Da Vinci - Coverage Requirements Discovery
1.1.0-ballot - STU 1.1 US

This page is part of the Da Vinci Coverage Requirements Discovery (CRD) FHIR IG (v1.1.0-ballot: STU 1.1 Ballot 1) based on FHIR R4. The current version which supercedes this version is 1.0.0. For a full list of available versions, see the Directory of published versions

Resource Profile: Coverage

Official URL: http://hl7.org/fhir/us/davinci-crd/StructureDefinition/profile-coverage Version: 1.1.0-ballot
Draft as of 2018-07-25 Computable Name: Coverage

This profile specifies constraints on the Coverage resource to support coverage requirements discovery.

Usage


CRD Clients SHALL use this profile to resolve references to insurance Coverage resources passed to CRD Services.

Information provided in Must Support elements will commonly be required for CRD Services to perform coverage requirements discovery.

Formal Views of Profile Content

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

This structure is derived from Coverage

Summary

Mandatory: 0 element (1 nested mandatory element)
Must-Support: 17 elements
Prohibited: 1 element

Structures

This structure refers to these other structures:

This structure is derived from Coverage

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..*CoverageInsurance or medical plan or a payment agreement
... identifier S0..*IdentifierBusiness Identifier for the coverage
... status S1..1codeactive | cancelled | draft | entered-in-error
... type S0..1CodeableConceptCoverage category such as medical or accident
... subscriber S0..1Reference(Patient)Subscriber to the policy
... subscriberId S0..1stringID assigned to the subscriber
... beneficiary S1..1Reference(Patient)Plan beneficiary
... dependent S0..1stringDependent number
... relationship S0..1CodeableConceptBeneficiary relationship to the subscriber
... period S0..1PeriodCoverage start and end dates
... payor S1..*Reference(Patient | Organization)Issuer of the policy
... class S0..1BackboneElementAdditional coverage classifications
.... type S1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CRD Coverage Classes (required): CRD Coverage Classes

.... value S1..1stringValue associated with the type
.... name S0..1stringHuman readable description of the type and value
... order S0..1positiveIntRelative order of the coverage
... network S0..1stringInsurer network
... costToBeneficiary 0..0

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..*CoverageInsurance or medical plan or a payment agreement
... id Σ0..1stringLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier SΣ0..*IdentifierBusiness Identifier for the coverage
... status ?!SΣ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... type SΣ0..1CodeableConceptCoverage category such as medical or accident
Binding: CoverageTypeAndSelf-PayCodes (preferred): The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization.

... policyHolder SΣ0..1Reference(Patient | Organization)Owner of the policy
... subscriber SΣ0..1Reference(Patient)Subscriber to the policy
... subscriberId SΣ0..1stringID assigned to the subscriber
... beneficiary SΣ1..1Reference(Patient)Plan beneficiary
... dependent SΣ0..1stringDependent number
... relationship S0..1CodeableConceptBeneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).

... period SΣ0..1PeriodCoverage start and end dates
... payor SΣ1..*Reference(Patient | Organization)Issuer of the policy
... class S0..1BackboneElementAdditional coverage classifications
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type SΣ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CRD Coverage Classes (required): CRD Coverage Classes

.... value SΣ1..1stringValue associated with the type
.... name SΣ0..1stringHuman readable description of the type and value
... order SΣ0..1positiveIntRelative order of the coverage
... network SΣ0..1stringInsurer network
... subrogation 0..1booleanReimbursement to insurer
... contract 0..*Reference(Contract)Contract details

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..*CoverageInsurance or medical plan or a payment agreement
... identifier Σ0..*IdentifierBusiness Identifier for the coverage
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... type Σ0..1CodeableConceptCoverage category such as medical or accident
Binding: CoverageTypeAndSelf-PayCodes (preferred): The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization.

... subscriber Σ0..1Reference(Patient)Subscriber to the policy
... subscriberId Σ0..1stringID assigned to the subscriber
... beneficiary Σ1..1Reference(Patient)Plan beneficiary
... dependent Σ0..1stringDependent number
... relationship 0..1CodeableConceptBeneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).

... period Σ0..1PeriodCoverage start and end dates
... payor Σ1..*Reference(Patient | Organization)Issuer of the policy
... class 0..1BackboneElementAdditional coverage classifications
.... type Σ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CRD Coverage Classes (required): CRD Coverage Classes

.... value Σ1..1stringValue associated with the type
.... name Σ0..1stringHuman readable description of the type and value
... order Σ0..1positiveIntRelative order of the coverage
... network Σ0..1stringInsurer network

doco Documentation for this format

This structure is derived from Coverage

Summary

Mandatory: 0 element (1 nested mandatory element)
Must-Support: 17 elements
Prohibited: 1 element

Structures

This structure refers to these other structures:

Differential View

This structure is derived from Coverage

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..*CoverageInsurance or medical plan or a payment agreement
... identifier S0..*IdentifierBusiness Identifier for the coverage
... status S1..1codeactive | cancelled | draft | entered-in-error
... type S0..1CodeableConceptCoverage category such as medical or accident
... subscriber S0..1Reference(Patient)Subscriber to the policy
... subscriberId S0..1stringID assigned to the subscriber
... beneficiary S1..1Reference(Patient)Plan beneficiary
... dependent S0..1stringDependent number
... relationship S0..1CodeableConceptBeneficiary relationship to the subscriber
... period S0..1PeriodCoverage start and end dates
... payor S1..*Reference(Patient | Organization)Issuer of the policy
... class S0..1BackboneElementAdditional coverage classifications
.... type S1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CRD Coverage Classes (required): CRD Coverage Classes

.... value S1..1stringValue associated with the type
.... name S0..1stringHuman readable description of the type and value
... order S0..1positiveIntRelative order of the coverage
... network S0..1stringInsurer network
... costToBeneficiary 0..0

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..*CoverageInsurance or medical plan or a payment agreement
... id Σ0..1stringLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier SΣ0..*IdentifierBusiness Identifier for the coverage
... status ?!SΣ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... type SΣ0..1CodeableConceptCoverage category such as medical or accident
Binding: CoverageTypeAndSelf-PayCodes (preferred): The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization.

... policyHolder SΣ0..1Reference(Patient | Organization)Owner of the policy
... subscriber SΣ0..1Reference(Patient)Subscriber to the policy
... subscriberId SΣ0..1stringID assigned to the subscriber
... beneficiary SΣ1..1Reference(Patient)Plan beneficiary
... dependent SΣ0..1stringDependent number
... relationship S0..1CodeableConceptBeneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).

... period SΣ0..1PeriodCoverage start and end dates
... payor SΣ1..*Reference(Patient | Organization)Issuer of the policy
... class S0..1BackboneElementAdditional coverage classifications
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type SΣ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CRD Coverage Classes (required): CRD Coverage Classes

.... value SΣ1..1stringValue associated with the type
.... name SΣ0..1stringHuman readable description of the type and value
... order SΣ0..1positiveIntRelative order of the coverage
... network SΣ0..1stringInsurer network
... subrogation 0..1booleanReimbursement to insurer
... contract 0..*Reference(Contract)Contract details

doco Documentation for this format

 

Other representations of profile: CSV, Excel, Schematron

Terminology Bindings

PathConformanceValueSet
Coverage.languagepreferredCommonLanguages
Max Binding: AllLanguages
Coverage.statusrequiredFinancialResourceStatusCodes
Coverage.typepreferredCoverageTypeAndSelf-PayCodes
Coverage.relationshipextensibleSubscriberRelationshipCodes
Coverage.class.typerequiredCRDCoverageClasses
Coverage.costToBeneficiary.typeextensibleCoverageCopayTypeCodes
Coverage.costToBeneficiary.exception.typeexampleExampleCoverageFinancialExceptionCodes

Constraints

IdGradePathDetailsRequirements
dom-2errorCoverageIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorCoverageIf 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-4errorCoverageIf 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-5errorCoverageIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6Best PracticeCoverageA resource should have narrative for robust management
: text.`div`.exists()
ele-1errorCoverage.metaAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.implicitRulesAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.languageAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.textAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1errorCoverage.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1errorCoverage.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1errorCoverage.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1errorCoverage.identifierAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.statusAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.typeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.policyHolderAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.subscriberAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.subscriberIdAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.beneficiaryAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.dependentAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.relationshipAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.periodAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.payorAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.classAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.class.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1errorCoverage.class.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1errorCoverage.class.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1errorCoverage.class.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1errorCoverage.class.typeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.class.valueAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.class.nameAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.orderAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.networkAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.costToBeneficiary.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1errorCoverage.costToBeneficiary.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1errorCoverage.costToBeneficiary.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1errorCoverage.costToBeneficiary.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1errorCoverage.costToBeneficiary.typeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.costToBeneficiary.value[x]All FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.costToBeneficiary.exceptionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.costToBeneficiary.exception.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1errorCoverage.costToBeneficiary.exception.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1errorCoverage.costToBeneficiary.exception.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1errorCoverage.costToBeneficiary.exception.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1errorCoverage.costToBeneficiary.exception.typeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.costToBeneficiary.exception.periodAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.subrogationAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCoverage.contractAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())