Structure Definition: Line Item info

Base Definition: http://hl7.org/fhir/StructureDefinition/Base

Status: draft

Kind: logical

Type: LineItemComponent

Elements (Differential)

Path	Cardinality	Type	Short
`LineItemComponent`	0..*		LineItemComponent
`LineItemComponent.CLM_LINE_NUM`	0..1	string	Line Item Sequence Number
`LineItemComponent.CLM_LINE_HCPCS_CD`	0..1	string	Line Item HCPCS Code
`LineItemComponent.CLM_REV_APC_HIPPS_CD`	0..1	string	Line Item APC / HIPPS Code
`LineItemComponent.CLM_LINE_NDC_CD`	0..1	string	National Drug Code
`LineItemComponent.CLM_LINE_NDC_QTY`	0..1	string	Line Item NDC Quantity
`LineItemComponent.CLM_LINE_NDC_QTY_QLFYR_CD`	0..1	string	Line Item NDC Quantity Qualifier Code
`LineItemComponent.CLM_LINE_SRVC_UNIT_QTY`	0..1	string	Line Item Service Unit Quantity
`LineItemComponent.CLM_LINE_REV_CTR_CD`	0..1	string	Line Item Revenue Center Code
`LineItemComponent.CLM_DDCTBL_COINSRNC_CD`	0..1	string	Line Item Revenue Center Code
`LineItemComponent.HCPCS_1_MDFR_CD`	0..1	string	HCPCS Modifier Code 1
`LineItemComponent.HCPCS_2_MDFR_CD`	0..1	string	HCPCS Modifier Code 2
`LineItemComponent.HCPCS_3_MDFR_CD`	0..1	string	HCPCS Modifier Code 3
`LineItemComponent.HCPCS_4_MDFR_CD`	0..1	string	HCPCS Modifier Code 4
`LineItemComponent.HCPCS_5_MDFR_CD`	0..1	string	HCPCS Modifier Code 5
`LineItemComponent.CLM_LINE_INSTNL_RATE_AMT`	0..1	string	Claim Line Institutional Rate Amount
`LineItemComponent.CLM_1_REV_CNTR_ANSI_RSN_CD`	0..1	string	Claim Line Adjustment Reason Code 1
`LineItemComponent.CLM_2_REV_CNTR_ANSI_RSN_CD`	0..1	string	Claim Line Adjustment Reason Code 2
`LineItemComponent.CLM_3_REV_CNTR_ANSI_RSN_CD`	0..1	string	Claim Line Adjustment Reason Code 3
`LineItemComponent.CLM_4_REV_CNTR_ANSI_RSN_CD`	0..1	string	Claim Line Adjustment Reason Code 4
`LineItemComponent.CLM_1_REV_CNTR_ANSI_GRP_CD`	0..1	string	Claim Line Adjustment Group Code 1
`LineItemComponent.CLM_2_REV_CNTR_ANSI_GRP_CD`	0..1	string	Claim Line Adjustment Group Code 2
`LineItemComponent.CLM_3_REV_CNTR_ANSI_GRP_CD`	0..1	string	Claim Line Adjustment Group Code 3
`LineItemComponent.CLM_4_REV_CNTR_ANSI_GRP_CD`	0..1	string	Claim Line Adjustment Group Code 4
`LineItemComponent.CLM_LINE_NCVRD_CHRG_AMT`	0..1	string	Non-Covered Charge Amount
`LineItemComponent.CLM_LINE_PRVDR_PMT_AMT`	0..1	string	Provider Payment Amount
`LineItemComponent.CLM_LINE_BENE_PMT_AMT`	0..1	string	Patient Responsibility Payment Amount
`LineItemComponent.CLM_LINE_BENE_PD_AMT`	0..1	string	Beneficiary Paid Amount
`LineItemComponent.CLM_LINE_CVRD_PD_AMT`	0..1	string	Claim Line Covered Paid Amount
`LineItemComponent.CLM_LINE_BLOOD_DDCTBL_AMT`	0..1	string	Claim Line Blood Deductible Amount
`LineItemComponent.CLM_LINE_MDCR_DDCTBL_AMT`	0..1	string	Part B Deductible Amount
`LineItemComponent.CLM_LINE_INSTNL_ADJSTD_AMT`	0..1	string	Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount
`LineItemComponent.CLM_LINE_INSTNL_RDCD_AMT`	0..1	string	Revenue Center Reduced Coinsurance Amount
`LineItemComponent.CLM_LINE_INSTNL_MSP1_PD_AMT`	0..1	string	Revenue Center 1st Medicare Secondary Payer Paid Amount
`LineItemComponent.CLM_LINE_INSTNL_MSP2_PD_AMT`	0..1	string	Revenue Center 2nd Medicare Secondary Payer Paid Amount
`LineItemComponent.CLM_LINE_INSTNL_REV_CTR_DT`	0..1	date	Revenue Center Date
`LineItemComponent.CLM_LINE_FROM_DT`	0..1	date	Line Item From Date
`LineItemComponent.CLM_LINE_ALOWD_CHRG_AMT`	0..1	string	Line Item Allowed Charge Amount
`LineItemComponent.CLM_LINE_SBMT_CHRG_AMT`	0..1	string	Submitted Charge Amount
`LineItemComponent.CLM_REV_DSCNT_IND_CD`	0..1	string	Revenue Center Discount Indicator Code
`LineItemComponent.CLM_OTAF_ONE_IND_CD`	0..1	string	Revenue Center Obligation to Accept As Full Payment Code
`LineItemComponent.CLM_REV_PACKG_IND_CD`	0..1	string	Revenue Center Packaging Indicator Code
`LineItemComponent.CLM_REV_PMT_MTHD_CD`	0..1	string	Revenue Center Payment Method Indicator Code
`LineItemComponent.CLM_REV_CNTR_STUS_CD`	0..1	string	Revenue Center Status Indicator Code
`LineItemComponent.CLM_LINE_GRS_ABOVE_THRSHLD_AMT`	0..1	string	Gross Drug Cost Above Out Of Pocket Threshold
`LineItemComponent.CLM_LINE_ANSTHSA_UNIT_CNT`	0..1	string	Anesthesia Unit Count
`LineItemComponent.CLM_LINE_GRS_BLW_THRSHLD_AMT`	0..1	string	Gross Drug Cost Below Out Of Pocket Threshold
`LineItemComponent.CLM_RNDRG_PRVDR_TAX_NUM`	0..1	string	Provider Tax Number
`LineItemComponent.CLM_LINE_LIS_AMT`	0..1	string	Low Income Cost Sharing Subsidy Amount
`LineItemComponent.PRVDR_RNDRNG_PRVDR_NPI_NUM`	0..1	string	Rendering Provider NPI Number - Line Level
`LineItemComponent.CLM_LINE_TROOP_TOT_AMT`	0..1	string	Other True Out Of Pocket Paid Amount
`LineItemComponent.providerSequence`	0..1	string	Provider sequence - derived, not to be populated in production
`LineItemComponent.CURRENT_SEGMENT`	0..1	string	Current Segment
`LineItemComponent.HCPCS_OR_CPT_OR_HIPPS`	0..1	string	HCPCS/CPT/HIPPS
`LineItemComponent.PRICE_MOD1`	0..1	string	Price Modifier 1
`LineItemComponent.PRICE_MOD2`	0..1	string	Price Modifier 2
`LineItemComponent.PLACE_OF_SERV`	0..1	string	Place of Service
`LineItemComponent.REV_CODE_1`	0..1	string	Revenue Code 1
`LineItemComponent.PA_DT_ADDED`	0..1	string	PA Date Added
`LineItemComponent.PA_DT_UPDATED`	0..1	string	PA Date Updated
`LineItemComponent.PA_DECISION`	0..1	string	PA Decision
`LineItemComponent.PA_REQ_SUB_DT`	0..1	string	PA Request Submitted Date
`LineItemComponent.PA_REQ_REC_DT`	0..1	string	PA Request Received Date
`LineItemComponent.PA_DECISION_DT`	0..1	string	PA Decision Date
`LineItemComponent.PA_DECISION_EXP_DT`	0..1	string	PA Decision Expiration Date
`LineItemComponent.SERVICE_CNTS`	0..1	string	Service Counts
`LineItemComponent.SVC_RENDER_ST`	0..1	string	Service Rendering State
`LineItemComponent.MR_COUNT_IND`	0..1	string	MR Count Indicator
`LineItemComponent.MR_COUNT_ST_DT`	0..1	string	MR Count Start Date
`LineItemComponent.MR_COUNT_END_DT`	0..1	string	MR Count End Date
`LineItemComponent.RRB_EXCL_IND`	0..1	string	RRB Exclusion Indicator
`LineItemComponent.CLM_LINE_PLRO_AMT`	0..1	string	Patient Liability Reduction Other Paid Amount
`LineItemComponent.CLM_LINE_RX_NUM`	0..1	string	RX Number
`LineItemComponent.CLM_RPTD_MFTR_DSCNT_AMT`	0..1	string	Gap Discount Amount
`LineItemComponent.CLM_LINE_INGRDNT_CST_AMT`	0..1	string	Ingredient Cost Amount
`LineItemComponent.CLM_LINE_MDCR_COINSRNC_AMT`	0..1	string	Coinsurance Amount
`LineItemComponent.CLM_LINE_SRVC_CST_AMT`	0..1	string	Dispensing Fee
`LineItemComponent.CLM_LINE_DGNS_CD`	0..1	string	Line Item Diagnosis Code
`LineItemComponent.diagnosisSequence`	0..*	string	Diagnosis Sequence Number
`LineItemComponent.CLM_LINE_SLS_TAX_AMT`	0..1	string	Sales Tax Amount
`LineItemComponent.CLM_LINE_THRU_DT`	0..1	string	Last Expense Date
`LineItemComponent.CLM_LINE_VCCN_ADMIN_FEE_AMT`	0..1	string	Vaccination Administration Fee
`LineItemComponent.CLM_POS_CD`	0..1	string	Place Of Service Code
`LineItemComponent.CLM_PRCNG_EXCPTN_CD`	0..1	string	Pricing Exception Code
`LineItemComponent.CLM_RNDRG_PRVDR_PRTCPTG_CD`	0..1	string	Provider Participating Indicator Code
`LineItemComponent.CLM_BENE_PRMRY_PYR_PD_AMT`	0..1	string	Line Primary Payer Paid Amount
`LineItemComponent.CLM_MTUS_IND_CD`	0..1	string	Carrier MTUS Indicator Code
`LineItemComponent.CLM_LINE_PRFNL_MTUS_CNT`	0..1	string	Carrier MTUS Count
`LineItemComponent.CLM_PRCNG_LCLTY_CD`	0..1	string	Line Pricing Locality Code
`LineItemComponent.CLM_PHYSN_ASTNT_CD`	0..1	string	Reduced Payment Physician Assistant Code
`LineItemComponent.CLM_LINE_CARR_HPSA_SCRCTY_CD`	0..1	string	HPSA Scarcity Code
`LineItemComponent.CLM_PRMRY_PYR_CD`	0..1	string	Line Primary Payer Code
`LineItemComponent.CLM_FED_TYPE_SRVC_CD`	0..1	string	CMS Service Type Code
`LineItemComponent.CLM_PMT_80_100_CD`	0..1	string	Payment Code
`LineItemComponent.CLM_PRCSG_IND_CD`	0..1	string	Processing Indicator Code
`LineItemComponent.CLM_SRVC_DDCTBL_SW`	0..1	string	Service Deductible Code
`LineItemComponent.CLM_PRVDR_SPCLTY_CD`	0..1	string	Provider Speciality Code
`LineItemComponent.CLM_LINE_DMERC_SCRN_SVGS_AMT`	0..1	string	Screen Savings Amount
`LineItemComponent.CLM_SUPLR_TYPE_CD`	0..1	string	Supplier Type Code
`LineItemComponent.CLM_LINE_PRFNL_DME_PRICE_AMT`	0..1	string	Purchase Price Amount
`LineItemComponent.CLM_RNDRG_PRVDR_TYPE_CD`	0..1	string	Claim Rendering Provider Type Code
`LineItemComponent.CLM_LINE_OTAF_AMT`	0..1	string	Provider Obligation To Accept as Full Amount
`LineItemComponent.CLM_LINE_OTHR_TP_PD_AMT`	0..1	string	Other Third Party Paid Amount
`LineItemComponent.CLM_LINE_NCVRD_PD_AMT`	0..1	string	Noncovered Paid Amount
`LineItemComponent.CLM_LINE_ADD_ON_PYMT_AMT`	0..1	string	Add On Payment Amount
`LineItemComponent.CLM_LINE_NON_EHR_RDCTN_AMT`	0..1	string	Non-EHR Reduction Amount
`LineItemComponent.CLM_REV_CNTR_TDAPA_AMT`	0..1	string	Transitional Drug Add-On Payment Adjustment
`LineItemComponent.CLM_LINE_CARR_CLNCL_CHRG_AMT`	0..1	string	Carrier Clinical Charge Amount
`LineItemComponent.CLM_LINE_CARR_PSYCH_OT_LMT_AMT`	0..1	string	Therapy Amount Applied to Limit
`LineItemComponent.CLM_LINE_PRFNL_INTRST_AMT`	0..1	string	Professional Interest Amount
`LineItemComponent.CLM_MDCR_PRMRY_PYR_ALOWD_AMT`	0..1	string	Line Primary Payer Allowed Amount
`LineItemComponent.CLM_CMS_CALCD_MFTR_DSCNT_AMT`	0..1	string	CMS Calculated Manufacturer Discount Amount
`LineItemComponent.CLM_LINE_GRS_CVRD_CST_TOT_AMT`	0..1	string	Gross Covered Cost Total Amount
`LineItemComponent.CLM_LINE_REBT_PASSTHRU_POS_AMT`	0..1	string	Reimbursement Pass Through Positive Amount
`LineItemComponent.CLM_PHRMCY_PRICE_DSCNT_AT_POS_AMT`	0..1	string	Pharmacy Price Discount At POS Amount
`LineItemComponent.isCompound`	0..1	string	Is Compound - derived
`LineItemComponent.careTeamSequence`	0..*	string	Derived Care Team Sequence Number
`LineItemComponent.CLM_LINE_PMD_UNIQ_TRKNG_NUM`	0..1	string	Claim Line Prior Authorization Unique Tracking Number (Adjudicated)
`LineItemComponent.CLM_LINE_PA_UNIQ_TRKNG_NUM`	0..1	string	Claim Line Prior Authorization Unique Tracking Number (Partially Adjudicated)
`LineItemComponent.SEQUENCE_INFO`	0..*	string	Supporting Info Sequence Number
`LineItemComponent.CLM_LINE_RPTD_GAP_DSCNT_AMT`	0..1	string	Claim Line Reported Gap Discount Amount
`LineItemComponent.TOT_RX_CST_AMT`	0..1	string	Total drug cost (Part D)
`LineItemComponent.CLM_LINE_BNFT_ENHNCMT_1_CD`	0..1	string	Claim Line Benefit Enhancement 1 Code
`LineItemComponent.CLM_LINE_BNFT_ENHNCMT_2_CD`	0..1	string	Claim Line Benefit Enhancement 2 Code
`LineItemComponent.CLM_LINE_BNFT_ENHNCMT_3_CD`	0..1	string	Claim Line Benefit Enhancement 3 Code
`LineItemComponent.CLM_LINE_BNFT_ENHNCMT_4_CD`	0..1	string	Claim Line Benefit Enhancement 4 Code
`LineItemComponent.CLM_LINE_BNFT_ENHNCMT_5_CD`	0..1	string	Claim Line Benefit Enhancement 5 Code
`LineItemComponent.CLM_LINE_NGACO_PBPMT_SW`	0..1	string	Claim Line NGACO PBPMT Switch
`LineItemComponent.CLM_LINE_NGACO_PDSCHRG_HCBS_SW`	0..1	string	Claim Line NGACO Post Discharge HCBS Switch
`LineItemComponent.CLM_LINE_NGACO_SNF_WVR_SW`	0..1	string	Claim Line NGACO SNF Waiver Switch
`LineItemComponent.CLM_LINE_NGACO_TLHLTH_SW`	0..1	string	Claim Line NGACO Telehealth Switch
`LineItemComponent.CLM_LINE_NGACO_CPTATN_SW`	0..1	string	Claim Line NGACO Capitation Switch
`LineItemComponent.CLM_LINE_ACO_CARE_MGMT_HCBS_SW`	0..1	string	Claim Line ACO Care Management HCBS Switch
`LineItemComponent.GEO_RNDRG_SSA_STATE_CD`	0..1	string	State FIPS Code
`LineItemComponent.CLM_BRND_GNRC_CD`	0..1	string	Brand/Generic Code
`LineItemComponent.CLM_CMPND_CD`	0..1	string	Compound Code
`LineItemComponent.CLM_CTSTRPHC_CVRG_IND_CD`	0..1	string	Catastrophic Coverage Indicator Code
`LineItemComponent.CLM_DAW_PROD_SLCTN_CD`	0..1	string	DAW Product Selection Code
`LineItemComponent.CLM_DRUG_CVRG_STUS_CD`	0..1	string	Drug Coverage Status Code
`LineItemComponent.CLM_DSPNSNG_STUS_CD`	0..1	string	Dispensing Status Code
`LineItemComponent.CLM_LINE_AUTHRZD_FILL_NUM`	0..1	string	Authorized Fill Number
`LineItemComponent.CLM_LINE_DAYS_SUPLY_QTY`	0..1	string	Days Supply Quantity
`LineItemComponent.CLM_LINE_RX_FILL_NUM`	0..1	string	RX Fill Number
`LineItemComponent.CLM_LINE_RX_ORGN_CD`	0..1	string	RX Origin Code
`LineItemComponent.CLM_LTC_DSPNSNG_MTHD_CD`	0..1	string	LTC Dispensing Method Code
`LineItemComponent.CLM_PHRMCY_SRVC_TYPE_CD`	0..1	string	Pharmacy Service Type Code
`LineItemComponent.CLM_PTNT_RSDNC_CD`	0..1	string	Patient Residence Code
`LineItemComponent.CLM_LINE_HCT_HGB_RSLT_NUM`	0..1	string	Hematocrit/Hemoglobin Result Number
`LineItemComponent.CLM_LINE_HCT_HGB_TYPE_CD`	0..1	string	Hematocrit/Hemoglobin Type Code
`LineItemComponent.CLM_LINE_CARR_CLNCL_LAB_NUM`	0..1	string	Carrier Clinical Lab Number