A provider issued list of professional services and products which have been provided, or are to be provided, to a patient which is sent to an insurer for reimbursement.

The Claim resource fulfills three information request requirements: Claim - a request for adjudication for reimbursement for products and/or services provided; Preauthorization - a request to authorize the future provision of products and/or services including an anticipated adjudication; and, Predetermination - a request for a non-bind adjudication of possible future products and/or services.

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

Không đặt chữ ký trong Claim.meta. Nếu hợp đồng trao đổi chọn Provenance hoặc Bundle.signature, phải quy định rõ target, phạm vi byte được ký, thuật toán, chứng thư, timestamp và quy tắc xác minh.

Khi Claim là một phần của hồ sơ điện tử gửi Cổng tiếp nhận dữ liệu BHYT để đề nghị thanh toán, tài liệu/dữ liệu gửi đi phải được ký số và xác thực theo TT 12/2026/TT-BTC Điều 2 và pháp luật về giao dịch điện tử. Cách biểu diễn chữ ký — ví dụ chữ ký ở thông điệp/transport, tài liệu ký, Bundle.signature hoặc Provenance.signature — phải theo hợp đồng trao đổi đã được bên nhận chấp thuận; chỉ tuân thủ profile Claim này không chứng minh chữ ký hợp lệ.

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

An Extension

Extension tổng hợp chi phí KCB theo từng nhóm nguồn chi trả. Mapping theo chuỗi XML QĐ 130/QĐ-BYT → QĐ 4750/QĐ-BYT → QĐ 3176/QĐ-BYT: T_THUOC, T_VTYT, T_BNCCT, T_BNTT, T_BHTT, T_NGUONKHAC, T_BHTT_GDV. Riêng T_NGOAIDS là trường của XML legacy QĐ 4210/QĐ-BYT, giữ để đọc/bridge dữ liệu lịch sử; không coi đó là trường của XML 3176 hoặc tự đổi thành T_BHTT_GDV. Căn cứ: QĐ 130/QĐ-BYT → QĐ 4750/QĐ-BYT → QĐ 3176/QĐ-BYT (29/10/2024), QĐ 697/QĐ-BYT. Các field tổng tiền này được chuẩn hoá thêm qua VNBHYTFinancialFieldCS và ConceptMap vn-cm-bhyt-financial-field-to-adjudication; extension chỉ giữ số tiền tổng hợp, không encode công thức adjudication của payer. Nguồn thiết kế: OHP Data Processor (Claim extensions production mapping).

Năm và tháng thanh toán BHYT. Mapping XML 3176: NAM_QT (năm), THANG_QT (tháng). Nguồn thiết kế: OHP Data Processor (claim-payment-year, claim-payment-month).

Phương thức thanh toán KCB BHYT: phí dịch vụ (FFS), định suất (Capitation), hoặc theo trường hợp bệnh (DRG). Mapping XML 3176: MA_PTTT (Bảng 2 STT 36, Bảng 3 STT 40). Nguồn thiết kế: OHP Data Processor (encounter-payment-method).

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

A unique identifier assigned to this claim.

Allows claims to be distinguished and referenced.

Khoá liên kết hồ sơ dùng chung cho toàn bộ dữ liệu của cùng một đợt KCB khi gửi cơ quan BHXH

Allows claims to be distinguished and referenced.

The purpose of this identifier.

Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.

Identifies the purpose for this identifier, if known .

Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.

A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.

This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type.

A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

Allows users to make use of identifiers when the identifier system is not known.

Establishes the namespace for the value - that is, a URL that describes a set values that are unique.

Identifier.system is always case sensitive.

There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.

The portion of the identifier typically relevant to the user and which is unique within the context of the system.

If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.

The status of the resource instance.

This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

A code specifying the state of the resource instance.

Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.

Loại yêu cầu theo semantics chuẩn FHIR. Không dùng Claim.type để chứa MA_LOAI_KCB; MA_LOAI_KCB thuộc VNCoreEncounter.type.

The majority of jurisdictions use: oral, pharmacy, vision, professional and institutional, or variants on those terms, as the general styles of claims. The valueset is extensible to accommodate other jurisdictional requirements.

The type or discipline-style of the claim.

Claim type determine the general sets of business rules applied for information requirements and adjudication.

Phân loại đối tượng đến KCB: KCB BHYT đúng tuyến (1.x), cấp cứu (2), trái tuyến (3.x), lĩnh thuốc (7.x), thu hồi (8), không BHYT (9). 27 mã theo QĐ 3276/QĐ-BYT (17/10/2025), Phụ lục 1. Không populate trường này từ Coverage.extension[bhytCardType] vì nhóm thẻ BHYT khác nghĩa với đối tượng/lý do đến KCB.

This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.

Some jurisdictions need a finer grained claim type for routing and adjudication.

A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future.

The purpose of the Claim: predetermination, preauthorization, claim.

This element is required to understand the nature of the request for adjudication.

The party to whom the professional services and/or products have been supplied or are being considered and for whom actual or forecast reimbursement is sought.

The patient must be supplied to the insurer so that confirmation of coverage and service history may be considered as part of the authorization and/or adjudiction.

The date this resource was created.

This field is independent of the date of creation of the resource as it may reflect the creation date of a source document prior to digitization. Typically for claims all services must be completed as of this date.

Need to record a timestamp for use by both the recipient and the issuer.

Cơ quan bảo hiểm xã hội thanh toán không phải là cơ sở khám chữa bệnh; biểu diễn bằng Organization và định danh theo NamingSystem BHXH. The paying social-insurance authority is not a healthcare facility; represent it as Organization identified with the BHXH NamingSystem.

Cơ sở hoặc người cung cấp dịch vụ cho hồ sơ thanh toán. Khi map MA_CSKCB, dùng Organization/Provider thực hiện lượt KCB; không fallback sang Coverage.extension[primaryCareFacility] vì đó là nơi đăng ký KCB ban đầu MA_DKBD trên thẻ.

Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below.

FHIR base yêu cầu Claim.priority. Trong đa số hồ sơ BHYT tại Việt Nam có thể dùng giá trị normal; chỉ dùng giá trị khác khi quy trình xử lý nghiệp vụ thật sự yêu cầu.

If a claim processor is unable to complete the processing as per the priority then they should generate and error and not process the request.

The timeliness with which processing is required: stat, normal, deferred.

The provider may need to indicate their processing requirements so that the processor can indicate if they are unable to comply.

Quan hệ tuỳ chọn giữ nguyên ngữ nghĩa FHIR R4: prior trỏ một Claim trước đó cho cùng nhóm dịch vụ dự kiến; associated trỏ một Claim cho nhóm dịch vụ khác có liên quan. VN Core 0.10.0 không đặt nghĩa vụ hỗ trợ tối thiểu cho phần tử này: không bắt buộc bên gửi sinh và không bắt buộc bên nhận xử lý không lỗi, lưu hay bảo toàn. Không dùng phần tử này để hướng dẫn chia một đợt KCB hoặc sinh MA_LK mới. Hồ sơ điều chỉnh/bổ sung giữ neo nhận diện XML1_ID, MA_LK và dòng dữ liệu gốc theo TT 12/2026/TT-BTC; VN Core 0.10.0 chưa quy định mô hình FHIR cho luồng đó. Optional relationship retaining FHIR R4 semantics: prior is an earlier Claim for the same intended suite of services; associated is a Claim for a different but related suite. VN Core 0.10.0 imposes no national minimum sender/receiver support obligation and does not define episode splitting or adjustment modeling through this element.

For example, for the original treatment and follow-up exams.

For workplace or other accidents it is common to relate separate claims arising from the same event.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Tham chiếu VNCoreClaim là đích của quan hệ FHIR tuỳ chọn; phần tử con này chỉ bắt buộc khi một mục related được khai. Reference to the VNCoreClaim targeted by the optional FHIR relationship; required only when a related entry is present.

For workplace or other accidents it is common to relate separate claims arising from the same event.

Mã quan hệ theo ValueSet FHIR R4: prior cho Claim trước của cùng nhóm dịch vụ dự kiến; associated cho Claim của nhóm dịch vụ khác có liên quan. Relationship code from the FHIR R4 ValueSet: prior for an earlier Claim for the same intended suite of services, or associated for a Claim for a different but related suite.

For example, prior claim or umbrella.

Relationship of this claim to a related Claim.

Some insurers need a declaration of the type of relationship.

Information about diagnoses relevant to the claim items.

Required for the adjudication by provided context for the services and product listed.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

A number to uniquely identify diagnosis entries.

Diagnosis are presented in list order to their expected importance: primary, secondary, etc.

Necessary to maintain the order of the diagnosis items and provide a mechanism to link to claim details.

The nature of illness or problem in a coded form or as a reference to an external defined Condition.

Example ICD10 Diagnostic codes.

Provides health context for the evaluation of the products and/or services.

The nature of illness or problem in a coded form or as a reference to an external defined Condition.

Provides health context for the evaluation of the products and/or services.

When the condition was observed or the relative ranking.

For example: admitting, primary, secondary, discharge.

The type of the diagnosis: admitting, principal, discharge.

Often required to capture a particular diagnosis, for example: primary or discharge.

Procedures performed on the patient relevant to the billing items with the claim.

The specific clinical invention are sometimes required to be provided to justify billing a greater than customary amount for a service.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

A number to uniquely identify procedure entries.

Necessary to provide a mechanism to link to claim details.

The code or reference to a Procedure resource which identifies the clinical intervention performed.

Example ICD10 Procedure codes.

This identifies the actual clinical procedure.

The code or reference to a Procedure resource which identifies the clinical intervention performed.

This identifies the actual clinical procedure.

Financial instruments for reimbursement for the health care products and services specified on the claim.

Khi thẻ được cấp mới giữa đợt, nên sắp sequence theo thứ tự các giá trị được ghi trong MA_THE_BHYT: thẻ trước đứng trước, thẻ mới ghi tiếp. Theo quy ước minh hoạ của VN Core — không phải quy định của QĐ 3176/QĐ-BYT hay NĐ 188/2025/NĐ-CP — đặt focal = true cho thẻ còn giá trị khi kết thúc đợt, là thẻ cơ sở kiểm tra quyền lợi trước khi kết thúc lượt KBCB/ra viện. Mức hưởng của từng dòng chi phí áp dụng theo thời điểm thẻ mới có giá trị sử dụng.

At least one insurer is required for a claim to be a claim.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

A number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order.

To maintain order of the coverages.

A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.

A patient may (will) have multiple insurance policies which provide reimbursement for healthcare services and products. For example a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for adjudicating this claim. Other claims would be created to request adjudication against the other listed policies.

To identify which coverage in the list is being used to adjudicate this claim.

Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.

Required to allow the adjudicator to locate the correct policy and history within their information system.

Details of an accident which resulted in injuries which required the products and services listed in the claim.

When healthcare products and services are accident related, benefits may be payable under accident provisions of policies, such as automotive, etc before they are payable under normal health insurance.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Date of an accident event related to the products and services contained in the claim.

The date of the accident has to precede the dates of the products and services but within a reasonable timeframe.

Required for audit purposes and adjudication.

The type or context of the accident event for the purposes of selection of potential insurance coverages and determination of coordination between insurers.

Coverage may be dependant on the type of accident.

A claim line. Either a simple product or service or a 'group' of details which can each be a simple items or groups of sub-details.

The items to be processed for adjudication.

An Extension

Mã khoa thực hiện dịch vụ/thuốc trên từng dòng chi phí. Mapping XML 3176: MA_KHOA. Nguồn thiết kế: OHP Data Processor (claim-item-department).

Dùng khi Claim.item biểu diễn thiết bị/vật tư y tế trong XML3 hoặc bảng kê chi phí. Đây là vị trí ưu tiên cho nhóm TBYT BHYT N01-N09; không dùng Device.type để biểu diễn nhóm thanh toán này.

Slice tương thích cho PHAM_VI VTYT legacy trong XML3. Khi tạo dữ liệu mới, dùng Claim.item.extension[insuranceCostInfo].extension[scope] để biểu diễn phạm vi BHYT thống nhất cho mọi dòng chi phí.

Extension tái sử dụng cho thông tin chi phí BHYT trên từng item (thuốc/DVKT/VTYT). Bao gồm: phạm vi BHYT (PHAM_VI), tỷ lệ thanh toán BHYT (TYLE_TT/TYLE_TT_BH), mức hưởng (MUC_HUONG), mức trần thanh toán BHYT (T_TRANTT), tỷ lệ thanh toán dịch vụ (TYLE_TT_DV), đơn giá BHYT (DON_GIA_BH) và thành tiền BHYT (THANH_TIEN_BH). Dùng trên Claim.item, Claim.item.detail, ExplanationOfBenefit.item, ExplanationOfBenefit.item.detail và Invoice.lineItem. Thông tin từ các resource lâm sàng hoặc dược được đưa vào dòng chi phí tương ứng; không gắn extension này trực tiếp lên những resource nguồn đó. Với thiết bị/vật tư, ưu tiên đặt trên Claim.item hoặc item.detail; không dùng trên DeviceUseStatement vì DeviceUseStatement là ghi nhận sử dụng lâm sàng. Theo QĐ 697/QĐ-BYT (các dòng hướng dẫn khoảng 389 và 407), component trong gói TBYT mang lossless các cột 5/6/8/9; chỉ các cột 10–13 được tính ở item tổng gói. Mapping XML 3176: PHAM_VI, TYLE_TT, MUC_HUONG; DON_GIA_BH (Bảng 3 STT 15), TYLE_TT_DV (Bảng 3 STT 17), THANH_TIEN_BH (Bảng 2 STT 21, Bảng 3 STT 20), T_TRANTT (Bảng 3 STT 21). Nguồn thiết kế: OHP Data Processor (medication-pham-vi, medication-payment-ratio, medication-benefit-level). Căn cứ: QĐ 3176/QĐ-BYT đọc cùng QĐ 1931/QĐ-BYT (áp dụng từ 01/07/2026) cho trường MUC_HUONG/SO_DANG_KY; QĐ 697/QĐ-BYT cho các cột bảng kê; VBHN 14/VBHN-BYT (hợp nhất TT 04/2017/TT-BYT với TT 50/2017/TT-BYT và TT 24/2025/TT-BYT) cho mức thanh toán TBYT; NĐ 188/2025/NĐ-CP là bối cảnh quyền lợi/ngoại lệ, không phải nguồn duy nhất của mọi trần dòng chi phí. English summary: Reusable BHYT cost information on Claim/EOB items and item details, and Invoice line items. Medication, procedure and service facts are represented on the corresponding financial line, not by placing this extension on the source clinical resource. On a medical-device package, each Claim/EOB item detail carries columns 5/6/8/9 losslessly, while columns 10–13 remain on the package item. insuranceLineAmount represents the insurance-eligible line amount (THANH_TIEN_BH/column 9), not the final BHYT fund allocation; on an EOB it aligns with adjudication eligible, while the fund allocation uses adjudication benefit.

Phân bổ thành tiền bệnh viện của một dòng Claim vào bốn nguồn thanh toán trên bảng kê chi phí KCB: quỹ BHYT, người bệnh cùng chi trả, nguồn khác và người bệnh tự trả. Mỗi khoản bắt buộc có giá trị không âm và tiền tệ VND. Dòng chi tiết bên trong gói thiết bị được biểu diễn bằng Claim.item.detail và không mang extension này; phân bổ chỉ bắt buộc ở item tổng gói. Căn cứ: [QĐ 697/QĐ-BYT] (ban hành 19/03/2026, hiệu lực 19/03/2026) — Mẫu bảng kê chi phí KCB.

This extension allocates a Claim line's hospital amount across the four payment sources in the itemized healthcare-cost statement: the BHYT fund, patient co-payment, other sources, and patient self-pay. Every component is required, non-negative, and denominated in VND. Device-package detail rows are represented by Claim.item.detail and do not carry this extension; allocation is required only on the package-level item.

Tách chi tiết 4 thành phần của T_NGUONKHAC theo dòng chi phí. Tổng T_NGUONKHAC = T_NGUONKHAC_NSNN + T_NGUONKHAC_VTNN + T_NGUONKHAC_VTTN + T_NGUONKHAC_CL. Theo QĐ 3176/QĐ-BYT (sửa đổi toàn bộ diễn giải trường T_NGUONKHAC): khi T_NGUONKHAC > 0 thì giảm trừ lần lượt vào các khoản T_BNTT → T_BNCCT → T_BHTT cho đến khi hết số tiền T_NGUONKHAC. Extension không encode công thức khấu trừ — chỉ mang số tiền từng nguồn; StructureMap của exporter chịu trách nhiệm áp dụng thứ tự khấu trừ này.

Mã phương pháp vô cảm được sử dụng trong phẫu thuật, thủ thuật. Mapping QĐ 3176/QĐ-BYT: PP_VO_CAM (Bảng 3 STT 42 — Chỉ tiêu chi tiết DVKT và VTYT): 1=Gây mê, 2=Gây tê, 3=Châm tê, 4=Các phương pháp vô cảm khác. Trường thông tin này chỉ bắt buộc khi thực hiện phẫu thuật, thủ thuật có sử dụng phương pháp vô cảm. Extension host cho CodeSystem/ValueSet phương pháp vô cảm đã tạo trong đợt terminology (VNAnesthesiaMethodCS / VNAnesthesiaMethodVS). Anesthesia method used in a surgery/procedure per QĐ 3176/QĐ-BYT field PP_VO_CAM. Căn cứ: QĐ 3176/QĐ-BYT (29/10/2024).

Nguồn chi trả cho dòng chi phí KCB, đặc biệt dùng cho XML2 thuốc (NGUON_CTRA) theo QĐ 3176/QĐ-BYT. Biểu diễn nguồn chi trả ở mức item thay vì gán vào Coverage.type hoặc payment method tổng thể. Nguồn thiết kế: QĐ 3176/QĐ-BYT và terminology VNPaymentSourceCS/VS.

Flag nghiệp vụ theo dòng chi phí BHYT cho XML2/XML3 trường VET_THUONG_TP. Chỉ dùng khi dòng thuốc, DVKT hoặc VTYT có quy định tỷ lệ thanh toán BHYT được dùng để điều trị vết thương tái phát hoặc bệnh tật tái phát cho thương binh, người hưởng chính sách như thương binh, bệnh binh theo field text của QĐ 130/QĐ-BYT và QĐ 3176/QĐ-BYT; field text này viện dẫn NĐ 131/2021/NĐ-CP. Đây không phải mã chẩn đoán tái phát và không phải thuộc tính cố định của thuốc, DVKT hoặc thiết bị.

Thông tin thầu của dòng thuốc/vật tư/thiết bị trong dữ liệu KCB/BHYT, đặc biệt dùng cho XML2/XML3 trường TT_THAU theo QĐ 130/QĐ-BYT và QĐ 3176/QĐ-BYT. Đây là chuỗi nghiệp vụ phục vụ thanh toán/gateway, không phải procurement package đầy đủ và không thay thế hồ sơ đấu thầu riêng.

Phương pháp chế biến vị thuốc, dược liệu hoặc thuốc y học cổ truyền — mang trường MA_PP_CHEBIEN của dữ liệu BHYT/KCB. Từ bản 0.9.0 đã có danh mục mã chính thức: vn-tcm-processing-method-vs (Phụ lục 3 QĐ 824/QĐ-BYT, 40 mã). Ưu tiên ghi valueCodeableConcept theo danh mục này. Vẫn cho phép valueString vì hai lý do thực tế: TT 14/2024/TT-BYT bổ sung ba phương pháp phức chế (chưng, tôi, rán dầu) mà bộ mã dùng chung chưa cấp mã riêng, và Điều 4 khoản 2 TT 14/2024/TT-BYT cho phép cơ sở tự xây dựng phương pháp chế biến khi phương pháp đó chưa được quy định.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

A number to uniquely identify item entries.

Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse.

Code to identify the general type of benefits under which products and services are provided.

Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.

When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

Allowable service and product codes.

Necessary to state what was provided or done.

The number of repetitions of a service or product.

Required when the product or service code does not convey the quantity provided.

If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

The amount charged to the patient by the provider for a single unit.

The quantity times the unit price for an additional service or product or charge.

For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

Provides the total amount claimed for the group (if a grouper) or the line item.

The total value of the all the items in the claim.

Used for control total purposes.

Không đặt chữ ký trong Claim.meta. Nếu hợp đồng trao đổi chọn Provenance hoặc Bundle.signature, phải quy định rõ target, phạm vi byte được ký, thuật toán, chứng thư, timestamp và quy tắc xác minh.

Khi Claim là một phần của hồ sơ điện tử gửi Cổng tiếp nhận dữ liệu BHYT để đề nghị thanh toán, tài liệu/dữ liệu gửi đi phải được ký số và xác thực theo TT 12/2026/TT-BTC Điều 2 và pháp luật về giao dịch điện tử. Cách biểu diễn chữ ký — ví dụ chữ ký ở thông điệp/transport, tài liệu ký, Bundle.signature hoặc Provenance.signature — phải theo hợp đồng trao đổi đã được bên nhận chấp thuận; chỉ tuân thủ profile Claim này không chứng minh chữ ký hợp lệ.

Khoá liên kết hồ sơ dùng chung cho toàn bộ dữ liệu của cùng một đợt KCB khi gửi cơ quan BHXH

Loại yêu cầu theo semantics chuẩn FHIR. Không dùng Claim.type để chứa MA_LOAI_KCB; MA_LOAI_KCB thuộc VNCoreEncounter.type.

Phân loại đối tượng đến KCB: KCB BHYT đúng tuyến (1.x), cấp cứu (2), trái tuyến (3.x), lĩnh thuốc (7.x), thu hồi (8), không BHYT (9). 27 mã theo QĐ 3276/QĐ-BYT (17/10/2025), Phụ lục 1. Không populate trường này từ Coverage.extension[bhytCardType] vì nhóm thẻ BHYT khác nghĩa với đối tượng/lý do đến KCB.

Cơ quan bảo hiểm xã hội thanh toán không phải là cơ sở khám chữa bệnh; biểu diễn bằng Organization và định danh theo NamingSystem BHXH. The paying social-insurance authority is not a healthcare facility; represent it as Organization identified with the BHXH NamingSystem.

Cơ sở hoặc người cung cấp dịch vụ cho hồ sơ thanh toán. Khi map MA_CSKCB, dùng Organization/Provider thực hiện lượt KCB; không fallback sang Coverage.extension[primaryCareFacility] vì đó là nơi đăng ký KCB ban đầu MA_DKBD trên thẻ.

FHIR base yêu cầu Claim.priority. Trong đa số hồ sơ BHYT tại Việt Nam có thể dùng giá trị normal; chỉ dùng giá trị khác khi quy trình xử lý nghiệp vụ thật sự yêu cầu.

Quan hệ tuỳ chọn giữ nguyên ngữ nghĩa FHIR R4: prior trỏ một Claim trước đó cho cùng nhóm dịch vụ dự kiến; associated trỏ một Claim cho nhóm dịch vụ khác có liên quan. VN Core 0.10.0 không đặt nghĩa vụ hỗ trợ tối thiểu cho phần tử này: không bắt buộc bên gửi sinh và không bắt buộc bên nhận xử lý không lỗi, lưu hay bảo toàn. Không dùng phần tử này để hướng dẫn chia một đợt KCB hoặc sinh MA_LK mới. Hồ sơ điều chỉnh/bổ sung giữ neo nhận diện XML1_ID, MA_LK và dòng dữ liệu gốc theo TT 12/2026/TT-BTC; VN Core 0.10.0 chưa quy định mô hình FHIR cho luồng đó. Optional relationship retaining FHIR R4 semantics: prior is an earlier Claim for the same intended suite of services; associated is a Claim for a different but related suite. VN Core 0.10.0 imposes no national minimum sender/receiver support obligation and does not define episode splitting or adjustment modeling through this element.

Tham chiếu VNCoreClaim là đích của quan hệ FHIR tuỳ chọn; phần tử con này chỉ bắt buộc khi một mục related được khai. Reference to the VNCoreClaim targeted by the optional FHIR relationship; required only when a related entry is present.

Mã quan hệ theo ValueSet FHIR R4: prior cho Claim trước của cùng nhóm dịch vụ dự kiến; associated cho Claim của nhóm dịch vụ khác có liên quan. Relationship code from the FHIR R4 ValueSet: prior for an earlier Claim for the same intended suite of services, or associated for a Claim for a different but related suite.

Khi thẻ được cấp mới giữa đợt, nên sắp sequence theo thứ tự các giá trị được ghi trong MA_THE_BHYT: thẻ trước đứng trước, thẻ mới ghi tiếp. Theo quy ước minh hoạ của VN Core — không phải quy định của QĐ 3176/QĐ-BYT hay NĐ 188/2025/NĐ-CP — đặt focal = true cho thẻ còn giá trị khi kết thúc đợt, là thẻ cơ sở kiểm tra quyền lợi trước khi kết thúc lượt KBCB/ra viện. Mức hưởng của từng dòng chi phí áp dụng theo thời điểm thẻ mới có giá trị sử dụng.

Dùng khi Claim.item biểu diễn thiết bị/vật tư y tế trong XML3 hoặc bảng kê chi phí. Đây là vị trí ưu tiên cho nhóm TBYT BHYT N01-N09; không dùng Device.type để biểu diễn nhóm thanh toán này.

Slice tương thích cho PHAM_VI VTYT legacy trong XML3. Khi tạo dữ liệu mới, dùng Claim.item.extension[insuranceCostInfo].extension[scope] để biểu diễn phạm vi BHYT thống nhất cho mọi dòng chi phí.

A provider issued list of professional services and products which have been provided, or are to be provided, to a patient which is sent to an insurer for reimbursement.

The Claim resource fulfills three information request requirements: Claim - a request for adjudication for reimbursement for products and/or services provided; Preauthorization - a request to authorize the future provision of products and/or services including an anticipated adjudication; and, Predetermination - a request for a non-bind adjudication of possible future products and/or services.

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

Không đặt chữ ký trong Claim.meta. Nếu hợp đồng trao đổi chọn Provenance hoặc Bundle.signature, phải quy định rõ target, phạm vi byte được ký, thuật toán, chứng thư, timestamp và quy tắc xác minh.

Khi Claim là một phần của hồ sơ điện tử gửi Cổng tiếp nhận dữ liệu BHYT để đề nghị thanh toán, tài liệu/dữ liệu gửi đi phải được ký số và xác thực theo TT 12/2026/TT-BTC Điều 2 và pháp luật về giao dịch điện tử. Cách biểu diễn chữ ký — ví dụ chữ ký ở thông điệp/transport, tài liệu ký, Bundle.signature hoặc Provenance.signature — phải theo hợp đồng trao đổi đã được bên nhận chấp thuận; chỉ tuân thủ profile Claim này không chứng minh chữ ký hợp lệ.

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

The base language in which the resource is written.

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

A human language.

A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.

These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.

An Extension

Extension tổng hợp chi phí KCB theo từng nhóm nguồn chi trả. Mapping theo chuỗi XML QĐ 130/QĐ-BYT → QĐ 4750/QĐ-BYT → QĐ 3176/QĐ-BYT: T_THUOC, T_VTYT, T_BNCCT, T_BNTT, T_BHTT, T_NGUONKHAC, T_BHTT_GDV. Riêng T_NGOAIDS là trường của XML legacy QĐ 4210/QĐ-BYT, giữ để đọc/bridge dữ liệu lịch sử; không coi đó là trường của XML 3176 hoặc tự đổi thành T_BHTT_GDV. Căn cứ: QĐ 130/QĐ-BYT → QĐ 4750/QĐ-BYT → QĐ 3176/QĐ-BYT (29/10/2024), QĐ 697/QĐ-BYT. Các field tổng tiền này được chuẩn hoá thêm qua VNBHYTFinancialFieldCS và ConceptMap vn-cm-bhyt-financial-field-to-adjudication; extension chỉ giữ số tiền tổng hợp, không encode công thức adjudication của payer. Nguồn thiết kế: OHP Data Processor (Claim extensions production mapping).

Năm và tháng thanh toán BHYT. Mapping XML 3176: NAM_QT (năm), THANG_QT (tháng). Nguồn thiết kế: OHP Data Processor (claim-payment-year, claim-payment-month).

Phương thức thanh toán KCB BHYT: phí dịch vụ (FFS), định suất (Capitation), hoặc theo trường hợp bệnh (DRG). Mapping XML 3176: MA_PTTT (Bảng 2 STT 36, Bảng 3 STT 40). Nguồn thiết kế: OHP Data Processor (encounter-payment-method).

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

A unique identifier assigned to this claim.

Allows claims to be distinguished and referenced.

Khoá liên kết hồ sơ dùng chung cho toàn bộ dữ liệu của cùng một đợt KCB khi gửi cơ quan BHXH

Allows claims to be distinguished and referenced.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

The purpose of this identifier.

Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.

Identifies the purpose for this identifier, if known .

Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.

A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.

This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type.

A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

Allows users to make use of identifiers when the identifier system is not known.

Establishes the namespace for the value - that is, a URL that describes a set values that are unique.

Identifier.system is always case sensitive.

There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.

The portion of the identifier typically relevant to the user and which is unique within the context of the system.

If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.

Time period during which identifier is/was valid for use.

Organization that issued/manages the identifier.

The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.

The status of the resource instance.

This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

A code specifying the state of the resource instance.

Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.

Loại yêu cầu theo semantics chuẩn FHIR. Không dùng Claim.type để chứa MA_LOAI_KCB; MA_LOAI_KCB thuộc VNCoreEncounter.type.

The majority of jurisdictions use: oral, pharmacy, vision, professional and institutional, or variants on those terms, as the general styles of claims. The valueset is extensible to accommodate other jurisdictional requirements.

The type or discipline-style of the claim.

Claim type determine the general sets of business rules applied for information requirements and adjudication.

Phân loại đối tượng đến KCB: KCB BHYT đúng tuyến (1.x), cấp cứu (2), trái tuyến (3.x), lĩnh thuốc (7.x), thu hồi (8), không BHYT (9). 27 mã theo QĐ 3276/QĐ-BYT (17/10/2025), Phụ lục 1. Không populate trường này từ Coverage.extension[bhytCardType] vì nhóm thẻ BHYT khác nghĩa với đối tượng/lý do đến KCB.

This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.

Some jurisdictions need a finer grained claim type for routing and adjudication.

A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future.

The purpose of the Claim: predetermination, preauthorization, claim.

This element is required to understand the nature of the request for adjudication.

The party to whom the professional services and/or products have been supplied or are being considered and for whom actual or forecast reimbursement is sought.

The patient must be supplied to the insurer so that confirmation of coverage and service history may be considered as part of the authorization and/or adjudiction.

The period for which charges are being submitted.

Typically this would be today or in the past for a claim, and today or in the future for preauthorizations and predeterminations. Typically line item dates of service should fall within the billing period if one is specified.

A number jurisdictions required the submission of the billing period when submitting claims for example for hospital stays or long-term care.

The date this resource was created.

This field is independent of the date of creation of the resource as it may reflect the creation date of a source document prior to digitization. Typically for claims all services must be completed as of this date.