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.

• Key Elements Table
• Differential Table
• Snapshot Table
• Statistics/References
• All

Name	Flags	Card.	Type	Description & Constraints
Coverage	C	0..*	USCoreCoverageProfile	Insurance or medical plan or a payment agreement dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management us-core-15: Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present
meta	SΣ	1..1	Meta	Metadata about the resource ele-1: All FHIR elements must have a @value or children
lastUpdated	SΣ	1..1	instant	When the resource version last changed ele-1: All FHIR elements must have a @value or children
profile	Σ	1..*	canonical(StructureDefinition)	Profiles this resource claims to conform to ele-1: All FHIR elements must have a @value or children
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
Slices for identifier	SΣ	0..*	Identifier	Member ID and other identifiers Slice: Unordered, Open by pattern:type ele-1: All FHIR elements must have a @value or children
identifier:memberid	SΣC	0..1	Identifier	(USCDI) Member ID ele-1: All FHIR elements must have a @value or children
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . ele-1: All FHIR elements must have a @value or children
type	SΣ	1..1	CodeableConcept	(USCDI) 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. ele-1: All FHIR elements must have a @value or children 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. ele-1: All FHIR elements must have a @value or children
type	SΣ	0..1	CodeableConcept	(USCDI) Coverage category such as medical or accident Binding: Payer Type (extensible): US Public Health Data Consortium Source of Payment Codes ele-1: All FHIR elements must have a @value or children
subscriberId	SΣC	1..1	string	(USCDI) ID assigned to the subscriber ele-1: All FHIR elements must have a @value or children
beneficiary	SΣ	1..1	Reference(C4BB Patient)	(USCDI) Plan beneficiary ele-1: All FHIR elements must have a @value or children
relationship	S	1..1	CodeableConcept	(USCDI) Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (required) ele-1: All FHIR elements must have a @value or children
period	SΣ	0..1	Period	(USCDI) Coverage start and end dates ele-1: All FHIR elements must have a @value or children
payor	SΣ	1..1	Reference(C4BB Organization)	(USCDI) Issuer of the policy ele-1: All FHIR elements must have a @value or children
Slices for class	S	0..*	BackboneElement	(USCDI) Additional coverage classifications Slice: Unordered, Open by pattern:type ele-1: All FHIR elements must have a @value or children
class:All Slices				Content/Rules for all slices
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
type	Σ	1..1	CodeableConcept	Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. ele-1: All FHIR elements must have a @value or children
value	Σ	1..1	string	Value associated with the type ele-1: All FHIR elements must have a @value or children
class:group	S	0..1	BackboneElement	(USCDI) Group ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
type	Σ	1..1	CodeableConcept	Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. ele-1: All FHIR elements must have a @value or children 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	(USCDI) Group Number ele-1: All FHIR elements must have a @value or children
name	SΣ	0..1	string	(USCDI) Group Name ele-1: All FHIR elements must have a @value or children
class:plan	S	0..1	BackboneElement	(USCDI) Plan ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
type	Σ	1..1	CodeableConcept	Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. ele-1: All FHIR elements must have a @value or children 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	(USCDI) Plan Number ele-1: All FHIR elements must have a @value or children
name	SΣ	0..1	string	(USCDI) Plan Name ele-1: All FHIR elements must have a @value or children
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Coverage.identifier:memberid.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard
Coverage.identifier:memberid.type	extensible	Pattern: MB http://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard
Coverage.status	required	FinancialResourceStatusCodes http://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard
Coverage.type	extensible	PayerType (a valid code from Source of Payment Typology (https://nahdo.org/sopt) http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 from https://vsac.nlm.nih.gov
Coverage.relationship	required	SubscriberRelationshipCodes http://hl7.org/fhir/ValueSet/subscriber-relationship from the FHIR Standard
Coverage.class.type	extensible	CoverageClassCodes http://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard
Coverage.class:group.type	extensible	Pattern: group http://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard
Coverage.class:plan.type	extensible	Pattern: plan http://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard

This structure is derived from USCoreCoverageProfile

Name	Flags	Card.	Type	Description & Constraints
Coverage		0..*	USCoreCoverageProfile	Insurance or medical plan or a payment agreement
meta	S	1..1	Meta	Metadata about the resource
lastUpdated	S	1..1	instant	When the resource version last changed
profile		1..*	canonical(StructureDefinition)	Profiles this resource claims to conform to
identifier		0..*	Identifier	Member ID and other identifiers
status		1..1	code	(USCDI) active | cancelled | draft | entered-in-error
type		0..1	CodeableConcept	(USCDI) Coverage category such as medical or accident
subscriberId		1..1	string	(USCDI) ID assigned to the subscriber
beneficiary		1..1	Reference(C4BB Patient)	(USCDI) Plan beneficiary
relationship		1..1	CodeableConcept	(USCDI) Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (required)
period		0..1	Period	(USCDI) Coverage start and end dates
payor		1..1	Reference(C4BB Organization)	(USCDI) Issuer of the policy
Slices for class				Content/Rules for all slices
class:group		0..1	BackboneElement	(USCDI) Group
value		1..1	string	(USCDI) Group Number
class:plan		0..1	BackboneElement	(USCDI) Plan
value		1..1	string	(USCDI) Plan Number
name		0..1	string	(USCDI) Plan Name
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Coverage.relationship	required	SubscriberRelationshipCodes http://hl7.org/fhir/ValueSet/subscriber-relationship from the FHIR Standard

Name	Flags	Card.	Type	Description & Constraints
Coverage	C	0..*	USCoreCoverageProfile	Insurance or medical plan or a payment agreement us-core-15: Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present
id	Σ	0..1	id	Logical id of this artifact
meta	SΣ	1..1	Meta	Metadata about the resource
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
versionId	Σ	0..1	id	Version specific identifier
lastUpdated	SΣ	1..1	instant	When the resource version last changed
source	Σ	0..1	uri	Identifies where the resource comes from
profile	Σ	1..*	canonical(StructureDefinition)	Profiles this resource claims to conform to
security	Σ	0..*	Coding	Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
tag	Σ	0..*	Coding	Tags 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	?!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. Additional Bindings Purpose AllLanguages Max Binding
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	SΣC	0..1	Identifier	(USCDI) 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	(USCDI) 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	(USCDI) Coverage category such as medical or accident Binding: Payer Type (extensible): US Public Health Data Consortium Source of Payment Codes
policyHolder	Σ	0..1	Reference(Patient | RelatedPerson | Organization)	Owner of the policy
subscriber	Σ	0..1	Reference(Patient | RelatedPerson)	Subscriber to the policy
subscriberId	SΣC	1..1	string	(USCDI) ID assigned to the subscriber
beneficiary	SΣ	1..1	Reference(C4BB Patient)	(USCDI) Plan beneficiary
dependent	Σ	0..1	string	Dependent number
relationship	S	1..1	CodeableConcept	(USCDI) Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (required)
period	SΣ	0..1	Period	(USCDI) Coverage start and end dates
payor	SΣ	1..1	Reference(C4BB Organization)	(USCDI) Issuer of the policy
Slices for class	S	0..*	BackboneElement	(USCDI) 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	(USCDI) 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	(USCDI) Group Number
name	SΣ	0..1	string	(USCDI) Group Name
class:plan	S	0..1	BackboneElement	(USCDI) 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	(USCDI) Plan Number
name	SΣ	0..1	string	(USCDI) 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

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Coverage.meta.security	extensible	All Security Labels http://hl7.org/fhir/ValueSet/security-labels from the FHIR Standard
Coverage.meta.tag	example	CommonTags http://hl7.org/fhir/ValueSet/common-tags from the FHIR Standard
Coverage.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
Coverage.identifier:memberid.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard
Coverage.identifier:memberid.type	extensible	Pattern: MB http://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard
Coverage.status	required	FinancialResourceStatusCodes http://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard
Coverage.type	extensible	PayerType (a valid code from Source of Payment Typology (https://nahdo.org/sopt) http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 from https://vsac.nlm.nih.gov
Coverage.relationship	required	SubscriberRelationshipCodes http://hl7.org/fhir/ValueSet/subscriber-relationship from the FHIR Standard
Coverage.class.type	extensible	CoverageClassCodes http://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard
Coverage.class:group.type	extensible	Pattern: group http://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard
Coverage.class:plan.type	extensible	Pattern: plan http://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard
Coverage.costToBeneficiary.type	extensible	CoverageCopayTypeCodes http://hl7.org/fhir/ValueSet/coverage-copay-type from the FHIR Standard
Coverage.costToBeneficiary.exception.type	example	ExampleCoverageFinancialExceptionCodes http://hl7.org/fhir/ValueSet/coverage-financial-exception from the FHIR Standard

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
Coverage	C	0..*	USCoreCoverageProfile	Insurance or medical plan or a payment agreement dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management us-core-15: Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present
meta	SΣ	1..1	Meta	Metadata about the resource ele-1: All FHIR elements must have a @value or children
lastUpdated	SΣ	1..1	instant	When the resource version last changed ele-1: All FHIR elements must have a @value or children
profile	Σ	1..*	canonical(StructureDefinition)	Profiles this resource claims to conform to ele-1: All FHIR elements must have a @value or children
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
Slices for identifier	SΣ	0..*	Identifier	Member ID and other identifiers Slice: Unordered, Open by pattern:type ele-1: All FHIR elements must have a @value or children
identifier:memberid	SΣC	0..1	Identifier	(USCDI) Member ID ele-1: All FHIR elements must have a @value or children
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . ele-1: All FHIR elements must have a @value or children
type	SΣ	1..1	CodeableConcept	(USCDI) 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. ele-1: All FHIR elements must have a @value or children 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. ele-1: All FHIR elements must have a @value or children
type	SΣ	0..1	CodeableConcept	(USCDI) Coverage category such as medical or accident Binding: Payer Type (extensible): US Public Health Data Consortium Source of Payment Codes ele-1: All FHIR elements must have a @value or children
subscriberId	SΣC	1..1	string	(USCDI) ID assigned to the subscriber ele-1: All FHIR elements must have a @value or children
beneficiary	SΣ	1..1	Reference(C4BB Patient)	(USCDI) Plan beneficiary ele-1: All FHIR elements must have a @value or children
relationship	S	1..1	CodeableConcept	(USCDI) Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (required) ele-1: All FHIR elements must have a @value or children
period	SΣ	0..1	Period	(USCDI) Coverage start and end dates ele-1: All FHIR elements must have a @value or children
payor	SΣ	1..1	Reference(C4BB Organization)	(USCDI) Issuer of the policy ele-1: All FHIR elements must have a @value or children
Slices for class	S	0..*	BackboneElement	(USCDI) Additional coverage classifications Slice: Unordered, Open by pattern:type ele-1: All FHIR elements must have a @value or children
class:All Slices				Content/Rules for all slices
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
type	Σ	1..1	CodeableConcept	Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. ele-1: All FHIR elements must have a @value or children
value	Σ	1..1	string	Value associated with the type ele-1: All FHIR elements must have a @value or children
class:group	S	0..1	BackboneElement	(USCDI) Group ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
type	Σ	1..1	CodeableConcept	Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. ele-1: All FHIR elements must have a @value or children 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	(USCDI) Group Number ele-1: All FHIR elements must have a @value or children
name	SΣ	0..1	string	(USCDI) Group Name ele-1: All FHIR elements must have a @value or children
class:plan	S	0..1	BackboneElement	(USCDI) Plan ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
type	Σ	1..1	CodeableConcept	Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. ele-1: All FHIR elements must have a @value or children 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	(USCDI) Plan Number ele-1: All FHIR elements must have a @value or children
name	SΣ	0..1	string	(USCDI) Plan Name ele-1: All FHIR elements must have a @value or children
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Coverage.identifier:memberid.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard
Coverage.identifier:memberid.type	extensible	Pattern: MB http://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard
Coverage.status	required	FinancialResourceStatusCodes http://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard
Coverage.type	extensible	PayerType (a valid code from Source of Payment Typology (https://nahdo.org/sopt) http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 from https://vsac.nlm.nih.gov
Coverage.relationship	required	SubscriberRelationshipCodes http://hl7.org/fhir/ValueSet/subscriber-relationship from the FHIR Standard
Coverage.class.type	extensible	CoverageClassCodes http://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard
Coverage.class:group.type	extensible	Pattern: group http://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard
Coverage.class:plan.type	extensible	Pattern: plan http://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard

Differential View

This structure is derived from USCoreCoverageProfile

Name	Flags	Card.	Type	Description & Constraints
Coverage		0..*	USCoreCoverageProfile	Insurance or medical plan or a payment agreement
meta	S	1..1	Meta	Metadata about the resource
lastUpdated	S	1..1	instant	When the resource version last changed
profile		1..*	canonical(StructureDefinition)	Profiles this resource claims to conform to
identifier		0..*	Identifier	Member ID and other identifiers
status		1..1	code	(USCDI) active | cancelled | draft | entered-in-error
type		0..1	CodeableConcept	(USCDI) Coverage category such as medical or accident
subscriberId		1..1	string	(USCDI) ID assigned to the subscriber
beneficiary		1..1	Reference(C4BB Patient)	(USCDI) Plan beneficiary
relationship		1..1	CodeableConcept	(USCDI) Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (required)
period		0..1	Period	(USCDI) Coverage start and end dates
payor		1..1	Reference(C4BB Organization)	(USCDI) Issuer of the policy
Slices for class				Content/Rules for all slices
class:group		0..1	BackboneElement	(USCDI) Group
value		1..1	string	(USCDI) Group Number
class:plan		0..1	BackboneElement	(USCDI) Plan
value		1..1	string	(USCDI) Plan Number
name		0..1	string	(USCDI) Plan Name
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Coverage.relationship	required	SubscriberRelationshipCodes http://hl7.org/fhir/ValueSet/subscriber-relationship from the FHIR Standard

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
Coverage	C	0..*	USCoreCoverageProfile	Insurance or medical plan or a payment agreement us-core-15: Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present
id	Σ	0..1	id	Logical id of this artifact
meta	SΣ	1..1	Meta	Metadata about the resource
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
versionId	Σ	0..1	id	Version specific identifier
lastUpdated	SΣ	1..1	instant	When the resource version last changed
source	Σ	0..1	uri	Identifies where the resource comes from
profile	Σ	1..*	canonical(StructureDefinition)	Profiles this resource claims to conform to
security	Σ	0..*	Coding	Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
tag	Σ	0..*	Coding	Tags 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	?!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. Additional Bindings Purpose AllLanguages Max Binding
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	SΣC	0..1	Identifier	(USCDI) 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	(USCDI) 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	(USCDI) Coverage category such as medical or accident Binding: Payer Type (extensible): US Public Health Data Consortium Source of Payment Codes
policyHolder	Σ	0..1	Reference(Patient | RelatedPerson | Organization)	Owner of the policy
subscriber	Σ	0..1	Reference(Patient | RelatedPerson)	Subscriber to the policy
subscriberId	SΣC	1..1	string	(USCDI) ID assigned to the subscriber
beneficiary	SΣ	1..1	Reference(C4BB Patient)	(USCDI) Plan beneficiary
dependent	Σ	0..1	string	Dependent number
relationship	S	1..1	CodeableConcept	(USCDI) Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (required)
period	SΣ	0..1	Period	(USCDI) Coverage start and end dates
payor	SΣ	1..1	Reference(C4BB Organization)	(USCDI) Issuer of the policy
Slices for class	S	0..*	BackboneElement	(USCDI) 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	(USCDI) 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	(USCDI) Group Number
name	SΣ	0..1	string	(USCDI) Group Name
class:plan	S	0..1	BackboneElement	(USCDI) 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	(USCDI) Plan Number
name	SΣ	0..1	string	(USCDI) 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

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Coverage.meta.security	extensible	All Security Labels http://hl7.org/fhir/ValueSet/security-labels from the FHIR Standard
Coverage.meta.tag	example	CommonTags http://hl7.org/fhir/ValueSet/common-tags from the FHIR Standard
Coverage.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
Coverage.identifier:memberid.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard
Coverage.identifier:memberid.type	extensible	Pattern: MB http://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard
Coverage.status	required	FinancialResourceStatusCodes http://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard
Coverage.type	extensible	PayerType (a valid code from Source of Payment Typology (https://nahdo.org/sopt) http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 from https://vsac.nlm.nih.gov
Coverage.relationship	required	SubscriberRelationshipCodes http://hl7.org/fhir/ValueSet/subscriber-relationship from the FHIR Standard
Coverage.class.type	extensible	CoverageClassCodes http://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard
Coverage.class:group.type	extensible	Pattern: group http://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard
Coverage.class:plan.type	extensible	Pattern: plan http://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard
Coverage.costToBeneficiary.type	extensible	CoverageCopayTypeCodes http://hl7.org/fhir/ValueSet/coverage-copay-type from the FHIR Standard
Coverage.costToBeneficiary.exception.type	example	ExampleCoverageFinancialExceptionCodes http://hl7.org/fhir/ValueSet/coverage-financial-exception from the FHIR Standard

This structure is derived from USCoreCoverageProfile

Summary

Mandatory: 4 elements
Must-Support: 2 elements

Structures

This structure refers to these other structures:

• C4BB Patient (http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Patient)
• C4BB Organization (http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Organization)