US Core Implementation Guide
6.0.0-ballot - STU6 Ballot US

This page is part of the US Core (v6.0.0-ballot: STU6 Ballot 1) based on FHIR R4. The current version which supercedes this version is 5.0.1. For a full list of available versions, see the Directory of published versions

Resource Profile: US Core Coverage Profile

Official URL: http://hl7.org/fhir/us/core/StructureDefinition/us-core-coverage Version: 6.0.0-ballot
Active as of 2022-09-24 Computable Name: USCoreCoverageProfile

Copyright/Legal: Used by permission of HL7 International, all rights reserved Creative Commons License

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.

This page is new content for US Core Version 6.0.0

Example Usage Scenarios:

The following are example usage scenarios for this profile:

  • Query for a patient’s insurance coverage
  • Record or update a past or present insurance coverages

Mandatory and Must Support Data Elements

The following data elements must always be present (Mandatory definition) or must be supported if the data is present in the sending system (Must Support definition). They are presented below in a simple human-readable explanation. Profile-specific guidance and examples are provided as well. The Formal Views below provides the formal summary, definitions, and terminology requirements.

Each Coverage must have:

  1. health insurance member or subscriber id
  2. a status
  3. the health insurance beneficiary (patient)
  4. beneficiary’s relationship to the subscriber
  5. the health insurance issuer (payer)

Each Coverage must support:

  1. health insurance coverage type (e.g., Medicare)
  2. coverage start and/or end date
  3. health insurance group and/or plan

Profile specific implementation guidance:

  • Coverage.status alone may not indicate whether an individual is covered. The Coverage.period needs to be considered as well. For example, the coverage may be expired with a status of “active”, or conversely, it may be “canceled” but still have covered claims.

Usage:

  • This Resource Profile is not used by any profiles in this Implementation Guide

Formal Views of Profile Content

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

This structure is derived from Coverage

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage C0..*CoverageInsurance or medical plan or a payment agreement
us-core-15: Coverage.identifier or Coverage.subscriberId SHALL be present
... identifier SC0..*IdentifierMember ID and other identifiers
... status S1..1codeactive | cancelled | draft | entered-in-error
... type S0..1CodeableConceptCoverage category such as medical or accident
Binding: Payer (extensible): US Public Health Data Consortium Source of Payment Codes

... subscriberId SC0..1stringID assigned to the subscriber
... beneficiary S1..1Reference(US Core Patient Profile)Plan beneficiary
... relationship S1..1CodeableConceptBeneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible)
... period S0..1PeriodCoverage start and end dates
... payor S1..1Reference(US Core Organization Profile S | US Core Patient Profile | US Core RelatedPerson Profile)Issuer of the policy
... Slices for class S0..*BackboneElementAdditional coverage classifications
Slice: Unordered, Open by pattern:type
.... class:group S0..1BackboneElementGroup
..... type 1..1CodeableConceptType of class such as 'group' or 'plan'
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: group
..... value S1..1stringGroup Number
..... name S0..1stringGroup Name
.... class:plan S0..1BackboneElementPlan
..... type 1..1CodeableConceptType of class such as 'group' or 'plan'
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: plan
..... value S1..1stringPlan Number
..... name S0..1stringPlan Name

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Coverage.typeextensiblePayer
Coverage.relationshipextensibleSubscriberRelationshipCodes

Constraints

IdGradePath(s)DetailsRequirements
us-core-15errorCoverageCoverage.identifier or Coverage.subscriberId SHALL be present
: identifier.exists() or subscriberId.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage C0..*CoverageInsurance or medical plan or a payment agreement
us-core-15: Coverage.identifier or Coverage.subscriberId SHALL be present
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier SΣC0..*IdentifierMember ID and other identifiers
... status ?!SΣ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... type SΣ0..1CodeableConceptCoverage category such as medical or accident
Binding: Payer (extensible): US Public Health Data Consortium Source of Payment Codes

... subscriberId SΣC0..1stringID assigned to the subscriber
... beneficiary SΣ1..1Reference(US Core Patient Profile)Plan beneficiary
... relationship S1..1CodeableConceptBeneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible)
... period SΣ0..1PeriodCoverage start and end dates
... payor SΣ1..1Reference(US Core Organization Profile)Issuer of the policy
... Slices for class S0..*BackboneElementAdditional coverage classifications
Slice: Unordered, Open by pattern:type
.... class:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type Σ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.

..... value Σ1..1stringValue associated with the type
.... class:group S0..1BackboneElementGroup
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type Σ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: group
..... value SΣ1..1stringGroup Number
..... name SΣ0..1stringGroup Name
.... class:plan S0..1BackboneElementPlan
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type Σ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: plan
..... value SΣ1..1stringPlan Number
..... name SΣ0..1stringPlan Name

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Coverage.statusrequiredFinancialResourceStatusCodes
Coverage.typeextensiblePayer
Coverage.relationshipextensibleSubscriberRelationshipCodes
Coverage.class.typeextensibleCoverageClassCodes
Coverage.class:group.typeextensiblePattern: group
Coverage.class:plan.typeextensiblePattern: plan

Constraints

IdGradePath(s)DetailsRequirements
us-core-15errorCoverageCoverage.identifier or Coverage.subscriberId SHALL be present
: identifier.exists() or subscriberId.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage C0..*CoverageInsurance or medical plan or a payment agreement
us-core-15: Coverage.identifier or Coverage.subscriberId SHALL be present
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier SΣC0..*IdentifierMember ID and other identifiers
... status ?!SΣ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... type SΣ0..1CodeableConceptCoverage category such as medical or accident
Binding: Payer (extensible): US Public Health Data Consortium Source of Payment Codes

... policyHolder Σ0..1Reference(Patient | RelatedPerson | Organization)Owner of the policy
... subscriber Σ0..1Reference(Patient | RelatedPerson)Subscriber to the policy
... subscriberId SΣC0..1stringID assigned to the subscriber
... beneficiary SΣ1..1Reference(US Core Patient Profile)Plan beneficiary
... dependent Σ0..1stringDependent number
... relationship S1..1CodeableConceptBeneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible)
... period SΣ0..1PeriodCoverage start and end dates
... payor SΣ1..1Reference(US Core Organization Profile S | US Core Patient Profile | US Core RelatedPerson Profile)Issuer of the policy
... Slices for class S0..*BackboneElementAdditional coverage classifications
Slice: Unordered, Open by pattern:type
.... class:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type Σ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.

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


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


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

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

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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Coverage.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Coverage.statusrequiredFinancialResourceStatusCodes
Coverage.typeextensiblePayer
Coverage.relationshipextensibleSubscriberRelationshipCodes
Coverage.class.typeextensibleCoverageClassCodes
Coverage.class:group.typeextensiblePattern: group
Coverage.class:plan.typeextensiblePattern: plan
Coverage.costToBeneficiary.typeextensibleCoverageCopayTypeCodes
Coverage.costToBeneficiary.exception.typeexampleExampleCoverageFinancialExceptionCodes

This structure is derived from Coverage

Summary

Mandatory: 1 element
Must-Support: 15 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

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

Differential View

This structure is derived from Coverage

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage C0..*CoverageInsurance or medical plan or a payment agreement
us-core-15: Coverage.identifier or Coverage.subscriberId SHALL be present
... identifier SC0..*IdentifierMember ID and other identifiers
... status S1..1codeactive | cancelled | draft | entered-in-error
... type S0..1CodeableConceptCoverage category such as medical or accident
Binding: Payer (extensible): US Public Health Data Consortium Source of Payment Codes

... subscriberId SC0..1stringID assigned to the subscriber
... beneficiary S1..1Reference(US Core Patient Profile)Plan beneficiary
... relationship S1..1CodeableConceptBeneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible)
... period S0..1PeriodCoverage start and end dates
... payor S1..1Reference(US Core Organization Profile S | US Core Patient Profile | US Core RelatedPerson Profile)Issuer of the policy
... Slices for class S0..*BackboneElementAdditional coverage classifications
Slice: Unordered, Open by pattern:type
.... class:group S0..1BackboneElementGroup
..... type 1..1CodeableConceptType of class such as 'group' or 'plan'
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: group
..... value S1..1stringGroup Number
..... name S0..1stringGroup Name
.... class:plan S0..1BackboneElementPlan
..... type 1..1CodeableConceptType of class such as 'group' or 'plan'
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: plan
..... value S1..1stringPlan Number
..... name S0..1stringPlan Name

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Coverage.typeextensiblePayer
Coverage.relationshipextensibleSubscriberRelationshipCodes

Constraints

IdGradePath(s)DetailsRequirements
us-core-15errorCoverageCoverage.identifier or Coverage.subscriberId SHALL be present
: identifier.exists() or subscriberId.exists()

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage C0..*CoverageInsurance or medical plan or a payment agreement
us-core-15: Coverage.identifier or Coverage.subscriberId SHALL be present
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier SΣC0..*IdentifierMember ID and other identifiers
... status ?!SΣ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... type SΣ0..1CodeableConceptCoverage category such as medical or accident
Binding: Payer (extensible): US Public Health Data Consortium Source of Payment Codes

... subscriberId SΣC0..1stringID assigned to the subscriber
... beneficiary SΣ1..1Reference(US Core Patient Profile)Plan beneficiary
... relationship S1..1CodeableConceptBeneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible)
... period SΣ0..1PeriodCoverage start and end dates
... payor SΣ1..1Reference(US Core Organization Profile)Issuer of the policy
... Slices for class S0..*BackboneElementAdditional coverage classifications
Slice: Unordered, Open by pattern:type
.... class:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type Σ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.

..... value Σ1..1stringValue associated with the type
.... class:group S0..1BackboneElementGroup
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type Σ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: group
..... value SΣ1..1stringGroup Number
..... name SΣ0..1stringGroup Name
.... class:plan S0..1BackboneElementPlan
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type Σ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: plan
..... value SΣ1..1stringPlan Number
..... name SΣ0..1stringPlan Name

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Coverage.statusrequiredFinancialResourceStatusCodes
Coverage.typeextensiblePayer
Coverage.relationshipextensibleSubscriberRelationshipCodes
Coverage.class.typeextensibleCoverageClassCodes
Coverage.class:group.typeextensiblePattern: group
Coverage.class:plan.typeextensiblePattern: plan

Constraints

IdGradePath(s)DetailsRequirements
us-core-15errorCoverageCoverage.identifier or Coverage.subscriberId SHALL be present
: identifier.exists() or subscriberId.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage C0..*CoverageInsurance or medical plan or a payment agreement
us-core-15: Coverage.identifier or Coverage.subscriberId SHALL be present
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier SΣC0..*IdentifierMember ID and other identifiers
... status ?!SΣ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... type SΣ0..1CodeableConceptCoverage category such as medical or accident
Binding: Payer (extensible): US Public Health Data Consortium Source of Payment Codes

... policyHolder Σ0..1Reference(Patient | RelatedPerson | Organization)Owner of the policy
... subscriber Σ0..1Reference(Patient | RelatedPerson)Subscriber to the policy
... subscriberId SΣC0..1stringID assigned to the subscriber
... beneficiary SΣ1..1Reference(US Core Patient Profile)Plan beneficiary
... dependent Σ0..1stringDependent number
... relationship S1..1CodeableConceptBeneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible)
... period SΣ0..1PeriodCoverage start and end dates
... payor SΣ1..1Reference(US Core Organization Profile S | US Core Patient Profile | US Core RelatedPerson Profile)Issuer of the policy
... Slices for class S0..*BackboneElementAdditional coverage classifications
Slice: Unordered, Open by pattern:type
.... class:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type Σ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.

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


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


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

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

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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Coverage.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Coverage.statusrequiredFinancialResourceStatusCodes
Coverage.typeextensiblePayer
Coverage.relationshipextensibleSubscriberRelationshipCodes
Coverage.class.typeextensibleCoverageClassCodes
Coverage.class:group.typeextensiblePattern: group
Coverage.class:plan.typeextensiblePattern: plan
Coverage.costToBeneficiary.typeextensibleCoverageCopayTypeCodes
Coverage.costToBeneficiary.exception.typeexampleExampleCoverageFinancialExceptionCodes

This structure is derived from Coverage

Summary

Mandatory: 1 element
Must-Support: 15 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

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

 

Other representations of profile: CSV, Excel, Schematron

Notes:

Quick Start

Below is an overview of the required Server RESTful FHIR interactions for this profile - for example, search and read operations - when supporting the US Core interactions to access this profile’s information (Profile Support + Interaction Support). Note that systems that support only US Core Profiles (Profile Only Support) are not required to support these interactions. See the US Core Server CapabilityStatement for a complete list of supported RESTful interactions for this IG.

  • The syntax used to describe the interactions is described here.
  • See the General Requirements section for additional rules and expectations when a server requires status parameters.
  • See the General Guidance section for additional guidance on searching for multiple patients.

  1. SHALL support searching for all coverages for a patient using the patient search parameter:

    GET [base]/Coverage?patient={Type/}[id]

    Example:

    1. GET [base]/Coverage?patient=1137192

    Implementation Notes: Fetches a bundle of all Coverage resources for the specified patient (how to search by reference)