MII IG Kerndatensatz-Modul Molekulares Tumorboard
2027.0.0-ballot.1 - Germany

This page is part of the MII Implementation Guide Molecular Tumor Board (v2027.0.0-ballot.1: Release) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

Resource Profile: MII PR MTB Antrag Kostenuebernahme

Official URL: https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/StructureDefinition/mii-pr-mtb-antrag-kostenuebernahme Version: 2027.0.0-ballot.1
Active as of 2026-09-15 Computable Name: MII_PR_MTB_Antrag_Kostenuebernahme

Antrag Kostenübernahme

Content

This profile describes the response to the application for Kostenübernahme (cost coverage) (MII_PR_Antrag_Kostenuebernahme). They are based on the Financial resource ClaimResponse. CAVE: The lifecycle status of a Financial resource does not correspond to the familiar workflows. The Financial resources maintain their own ValueSet with their own semantic meanings (see https://hl7.org/fhir/R4/valueset-fm-status.html). A ClaimResponse should therefore normally always be active as long as it has not been withdrawn.

The element "prescription" references the MedicationRequest, ideally the profile MII_PR_Medikation_MedicationRequest.

Content

Mapping dataset to FHIR

Search parameters

The following search parameters are relevant for the Oncology module, also in combination:

  1. The search parameter "_id" MUST be supported:

    Examples:

    GET [base]/Claim?_id=12345

    Usage notes: Further information on searching for "_id" can be found in the FHIR base specification - section "Parameters for all resources".

  2. The search parameter "_profile" MUST be supported:

    Examples:

    GET [base]/Claim?_profile=https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/StructureDefinition/mii-pr-mtb-antrag-kostenuebernahme

    Usage notes: Further information on searching for "_profile" can be found in the FHIR base specification - section "Parameters for all resources".

  3. The search parameter "claim-type" MUST be supported:

    Examples:

    GET [base]/Claim?claim-type=https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/ValueSet/mii-vs-mtb-antrag-kostenuebernahme

    Usage notes: Further information on searching for "Claim.type" can be found in the FHIR base specification - section "Token Search".

  4. The search parameter "use" MUST be supported:

    Examples:

    GET [base]/Claim?use=claim

    Usage notes: Further information on searching for "Claim.use" can be found in the FHIR base specification - section "Token Search".

  5. The search parameter "patient" MUST be supported:

    Examples:

    GET [base]/Claim?patient=Patient/example

    Usage notes: Further information on searching for "Claim.patient" can be found in the FHIR base specification - section "Reference Search".

  6. The search parameter "created" MUST be supported:

    Examples:

    GET [base]/Claim?created=eq2022-01-01

    Usage notes: Further information on searching for "Claim.created" can be found in the FHIR base specification - section "Date Search".

  7. The search parameter "provider" MUST be supported:

    Examples:

    GET [base]/Claim?provider=Practicioner/example

    Usage notes: Further information on searching for "Claim.provider" can be found in the FHIR base specification - section "Reference Search".

  8. The search parameter "claim-related" MUST be supported:

    Examples:

    GET [base]/Claim?claim-related=Claim/example

    Usage notes: Further information on searching for "Claim.related.claim" can be found in the FHIR base specification - section "Reference Search".

  9. The search parameter "claim-related-relationship" MUST be supported:

    Examples:

    GET [base]/Claim?claim-related-relationship=https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/CodeSystem/mii-cs-mtb-antrag-kostenuebernahme-antragsstadium#accepted

    Usage notes: Further information on searching for "Claim.related.claim" can be found in the FHIR base specification - section "Reference Search".

  10. The search parameter "claim-related-relationship" MUST be supported:

    Examples:

    GET [base]/Claim?claim-related-relationship=https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/CodeSystem/mii-cs-mtb-antrag-kostenuebernahme-antragsstadium#accepted

    Usage notes: Further information on searching for "Claim.related.relationship.coding" can be found in the FHIR base specification - section "Token Search".

Examples

Usages:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots, and their representations.

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Claim 0..* Claim Claim, Pre-determination or Pre-authorization
... meta SΣ 0..1 Meta Metadata about the resource
.... profile SΣ 0..* canonical(StructureDefinition) Profiles this resource claims to conform to
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... type SΣ 1..1 CodeableConcept Applicant Category
Binding: MII VS MTB Antrag Kostenuebernahme (required)
... use SΣ 1..1 code Type of cost reimbursement application - claim or predetermination or preauthorization
Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim.
... patient SΣ 1..1 Reference(Patient) The recipient of the products and services
... created SΣ 1..1 dateTime Application Date
... provider SΣ 1..1 Reference(Practitioner | PractitionerRole | Organization) Applicant Institution / Clinic / Person
... priority SΣ 1..1 CodeableConcept Application Priority
Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.
Required Pattern: At least the following
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/processpriority
..... version 0..1 string Version of the system - if relevant
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: normal
..... display 0..1 string Representation defined by the system
..... userSelected 0..1 boolean If this coding was chosen directly by the user
.... text 0..1 string Plain text representation of the concept
... related S 0..* BackboneElement Prior or corollary claims
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... claim S 0..1 Reference(MII PR MTB Antrag Kostenuebernahme) for follow-up application/objection: Reference to original initial application
.... relationship S 0..1 CodeableConcept How the reference claim is related
Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim.
..... coding SΣ 1..* Coding Application Stage
...... system Σ 0..1 uri Identity of the terminology system
Required Pattern: https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/CodeSystem/mii-cs-mtb-antrag-kostenuebernahme-antragsstadium
...... code SΣ 1..1 code Symbol in syntax defined by the system
... prescription S 0..1 Reference(MedicationRequest) Therapy Recommendation
... Slices for careTeam 1..* BackboneElement Members of the care team
Slice: Unordered, Open by type:sequence
.... careTeam:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Order of care team
..... provider 1..1 Reference(Practitioner | PractitionerRole | Organization) Practitioner or organization
.... careTeam:ZPMBeteiligung S 1..1 BackboneElement ZPM Application
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence S 1..1 positiveInt internal variable of the participating institution
Required Pattern: 1
..... provider S 1..1 Reference(Organization) Reference to ZPM
..... responsible S 1..1 boolean ZPM Participation - Yes/No
... insurance SΣ 1..* BackboneElement Patient insurance information
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence SΣ 1..1 positiveInt Insurance Priority
.... focal SΣ 1..1 boolean Insurance relevant for this application
Required Pattern: true
.... coverage SΣ 1..1 Reference(Coverage) Insurance relevant for this application
.... claimResponse S 0..1 Reference(ClaimResponse) Adjudication results

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Claim.status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
Claim.type Base required MII VS MTB Antrag Kostenuebernahme 📦2027.0.0-ballot.1 This IG
Claim.use Base required Use 📍4.0.1 FHIR Std.
Claim.priority Base example Process Priority Codes 📍4.0.1 FHIR Std.
Claim.related.relationship Base example Example Related Claim Relationship Codes 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error Claim If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Claim 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().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error Claim 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()
dom-5 error Claim If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Claim A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Claim 0..* Claim Claim, Pre-determination or Pre-authorization
... meta S 0..1 Meta Metadata about the resource
.... profile S 0..* canonical(StructureDefinition) Profiles this resource claims to conform to
... status S 1..1 code Application
Fixed Value: active
... type S 1..1 CodeableConcept Applicant Category
Binding: MII VS MTB Antrag Kostenuebernahme (required)
... patient S 1..1 Reference(Patient) The recipient of the products and services
... created S 1..1 dateTime Application Date
... provider S 1..1 Reference(Practitioner | PractitionerRole | Organization) Applicant Institution / Clinic / Person
... priority S 1..1 CodeableConcept Application Priority
Required Pattern: At least the following
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/processpriority
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: normal
... related S 0..* BackboneElement Prior or corollary claims
.... claim S 0..1 Reference(MII PR MTB Antrag Kostenuebernahme) for follow-up application/objection: Reference to original initial application
.... relationship S 0..1 CodeableConcept How the reference claim is related
..... coding S 1..* Coding Application Stage
...... system 0..1 uri Identity of the terminology system
Required Pattern: https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/CodeSystem/mii-cs-mtb-antrag-kostenuebernahme-antragsstadium
...... code S 1..1 code Symbol in syntax defined by the system
... prescription S 0..1 Reference(MedicationRequest) Therapy Recommendation
... Slices for careTeam 1..* BackboneElement Members of the care team
Slice: Unordered, Open by type:sequence
.... careTeam:ZPMBeteiligung S 1..1 BackboneElement ZPM Application
..... sequence S 1..1 positiveInt internal variable of the participating institution
Required Pattern: 1
..... provider S 1..1 Reference(Organization) Reference to ZPM
..... responsible S 1..1 boolean ZPM Participation - Yes/No
... insurance S 1..* BackboneElement Patient insurance information
.... sequence S 1..1 positiveInt Insurance Priority
.... focal S 1..1 boolean Insurance relevant for this application
Required Pattern: true
.... coverage S 1..1 Reference(Coverage) Insurance relevant for this application
.... claimResponse S 0..1 Reference(ClaimResponse) Adjudication results

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
Claim.type Base required MII VS MTB Antrag Kostenuebernahme 📦2027.0.0-ballot.1 This IG
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Claim 0..* Claim Claim, Pre-determination or Pre-authorization
... id Σ 0..1 id Logical id of this artifact
... meta SΣ 0..1 Meta Metadata about the resource
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ 0..1 id Version specific identifier
.... lastUpdated Σ 0..1 instant When the resource version last changed
.... source Σ 0..1 uri Identifies where the resource comes from
.... profile SΣ 0..* canonical(StructureDefinition) Profiles this resource claims to conform to
.... security Σ 0..* Coding Security Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
.... tag Σ 0..* Coding Tags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier 0..* Identifier Business Identifier for claim
... status ?!SΣ 1..1 code Application
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
Fixed Value: active
... type SΣ 1..1 CodeableConcept Applicant Category
Binding: MII VS MTB Antrag Kostenuebernahme (required)
... subType 0..1 CodeableConcept More granular claim type
Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
... use SΣ 1..1 code Type of cost reimbursement application - claim or predetermination or preauthorization
Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim.
... patient SΣ 1..1 Reference(Patient) The recipient of the products and services
... billablePeriod Σ 0..1 Period Relevant time frame for the claim
... created SΣ 1..1 dateTime Application Date
... enterer 0..1 Reference(Practitioner | PractitionerRole) Author of the claim
... insurer Σ 0..1 Reference(Organization) Target
... provider SΣ 1..1 Reference(Practitioner | PractitionerRole | Organization) Applicant Institution / Clinic / Person
... priority SΣ 1..1 CodeableConcept Application Priority
Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.
Required Pattern: At least the following
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/processpriority
..... version 0..1 string Version of the system - if relevant
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: normal
..... display 0..1 string Representation defined by the system
..... userSelected 0..1 boolean If this coding was chosen directly by the user
.... text 0..1 string Plain text representation of the concept
... fundsReserve 0..1 CodeableConcept For whom to reserve funds
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
... related S 0..* BackboneElement Prior or corollary claims
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... claim S 0..1 Reference(MII PR MTB Antrag Kostenuebernahme) for follow-up application/objection: Reference to original initial application
.... relationship S 0..1 CodeableConcept How the reference claim is related
Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim.
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... coding SΣ 1..* Coding Application Stage
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system Σ 0..1 uri Identity of the terminology system
Required Pattern: https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/CodeSystem/mii-cs-mtb-antrag-kostenuebernahme-antragsstadium
...... version Σ 0..1 string Version of the system - if relevant
...... code SΣ 1..1 code Symbol in syntax defined by the system
...... display Σ 0..1 string Representation defined by the system
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
..... text Σ 0..1 string Plain text representation of the concept
.... reference 0..1 Identifier File or case reference
... prescription S 0..1 Reference(MedicationRequest) Therapy Recommendation
... originalPrescription 0..1 Reference(DeviceRequest | MedicationRequest | VisionPrescription) Original prescription if superseded by fulfiller
... payee 0..1 BackboneElement Recipient of benefits payable
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type 1..1 CodeableConcept Category of recipient
Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
.... party 0..1 Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) Recipient reference
... referral 0..1 Reference(ServiceRequest) Treatment referral
... facility 0..1 Reference(Location) Servicing facility
... Slices for careTeam 1..* BackboneElement Members of the care team
Slice: Unordered, Open by type:sequence
.... careTeam:All Slices Content/Rules for all slices
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Order of care team
..... provider 1..1 Reference(Practitioner | PractitionerRole | Organization) Practitioner or organization
..... responsible 0..1 boolean Indicator of the lead practitioner
..... role 0..1 CodeableConcept Function within the team
Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members.
..... qualification 0..1 CodeableConcept Practitioner credential or specialization
Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.
.... careTeam:ZPMBeteiligung S 1..1 BackboneElement ZPM Application
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence S 1..1 positiveInt internal variable of the participating institution
Required Pattern: 1
..... provider S 1..1 Reference(Organization) Reference to ZPM
..... responsible S 1..1 boolean ZPM Participation - Yes/No
..... role 0..1 CodeableConcept Function within the team
Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members.
..... qualification 0..1 CodeableConcept Practitioner credential or specialization
Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.
... supportingInfo 0..* BackboneElement Supporting information
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Information instance identifier
.... category 1..1 CodeableConcept Classification of the supplied information
Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes.
.... code 0..1 CodeableConcept Type of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.
.... timing[x] 0..1 When it occurred
..... timingDate date
..... timingPeriod Period
.... value[x] 0..1 Data to be provided
..... valueBoolean boolean
..... valueString string
..... valueQuantity Quantity
..... valueAttachment Attachment
..... valueReference Reference(Resource)
.... reason 0..1 CodeableConcept Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
... diagnosis 0..* BackboneElement Pertinent diagnosis information
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Diagnosis instance identifier
.... diagnosis[x] 1..1 Nature of illness or problem
Binding: ICD-10Codes (example): Example ICD10 Diagnostic codes.
..... diagnosisCodeableConcept CodeableConcept
..... diagnosisReference Reference(Condition)
.... type 0..* CodeableConcept Timing or nature of the diagnosis
Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge.
.... onAdmission 0..1 CodeableConcept Present on admission
Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.
.... packageCode 0..1 CodeableConcept Package billing code
Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.
... procedure 0..* BackboneElement Clinical procedures performed
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Procedure instance identifier
.... type 0..* CodeableConcept Category of Procedure
Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.
.... date 0..1 dateTime When the procedure was performed
.... procedure[x] 1..1 Specific clinical procedure
Binding: ICD-10ProcedureCodes (example): Example ICD10 Procedure codes.
..... procedureCodeableConcept CodeableConcept
..... procedureReference Reference(Procedure)
.... udi 0..* Reference(Device) Unique device identifier
... insurance SΣ 1..* BackboneElement Patient insurance information
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence SΣ 1..1 positiveInt Insurance Priority
.... focal SΣ 1..1 boolean Insurance relevant for this application
Required Pattern: true
.... identifier 0..1 Identifier Pre-assigned Claim number
.... coverage SΣ 1..1 Reference(Coverage) Insurance relevant for this application
.... businessArrangement 0..1 string Additional provider contract number
.... preAuthRef 0..* string Prior authorization reference number
.... claimResponse S 0..1 Reference(ClaimResponse) Adjudication results
... accident 0..1 BackboneElement Details of the event
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... date 1..1 date When the incident occurred
.... type 0..1 CodeableConcept The nature of the accident
Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc.
.... location[x] 0..1 Where the event occurred
..... locationAddress Address
..... locationReference Reference(Location)
... item 0..* BackboneElement Product or service provided
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Item instance identifier
.... careTeamSequence 0..* positiveInt Applicable careTeam members
.... diagnosisSequence 0..* positiveInt Applicable diagnoses
.... procedureSequence 0..* positiveInt Applicable procedures
.... informationSequence 0..* positiveInt Applicable exception and supporting information
.... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
.... category 0..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.
.... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
.... modifier 0..* CodeableConcept Product or service billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
.... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
.... serviced[x] 0..1 Date or dates of service or product delivery
..... servicedDate date
..... servicedPeriod Period
.... location[x] 0..1 Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.
..... locationCodeableConcept CodeableConcept
..... locationAddress Address
..... locationReference Reference(Location)
.... quantity 0..1 SimpleQuantity(4.0.1) Count of products or services
.... unitPrice 0..1 Money Fee, charge or cost per item
.... factor 0..1 decimal Price scaling factor
.... net 0..1 Money Total item cost
.... udi 0..* Reference(Device) Unique device identifier
.... bodySite 0..1 CodeableConcept Anatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
.... subSite 0..* CodeableConcept Anatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
.... encounter 0..* Reference(Encounter) Encounters related to this billed item
.... detail 0..* BackboneElement Product or service provided
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Item instance identifier
..... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
..... category 0..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.
..... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
..... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
..... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
..... quantity 0..1 SimpleQuantity(4.0.1) Count of products or services
..... unitPrice 0..1 Money Fee, charge or cost per item
..... factor 0..1 decimal Price scaling factor
..... net 0..1 Money Total item cost
..... udi 0..* Reference(Device) Unique device identifier
..... subDetail 0..* BackboneElement Product or service provided
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... sequence 1..1 positiveInt Item instance identifier
...... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
...... category 0..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.
...... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
...... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
...... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
...... quantity 0..1 SimpleQuantity(4.0.1) Count of products or services
...... unitPrice 0..1 Money Fee, charge or cost per item
...... factor 0..1 decimal Price scaling factor
...... net 0..1 Money Total item cost
...... udi 0..* Reference(Device) Unique device identifier
... total 0..1 Money Total claim cost

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Claim.meta.security Base extensible SecurityLabels 📍4.0.1 FHIR Std.
Claim.meta.tag Base example Common Tags 📍4.0.1 FHIR Std.
Claim.language Base preferred Common Languages 📍4.0.1 FHIR Std.
Claim.status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
Claim.type Base required MII VS MTB Antrag Kostenuebernahme 📦2027.0.0-ballot.1 This IG
Claim.subType Base example Example Claim SubType Codes 📍4.0.1 FHIR Std.
Claim.use Base required Use 📍4.0.1 FHIR Std.
Claim.priority Base example Process Priority Codes 📍4.0.1 FHIR Std.
Claim.fundsReserve Base example FundsReserve 📍4.0.1 FHIR Std.
Claim.related.relationship Base example Example Related Claim Relationship Codes 📍4.0.1 FHIR Std.
Claim.payee.type Base example PayeeType 📍4.0.1 FHIR Std.
Claim.careTeam.role Base example Claim Care Team Role Codes 📍4.0.1 FHIR Std.
Claim.careTeam.qualification Base example Example Provider Qualification Codes 📍4.0.1 FHIR Std.
Claim.careTeam:ZPMBeteiligung.​role Base example Claim Care Team Role Codes 📍4.0.1 FHIR Std.
Claim.careTeam:ZPMBeteiligung.​qualification Base example Example Provider Qualification Codes 📍4.0.1 FHIR Std.
Claim.supportingInfo.​category Base example Claim Information Category Codes 📍4.0.1 FHIR Std.
Claim.supportingInfo.​code Base example Exception Codes 📍4.0.1 FHIR Std.
Claim.supportingInfo.​reason Base example Missing Tooth Reason Codes 📍4.0.1 FHIR Std.
Claim.diagnosis.diagnosis[x] Base example ICD-10 Codes 📍4.0.1 FHIR Std.
Claim.diagnosis.type Base example Example Diagnosis Type Codes 📍4.0.1 FHIR Std.
Claim.diagnosis.onAdmission Base example Example Diagnosis on Admission Codes 📍4.0.1 FHIR Std.
Claim.diagnosis.packageCode Base example Example Diagnosis Related Group Codes 📍4.0.1 FHIR Std.
Claim.procedure.type Base example Example Procedure Type Codes 📍4.0.1 FHIR Std.
Claim.procedure.procedure[x] Base example ICD-10 Procedure Codes 📍4.0.1 FHIR Std.
Claim.accident.type Base extensible ActIncidentCode 📦3.0.0 THO v7.3
Claim.item.revenue Base example Example Revenue Center Codes 📍4.0.1 FHIR Std.
Claim.item.category Base example Benefit Category Codes 📍4.0.1 FHIR Std.
Claim.item.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
Claim.item.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
Claim.item.programCode Base example Example Program Reason Codes 📍4.0.1 FHIR Std.
Claim.item.location[x] Base example Example Service Place Codes 📍4.0.1 FHIR Std.
Claim.item.bodySite Base example Oral Site Codes 📍4.0.1 FHIR Std.
Claim.item.subSite Base example Surface Codes 📍4.0.1 FHIR Std.
Claim.item.detail.revenue Base example Example Revenue Center Codes 📍4.0.1 FHIR Std.
Claim.item.detail.category Base example Benefit Category Codes 📍4.0.1 FHIR Std.
Claim.item.detail.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
Claim.item.detail.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
Claim.item.detail.programCode Base example Example Program Reason Codes 📍4.0.1 FHIR Std.
Claim.item.detail.subDetail.​revenue Base example Example Revenue Center Codes 📍4.0.1 FHIR Std.
Claim.item.detail.subDetail.​category Base example Benefit Category Codes 📍4.0.1 FHIR Std.
Claim.item.detail.subDetail.​productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
Claim.item.detail.subDetail.​modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
Claim.item.detail.subDetail.​programCode Base example Example Program Reason Codes 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error Claim If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Claim 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().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error Claim 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()
dom-5 error Claim If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Claim A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

Summary

Mandatory: 3 elements(2 nested mandatory elements)
Must-Support: 24 elements
Fixed: 1 element

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of Claim.careTeam

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Claim 0..* Claim Claim, Pre-determination or Pre-authorization
... meta SΣ 0..1 Meta Metadata about the resource
.... profile SΣ 0..* canonical(StructureDefinition) Profiles this resource claims to conform to
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... type SΣ 1..1 CodeableConcept Applicant Category
Binding: MII VS MTB Antrag Kostenuebernahme (required)
... use SΣ 1..1 code Type of cost reimbursement application - claim or predetermination or preauthorization
Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim.
... patient SΣ 1..1 Reference(Patient) The recipient of the products and services
... created SΣ 1..1 dateTime Application Date
... provider SΣ 1..1 Reference(Practitioner | PractitionerRole | Organization) Applicant Institution / Clinic / Person
... priority SΣ 1..1 CodeableConcept Application Priority
Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.
Required Pattern: At least the following
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/processpriority
..... version 0..1 string Version of the system - if relevant
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: normal
..... display 0..1 string Representation defined by the system
..... userSelected 0..1 boolean If this coding was chosen directly by the user
.... text 0..1 string Plain text representation of the concept
... related S 0..* BackboneElement Prior or corollary claims
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... claim S 0..1 Reference(MII PR MTB Antrag Kostenuebernahme) for follow-up application/objection: Reference to original initial application
.... relationship S 0..1 CodeableConcept How the reference claim is related
Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim.
..... coding SΣ 1..* Coding Application Stage
...... system Σ 0..1 uri Identity of the terminology system
Required Pattern: https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/CodeSystem/mii-cs-mtb-antrag-kostenuebernahme-antragsstadium
...... code SΣ 1..1 code Symbol in syntax defined by the system
... prescription S 0..1 Reference(MedicationRequest) Therapy Recommendation
... Slices for careTeam 1..* BackboneElement Members of the care team
Slice: Unordered, Open by type:sequence
.... careTeam:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Order of care team
..... provider 1..1 Reference(Practitioner | PractitionerRole | Organization) Practitioner or organization
.... careTeam:ZPMBeteiligung S 1..1 BackboneElement ZPM Application
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence S 1..1 positiveInt internal variable of the participating institution
Required Pattern: 1
..... provider S 1..1 Reference(Organization) Reference to ZPM
..... responsible S 1..1 boolean ZPM Participation - Yes/No
... insurance SΣ 1..* BackboneElement Patient insurance information
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence SΣ 1..1 positiveInt Insurance Priority
.... focal SΣ 1..1 boolean Insurance relevant for this application
Required Pattern: true
.... coverage SΣ 1..1 Reference(Coverage) Insurance relevant for this application
.... claimResponse S 0..1 Reference(ClaimResponse) Adjudication results

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Claim.status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
Claim.type Base required MII VS MTB Antrag Kostenuebernahme 📦2027.0.0-ballot.1 This IG
Claim.use Base required Use 📍4.0.1 FHIR Std.
Claim.priority Base example Process Priority Codes 📍4.0.1 FHIR Std.
Claim.related.relationship Base example Example Related Claim Relationship Codes 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error Claim If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Claim 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().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error Claim 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()
dom-5 error Claim If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Claim A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

Differential View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Claim 0..* Claim Claim, Pre-determination or Pre-authorization
... meta S 0..1 Meta Metadata about the resource
.... profile S 0..* canonical(StructureDefinition) Profiles this resource claims to conform to
... status S 1..1 code Application
Fixed Value: active
... type S 1..1 CodeableConcept Applicant Category
Binding: MII VS MTB Antrag Kostenuebernahme (required)
... patient S 1..1 Reference(Patient) The recipient of the products and services
... created S 1..1 dateTime Application Date
... provider S 1..1 Reference(Practitioner | PractitionerRole | Organization) Applicant Institution / Clinic / Person
... priority S 1..1 CodeableConcept Application Priority
Required Pattern: At least the following
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/processpriority
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: normal
... related S 0..* BackboneElement Prior or corollary claims
.... claim S 0..1 Reference(MII PR MTB Antrag Kostenuebernahme) for follow-up application/objection: Reference to original initial application
.... relationship S 0..1 CodeableConcept How the reference claim is related
..... coding S 1..* Coding Application Stage
...... system 0..1 uri Identity of the terminology system
Required Pattern: https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/CodeSystem/mii-cs-mtb-antrag-kostenuebernahme-antragsstadium
...... code S 1..1 code Symbol in syntax defined by the system
... prescription S 0..1 Reference(MedicationRequest) Therapy Recommendation
... Slices for careTeam 1..* BackboneElement Members of the care team
Slice: Unordered, Open by type:sequence
.... careTeam:ZPMBeteiligung S 1..1 BackboneElement ZPM Application
..... sequence S 1..1 positiveInt internal variable of the participating institution
Required Pattern: 1
..... provider S 1..1 Reference(Organization) Reference to ZPM
..... responsible S 1..1 boolean ZPM Participation - Yes/No
... insurance S 1..* BackboneElement Patient insurance information
.... sequence S 1..1 positiveInt Insurance Priority
.... focal S 1..1 boolean Insurance relevant for this application
Required Pattern: true
.... coverage S 1..1 Reference(Coverage) Insurance relevant for this application
.... claimResponse S 0..1 Reference(ClaimResponse) Adjudication results

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
Claim.type Base required MII VS MTB Antrag Kostenuebernahme 📦2027.0.0-ballot.1 This IG

Snapshot ViewView

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Claim 0..* Claim Claim, Pre-determination or Pre-authorization
... id Σ 0..1 id Logical id of this artifact
... meta SΣ 0..1 Meta Metadata about the resource
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ 0..1 id Version specific identifier
.... lastUpdated Σ 0..1 instant When the resource version last changed
.... source Σ 0..1 uri Identifies where the resource comes from
.... profile SΣ 0..* canonical(StructureDefinition) Profiles this resource claims to conform to
.... security Σ 0..* Coding Security Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
.... tag Σ 0..* Coding Tags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier 0..* Identifier Business Identifier for claim
... status ?!SΣ 1..1 code Application
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
Fixed Value: active
... type SΣ 1..1 CodeableConcept Applicant Category
Binding: MII VS MTB Antrag Kostenuebernahme (required)
... subType 0..1 CodeableConcept More granular claim type
Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
... use SΣ 1..1 code Type of cost reimbursement application - claim or predetermination or preauthorization
Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim.
... patient SΣ 1..1 Reference(Patient) The recipient of the products and services
... billablePeriod Σ 0..1 Period Relevant time frame for the claim
... created SΣ 1..1 dateTime Application Date
... enterer 0..1 Reference(Practitioner | PractitionerRole) Author of the claim
... insurer Σ 0..1 Reference(Organization) Target
... provider SΣ 1..1 Reference(Practitioner | PractitionerRole | Organization) Applicant Institution / Clinic / Person
... priority SΣ 1..1 CodeableConcept Application Priority
Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.
Required Pattern: At least the following
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/processpriority
..... version 0..1 string Version of the system - if relevant
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: normal
..... display 0..1 string Representation defined by the system
..... userSelected 0..1 boolean If this coding was chosen directly by the user
.... text 0..1 string Plain text representation of the concept
... fundsReserve 0..1 CodeableConcept For whom to reserve funds
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
... related S 0..* BackboneElement Prior or corollary claims
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... claim S 0..1 Reference(MII PR MTB Antrag Kostenuebernahme) for follow-up application/objection: Reference to original initial application
.... relationship S 0..1 CodeableConcept How the reference claim is related
Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim.
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... coding SΣ 1..* Coding Application Stage
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system Σ 0..1 uri Identity of the terminology system
Required Pattern: https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/CodeSystem/mii-cs-mtb-antrag-kostenuebernahme-antragsstadium
...... version Σ 0..1 string Version of the system - if relevant
...... code SΣ 1..1 code Symbol in syntax defined by the system
...... display Σ 0..1 string Representation defined by the system
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
..... text Σ 0..1 string Plain text representation of the concept
.... reference 0..1 Identifier File or case reference
... prescription S 0..1 Reference(MedicationRequest) Therapy Recommendation
... originalPrescription 0..1 Reference(DeviceRequest | MedicationRequest | VisionPrescription) Original prescription if superseded by fulfiller
... payee 0..1 BackboneElement Recipient of benefits payable
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type 1..1 CodeableConcept Category of recipient
Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
.... party 0..1 Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) Recipient reference
... referral 0..1 Reference(ServiceRequest) Treatment referral
... facility 0..1 Reference(Location) Servicing facility
... Slices for careTeam 1..* BackboneElement Members of the care team
Slice: Unordered, Open by type:sequence
.... careTeam:All Slices Content/Rules for all slices
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Order of care team
..... provider 1..1 Reference(Practitioner | PractitionerRole | Organization) Practitioner or organization
..... responsible 0..1 boolean Indicator of the lead practitioner
..... role 0..1 CodeableConcept Function within the team
Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members.
..... qualification 0..1 CodeableConcept Practitioner credential or specialization
Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.
.... careTeam:ZPMBeteiligung S 1..1 BackboneElement ZPM Application
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence S 1..1 positiveInt internal variable of the participating institution
Required Pattern: 1
..... provider S 1..1 Reference(Organization) Reference to ZPM
..... responsible S 1..1 boolean ZPM Participation - Yes/No
..... role 0..1 CodeableConcept Function within the team
Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members.
..... qualification 0..1 CodeableConcept Practitioner credential or specialization
Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.
... supportingInfo 0..* BackboneElement Supporting information
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Information instance identifier
.... category 1..1 CodeableConcept Classification of the supplied information
Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes.
.... code 0..1 CodeableConcept Type of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.
.... timing[x] 0..1 When it occurred
..... timingDate date
..... timingPeriod Period
.... value[x] 0..1 Data to be provided
..... valueBoolean boolean
..... valueString string
..... valueQuantity Quantity
..... valueAttachment Attachment
..... valueReference Reference(Resource)
.... reason 0..1 CodeableConcept Explanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
... diagnosis 0..* BackboneElement Pertinent diagnosis information
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Diagnosis instance identifier
.... diagnosis[x] 1..1 Nature of illness or problem
Binding: ICD-10Codes (example): Example ICD10 Diagnostic codes.
..... diagnosisCodeableConcept CodeableConcept
..... diagnosisReference Reference(Condition)
.... type 0..* CodeableConcept Timing or nature of the diagnosis
Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge.
.... onAdmission 0..1 CodeableConcept Present on admission
Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.
.... packageCode 0..1 CodeableConcept Package billing code
Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.
... procedure 0..* BackboneElement Clinical procedures performed
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Procedure instance identifier
.... type 0..* CodeableConcept Category of Procedure
Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.
.... date 0..1 dateTime When the procedure was performed
.... procedure[x] 1..1 Specific clinical procedure
Binding: ICD-10ProcedureCodes (example): Example ICD10 Procedure codes.
..... procedureCodeableConcept CodeableConcept
..... procedureReference Reference(Procedure)
.... udi 0..* Reference(Device) Unique device identifier
... insurance SΣ 1..* BackboneElement Patient insurance information
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence SΣ 1..1 positiveInt Insurance Priority
.... focal SΣ 1..1 boolean Insurance relevant for this application
Required Pattern: true
.... identifier 0..1 Identifier Pre-assigned Claim number
.... coverage SΣ 1..1 Reference(Coverage) Insurance relevant for this application
.... businessArrangement 0..1 string Additional provider contract number
.... preAuthRef 0..* string Prior authorization reference number
.... claimResponse S 0..1 Reference(ClaimResponse) Adjudication results
... accident 0..1 BackboneElement Details of the event
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... date 1..1 date When the incident occurred
.... type 0..1 CodeableConcept The nature of the accident
Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc.
.... location[x] 0..1 Where the event occurred
..... locationAddress Address
..... locationReference Reference(Location)
... item 0..* BackboneElement Product or service provided
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Item instance identifier
.... careTeamSequence 0..* positiveInt Applicable careTeam members
.... diagnosisSequence 0..* positiveInt Applicable diagnoses
.... procedureSequence 0..* positiveInt Applicable procedures
.... informationSequence 0..* positiveInt Applicable exception and supporting information
.... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
.... category 0..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.
.... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
.... modifier 0..* CodeableConcept Product or service billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
.... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
.... serviced[x] 0..1 Date or dates of service or product delivery
..... servicedDate date
..... servicedPeriod Period
.... location[x] 0..1 Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.
..... locationCodeableConcept CodeableConcept
..... locationAddress Address
..... locationReference Reference(Location)
.... quantity 0..1 SimpleQuantity(4.0.1) Count of products or services
.... unitPrice 0..1 Money Fee, charge or cost per item
.... factor 0..1 decimal Price scaling factor
.... net 0..1 Money Total item cost
.... udi 0..* Reference(Device) Unique device identifier
.... bodySite 0..1 CodeableConcept Anatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
.... subSite 0..* CodeableConcept Anatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
.... encounter 0..* Reference(Encounter) Encounters related to this billed item
.... detail 0..* BackboneElement Product or service provided
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... sequence 1..1 positiveInt Item instance identifier
..... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
..... category 0..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.
..... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
..... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
..... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
..... quantity 0..1 SimpleQuantity(4.0.1) Count of products or services
..... unitPrice 0..1 Money Fee, charge or cost per item
..... factor 0..1 decimal Price scaling factor
..... net 0..1 Money Total item cost
..... udi 0..* Reference(Device) Unique device identifier
..... subDetail 0..* BackboneElement Product or service provided
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... sequence 1..1 positiveInt Item instance identifier
...... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
...... category 0..1 CodeableConcept Benefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.
...... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
...... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
...... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
...... quantity 0..1 SimpleQuantity(4.0.1) Count of products or services
...... unitPrice 0..1 Money Fee, charge or cost per item
...... factor 0..1 decimal Price scaling factor
...... net 0..1 Money Total item cost
...... udi 0..* Reference(Device) Unique device identifier
... total 0..1 Money Total claim cost

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Claim.meta.security Base extensible SecurityLabels 📍4.0.1 FHIR Std.
Claim.meta.tag Base example Common Tags 📍4.0.1 FHIR Std.
Claim.language Base preferred Common Languages 📍4.0.1 FHIR Std.
Claim.status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
Claim.type Base required MII VS MTB Antrag Kostenuebernahme 📦2027.0.0-ballot.1 This IG
Claim.subType Base example Example Claim SubType Codes 📍4.0.1 FHIR Std.
Claim.use Base required Use 📍4.0.1 FHIR Std.
Claim.priority Base example Process Priority Codes 📍4.0.1 FHIR Std.
Claim.fundsReserve Base example FundsReserve 📍4.0.1 FHIR Std.
Claim.related.relationship Base example Example Related Claim Relationship Codes 📍4.0.1 FHIR Std.
Claim.payee.type Base example PayeeType 📍4.0.1 FHIR Std.
Claim.careTeam.role Base example Claim Care Team Role Codes 📍4.0.1 FHIR Std.
Claim.careTeam.qualification Base example Example Provider Qualification Codes 📍4.0.1 FHIR Std.
Claim.careTeam:ZPMBeteiligung.​role Base example Claim Care Team Role Codes 📍4.0.1 FHIR Std.
Claim.careTeam:ZPMBeteiligung.​qualification Base example Example Provider Qualification Codes 📍4.0.1 FHIR Std.
Claim.supportingInfo.​category Base example Claim Information Category Codes 📍4.0.1 FHIR Std.
Claim.supportingInfo.​code Base example Exception Codes 📍4.0.1 FHIR Std.
Claim.supportingInfo.​reason Base example Missing Tooth Reason Codes 📍4.0.1 FHIR Std.
Claim.diagnosis.diagnosis[x] Base example ICD-10 Codes 📍4.0.1 FHIR Std.
Claim.diagnosis.type Base example Example Diagnosis Type Codes 📍4.0.1 FHIR Std.
Claim.diagnosis.onAdmission Base example Example Diagnosis on Admission Codes 📍4.0.1 FHIR Std.
Claim.diagnosis.packageCode Base example Example Diagnosis Related Group Codes 📍4.0.1 FHIR Std.
Claim.procedure.type Base example Example Procedure Type Codes 📍4.0.1 FHIR Std.
Claim.procedure.procedure[x] Base example ICD-10 Procedure Codes 📍4.0.1 FHIR Std.
Claim.accident.type Base extensible ActIncidentCode 📦3.0.0 THO v7.3
Claim.item.revenue Base example Example Revenue Center Codes 📍4.0.1 FHIR Std.
Claim.item.category Base example Benefit Category Codes 📍4.0.1 FHIR Std.
Claim.item.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
Claim.item.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
Claim.item.programCode Base example Example Program Reason Codes 📍4.0.1 FHIR Std.
Claim.item.location[x] Base example Example Service Place Codes 📍4.0.1 FHIR Std.
Claim.item.bodySite Base example Oral Site Codes 📍4.0.1 FHIR Std.
Claim.item.subSite Base example Surface Codes 📍4.0.1 FHIR Std.
Claim.item.detail.revenue Base example Example Revenue Center Codes 📍4.0.1 FHIR Std.
Claim.item.detail.category Base example Benefit Category Codes 📍4.0.1 FHIR Std.
Claim.item.detail.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
Claim.item.detail.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
Claim.item.detail.programCode Base example Example Program Reason Codes 📍4.0.1 FHIR Std.
Claim.item.detail.subDetail.​revenue Base example Example Revenue Center Codes 📍4.0.1 FHIR Std.
Claim.item.detail.subDetail.​category Base example Benefit Category Codes 📍4.0.1 FHIR Std.
Claim.item.detail.subDetail.​productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
Claim.item.detail.subDetail.​modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
Claim.item.detail.subDetail.​programCode Base example Example Program Reason Codes 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error Claim If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Claim 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().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error Claim 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()
dom-5 error Claim If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Claim A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

Summary

Mandatory: 3 elements(2 nested mandatory elements)
Must-Support: 24 elements
Fixed: 1 element

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of Claim.careTeam

 

Other representations of profile: CSV, Excel, Schematron