Generated Narrative: StructureDefinition MopedARKRequest Name Flags Card. Type Description & Constraints Claim 0..* Claim Claim, Pre-determination or Pre-authorization #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:DiagnoseKnoten O 0..1 Coding LKF: Abrechnung – Knoten; KaOrg: LDF-Gruppe Teil 2 URL: https://elga.moped.at/StructureDefinition/moped-ext-diagnoseKnoten Binding: LKF Abrechnungsknoten (required) Obligations Actor SHALL:populate Moped LGF Actor #xD; extension:Beihilfenaequivalent O 0..1 decimal KaOrg: Beihilfenäquivalent URL: https://elga.moped.at/StructureDefinition/moped-ext-Beihilfenaequivalent Obligations Actor SHALL:populate Moped LGF Actor #xD; status O 1..1 code active | cancelled | draft | entered-in-error Obligations Actor SHALL:populate Moped LGF Actor SHALL:handle Moped Device Actor #xD; type O 1..1 CodeableConcept Category or discipline Required Pattern: At least the following Obligations Actor SHALL:populate Moped LGF Actor #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: institutional #xD; subType O 1..1 CodeableConcept KaOrg: Kostenmeldung für (A/R/K); Kostenmeldung für Ausländerverrechnung, Regressangelegenheiten und Kosteninformation Binding: Kostenmeldung für (A/R/K) (required) Obligations Actor SHALL:populate Moped LGF Actor #xD; use O 1..1 code claim | preauthorization | predetermination Required Pattern: claim Obligations Actor SHALL:populate Moped LGF Actor #xD; patient O 1..1 Reference(MOPED Patient) The recipient of the products and services Obligations Actor SHALL:handle Moped Device Actor #xD; insurer O 1..1 Reference(SV Organization) Target Obligations Actor SHALL:handle Moped Device Actor #xD; provider O 1..1 Reference(KH Organization) Party responsible for the claim Obligations Actor SHALL:handle Moped Device Actor #xD; related #xD; claim O 1..1 Reference(MOPED LKFRequest) Reference to the related claim Obligations Actor SHALL:populate Moped LGF Actor #xD; relationship O 0..1 CodeableConcept How the reference claim is related Required Pattern: At least the following Obligations Actor SHALL:populate Moped LGF Actor #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/ex-relatedclaimrelationship #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: associated #xD; Slices for encounter O 1..* Reference(Encounter) Encounters associated with the listed treatments Slice: Unordered, Open by profile:resolve() Obligations Actor SHALL:handle Moped Device Actor #xD; encounter:MopedEncounter 1..1 Reference(MOPED Encounter) Generelle Informationen zu Aufnahme und Entlassung des Patienten #xD; diagnosisRelatedGroup O 0..1 CodeableConcept LKF: Abrechnung - Gruppe; KaOrg: LDF-Gruppe Teil 1 Binding: LKF Abrechnungsgruppe (required) Obligations Actor SHALL:populate Moped LGF Actor #xD; Slices for item 3..* BackboneElement Product or service provided Slice: Unordered, Open by value:category.coding #xD; item:Leistungskomponente O 1..1 BackboneElement LKF: Leistungskomponente/Leistungspunkte; KaOrg: Leistungspunkte Obligations Actor SHALL:populate Moped LGF Actor #xD; category 0..1 CodeableConcept Benefit classification Binding: Moped Claim Item Category ValueSet (required) #xD; coding 1..* Coding Code defined by a terminology system Required Pattern: At least the following #xD; system 1..1 uri Identity of the terminology system Fixed Value: https://elga.moped.at/CodeSystem/MopedClaimItemCategoryCS #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: LDFPLK #xD; quantity 1..1 SimpleQuantity(5.0.0) Punkteanzahl #xD; unit 0..1 string Unit representation Required Pattern: LKF Punkte #xD; item:Tageskomponente O 1..1 BackboneElement LKF: Tageskomponente/Kontaktpunkte; KaOrg: Kontaktpunkte Obligations Actor SHALL:populate Moped LGF Actor #xD; category #xD; coding 1..* Coding Code defined by a terminology system Binding: Moped Claim Item Category ValueSet (required) Required Pattern: At least the following #xD; system 1..1 uri Identity of the terminology system Fixed Value: https://elga.moped.at/CodeSystem/MopedClaimItemCategoryCS #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: LDFPTK #xD; quantity 1..1 SimpleQuantity(5.0.0) Punkteanzahl #xD; value 1..1 decimal Numerical value (with implicit precision) #xD; unit 0..1 string Unit representation Required Pattern: LKF Punkte #xD; item:PunkteBelagsdauerausreisserUntenLeistungskomponente O 0..1 BackboneElement LKF: Punkte Belagsdauerausreißer nach unten – Leistungskomponente Obligations Actor SHALL:populate Moped LGF Actor #xD; category #xD; coding 1..* Coding Code defined by a terminology system Binding: Moped Claim Item Category ValueSet (required) Required Pattern: At least the following #xD; system 1..1 uri Identity of the terminology system Fixed Value: https://elga.moped.at/CodeSystem/MopedClaimItemCategoryCS #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: SCULK #xD; quantity 1..1 SimpleQuantity(5.0.0) Punkteanzahl #xD; value 1..1 decimal Numerical value (with implicit precision) #xD; unit 0..1 string Unit representation Required Pattern: LKF Punkte #xD; item:PunkteBelagsdauerausreisserUntenTageskomponente O 0..1 BackboneElement LKF: Punkte Belagsdauerausreißer nach unten – Tageskomponente Obligations Actor SHALL:populate Moped LGF Actor #xD; category #xD; coding 1..* Coding Code defined by a terminology system Binding: Moped Claim Item Category ValueSet (required) Required Pattern: At least the following #xD; system 1..1 uri Identity of the terminology system Fixed Value: https://elga.moped.at/CodeSystem/MopedClaimItemCategoryCS #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: SCUTK #xD; quantity 1..1 SimpleQuantity(5.0.0) Punkteanzahl #xD; value 1..1 decimal Numerical value (with implicit precision) #xD; unit 0..1 string Unit representation Required Pattern: LKF Punkte #xD; item:ZusatzpunkteBelagsdauerausreisserNachOben O 0..1 BackboneElement LKF: Zusatzpunkte Belagsdauerausreißer nach oben; KaOrg: Zusatzpunkte Verweildauerausreißer oben Obligations Actor SHALL:populate Moped LGF Actor #xD; category #xD; coding 1..* Coding Code defined by a terminology system Binding: Moped Claim Item Category ValueSet (required) Required Pattern: At least the following #xD; system 1..1 uri Identity of the terminology system Fixed Value: https://elga.moped.at/CodeSystem/MopedClaimItemCategoryCS #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: BDZU #xD; quantity 1..1 SimpleQuantity(5.0.0) Punkteanzahl #xD; value 1..1 decimal Numerical value (with implicit precision) #xD; unit 0..1 string Unit representation Required Pattern: LKF Punkte #xD; item:ZusatzpunkteIntensiv O 0..1 BackboneElement LKF: Zusatzpunkte Intensiv; KaOrg: Zusatzpunkte Intensiv Obligations Actor SHALL:populate Moped LGF Actor #xD; category #xD; coding 1..* Coding Code defined by a terminology system Binding: Moped Claim Item Category ValueSet (required) Required Pattern: At least the following #xD; system 1..1 uri Identity of the terminology system Fixed Value: https://elga.moped.at/CodeSystem/MopedClaimItemCategoryCS #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: INTZU #xD; quantity 1..1 SimpleQuantity(5.0.0) Punkteanzahl #xD; value 1..1 decimal Numerical value (with implicit precision) #xD; unit 0..1 string Unit representation Required Pattern: LKF Punkte #xD; item:ZusatzpunkteMehrfachleistungen O 0..1 BackboneElement LKF: Zusatzpunkte Mehrfachleistungen; KaOrg: Zusatzpunkte Mehrleistungen Obligations Actor SHALL:populate Moped LGF Actor #xD; category #xD; coding 1..* Coding Code defined by a terminology system Binding: Moped Claim Item Category ValueSet (required) Required Pattern: At least the following #xD; system 1..1 uri Identity of the terminology system Fixed Value: https://elga.moped.at/CodeSystem/MopedClaimItemCategoryCS #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: MELZU #xD; quantity 1..1 SimpleQuantity(5.0.0) Punkteanzahl #xD; value 1..1 decimal Numerical value (with implicit precision) #xD; unit 0..1 string Unit representation Required Pattern: LKF Punkte #xD; item:PunkteSpeziellerBereicheTageweise 0..1 BackboneElement LKF: Punkte spezieller Bereiche (tageweise); KaOrg: Punkte spezieller Bereich #xD; category #xD; coding 1..* Coding Code defined by a terminology system Binding: Moped Claim Item Category ValueSet (required) Required Pattern: At least the following #xD; system 1..1 uri Identity of the terminology system Fixed Value: https://elga.moped.at/CodeSystem/MopedClaimItemCategoryCS #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: SCSPEZ #xD; quantity 1..1 SimpleQuantity(5.0.0) Punkteanzahl #xD; value 1..1 decimal Numerical value (with implicit precision) #xD; unit 0..1 string Unit representation Required Pattern: LKF Punkte #xD; item:Gesamtpunkte O 1..1 BackboneElement LKF: Punkte total; KaOrg: Punkte total Obligations Actor SHALL:populate Moped LGF Actor #xD; category #xD; coding 1..* Coding Code defined by a terminology system Binding: Moped Claim Item Category ValueSet (required) Required Pattern: At least the following #xD; system 1..1 uri Identity of the terminology system Fixed Value: https://elga.moped.at/CodeSystem/MopedClaimItemCategoryCS #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: SCGES #xD; quantity 1..1 SimpleQuantity(5.0.0) Punkteanzahl #xD; value 1..1 decimal Numerical value (with implicit precision) #xD; unit 0..1 string Unit representation Required Pattern: LKF Punkte #xD; unitPrice 1..1 Money KaOrg: LDF-Punktewert Netto #xD; factor 0..1 decimal Price scaling factor Required Pattern: 1 #xD; net 1..1 Money KaOrg: LDF-Betrag Netto #xD; item:Patientenanteil O 0..1 BackboneElement Product or service provided Obligations Actor SHALL:populate Moped LGF Actor #xD; category #xD; coding 1..* Coding Code defined by a terminology system Binding: Moped Claim Item Category ValueSet (required) Required Pattern: At least the following #xD; system 1..1 uri Identity of the terminology system Fixed Value: https://elga.moped.at/CodeSystem/MopedClaimItemCategoryCS #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: Patientenanteil #xD; unitPrice 1..1 Money KaOrg: Patientenanteil für Angehörige (tägl. Satz) netto #xD; factor 0..1 decimal Price scaling factor Required Pattern: -1 #xD; net 1..1 Money KaOrg: Patientenanteil netto #xD; total O 0..1 Money KaOrg: Forderungsbetrag für Ausländerverrechnung/Regress Obligations Actor SHALL:populate Moped LGF Actor #xD; Documentation for this format
MOPED Profil der Claim Ressource für die Kostenmeldung für Ausländerverrechnung und Regresse.
Claim, Pre-determination or Pre-authorization
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.
If the resource is contained in another resource, it SHALL NOT contain nested Resources
If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().ofType(canonical) | %resource.descendants().ofType(uri) | %resource.descendants().ofType(url))) or descendants().where(reference = '#').exists() or descendants().where(ofType(canonical) = '#').exists() or descendants().where(ofType(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
If a resource is contained in another resource, it SHALL NOT have a security label
When a resource has no narrative, only systems that fully understand the data can display the resource to a human safely. Including a human readable representation in the resource makes for a much more robust eco-system and cheaper handling of resources by intermediary systems. Some ecosystems restrict distribution of resources to only those systems that do fully understand the resources, and as a consequence implementers may believe that the narrative is superfluous. However experience shows that such eco-systems often open up to new participants over time.
A resource should have narrative for robust management
The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
Within the context of the FHIR RESTful interactions, the resource has an id except for cases like the create and conditional update. Otherwise, the use of the resouce id depends on the given use case.
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.
All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
A set of rules under which this content was created
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 its narrative along with other profiles, value sets, etc.
This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies its meaning or interpretation
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).
Text summary of the resource, for human interpretation
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 a 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, nor can they have their own independent transaction scope. This is allowed to be a Parameters resource if and only if it is referenced by a resource that provides context/meaning.
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.
Must have either extensions or value[x], not both
LKF: Abrechnung – Knoten; KaOrg: LDF-Gruppe Teil 2
"Abrechnung - Knoten:" Lukriert die Patient:innen über eine reguläre Gruppe Punkte, so ist in diesem Datenfeld die entsprechende Knotenbezeichnung einzutragen.
MOPED Extension für das Beihilfenaequivalent
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 managable, 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](http://hl7.org/fhir/R5/extensibility.html#modifierExtension).
Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
A unique identifier assigned to this claim.
Allows claims to be distinguished and referenced.
Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners.
Allows partners to uniquely identify components for tracking.
active | cancelled | draft | entered-in-error
This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.
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'.
This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
A code specifying the state of the resource instance.
The category of claim, e.g. oral, pharmacy, vision, institutional, professional.
The code system provides oral, pharmacy, vision, professional and institutional claim types. Those supported depends on the requirements of the jurisdiction. The valueset is extensible to accommodate other types of claims as required by the jurisdiction.
Claim type determine the general sets of business rules applied for information requirements and adjudication.
The type or discipline-style of the claim.
KaOrg: Kostenmeldung für (A/R/K); Kostenmeldung für Ausländerverrechnung, Regressangelegenheiten und Kosteninformation
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, 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.
claim | preauthorization | predetermination
A code to indicate whether the nature of the request is: Claim - A request to an Insurer to adjudicate the supplied charges for health care goods and services under the identified policy and to pay the determined Benefit amount, if any; Preauthorization - A request to an Insurer to adjudicate the supplied proposed future charges for health care goods and services under the identified policy and to approve the services and provide the expected benefit amounts and potentially to reserve funds to pay the benefits when Claims for the indicated services are later submitted; or, Pre-determination - A request to an Insurer to adjudicate the supplied 'what if' charges for health care goods and services under the identified policy and report back what the Benefit payable would be had the services actually been provided.
This element is required to understand the nature of the request for adjudication.
The purpose of the Claim: predetermination, preauthorization, claim.
The recipient of the products and services
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.
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 Insurer who is target of the request.
The provider which is responsible for the claim, predetermination or preauthorization.
Typically this field would be 1..1 where this party is accountable for the data content within the claim but is not necessarily the facility, provider group or practitioner who provided the products and services listed within this claim resource. This field is the Billing Provider, for example, a facility, provider group, lab or practitioner.
The provider-required urgency of processing the request. Typical values include: stat, normal, deferred.
If a claim processor is unable to complete the processing as per the priority then they should generate an error and not process the request.
The provider may need to indicate their processing requirements so that the processor can indicate if they are unable to comply.
The timeliness with which processing is required: stat, normal, deferred.
A code to indicate whether and for whom funds are to be reserved for future claims.
This field is only used for preauthorizations.
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.
For whom funds are to be reserved: (Patient, Provider, None).
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.
Additional content defined by implementations
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 managable, 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.
Extensions that cannot be ignored even if unrecognized
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 managable, 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).
Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
A code to convey how the claims are related.
Some insurers need a declaration of the type of relationship.
Relationship of this claim to a related Claim.
An alternate organizational reference to the case or file to which this particular claim pertains.
For example, Property/Casualty insurer claim # or Workers Compensation case # .
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 authorizing services and products
Prescription is the document/authorization given to the claim author for them to provide products and services for which consideration (reimbursement) is sought. Could be a RX for medications, an 'order' for oxygen or wheelchair or physiotherapy treatments.
Required to authorize the dispensing of controlled substances and devices.
Original prescription if superseded by fulfiller
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 therefore 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 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.
Type of Party to be reimbursed: subscriber, provider, other.
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'.
The referral information received by the claim author, it is not to be used when the author generates a referral for a patient. A copy of that referral may be provided as supporting information. Some insurers require proof of referral to pay for services or to pay specialist rates for services.
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.
Encounters associated with the listed treatments
Healthcare encounters related to this claim.
This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter.
Used in some jurisdictions to link clinical events to claim items.
Generelle Informationen zu Aufnahme und Entlassung des Patienten
Facility where the services were provided.
Insurance adjudication can be dependant on where services were delivered.
LKF: Abrechnung - Gruppe; KaOrg: LDF-Gruppe Teil 1
A package billing code or bundle code used to group products and services to a particular health condition (such as heart attack) which is based on a predetermined grouping code system.
For example DRG (Diagnosis Related Group) or a bundled billing code. A patient may have a diagnosis of a Myocardial Infarction and a DRG for HeartAttack would be assigned. The Claim item (and possible subsequent claims) would refer to the DRG for those line items that were for services related to the heart attack event.
Required to relate the current diagnosis to a package billing code that is then referenced on the individual claim items which are specific to the health condition covered by the package code.
Information code for an event with a corresponding date or period.
A coded event such as when a service is expected or a card printed.
A date or period in the past or future indicating when the event occurred or is expectd to occur.
The members of the team who provided the products and services.
Common to identify the responsible and supporting practitioners.
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.
When multiple parties are present it is required to distinguish the roles performed by each member.
The role codes for the care team members.
The specialization of the practitioner or provider which is applicable for this service.
Need to specify which specialization a practitioner or provider acting under when delivering the product or service.
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.
Attachments Exception Codes Occurrence Codes Value codes
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.
Classification of the supplied information
The general class of the information supplied: information; exception; accident, employment; onset, etc.
This may contain a category for the local bill type codes.
Required to group or associate information items with common characteristics. For example: admission information or prior treatments.
The valuset used for additional information category codes.
System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought.
Required to identify the kind of additional information.
The valuset used for additional information codes.
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.
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.
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.
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.
Often required to capture a particular diagnosis, for example: primary or discharge.
The type of the diagnosis: admitting, principal, discharge.
Indication of whether the diagnosis was present on admission to a facility.
Many systems need to understand for adjudication if the diagnosis was present a time of admission.
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.
A number to uniquely identify procedure entries.
Necessary to provide a mechanism to link to claim details.
Date and optionally time the procedure was performed.
The code or reference to a Procedure resource which identifies the clinical intervention performed.
This identifies the actual clinical procedure.
Unique Device Identifiers associated with this line item.
The UDI code allows the insurer to obtain device level information on the product supplied.
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.
A number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order.
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.
The business identifier to be used when the claim is sent for adjudication against this insurance policy.
Only required in jurisdictions where insurers, rather than the provider, are required to send claims to insurers that appear after them in the list. This element is not required when 'subrogation=true'.
This will be the claim number should it be necessary to create this claim in the future. This is provided so that payors may forward claims to other payors in the Coordination of Benefit for adjudication rather than the provider being required to initiate each adjudication.
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 business agreement number established between the provider and the insurer for special business processing purposes.
Providers may have multiple business arrangements with a given insurer and must supply the specific contract number for adjudication.
Reference numbers previously provided by the insurer to the provider to be quoted on subsequent claims containing services or products related to the prior authorization.
This value is an alphanumeric string that may be provided over the phone, via text, via paper, or within a ClaimResponse resource and is not a FHIR Identifier.
Providers must quote previously issued authorization reference numbers in order to obtain adjudication as previously advised on the Preauthorization.
The result of the adjudication of the line items for the Coverage specified in this insurance.
Must not be specified when 'focal=true' for this insurance.
An insurer need the adjudication results from prior insurers to determine the outstanding balance remaining by item for the items in the curent claim.
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.
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.
Type of accident: work place, auto, etc.
The physical location of the accident event.
Required for audit purposes and determination of applicable insurance liability.
The amount paid by the patient, in total at the claim claim level or specifically for the item and detail level, to the provider for goods and services.
Necessary to demonstrate that copayments, co-insurance and similar patient payments have been made or accounted for.
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.
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.
CareTeam members related to this service or product.
Need to identify the individuals and their roles in the provision of the product or service.
Diagnosis applicable for this service or product.
Need to related the product or service to the associated diagnoses.
Procedures applicable for this service or product.
Need to provide any listed specific procedures to support the product or service being claimed.
Applicable exception and supporting information
Exceptions, special conditions and supporting information applicable for this service or product.
Need to reference the supporting information items that relate directly to this product or service.
The type of revenue or cost center providing the product and/or service.
Needed in the processing of institutional claims.
Codes for the revenue or cost centers supplying the service and/or products.
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.
Benefit categories such as: oral-basic, major, glasses.
When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used.
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'.
Necessary to state what was provided or done.
This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claims.
End of a range of Drug Code; Bill Code; Service Cod
Request or Referral for Goods or Service to be rendered.
May identify the service to be provided or provider authorization for the service.
Item typification or modifiers codes to convey additional context for the product or service.
For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours.
To support inclusion of the item for adjudication or to charge an elevated fee.
Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
Program the product or service is provided under
Identifies the program under which this may be recovered.
For example: Neonatal program, child dental program or drug users recovery program.
Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.
Date or dates of service or product delivery
The date or dates when the service or product was supplied, performed or completed.
Needed to determine whether the service or product was provided during the term of the insurance coverage.
Place of service or where product was supplied
Where the product or service was provided.
The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount.
Place of service: pharmacy, school, prison, etc.
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.
A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.
To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.
The total of taxes applicable for this product or service.
Required when taxes are not embedded in the unit price or provided as a separate service.
The total amount claimed for the group (if a grouper) or the line item. Net = unit price * quantity * factor.
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.
Physical location where the service is performed or applies.
Physical service site on the patient (limb, tooth, etc.).
For example: Providing a tooth code, allows an insurer to identify a provider performing a filling on a tooth that was previously removed.
Allows insurer to validate specific procedures.
A region or surface of the bodySite, e.g. limb region or tooth surface(s).
A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.
For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.
The total amount claimed for the group (if a grouper) or the line item.detail. Net = unit price * quantity * factor.
The total amount claimed for line item.detail.subDetail. Net = unit price * quantity * factor.
LKF: Leistungskomponente/Leistungspunkte; KaOrg: Leistungspunkte
Extensions are always sliced by (at least) url
A reference to a code defined by a terminology system.
Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
Allows for alternative encodings within a code system, and translations to other code systems.
fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
Plain text representation of the concept
A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.
Very often the text is the same as a displayName of one of the codings.
The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.
C*E.9. But note many systems use C*E.2 for this
fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
Numerical value (with implicit precision)
The value of the measured amount. The value includes an implicit precision in the presentation of the value.
The implicit precision in the value should always be honored. Monetary values have their own rules for handling precision (refer to standard accounting text books).
Precision is handled implicitly in almost all cases of measurement.
PQ.value, CO.value, MO.value, IVL.high or IVL.low depending on the value
< | <= | >= | > | ad - how to understand the value
Need a framework for handling measures where the value is <5ug/L or >400mg/L due to the limitations of measuring methodology.
If there is no comparator, then there is no modification of the value
This is labeled as "Is Modifier" because the comparator modifies the interpretation of the value significantly. If there is no comparator, then there is no modification of the value
How the Quantity should be understood and represented.
There are many representations for units of measure and in many contexts, particular representations are fixed and required. I.e. mcg for micrograms.
The identification of the system that provides the coded form of the unit.
Need to know the system that defines the coded form of the unit.
CO.codeSystem, PQ.translation.codeSystem
A computer processable form of the unit in some unit representation system.
The preferred system is UCUM, but SNOMED CT can also be used (for customary units) or ISO 4217 for currency. The context of use may additionally require a code from a particular system.
Need a computable form of the unit that is fixed across all forms. UCUM provides this for quantities, but SNOMED CT provides many units of interest.
PQ.code, MO.currency, PQ.translation.code
LKF: Tageskomponente/Kontaktpunkte; KaOrg: Kontaktpunkte
LKF: Punkte Belagsdauerausreißer nach unten – Leistungskomponente
LKF: Punkte Belagsdauerausreißer nach unten – Tageskomponente
LKF: Zusatzpunkte Belagsdauerausreißer nach oben; KaOrg: Zusatzpunkte Verweildauerausreißer oben
LKF: Zusatzpunkte Intensiv; KaOrg: Zusatzpunkte Intensiv
LKF: Zusatzpunkte Mehrfachleistungen; KaOrg: Zusatzpunkte Mehrleistungen
LKF: Punkte spezieller Bereiche (tageweise); KaOrg: Punkte spezieller Bereich
KaOrg: Patientenanteil für Angehörige (tägl. Satz) netto
KaOrg: Forderungsbetrag für Ausländerverrechnung/Regress
The total value of the all the items in the claim.