FHIR Implementation Guide for ABDM
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This page is part of the FHIR Implementation Guide for ABDM (v6.5.0: Release) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions

Extension: ClaimExclusion

Official URL: https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-Exclusion Version: 6.5.0
Draft as of 2025-03-18 Computable Name: ClaimExclusion

This extension specifies excluded coverage details within a health insurance product. It outlines services, treatments or conditions not covered.

Context of Use

    This extension may be used on the following element(s):

    • Element ID: https://nrces.in/ndhm/fhir/r4/StructureDefinition/InsurancePlan#InsurancePlan
    • Element ID: https://nrces.in/ndhm/fhir/r4/StructureDefinition/InsurancePlan#InsurancePlan.plan

Usage info

Usage:

Formal Views of Extension Content

Description of Profiles, Differentials, Snapshots, and how the XML and JSON presentations work.

This structure is derived from Extension

NameFlagsCard.TypeDescription & Constraintsdoco
.. Extension 0..* Extension Excluded coverage details within a health insurance product. It outlines services, treatments or conditions not covered.
... Slices for extension Content/Rules for all slices
.... extension:category 0..1 Extension Illustrates a standard or specific exclusion category e.g: pre-existing diseases, specific disease/procedure waiting period.
..... extension 0..0
..... url 1..1 uri "category"
..... value[x] 0..1 CodeableConcept Value of extension
Binding: Claim Exclusion (example): standard or specific exclusion category e.g: pre-existing diseases, specific disease/procedure waiting period.

.... extension:statement 0..* Extension General statement about the exclusion.
..... extension 0..0
..... url 1..1 uri "statement"
..... value[x] 0..1 string Value of extension
.... extension:item 0..* Extension Outline list of medical illness, associated treatments, as well as other non-medical items that are excluded from the health insurance product. e.g. cataract surgery, skin tumour, baby food etc.
..... extension 0..0
..... url 1..1 uri "item"
..... value[x] 0..1 CodeableConcept Value of extension
... url 1..1 uri "https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-Exclusion"
... value[x] 0..0

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Extension 0..* Extension Excluded coverage details within a health insurance product. It outlines services, treatments or conditions not covered.
... id 0..1 string Unique id for inter-element referencing
... Slices for extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... extension:category 0..1 Extension Illustrates a standard or specific exclusion category e.g: pre-existing diseases, specific disease/procedure waiting period.
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..0
..... url 1..1 uri "category"
..... value[x] 0..1 CodeableConcept Value of extension
Binding: Claim Exclusion (example): standard or specific exclusion category e.g: pre-existing diseases, specific disease/procedure waiting period.

.... extension:statement 0..* Extension General statement about the exclusion.
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..0
..... url 1..1 uri "statement"
..... value[x] 0..1 string Value of extension
.... extension:item 0..* Extension Outline list of medical illness, associated treatments, as well as other non-medical items that are excluded from the health insurance product. e.g. cataract surgery, skin tumour, baby food etc.
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..0
..... url 1..1 uri "item"
..... value[x] 0..1 CodeableConcept Value of extension
... url 1..1 uri "https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-Exclusion"

doco Documentation for this format

This structure is derived from Extension

Summary

Complex Extension: This extension specifies excluded coverage details within a health insurance product. It outlines services, treatments or conditions not covered.

  • category: CodeableConcept: An Extension
  • statement: string: An Extension
  • item: CodeableConcept: An Extension

Differential View

This structure is derived from Extension

NameFlagsCard.TypeDescription & Constraintsdoco
.. Extension 0..* Extension Excluded coverage details within a health insurance product. It outlines services, treatments or conditions not covered.
... Slices for extension Content/Rules for all slices
.... extension:category 0..1 Extension Illustrates a standard or specific exclusion category e.g: pre-existing diseases, specific disease/procedure waiting period.
..... extension 0..0
..... url 1..1 uri "category"
..... value[x] 0..1 CodeableConcept Value of extension
Binding: Claim Exclusion (example): standard or specific exclusion category e.g: pre-existing diseases, specific disease/procedure waiting period.

.... extension:statement 0..* Extension General statement about the exclusion.
..... extension 0..0
..... url 1..1 uri "statement"
..... value[x] 0..1 string Value of extension
.... extension:item 0..* Extension Outline list of medical illness, associated treatments, as well as other non-medical items that are excluded from the health insurance product. e.g. cataract surgery, skin tumour, baby food etc.
..... extension 0..0
..... url 1..1 uri "item"
..... value[x] 0..1 CodeableConcept Value of extension
... url 1..1 uri "https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-Exclusion"
... value[x] 0..0

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Extension 0..* Extension Excluded coverage details within a health insurance product. It outlines services, treatments or conditions not covered.
... id 0..1 string Unique id for inter-element referencing
... Slices for extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... extension:category 0..1 Extension Illustrates a standard or specific exclusion category e.g: pre-existing diseases, specific disease/procedure waiting period.
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..0
..... url 1..1 uri "category"
..... value[x] 0..1 CodeableConcept Value of extension
Binding: Claim Exclusion (example): standard or specific exclusion category e.g: pre-existing diseases, specific disease/procedure waiting period.

.... extension:statement 0..* Extension General statement about the exclusion.
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..0
..... url 1..1 uri "statement"
..... value[x] 0..1 string Value of extension
.... extension:item 0..* Extension Outline list of medical illness, associated treatments, as well as other non-medical items that are excluded from the health insurance product. e.g. cataract surgery, skin tumour, baby food etc.
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..0
..... url 1..1 uri "item"
..... value[x] 0..1 CodeableConcept Value of extension
... url 1..1 uri "https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-Exclusion"

doco Documentation for this format

This structure is derived from Extension

Summary

Complex Extension: This extension specifies excluded coverage details within a health insurance product. It outlines services, treatments or conditions not covered.

  • category: CodeableConcept: An Extension
  • statement: string: An Extension
  • item: CodeableConcept: An Extension

 

Other representations of profile: CSV, Excel, Schematron

Terminology Bindings

PathConformanceValueSetURI
Extension.extension:category.value[x]exampleClaimExclusion (a valid code from Claim Exclusion)
https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-claim-exclusion
from this IG

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()