German Dental FHIR Profiles (R4) - Local Development build (v0.41.6) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Dental Mixed Billing Claim

Dental mixed billing claim

DentalClaimDE is the validation anchor for a structured dental claim that can carry BEMA and GOZ lines in one billing event.

Resource boundary

The resources remain separated by responsibility:

1. DentalCarePlanDE represents alternatives (intent = option) and the selected executable plan (intent = plan).
2. BEMA and GOZ ServiceRequest resources represent the planned services.
3. BemaChargeItemDE and GozChargeItemDE represent performed charges and carry the billing Account context.
4. DentalClaimDE submits machine-readable lines and coverage order.

The Claim does not embed a ChargeItem in item.detail. FHIR R4 has no ChargeItem reference at that path. Instead, each typed ChargeItem is carried in supportingInfo.valueReference; the Claim line points to its supporting entry through item.informationSequence.

Line contract

DentalClaimDE.item has open BEMA and GOZ slices, discriminated by the coding system in productOrService. Each prosthesis line may carry:

• careType using regelversorgung, gleichartig, or andersartig;
• festzuschussAmount with finding, benefit percentage, amount, effective period, and exact source edition; and
• informationSequence linking the line to its performed ChargeItem.

Within this profile, any gleichartig line activates the dental-claim-equal-type-mix rule: at least one BEMA and one GOZ line must be present. This is the IG's interoperability contract for a mixed equal-type claim, not a statement that every legal billing transport uses one FHIR Claim.

Coverage order

insurance.sequence expresses payer order. The example uses the statutory coverage as focal sequence 1 and a supplementary dental coverage as sequence 2. Coverage sequence does not change the BEMA or GOZ identity of a line.

Examples and invalid variant

ExampleDentalClaimMixed contains:

• BEMA 91d and GOZ 5040 lines marked gleichartig;
• typed links to ExampleMixedBemaChargeItem and ExampleMixedGozChargeItem;
• GKV and supplementary dental coverage; and
• a clearly synthetic 2026 Festzuschuss amount.

Removing the BEMA line while retaining a gleichartig GOZ line violates dental-claim-equal-type-mix. A BEMA-only regelversorgung claim and a GOZ-only andersartig claim do not activate that rule.

See Billing and Legal Sources for source scope and the public/private amount boundary.