This page is part of the Da Vinci Coverage Requirements Discovery (CRD) FHIR IG (v0.1.0: STU 1 Ballot 1) based on FHIR v3.5.0. The current version which supercedes this version is 1.0.0. For a full list of available versions, see the Directory of published versions

StructureDefinition: CRD Coverage - Detailed Descriptions

Definitions for the profile-coverage-deident-r4 Profile.

Coverage
Definition

Financial instrument which may be used to reimburse or pay for health care products and services.

Control0..*
InvariantsDefined 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())
Coverage.id
Definition

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

Control0..1
Typeid
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.

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.

Control0..1
TypeMeta
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.

Control0..1
Typeuri
Is Modifiertrue
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.

Coverage.language
Definition

The base language in which the resource is written.

Control0..1
BindingA human language.
The codes SHOULD be taken from Common Languages
Typecode
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).

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.

Control0..1
TypeNarrative
Alternate Namesnarrative, 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.

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.

Control0..*
TypeResource
Alternate Namesinline 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.

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.

Control0..*
TypeExtension
Alternate Namesextensions, 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.

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. 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).

Control0..*
TypeExtension
Is Modifiertrue
Alternate Namesextensions, 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.

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 concatenation of the Coverage.SubscriberID and the Coverage.dependant.

NoteThis is a business identifer, not a resource identifier (see discussion)
Control0..0
TypeIdentifier
Requirements

This value may uniquely identify the coverage or it may be used in conjunction with the additional identifiers below.

Coverage.status
Definition

The status of the resource instance.

Control0..1
BindingA code specifying the state of the resource instance.
The codes SHALL be taken from FinancialResourceStatusCodes
Typecode
Is Modifiertrue
Must Supporttrue
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.

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.

Control0..1
BindingThe 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
TypeCodeableConcept
Must Supporttrue
Requirements

The order of application of coverages is dependent on the types of coverage.

Coverage.policyHolder
Definition

The party who 'owns' the insurance policy, may be an individual, corporation or the subscriber's employer.

Control0..0
TypeReference(Patient | RelatedPerson | Organization)
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.

Control0..0
TypeReference(Patient | RelatedPerson)
Coverage.subscriberId
Definition

The insurer assigned ID for the Subscriber.

Control0..0
Typestring
Coverage.beneficiary
Definition

The party who benefits from the insurance coverage; the patient when services are provided.

Control0..0
TypeReference(Patient)
Coverage.dependent
Definition

A unique identifier for a dependent under the coverage.

Control0..0
Typestring
Requirements

For some coverage a single identifier is issued to the Subscriber and a dependent number issued to each beneficiary.

Coverage.relationship
Definition

The relationship of beneficiary (patient) to the subscriber.

Control0..0
BindingThe relationship between the Policyholder and the Beneficiary (insured/covered party/patient).
For example codes, see PolicyholderRelationshipCodes
TypeCodeableConcept
Requirements

To determine relationship between the patient and the subscriber.

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.

Control0..1
TypePeriod
Must Supporttrue
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).

Control0..*
TypeReference(CRD Deidentified Patient | CRD Organization)
Must Supporttrue
Requirements

Need to identify the issuer to target for processing and for coordination of benefit processing.

Coverage.class
Definition

A suite of underwrite specific classifiers, for example may be used to identify a class of coverage or employer group, Policy, Plan.

Control0..1
TypeBackboneElement
Must Supporttrue
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
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.

Control0..1
Typestring
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.

Control0..*
TypeExtension
Alternate Namesextensions, 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.

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. 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).

Control0..*
TypeExtension
Is Modifiertrue
Alternate Namesextensions, 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.

Coverage.class.type
Definition

The type of classification for which an insurer-specific class tag or number and optional name is provided, for example may be used to identify a class of coverage or employer group, Policy, Plan.

Control1..1
BindingThe policy classifications, eg. Group, Plan, Class, etc.
The codes SHALL be taken from CoverageClassCodes; other codes may be used where these codes are not suitable
TypeCoding
Must Supporttrue
Fixed Value<valueCoding xmlns="http://hl7.org/fhir">
  <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
  <code value="plan"/>
</valueCoding>
Coverage.class.value
Definition

For example, the Group or Plan number.

Control1..1
Typestring
Must Supporttrue
Coverage.class.name
Definition

A short description for the class.

Control0..1
Typestring
Must Supporttrue
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.

Control0..0
TypepositiveInt
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.

Control0..0
Typestring
Coverage.copay
Definition

A suite of underwrite specific classifiers, for example may be used to identify a class of coverage or employer group, Policy, Plan.

Control0..0
TypeBackboneElement
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
Coverage.copay.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
Coverage.copay.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.

Control0..*
TypeExtension
Alternate Namesextensions, 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.

Coverage.copay.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. 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).

Control0..*
TypeExtension
Is Modifiertrue
Alternate Namesextensions, 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.

Coverage.copay.type
Definition

Types of products or services such as visit, specialist visits, emergency, inpatient care, etc.

Control0..1
BindingThe tytpes 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
TypeCoding
Coverage.copay.value
Definition

The amount of patient payments for various types of services/products, expressed as a percentage of the service/product cost or a fixed amount of currency.

Control1..1
TypeQuantity
Coverage.contract
Definition

The policy(s) which constitute this insurance coverage.

Control0..0
TypeReference(Contract)