| Left: | US Core Coverage Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-coverage) |
| Right: | C4BB Coverage (http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Coverage) |
| Error | StructureDefinition.url | Values for url differ: 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-coverage' vs 'http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Coverage' |
| Error | StructureDefinition.version | Values for version differ: '6.0.0-ballot' vs '2.0.0' |
| Information | StructureDefinition.name | Values for name differ: 'USCoreCoverageProfile' vs 'C4BBCoverage' |
| Information | StructureDefinition.title | Values for title differ: 'US Core Coverage Profile' vs 'C4BB Coverage' |
| Information | StructureDefinition.date | Values for date differ: '2022-09-24' vs '2022-11-28T15:29:06+00:00' |
| Information | StructureDefinition.publisher | Values for publisher differ: 'HL7 International - Cross-Group Projects' vs 'HL7 Financial Management Working Group' |
| Warning | Coverage.meta | Elements differ in definition for mustSupport: 'false' vs 'true' |
| Information | Coverage.meta | Element minimum cardinalities differ: '0' vs '1' |
| Warning | Coverage.meta.lastUpdated | Elements differ in comments: 'This value is always populated except when the resource is first being created. The server / resource manager sets this value; what a client provides is irrelevant. This is equivalent to the HTTP Last-Modified and SHOULD have the same value on a [read] interaction.' vs 'Defines the date the coverage that was effective as of the date of service or admission (163). The Coverage Reference Resource SHALL be returned with data that was effective as of the date of service or admission of the claim' |
| Warning | Coverage.meta.lastUpdated | Elements differ in definition for mustSupport: 'false' vs 'true' |
| Information | Coverage.meta.lastUpdated | Element minimum cardinalities differ: '0' vs '1' |
| Warning | Coverage.meta.profile | Elements differ in comments: 'It is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set.' vs '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. CPCDS data element (190)' |
| Information | Coverage.meta.profile | Element minimum cardinalities differ: '0' vs '1' |
| Warning | Coverage.status | Elements differ in comments: 'The `Coverage.status` alone does not indicate whether an individual's coverage is terminated or that the individual is not covered. The `Coverage.period` needs to be considered as well.' vs 'Identifies the status of the coverage information (default: active) (133)' |
| Warning | Coverage.type | Elements differ in comments: 'Identifies if the coverage is PPO, HMO, POS, etc.' vs 'Identifies if the coverage is PPO, HMO, POS, etc. (3)' |
| Warning | Coverage.type | Elements differ in definition for mustSupport: 'true' vs 'false' |
| Warning | Coverage.type | Elements differ in binding.description: 'US Public Health Data Consortium Source of Payment Codes' vs 'The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization.' |
| Warning | Coverage.subscriberId | Elements differ in comments: 'The identifier assigned by the Payer on the subscriber's ID card' vs 'The identifier assigned by the Payer on the subscriber's ID card (132)' |
| Information | Coverage.subscriberId | Element minimum cardinalities differ: '0' vs '1' |
| Warning | Coverage.beneficiary | Elements differ in comments: 'Identifier for a member assigned by the Payer.' vs 'Identifier for a member assigned by the Payer. If members receive ID cards, that is the identifier that should be provided (1). This is the party who receives treatment for which the costs are reimbursed under the coverage. alternate path: EOB.patient(Patient).identifier' |
| Warning | Coverage.relationship | Elements differ in comments: 'Relationship of the member to the person insured (subscriber)' vs 'Relationship of the member to the person insured (subscriber). (72)' |
| Warning | Coverage.period | Elements differ in comments: 'Date that the contract became effective and Date that the contract was terminated or coverage changed.' vs 'Date that the contract became effective (74) and Date that the contract was terminated or coverage changed (75)' |
| Warning | Coverage.payor | Elements differ in comments: 'Issuer of the Policy' vs 'Issuer of the Policy (2)' |
| Name | Value | Comments | |
|---|---|---|---|
 abstract | false | ||
| baseDefinition | http://hl7.org/fhir/StructureDefinition/Coverage | ||
| copyright | Used by permission of HL7 International, all rights reserved Creative Commons License |
| |
| date | 2022-09-24 | 2022-11-28T15:29:06+00:00 |
|
| description | The US Core CoverageProfile is based upon the core FHIR Coverage Resource and implements the US Core Data for Interoperability (USCDI) v3 Health Insurance Information requirements. To promote interoperability and adoption through common implementation, this profile sets minimum expectations for the Observation resource to record, search, and fetch the "data related to an individual's insurance coverage for health care". It identifies which core elements, extensions, vocabularies, and value sets **SHALL** be present in the resource when using this profile. It provides the floor for standards development for specific use cases. | Data that reflect a payer’s coverage that was effective as of the date of service or the date of admission of the claim. |
|
| experimental | false |
| |
| fhirVersion | 4.0.1 | ||
| jurisdiction | |||
 jurisdiction[0] | urn:iso:std:iso:3166#US | ||
| kind | resource | ||
| name | USCoreCoverageProfile | C4BBCoverage |
|
| publisher | HL7 International - Cross-Group Projects | HL7 Financial Management Working Group |
|
| purpose | |||
| status | active | ||
| title | US Core Coverage Profile | C4BB Coverage |
|
| type | Coverage | ||
| url | http://hl7.org/fhir/us/core/StructureDefinition/us-core-coverage | http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Coverage |
|
| version | 6.0.0-ballot | 2.0.0 |
|
| Name | L Flags | L Card. | L Type | L Description & Constraints | R Flags | R Card. | L Type | L Description & Constraints | Comments | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
 Coverage | C | 0..* | Coverage | Insurance or medical plan or a payment agreement us-core-15: Coverage.identifier or Coverage.subscriberId SHALL be present | C | 0..* | Coverage | Insurance or medical plan or a payment agreement coverage-meta-profile-version: Coverage: meta.profile with canonical and major.minor. version required. | |||||||||
 id | Σ | 0..1 | id | Logical id of this artifact | Σ | 0..1 | id | Logical id of this artifact | |||||||||
 meta | Σ | 0..1 | Meta | Metadata about the resource | SΣ | 1..1 | Meta | Metadata about the resource |
| ||||||||
 id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
 Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||||||||
| versionId | Σ | 0..1 | id | Version specific identifier | Σ | 0..1 | id | Version specific identifier | |||||||||
| lastUpdated | Σ | 0..1 | instant | When the resource version last changed | SΣ | 1..1 | instant | When the resource version last changed |
| ||||||||
| source | Σ | 0..1 | uri | Identifies where the resource comes from | Σ | 0..1 | uri | Identifies where the resource comes from | |||||||||
| profile | Σ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to | 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. | 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". | 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 | ?!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.
| 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 | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||||||||
| contained | 0..* | Resource | Contained, inline Resources | 0..* | Resource | Contained, inline Resources | |||||||||||
| extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ?! | 0..* | Extension | Extensions that cannot be ignored | |||||||||
| identifier | SΣC | 0..* | Identifier | Member ID and other identifiers | SΣ | 0..* | Identifier | Member ID and other identifiers | |||||||||
| status | ?!SΣ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. | ?!SΣ | 1..1 | code | 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 (extensible): US Public Health Data Consortium Source of Payment Codes | Σ | 0..1 | CodeableConcept | Coverage 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 | Σ | 0..1 | Reference(Patient | RelatedPerson | Organization) | Owner of the policy | Σ | 0..1 | Reference(Patient | RelatedPerson | Organization) | Owner of the policy | |||||||||
| subscriber | Σ | 0..1 | Reference(Patient | RelatedPerson) | Subscriber to the policy | Σ | 0..1 | Reference(Patient | RelatedPerson) | Subscriber to the policy | |||||||||
| subscriberId | SΣC | 0..1 | string | ID assigned to the subscriber | SΣ | 1..1 | string | ID assigned to the subscriber |
| ||||||||
| beneficiary | SΣ | 1..1 | Reference(US Core Patient Profile) | Plan beneficiary | SΣ | 1..1 | Reference(C4BB Patient) | Plan beneficiary |
| ||||||||
| dependent | Σ | 0..1 | string | Dependent number | Σ | 0..1 | string | Dependent number | |||||||||
| relationship | S | 1..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible) | S | 1..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (required) |
| ||||||||
| period | SΣ | 0..1 | Period | Coverage start and end dates | SΣ | 0..1 | Period | Coverage start and end dates |
| ||||||||
| payor | SΣ | 1..1 | Reference(US Core Organization Profile S | US Core Patient Profile | US Core RelatedPerson Profile) | Issuer of the policy | SΣ | 1..1 | Reference(C4BB Organization) | Issuer of the policy |
| ||||||||
| Slices for class | S | 0..* | BackboneElement | Additional coverage classifications Slice: Unordered, Open by pattern:type | S | 0..* | BackboneElement | Additional coverage classifications Slice: Unordered, Open by pattern:type | |||||||||
| id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
| extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!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. | 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 | Σ | 1..1 | string | Value associated with the type | |||||||||
| name | Σ | 0..1 | string | Human readable description of the type and value | Σ | 0..1 | string | Human readable description of the type and value | |||||||||
| order | Σ | 0..1 | positiveInt | Relative order of the coverage | Σ | 0..1 | positiveInt | Relative order of the coverage | |||||||||
| network | Σ | 0..1 | string | Insurer network | Σ | 0..1 | string | Insurer network | |||||||||
| costToBeneficiary | 0..* | BackboneElement | Patient payments for services/products | 0..* | BackboneElement | Patient payments for services/products | |||||||||||
| id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
| extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!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. | Σ | 0..1 | CodeableConcept | Cost category Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified. | |||||||||
| value[x] | Σ | 1..1 | SimpleQuantity, Money | The amount or percentage due from the beneficiary | Σ | 1..1 | SimpleQuantity, Money | The amount or percentage due from the beneficiary | |||||||||
 exception | 0..* | BackboneElement | Exceptions for patient payments | 0..* | BackboneElement | Exceptions for patient payments | |||||||||||
 id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
| extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!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. | 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 | Σ | 0..1 | Period | The effective period of the exception | |||||||||
| subrogation | 0..1 | boolean | Reimbursement to insurer | 0..1 | boolean | Reimbursement to insurer | |||||||||||
| contract | 0..* | Reference(Contract) | Contract details | 0..* | Reference(Contract) | Contract details | |||||||||||
| Documentation for this format | |||||||||||||||||