Bidirectional Services eReferral (BSeR)
2.0.0-ballot - STU2
Bidirectional Services eReferral (BSeR)
2.0.0-ballot - STU2
This page is part of the Bidirectional Services eReferrals (BSeR) (v2.0.0-ballot: STU 2) based on FHIR R4. The current version which supercedes this version is 1.0.0. For a full list of available versions, see the Directory of published versions 
| Official URL: http://hl7.org/fhir/us/bser/StructureDefinition/BSeR-Coverage | Version: 2.0.0-ballot | |||
| Active as of 2023-07-31 | Computable Name: BSeRCoverage | |||
This Coverage profile represents identifiers and descriptors of an insurance plan underwriting some or all of the cost of the referral services provided.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Coverage
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Coverage | 0..* | Coverage | Insurance or medical plan or a payment agreement | |
  Slices for identifier | S | 0..* | Identifier | Member ID and other identifiers Slice: Unordered, Open by pattern:type |
   identifier:memberid | S | 0..1 | Identifier | Member ID |
   type | S | 1..1 | CodeableConcept | Member Number identifier type 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/v2-0203 | |
 code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: MB | |
| status | S | 1..1 | code | (USCDI) active | cancelled | draft | entered-in-error |
| type | S | 0..1 | CodeableConcept | Coverage category such as medical or accident Binding: Payer Type (extensible) |
 subscriber | S | 0..1 | Reference(US Core Patient Profile | US Core RelatedPerson Profile) | Subscriber to the policy |
| subscriberId | S | 0..1 | string | ID assigned to the subscriber |
| beneficiary | S | 1..1 | Reference(US Core Patient Profile) | Plan beneficiary |
| relationship | S | 1..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible) |
| period | S | 0..1 | Period | Coverage start and end dates |
| payor | S | 1..1 | Reference(US Core Organization Profile | US Core Patient Profile | US Core RelatedPerson Profile) | Issuer of the policy |
| Slices for class | S | 0..* | BackboneElement | Additional coverage classifications Slice: Unordered, Open by pattern:type |
 class:group | S | 0..1 | BackboneElement | Group |
  type | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' 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/coverage-class | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: group | |
 value | S | 1..1 | string | Group Number |
 name | S | 0..1 | string | Group Name |
| class:plan | S | 0..1 | BackboneElement | Plan |
| type | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' 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/coverage-class | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: plan | |
| value | S | 1..1 | string | Plan Number |
| name | S | 0..1 | string | Plan Name |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Coverage.type | extensible | PayerType |
| Coverage.relationship | extensible | SubscriberRelationshipCodes |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Coverage | 0..* | Coverage | Insurance or medical plan or a payment agreement | |
 implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| Slices for identifier | SΣ | 0..* | Identifier | Member ID and other identifiers Slice: Unordered, Open by pattern:type |
| identifier:memberid | SΣ | 0..1 | Identifier | Member ID |
| use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . |
 type | SΣ | 1..1 | CodeableConcept | Member Number identifier type Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. 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/v2-0203 | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: MB | |
| status | ?!SΣ | 1..1 | code | (USCDI) active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. |
| type | SΣ | 0..1 | CodeableConcept | Coverage category such as medical or accident Binding: Payer Type (extensible) |
| subscriber | SΣ | 0..1 | Reference(US Core Patient Profile | US Core RelatedPerson Profile) | Subscriber to the policy |
| subscriberId | SΣ | 0..1 | string | ID assigned to the subscriber |
| beneficiary | SΣ | 1..1 | Reference(US Core Patient Profile) | Plan beneficiary |
| relationship | S | 1..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible) |
| period | SΣ | 0..1 | Period | Coverage start and end dates |
| payor | SΣ | 1..1 | Reference(US Core Organization Profile | US Core Patient Profile | US Core RelatedPerson Profile) | Issuer of the policy |
| Slices for class | S | 0..* | BackboneElement | Additional coverage classifications Slice: Unordered, Open by pattern:type |
| class:All Slices | Content/Rules for all slices | |||
 modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. |
 value | Σ | 1..1 | string | Value associated with the type |
| class:group | S | 0..1 | BackboneElement | Group |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. 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/coverage-class | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: group | |
| value | SΣ | 1..1 | string | Group Number |
| name | SΣ | 0..1 | string | Group Name |
| class:plan | S | 0..1 | BackboneElement | Plan |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. 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/coverage-class | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: plan | |
| value | SΣ | 1..1 | string | Plan Number |
| name | SΣ | 0..1 | string | Plan Name |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Coverage.identifier:memberid.use | required | IdentifierUse |
| Coverage.identifier:memberid.type | extensible | Pattern: MB |
| Coverage.status | required | FinancialResourceStatusCodes |
| Coverage.type | extensible | PayerType |
| Coverage.relationship | extensible | SubscriberRelationshipCodes |
| Coverage.class.type | extensible | CoverageClassCodes |
| Coverage.class:group.type | extensible | Pattern: group |
| Coverage.class:plan.type | extensible | Pattern: plan |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Coverage | 0..* | Coverage | Insurance or medical plan or a payment agreement | |||||
| id | Σ | 0..1 | id | Logical id of this artifact | ||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
| 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.
| |||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
 extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| Slices for identifier | SΣ | 0..* | Identifier | Member ID and other identifiers Slice: Unordered, Open by pattern:type | ||||
| identifier:memberid | SΣ | 0..1 | Identifier | Member ID | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
| type | SΣ | 1..1 | CodeableConcept | Member Number identifier type Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. 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/v2-0203 | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: MB | |||||
| 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 | |||||
| system | Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
| value | Σ | 0..1 | string | The value that is unique Example General: 123456 | ||||
| period | Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
| assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||
| status | ?!SΣ | 1..1 | code | (USCDI) active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. | ||||
| type | SΣ | 0..1 | CodeableConcept | Coverage category such as medical or accident Binding: Payer Type (extensible) | ||||
| policyHolder | Σ | 0..1 | Reference(Patient | RelatedPerson | Organization) | Owner of the policy | ||||
| subscriber | SΣ | 0..1 | Reference(US Core Patient Profile | US Core RelatedPerson Profile) | Subscriber to the policy | ||||
| subscriberId | SΣ | 0..1 | string | ID assigned to the subscriber | ||||
| beneficiary | SΣ | 1..1 | Reference(US Core Patient Profile) | Plan beneficiary | ||||
| dependent | Σ | 0..1 | string | Dependent number | ||||
| relationship | S | 1..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible) | ||||
| period | SΣ | 0..1 | Period | Coverage start and end dates | ||||
| payor | SΣ | 1..1 | Reference(US Core Organization Profile | US Core Patient Profile | US Core RelatedPerson Profile) | Issuer of the policy | ||||
| Slices for class | S | 0..* | BackboneElement | Additional coverage classifications Slice: Unordered, Open by pattern:type | ||||
| class: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 | ||||
| type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. | ||||
| value | Σ | 1..1 | string | Value associated with the type | ||||
| name | Σ | 0..1 | string | Human readable description of the type and value | ||||
| class:group | S | 0..1 | BackboneElement | Group | ||||
| 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 | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. 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/coverage-class | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: group | |||||
| 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 | |||||
| value | SΣ | 1..1 | string | Group Number | ||||
| name | SΣ | 0..1 | string | Group Name | ||||
| class:plan | S | 0..1 | BackboneElement | Plan | ||||
| 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 | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. 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/coverage-class | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: plan | |||||
| 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 | |||||
| value | SΣ | 1..1 | string | Plan Number | ||||
| name | SΣ | 0..1 | string | Plan Name | ||||
| order | Σ | 0..1 | positiveInt | Relative order of the coverage | ||||
| network | Σ | 0..1 | string | Insurer network | ||||
| costToBeneficiary | 0..* | BackboneElement | Patient payments for services/products | |||||
| 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 | Σ | 0..1 | CodeableConcept | Cost category Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified. | ||||
 value[x] | Σ | 1..1 | The amount or percentage due from the beneficiary | |||||
| valueQuantity | Quantity(SimpleQuantity) | |||||||
| valueMoney | Money | |||||||
| exception | 0..* | BackboneElement | Exceptions for patient payments | |||||
| 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 | Σ | 1..1 | CodeableConcept | Exception category Binding: ExampleCoverageFinancialExceptionCodes (example): The types of exceptions from the part or full value of financial obligations such as copays. | ||||
| period | Σ | 0..1 | Period | The effective period of the exception | ||||
| subrogation | 0..1 | boolean | Reimbursement to insurer | |||||
| contract | 0..* | Reference(Contract) | Contract details | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | ||||
| Coverage.language | preferred | CommonLanguages
| ||||
| Coverage.identifier:memberid.use | required | IdentifierUse | ||||
| Coverage.identifier:memberid.type | extensible | Pattern: MB | ||||
| Coverage.status | required | FinancialResourceStatusCodes | ||||
| Coverage.type | extensible | PayerType | ||||
| Coverage.relationship | extensible | SubscriberRelationshipCodes | ||||
| Coverage.class.type | extensible | CoverageClassCodes | ||||
| Coverage.class:group.type | extensible | Pattern: group | ||||
| Coverage.class:plan.type | extensible | Pattern: plan | ||||
| Coverage.costToBeneficiary.type | extensible | CoverageCopayTypeCodes | ||||
| Coverage.costToBeneficiary.exception.type | example | ExampleCoverageFinancialExceptionCodes |
This structure is derived from Coverage
Summary
Mandatory: 1 element (1 nested mandatory element)
Must-Support: 18 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from Coverage
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Coverage | 0..* | Coverage | Insurance or medical plan or a payment agreement | |
| Slices for identifier | S | 0..* | Identifier | Member ID and other identifiers Slice: Unordered, Open by pattern:type |
| identifier:memberid | S | 0..1 | Identifier | Member ID |
| type | S | 1..1 | CodeableConcept | Member Number identifier type 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/v2-0203 | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: MB | |
| status | S | 1..1 | code | (USCDI) active | cancelled | draft | entered-in-error |
| type | S | 0..1 | CodeableConcept | Coverage category such as medical or accident Binding: Payer Type (extensible) |
| subscriber | S | 0..1 | Reference(US Core Patient Profile | US Core RelatedPerson Profile) | Subscriber to the policy |
| subscriberId | S | 0..1 | string | ID assigned to the subscriber |
| beneficiary | S | 1..1 | Reference(US Core Patient Profile) | Plan beneficiary |
| relationship | S | 1..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible) |
| period | S | 0..1 | Period | Coverage start and end dates |
| payor | S | 1..1 | Reference(US Core Organization Profile | US Core Patient Profile | US Core RelatedPerson Profile) | Issuer of the policy |
| Slices for class | S | 0..* | BackboneElement | Additional coverage classifications Slice: Unordered, Open by pattern:type |
| class:group | S | 0..1 | BackboneElement | Group |
| type | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' 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/coverage-class | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: group | |
| value | S | 1..1 | string | Group Number |
| name | S | 0..1 | string | Group Name |
| class:plan | S | 0..1 | BackboneElement | Plan |
| type | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' 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/coverage-class | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: plan | |
| value | S | 1..1 | string | Plan Number |
| name | S | 0..1 | string | Plan Name |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Coverage.type | extensible | PayerType |
| Coverage.relationship | extensible | SubscriberRelationshipCodes |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Coverage | 0..* | Coverage | Insurance or medical plan or a payment agreement | |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| Slices for identifier | SΣ | 0..* | Identifier | Member ID and other identifiers Slice: Unordered, Open by pattern:type |
| identifier:memberid | SΣ | 0..1 | Identifier | Member ID |
| use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . |
| type | SΣ | 1..1 | CodeableConcept | Member Number identifier type Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. 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/v2-0203 | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: MB | |
| status | ?!SΣ | 1..1 | code | (USCDI) active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. |
| type | SΣ | 0..1 | CodeableConcept | Coverage category such as medical or accident Binding: Payer Type (extensible) |
| subscriber | SΣ | 0..1 | Reference(US Core Patient Profile | US Core RelatedPerson Profile) | Subscriber to the policy |
| subscriberId | SΣ | 0..1 | string | ID assigned to the subscriber |
| beneficiary | SΣ | 1..1 | Reference(US Core Patient Profile) | Plan beneficiary |
| relationship | S | 1..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible) |
| period | SΣ | 0..1 | Period | Coverage start and end dates |
| payor | SΣ | 1..1 | Reference(US Core Organization Profile | US Core Patient Profile | US Core RelatedPerson Profile) | Issuer of the policy |
| Slices for class | S | 0..* | BackboneElement | Additional coverage classifications Slice: Unordered, Open by pattern:type |
| class:All Slices | Content/Rules for all slices | |||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. |
| value | Σ | 1..1 | string | Value associated with the type |
| class:group | S | 0..1 | BackboneElement | Group |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. 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/coverage-class | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: group | |
| value | SΣ | 1..1 | string | Group Number |
| name | SΣ | 0..1 | string | Group Name |
| class:plan | S | 0..1 | BackboneElement | Plan |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. 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/coverage-class | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: plan | |
| value | SΣ | 1..1 | string | Plan Number |
| name | SΣ | 0..1 | string | Plan Name |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Coverage.identifier:memberid.use | required | IdentifierUse |
| Coverage.identifier:memberid.type | extensible | Pattern: MB |
| Coverage.status | required | FinancialResourceStatusCodes |
| Coverage.type | extensible | PayerType |
| Coverage.relationship | extensible | SubscriberRelationshipCodes |
| Coverage.class.type | extensible | CoverageClassCodes |
| Coverage.class:group.type | extensible | Pattern: group |
| Coverage.class:plan.type | extensible | Pattern: plan |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Coverage | 0..* | Coverage | Insurance or medical plan or a payment agreement | |||||
| id | Σ | 0..1 | id | Logical id of this artifact | ||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
| 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.
| |||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| Slices for identifier | SΣ | 0..* | Identifier | Member ID and other identifiers Slice: Unordered, Open by pattern:type | ||||
| identifier:memberid | SΣ | 0..1 | Identifier | Member ID | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
| type | SΣ | 1..1 | CodeableConcept | Member Number identifier type Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. 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/v2-0203 | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: MB | |||||
| 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 | |||||
| system | Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
| value | Σ | 0..1 | string | The value that is unique Example General: 123456 | ||||
| period | Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
| assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||
| status | ?!SΣ | 1..1 | code | (USCDI) active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. | ||||
| type | SΣ | 0..1 | CodeableConcept | Coverage category such as medical or accident Binding: Payer Type (extensible) | ||||
| policyHolder | Σ | 0..1 | Reference(Patient | RelatedPerson | Organization) | Owner of the policy | ||||
| subscriber | SΣ | 0..1 | Reference(US Core Patient Profile | US Core RelatedPerson Profile) | Subscriber to the policy | ||||
| subscriberId | SΣ | 0..1 | string | ID assigned to the subscriber | ||||
| beneficiary | SΣ | 1..1 | Reference(US Core Patient Profile) | Plan beneficiary | ||||
| dependent | Σ | 0..1 | string | Dependent number | ||||
| relationship | S | 1..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible) | ||||
| period | SΣ | 0..1 | Period | Coverage start and end dates | ||||
| payor | SΣ | 1..1 | Reference(US Core Organization Profile | US Core Patient Profile | US Core RelatedPerson Profile) | Issuer of the policy | ||||
| Slices for class | S | 0..* | BackboneElement | Additional coverage classifications Slice: Unordered, Open by pattern:type | ||||
| class: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 | ||||
| type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. | ||||
| value | Σ | 1..1 | string | Value associated with the type | ||||
| name | Σ | 0..1 | string | Human readable description of the type and value | ||||
| class:group | S | 0..1 | BackboneElement | Group | ||||
| 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 | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. 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/coverage-class | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: group | |||||
| 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 | |||||
| value | SΣ | 1..1 | string | Group Number | ||||
| name | SΣ | 0..1 | string | Group Name | ||||
| class:plan | S | 0..1 | BackboneElement | Plan | ||||
| 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 | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. 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/coverage-class | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: plan | |||||
| 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 | |||||
| value | SΣ | 1..1 | string | Plan Number | ||||
| name | SΣ | 0..1 | string | Plan Name | ||||
| order | Σ | 0..1 | positiveInt | Relative order of the coverage | ||||
| network | Σ | 0..1 | string | Insurer network | ||||
| costToBeneficiary | 0..* | BackboneElement | Patient payments for services/products | |||||
| 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 | Σ | 0..1 | CodeableConcept | Cost category Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified. | ||||
| value[x] | Σ | 1..1 | The amount or percentage due from the beneficiary | |||||
| valueQuantity | Quantity(SimpleQuantity) | |||||||
| valueMoney | Money | |||||||
| exception | 0..* | BackboneElement | Exceptions for patient payments | |||||
| 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 | Σ | 1..1 | CodeableConcept | Exception category Binding: ExampleCoverageFinancialExceptionCodes (example): The types of exceptions from the part or full value of financial obligations such as copays. | ||||
| period | Σ | 0..1 | Period | The effective period of the exception | ||||
| subrogation | 0..1 | boolean | Reimbursement to insurer | |||||
| contract | 0..* | Reference(Contract) | Contract details | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | ||||
| Coverage.language | preferred | CommonLanguages
| ||||
| Coverage.identifier:memberid.use | required | IdentifierUse | ||||
| Coverage.identifier:memberid.type | extensible | Pattern: MB | ||||
| Coverage.status | required | FinancialResourceStatusCodes | ||||
| Coverage.type | extensible | PayerType | ||||
| Coverage.relationship | extensible | SubscriberRelationshipCodes | ||||
| Coverage.class.type | extensible | CoverageClassCodes | ||||
| Coverage.class:group.type | extensible | Pattern: group | ||||
| Coverage.class:plan.type | extensible | Pattern: plan | ||||
| Coverage.costToBeneficiary.type | extensible | CoverageCopayTypeCodes | ||||
| Coverage.costToBeneficiary.exception.type | example | ExampleCoverageFinancialExceptionCodes |
This structure is derived from Coverage
Summary
Mandatory: 1 element (1 nested mandatory element)
Must-Support: 18 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron
IG © 2022+ HL7 Public Health Working Group. Package hl7.fhir.us.bser#2.0.0-ballot based on FHIR 4.0.1. Generated 2023-07-31
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