FHIR Release 3 (STU)
This page is part of the FHIR Specification (v3.0.2: STU 3). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions 
. Page versions: R5 R4B R4 R3 R2
| Financial Management Work Group | Maturity Level: N/A | Ballot Status: Informative | Compartments: Patient, RelatedPerson |
StructureDefinition for coverage
Financial
{
"resourceType": "StructureDefinition",
"id": "Coverage",
"meta": {
"lastUpdated": "2019-10-24T11:53:00+11:00"
},
"text": {
"status": "generated",
"div": "<div>!-- Snipped for Brevity --></div>"
},
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm",
"valueInteger": 2
},
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
"valueCode": "fm"
}
],
"url": "http://hl7.org/fhir/StructureDefinition/Coverage",
"name": "Coverage",
"status": "draft",
"date": "2019-10-24T11:53:00+11:00",
"publisher": "Health Level Seven International (Financial Management)",
"contact": [
{
"telecom": [
{
"system": "url",
"value": "http://hl7.org/fhir"
}
]
},
{
"telecom": [
{
"system": "url",
"value": "http://www.hl7.org/Special/committees/fm/index.cfm"
}
]
}
],
"description": "Base StructureDefinition for Coverage Resource",
"purpose": "Health care programs and insurers are significant payors of health service costs.",
"fhirVersion": "3.0.2",
"mapping": [
{
"identity": "workflow",
"uri": "http://hl7.org/fhir/workflow",
"name": "Workflow Mapping"
},
{
"identity": "rim",
"uri": "http://hl7.org/v3",
"name": "RIM Mapping"
},
{
"identity": "w5",
"uri": "http://hl7.org/fhir/w5",
"name": "W5 Mapping"
},
{
"identity": "cdanetv4",
"uri": "http://www.cda-adc.ca/en/services/cdanet/",
"name": "Canadian Dental Association eclaims standard"
},
{
"identity": "v2",
"uri": "http://hl7.org/v2",
"name": "HL7 v2 Mapping"
},
{
"identity": "cpha3pharm",
"uri": "http://www.pharmacists.ca/",
"name": "Canadian Pharmacy Associaiton eclaims standard"
}
],
"kind": "resource",
"abstract": false,
"type": "Coverage",
"baseDefinition": "http://hl7.org/fhir/StructureDefinition/DomainResource",
"derivation": "specialization",
"snapshot": {
"element": [
{
"id": "Coverage",
"path": "Coverage",
"short": "Insurance or medical plan or a payment agreement",
"definition": "Financial instrument which may be used to reimburse or pay for health care products and services.",
"min": 0,
"max": "*",
"constraint": [
{
"key": "dom-2",
"severity": "error",
"human": "If the resource is contained in another resource, it SHALL NOT contain nested Resources",
"expression": "contained.contained.empty()",
"xpath": "not(parent::f:contained and f:contained)",
"source": "DomainResource"
},
{
"key": "dom-1",
"severity": "error",
"human": "If the resource is contained in another resource, it SHALL NOT contain any narrative",
"expression": "contained.text.empty()",
"xpath": "not(parent::f:contained and f:text)",
"source": "DomainResource"
},
{
"key": "dom-4",
"severity": "error",
"human": "If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated",
"expression": "contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()",
"xpath": "not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))",
"source": "DomainResource"
},
{
"key": "dom-3",
"severity": "error",
"human": "If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource",
"expression": "contained.where(('#'+id in %resource.descendants().reference).not()).empty()",
"xpath": "not(exists(for $id in f:contained/*/@id return $id[not(ancestor::f:contained/parent::*/descendant::f:reference/@value=concat('#', $id))]))",
"source": "DomainResource"
}
],
"mapping": [
{
"identity": "rim",
"map": "Entity. Role, or Act"
},
{
"identity": "workflow",
"map": "Event"
},
{
"identity": "rim",
"map": "Coverage"
},
{
"identity": "w5",
"map": "financial.support"
}
]
},
{
"id": "Coverage.id",
"path": "Coverage.id",
"short": "Logical id of this artifact",
"definition": "The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.",
"comment": "The only time that a resource does not have an id is when it is being submitted to the server using a create operation.",
"min": 0,
"max": "1",
"base": {
"path": "Resource.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "id"
}
],
"isSummary": true
},
{
"id": "Coverage.meta",
"path": "Coverage.meta",
"short": "Metadata about the resource",
"definition": "The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content may not always be associated with version changes to the resource.",
"min": 0,
"max": "1",
"base": {
"path": "Resource.meta",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Meta"
}
],
"isSummary": true
},
{
"id": "Coverage.implicitRules",
"path": "Coverage.implicitRules",
"short": "A set of rules under which this content was created",
"definition": "A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content.",
"comment": "Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. \n\nThis element is labelled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation.",
"min": 0,
"max": "1",
"base": {
"path": "Resource.implicitRules",
"min": 0,
"max": "1"
},
"type": [
{
"code": "uri"
}
],
"isModifier": true,
"isSummary": true
},
{
"id": "Coverage.language",
"path": "Coverage.language",
"short": "Language of the resource content",
"definition": "The base language in which the resource is written.",
"comment": "Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).",
"min": 0,
"max": "1",
"base": {
"path": "Resource.language",
"min": 0,
"max": "1"
},
"type": [
{
"code": "code"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-maxValueSet",
"valueReference": {
"reference": "http://hl7.org/fhir/ValueSet/all-languages"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Language"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
}
],
"strength": "extensible",
"description": "A human language.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/languages"
}
}
},
{
"id": "Coverage.text",
"path": "Coverage.text",
"short": "Text summary of the resource, for human interpretation",
"definition": "A human-readable narrative that contains a summary of the resource, and may be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it \"clinically safe\" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.",
"comment": "Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a \"text blob\" or where text is additionally entered raw or narrated and encoded in formation is added later.",
"alias": [
"narrative",
"html",
"xhtml",
"display"
],
"min": 0,
"max": "1",
"base": {
"path": "DomainResource.text",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Narrative"
}
],
"condition": [
"dom-1"
],
"mapping": [
{
"identity": "rim",
"map": "Act.text?"
}
]
},
{
"id": "Coverage.contained",
"path": "Coverage.contained",
"short": "Contained, inline Resources",
"definition": "These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.",
"comment": "This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again.",
"alias": [
"inline resources",
"anonymous resources",
"contained resources"
],
"min": 0,
"max": "*",
"base": {
"path": "DomainResource.contained",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Resource"
}
],
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "Coverage.extension",
"path": "Coverage.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the resource. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "DomainResource.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "Coverage.modifierExtension",
"path": "Coverage.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the resource, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "DomainResource.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "Coverage.identifier",
"path": "Coverage.identifier",
"short": "The primary coverage ID",
"definition": "The main (and possibly only) identifier for the coverage - often referred to as a Member Id, Certificate number, Personal Health Number or Case ID. May be constructed as the concatination of the Coverage.SubscriberID and the Coverage.dependant.",
"requirements": "This value may uniquely identify the coverage or it may be used in conjunction with the additional identifiers below.",
"min": 0,
"max": "*",
"type": [
{
"code": "Identifier"
}
],
"isSummary": true,
"mapping": [
{
"identity": "workflow",
"map": "Event.identifier"
},
{
"identity": "cdanetv4",
"map": "C02"
},
{
"identity": "v2",
"map": "IN1-2"
},
{
"identity": "cpha3pharm",
"map": "C.32, C.33, C.39"
},
{
"identity": "w5",
"map": "id"
}
]
},
{
"id": "Coverage.status",
"path": "Coverage.status",
"short": "active | cancelled | draft | entered-in-error",
"definition": "The status of the resource instance.",
"comment": "This element is labeled as a modifier because the status contains the code entered-in-error that marks the coverage as not currently valid.",
"min": 0,
"max": "1",
"type": [
{
"code": "code"
}
],
"isModifier": true,
"isSummary": true,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CoverageStatus"
}
],
"strength": "required",
"description": "A code specifying the state of the resource instance.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/fm-status"
}
},
"mapping": [
{
"identity": "workflow",
"map": "Event.status"
},
{
"identity": "w5",
"map": "status"
}
]
},
{
"id": "Coverage.type",
"path": "Coverage.type",
"short": "Type of coverage such as medical or accident",
"definition": "The type of coverage: social program, medical plan, accident coverage (workers compensation, auto), group health or payment by an individual or organization.",
"requirements": "The order of application of coverages is dependent on the types of coverage.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CoverageType"
}
],
"strength": "preferred",
"description": "The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/coverage-type"
}
},
"mapping": [
{
"identity": "v2",
"map": "IN1-15"
},
{
"identity": "w5",
"map": "class"
}
]
},
{
"id": "Coverage.policyHolder",
"path": "Coverage.policyHolder",
"short": "Owner of the policy",
"definition": "The party who 'owns' the insurance policy, may be an individual, corporation or the subscriber's employer.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Patient"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/RelatedPerson"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization"
}
],
"isSummary": true,
"mapping": [
{
"identity": "cdanetv4",
"map": "D01 through D09"
},
{
"identity": "v2",
"map": "IN1-16, 18, 19-name of insured, address, date of birth"
},
{
"identity": "cpha3pharm",
"map": "C.35"
},
{
"identity": "w5",
"map": "who.focus"
}
]
},
{
"id": "Coverage.subscriber",
"path": "Coverage.subscriber",
"short": "Subscriber to the policy",
"definition": "The party who has signed-up for or 'owns' the contractual relationship to the policy or to whom the benefit of the policy for services rendered to them or their family is due.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Patient"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/RelatedPerson"
}
],
"isSummary": true,
"mapping": [
{
"identity": "cdanetv4",
"map": "D01 through D09"
},
{
"identity": "v2",
"map": "IN1-16, 18, 19-name of insured, address, date of birth"
},
{
"identity": "cpha3pharm",
"map": "C.35"
},
{
"identity": "w5",
"map": "who.focus"
}
]
},
{
"id": "Coverage.subscriberId",
"path": "Coverage.subscriberId",
"short": "ID assigned to the Subscriber",
"definition": "The insurer assigned ID for the Subscriber.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"isSummary": true,
"mapping": [
{
"identity": "cdanetv4",
"map": "D01 through D09"
},
{
"identity": "v2",
"map": "IN1-16, 18, 19-name of insured, address, date of birth"
},
{
"identity": "cpha3pharm",
"map": "C.35"
},
{
"identity": "w5",
"map": "who.focus"
}
]
},
{
"id": "Coverage.beneficiary",
"path": "Coverage.beneficiary",
"short": "Plan Beneficiary",
"definition": "The party who benefits from the insurance coverage., the patient when services are provided.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Patient"
}
],
"isSummary": true,
"mapping": [
{
"identity": "workflow",
"map": "Event.subject"
},
{
"identity": "cdanetv4",
"map": "D01 through D09"
},
{
"identity": "v2",
"map": "IN1-16, 18, 19-name of insured, address, date of birth"
},
{
"identity": "cpha3pharm",
"map": "C.35"
},
{
"identity": "w5",
"map": "who.focus"
}
]
},
{
"id": "Coverage.relationship",
"path": "Coverage.relationship",
"short": "Beneficiary relationship to the Subscriber",
"definition": "The relationship of beneficiary (patient) to the subscriber.",
"requirements": "To determine relationship between the patient and the subscriber.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Relationship"
}
],
"strength": "example",
"description": "The relationship between the Policyholder and the Beneficiary (insured/covered party/patient).",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/policyholder-relationship"
}
},
"mapping": [
{
"identity": "cdanetv4",
"map": "C03"
}
]
},
{
"id": "Coverage.period",
"path": "Coverage.period",
"short": "Coverage start and end dates",
"definition": "Time period during which the coverage is in force. A missing start date indicates the start date isn't known, a missing end date means the coverage is continuing to be in force.",
"min": 0,
"max": "1",
"type": [
{
"code": "Period"
}
],
"isSummary": true,
"mapping": [
{
"identity": "workflow",
"map": "Event.occurrence"
},
{
"identity": "v2",
"map": "IN1-12 / IN1-13"
},
{
"identity": "w5",
"map": "when.done"
}
]
},
{
"id": "Coverage.payor",
"path": "Coverage.payor",
"short": "Identifier for the plan or agreement issuer",
"definition": "The program or plan underwriter or payor including both insurance and non-insurance agreements, such as patient-pay agreements. May provide multiple identifiers such as insurance company identifier or business identifier (BIN number).",
"requirements": "Need to identify the issuer to target for processing and for coordination of benefit processing.",
"min": 0,
"max": "*",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Patient"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/RelatedPerson"
}
],
"isSummary": true,
"mapping": [
{
"identity": "cdanetv4",
"map": "A05"
},
{
"identity": "v2",
"map": "IN1-3"
},
{
"identity": "cpha3pharm",
"map": "C.30"
},
{
"identity": "w5",
"map": "who.author"
}
]
},
{
"id": "Coverage.grouping",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Group"
}
],
"path": "Coverage.grouping",
"short": "Additional coverage classifications",
"definition": "A suite of underwrite specific classifiers, for example may be used to identify a class of coverage or employer group, Policy, Plan.",
"min": 0,
"max": "1",
"type": [
{
"code": "BackboneElement"
}
],
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
]
},
{
"id": "Coverage.grouping.id",
"path": "Coverage.grouping.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Coverage.grouping.extension",
"path": "Coverage.grouping.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "Coverage.grouping.modifierExtension",
"path": "Coverage.grouping.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "Coverage.grouping.group",
"path": "Coverage.grouping.group",
"short": "An identifier for the group",
"definition": "Identifies a style or collective of coverage issued by the underwriter, for example may be used to identify an employer group. May also be referred to as a Policy or Group ID.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"isSummary": true,
"mapping": [
{
"identity": "cdanetv4",
"map": "C11 (Division,Section)"
},
{
"identity": "v2",
"map": "IN1-8"
},
{
"identity": "cpha3pharm",
"map": "C.31"
}
]
},
{
"id": "Coverage.grouping.groupDisplay",
"path": "Coverage.grouping.groupDisplay",
"short": "Display text for an identifier for the group",
"definition": "A short description for the group.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"isSummary": true,
"mapping": [
{
"identity": "cdanetv4",
"map": "C11 (Division,Section)"
},
{
"identity": "v2",
"map": "IN1-8"
},
{
"identity": "cpha3pharm",
"map": "C.31"
}
]
},
{
"id": "Coverage.grouping.subGroup",
"path": "Coverage.grouping.subGroup",
"short": "An identifier for the subsection of the group",
"definition": "Identifies a style or collective of coverage issued by the underwriter, for example may be used to identify a subset of an employer group.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"isSummary": true,
"mapping": [
{
"identity": "v2",
"map": "IN1-8"
}
]
},
{
"id": "Coverage.grouping.subGroupDisplay",
"path": "Coverage.grouping.subGroupDisplay",
"short": "Display text for the subsection of the group",
"definition": "A short description for the subgroup.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"isSummary": true,
"mapping": [
{
"identity": "v2",
"map": "IN1-8"
}
]
},
{
"id": "Coverage.grouping.plan",
"path": "Coverage.grouping.plan",
"short": "An identifier for the plan",
"definition": "Identifies a style or collective of coverage issued by the underwriter, for example may be used to identify a collection of benefits provided to employees. May be referred to as a Section or Division ID.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"isSummary": true,
"mapping": [
{
"identity": "cdanetv4",
"map": "C01"
},
{
"identity": "v2",
"map": "IN1-35"
}
]
},
{
"id": "Coverage.grouping.planDisplay",
"path": "Coverage.grouping.planDisplay",
"short": "Display text for the plan",
"definition": "A short description for the plan.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"isSummary": true,
"mapping": [
{
"identity": "cdanetv4",
"map": "C01"
},
{
"identity": "v2",
"map": "IN1-35"
}
]
},
{
"id": "Coverage.grouping.subPlan",
"path": "Coverage.grouping.subPlan",
"short": "An identifier for the subsection of the plan",
"definition": "Identifies a sub-style or sub-collective of coverage issued by the underwriter, for example may be used to identify a subset of a collection of benefits provided to employees.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"isSummary": true,
"mapping": [
{
"identity": "v2",
"map": "IN1-10"
}
]
},
{
"id": "Coverage.grouping.subPlanDisplay",
"path": "Coverage.grouping.subPlanDisplay",
"short": "Display text for the subsection of the plan",
"definition": "A short description for the subplan.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"isSummary": true,
"mapping": [
{
"identity": "v2",
"map": "IN1-10"
}
]
},
{
"id": "Coverage.grouping.class",
"path": "Coverage.grouping.class",
"short": "An identifier for the class",
"definition": "Identifies a style or collective of coverage issues by the underwriter, for example may be used to identify a class of coverage such as a level of deductables or co-payment.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"isSummary": true,
"mapping": [
{
"identity": "cdanetv4",
"map": "C01"
},
{
"identity": "v2",
"map": "IN1-35"
}
]
},
{
"id": "Coverage.grouping.classDisplay",
"path": "Coverage.grouping.classDisplay",
"short": "Display text for the class",
"definition": "A short description for the class.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"isSummary": true,
"mapping": [
{
"identity": "cdanetv4",
"map": "C01"
},
{
"identity": "v2",
"map": "IN1-35"
}
]
},
{
"id": "Coverage.grouping.subClass",
"path": "Coverage.grouping.subClass",
"short": "An identifier for the subsection of the class",
"definition": "Identifies a sub-style or sub-collective of coverage issues by the underwriter, for example may be used to identify a subclass of coverage such as a sub-level of deductables or co-payment.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"isSummary": true,
"mapping": [
{
"identity": "cdanetv4",
"map": "C01"
},
{
"identity": "v2",
"map": "IN1-35"
}
]
},
{
"id": "Coverage.grouping.subClassDisplay",
"path": "Coverage.grouping.subClassDisplay",
"short": "Display text for the subsection of the subclass",
"definition": "A short description for the subclass.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"isSummary": true,
"mapping": [
{
"identity": "cdanetv4",
"map": "C01"
},
{
"identity": "v2",
"map": "IN1-35"
}
]
},
{
"id": "Coverage.dependent",
"path": "Coverage.dependent",
"short": "Dependent number",
"definition": "A unique identifier for a dependent under the coverage.",
"requirements": "For some coverage a single identifier is issued to the Subscriber and a dependent number issued to each beneficiary.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"isSummary": true,
"mapping": [
{
"identity": "cdanetv4",
"map": "C17"
},
{
"identity": "v2",
"map": "- No exact HL7 v2 equivalent concept seems to exist;"
}
]
},
{
"id": "Coverage.sequence",
"path": "Coverage.sequence",
"short": "The plan instance or sequence counter",
"definition": "An optional counter for a particular instance of the identified coverage which increments upon each renewal.",
"requirements": "Some coverage, for example social plans, may be offered in short time increments, for example for a week or a month at a time, so while the rest of the plan details and identifiers may remain constant over time, the instance is incremented with each renewal and provided to the covered party on their 'card'.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"isSummary": true,
"mapping": [
{
"identity": "cdanetv4",
"map": "D11"
},
{
"identity": "v2",
"map": "No HL7 v2 equivalent concept seems to exist"
}
]
},
{
"id": "Coverage.order",
"path": "Coverage.order",
"short": "Relative order of the coverage",
"definition": "The order of applicability of this coverage relative to other coverages which are currently inforce. Note, there may be gaps in the numbering and this does not imply primary, secondard etc. as the specific positioning of coverages depends upon the episode of care.",
"min": 0,
"max": "1",
"type": [
{
"code": "positiveInt"
}
],
"isSummary": true,
"mapping": [
{
"identity": "v2",
"map": "- No exact HL7 v2 equivalent concept seems to exist;"
}
]
},
{
"id": "Coverage.network",
"path": "Coverage.network",
"short": "Insurer network",
"definition": "The insurer-specific identifier for the insurer-defined network of providers to which the beneficiary may seek treatment which will be covered at the 'in-network' rate, otherwise 'out of network' terms and conditions apply.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"isSummary": true,
"mapping": [
{
"identity": "cdanetv4",
"map": "D10"
}
]
},
{
"id": "Coverage.contract",
"path": "Coverage.contract",
"short": "Contract details",
"definition": "The policy(s) which constitute this insurance coverage.",
"min": 0,
"max": "*",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Contract"
}
],
"mapping": [
{
"identity": "cdanetv4",
"map": "D01 through D09"
},
{
"identity": "v2",
"map": "IN1-16, 18, 19"
},
{
"identity": "cpha3pharm",
"map": "C.35"
}
]
}
]
},
"differential": {
"element": [
{
"id": "Coverage",
"path": "Coverage",
"short": "Insurance or medical plan or a payment agreement",
"definition": "Financial instrument which may be used to reimburse or pay for health care products and services.",
"min": 0,
"max": "*",
"mapping": [
{
"identity": "workflow",
"map": "Event"
},
{
"identity": "rim",
"map": "Coverage"
},
{
"identity": "w5",
"map": "financial.support"
}
]
},
{
"id": "Coverage.identifier",
"path": "Coverage.identifier",
"short": "The primary coverage ID",
"definition": "The main (and possibly only) identifier for the coverage - often referred to as a Member Id, Certificate number, Personal Health Number or Case ID. May be constructed as the concatination of the Coverage.SubscriberID and the Coverage.dependant.",
"requirements": "This value may uniquely identify the coverage or it may be used in conjunction with the additional identifiers below.",
"min": 0,
"max": "*",
"type": [
{
"code": "Identifier"
}
],
"isSummary": true,
"mapping": [
{
"identity": "workflow",
"map": "Event.identifier"
},
{
"identity": "cdanetv4",
"map": "C02"
},
{
"identity": "v2",
"map": "IN1-2"
},
{
"identity": "cpha3pharm",
"map": "C.32, C.33, C.39"
},
{
"identity": "w5",
"map": "id"
}
]
},
{
"id": "Coverage.status",
"path": "Coverage.status",
"short": "active | cancelled | draft | entered-in-error",
"definition": "The status of the resource instance.",
"comment": "This element is labeled as a modifier because the status contains the code entered-in-error that marks the coverage as not currently valid.",
"min": 0,
"max": "1",
"type": [
{
"code": "code"
}
],
"isModifier": true,
"isSummary": true,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CoverageStatus"
}
],
"strength": "required",
"description": "A code specifying the state of the resource instance.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/fm-status"
}
},
"mapping": [
{
"identity": "workflow",
"map": "Event.status"
},
{
"identity": "w5",
"map": "status"
}
]
},
{
"id": "Coverage.type",
"path": "Coverage.type",
"short": "Type of coverage such as medical or accident",
"definition": "The type of coverage: social program, medical plan, accident coverage (workers compensation, auto), group health or payment by an individual or organization.",
"requirements": "The order of application of coverages is dependent on the types of coverage.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "CoverageType"
}
],
"strength": "preferred",
"description": "The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/coverage-type"
}
},
"mapping": [
{
"identity": "v2",
"map": "IN1-15"
},
{
"identity": "w5",
"map": "class"
}
]
},
{
"id": "Coverage.policyHolder",
"path": "Coverage.policyHolder",
"short": "Owner of the policy",
"definition": "The party who 'owns' the insurance policy, may be an individual, corporation or the subscriber's employer.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Patient"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/RelatedPerson"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization"
}
],
"isSummary": true,
"mapping": [
{
"identity": "cdanetv4",
"map": "D01 through D09"
},
{
"identity": "v2",
"map": "IN1-16, 18, 19-name of insured, address, date of birth"
},
{
"identity": "cpha3pharm",
"map": "C.35"
},
{
"identity": "w5",
"map": "who.focus"
}
]
},
{
"id": "Coverage.subscriber",
"path": "Coverage.subscriber",
"short": "Subscriber to the policy",
"definition": "The party who has signed-up for or 'owns' the contractual relationship to the policy or to whom the benefit of the policy for services rendered to them or their family is due.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Patient"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/RelatedPerson"
}
],
"isSummary": true,
"mapping": [
{
"identity": "cdanetv4",
"map": "D01 through D09"
},
{
"identity": "v2",
"map": "IN1-16, 18, 19-name of insured, address, date of birth"
},
{
"identity": "cpha3pharm",
"map": "C.35"
},
{
"identity": "w5",
"map": "who.focus"
}
]
},
{
"id": "Coverage.subscriberId",
"path": "Coverage.subscriberId",
"short": "ID assigned to the Subscriber",
"definition": "The insurer assigned ID for the Subscriber.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"isSummary": true,
"mapping": [
{
"identity": "cdanetv4",
"map": "D01 through D09"
},
{
"identity": "v2",
"map": "IN1-16, 18, 19-name of insured, address, date of birth"
},
{
"identity": "cpha3pharm",
"map": "C.35"
},
{
"identity": "w5",
"map": "who.focus"
}
]
},
{
"id": "Coverage.beneficiary",
"path": "Coverage.beneficiary",
"short": "Plan Beneficiary",
"definition": "The party who benefits from the insurance coverage., the patient when services are provided.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Patient"
}
],
"isSummary": true,
"mapping": [
{
"identity": "workflow",
"map": "Event.subject"
},
{
"identity": "cdanetv4",
"map": "D01 through D09"
},
{
"identity": "v2",
"map": "IN1-16, 18, 19-name of insured, address, date of birth"
},
{
"identity": "cpha3pharm",
"map": "C.35"
},
{
"identity": "w5",
"map": "who.focus"
}
]
},
{
"id": "Coverage.relationship",
"path": "Coverage.relationship",
"short": "Beneficiary relationship to the Subscriber",
"definition": "The relationship of beneficiary (patient) to the subscriber.",
"requirements": "To determine relationship between the patient and the subscriber.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Relationship"
}
],
"strength": "example",
"description": "The relationship between the Policyholder and the Beneficiary (insured/covered party/patient).",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/policyholder-relationship"
}
},
"mapping": [
{
"identity": "cdanetv4",
"map": "C03"
}
]
},
{
"id": "Coverage.period",
"path": "Coverage.period",
"short": "Coverage start and end dates",
"definition": "Time period during which the coverage is in force. A missing start date indicates the start date isn't known, a missing end date means the coverage is continuing to be in force.",
"min": 0,
"max": "1",
"type": [
{
"code": "Period"
}
],
"isSummary": true,
"mapping": [
{
"identity": "workflow",
"map": "Event.occurrence"
},
{
"identity": "v2",
"map": "IN1-12 / IN1-13"
},
{
"identity": "w5",
"map": "when.done"
}
]
},
{
"id": "Coverage.payor",
"path": "Coverage.payor",
"short": "Identifier for the plan or agreement issuer",
"definition": "The program or plan underwriter or payor including both insurance and non-insurance agreements, such as patient-pay agreements. May provide multiple identifiers such as insurance company identifier or business identifier (BIN number).",
"requirements": "Need to identify the issuer to target for processing and for coordination of benefit processing.",
"min": 0,
"max": "*",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Patient"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/RelatedPerson"
}
],
"isSummary": true,
"mapping": [
{
"identity": "cdanetv4",
"map": "A05"
},
{
"identity": "v2",
"map": "IN1-3"
},
{
"identity": "cpha3pharm",
"map": "C.30"
},
{
"identity": "w5",
"map": "who.author"
}
]
},
{
"id": "Coverage.grouping",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Group"
}
],
"path": "Coverage.grouping",
"short": "Additional coverage classifications",
"definition": "A suite of underwrite specific classifiers, for example may be used to identify a class of coverage or employer group, Policy, Plan.",
"min": 0,
"max": "1",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "Coverage.grouping.group",
"path": "Coverage.grouping.group",
"short": "An identifier for the group",
"definition": "Identifies a style or collective of coverage issued by the underwriter, for example may be used to identify an employer group. May also be referred to as a Policy or Group ID.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"isSummary": true,
"mapping": [
{
"identity": "cdanetv4",
"map": "C11 (Division,Section)"
},
{
"identity": "v2",
"map": "IN1-8"
},
{
"identity": "cpha3pharm",
"map": "C.31"
}
]
},
{
"id": "Coverage.grouping.groupDisplay",
"path": "Coverage.grouping.groupDisplay",
"short": "Display text for an identifier for the group",
"definition": "A short description for the group.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"isSummary": true,
"mapping": [
{
"identity": "cdanetv4",
"map": "C11 (Division,Section)"
},
{
"identity": "v2",
"map": "IN1-8"
},
{
"identity": "cpha3pharm",
"map": "C.31"
}
]
},
{
"id": "Coverage.grouping.subGroup",
"path": "Coverage.grouping.subGroup",
"short": "An identifier for the subsection of the group",
"definition": "Identifies a style or collective of coverage issued by the underwriter, for example may be used to identify a subset of an employer group.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"isSummary": true,
"mapping": [
{
"identity": "v2",
"map": "IN1-8"
}
]
},
{
"id": "Coverage.grouping.subGroupDisplay",
"path": "Coverage.grouping.subGroupDisplay",
"short": "Display text for the subsection of the group",
"definition": "A short description for the subgroup.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"isSummary": true,
"mapping": [
{
"identity": "v2",
"map": "IN1-8"
}
]
},
{
"id": "Coverage.grouping.plan",
"path": "Coverage.grouping.plan",
"short": "An identifier for the plan",
"definition": "Identifies a style or collective of coverage issued by the underwriter, for example may be used to identify a collection of benefits provided to employees. May be referred to as a Section or Division ID.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"isSummary": true,
"mapping": [
{
"identity": "cdanetv4",
"map": "C01"
},
{
"identity": "v2",
"map": "IN1-35"
}
]
},
{
"id": "Coverage.grouping.planDisplay",
"path": "Coverage.grouping.planDisplay",
"short": "Display text for the plan",
"definition": "A short description for the plan.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"isSummary": true,
"mapping": [
{
"identity": "cdanetv4",
"map": "C01"
},
{
"identity": "v2",
"map": "IN1-35"
}
]
},
{
"id": "Coverage.grouping.subPlan",
"path": "Coverage.grouping.subPlan",
"short": "An identifier for the subsection of the plan",
"definition": "Identifies a sub-style or sub-collective of coverage issued by the underwriter, for example may be used to identify a subset of a collection of benefits provided to employees.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"isSummary": true,
"mapping": [
{
"identity": "v2",
"map": "IN1-10"
}
]
},
{
"id": "Coverage.grouping.subPlanDisplay",
"path": "Coverage.grouping.subPlanDisplay",
"short": "Display text for the subsection of the plan",
"definition": "A short description for the subplan.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"isSummary": true,
"mapping": [
{
"identity": "v2",
"map": "IN1-10"
}
]
},
{
"id": "Coverage.grouping.class",
"path": "Coverage.grouping.class",
"short": "An identifier for the class",
"definition": "Identifies a style or collective of coverage issues by the underwriter, for example may be used to identify a class of coverage such as a level of deductables or co-payment.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"isSummary": true,
"mapping": [
{
"identity": "cdanetv4",
"map": "C01"
},
{
"identity": "v2",
"map": "IN1-35"
}
]
},
{
"id": "Coverage.grouping.classDisplay",
"path": "Coverage.grouping.classDisplay",
"short": "Display text for the class",
"definition": "A short description for the class.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"isSummary": true,
"mapping": [
{
"identity": "cdanetv4",
"map": "C01"
},
{
"identity": "v2",
"map": "IN1-35"
}
]
},
{
"id": "Coverage.grouping.subClass",
"path": "Coverage.grouping.subClass",
"short": "An identifier for the subsection of the class",
"definition": "Identifies a sub-style or sub-collective of coverage issues by the underwriter, for example may be used to identify a subclass of coverage such as a sub-level of deductables or co-payment.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"isSummary": true,
"mapping": [
{
"identity": "cdanetv4",
"map": "C01"
},
{
"identity": "v2",
"map": "IN1-35"
}
]
},
{
"id": "Coverage.grouping.subClassDisplay",
"path": "Coverage.grouping.subClassDisplay",
"short": "Display text for the subsection of the subclass",
"definition": "A short description for the subclass.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"isSummary": true,
"mapping": [
{
"identity": "cdanetv4",
"map": "C01"
},
{
"identity": "v2",
"map": "IN1-35"
}
]
},
{
"id": "Coverage.dependent",
"path": "Coverage.dependent",
"short": "Dependent number",
"definition": "A unique identifier for a dependent under the coverage.",
"requirements": "For some coverage a single identifier is issued to the Subscriber and a dependent number issued to each beneficiary.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"isSummary": true,
"mapping": [
{
"identity": "cdanetv4",
"map": "C17"
},
{
"identity": "v2",
"map": "- No exact HL7 v2 equivalent concept seems to exist;"
}
]
},
{
"id": "Coverage.sequence",
"path": "Coverage.sequence",
"short": "The plan instance or sequence counter",
"definition": "An optional counter for a particular instance of the identified coverage which increments upon each renewal.",
"requirements": "Some coverage, for example social plans, may be offered in short time increments, for example for a week or a month at a time, so while the rest of the plan details and identifiers may remain constant over time, the instance is incremented with each renewal and provided to the covered party on their 'card'.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"isSummary": true,
"mapping": [
{
"identity": "cdanetv4",
"map": "D11"
},
{
"identity": "v2",
"map": "No HL7 v2 equivalent concept seems to exist"
}
]
},
{
"id": "Coverage.order",
"path": "Coverage.order",
"short": "Relative order of the coverage",
"definition": "The order of applicability of this coverage relative to other coverages which are currently inforce. Note, there may be gaps in the numbering and this does not imply primary, secondard etc. as the specific positioning of coverages depends upon the episode of care.",
"min": 0,
"max": "1",
"type": [
{
"code": "positiveInt"
}
],
"isSummary": true,
"mapping": [
{
"identity": "v2",
"map": "- No exact HL7 v2 equivalent concept seems to exist;"
}
]
},
{
"id": "Coverage.network",
"path": "Coverage.network",
"short": "Insurer network",
"definition": "The insurer-specific identifier for the insurer-defined network of providers to which the beneficiary may seek treatment which will be covered at the 'in-network' rate, otherwise 'out of network' terms and conditions apply.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"isSummary": true,
"mapping": [
{
"identity": "cdanetv4",
"map": "D10"
}
]
},
{
"id": "Coverage.contract",
"path": "Coverage.contract",
"short": "Contract details",
"definition": "The policy(s) which constitute this insurance coverage.",
"min": 0,
"max": "*",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Contract"
}
],
"mapping": [
{
"identity": "cdanetv4",
"map": "D01 through D09"
},
{
"identity": "v2",
"map": "IN1-16, 18, 19"
},
{
"identity": "cpha3pharm",
"map": "C.35"
}
]
}
]
}
}
Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.
®© HL7.org 2011+. FHIR Release 3 (STU; v3.0.2-11200) generated on Thurs, Oct 24, 2019 11:53+1100. QA Page
Links: Search |
Version History |
Table of Contents |
Credits |
Compare to DSTU2 |
|
Propose a change