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: CoverageR4 - Detailed Descriptions

Definitions for the profile-coverage-r4 Profile.

1. Coverage
Definition | Financial instrument which may be used to reimburse or pay for health care products and services. Includes both insurance and self-payment.
Control | 0..*
Comments | The Coverage resource contains the insurance card level information, which is customary to provide on claims and other communications between providers and insurers.
Invariants | Defined on this element 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 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: 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: If a resource is contained in another resource, it SHALL NOT have a security label (: contained.meta.security.empty()) dom-6: A resource should have narrative for robust management (: text.div.exists())
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 might 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. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.
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. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
5. Coverage.language
Definition | The base language in which the resource is written.
Control | 0..1
Binding | A human language. The codes SHOULD be taken from CommonLanguages Max Binding: AllLanguages
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 can 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
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 information 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. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
8. Coverage.extension
Definition | May be used to represent additional information that is not part of the basic definition of the resource. 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 can 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 and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Control | 0..*
Type | Extension
Is Modifier | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
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 | A unique identifier assigned to this coverage.
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 0..*
Type | Identifier
Must Support | true
Requirements | Allows coverages to be distinguished and referenced.
Comments | 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 concatenation of the Coverage.SubscriberID and the Coverage.dependant.
11. Coverage.status
Definition | The status of the resource instance.
Control | 1..1
Binding | A code specifying the state of the resource instance. The codes SHALL be taken from FinancialResourceStatusCodes
Type | code
Is Modifier | true
Must Support | true
Requirements | Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.
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 CoverageTypeAndSelf-PayCodes
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.
Control | 0..1
Type | Reference(PatientR4 | OrganizationR4)
Must Support | true
Requirements | This provides employer information in the case of Worker's Compensation and other policies.
Comments | For example: may be an individual, corporation or the subscriber's employer.
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(PatientR4)
Must Support | true
Requirements | This is the party who is entitled to the benfits under the policy.
Comments | May be self or a parent in the case of dependants.
15. Coverage.subscriberId
Definition | The insurer assigned ID for the Subscriber.
Control | 0..1
Type | string
Must Support | true
Requirements | The insurer requires this identifier on correspondance and claims (digital and otherwise).
16. Coverage.beneficiary
Definition | The party who benefits from the insurance coverage; the patient when products and/or services are provided.
Control | 1..1
Type | Reference(PatientR4)
Must Support | true
Requirements | This is the party who receives treatment for which the costs are reimbursed under the coverage.
17. Coverage.dependent
Definition | A unique identifier for a dependent under the coverage.
Control | 0..1
Type | string
Must Support | true
Requirements | For some coverages a single identifier is issued to the Subscriber and then a unique dependent number is issued to each beneficiary.
Comments | Periodically the member number is constructed from the subscriberId and the dependant number.
18. Coverage.relationship
Definition | The relationship of beneficiary (patient) to the subscriber.
Control | 0..1
Binding | The relationship between the Subscriber and the Beneficiary (insured/covered party/patient). The codes SHALL be taken from SubscriberRelationshipCodes; other codes may be used where these codes are not suitable
Type | CodeableConcept
Must Support | true
Requirements | To determine relationship between the patient and the subscriber to determine coordination of benefits.
Comments | Typically, an individual uses policies which are theirs (relationship='self') before policies owned by others.
19. 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
Requirements | Some insurers require the submission of the coverage term.
20. Coverage.payor
Definition | The program or plan underwriter or payor including both insurance and non-insurance agreements, such as patient-pay agreements.
Control | 1..*
Type | Reference(PatientR4 | OrganizationR4)
Must Support | true
Requirements | Need to identify the issuer to target for claim processing and for coordination of benefit processing.
Comments | May provide multiple identifiers such as insurance company identifier or business identifier (BIN number). For selfpay it may provide multiple paying persons and/or organizations.
21. Coverage.class
Definition | A suite of underwriter specific classifiers.
Control | 0..1
Type | BackboneElement
Must Support | true
Requirements | The codes provided on the health card which identify or confirm the specific policy for the insurer.
Comments | For example may be used to identify a class of coverage or employer group, Policy, Plan.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
22. Coverage.class.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
23. Coverage.class.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. 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 can 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.
24. Coverage.class.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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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 can 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Control | 0..*
Type | Extension
Is Modifier | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
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.
25. Coverage.class.type
Definition | The type of classification for which an insurer-specific class label or number and optional name is provided, for example may be used to identify a class of coverage or employer group, Policy, Plan.
Control | 1..1
Binding | CRD Coverage Classes The codes SHALL be taken from CRD Coverage Classes
Type | CodeableConcept
Must Support | true
Requirements | The insurer issued label for a specific health card value.
26. Coverage.class.value
Definition | The alphanumeric string value associated with the insurer issued label.
Control | 1..1
Type | string
Must Support | true
Requirements | The insurer issued label and value are necessary to identify the specific policy.
Comments | For example, the Group or Plan number.
27. Coverage.class.name
Definition | A short description for the class.
Control | 0..1
Type | string
Must Support | true
Requirements | Used to provide a meaningful description in correspondence to the patient.
28. Coverage.order
Definition | The order of applicability of this coverage relative to other coverages which are currently in force. Note, there may be gaps in the numbering and this does not imply primary, secondary etc. as the specific positioning of coverages depends upon the episode of care.
Control | 0..1
Type | positiveInt
Must Support | true
Requirements | Used in managing the coordination of benefits.
29. 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
Requirements | Used in referral for treatment and in claims processing.
30. Coverage.costToBeneficiary
Definition | A suite of codes indicating the cost category and associated amount which have been detailed in the policy and may have been included on the health card.
Control | 0..0
Type | BackboneElement
Requirements | Required by providers to manage financial transaction with the patient.
Alternate Names | CoPay, Deductible, Exceptions
Comments | For example by knowing the patient visit co-pay, the provider can collect the amount prior to undertaking treatment.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
31. Coverage.costToBeneficiary.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
32. Coverage.costToBeneficiary.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. 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 can 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.
33. Coverage.costToBeneficiary.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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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 can 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Control | 0..*
Type | Extension
Is Modifier | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
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.
34. Coverage.costToBeneficiary.type
Definition | The category of patient centric costs associated with treatment.
Control | 0..1
Binding | The types of services to which patient copayments are specified. The codes SHALL be taken from CoverageCopayTypeCodes; other codes may be used where these codes are not suitable
Type | CodeableConcept
Requirements | Needed to identify the category associated with the amount for the patient.
Comments | For example visit, specialist visits, emergency, inpatient care, etc.
35. Coverage.costToBeneficiary.value[x]
Definition | The amount due from the patient for the cost category.
Control | 1..1
Type | Choice of: Quantity(SimpleQuantity), Money
[x] Note | See Choice of Data Types for further information about how to use [x]
Requirements | Needed to identify the amount for the patient associated with the category.
Comments | Amount may be expressed as a percentage of the service/product cost or a fixed amount of currency.
36. Coverage.costToBeneficiary.exception
Definition | A suite of codes indicating exceptions or reductions to patient costs and their effective periods.
Control | 0..*
Type | BackboneElement
Requirements | Required by providers to manage financial transaction with the patient.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
37. Coverage.costToBeneficiary.exception.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
38. Coverage.costToBeneficiary.exception.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. 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 can 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.
39. Coverage.costToBeneficiary.exception.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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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 can 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Control | 0..*
Type | Extension
Is Modifier | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
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.
40. Coverage.costToBeneficiary.exception.type
Definition | The code for the specific exception.
Control | 1..1
Binding | The types of exceptions from the part or full value of financial obligations such as copays. For example codes, see ExampleCoverageFinancialExceptionCodes
Type | CodeableConcept
Requirements | Needed to identify the exception associated with the amount for the patient.
41. Coverage.costToBeneficiary.exception.period
Definition | The timeframe during when the exception is in force.
Control | 0..1
Type | Period
Requirements | Needed to identify the applicable timeframe for the exception for the correct calculation of patient costs.
42. Coverage.subrogation
Definition | When 'subrogation=true' this insurance instance has been included not for adjudication but to provide insurers with the details to recover costs.
Control | 0..1
Type | boolean
Requirements | See definition for when to be used.
Comments | Typically, automotive and worker's compensation policies would be flagged with 'subrogation=true' to enable healthcare payors to collect against accident claims.
43. Coverage.contract
Definition | The policy(s) which constitute this insurance coverage.
Control | 0..*
Type | Reference(Contract)
Requirements | To reference the legally binding contract between the policy holder and the insurer.