CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
1.2.0 - STU 2 Ballot

This page is part of the CARIN Blue Button Implementation Guide (v1.2.0: STU 2 Ballot 1) based on FHIR R4. The current version which supercedes this version is 2.0.0. For a full list of available versions, see the Directory of published versions

Resource Profile: C4BB Coverage

Defining URL:http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Coverage
Version:1.2.0
Name:C4BBCoverage
Title:C4BB Coverage
Status:Active as of 12/6/21 8:26 PM
Definition:

Data that reflect a payer’s coverage that was effective as of the date of service or the date of admission of the claim.

Publisher:HL7 Financial Management Working Group
Source Resource:XML / JSON / Turtle

The official URL for this profile is: 

http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Coverage

Notes on Fields

  • The Coverage FHIR Resource defines a comprehensive set of data elements.  Many of them are not relevant to this use case.  When reviewing the Profile Snapshot, several data elements previously hidden are now exposed.  Fields intended for consideration to be provided in the API are marked as Must Support; i.e., a red S or have a minimum cardinality of 1.  All other data elements are not expected to be sent by a Responder; if they are sent a Requestor can choose to ignore them
  • The Coverage Reference Resource shall be returned with data that was effective as of the date of service of the claim
  • The numbers, e.g. (1), following the data element descriptions correlate to the MapID in the CPCDS Data Dictionary and the Mapping Worksheet as described here.
  • meta.profile is required as a matter of convenience of receiving systems. The meta.profile should be used by the Server to hint/assert/declare that this instance conforms to one (or more) stated profiles (with business versions). meta.profile does not capture any business logic, processing directives, or semantics (for example, inpatient or outpatient). Clients should not assume that the Server will exhaustively indicate all profiles with all versions that this instance conforms to. Clients can (and should) perform their own validation of conformance to the indicated profile(s) and to any other profiles of interest.

Formal Views of Profile Content

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

This structure is derived from Coverage

Summary

Mandatory: 6 elements
Must-Support: 16 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Coverage.meta.profile is sliced based on the value of pattern:$this
  • The element Coverage.class is sliced based on the value of pattern:type

This structure is derived from Coverage

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..*CoverageInsurance or medical plan or a payment agreement
... meta S1..1MetaMetadata about the resource
.... lastUpdated S1..1instantWhen the resource version last changed
.... Slices for profile 1..*canonical(StructureDefinition)Profiles this resource claims to conform to
Slice: Unordered, Open by pattern:$this
..... profile:supportedProfile 1..1canonical(StructureDefinition)Profiles this resource claims to conform to
Required Pattern: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Coverage|1.2.0
... identifier S0..*IdentifierBusiness Identifier for the coverage
... status S1..1codeactive | cancelled | draft | entered-in-error
... subscriberId S1..1stringID assigned to the subscriber
... beneficiary S1..1Reference(C4BB Patient)Plan beneficiary
... relationship S1..1CodeableConceptBeneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (required)
... period S0..1PeriodCoverage start and end dates
... payor S1..1Reference(C4BB Organization)Issuer of the policy
... Slices for class S0..*BackboneElementAdditional coverage classifications
Slice: Unordered, Open by pattern:type
.... class:group S0..1BackboneElementGroup
..... type 1..1CodeableConceptType of class such as 'group' or 'plan'
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: group
..... value S1..1stringGroup Number
..... name S0..1stringGroup Name
.... class:plan S0..1BackboneElementPlan
..... type 1..1CodeableConceptType of class such as 'group' or 'plan'
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: plan
..... value S1..1stringPlan Number
..... name S0..1stringPlan Name

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..*CoverageInsurance or medical plan or a payment agreement
... id Σ0..1stringLogical id of this artifact
... meta SΣ1..1MetaMetadata about the resource
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ0..1idVersion specific identifier
.... lastUpdated SΣ1..1instantWhen the resource version last changed
.... source Σ0..1uriIdentifies where the resource comes from
.... Slices for profile Σ1..*canonical(StructureDefinition)Profiles this resource claims to conform to
Slice: Unordered, Open by pattern:$this
..... profile:supportedProfile Σ1..1canonical(StructureDefinition)Profiles this resource claims to conform to

Required Pattern: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Coverage|1.2.0
.... security Σ0..*CodingSecurity Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


.... tag Σ0..*CodingTags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".


... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier SΣ0..*IdentifierBusiness Identifier for the coverage
... status ?!SΣ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... type Σ0..1CodeableConceptCoverage category such as medical or accident
Binding: CoverageTypeAndSelf-PayCodes (preferred): The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization.

... policyHolder Σ0..1Reference(Patient | RelatedPerson | Organization)Owner of the policy
... subscriber Σ0..1Reference(Patient | RelatedPerson)Subscriber to the policy
... subscriberId SΣ1..1stringID assigned to the subscriber
... beneficiary SΣ1..1Reference(C4BB Patient)Plan beneficiary
... dependent Σ0..1stringDependent number
... relationship S1..1CodeableConceptBeneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (required)
... period SΣ0..1PeriodCoverage start and end dates
... payor SΣ1..1Reference(C4BB Organization)Issuer of the policy
... Slices for class S0..*BackboneElementAdditional coverage classifications
Slice: Unordered, Open by pattern:type
.... class:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type Σ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.

..... value Σ1..1stringValue associated with the type
..... name Σ0..1stringHuman readable description of the type and value
.... class:group S0..1BackboneElementGroup
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type Σ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: group
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... value SΣ1..1stringGroup Number
..... name SΣ0..1stringGroup Name
.... class:plan S0..1BackboneElementPlan
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type Σ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: plan
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... value SΣ1..1stringPlan Number
..... name SΣ0..1stringPlan Name
... order Σ0..1positiveIntRelative order of the coverage
... network Σ0..1stringInsurer network
... costToBeneficiary 0..*BackboneElementPatient payments for services/products
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type Σ0..1CodeableConceptCost category
Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified.

.... value[x] Σ1..1The amount or percentage due from the beneficiary
..... valueQuantityQuantity(SimpleQuantity)
..... valueMoneyMoney
.... exception 0..*BackboneElementExceptions for patient payments
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type Σ1..1CodeableConceptException category
Binding: ExampleCoverageFinancialExceptionCodes (example): The types of exceptions from the part or full value of financial obligations such as copays.

..... period Σ0..1PeriodThe effective period of the exception
... subrogation 0..1booleanReimbursement to insurer
... contract 0..*Reference(Contract)Contract details

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..*CoverageInsurance or medical plan or a payment agreement
... meta Σ1..1MetaMetadata about the resource
.... lastUpdated Σ1..1instantWhen the resource version last changed
... identifier Σ0..*IdentifierBusiness Identifier for the coverage
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... beneficiary Σ1..1Reference(C4BB Patient)Plan beneficiary
... relationship 1..1CodeableConceptBeneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (required)
... period Σ0..1PeriodCoverage start and end dates
... payor Σ1..1Reference(C4BB Organization)Issuer of the policy
... Slices for class 0..*BackboneElementAdditional coverage classifications
Slice: Unordered, Open by pattern:type
.... class:group 0..1BackboneElementGroup
..... value Σ1..1stringGroup Number
..... name Σ0..1stringGroup Name
.... class:plan 0..1BackboneElementPlan
..... value Σ1..1stringPlan Number
..... name Σ0..1stringPlan Name

doco Documentation for this format

This structure is derived from Coverage

Summary

Mandatory: 6 elements
Must-Support: 16 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Coverage.meta.profile is sliced based on the value of pattern:$this
  • The element Coverage.class is sliced based on the value of pattern:type

Differential View

This structure is derived from Coverage

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..*CoverageInsurance or medical plan or a payment agreement
... meta S1..1MetaMetadata about the resource
.... lastUpdated S1..1instantWhen the resource version last changed
.... Slices for profile 1..*canonical(StructureDefinition)Profiles this resource claims to conform to
Slice: Unordered, Open by pattern:$this
..... profile:supportedProfile 1..1canonical(StructureDefinition)Profiles this resource claims to conform to
Required Pattern: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Coverage|1.2.0
... identifier S0..*IdentifierBusiness Identifier for the coverage
... status S1..1codeactive | cancelled | draft | entered-in-error
... subscriberId S1..1stringID assigned to the subscriber
... beneficiary S1..1Reference(C4BB Patient)Plan beneficiary
... relationship S1..1CodeableConceptBeneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (required)
... period S0..1PeriodCoverage start and end dates
... payor S1..1Reference(C4BB Organization)Issuer of the policy
... Slices for class S0..*BackboneElementAdditional coverage classifications
Slice: Unordered, Open by pattern:type
.... class:group S0..1BackboneElementGroup
..... type 1..1CodeableConceptType of class such as 'group' or 'plan'
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: group
..... value S1..1stringGroup Number
..... name S0..1stringGroup Name
.... class:plan S0..1BackboneElementPlan
..... type 1..1CodeableConceptType of class such as 'group' or 'plan'
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: plan
..... value S1..1stringPlan Number
..... name S0..1stringPlan Name

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..*CoverageInsurance or medical plan or a payment agreement
... id Σ0..1stringLogical id of this artifact
... meta SΣ1..1MetaMetadata about the resource
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ0..1idVersion specific identifier
.... lastUpdated SΣ1..1instantWhen the resource version last changed
.... source Σ0..1uriIdentifies where the resource comes from
.... Slices for profile Σ1..*canonical(StructureDefinition)Profiles this resource claims to conform to
Slice: Unordered, Open by pattern:$this
..... profile:supportedProfile Σ1..1canonical(StructureDefinition)Profiles this resource claims to conform to

Required Pattern: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Coverage|1.2.0
.... security Σ0..*CodingSecurity Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


.... tag Σ0..*CodingTags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".


... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier SΣ0..*IdentifierBusiness Identifier for the coverage
... status ?!SΣ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... type Σ0..1CodeableConceptCoverage category such as medical or accident
Binding: CoverageTypeAndSelf-PayCodes (preferred): The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization.

... policyHolder Σ0..1Reference(Patient | RelatedPerson | Organization)Owner of the policy
... subscriber Σ0..1Reference(Patient | RelatedPerson)Subscriber to the policy
... subscriberId SΣ1..1stringID assigned to the subscriber
... beneficiary SΣ1..1Reference(C4BB Patient)Plan beneficiary
... dependent Σ0..1stringDependent number
... relationship S1..1CodeableConceptBeneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (required)
... period SΣ0..1PeriodCoverage start and end dates
... payor SΣ1..1Reference(C4BB Organization)Issuer of the policy
... Slices for class S0..*BackboneElementAdditional coverage classifications
Slice: Unordered, Open by pattern:type
.... class:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type Σ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.

..... value Σ1..1stringValue associated with the type
..... name Σ0..1stringHuman readable description of the type and value
.... class:group S0..1BackboneElementGroup
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type Σ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: group
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... value SΣ1..1stringGroup Number
..... name SΣ0..1stringGroup Name
.... class:plan S0..1BackboneElementPlan
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type Σ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: plan
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... value SΣ1..1stringPlan Number
..... name SΣ0..1stringPlan Name
... order Σ0..1positiveIntRelative order of the coverage
... network Σ0..1stringInsurer network
... costToBeneficiary 0..*BackboneElementPatient payments for services/products
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type Σ0..1CodeableConceptCost category
Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified.

.... value[x] Σ1..1The amount or percentage due from the beneficiary
..... valueQuantityQuantity(SimpleQuantity)
..... valueMoneyMoney
.... exception 0..*BackboneElementExceptions for patient payments
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type Σ1..1CodeableConceptException category
Binding: ExampleCoverageFinancialExceptionCodes (example): The types of exceptions from the part or full value of financial obligations such as copays.

..... period Σ0..1PeriodThe effective period of the exception
... subrogation 0..1booleanReimbursement to insurer
... contract 0..*Reference(Contract)Contract details

doco Documentation for this format

 

Other representations of profile: CSV, Excel, Schematron

Terminology Bindings

PathConformanceValueSet / Code
Coverage.meta.securityextensibleAll Security Labels
Coverage.meta.tagexampleCommonTags
Coverage.languagepreferredCommonLanguages
Max Binding: AllLanguages
Coverage.statusrequiredFinancialResourceStatusCodes
Coverage.typepreferredCoverageTypeAndSelf-PayCodes
Coverage.relationshiprequiredSubscriberRelationshipCodes
Coverage.class.typeextensibleCoverageClassCodes
Coverage.class:group.typeextensiblePattern: group
Coverage.class:plan.typeextensiblePattern: plan
Coverage.costToBeneficiary.typeextensibleCoverageCopayTypeCodes
Coverage.costToBeneficiary.exception.typeexampleExampleCoverageFinancialExceptionCodes