FHIR IG Statistics: StructureDefinition/profile-claim-professional
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Resources that this resource uses
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Source
{
"resourceType": "StructureDefinition",
"id": "profile-claim-professional",
"url": "http://pharmacyeclaims.ca/FHIR/v1.0/StructureDefinition/profile-claim-professional",
"name": "ProfessionalServicesClaimRequest",
"title": "Professional Services Claim",
"status": "draft",
"description": "Claim request specifically for professional services in Canada",
"purpose": "Claim request specifically for professional services in Canada",
"fhirVersion": "4.0.1",
"kind": "resource",
"abstract": false,
"type": "Claim",
"baseDefinition": "http://hl7.org/fhir/StructureDefinition/Claim",
"derivation": "constraint",
"differential": {
"element": [
{
"id": "Claim",
"path": "Claim",
"comment": "Usage Note: This profile is used for both Pay Provider claims and Pay Subscriber/Cardholder claims, which are differentiated by the payee.type\r\n\r\nThe 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."
},
{
"id": "Claim.id",
"path": "Claim.id",
"min": 1,
"mustSupport": true
},
{
"id": "Claim.meta",
"path": "Claim.meta",
"min": 1,
"mustSupport": true
},
{
"id": "Claim.meta.profile",
"path": "Claim.meta.profile",
"min": 1,
"max": "1",
"fixedCanonical": "http://pharmacyeclaims.ca/FHIR/v1.0/StructureDefinition/profile-claim-professional",
"mustSupport": true
},
{
"id": "Claim.identifier",
"path": "Claim.identifier",
"slicing": {
"discriminator": [
{
"type": "value",
"path": "system"
}
],
"rules": "open"
},
"comment": "Usage Note: Both the CPHA Trace Number and the Claim Identifier must be present in the message. The CPHA Trace number is present for backward compatibility purposes. It will be phased out as it is limited to 6N",
"min": 1,
"mustSupport": true
},
{
"id": "Claim.identifier.system",
"path": "Claim.identifier.system",
"mustSupport": true
},
{
"id": "Claim.identifier.value",
"path": "Claim.identifier.value",
"min": 1,
"mustSupport": true
},
{
"id": "Claim.identifier:CPHA-Trace-Number",
"path": "Claim.identifier",
"sliceName": "CPHA-Trace-Number",
"comment": "Usage Note: This is limited to 6N, as per the CPHA message specification. This is present for backward compatibility. In the future, once all implementations natively support FHIR, this identifier will be deprecated in favour of the Claim-identifier which has no limitations.\r\n\r\nUsage Note: This will be the trace number from the Claim Request.identifier. The number assigned, by the provider, to the transaction to which this response applies. This is limited to 6N, in order to maintain backward compatibility with CPHA.\r\r\nCPHA Mapping: Trace Number B.23.03",
"max": "1"
},
{
"id": "Claim.identifier:CPHA-Trace-Number.system",
"path": "Claim.identifier.system",
"comment": "Set value = http://pharmacyeclaims.ca/FHIR/CPHA-identifier/trace-number\r\n\r\nIdentifier.system is always case sensitive.",
"min": 1,
"mustSupport": true
},
{
"id": "Claim.identifier:CPHA-Trace-Number.value",
"path": "Claim.identifier.value",
"comment": "Usage Note: Unique number produced sequentially by the provider software (or manually in absence of computer) for each transaction transmitted by the provider. \r\r\nCPHA Map: Trace Number E.02.03 6N\r\n\r\nIf the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the [Rendered Value extension](extension-rendered-value.html). Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.",
"min": 1,
"mustSupport": true
},
{
"id": "Claim.identifier:Claim-identifier",
"path": "Claim.identifier",
"sliceName": "Claim-identifier",
"comment": "Usage Note: This must be present for all FHIR-based identfiiers. This identifier is not limited as is the Trace-Number\r\nCPHA Map: Maps to the D.55.03 Current RX Number and also the D.53.03 Original RX Number and is therefore limited to 9N. In professional services claims, these have the same values.\r\nUsage: serves as an invoice number for professional services whereby there is no Prescription number",
"min": 1,
"max": "1",
"mustSupport": true
},
{
"id": "Claim.identifier:Claim-identifier.system",
"path": "Claim.identifier.system",
"comment": "Usage Note: This is assigned by the sending system to uniquely identify the namespace.\r\nIdentifier.system is always case sensitive.\r\nCPHA Mapping: None; this is new",
"min": 1,
"mustSupport": true
},
{
"id": "Claim.identifier:Claim-identifier.value",
"path": "Claim.identifier.value",
"min": 1,
"mustSupport": true
},
{
"id": "Claim.status",
"path": "Claim.status",
"comment": "This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.\r\nCPHA - no mapping",
"fixedCode": "active",
"mustSupport": true
},
{
"id": "Claim.type",
"path": "Claim.type",
"comment": "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.\r\nCPHA - no mapping",
"fixedCodeableConcept": {
"text": "pharmacy"
},
"mustSupport": true
},
{
"id": "Claim.type.text",
"path": "Claim.type.text",
"min": 1,
"mustSupport": true
},
{
"id": "Claim.use",
"path": "Claim.use",
"fixedCode": "claim",
"mustSupport": true
},
{
"id": "Claim.patient",
"path": "Claim.patient",
"type": [
{
"code": "Reference",
"targetProfile": [
"http://pharmacyeclaims.ca/FHIR/v1.0/StructureDefinition/profile-patient"
],
"aggregation": [
"bundled"
]
}
],
"mustSupport": true
},
{
"id": "Claim.patient.reference",
"path": "Claim.patient.reference",
"min": 1,
"mustSupport": true
},
{
"id": "Claim.created",
"path": "Claim.created",
"comment": "Usage note: This may be different from the service date and is mandatory in FHIR\r\n\r\nThis 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.",
"mustSupport": true
},
{
"id": "Claim.enterer",
"path": "Claim.enterer",
"mustSupport": true
},
{
"id": "Claim.enterer.identifier",
"path": "Claim.enterer.identifier",
"mustSupport": true
},
{
"id": "Claim.provider",
"path": "Claim.provider",
"mustSupport": true
},
{
"id": "Claim.provider.reference",
"path": "Claim.provider.reference",
"mustSupport": true
},
{
"id": "Claim.provider.identifier",
"path": "Claim.provider.identifier",
"comment": "CPHA Map: B.21.03 Pharmacy ID Code\r\nWhen an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. \n\nWhen both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference\n\nApplications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.\n\nReference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).",
"mustSupport": true
},
{
"id": "Claim.priority",
"path": "Claim.priority",
"mustSupport": true
},
{
"id": "Claim.priority.coding",
"path": "Claim.priority.coding",
"min": 1,
"max": "1"
},
{
"id": "Claim.priority.coding.system",
"path": "Claim.priority.coding.system",
"min": 1,
"fixedUri": "http://terminology.hl7.org/CodeSystem/processpriority",
"mustSupport": true
},
{
"id": "Claim.priority.coding.code",
"path": "Claim.priority.coding.code",
"min": 1,
"fixedCode": "stat",
"mustSupport": true
},
{
"id": "Claim.priority.text",
"path": "Claim.priority.text",
"comment": "CPHA Map: None, this is a new mandatory field\r\n\r\nVery often the text is the same as a displayName of one of the codings.",
"min": 1,
"fixedString": "Immediate",
"mustSupport": true
},
{
"id": "Claim.related",
"path": "Claim.related",
"comment": "Usage Note: This is a reference to a related dispense claim identifier to allow adjudicators to formally relate the professional claim to the claim for the medication dispense. \r\nUsage Note: If known to the pharmacy, this link should be provided.\r\nCPHA Map: None - this is a new data element\r\n\r\nFor example, for the original treatment and follow-up exams.",
"mustSupport": true
},
{
"id": "Claim.related.claim",
"path": "Claim.related.claim",
"min": 1,
"mustSupport": true
},
{
"id": "Claim.related.claim.identifier",
"path": "Claim.related.claim.identifier",
"min": 1,
"mustSupport": true
},
{
"id": "Claim.related.claim.identifier.system",
"path": "Claim.related.claim.identifier.system",
"mustSupport": true
},
{
"id": "Claim.related.claim.identifier.value",
"path": "Claim.related.claim.identifier.value",
"min": 1,
"mustSupport": true
},
{
"id": "Claim.prescription",
"path": "Claim.prescription",
"max": "0"
},
{
"id": "Claim.prescription.reference",
"path": "Claim.prescription.reference",
"min": 1,
"mustSupport": true
},
{
"id": "Claim.originalPrescription",
"path": "Claim.originalPrescription",
"comment": "Usage: Number assigned to a prescription or service record on the original date of prescription or professional service was provided. In a professional sevices claim, this is typically the same identifier as the current prescription number.\r\nCPHA Map - D.53.03 Original Prescription Number 9N\r\n\r\nFor 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'.",
"max": "0",
"mustSupport": false
},
{
"id": "Claim.payee",
"path": "Claim.payee",
"comment": "Usage Note: This field differentiates between the \"Pay Provider\" and \"Pay Cardholder (aka Subscriber) \" claims. \r\nUsage Note: Set code = \"subscriber\" or \"provider\" to indicate the payee type requested.\r\nCPHA Map: This was differentiated by transaction type 01 or 04. \r\n\r\nOften 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.",
"min": 1,
"mustSupport": true
},
{
"id": "Claim.payee.type",
"path": "Claim.payee.type",
"mustSupport": true
},
{
"id": "Claim.payee.type.coding",
"path": "Claim.payee.type.coding",
"min": 1,
"max": "1",
"mustSupport": true,
"binding": {
"strength": "extensible",
"valueSet": "http://hl7.org/fhir/ValueSet/payeetype"
}
},
{
"id": "Claim.payee.type.coding.system",
"path": "Claim.payee.type.coding.system",
"min": 1,
"fixedUri": "http://terminology.hl7.org/CodeSystem/payeetype",
"mustSupport": true
},
{
"id": "Claim.payee.type.coding.code",
"path": "Claim.payee.type.coding.code",
"comment": "Usage Note: Set code = \"subscriber\" or \"provider\" to indicate the payee type requested.\r\nCPHA Map: Transaction Code 01 for Provider claims, code 04 for cardholder claims.\r\n\r\nNote that FHIR strings SHALL NOT exceed 1MB in size",
"min": 1,
"mustSupport": true
},
{
"id": "Claim.careTeam",
"path": "Claim.careTeam",
"comment": "Usage Note: This is used to specify who delivered the service as well as who was responsible for the service. For example, a nurse may deliver the service but the pharmacist may be responsible for the service. In this case, both providers should be specified.\r\nCPHA Map: New data element and is therefore not mandatory; must be populated when known.",
"max": "1",
"mustSupport": true
},
{
"id": "Claim.careTeam.sequence",
"path": "Claim.careTeam.sequence",
"mustSupport": true
},
{
"id": "Claim.careTeam.provider",
"path": "Claim.careTeam.provider",
"mustSupport": true
},
{
"id": "Claim.careTeam.provider.identifier",
"path": "Claim.careTeam.provider.identifier",
"comment": "Usage Note: The identifier of the pharmacist or other clinician\r\n\r\nWhen an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. \n\nWhen both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference\n\nApplications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.\n\nReference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).",
"min": 1
},
{
"id": "Claim.careTeam.provider.identifier.system",
"path": "Claim.careTeam.provider.identifier.system",
"min": 1,
"mustSupport": true
},
{
"id": "Claim.careTeam.provider.identifier.value",
"path": "Claim.careTeam.provider.identifier.value",
"min": 1,
"mustSupport": true
},
{
"id": "Claim.careTeam.responsible",
"path": "Claim.careTeam.responsible",
"comment": "Usage Note: This value is \"true\" for the pharmacist who is responsible for the claim. This is \"false\" for a clinician (eg nurse) who is under the supervision of the responsible pharmacist.\r\n\r\nResponsible might not be required when there is only a single provider listed.",
"min": 1
},
{
"id": "Claim.supportingInfo",
"path": "Claim.supportingInfo",
"slicing": {
"discriminator": [
{
"type": "value",
"path": "code.coding.code"
}
],
"rules": "open"
},
"mustSupport": true
},
{
"id": "Claim.supportingInfo.sequence",
"path": "Claim.supportingInfo.sequence",
"mustSupport": true
},
{
"id": "Claim.supportingInfo.category",
"path": "Claim.supportingInfo.category",
"mustSupport": true
},
{
"id": "Claim.supportingInfo.category.coding",
"path": "Claim.supportingInfo.category.coding",
"comment": "Conformance Rule: Set code value = Dispense, and value = reference to the dispense resource. Set code = DaysSupply Set code = Refils Remaining\r\n\r\nCodes 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.",
"min": 1,
"max": "1",
"mustSupport": true
},
{
"id": "Claim.supportingInfo.category.coding.code",
"path": "Claim.supportingInfo.category.coding.code",
"min": 1,
"mustSupport": true
},
{
"id": "Claim.supportingInfo.value[x]",
"path": "Claim.supportingInfo.value[x]",
"mustSupport": true
},
{
"id": "Claim.supportingInfo.reason",
"path": "Claim.supportingInfo.reason",
"comment": "Usage: for professional services, a reason may be provided.\r\n\r\nFor example: the reason for the additional stay, or why a tooth is missing.",
"mustSupport": true
},
{
"id": "Claim.supportingInfo:Reason",
"path": "Claim.supportingInfo",
"sliceName": "Reason",
"comment": "Usage: A reason may be specified for a professional service.\r\n\r\nOften there are multiple jurisdiction specific valuesets which are required."
},
{
"id": "Claim.supportingInfo:Reason.sequence",
"path": "Claim.supportingInfo.sequence",
"mustSupport": true
},
{
"id": "Claim.supportingInfo:Reason.category",
"path": "Claim.supportingInfo.category",
"mustSupport": true
},
{
"id": "Claim.supportingInfo:Reason.category.coding",
"path": "Claim.supportingInfo.category.coding",
"min": 1,
"max": "1",
"mustSupport": true
},
{
"id": "Claim.supportingInfo:Reason.category.coding.code",
"path": "Claim.supportingInfo.category.coding.code",
"min": 1,
"fixedCode": "Reason",
"mustSupport": true
},
{
"id": "Claim.supportingInfo:Reason.value[x]",
"path": "Claim.supportingInfo.value[x]",
"max": "0"
},
{
"id": "Claim.supportingInfo:Reason.reason",
"path": "Claim.supportingInfo.reason",
"comment": "Usage: A code must be specified when known; text is also supported for audit purposes only\r\n\r\nFor example: the reason for the additional stay, or why a tooth is missing.",
"min": 1,
"mustSupport": true
},
{
"id": "Claim.supportingInfo:Reason.reason.coding",
"path": "Claim.supportingInfo.reason.coding",
"mustSupport": true
},
{
"id": "Claim.supportingInfo:Reason.reason.coding.code",
"path": "Claim.supportingInfo.reason.coding.code",
"mustSupport": true
},
{
"id": "Claim.supportingInfo:Reason.reason.text",
"path": "Claim.supportingInfo.reason.text",
"mustSupport": true
},
{
"id": "Claim.supportingInfo:SpecialAuth",
"path": "Claim.supportingInfo",
"sliceName": "SpecialAuth",
"comment": "Usage Note: This allows the provider to claim for products and services which require prior authorization, This field enables the provider to claim for a product or service which is not ordinarily covered (e.g. NIHB Non-Formulary Benefits which can be provided by prior authorization). Authorization \r\nnumbers will be issued by the payor. \r\nCPHA Map: Special Authorization Number or Code D.64.03 \r\n\r\nOften there are multiple jurisdiction specific valuesets which are required.",
"mustSupport": true
},
{
"id": "Claim.supportingInfo:SpecialAuth.sequence",
"path": "Claim.supportingInfo.sequence",
"fixedPositiveInt": 2,
"mustSupport": true
},
{
"id": "Claim.supportingInfo:SpecialAuth.category",
"path": "Claim.supportingInfo.category",
"comment": "Usage: This is a fixed value of \"SpecialAuth\"\r\nThis may contain a category for the local bill type codes.",
"fixedCodeableConcept": {
"coding": [
{
"code": "SpecialAuth"
}
]
},
"mustSupport": true
},
{
"id": "Claim.supportingInfo:SpecialAuth.category.coding",
"path": "Claim.supportingInfo.category.coding",
"min": 1,
"max": "1",
"mustSupport": true
},
{
"id": "Claim.supportingInfo:SpecialAuth.category.coding.code",
"path": "Claim.supportingInfo.category.coding.code",
"min": 1,
"fixedCode": "SpecialAuth",
"mustSupport": true
},
{
"id": "Claim.supportingInfo:SpecialAuth.code.coding",
"path": "Claim.supportingInfo.code.coding",
"mustSupport": false
},
{
"id": "Claim.supportingInfo:SpecialAuth.code.coding.system",
"path": "Claim.supportingInfo.code.coding.system",
"mustSupport": false
},
{
"id": "Claim.supportingInfo:SpecialAuth.code.coding.code",
"path": "Claim.supportingInfo.code.coding.code",
"mustSupport": false
},
{
"id": "Claim.supportingInfo:SpecialAuth.value[x]",
"path": "Claim.supportingInfo.value[x]",
"comment": "Usage Note: This allows the provider to claim for products and services which require prior authorization, This field enables the provider to claim for a product or service which is not ordinarily covered (e.g. NIHB Non-Formulary Benefits which can be provided by prior authorization). Authorization \r\nnumbers will be issued by the payor. \r\nCPHA Map: Special Authorization Number or Code D.64.03 \r\n\r\nCould 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.",
"min": 1,
"type": [
{
"code": "string"
}
],
"mustSupport": true
},
{
"id": "Claim.diagnosis",
"path": "Claim.diagnosis",
"comment": "Usage Note: Indicates prescriber's designation of the medical condition for which the patient is being treated if required by plan.\r\nConformance Rule: Current support for: ICD-9 or ICD-10CA, ODB reason for use codes, DND Eligible Medical Conditions. If one or more are known, they must be included. Adjudicators may also include implementation specific rules, eg SNOMED and this may also be included if known or agreed to by implementers.\r\n\r\nCPHA Map: Medical Condition/ Reason for Use D.51.03 A/N6 and Medical Reason/Reference D.50.03 Limited to one code",
"mustSupport": true
},
{
"id": "Claim.diagnosis.sequence",
"path": "Claim.diagnosis.sequence",
"mustSupport": true
},
{
"id": "Claim.diagnosis.diagnosis[x]",
"path": "Claim.diagnosis.diagnosis[x]",
"type": [
{
"code": "CodeableConcept"
}
],
"mustSupport": true
},
{
"id": "Claim.diagnosis.diagnosis[x].coding",
"path": "Claim.diagnosis.diagnosis[x].coding",
"comment": "Usage Note: Allows multiple codes to be specified where translation has occurred. Vendors should send all possible codings as this may vary amongst adjudicators.\r\nAlignment: PrescribeIT supports SNOMED\r\n\r\nCodes 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.",
"min": 1,
"mustSupport": true
},
{
"id": "Claim.diagnosis.diagnosis[x].coding.system",
"path": "Claim.diagnosis.diagnosis[x].coding.system",
"comment": "Usage: Provides for the Identification of reference codes that are used by the prescriber to designate the medical condition or reason for use. \r\nConformance Rule: System values are: \r\n\r\nCPHA Map: Medical Reason Reference D.50.03 A1\r\nICD-9 (http://hl7.org/fhir/sid/icd-9-cm)\r\nODB reason for use (system =http://pharmacyeclaims.ca/FHIR/CPHA-diagnosis-ODB-reason-code|\r\nICD-10 (http://hl7.org/fhir/sid/icd-10)\r\nDND Eligible Medical Conditions (system = http://pharmacyeclaims.ca/FHIR/CPHA-diagnosis-DND-eligible-medical-conditions|Claim.diagnosis.code)\r\r\nThe URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.",
"mustSupport": true
},
{
"id": "Claim.diagnosis.diagnosis[x].coding.code",
"path": "Claim.diagnosis.diagnosis[x].coding.code",
"min": 1,
"mustSupport": true
},
{
"id": "Claim.diagnosis.diagnosis[x].text",
"path": "Claim.diagnosis.diagnosis[x].text",
"comment": "Usage Note: May be included where code system mapping has occurred\r\n\r\nVery often the text is the same as a displayName of one of the codings.",
"mustSupport": true
},
{
"id": "Claim.insurance",
"path": "Claim.insurance",
"comment": "Usage Note: This is currently restricted to 5 instances of insurance. All known instances should be included with the sequence number reflecting the COB Order. Only one instance can be the focal=true. The first/primary claim submission will not include any prior ClaimResponses.\r\n\r\nAll 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.",
"mustSupport": true
},
{
"id": "Claim.insurance.sequence",
"path": "Claim.insurance.sequence",
"comment": "Usage Note: This reflects the order for COB purposes. By example, if a secondary claim is being submitted, the sequence = 2 and focal = true and the claimResponse from the primary adjudicator will be present. If a primary claim is being submitted, multiple coverages can be included. Sequence 1 and focal=true.\r\nUsage Note: Where available, the claimResponse frrom prior claims must be included.\r\n\r\nCPHA Map: N/A - new\r\n32 bit number; for values larger than this, use decimal",
"mustSupport": true
},
{
"id": "Claim.insurance.focal",
"path": "Claim.insurance.focal",
"mustSupport": true
},
{
"id": "Claim.insurance.coverage",
"path": "Claim.insurance.coverage",
"type": [
{
"code": "Reference",
"targetProfile": [
"http://pharmacyeclaims.ca/FHIR/v1.0/StructureDefinition/profile-coverage"
],
"aggregation": [
"bundled"
]
}
],
"mustSupport": true
},
{
"id": "Claim.insurance.coverage.reference",
"path": "Claim.insurance.coverage.reference",
"min": 1,
"mustSupport": true
},
{
"id": "Claim.insurance.claimResponse",
"path": "Claim.insurance.claimResponse",
"comment": "Usage Note: Includes the claim response from prior adjudicators, for secondary, tertiary claims.\r\nCPHA Map: N/A - new\r\nMust not be specified when 'focal=true' for this insurance.",
"mustSupport": true
},
{
"id": "Claim.item",
"path": "Claim.item",
"comment": "Usage Note: Only a single item may be submitted per claim",
"min": 1,
"max": "1",
"mustSupport": true
},
{
"id": "Claim.item.sequence",
"path": "Claim.item.sequence",
"comment": "Usage Note: This is expected to be a value of \"1\"\r\n32 bit number; for values larger than this, use decimal",
"mustSupport": true
},
{
"id": "Claim.item.productOrService",
"path": "Claim.item.productOrService",
"comment": "Usage Note: This is the product or service being claimed. \r\nUsage Note: This element is used to represent the medication that has been dispensed. A 'code' (Canadian Clinical Drug Data Set (CCDD), or DIN or NPN) must be provided. For compounds, description will be sent as 'text'. A DIN, or an NPN may also be used if a CCDD code is not available. This has an extensible binding meaning that the CCDD code system should be used but if a code is not available, vendors may also submit a code from the DIN or NPN code system. Note: CCDD will encompass all DINs and NPNs.\r\n\r\nUsage Note: For compounds, which do not have an assigned PIN, the DIN of the eligible active ingredient with the highest total cost will be specified in the medication.code. The \"unlisted compound code\" will be specified here. This field is optional only if Field D.57.03 (SSC) is used and no product, compound or other item(s) are provided to the patient.\r\nConformance Rule: This field is optional only a Special Service Code is used and no product, compound or other item(s) are provided to the patient.\r\n\r\nCode systems that are acceptable in the message are:\r\nCCDD - https://fhir.infoway-inforoute.ca/CodeSystem/canadianclinicaldrugdataset\r\nDIN - http://hl7.org/fhir/NamingSystem/ca-hc-din\r\nNPN - http://hl7.org/fhir/NamingSystem/ca-hc-npn\r\nUnlistedCompound PINS- http://pharmacyeclaims.ca/FHIR/CodeSystem/unlisted-compound-codes \r\nOpinions - PIN - 2.16.840.1.113883.5.1102 (source PEI)\r\nAdjudicator-specific Psuedo DINs - Adjudicator specific. Each adjudicator will provide the \"Code system\" associated with their set of codes. Once established this specificaiton can be updated to include\r\n\r\n\r\n\r\nCPHA Map: DIN/GP#/PIN/UNLISTED COMPOUND\r\n\r\nIf 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'.",
"mustSupport": true
},
{
"id": "Claim.item.productOrService.coding",
"path": "Claim.item.productOrService.coding",
"min": 1,
"max": "1",
"mustSupport": true
},
{
"id": "Claim.item.productOrService.coding.system",
"path": "Claim.item.productOrService.coding.system",
"comment": "Usage Note: Differentiates between code systems\r\nCPHA Map; N/A - New\r\n\r\nThe URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.",
"min": 1,
"mustSupport": true
},
{
"id": "Claim.item.productOrService.coding.code",
"path": "Claim.item.productOrService.coding.code",
"min": 1,
"mustSupport": true
},
{
"id": "Claim.item.productOrService.text",
"path": "Claim.item.productOrService.text",
"comment": "Usage Note: May be used to convey the description of the compound (eg Magic Mouthwash)\r\n\r\nVery often the text is the same as a displayName of one of the codings.",
"mustSupport": true
},
{
"id": "Claim.item.modifier",
"path": "Claim.item.modifier",
"comment": "Usage Note: Provides codes which detail intervention procedures taken or identify that special coverage and payment rules are being claimed. Conformance Rule: This supports up to 10 intervention codes \r\n\r\nCPHA Map: INTERVENTION CODES D.65.03. Limt of two for CPHA; limit of 10 or FHIR. As FHIR allows more, only two intervention codes should be sent if the claim is going to an adjudicator who supports CPHA. Note: As a general rule, the vendor submitting the claim will submit it in the format supported by the adjudication system.\r\n\r\nFor 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.",
"mustSupport": true
},
{
"id": "Claim.item.modifier.coding",
"path": "Claim.item.modifier.coding",
"slicing": {
"discriminator": [
{
"type": "value",
"path": "system"
}
],
"rules": "open"
},
"min": 1,
"mustSupport": true
},
{
"id": "Claim.item.modifier.coding.system",
"path": "Claim.item.modifier.coding.system",
"min": 1,
"fixedUri": "http://pharmacyeclaims.ca/FHIR/CodeSystem/intervention-codes",
"mustSupport": true
},
{
"id": "Claim.item.modifier.coding.code",
"path": "Claim.item.modifier.coding.code",
"min": 1,
"mustSupport": true
},
{
"id": "Claim.item.modifier.coding:SpecialServiceCode",
"path": "Claim.item.modifier.coding",
"sliceName": "SpecialServiceCode",
"comment": "CPHA Mapping: SSC D.57.03 Limited to 3 \r\nUsage Note: This has increased to allow for 10 codes in the future. This may be configurable and may vary by adjudicator\r\r\n\r\nCodes 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.",
"max": "10"
},
{
"id": "Claim.item.modifier.coding:SpecialServiceCode.system",
"path": "Claim.item.modifier.coding.system",
"min": 1,
"fixedUri": "http://pharmacyeclaims.ca/FHIR/CodeSystem/special-service-codes",
"mustSupport": true
},
{
"id": "Claim.item.modifier.coding:SpecialServiceCode.code",
"path": "Claim.item.modifier.coding.code",
"min": 1,
"mustSupport": true
},
{
"id": "Claim.item.modifier.coding:InterventionCode",
"path": "Claim.item.modifier.coding",
"sliceName": "InterventionCode",
"comment": "CPHA Mapping: Intervention and Exception CodesD.65.03\r\nThis field provides codes which detail DUR intervention procedures taken or identify that special coverage and payment rules are being claimed\r\r\n\r\nCodes 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.",
"max": "10"
},
{
"id": "Claim.item.modifier.coding:InterventionCode.system",
"path": "Claim.item.modifier.coding.system",
"min": 1,
"fixedUri": "http://pharmacyeclaims.ca/FHIR/CodeSystem/intervention-codes",
"mustSupport": true
},
{
"id": "Claim.item.modifier.coding:InterventionCode.code",
"path": "Claim.item.modifier.coding.code",
"min": 1,
"mustSupport": true
},
{
"id": "Claim.item.serviced[x]",
"path": "Claim.item.serviced[x]",
"comment": "Usage note: Date on which prescription and/or professional service is provided. Established by the provider in accordance with the official time in the zone where the provider is located\r\nCPHA Map: B.22.03 - Provider Transaction Date",
"min": 1,
"type": [
{
"code": "date"
}
],
"mustSupport": true
},
{
"id": "Claim.item.quantity",
"path": "Claim.item.quantity",
"binding": {
"strength": "extensible",
"valueSet": "https://fhir.infoway-inforoute.ca/ValueSet/prescribedquantityunit"
}
},
{
"id": "Claim.item.quantity.value",
"path": "Claim.item.quantity.value",
"min": 1,
"mustSupport": true
},
{
"id": "Claim.item.quantity.unit",
"path": "Claim.item.quantity.unit",
"mustSupport": true
},
{
"id": "Claim.item.quantity.system",
"path": "Claim.item.quantity.system",
"comment": "Note: Alignment to PrescribeIT value set; codes from both UCUM and SNOMED\r\nCPHA map: N/A new\r\n\r\nsee http://en.wikipedia.org/wiki/Uniform_resource_identifier",
"min": 1,
"mustSupport": true
},
{
"id": "Claim.item.quantity.code",
"path": "Claim.item.quantity.code",
"comment": "Usage Rule: Allows for units, eg unit, package, mL, L,g, kg. \r\n\r\nThe 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.",
"min": 1,
"mustSupport": true
},
{
"id": "Claim.item.net",
"path": "Claim.item.net",
"comment": "Usage Note: Total amount claimed in Canadian dollars.\r\nCPHA Mapping: None\r\n\r\nFor example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.",
"mustSupport": true
},
{
"id": "Claim.item.net.value",
"path": "Claim.item.net.value",
"min": 1,
"mustSupport": true
},
{
"id": "Claim.item.detail",
"path": "Claim.item.detail",
"slicing": {
"discriminator": [
{
"type": "value",
"path": "productOrService.coding.code"
}
],
"rules": "open"
},
"comment": "Usage Note: Details are used to specify each component pertaining to the item being claimed, including the Drug Cost, Dispense Fee, Quebec Professional Fee, Quebec Reference Price, Quebec Retail+Dispense, Special Service Fee, Cost Upcharge, Compounding Fee, Compounding Time. For each, a sequence number, code and net amount will be specified.",
"min": 1,
"mustSupport": true
},
{
"id": "Claim.item.detail.sequence",
"path": "Claim.item.detail.sequence",
"comment": "Usage Note: This is a sequential number assigned for each detail\r\n32 bit number; for values larger than this, use decimal",
"mustSupport": true
},
{
"id": "Claim.item.detail.productOrService",
"path": "Claim.item.detail.productOrService",
"comment": "Usage: This will identify the service being provided.\r\n\r\nIf 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'.",
"mustSupport": true,
"binding": {
"strength": "extensible",
"valueSet": "http://pharmacyeclaims.ca/FHIR/ValueSet/pharma-service"
}
},
{
"id": "Claim.item.detail.productOrService.coding",
"path": "Claim.item.detail.productOrService.coding",
"min": 1,
"mustSupport": true
},
{
"id": "Claim.item.detail.productOrService.coding.system",
"path": "Claim.item.detail.productOrService.coding.system",
"min": 1,
"fixedUri": "http://pharmacyeclaims.ca/FHIR/CodeSystem/pharma-service",
"mustSupport": true
},
{
"id": "Claim.item.detail.productOrService.coding.code",
"path": "Claim.item.detail.productOrService.coding.code",
"min": 1,
"mustSupport": true
},
{
"id": "Claim.item.detail.net",
"path": "Claim.item.detail.net",
"comment": "Usage Note: Must be populated for all except Compounding Time.\r\nConformance Rule: The sum of all net amounts for the details must equal the net amount charged for the item (claim.item.net) \r\n\r\nFor example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.",
"mustSupport": true
},
{
"id": "Claim.item.detail:ProfessionalFee",
"path": "Claim.item.detail",
"sliceName": "ProfessionalFee",
"comment": "Usage Note: Pharmacist's fee for professional and technical activities associated with providing the prescribed medication and service. This is a fee to compensate the pharacist for professional services associated with the dispensing of a prescription. Unless a plan, or agreement between a provider and a payor, contains provisions for including compensation for compounding or special services in the professional fee, compensation for these services will be claimed separately as a \"Compounding Charge\" ( D.70.03) and a \"Special Services Fee\" (D.72.03).\r\n\r\nCPHA Mapping: D.66.03 Drug Cost",
"max": "1",
"mustSupport": true
},
{
"id": "Claim.item.detail:ProfessionalFee.sequence",
"path": "Claim.item.detail.sequence",
"comment": "Usage Note: When item is specified, the next availabe sequence number will be assigned. eg 1,2,3\r\n\r\n32 bit number; for values larger than this, use decimal",
"mustSupport": true
},
{
"id": "Claim.item.detail:ProfessionalFee.productOrService",
"path": "Claim.item.detail.productOrService",
"mustSupport": true
},
{
"id": "Claim.item.detail:ProfessionalFee.productOrService.coding",
"path": "Claim.item.detail.productOrService.coding",
"min": 1,
"max": "1",
"mustSupport": true
},
{
"id": "Claim.item.detail:ProfessionalFee.productOrService.coding.code",
"path": "Claim.item.detail.productOrService.coding.code",
"min": 1,
"fixedCode": "D.68.03",
"mustSupport": true
},
{
"id": "Claim.item.detail:ProfessionalFee.net",
"path": "Claim.item.detail.net",
"min": 1,
"mustSupport": true
}
]
}
}
FHIR