Consumer Real-Time Pharmacy Benefit Check
1.0.0 - STU1
Consumer Real-Time Pharmacy Benefit Check
1.0.0 - STU1
This page is part of the Consumer Real-time Pharmacy Benefit Check (v1.0.0: STU 1) based on FHIR R4. This is the current published version. For a full list of available versions, see the Directory of published versions 
This profile constrains the Coverage resource for carrying the pharmacy benefit information required in the consumer real-time pharmacy benefit check process
The official URL for this profile is:
http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-coverage
This profile constrains the Coverage resource to carry the member and and coverage identifiers that insurers use to locate the patient’s specific plan coverage rules.
(Note: When the responder is a medication pricing source, the Coverage resource is not required).
The Coverage elements available to be used by the RTPBC process are:
Different insurers PBMs or other responders may require just a subset of these elements. Implementers may populate all elements for which information is available, or scope the population based the particular responder’s requirements.
Client and Responding systems
The elements identified as Must Support are the typical set used in US pharmacy benefit processing; client systems must enable these to be submitted in requests, and responders must be able to accept them to be used as appropriate during processing.
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 | |
  subscriberId | S | 0..1 | string | Health Plan Cardholder ID |
| beneficiary | S | 1..1 | Reference(Patient) | Plan beneficiary |
 payor | S | 1..1 | Reference(Organization | Patient | RelatedPerson) | Payer ID |
  identifier | S | 0..1 | Identifier | Payer ID |
  value | S | 1..1 | string | Payer ID Value |
 class | S | 0..* | (Slice Definition) | Pharmacy coverage identifiers Slice: Unordered, Open by value:type |
 class:All Slices | Content/Rules for all slices | |||
  type | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible) | |
 class:bin | S | 0..1 | BackboneElement | IIN (BIN) number |
 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: rxbin | |
| class:pcn | S | 0..1 | BackboneElement | Processor Control Number (PCN) |
| 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: rxpcn | |
| class:rxgroup-id | S | 0..1 | BackboneElement | Pharmacy Benefit Group ID |
| 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: rxgroup | |
 class:pbm-member-id | S | 0..1 | BackboneElement | PBM Member ID |
| 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: rxid | |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Coverage | I | 0..* | Coverage | Insurance or medical plan or a payment agreement |
 id | Σ | 0..1 | string | Logical id of this artifact |
 meta | ΣI | 0..1 | Meta | Metadata about the resource |
| implicitRules | ?!ΣI | 0..1 | uri | A set of rules under which this content was created |
| language | I | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages |
| text | I | 0..1 | Narrative | Text summary of the resource, for human interpretation |
| contained | 0..* | Resource | Contained, inline Resources | |
 extension | I | 0..* | Extension | Additional content defined by implementations |
 modifierExtension | ?!I | 0..* | Extension | Extensions that cannot be ignored |
| identifier | ΣI | 0..* | Identifier | Business Identifier for the coverage |
| status | ?!ΣI | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required) |
| type | ΣI | 0..1 | CodeableConcept | Coverage category such as medical or accident Binding: CoverageTypeAndSelf-PayCodes (preferred) |
 policyHolder | ΣI | 0..1 | Reference(Patient | RelatedPerson | Organization) | Owner of the policy |
| subscriber | ΣI | 0..1 | Reference(Patient | RelatedPerson) | Subscriber to the policy |
| subscriberId | SΣI | 0..1 | string | Health Plan Cardholder ID |
| beneficiary | SΣI | 1..1 | Reference(Patient) | Plan beneficiary |
| dependent | ΣI | 0..1 | string | Dependent number |
| relationship | I | 0..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible) |
| period | ΣI | 0..1 | Period | Coverage start and end dates |
| payor | SΣI | 1..1 | Reference(Organization | Patient | RelatedPerson) | Payer ID |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| reference | ΣI | 0..1 | string | Literal reference, Relative, internal or absolute URL |
| type | ΣI | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible) |
| identifier | SΣI | 0..1 | Identifier | Payer ID |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| use | ?!ΣI | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required) |
| type | ΣI | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible) |
| system | ΣI | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient |
| value | SΣI | 1..1 | string | Payer ID Value Example General: 123456 |
| period | ΣI | 0..1 | Period | Time period when id is/was valid for use |
| assigner | ΣI | 0..1 | Reference(Organization) | Organization that issued id (may be just text) |
| display | ΣI | 0..1 | string | Text alternative for the resource |
| class | SI | 0..* | (Slice Definition) | Pharmacy coverage identifiers Slice: Unordered, Open by value:type |
| class:All Slices | Content/Rules for all slices | |||
 id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | ΣI | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible) |
| value | ΣI | 1..1 | string | Value associated with the type |
| name | ΣI | 0..1 | string | Human readable description of the type and value |
| class:bin | SI | 0..1 | BackboneElement | IIN (BIN) number |
 id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
 type | ΣI | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible) 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: rxbin | |
| 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 | ΣI | 1..1 | string | Value associated with the type |
 name | ΣI | 0..1 | string | Human readable description of the type and value |
| class:pcn | SI | 0..1 | BackboneElement | Processor Control Number (PCN) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | ΣI | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible) 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: rxpcn | |
| 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 | ΣI | 1..1 | string | Value associated with the type |
| name | ΣI | 0..1 | string | Human readable description of the type and value |
| class:rxgroup-id | SI | 0..1 | BackboneElement | Pharmacy Benefit Group ID |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | ΣI | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible) 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: rxgroup | |
| 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 | ΣI | 1..1 | string | Value associated with the type |
| name | ΣI | 0..1 | string | Human readable description of the type and value |
| class:pbm-member-id | SI | 0..1 | BackboneElement | PBM Member ID |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | ΣI | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible) 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: rxid | |
| 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 | ΣI | 1..1 | string | Value associated with the type |
| name | ΣI | 0..1 | string | Human readable description of the type and value |
| order | ΣI | 0..1 | positiveInt | Relative order of the coverage |
| network | ΣI | 0..1 | string | Insurer network |
| costToBeneficiary | I | 0..* | BackboneElement | Patient payments for services/products |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | ΣI | 0..1 | CodeableConcept | Cost category Binding: CoverageCopayTypeCodes (extensible) |
 value[x] | ΣI | 1..1 | The amount or percentage due from the beneficiary | |
| valueQuantity | Quantity(SimpleQuantity) | |||
| valueMoney | Money | |||
| exception | I | 0..* | BackboneElement | Exceptions for patient payments |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | ΣI | 1..1 | CodeableConcept | Exception category Binding: ExampleCoverageFinancialExceptionCodes (example) |
| period | ΣI | 0..1 | Period | The effective period of the exception |
| subrogation | I | 0..1 | boolean | Reimbursement to insurer |
| contract | I | 0..* | Reference(Contract) | Contract details |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Coverage | I | 0..* | Coverage | Insurance or medical plan or a payment agreement |
| subscriberId | ΣI | 0..1 | string | Health Plan Cardholder ID |
| beneficiary | ΣI | 1..1 | Reference(Patient) | Plan beneficiary |
| payor | ΣI | 1..1 | Reference(Organization | Patient | RelatedPerson) | Payer ID |
| identifier | ΣI | 0..1 | Identifier | Payer ID |
| value | ΣI | 1..1 | string | Payer ID Value |
| class | I | 0..* | (Slice Definition) | Pharmacy coverage identifiers Slice: Unordered, Open by value:type |
| class:bin | I | 0..1 | BackboneElement | IIN (BIN) number |
| class:pcn | I | 0..1 | BackboneElement | Processor Control Number (PCN) |
| class:rxgroup-id | I | 0..1 | BackboneElement | Pharmacy Benefit Group ID |
| class:pbm-member-id | I | 0..1 | BackboneElement | PBM Member ID |
| Documentation for this format | ||||
This structure is derived from Coverage
Summary
Mandatory: 0 element (5 nested mandatory elements)
Must-Support: 10 elements
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 | |
| subscriberId | S | 0..1 | string | Health Plan Cardholder ID |
| beneficiary | S | 1..1 | Reference(Patient) | Plan beneficiary |
| payor | S | 1..1 | Reference(Organization | Patient | RelatedPerson) | Payer ID |
| identifier | S | 0..1 | Identifier | Payer ID |
| value | S | 1..1 | string | Payer ID Value |
| class | S | 0..* | (Slice Definition) | Pharmacy coverage identifiers Slice: Unordered, Open by value:type |
| class:All Slices | Content/Rules for all slices | |||
| type | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible) | |
| class:bin | S | 0..1 | BackboneElement | IIN (BIN) number |
| 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: rxbin | |
| class:pcn | S | 0..1 | BackboneElement | Processor Control Number (PCN) |
| 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: rxpcn | |
| class:rxgroup-id | S | 0..1 | BackboneElement | Pharmacy Benefit Group ID |
| 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: rxgroup | |
| class:pbm-member-id | S | 0..1 | BackboneElement | PBM Member ID |
| 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: rxid | |
| Documentation for this format | ||||
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Coverage | I | 0..* | Coverage | Insurance or medical plan or a payment agreement |
| id | Σ | 0..1 | string | Logical id of this artifact |
| meta | ΣI | 0..1 | Meta | Metadata about the resource |
| implicitRules | ?!ΣI | 0..1 | uri | A set of rules under which this content was created |
| language | I | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages |
| text | I | 0..1 | Narrative | Text summary of the resource, for human interpretation |
| contained | 0..* | Resource | Contained, inline Resources | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!I | 0..* | Extension | Extensions that cannot be ignored |
| identifier | ΣI | 0..* | Identifier | Business Identifier for the coverage |
| status | ?!ΣI | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required) |
| type | ΣI | 0..1 | CodeableConcept | Coverage category such as medical or accident Binding: CoverageTypeAndSelf-PayCodes (preferred) |
| policyHolder | ΣI | 0..1 | Reference(Patient | RelatedPerson | Organization) | Owner of the policy |
| subscriber | ΣI | 0..1 | Reference(Patient | RelatedPerson) | Subscriber to the policy |
| subscriberId | SΣI | 0..1 | string | Health Plan Cardholder ID |
| beneficiary | SΣI | 1..1 | Reference(Patient) | Plan beneficiary |
| dependent | ΣI | 0..1 | string | Dependent number |
| relationship | I | 0..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible) |
| period | ΣI | 0..1 | Period | Coverage start and end dates |
| payor | SΣI | 1..1 | Reference(Organization | Patient | RelatedPerson) | Payer ID |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| reference | ΣI | 0..1 | string | Literal reference, Relative, internal or absolute URL |
| type | ΣI | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible) |
| identifier | SΣI | 0..1 | Identifier | Payer ID |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| use | ?!ΣI | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required) |
| type | ΣI | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible) |
| system | ΣI | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient |
| value | SΣI | 1..1 | string | Payer ID Value Example General: 123456 |
| period | ΣI | 0..1 | Period | Time period when id is/was valid for use |
| assigner | ΣI | 0..1 | Reference(Organization) | Organization that issued id (may be just text) |
| display | ΣI | 0..1 | string | Text alternative for the resource |
| class | SI | 0..* | (Slice Definition) | Pharmacy coverage identifiers Slice: Unordered, Open by value:type |
| class:All Slices | Content/Rules for all slices | |||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | ΣI | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible) |
| value | ΣI | 1..1 | string | Value associated with the type |
| name | ΣI | 0..1 | string | Human readable description of the type and value |
| class:bin | SI | 0..1 | BackboneElement | IIN (BIN) number |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | ΣI | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible) 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: rxbin | |
| 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 | ΣI | 1..1 | string | Value associated with the type |
| name | ΣI | 0..1 | string | Human readable description of the type and value |
| class:pcn | SI | 0..1 | BackboneElement | Processor Control Number (PCN) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | ΣI | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible) 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: rxpcn | |
| 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 | ΣI | 1..1 | string | Value associated with the type |
| name | ΣI | 0..1 | string | Human readable description of the type and value |
| class:rxgroup-id | SI | 0..1 | BackboneElement | Pharmacy Benefit Group ID |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | ΣI | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible) 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: rxgroup | |
| 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 | ΣI | 1..1 | string | Value associated with the type |
| name | ΣI | 0..1 | string | Human readable description of the type and value |
| class:pbm-member-id | SI | 0..1 | BackboneElement | PBM Member ID |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | ΣI | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible) 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: rxid | |
| 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 | ΣI | 1..1 | string | Value associated with the type |
| name | ΣI | 0..1 | string | Human readable description of the type and value |
| order | ΣI | 0..1 | positiveInt | Relative order of the coverage |
| network | ΣI | 0..1 | string | Insurer network |
| costToBeneficiary | I | 0..* | BackboneElement | Patient payments for services/products |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | ΣI | 0..1 | CodeableConcept | Cost category Binding: CoverageCopayTypeCodes (extensible) |
| value[x] | ΣI | 1..1 | The amount or percentage due from the beneficiary | |
| valueQuantity | Quantity(SimpleQuantity) | |||
| valueMoney | Money | |||
| exception | I | 0..* | BackboneElement | Exceptions for patient payments |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | ΣI | 1..1 | CodeableConcept | Exception category Binding: ExampleCoverageFinancialExceptionCodes (example) |
| period | ΣI | 0..1 | Period | The effective period of the exception |
| subrogation | I | 0..1 | boolean | Reimbursement to insurer |
| contract | I | 0..* | Reference(Contract) | Contract details |
| Documentation for this format | ||||
Other representations of profile: Schematron
| Path | Conformance | ValueSet / Code |
| Coverage.language | preferred | CommonLanguages Max Binding: AllLanguages |
| Coverage.status | required | FinancialResourceStatusCodes |
| Coverage.type | preferred | CoverageTypeAndSelf-PayCodes |
| Coverage.relationship | extensible | SubscriberRelationshipCodes |
| Coverage.payor.type | extensible | ResourceType |
| Coverage.payor.identifier.use | required | IdentifierUse |
| Coverage.payor.identifier.type | extensible | Identifier Type Codes |
| Coverage.class.type | extensible | CoverageClassCodes |
| Coverage.class:bin.type | extensible | Pattern: rxbin |
| Coverage.class:pcn.type | extensible | Pattern: rxpcn |
| Coverage.class:rxgroup-id.type | extensible | Pattern: rxgroup |
| Coverage.class:pbm-member-id.type | extensible | Pattern: rxid |
| Coverage.costToBeneficiary.type | extensible | CoverageCopayTypeCodes |
| Coverage.costToBeneficiary.exception.type | example | ExampleCoverageFinancialExceptionCodes |
| Id | Path | Details | Requirements |
| dom-2 | Coverage | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | Coverage | 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 : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | Coverage | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | Coverage | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | Coverage | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | Coverage.meta | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.implicitRules | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.language | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Coverage.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Coverage.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Coverage.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Coverage.identifier | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.status | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.type | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.policyHolder | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.subscriber | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.subscriberId | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.beneficiary | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.dependent | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.relationship | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.period | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.payor | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.payor.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Coverage.payor.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Coverage.payor.reference | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.payor.type | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.payor.identifier | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.payor.identifier.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Coverage.payor.identifier.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Coverage.payor.identifier.use | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.payor.identifier.type | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.payor.identifier.system | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.payor.identifier.value | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.payor.identifier.period | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.payor.identifier.assigner | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.payor.display | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.class | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.class.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Coverage.class.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Coverage.class.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Coverage.class.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Coverage.class.type | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.class.value | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.class.name | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.class:bin | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.class:bin.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Coverage.class:bin.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Coverage.class:bin.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Coverage.class:bin.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Coverage.class:bin.type | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.class:bin.value | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.class:bin.name | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.class:pcn | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.class:pcn.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Coverage.class:pcn.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Coverage.class:pcn.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Coverage.class:pcn.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Coverage.class:pcn.type | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.class:pcn.value | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.class:pcn.name | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.class:rxgroup-id | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.class:rxgroup-id.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Coverage.class:rxgroup-id.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Coverage.class:rxgroup-id.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Coverage.class:rxgroup-id.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Coverage.class:rxgroup-id.type | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.class:rxgroup-id.value | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.class:rxgroup-id.name | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.class:pbm-member-id | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.class:pbm-member-id.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Coverage.class:pbm-member-id.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Coverage.class:pbm-member-id.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Coverage.class:pbm-member-id.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Coverage.class:pbm-member-id.type | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.class:pbm-member-id.value | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.class:pbm-member-id.name | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.order | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.network | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.costToBeneficiary | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.costToBeneficiary.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Coverage.costToBeneficiary.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Coverage.costToBeneficiary.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Coverage.costToBeneficiary.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Coverage.costToBeneficiary.type | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.costToBeneficiary.value[x] | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.costToBeneficiary.exception | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.costToBeneficiary.exception.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Coverage.costToBeneficiary.exception.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Coverage.costToBeneficiary.exception.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Coverage.costToBeneficiary.exception.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Coverage.costToBeneficiary.exception.type | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.costToBeneficiary.exception.period | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.subrogation | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.contract | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
IG © 2020+ HL7 International - Pharmacy. Package hl7.fhir.us.carin-rtpbc#1.0.0 based on FHIR 4.0.1. Generated 2020-08-25
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