0.3.0 - Second STU ballot

This page is part of a downloaded copy of this specification. This page is part of the Da Vinci Coverage Requirements Discovery (CRD) FHIR IG (v0.3.0: STU 1 Ballot 2) based on FHIR R4. . For a full list of available versions, see the Directory of published versions

## StructureDefinition: CoverageSTU3 - Detailed Descriptions

Definitions for the profile-coverage-stu3 Profile.

1. Coverage
Definition | Financial instrument which may be used to reimburse or pay for health care products and services.
Control | 0..*
Invariants | Defined on this element dom-1: If the resource is contained in another resource, it SHALL NOT contain any narrative (: contained.text.empty()) dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (: contained.contained.empty()) dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource (: contained.where(('#'+id in %resource.descendants().reference).not()).empty()) dom-4: 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())
2. Coverage.id
Definition | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
Control | 0..1
Type | id
Comments | The only time that a resource does not have an id is when it is being submitted to the server using a create operation.
3. Coverage.meta
Definition | The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content may not always be associated with version changes to the resource.
Control | 0..1
Type | Meta
4. Coverage.implicitRules
Definition | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content.
Control | 0..1
Type | uri
Is Modifier | true
Comments | Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. This element is labelled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation.
5. Coverage.language
Definition | The base language in which the resource is written.
Control | 0..1
Binding | A human language. The codes SHALL be taken from Common Languages; other codes may be used where these codes are not suitable Max Binding: All Languages
Type | code
Comments | Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).
6. Coverage.text
Definition | A human-readable narrative that contains a summary of the resource, and may be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.
Control | 0..1 This element is affected by the following invariants: dom-1
Type | Narrative
Alternate Names | narrative, html, xhtml, display
Comments | Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded in formation is added later.
7. Coverage.contained
Definition | These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.
Control | 0..*
Type | Resource
Alternate Names | inline resources, anonymous resources, contained resources
Comments | This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again.
8. Coverage.extension
Definition | May be used to represent additional information that is not part of the basic definition of the resource. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Control | 0..*
Type | Extension
Alternate Names | extensions, user content
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
9. Coverage.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the resource, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.
Control | 0..*
Type | Extension
Is Modifier | true
Alternate Names | extensions, user content
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
10. Coverage.identifier
Definition | The main (and possibly only) identifier for the coverage - often referred to as a Member Id, Certificate number, Personal Health Number or Case ID. May be constructed as the concatination of the Coverage.SubscriberID and the Coverage.dependant.
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 0..*
Type | Identifier
Must Support | true
Requirements | This value may uniquely identify the coverage or it may be used in conjunction with the additional identifiers below.
11. Coverage.status
Definition | The status of the resource instance.
Control | 0..1
Binding | A code specifying the state of the resource instance. The codes SHALL be taken from Financial Resource Status Codes
Type | code
Is Modifier | true
Must Support | true
Comments | This element is labeled as a modifier because the status contains the code entered-in-error that marks the coverage as not currently valid.
12. Coverage.type
Definition | The type of coverage: social program, medical plan, accident coverage (workers compensation, auto), group health or payment by an individual or organization.
Control | 0..1
Binding | The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization. The codes SHOULD be taken from Coverage Type and Self-Pay Codes
Type | CodeableConcept
Must Support | true
Requirements | The order of application of coverages is dependent on the types of coverage.
13. Coverage.policyHolder
Definition | The party who 'owns' the insurance policy, may be an individual, corporation or the subscriber's employer.
Control | 0..1
Type | Reference(PatientSTU3 | OrganizationSTU3)
Must Support | true
14. Coverage.subscriber
Definition | The party who has signed-up for or 'owns' the contractual relationship to the policy or to whom the benefit of the policy for services rendered to them or their family is due.
Control | 0..1
Type | Reference(PatientSTU3)
Must Support | true
15. Coverage.subscriberId
Definition | The insurer assigned ID for the Subscriber.
Control | 0..1
Type | string
Must Support | true
16. Coverage.beneficiary
Definition | The party who benefits from the insurance coverage., the patient when services are provided.
Control | 0..1
Type | Reference(PatientSTU3)
Must Support | true
17. Coverage.relationship
Definition | The relationship of beneficiary (patient) to the subscriber.
Control | 0..1
Binding | The relationship between the Policyholder and the Beneficiary (insured/covered party/patient). For example codes, see Policyholder Relationship Codes
Type | CodeableConcept
Must Support | true
Requirements | To determine relationship between the patient and the subscriber.
18. Coverage.period
Definition | Time period during which the coverage is in force. A missing start date indicates the start date isn't known, a missing end date means the coverage is continuing to be in force.
Control | 0..1
Type | Period
Must Support | true
19. Coverage.payor
Definition | The program or plan underwriter or payor including both insurance and non-insurance agreements, such as patient-pay agreements. May provide multiple identifiers such as insurance company identifier or business identifier (BIN number).
Control | 0..*
Type | Reference(PatientSTU3 | OrganizationSTU3)
Must Support | true
Requirements | Need to identify the issuer to target for processing and for coordination of benefit processing.
20. Coverage.grouping
Definition | A suite of underwrite specific classifiers, for example may be used to identify a class of coverage or employer group, Policy, Plan.
Control | 0..1
Type | BackboneElement
Must Support | true
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() | (children().count() > id.count()))
21. Coverage.grouping.id
Definition | unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Control | 0..1
Type | string
22. Coverage.grouping.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Control | 0..*
Type | Extension
Alternate Names | extensions, user content
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
23. Coverage.grouping.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.
Control | 0..*
Type | Extension
Is Modifier | true
Alternate Names | extensions, user content, modifiers
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
24. Coverage.grouping.group
Definition | Identifies a style or collective of coverage issued by the underwriter, for example may be used to identify an employer group. May also be referred to as a Policy or Group ID.
Control | 0..1
Type | string
Must Support | true
25. Coverage.grouping.groupDisplay
Definition | A short description for the group.
Control | 0..1
Type | string
Must Support | true
26. Coverage.grouping.subGroup
Definition | Identifies a style or collective of coverage issued by the underwriter, for example may be used to identify a subset of an employer group.
Control | 0..1
Type | string
Must Support | true
27. Coverage.grouping.subGroupDisplay
Definition | A short description for the subgroup.
Control | 0..1
Type | string
Must Support | true
28. Coverage.grouping.plan
Definition | Identifies a style or collective of coverage issued by the underwriter, for example may be used to identify a collection of benefits provided to employees. May be referred to as a Section or Division ID.
Control | 0..1
Type | string
Must Support | true
29. Coverage.grouping.planDisplay
Definition | A short description for the plan.
Control | 0..1
Type | string
Must Support | true
30. Coverage.grouping.subPlan
Definition | Identifies a sub-style or sub-collective of coverage issued by the underwriter, for example may be used to identify a subset of a collection of benefits provided to employees.
Control | 0..1
Type | string
Must Support | true
31. Coverage.grouping.subPlanDisplay
Definition | A short description for the subplan.
Control | 0..1
Type | string
Must Support | true
32. Coverage.grouping.class
Definition | Identifies a style or collective of coverage issues by the underwriter, for example may be used to identify a class of coverage such as a level of deductables or co-payment.
Control | 0..1
Type | string
Must Support | true
33. Coverage.grouping.classDisplay
Definition | A short description for the class.
Control | 0..1
Type | string
Must Support | true
34. Coverage.grouping.subClass
Definition | Identifies a sub-style or sub-collective of coverage issues by the underwriter, for example may be used to identify a subclass of coverage such as a sub-level of deductables or co-payment.
Control | 0..1
Type | string
Must Support | true
35. Coverage.grouping.subClassDisplay
Definition | A short description for the subclass.
Control | 0..1
Type | string
Must Support | true
36. Coverage.dependent
Definition | A unique identifier for a dependent under the coverage.
Control | 0..1
Type | string
Must Support | true
Requirements | For some coverage a single identifier is issued to the Subscriber and a dependent number issued to each beneficiary.
37. Coverage.sequence
Definition | An optional counter for a particular instance of the identified coverage which increments upon each renewal.
Control | 0..1
Type | string
Requirements | Some coverage, for example social plans, may be offered in short time increments, for example for a week or a month at a time, so while the rest of the plan details and identifiers may remain constant over time, the instance is incremented with each renewal and provided to the covered party on their 'card'.
38. Coverage.order
Definition | The order of applicability of this coverage relative to other coverages which are currently inforce. Note, there may be gaps in the numbering and this does not imply primary, secondard etc. as the specific positioning of coverages depends upon the episode of care.
Control | 0..1
Type | positiveInt
Must Support | true
39. Coverage.network
Definition | The insurer-specific identifier for the insurer-defined network of providers to which the beneficiary may seek treatment which will be covered at the 'in-network' rate, otherwise 'out of network' terms and conditions apply.
Control | 0..1
Type | string
Must Support | true
40. Coverage.contract
Definition | The policy(s) which constitute this insurance coverage.
Control | 0..*
Type | Reference(Contract)