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 coverage

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 identifier 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.
• The hierarchical nature of the Coverage.type code system “Payer” (also known as the US Public Health Data Consortium Source of Payment Codes) may be unclear in the expansion, and some of the codes may be inappropriate for the use case. Implementers should refer to the PHDSC Payer Type Committee User’s Guide for the Source of Payment Typology when selecting codes.
• If Insurers issue unique member Ids for dependents, then the memberId Coverage.identifier should be used instead of Coverage.dependent to to uniquely refer to the dependent with respect to their insurance.

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

This structure is derived from Coverage

Name	Flags	Card.	Type	Description & Constraints
Coverage	C	0..*	Coverage	Insurance or medical plan or a payment agreement us-core-15: Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present
Slices for identifier	S	0..*	Identifier	(USCDI) Member ID and other identifiers Slice: Unordered, Open by pattern:type
identifier:memberid	SC	0..1	Identifier	(USCDI) Member ID
type	S	1..1	CodeableConcept	(USCDI) Member Number identifier type Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
code		1..1	code	Symbol in syntax defined by the system Fixed Value: MB
status	S	1..1	code	(USCDI) active | cancelled | draft | entered-in-error
type	S	0..1	CodeableConcept	(USCDI) Coverage category such as medical or accident Binding: Payer Type (extensible): US Public Health Data Consortium Source of Payment Codes
subscriberId	SC	0..1	string	(USCDI) ID assigned to the subscriber
beneficiary	S	1..1	Reference(US Core Patient Profile)	(USCDI) Plan beneficiary
relationship	S	1..1	CodeableConcept	(USCDI) Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible)
period	S	0..1	Period	(USCDI) Coverage start and end dates
payor	S	1..1	Reference(US Core Organization Profile S | US Core Patient Profile | US Core RelatedPerson Profile)	(USCDI) Issuer of the policy
Slices for class	S	0..*	BackboneElement	(USCDI) Additional coverage classifications Slice: Unordered, Open by pattern:type
class:group	S	0..1	BackboneElement	(USCDI) Group
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: group
value	S	1..1	string	(USCDI) Group Number
name	S	0..1	string	(USCDI) Group Name
class:plan	S	0..1	BackboneElement	(USCDI) Plan
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: plan
value	S	1..1	string	(USCDI) Plan Number
name	S	0..1	string	(USCDI) Plan Name
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet
Coverage.type	extensible	PayerType
Coverage.relationship	extensible	SubscriberRelationshipCodes

Constraints

Id	Grade	Path(s)	Details	Requirements
us-core-15	error	Coverage	Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present : identifier.type.coding.where(system='http://terminology.hl7.org/CodeSystem/v2-0203' and code='MB').exists() or subscriberId.exists()

Name	Flags	Card.	Type	Description & Constraints
Coverage	C	0..*	Coverage	Insurance or medical plan or a payment agreement us-core-15: Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
Slices for identifier	SΣ	0..*	Identifier	(USCDI) Member ID and other identifiers Slice: Unordered, Open by pattern:type
identifier:memberid	SΣC	0..1	Identifier	(USCDI) Member ID
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type	SΣ	1..1	CodeableConcept	(USCDI) Member Number identifier type Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
code		1..1	code	Symbol in syntax defined by the system Fixed Value: MB
status	?!SΣ	1..1	code	(USCDI) active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
type	SΣ	0..1	CodeableConcept	(USCDI) Coverage category such as medical or accident Binding: Payer Type (extensible): US Public Health Data Consortium Source of Payment Codes
subscriberId	SΣC	0..1	string	(USCDI) ID assigned to the subscriber
beneficiary	SΣ	1..1	Reference(US Core Patient Profile)	(USCDI) Plan beneficiary
relationship	S	1..1	CodeableConcept	(USCDI) Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible)
period	SΣ	0..1	Period	(USCDI) Coverage start and end dates
payor	SΣ	1..1	Reference(US Core Organization Profile)	(USCDI) Issuer of the policy
Slices for class	S	0..*	BackboneElement	(USCDI) Additional coverage classifications Slice: Unordered, Open by pattern:type
class:All Slices				Content/Rules for all slices
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	Σ	1..1	CodeableConcept	Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.
value	Σ	1..1	string	Value associated with the type
class:group	S	0..1	BackboneElement	(USCDI) Group
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	Σ	1..1	CodeableConcept	Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
code		1..1	code	Symbol in syntax defined by the system Fixed Value: group
value	SΣ	1..1	string	(USCDI) Group Number
name	SΣ	0..1	string	(USCDI) Group Name
class:plan	S	0..1	BackboneElement	(USCDI) Plan
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	Σ	1..1	CodeableConcept	Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
code		1..1	code	Symbol in syntax defined by the system Fixed Value: plan
value	SΣ	1..1	string	(USCDI) Plan Number
name	SΣ	0..1	string	(USCDI) Plan Name
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
Coverage.identifier:memberid.use	required	IdentifierUse
Coverage.identifier:memberid.type	extensible	Pattern: MB
Coverage.status	required	FinancialResourceStatusCodes
Coverage.type	extensible	PayerType
Coverage.relationship	extensible	SubscriberRelationshipCodes
Coverage.class.type	extensible	CoverageClassCodes
Coverage.class:group.type	extensible	Pattern: group
Coverage.class:plan.type	extensible	Pattern: plan

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	Coverage	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	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	error	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	error	Coverage	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Coverage	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()
us-core-15	error	Coverage	Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present : identifier.type.coding.where(system='http://terminology.hl7.org/CodeSystem/v2-0203' and code='MB').exists() or subscriberId.exists()

Name	Flags	Card.	Type	Description & Constraints
Coverage	C	0..*	Coverage	Insurance or medical plan or a payment agreement us-core-15: Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
Slices for identifier	SΣ	0..*	Identifier	(USCDI) Member ID and other identifiers Slice: Unordered, Open by pattern:type
identifier:memberid	SΣC	0..1	Identifier	(USCDI) Member ID
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type	SΣ	1..1	CodeableConcept	(USCDI) Member Number identifier type Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: MB
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
system	Σ	0..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value	Σ	0..1	string	The value that is unique Example General: 123456
period	Σ	0..1	Period	Time period when id is/was valid for use
assigner	Σ	0..1	Reference(Organization)	Organization that issued id (may be just text)
status	?!SΣ	1..1	code	(USCDI) active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
type	SΣ	0..1	CodeableConcept	(USCDI) Coverage category such as medical or accident Binding: Payer Type (extensible): US Public Health Data Consortium Source of Payment Codes
policyHolder	Σ	0..1	Reference(Patient | RelatedPerson | Organization)	Owner of the policy
subscriber	Σ	0..1	Reference(Patient | RelatedPerson)	Subscriber to the policy
subscriberId	SΣC	0..1	string	(USCDI) ID assigned to the subscriber
beneficiary	SΣ	1..1	Reference(US Core Patient Profile)	(USCDI) Plan beneficiary
dependent	Σ	0..1	string	Dependent number
relationship	S	1..1	CodeableConcept	(USCDI) Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible)
period	SΣ	0..1	Period	(USCDI) Coverage start and end dates
payor	SΣ	1..1	Reference(US Core Organization Profile S | US Core Patient Profile | US Core RelatedPerson Profile)	(USCDI) Issuer of the policy
Slices for class	S	0..*	BackboneElement	(USCDI) Additional coverage classifications Slice: Unordered, Open by pattern:type
class:All Slices				Content/Rules for all slices
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	Σ	1..1	CodeableConcept	Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.
value	Σ	1..1	string	Value associated with the type
name	Σ	0..1	string	Human readable description of the type and value
class:group	S	0..1	BackboneElement	(USCDI) Group
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	Σ	1..1	CodeableConcept	Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: group
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
value	SΣ	1..1	string	(USCDI) Group Number
name	SΣ	0..1	string	(USCDI) Group Name
class:plan	S	0..1	BackboneElement	(USCDI) Plan
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	Σ	1..1	CodeableConcept	Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: plan
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
value	SΣ	1..1	string	(USCDI) Plan Number
name	SΣ	0..1	string	(USCDI) Plan Name
order	Σ	0..1	positiveInt	Relative order of the coverage
network	Σ	0..1	string	Insurer network
costToBeneficiary		0..*	BackboneElement	Patient payments for services/products
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	Σ	0..1	CodeableConcept	Cost category Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified.
value[x]	Σ	1..1		The amount or percentage due from the beneficiary
valueQuantity			Quantity(SimpleQuantity)
valueMoney			Money
exception		0..*	BackboneElement	Exceptions for patient payments
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	Σ	1..1	CodeableConcept	Exception category Binding: ExampleCoverageFinancialExceptionCodes (example): The types of exceptions from the part or full value of financial obligations such as copays.
period	Σ	0..1	Period	The effective period of the exception
subrogation		0..1	boolean	Reimbursement to insurer
contract		0..*	Reference(Contract)	Contract details
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
Coverage.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
Coverage.identifier:memberid.use	required	IdentifierUse
Coverage.identifier:memberid.type	extensible	Pattern: MB
Coverage.status	required	FinancialResourceStatusCodes
Coverage.type	extensible	PayerType
Coverage.relationship	extensible	SubscriberRelationshipCodes
Coverage.class.type	extensible	CoverageClassCodes
Coverage.class:group.type	extensible	Pattern: group
Coverage.class:plan.type	extensible	Pattern: plan
Coverage.costToBeneficiary.type	extensible	CoverageCopayTypeCodes
Coverage.costToBeneficiary.exception.type	example	ExampleCoverageFinancialExceptionCodes

Constraints

Id	Grade	Path(s)	Details	Requirements
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

Differential View

This structure is derived from Coverage

Name	Flags	Card.	Type	Description & Constraints
Coverage	C	0..*	Coverage	Insurance or medical plan or a payment agreement us-core-15: Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present
Slices for identifier	S	0..*	Identifier	(USCDI) Member ID and other identifiers Slice: Unordered, Open by pattern:type
identifier:memberid	SC	0..1	Identifier	(USCDI) Member ID
type	S	1..1	CodeableConcept	(USCDI) Member Number identifier type Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
code		1..1	code	Symbol in syntax defined by the system Fixed Value: MB
status	S	1..1	code	(USCDI) active | cancelled | draft | entered-in-error
type	S	0..1	CodeableConcept	(USCDI) Coverage category such as medical or accident Binding: Payer Type (extensible): US Public Health Data Consortium Source of Payment Codes
subscriberId	SC	0..1	string	(USCDI) ID assigned to the subscriber
beneficiary	S	1..1	Reference(US Core Patient Profile)	(USCDI) Plan beneficiary
relationship	S	1..1	CodeableConcept	(USCDI) Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible)
period	S	0..1	Period	(USCDI) Coverage start and end dates
payor	S	1..1	Reference(US Core Organization Profile S | US Core Patient Profile | US Core RelatedPerson Profile)	(USCDI) Issuer of the policy
Slices for class	S	0..*	BackboneElement	(USCDI) Additional coverage classifications Slice: Unordered, Open by pattern:type
class:group	S	0..1	BackboneElement	(USCDI) Group
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: group
value	S	1..1	string	(USCDI) Group Number
name	S	0..1	string	(USCDI) Group Name
class:plan	S	0..1	BackboneElement	(USCDI) Plan
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: plan
value	S	1..1	string	(USCDI) Plan Number
name	S	0..1	string	(USCDI) Plan Name
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet
Coverage.type	extensible	PayerType
Coverage.relationship	extensible	SubscriberRelationshipCodes

Constraints

Id	Grade	Path(s)	Details	Requirements
us-core-15	error	Coverage	Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present : identifier.type.coding.where(system='http://terminology.hl7.org/CodeSystem/v2-0203' and code='MB').exists() or subscriberId.exists()

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
Coverage	C	0..*	Coverage	Insurance or medical plan or a payment agreement us-core-15: Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
Slices for identifier	SΣ	0..*	Identifier	(USCDI) Member ID and other identifiers Slice: Unordered, Open by pattern:type
identifier:memberid	SΣC	0..1	Identifier	(USCDI) Member ID
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type	SΣ	1..1	CodeableConcept	(USCDI) Member Number identifier type Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
code		1..1	code	Symbol in syntax defined by the system Fixed Value: MB
status	?!SΣ	1..1	code	(USCDI) active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
type	SΣ	0..1	CodeableConcept	(USCDI) Coverage category such as medical or accident Binding: Payer Type (extensible): US Public Health Data Consortium Source of Payment Codes
subscriberId	SΣC	0..1	string	(USCDI) ID assigned to the subscriber
beneficiary	SΣ	1..1	Reference(US Core Patient Profile)	(USCDI) Plan beneficiary
relationship	S	1..1	CodeableConcept	(USCDI) Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible)
period	SΣ	0..1	Period	(USCDI) Coverage start and end dates
payor	SΣ	1..1	Reference(US Core Organization Profile)	(USCDI) Issuer of the policy
Slices for class	S	0..*	BackboneElement	(USCDI) Additional coverage classifications Slice: Unordered, Open by pattern:type
class:All Slices				Content/Rules for all slices
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	Σ	1..1	CodeableConcept	Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.
value	Σ	1..1	string	Value associated with the type
class:group	S	0..1	BackboneElement	(USCDI) Group
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	Σ	1..1	CodeableConcept	Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
code		1..1	code	Symbol in syntax defined by the system Fixed Value: group
value	SΣ	1..1	string	(USCDI) Group Number
name	SΣ	0..1	string	(USCDI) Group Name
class:plan	S	0..1	BackboneElement	(USCDI) Plan
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	Σ	1..1	CodeableConcept	Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
code		1..1	code	Symbol in syntax defined by the system Fixed Value: plan
value	SΣ	1..1	string	(USCDI) Plan Number
name	SΣ	0..1	string	(USCDI) Plan Name
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
Coverage.identifier:memberid.use	required	IdentifierUse
Coverage.identifier:memberid.type	extensible	Pattern: MB
Coverage.status	required	FinancialResourceStatusCodes
Coverage.type	extensible	PayerType
Coverage.relationship	extensible	SubscriberRelationshipCodes
Coverage.class.type	extensible	CoverageClassCodes
Coverage.class:group.type	extensible	Pattern: group
Coverage.class:plan.type	extensible	Pattern: plan

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	Coverage	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	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	error	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	error	Coverage	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Coverage	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()
us-core-15	error	Coverage	Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present : identifier.type.coding.where(system='http://terminology.hl7.org/CodeSystem/v2-0203' and code='MB').exists() or subscriberId.exists()

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
Coverage	C	0..*	Coverage	Insurance or medical plan or a payment agreement us-core-15: Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
Slices for identifier	SΣ	0..*	Identifier	(USCDI) Member ID and other identifiers Slice: Unordered, Open by pattern:type
identifier:memberid	SΣC	0..1	Identifier	(USCDI) Member ID
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type	SΣ	1..1	CodeableConcept	(USCDI) Member Number identifier type Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: MB
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
system	Σ	0..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value	Σ	0..1	string	The value that is unique Example General: 123456
period	Σ	0..1	Period	Time period when id is/was valid for use
assigner	Σ	0..1	Reference(Organization)	Organization that issued id (may be just text)
status	?!SΣ	1..1	code	(USCDI) active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
type	SΣ	0..1	CodeableConcept	(USCDI) Coverage category such as medical or accident Binding: Payer Type (extensible): US Public Health Data Consortium Source of Payment Codes
policyHolder	Σ	0..1	Reference(Patient | RelatedPerson | Organization)	Owner of the policy
subscriber	Σ	0..1	Reference(Patient | RelatedPerson)	Subscriber to the policy
subscriberId	SΣC	0..1	string	(USCDI) ID assigned to the subscriber
beneficiary	SΣ	1..1	Reference(US Core Patient Profile)	(USCDI) Plan beneficiary
dependent	Σ	0..1	string	Dependent number
relationship	S	1..1	CodeableConcept	(USCDI) Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible)
period	SΣ	0..1	Period	(USCDI) Coverage start and end dates
payor	SΣ	1..1	Reference(US Core Organization Profile S | US Core Patient Profile | US Core RelatedPerson Profile)	(USCDI) Issuer of the policy
Slices for class	S	0..*	BackboneElement	(USCDI) Additional coverage classifications Slice: Unordered, Open by pattern:type
class:All Slices				Content/Rules for all slices
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	Σ	1..1	CodeableConcept	Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.
value	Σ	1..1	string	Value associated with the type
name	Σ	0..1	string	Human readable description of the type and value
class:group	S	0..1	BackboneElement	(USCDI) Group
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	Σ	1..1	CodeableConcept	Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: group
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
value	SΣ	1..1	string	(USCDI) Group Number
name	SΣ	0..1	string	(USCDI) Group Name
class:plan	S	0..1	BackboneElement	(USCDI) Plan
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	Σ	1..1	CodeableConcept	Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: plan
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
value	SΣ	1..1	string	(USCDI) Plan Number
name	SΣ	0..1	string	(USCDI) Plan Name
order	Σ	0..1	positiveInt	Relative order of the coverage
network	Σ	0..1	string	Insurer network
costToBeneficiary		0..*	BackboneElement	Patient payments for services/products
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	Σ	0..1	CodeableConcept	Cost category Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified.
value[x]	Σ	1..1		The amount or percentage due from the beneficiary
valueQuantity			Quantity(SimpleQuantity)
valueMoney			Money
exception		0..*	BackboneElement	Exceptions for patient payments
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	Σ	1..1	CodeableConcept	Exception category Binding: ExampleCoverageFinancialExceptionCodes (example): The types of exceptions from the part or full value of financial obligations such as copays.
period	Σ	0..1	Period	The effective period of the exception
subrogation		0..1	boolean	Reimbursement to insurer
contract		0..*	Reference(Contract)	Contract details
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
Coverage.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
Coverage.identifier:memberid.use	required	IdentifierUse
Coverage.identifier:memberid.type	extensible	Pattern: MB
Coverage.status	required	FinancialResourceStatusCodes
Coverage.type	extensible	PayerType
Coverage.relationship	extensible	SubscriberRelationshipCodes
Coverage.class.type	extensible	CoverageClassCodes
Coverage.class:group.type	extensible	Pattern: group
Coverage.class:plan.type	extensible	Pattern: plan
Coverage.costToBeneficiary.type	extensible	CoverageCopayTypeCodes
Coverage.costToBeneficiary.exception.type	example	ExampleCoverageFinancialExceptionCodes

Constraints

Id	Grade	Path(s)	Details	Requirements
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

This structure is derived from Coverage

Summary

Mandatory: 1 element (1 nested mandatory element)
Must-Support: 17 elements

Structures

This structure refers to these other structures:

• US Core Patient Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient)
• US Core Organization Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-organization)
• US Core RelatedPerson Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-relatedperson)

Slices

This structure defines the following Slices:

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

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.

• Servers providing access to coverage data can use US Core SMART Scopes for:
  • resource level scopes (for example, patient/Coverage.rs).
• 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.

Mandatory Search Parameters:

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)