This resource provides: the claim details; adjudication details from the processing of a Claim; and optionally account balance information, for informing the subscriber of the benefits provided.

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 từ XML 3176: T_THUOC, T_VTYT, T_BNCCT, T_BNTT, T_BHTT, T_NGUONKHAC, T_NGOAIDS. Căn cứ: QĐ 130/QĐ-BYT → QĐ 3176, QĐ 697/QĐ-BYT. Các field tổng tiền này được chuẩn hóa 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_QT. 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.

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'.

The category of claim, e.g. oral, pharmacy, vision, institutional, professional.

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.

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.

Complete, proposed, exploratory, other.

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 for 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.

The party responsible for authorization, adjudication and reimbursement.

To be a valid claim, preauthorization or predetermination there must be a party who is responsible for adjudicating the contents against a policy which provides benefits for the patient.

The provider which is responsible for the claim, predetermination or preauthorization.

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.

The outcome of the claim, predetermination, or preauthorization processing.

The resource may be used to indicate that: the request has been held (queued) for processing; that it has been processed and errors found (error); that no errors were found and that some of the adjudication has been undertaken (partial) or that all of the adjudication has been undertaken (complete).

The result of the claim processing.

To advise the requestor of an overall processing outcome.

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.

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.

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.

All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. Coverages appearing before the focal Coverage in the list, and where 'Coverage.subrogation=false', should provide a reference to the ClaimResponse containing the adjudication results of the prior claim.

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 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.

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

The items to be processed for adjudication.

An Extension

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.

Raw gateway carrier cho XML2 MA_PP_CHEBIEN trong dữ liệu BHYT/KCB đối với vị thuốc, dược liệu hoặc thuốc YHCT có thông tin chế biến. QĐ 3176/QĐ-BYT vẫn tham chiếu bộ mã qua nền pháp lý cũ; hiện hành, Thông tư 14/2024/TT-BYT là nguồn mô tả phương pháp chế biến các vị thuốc cổ truyền. Do repo chưa ingest được một CodeSystem FHIR-ready có provenance đầy đủ từ nguồn hiện hành, extension này giữ nguyên chuỗi nghiệp vụ/raw legal string thay vì công bố mã chính thức sớm.

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.

Kết quả giám định từng dòng nếu hệ thống nguồn có line-level adjudication. EOB có thể chỉ mang total-level adjudication trong một số báo cáo/patient-facing use case, nên element này không bị bắt buộc như VNCoreClaimResponse.

The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage.

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.

Category giám định từng dòng. Ưu tiên HL7 adjudication (submitted, eligible, copay, benefit) cho line-level adjudication; các subtotal cục bộ của VN Core không dùng ở line-level.

For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

Needed to enable understanding of the context of the other information in the adjudication.

Monetary amount associated with the category.

For example, amount submitted, eligible amount, co-payment, and benefit payable.

Most adjuciation categories convey a monetary amount.

Categorized monetary totals for the adjudication.

Totals for amounts submitted, co-pays, benefits payable etc.

To provide the requestor with financial totals by category for the adjudication.

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.

Category tổng hợp tài chính/adjudication. Dùng ConceptMap vn-cm-bhyt-financial-field-to-adjudication để map các trường tổng tiền BHYT như T_TONGCHI, T_TONGCHI_BH, T_BHTT, T_BNCCT, T_BNTT, T_NGUONKHAC, T_NGOAIDS, T_THUOC, T_VTYT. Không encode công thức quyền lợi hoặc adjudication business rule tại profile.

For example, codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

Needed to convey the type of total provided.

Monetary total amount associated with the category.

Needed to convey the total monetary amount.

Payment details for the adjudication of the claim.

Needed to convey references to the financial instrument that has been used if payment has been made.

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.

Whether this represents partial or complete payment of the benefits payable.

The type (partial, complete) of the payment.

To advise the requestor when the insurer believes all payments to have been completed.

Benefits payable less any payment adjustment.

Needed to provide the actual payment amount.

The term of the benefits documented in this response.

Not applicable when use=claim.

Needed as coverages may be multi-year while benefits tend to be annual therefore a separate expression of the benefit period is needed.

Kết quả giám định từng dòng nếu hệ thống nguồn có line-level adjudication. EOB có thể chỉ mang total-level adjudication trong một số báo cáo/patient-facing use case, nên element này không bị bắt buộc như VNCoreClaimResponse.

Category giám định từng dòng. Ưu tiên HL7 adjudication (submitted, eligible, copay, benefit) cho line-level adjudication; các subtotal cục bộ của VN Core không dùng ở line-level.

Category tổng hợp tài chính/adjudication. Dùng ConceptMap vn-cm-bhyt-financial-field-to-adjudication để map các trường tổng tiền BHYT như T_TONGCHI, T_TONGCHI_BH, T_BHTT, T_BNCCT, T_BNTT, T_NGUONKHAC, T_NGOAIDS, T_THUOC, T_VTYT. Không encode công thức quyền lợi hoặc adjudication business rule tại profile.

This resource provides: the claim details; adjudication details from the processing of a Claim; and optionally account balance information, for informing the subscriber of the benefits provided.

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.

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 từ XML 3176: T_THUOC, T_VTYT, T_BNCCT, T_BNTT, T_BHTT, T_NGUONKHAC, T_NGOAIDS. Căn cứ: QĐ 130/QĐ-BYT → QĐ 3176, QĐ 697/QĐ-BYT. Các field tổng tiền này được chuẩn hóa 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_QT. 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 explanation of benefit.

Allows EOBs to be distinguished and referenced.

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'.

The category of claim, e.g. oral, pharmacy, vision, institutional, professional.

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.

A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.

This may contain the local bill type codes such as the US UB-04 bill type code.

A more granular claim typecode.

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.

Complete, proposed, exploratory, other.

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 for 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 prodeterminations. 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.

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

Individual who created the claim, predetermination or preauthorization.

Some jurisdictions require the contact information for personnel completing claims.

The party responsible for authorization, adjudication and reimbursement.

To be a valid claim, preauthorization or predetermination there must be a party who is responsible for adjudicating the contents against a policy which provides benefits for the patient.

The provider which is responsible for the claim, predetermination or preauthorization.

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.

The provider-required urgency of processing the request. Typical values include: stat, routine deferred.

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.

A code to indicate whether and for whom funds are to be reserved for future claims.

This field is only used for preauthorizations.

For whom funds are to be reserved: (Patient, Provider, None).

In the case of a Pre-Determination/Pre-Authorization the provider may request that funds in the amount of the expected Benefit be reserved ('Patient' or 'Provider') to pay for the Benefits determined on the subsequent claim(s). 'None' explicitly indicates no funds reserving is requested.

A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom.

Fund would be release by a future claim quoting the preAuthRef of this response. Examples of values include: provider, patient, none.

For whom funds are to be reserved: (Patient, Provider, None).

Needed to advise the submitting provider on whether the rquest for reservation of funds has been honored.

Other claims which are related to this claim such as prior submissions or claims for related services or for the same event.

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.

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.

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.

Reference to a related claim.

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

A code to convey how the claims are related.

For example, prior claim or umbrella.

Relationship of this claim to a related Claim.

Some insurers need a declaration of the type of relationship.

An alternate organizational reference to the case or file to which this particular claim pertains.

For example, Property/Casualty insurer claim number or Workers Compensation case number.

In cases where an event-triggered claim is being submitted to an insurer which requires a reference number to be specified on all exchanges.

Prescription to support the dispensing of pharmacy, device or vision products.

Required to authorize the dispensing of controlled substances and devices.

Original prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or products.

For example, a physician may prescribe a medication which the pharmacy determines is contraindicated, or for which the patient has an intolerance, and therefor issues a new prescription for an alternate medication which has the same therapeutic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription'.

Often required when a fulfiller varies what is fulfilled from that authorized on the original prescription.

The party to be reimbursed for cost of the products and services according to the terms of the policy.

Often providers agree to receive the benefits payable to reduce the near-term costs to the patient. The insurer may decline to pay the provider and may choose to pay the subscriber instead.

The provider needs to specify who they wish to be reimbursed and the claims processor needs express who they will reimburse.

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.

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.

Type of Party to be reimbursed: Subscriber, provider, other.

A code for the party to be reimbursed.

Need to know who should receive payment with the most common situations being the Provider (assignment of benefits) or the Subscriber.

Reference to the individual or organization to whom any payment will be made.

Not required if the payee is 'subscriber' or 'provider'.

Need to provide demographics if the payee is not 'subscriber' nor 'provider'.

A reference to a referral resource.

The referral resource which lists the date, practitioner, reason and other supporting information.

Some insurers require proof of referral to pay for services or to pay specialist rates for services.

Facility where the services were provided.

Insurance adjudication can be dependant on where services were delivered.

The business identifier for the instance of the adjudication request: claim predetermination or preauthorization.

To provide a link to the original adjudication request.

The business identifier for the instance of the adjudication response: claim, predetermination or preauthorization response.

To provide a link to the original adjudication response.

The outcome of the claim, predetermination, or preauthorization processing.

The resource may be used to indicate that: the request has been held (queued) for processing; that it has been processed and errors found (error); that no errors were found and that some of the adjudication has been undertaken (partial) or that all of the adjudication has been undertaken (complete).

The result of the claim processing.

To advise the requestor of an overall processing outcome.

A human readable description of the status of the adjudication.

Provided for user display.

Reference from the Insurer which is used in later communications which refers to this adjudication.

This value is only present on preauthorization adjudications.

On subsequent claims, the insurer may require the provider to quote this value.

The timeframe during which the supplied preauthorization reference may be quoted on claims to obtain the adjudication as provided.

This value is only present on preauthorization adjudications.

On subsequent claims, the insurer may require the provider to quote this value.

The members of the team who provided the products and services.

Common to identify the responsible and supporting practitioners.

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.

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 care team entries.

Necessary to maintain the order of the care team and provide a mechanism to link individuals to claim details.

Member of the team who provided the product or service.

Often a regulatory requirement to specify the responsible provider.

The party who is billing and/or responsible for the claimed products or services.

Responsible might not be required when there is only a single provider listed.

When multiple parties are present it is required to distinguish the lead or responsible individual.

The lead, assisting or supervising practitioner and their discipline if a multidisciplinary team.

Role might not be required when there is only a single provider listed.

The role codes for the care team members.

When multiple parties are present it is required to distinguish the roles performed by each member.

The qualification of the practitioner which is applicable for this service.

Provider professional qualifications.

Need to specify which qualification a provider is delivering the product or service under.

Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.

Often there are multiple jurisdiction specific valuesets which are required.

Typically these information codes are required to support the services rendered or the adjudication of the services rendered.

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.

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 supporting information entries.

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

The general class of the information supplied: information; exception; accident, employment; onset, etc.

This may contain a category for the local bill type codes.

The valuset used for additional information category codes.

Required to group or associate information items with common characteristics. For example: admission information or prior treatments.

System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought.

This may contain the local bill type codes such as the US UB-04 bill type code.

The valuset used for additional information codes.

Required to identify the kind of additional information.

The date when or period to which this information refers.

Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.

Could be used to provide references to other resources, document. For example, could contain a PDF in an Attachment of the Police Report for an Accident.

To convey the data content to be provided when the information is more than a simple code or period.

Provides the reason in the situation where a reason code is required in addition to the content.

For example: the reason for the additional stay, or why a tooth is missing.

Reason codes for the missing teeth.

Needed when the supporting information has both a date and amount/value and requires explanation.

Information about diagnoses relevant to the claim items.

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

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.

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.