醫療保險理賠實作指引
0.1.3 - CI Build

This page is part of the 醫療保險理賠實作指引 (v0.1.3: Releases Ballot 2) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions

Resource Profile: Claim iClaim

Official URL: https://claim.cgh.org.tw/iclaim/StructureDefinition/claim-iclaim Version: 0.1.3
Active as of 2023-12-25 Computable Name: ClaimiClaim

此Claim iClaim Profile說明本IG如何進一步定義FHIR的Claim Resource以呈現理賠申請書

Usage:

Formal Views of Profile Content

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

This structure is derived from Claim

NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim Claim
... identifier S0..1Identifier即為「案件編號」,Business Identifier for claim
... use 1..1codeclaim | preauthorization | predetermination
Required Pattern: claim
... patient 1..1Reference(Patient iClaim)The recipient of the products and services
... diagnosis
.... diagnosis[x] 1..1Reference(Condition iClaim)Nature of illness or problem
... insurance
.... coverage 1..1Reference(Coverage iClaim)Insurance information
... item S0..*BackboneElementProduct or service provided
.... category S0..1CodeableConceptBenefit classification
Binding: InvoicePriceComponentType值集 (required)
.... productOrService S1..1CodeableConcept即為「費用項目」,Billing, service, product, or drug code
Binding: 費用項目值集 (required)
.... modifier S0..1CodeableConcept即為「就醫身分」,Product or service billing modifiers
Binding: CoverageSelfPay值集 (required)
.... serviced[x] S1..1dateDate or dates of service or product delivery
.... net S0..1Money即為「自付金額/健保點數/減免」,Total item cost
.... encounter 0..*Reference(Encounter iClaim)Encounters related to this billed item
... total S0..1Money即為「收據金額」,Total claim cost

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Claim.item.categoryrequiredPriceComponentType
Claim.item.productOrServicerequiredCathayChargeItemCodes
Claim.item.modifierrequiredMedicalIdentity
NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim 0..*ClaimClaim, Pre-determination or Pre-authorization
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier S0..1Identifier即為「案件編號」,Business Identifier for claim
... type Σ1..1CodeableConceptCategory or discipline
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.

... use Σ1..1codeclaim | preauthorization | predetermination
Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim.


Required Pattern: claim
... patient Σ1..1Reference(Patient iClaim)The recipient of the products and services
... created Σ1..1dateTimeResource creation date
... provider Σ1..1Reference(TW Core Organization Hospital Department)Party responsible for the claim
... priority Σ1..1CodeableConceptDesired processing ugency
Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.

... insurance Σ1..*BackboneElementPatient insurance information
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence Σ1..1positiveIntInsurance instance identifier
.... focal Σ1..1booleanCoverage to be used for adjudication
.... coverage Σ1..1Reference(Coverage iClaim)Insurance information
... item S0..*BackboneElementProduct or service provided
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntItem instance identifier
.... category S0..1CodeableConceptBenefit classification
Binding: InvoicePriceComponentType值集 (required)
.... productOrService S1..1CodeableConcept即為「費用項目」,Billing, service, product, or drug code
Binding: 費用項目值集 (required)
.... modifier S0..1CodeableConcept即為「就醫身分」,Product or service billing modifiers
Binding: CoverageSelfPay值集 (required)
.... serviced[x] S1..1dateDate or dates of service or product delivery
.... net S0..1Money即為「自付金額/健保點數/減免」,Total item cost
.... encounter 0..*Reference(Encounter iClaim)Encounters related to this billed item
... total S0..1Money即為「收據金額」,Total claim cost

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Claim.statusrequiredFinancialResourceStatusCodes
Claim.typeextensibleClaimTypeCodes
Claim.userequiredPattern: claim
Claim.priorityexampleProcessPriorityCodes
Claim.item.categoryrequiredPriceComponentType
Claim.item.productOrServicerequiredCathayChargeItemCodes
Claim.item.modifierrequiredMedicalIdentity
NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim 0..*ClaimClaim, Pre-determination or Pre-authorization
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier S0..1Identifier即為「案件編號」,Business Identifier for claim
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

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

... subType 0..1CodeableConceptMore granular claim type
Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.

... use Σ1..1codeclaim | preauthorization | predetermination
Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim.


Required Pattern: claim
... patient Σ1..1Reference(Patient iClaim)The recipient of the products and services
... billablePeriod Σ0..1PeriodRelevant time frame for the claim
... created Σ1..1dateTimeResource creation date
... enterer 0..1Reference(Practitioner | PractitionerRole)Author of the claim
... insurer Σ0..1Reference(Organization)Target
... provider Σ1..1Reference(TW Core Organization Hospital Department)Party responsible for the claim
... priority Σ1..1CodeableConceptDesired processing ugency
Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.

... fundsReserve 0..1CodeableConceptFor whom to reserve funds
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).

... related 0..*BackboneElementPrior or corollary claims
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... claim 0..1Reference(Claim)Reference to the related claim
.... relationship 0..1CodeableConceptHow the reference claim is related
Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim.

.... reference 0..1IdentifierFile or case reference
... prescription 0..1Reference(DeviceRequest | MedicationRequest | VisionPrescription)Prescription authorizing services and products
... originalPrescription 0..1Reference(DeviceRequest | MedicationRequest | VisionPrescription)Original prescription if superseded by fulfiller
... payee 0..1BackboneElementRecipient of benefits payable
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type 1..1CodeableConceptCategory of recipient
Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.

.... party 0..1Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson)Recipient reference
... referral 0..1Reference(ServiceRequest)Treatment referral
... facility 0..1Reference(Location)Servicing facility
... careTeam 0..*BackboneElementMembers of the care team
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntOrder of care team
.... provider 1..1Reference(Practitioner | PractitionerRole | Organization)Practitioner or organization
.... responsible 0..1booleanIndicator of the lead practitioner
.... role 0..1CodeableConceptFunction within the team
Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members.

.... qualification 0..1CodeableConceptPractitioner credential or specialization
Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.

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

.... code 0..1CodeableConceptType of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

.... timing[x] 0..1When it occurred
..... timingDatedate
..... timingPeriodPeriod
.... value[x] 0..1Data to be provided
..... valueBooleanboolean
..... valueStringstring
..... valueQuantityQuantity
..... valueAttachmentAttachment
..... valueReferenceReference(Resource)
.... reason 0..1CodeableConceptExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

... diagnosis 0..*BackboneElementPertinent diagnosis information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntDiagnosis instance identifier
.... diagnosis[x] 1..1Reference(Condition iClaim)Nature of illness or problem
.... type 0..*CodeableConceptTiming or nature of the diagnosis
Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge.


.... onAdmission 0..1CodeableConceptPresent on admission
Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.

.... packageCode 0..1CodeableConceptPackage billing code
Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.

... procedure 0..*BackboneElementClinical procedures performed
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntProcedure instance identifier
.... type 0..*CodeableConceptCategory of Procedure
Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.


.... date 0..1dateTimeWhen the procedure was performed
.... procedure[x] 1..1Specific clinical procedure
Binding: ICD-10ProcedureCodes (example): Example ICD10 Procedure codes.

..... procedureCodeableConceptCodeableConcept
..... procedureReferenceReference(Procedure)
.... udi 0..*Reference(Device)Unique device identifier
... insurance Σ1..*BackboneElementPatient insurance information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence Σ1..1positiveIntInsurance instance identifier
.... focal Σ1..1booleanCoverage to be used for adjudication
.... identifier 0..1IdentifierPre-assigned Claim number
.... coverage Σ1..1Reference(Coverage iClaim)Insurance information
.... businessArrangement 0..1stringAdditional provider contract number
.... preAuthRef 0..*stringPrior authorization reference number
.... claimResponse 0..1Reference(ClaimResponse)Adjudication results
... accident 0..1BackboneElementDetails of the event
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... date 1..1dateWhen the incident occurred
.... type 0..1CodeableConceptThe nature of the accident
Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc.

.... location[x] 0..1Where the event occurred
..... locationAddressAddress
..... locationReferenceReference(Location)
... item S0..*BackboneElementProduct or service provided
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntItem instance identifier
.... careTeamSequence 0..*positiveIntApplicable careTeam members
.... diagnosisSequence 0..*positiveIntApplicable diagnoses
.... procedureSequence 0..*positiveIntApplicable procedures
.... informationSequence 0..*positiveIntApplicable exception and supporting information
.... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

.... category S0..1CodeableConceptBenefit classification
Binding: InvoicePriceComponentType值集 (required)
.... productOrService S1..1CodeableConcept即為「費用項目」,Billing, service, product, or drug code
Binding: 費用項目值集 (required)
.... modifier S0..1CodeableConcept即為「就醫身分」,Product or service billing modifiers
Binding: CoverageSelfPay值集 (required)
.... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


.... serviced[x] S1..1dateDate or dates of service or product delivery
.... location[x] 0..1Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.

..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... net S0..1Money即為「自付金額/健保點數/減免」,Total item cost
.... udi 0..*Reference(Device)Unique device identifier
.... bodySite 0..1CodeableConceptAnatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.

.... subSite 0..*CodeableConceptAnatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.


.... encounter 0..*Reference(Encounter iClaim)Encounters related to this billed item
.... detail 0..*BackboneElementProduct or service provided
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntItem instance identifier
..... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

..... category 0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.

..... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

..... modifier 0..*CodeableConceptService/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..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


..... quantity 0..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal item cost
..... udi 0..*Reference(Device)Unique device identifier
..... subDetail 0..*BackboneElementProduct or service provided
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... sequence 1..1positiveIntItem instance identifier
...... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

...... category 0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.

...... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

...... modifier 0..*CodeableConceptService/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..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


...... quantity 0..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyTotal item cost
...... udi 0..*Reference(Device)Unique device identifier
... total S0..1Money即為「收據金額」,Total claim cost

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Claim.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Claim.statusrequiredFinancialResourceStatusCodes
Claim.typeextensibleClaimTypeCodes
Claim.subTypeexampleExampleClaimSubTypeCodes
Claim.userequiredPattern: claim
Claim.priorityexampleProcessPriorityCodes
Claim.fundsReserveexampleFunds Reservation Codes
Claim.related.relationshipexampleExampleRelatedClaimRelationshipCodes
Claim.payee.typeexampleClaim Payee Type Codes
Claim.careTeam.roleexampleClaimCareTeamRoleCodes
Claim.careTeam.qualificationexampleExampleProviderQualificationCodes
Claim.supportingInfo.categoryexampleClaimInformationCategoryCodes
Claim.supportingInfo.codeexampleExceptionCodes
Claim.supportingInfo.reasonexampleMissingToothReasonCodes
Claim.diagnosis.typeexampleExampleDiagnosisTypeCodes
Claim.diagnosis.onAdmissionexampleExampleDiagnosisOnAdmissionCodes
Claim.diagnosis.packageCodeexampleExampleDiagnosisRelatedGroupCodes
Claim.procedure.typeexampleExampleProcedureTypeCodes
Claim.procedure.procedure[x]exampleICD-10ProcedureCodes
Claim.accident.typeextensibleActIncidentCode
Claim.item.revenueexampleExampleRevenueCenterCodes
Claim.item.categoryrequiredPriceComponentType
Claim.item.productOrServicerequiredCathayChargeItemCodes
Claim.item.modifierrequiredMedicalIdentity
Claim.item.programCodeexampleExampleProgramReasonCodes
Claim.item.location[x]exampleExampleServicePlaceCodes
Claim.item.bodySiteexampleOralSiteCodes
Claim.item.subSiteexampleSurfaceCodes
Claim.item.detail.revenueexampleExampleRevenueCenterCodes
Claim.item.detail.categoryexampleBenefitCategoryCodes
Claim.item.detail.productOrServiceexampleUSCLSCodes
Claim.item.detail.modifierexampleModifierTypeCodes
Claim.item.detail.programCodeexampleExampleProgramReasonCodes
Claim.item.detail.subDetail.revenueexampleExampleRevenueCenterCodes
Claim.item.detail.subDetail.categoryexampleBenefitCategoryCodes
Claim.item.detail.subDetail.productOrServiceexampleUSCLSCodes
Claim.item.detail.subDetail.modifierexampleModifierTypeCodes
Claim.item.detail.subDetail.programCodeexampleExampleProgramReasonCodes

Differential View

This structure is derived from Claim

NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim Claim
... identifier S0..1Identifier即為「案件編號」,Business Identifier for claim
... use 1..1codeclaim | preauthorization | predetermination
Required Pattern: claim
... patient 1..1Reference(Patient iClaim)The recipient of the products and services
... diagnosis
.... diagnosis[x] 1..1Reference(Condition iClaim)Nature of illness or problem
... insurance
.... coverage 1..1Reference(Coverage iClaim)Insurance information
... item S0..*BackboneElementProduct or service provided
.... category S0..1CodeableConceptBenefit classification
Binding: InvoicePriceComponentType值集 (required)
.... productOrService S1..1CodeableConcept即為「費用項目」,Billing, service, product, or drug code
Binding: 費用項目值集 (required)
.... modifier S0..1CodeableConcept即為「就醫身分」,Product or service billing modifiers
Binding: CoverageSelfPay值集 (required)
.... serviced[x] S1..1dateDate or dates of service or product delivery
.... net S0..1Money即為「自付金額/健保點數/減免」,Total item cost
.... encounter 0..*Reference(Encounter iClaim)Encounters related to this billed item
... total S0..1Money即為「收據金額」,Total claim cost

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Claim.item.categoryrequiredPriceComponentType
Claim.item.productOrServicerequiredCathayChargeItemCodes
Claim.item.modifierrequiredMedicalIdentity

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim 0..*ClaimClaim, Pre-determination or Pre-authorization
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier S0..1Identifier即為「案件編號」,Business Identifier for claim
... type Σ1..1CodeableConceptCategory or discipline
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.

... use Σ1..1codeclaim | preauthorization | predetermination
Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim.


Required Pattern: claim
... patient Σ1..1Reference(Patient iClaim)The recipient of the products and services
... created Σ1..1dateTimeResource creation date
... provider Σ1..1Reference(TW Core Organization Hospital Department)Party responsible for the claim
... priority Σ1..1CodeableConceptDesired processing ugency
Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.

... insurance Σ1..*BackboneElementPatient insurance information
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence Σ1..1positiveIntInsurance instance identifier
.... focal Σ1..1booleanCoverage to be used for adjudication
.... coverage Σ1..1Reference(Coverage iClaim)Insurance information
... item S0..*BackboneElementProduct or service provided
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntItem instance identifier
.... category S0..1CodeableConceptBenefit classification
Binding: InvoicePriceComponentType值集 (required)
.... productOrService S1..1CodeableConcept即為「費用項目」,Billing, service, product, or drug code
Binding: 費用項目值集 (required)
.... modifier S0..1CodeableConcept即為「就醫身分」,Product or service billing modifiers
Binding: CoverageSelfPay值集 (required)
.... serviced[x] S1..1dateDate or dates of service or product delivery
.... net S0..1Money即為「自付金額/健保點數/減免」,Total item cost
.... encounter 0..*Reference(Encounter iClaim)Encounters related to this billed item
... total S0..1Money即為「收據金額」,Total claim cost

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Claim.statusrequiredFinancialResourceStatusCodes
Claim.typeextensibleClaimTypeCodes
Claim.userequiredPattern: claim
Claim.priorityexampleProcessPriorityCodes
Claim.item.categoryrequiredPriceComponentType
Claim.item.productOrServicerequiredCathayChargeItemCodes
Claim.item.modifierrequiredMedicalIdentity

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim 0..*ClaimClaim, Pre-determination or Pre-authorization
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier S0..1Identifier即為「案件編號」,Business Identifier for claim
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

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

... subType 0..1CodeableConceptMore granular claim type
Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.

... use Σ1..1codeclaim | preauthorization | predetermination
Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim.


Required Pattern: claim
... patient Σ1..1Reference(Patient iClaim)The recipient of the products and services
... billablePeriod Σ0..1PeriodRelevant time frame for the claim
... created Σ1..1dateTimeResource creation date
... enterer 0..1Reference(Practitioner | PractitionerRole)Author of the claim
... insurer Σ0..1Reference(Organization)Target
... provider Σ1..1Reference(TW Core Organization Hospital Department)Party responsible for the claim
... priority Σ1..1CodeableConceptDesired processing ugency
Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.

... fundsReserve 0..1CodeableConceptFor whom to reserve funds
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).

... related 0..*BackboneElementPrior or corollary claims
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... claim 0..1Reference(Claim)Reference to the related claim
.... relationship 0..1CodeableConceptHow the reference claim is related
Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim.

.... reference 0..1IdentifierFile or case reference
... prescription 0..1Reference(DeviceRequest | MedicationRequest | VisionPrescription)Prescription authorizing services and products
... originalPrescription 0..1Reference(DeviceRequest | MedicationRequest | VisionPrescription)Original prescription if superseded by fulfiller
... payee 0..1BackboneElementRecipient of benefits payable
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type 1..1CodeableConceptCategory of recipient
Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.

.... party 0..1Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson)Recipient reference
... referral 0..1Reference(ServiceRequest)Treatment referral
... facility 0..1Reference(Location)Servicing facility
... careTeam 0..*BackboneElementMembers of the care team
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntOrder of care team
.... provider 1..1Reference(Practitioner | PractitionerRole | Organization)Practitioner or organization
.... responsible 0..1booleanIndicator of the lead practitioner
.... role 0..1CodeableConceptFunction within the team
Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members.

.... qualification 0..1CodeableConceptPractitioner credential or specialization
Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.

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

.... code 0..1CodeableConceptType of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

.... timing[x] 0..1When it occurred
..... timingDatedate
..... timingPeriodPeriod
.... value[x] 0..1Data to be provided
..... valueBooleanboolean
..... valueStringstring
..... valueQuantityQuantity
..... valueAttachmentAttachment
..... valueReferenceReference(Resource)
.... reason 0..1CodeableConceptExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

... diagnosis 0..*BackboneElementPertinent diagnosis information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntDiagnosis instance identifier
.... diagnosis[x] 1..1Reference(Condition iClaim)Nature of illness or problem
.... type 0..*CodeableConceptTiming or nature of the diagnosis
Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge.


.... onAdmission 0..1CodeableConceptPresent on admission
Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.

.... packageCode 0..1CodeableConceptPackage billing code
Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.

... procedure 0..*BackboneElementClinical procedures performed
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntProcedure instance identifier
.... type 0..*CodeableConceptCategory of Procedure
Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.


.... date 0..1dateTimeWhen the procedure was performed
.... procedure[x] 1..1Specific clinical procedure
Binding: ICD-10ProcedureCodes (example): Example ICD10 Procedure codes.

..... procedureCodeableConceptCodeableConcept
..... procedureReferenceReference(Procedure)
.... udi 0..*Reference(Device)Unique device identifier
... insurance Σ1..*BackboneElementPatient insurance information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence Σ1..1positiveIntInsurance instance identifier
.... focal Σ1..1booleanCoverage to be used for adjudication
.... identifier 0..1IdentifierPre-assigned Claim number
.... coverage Σ1..1Reference(Coverage iClaim)Insurance information
.... businessArrangement 0..1stringAdditional provider contract number
.... preAuthRef 0..*stringPrior authorization reference number
.... claimResponse 0..1Reference(ClaimResponse)Adjudication results
... accident 0..1BackboneElementDetails of the event
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... date 1..1dateWhen the incident occurred
.... type 0..1CodeableConceptThe nature of the accident
Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc.

.... location[x] 0..1Where the event occurred
..... locationAddressAddress
..... locationReferenceReference(Location)
... item S0..*BackboneElementProduct or service provided
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntItem instance identifier
.... careTeamSequence 0..*positiveIntApplicable careTeam members
.... diagnosisSequence 0..*positiveIntApplicable diagnoses
.... procedureSequence 0..*positiveIntApplicable procedures
.... informationSequence 0..*positiveIntApplicable exception and supporting information
.... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

.... category S0..1CodeableConceptBenefit classification
Binding: InvoicePriceComponentType值集 (required)
.... productOrService S1..1CodeableConcept即為「費用項目」,Billing, service, product, or drug code
Binding: 費用項目值集 (required)
.... modifier S0..1CodeableConcept即為「就醫身分」,Product or service billing modifiers
Binding: CoverageSelfPay值集 (required)
.... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


.... serviced[x] S1..1dateDate or dates of service or product delivery
.... location[x] 0..1Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.

..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... net S0..1Money即為「自付金額/健保點數/減免」,Total item cost
.... udi 0..*Reference(Device)Unique device identifier
.... bodySite 0..1CodeableConceptAnatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.

.... subSite 0..*CodeableConceptAnatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.


.... encounter 0..*Reference(Encounter iClaim)Encounters related to this billed item
.... detail 0..*BackboneElementProduct or service provided
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntItem instance identifier
..... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

..... category 0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.

..... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

..... modifier 0..*CodeableConceptService/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..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


..... quantity 0..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal item cost
..... udi 0..*Reference(Device)Unique device identifier
..... subDetail 0..*BackboneElementProduct or service provided
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... sequence 1..1positiveIntItem instance identifier
...... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

...... category 0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.

...... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

...... modifier 0..*CodeableConceptService/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..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


...... quantity 0..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyTotal item cost
...... udi 0..*Reference(Device)Unique device identifier
... total S0..1Money即為「收據金額」,Total claim cost

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Claim.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Claim.statusrequiredFinancialResourceStatusCodes
Claim.typeextensibleClaimTypeCodes
Claim.subTypeexampleExampleClaimSubTypeCodes
Claim.userequiredPattern: claim
Claim.priorityexampleProcessPriorityCodes
Claim.fundsReserveexampleFunds Reservation Codes
Claim.related.relationshipexampleExampleRelatedClaimRelationshipCodes
Claim.payee.typeexampleClaim Payee Type Codes
Claim.careTeam.roleexampleClaimCareTeamRoleCodes
Claim.careTeam.qualificationexampleExampleProviderQualificationCodes
Claim.supportingInfo.categoryexampleClaimInformationCategoryCodes
Claim.supportingInfo.codeexampleExceptionCodes
Claim.supportingInfo.reasonexampleMissingToothReasonCodes
Claim.diagnosis.typeexampleExampleDiagnosisTypeCodes
Claim.diagnosis.onAdmissionexampleExampleDiagnosisOnAdmissionCodes
Claim.diagnosis.packageCodeexampleExampleDiagnosisRelatedGroupCodes
Claim.procedure.typeexampleExampleProcedureTypeCodes
Claim.procedure.procedure[x]exampleICD-10ProcedureCodes
Claim.accident.typeextensibleActIncidentCode
Claim.item.revenueexampleExampleRevenueCenterCodes
Claim.item.categoryrequiredPriceComponentType
Claim.item.productOrServicerequiredCathayChargeItemCodes
Claim.item.modifierrequiredMedicalIdentity
Claim.item.programCodeexampleExampleProgramReasonCodes
Claim.item.location[x]exampleExampleServicePlaceCodes
Claim.item.bodySiteexampleOralSiteCodes
Claim.item.subSiteexampleSurfaceCodes
Claim.item.detail.revenueexampleExampleRevenueCenterCodes
Claim.item.detail.categoryexampleBenefitCategoryCodes
Claim.item.detail.productOrServiceexampleUSCLSCodes
Claim.item.detail.modifierexampleModifierTypeCodes
Claim.item.detail.programCodeexampleExampleProgramReasonCodes
Claim.item.detail.subDetail.revenueexampleExampleRevenueCenterCodes
Claim.item.detail.subDetail.categoryexampleBenefitCategoryCodes
Claim.item.detail.subDetail.productOrServiceexampleUSCLSCodes
Claim.item.detail.subDetail.modifierexampleModifierTypeCodes
Claim.item.detail.subDetail.programCodeexampleExampleProgramReasonCodes

 

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