared Care Item Tax
URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/shared-care-item-tax
.... sequence S 1..1 positiveInt Referred to by the ClaimResponse.item.itemSequence
.... productOrService S 1..1 CodeableConcept Purchase unit code for the transaction
.... 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

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Claim.typeextensibleNzClaimTypes(a valid code from NZ Claim Type Code System)
https://fhir-ig.digital.health.nz/shared-care/ValueSet/nz-claim-types
From this IG
Claim.subTypeextensibleNzClaimSubtypes(a valid code from NZ Claim Subtype Code System)
https://fhir-ig.digital.health.nz/shared-care/ValueSet/nz-claim-subtypes
From this IG
Claim.careTeam.roleextensibleClaimCareTeamRoleCodes(a valid code from Claim Care Team Role Code System)
https://fhir-ig.digital.health.nz/shared-care/ValueSet/claim-careteam-role-codes
From this IG
Claim.careTeam.qualificationextensibleProviderQualificationCodes(a valid code from Provider Qualification Code System)
https://fhir-ig.digital.health.nz/shared-care/ValueSet/provider-qualification-codes
From this IG
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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 BindingsPurpose
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 Shared Care Claim Trace Number
URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/shared-care-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 Shared Care Patient Copayment
URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/shared-care-patient-copayment
..... extension:itemTax 0..1 Money Shared Care Item Tax
URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/shared-care-item-tax
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence S 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 S 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.
.... serviced[x] 0..1 Date or dates of service or product delivery
..... servicedDate date
..... servicedPeriod Period
.... 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Claim.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
From the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
Claim.statusrequiredFinancialResourceStatusCodes
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
From the FHIR Standard
Claim.typeextensibleNzClaimTypes(a valid code from NZ Claim Type Code System)
https://fhir-ig.digital.health.nz/shared-care/ValueSet/nz-claim-types
From this IG
Claim.subTypeextensibleNzClaimSubtypes(a valid code from NZ Claim Subtype Code System)
https://fhir-ig.digital.health.nz/shared-care/ValueSet/nz-claim-subtypes
From this IG
Claim.userequiredUse
http://hl7.org/fhir/ValueSet/claim-use|4.0.1
From the FHIR Standard
Claim.priorityexampleProcessPriorityCodes
http://hl7.org/fhir/ValueSet/process-priority
From the FHIR Standard
Claim.fundsReserveexampleFunds Reservation Codes
http://hl7.org/fhir/ValueSet/fundsreserve
From the FHIR Standard
Claim.related.relationshipexampleExampleRelatedClaimRelationshipCodes
http://hl7.org/fhir/ValueSet/related-claim-relationship
From the FHIR Standard
Claim.payee.typeexampleClaim Payee Type Codes
http://hl7.org/fhir/ValueSet/payeetype
From the FHIR Standard
Claim.careTeam.roleextensibleClaimCareTeamRoleCodes(a valid code from Claim Care Team Role Code System)
https://fhir-ig.digital.health.nz/shared-care/ValueSet/claim-careteam-role-codes
From this IG
Claim.careTeam.qualificationextensibleProviderQualificationCodes(a valid code from Provider Qualification Code System)
https://fhir-ig.digital.health.nz/shared-care/ValueSet/provider-qualification-codes
From this IG
Claim.supportingInfo.categoryexampleClaimInformationCategoryCodes
http://hl7.org/fhir/ValueSet/claim-informationcategory
From the FHIR Standard
Claim.supportingInfo.codeexampleExceptionCodes
http://hl7.org/fhir/ValueSet/claim-exception
From the FHIR Standard
Claim.supportingInfo.reasonexampleMissingToothReasonCodes
http://hl7.org/fhir/ValueSet/missing-tooth-reason
From the FHIR Standard
Claim.diagnosis.diagnosis[x]exampleICD-10Codes
http://hl7.org/fhir/ValueSet/icd-10
From the FHIR Standard
Claim.diagnosis.typeexampleExampleDiagnosisTypeCodes
http://hl7.org/fhir/ValueSet/ex-diagnosistype
From the FHIR Standard
Claim.diagnosis.onAdmissionexampleExampleDiagnosisOnAdmissionCodes
http://hl7.org/fhir/ValueSet/ex-diagnosis-on-admission
From the FHIR Standard
Claim.diagnosis.packageCodeexampleExampleDiagnosisRelatedGroupCodes
http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup
From the FHIR Standard
Claim.procedure.typeexampleExampleProcedureTypeCodes
http://hl7.org/fhir/ValueSet/ex-procedure-type
From the FHIR Standard
Claim.procedure.procedure[x]exampleICD-10ProcedureCodes
http://hl7.org/fhir/ValueSet/icd-10-procedures
From the FHIR Standard
Claim.accident.typeextensibleActIncidentCode
http://terminology.hl7.org/ValueSet/v3-ActIncidentCode
Claim.item.revenueexampleExampleRevenueCenterCodes
http://hl7.org/fhir/ValueSet/ex-revenue-center
From the FHIR Standard
Claim.item.categoryexampleBenefitCategoryCodes
http://hl7.org/fhir/ValueSet/ex-benefitcategory
From the FHIR Standard
Claim.item.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
From the FHIR Standard
Claim.item.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
From the FHIR Standard
Claim.item.programCodeexampleExampleProgramReasonCodes
http://hl7.org/fhir/ValueSet/ex-program-code
From the FHIR Standard
Claim.item.location[x]exampleExampleServicePlaceCodes
http://hl7.org/fhir/ValueSet/service-place
From the FHIR Standard
Claim.item.bodySiteexampleOralSiteCodes
http://hl7.org/fhir/ValueSet/tooth
From the FHIR Standard
Claim.item.subSiteexampleSurfaceCodes
http://hl7.org/fhir/ValueSet/surface
From the FHIR Standard
Claim.item.detail.revenueexampleExampleRevenueCenterCodes
http://hl7.org/fhir/ValueSet/ex-revenue-center
From the FHIR Standard
Claim.item.detail.categoryexampleBenefitCategoryCodes
http://hl7.org/fhir/ValueSet/ex-benefitcategory
From the FHIR Standard
Claim.item.detail.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
From the FHIR Standard
Claim.item.detail.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
From the FHIR Standard
Claim.item.detail.programCodeexampleExampleProgramReasonCodes
http://hl7.org/fhir/ValueSet/ex-program-code
From the FHIR Standard
Claim.item.detail.subDetail.revenueexampleExampleRevenueCenterCodes
http://hl7.org/fhir/ValueSet/ex-revenue-center
From the FHIR Standard
Claim.item.detail.subDetail.categoryexampleBenefitCategoryCodes
http://hl7.org/fhir/ValueSet/ex-benefitcategory
From the FHIR Standard
Claim.item.detail.subDetail.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
From the FHIR Standard
Claim.item.detail.subDetail.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
From the FHIR Standard
Claim.item.detail.subDetail.programCodeexampleExampleProgramReasonCodes
http://hl7.org/fhir/ValueSet/ex-program-code
From the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorClaimIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorClaimIf 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-4errorClaimIf 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-5errorClaimIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceClaimA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

This structure is derived from Claim

Summary

Mandatory: 1 element
Must-Support: 2 elements

Extensions

This structure refers to these extensions:

Slices

This structure defines the following Slices:

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

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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 Shared Care Claim Trace Number
URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/shared-care-trace-number
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... 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 Shared Care Patient Copayment
URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/shared-care-patient-copayment
..... extension:itemTax 0..1 Money Shared Care Item Tax
URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/shared-care-item-tax
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence S 1..1 positiveInt Referred to by the ClaimResponse.item.itemSequence
.... productOrService S 1..1 CodeableConcept Purchase unit code for the transaction
Binding: USCLSCodes (example): Allowable service and product codes.
.... 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Claim.statusrequiredFinancialResourceStatusCodes
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
From the FHIR Standard
Claim.typeextensibleNzClaimTypes(a valid code from NZ Claim Type Code System)
https://fhir-ig.digital.health.nz/shared-care/ValueSet/nz-claim-types
From this IG
Claim.subTypeextensibleNzClaimSubtypes(a valid code from NZ Claim Subtype Code System)
https://fhir-ig.digital.health.nz/shared-care/ValueSet/nz-claim-subtypes
From this IG
Claim.userequiredUse
http://hl7.org/fhir/ValueSet/claim-use|4.0.1
From the FHIR Standard
Claim.priorityexampleProcessPriorityCodes
http://hl7.org/fhir/ValueSet/process-priority
From the FHIR Standard
Claim.payee.typeexampleClaim Payee Type Codes
http://hl7.org/fhir/ValueSet/payeetype
From the FHIR Standard
Claim.careTeam.roleextensibleClaimCareTeamRoleCodes(a valid code from Claim Care Team Role Code System)
https://fhir-ig.digital.health.nz/shared-care/ValueSet/claim-careteam-role-codes
From this IG
Claim.careTeam.qualificationextensibleProviderQualificationCodes(a valid code from Provider Qualification Code System)
https://fhir-ig.digital.health.nz/shared-care/ValueSet/provider-qualification-codes
From this IG
Claim.supportingInfo.categoryexampleClaimInformationCategoryCodes
http://hl7.org/fhir/ValueSet/claim-informationcategory
From the FHIR Standard
Claim.item.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
From the FHIR Standard
Claim.item.location[x]exampleExampleServicePlaceCodes
http://hl7.org/fhir/ValueSet/service-place
From the FHIR Standard
Claim.item.detail.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
From the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorClaimIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorClaimIf 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-4errorClaimIf 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-5errorClaimIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceClaimA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

Differential View

This structure is derived from Claim

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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 Shared Care Claim Trace Number
URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/shared-care-trace-number
... identifier 0..* Identifier Business identifier(s) for the claim
... type 1..1 CodeableConcept Claim type
Binding: NZ Claim Types (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 Shared Care Patient Copayment
URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/shared-care-patient-copayment
..... extension:itemTax 0..1 Money Shared Care Item Tax
URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/shared-care-item-tax
.... sequence S 1..1 positiveInt Referred to by the ClaimResponse.item.itemSequence
.... productOrService S 1..1 CodeableConcept Purchase unit code for the transaction
.... 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

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Claim.typeextensibleNzClaimTypes(a valid code from NZ Claim Type Code System)
https://fhir-ig.digital.health.nz/shared-care/ValueSet/nz-claim-types
From this IG
Claim.subTypeextensibleNzClaimSubtypes(a valid code from NZ Claim Subtype Code System)
https://fhir-ig.digital.health.nz/shared-care/ValueSet/nz-claim-subtypes
From this IG
Claim.careTeam.roleextensibleClaimCareTeamRoleCodes(a valid code from Claim Care Team Role Code System)
https://fhir-ig.digital.health.nz/shared-care/ValueSet/claim-careteam-role-codes
From this IG
Claim.careTeam.qualificationextensibleProviderQualificationCodes(a valid code from Provider Qualification Code System)
https://fhir-ig.digital.health.nz/shared-care/ValueSet/provider-qualification-codes
From this IG

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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 BindingsPurpose
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 Shared Care Claim Trace Number
URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/shared-care-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 Shared Care Patient Copayment
URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/shared-care-patient-copayment
..... extension:itemTax 0..1 Money Shared Care Item Tax
URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/shared-care-item-tax
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence S 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 S 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.
.... serviced[x] 0..1 Date or dates of service or product delivery
..... servicedDate date
..... servicedPeriod Period
.... 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Claim.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
From the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
Claim.statusrequiredFinancialResourceStatusCodes
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
From the FHIR Standard
Claim.typeextensibleNzClaimTypes(a valid code from NZ Claim Type Code System)
https://fhir-ig.digital.health.nz/shared-care/ValueSet/nz-claim-types
From this IG
Claim.subTypeextensibleNzClaimSubtypes(a valid code from NZ Claim Subtype Code System)
https://fhir-ig.digital.health.nz/shared-care/ValueSet/nz-claim-subtypes
From this IG
Claim.userequiredUse
http://hl7.org/fhir/ValueSet/claim-use|4.0.1
From the FHIR Standard
Claim.priorityexampleProcessPriorityCodes
http://hl7.org/fhir/ValueSet/process-priority
From the FHIR Standard
Claim.fundsReserveexampleFunds Reservation Codes
http://hl7.org/fhir/ValueSet/fundsreserve
From the FHIR Standard
Claim.related.relationshipexampleExampleRelatedClaimRelationshipCodes
http://hl7.org/fhir/ValueSet/related-claim-relationship
From the FHIR Standard
Claim.payee.typeexampleClaim Payee Type Codes
http://hl7.org/fhir/ValueSet/payeetype
From the FHIR Standard
Claim.careTeam.roleextensibleClaimCareTeamRoleCodes(a valid code from Claim Care Team Role Code System)
https://fhir-ig.digital.health.nz/shared-care/ValueSet/claim-careteam-role-codes
From this IG
Claim.careTeam.qualificationextensibleProviderQualificationCodes(a valid code from Provider Qualification Code System)
https://fhir-ig.digital.health.nz/shared-care/ValueSet/provider-qualification-codes
From this IG
Claim.supportingInfo.categoryexampleClaimInformationCategoryCodes
http://hl7.org/fhir/ValueSet/claim-informationcategory
From the FHIR Standard
Claim.supportingInfo.codeexampleExceptionCodes
http://hl7.org/fhir/ValueSet/claim-exception
From the FHIR Standard
Claim.supportingInfo.reasonexampleMissingToothReasonCodes
http://hl7.org/fhir/ValueSet/missing-tooth-reason
From the FHIR Standard
Claim.diagnosis.diagnosis[x]exampleICD-10Codes
http://hl7.org/fhir/ValueSet/icd-10
From the FHIR Standard
Claim.diagnosis.typeexampleExampleDiagnosisTypeCodes
http://hl7.org/fhir/ValueSet/ex-diagnosistype
From the FHIR Standard
Claim.diagnosis.onAdmissionexampleExampleDiagnosisOnAdmissionCodes
http://hl7.org/fhir/ValueSet/ex-diagnosis-on-admission
From the FHIR Standard
Claim.diagnosis.packageCodeexampleExampleDiagnosisRelatedGroupCodes
http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup
From the FHIR Standard
Claim.procedure.typeexampleExampleProcedureTypeCodes
http://hl7.org/fhir/ValueSet/ex-procedure-type
From the FHIR Standard
Claim.procedure.procedure[x]exampleICD-10ProcedureCodes
http://hl7.org/fhir/ValueSet/icd-10-procedures
From the FHIR Standard
Claim.accident.typeextensibleActIncidentCode
http://terminology.hl7.org/ValueSet/v3-ActIncidentCode
Claim.item.revenueexampleExampleRevenueCenterCodes
http://hl7.org/fhir/ValueSet/ex-revenue-center
From the FHIR Standard
Claim.item.categoryexampleBenefitCategoryCodes
http://hl7.org/fhir/ValueSet/ex-benefitcategory
From the FHIR Standard
Claim.item.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
From the FHIR Standard
Claim.item.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
From the FHIR Standard
Claim.item.programCodeexampleExampleProgramReasonCodes
http://hl7.org/fhir/ValueSet/ex-program-code
From the FHIR Standard
Claim.item.location[x]exampleExampleServicePlaceCodes
http://hl7.org/fhir/ValueSet/service-place
From the FHIR Standard
Claim.item.bodySiteexampleOralSiteCodes
http://hl7.org/fhir/ValueSet/tooth
From the FHIR Standard
Claim.item.subSiteexampleSurfaceCodes
http://hl7.org/fhir/ValueSet/surface
From the FHIR Standard
Claim.item.detail.revenueexampleExampleRevenueCenterCodes
http://hl7.org/fhir/ValueSet/ex-revenue-center
From the FHIR Standard
Claim.item.detail.categoryexampleBenefitCategoryCodes
http://hl7.org/fhir/ValueSet/ex-benefitcategory
From the FHIR Standard
Claim.item.detail.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
From the FHIR Standard
Claim.item.detail.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
From the FHIR Standard
Claim.item.detail.programCodeexampleExampleProgramReasonCodes
http://hl7.org/fhir/ValueSet/ex-program-code
From the FHIR Standard
Claim.item.detail.subDetail.revenueexampleExampleRevenueCenterCodes
http://hl7.org/fhir/ValueSet/ex-revenue-center
From the FHIR Standard
Claim.item.detail.subDetail.categoryexampleBenefitCategoryCodes
http://hl7.org/fhir/ValueSet/ex-benefitcategory
From the FHIR Standard
Claim.item.detail.subDetail.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
From the FHIR Standard
Claim.item.detail.subDetail.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
From the FHIR Standard
Claim.item.detail.subDetail.programCodeexampleExampleProgramReasonCodes
http://hl7.org/fhir/ValueSet/ex-program-code
From the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorClaimIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorClaimIf 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-4errorClaimIf 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-5errorClaimIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceClaimA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

This structure is derived from Claim

Summary

Mandatory: 1 element
Must-Support: 2 elements

Extensions

This structure refers to these extensions:

Slices

This structure defines the following Slices:

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

 

Other representations of profile: CSV, Excel, Schematron