Da Vinci - Coverage Requirements Discovery
2.1.0 - STU 2.1 United States of America flag

This page is part of the Da Vinci Coverage Requirements Discovery (CRD) FHIR IG (v2.1.0: STU 2.1) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions

Resource Profile: CRD Coverage

Official URL: http://hl7.org/fhir/us/davinci-crd/StructureDefinition/profile-coverage Version: 2.1.0
Standards status: Trial-use Maturity Level: 3 Computable Name: CRDCoverage
Other Identifiers: OID:2.16.840.1.113883.4.642.40.18.42.7

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 Servers.

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

Usage:

Formal Views of Profile Content

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

This structure is derived from USCoreCoverageProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..* USCoreCoverageProfile(7.0.0) Insurance or medical plan or a payment agreement
This profile also complies with the profile US Core Coverage Profile (6.1.0)
... policyHolder S 0..1 Reference(CRD Patient | CRD Organization) Owner of the policy
... subscriber S 0..1 Reference(CRD Patient) Subscriber to the policy
... beneficiary 1..1 Reference(CRD Patient) Plan beneficiary
... payor 1..1 Reference(CRD Patient | CRD Organization) Issuer of the policy
... order S 0..1 positiveInt Relative order of the coverage
... network S 0..1 string Insurer network
... costToBeneficiary 0..0

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage C 0..* USCoreCoverageProfile(7.0.0) Insurance or medical plan or a payment agreement
This profile also complies with the profile US Core Coverage Profile (6.1.0)
dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
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
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
dom-6: A resource should have narrative for robust management
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
ele-1: All FHIR elements must have a @value or children
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
... Slices for identifier SΣ 0..* Identifier Member ID and other identifiers
Slice: Unordered, Open by pattern:type
ele-1: All FHIR elements must have a @value or children
.... identifier:memberid SΣC 0..1 Identifier Member ID
ele-1: All FHIR elements must have a @value or children
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .


ele-1: All FHIR elements must have a @value or children
..... type SΣ 1..1 CodeableConcept 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.


ele-1: All FHIR elements must have a @value or children
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
... type SΣ 0..1 CodeableConcept Coverage category such as medical or accident
Binding: Payer Type . (extensible): US Public Health Data Consortium Source of Payment Codes


ele-1: All FHIR elements must have a @value or children
... policyHolder SΣ 0..1 Reference(CRD Patient | CRD Organization) Owner of the policy
ele-1: All FHIR elements must have a @value or children
... subscriber SΣ 0..1 Reference(CRD Patient) Subscriber to the policy
ele-1: All FHIR elements must have a @value or children
... subscriberId SΣC 0..1 string ID assigned to the subscriber
ele-1: All FHIR elements must have a @value or children
... beneficiary SΣ 1..1 Reference(CRD Patient) Plan beneficiary
ele-1: All FHIR elements must have a @value or children
... dependent SΣ 0..1 string Dependent number
ele-1: All FHIR elements must have a @value or children
... relationship S 1..1 CodeableConcept Beneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible)
ele-1: All FHIR elements must have a @value or children
... period SΣ 0..1 Period Coverage start and end dates
ele-1: All FHIR elements must have a @value or children
... payor SΣ 1..1 Reference(CRD Patient | CRD Organization) Issuer of the policy
ele-1: All FHIR elements must have a @value or children
... Slices for class S 0..* BackboneElement Additional coverage classifications
Slice: Unordered, Open by pattern:type
ele-1: All FHIR elements must have a @value or children
.... class:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... type Σ 1..1 CodeableConcept Type of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.


ele-1: All FHIR elements must have a @value or children
..... value Σ 1..1 string Value associated with the type
ele-1: All FHIR elements must have a @value or children
.... class:group S 0..1 BackboneElement Group
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... type Σ 1..1 CodeableConcept Type of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.


ele-1: All FHIR elements must have a @value or children
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 Group Number
ele-1: All FHIR elements must have a @value or children
..... name SΣ 0..1 string Group Name
ele-1: All FHIR elements must have a @value or children
.... class:plan S 0..1 BackboneElement Plan
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... type Σ 1..1 CodeableConcept Type of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.


ele-1: All FHIR elements must have a @value or children
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 Plan Number
ele-1: All FHIR elements must have a @value or children
..... name SΣ 0..1 string Plan Name
ele-1: All FHIR elements must have a @value or children
... order SΣ 0..1 positiveInt Relative order of the coverage
ele-1: All FHIR elements must have a @value or children
... network SΣ 0..1 string Insurer network
ele-1: All FHIR elements must have a @value or children

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Coverage.identifier:memberid.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
Coverage.identifier:memberid.typeextensiblePattern: MB
http://hl7.org/fhir/ValueSet/identifier-type
from the FHIR Standard
Coverage.statusrequiredFinancialResourceStatusCodes
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
from the FHIR Standard
Coverage.typeextensiblePayerType . (a valid code from Source of Payment Typology (https://nahdo.org/sopt)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591
Coverage.relationshipextensibleSubscriberRelationshipCodes
http://hl7.org/fhir/ValueSet/subscriber-relationship
from the FHIR Standard
Coverage.class.typeextensibleCoverageClassCodes
http://hl7.org/fhir/ValueSet/coverage-class
from the FHIR Standard
Coverage.class:group.typeextensiblePattern: group
http://hl7.org/fhir/ValueSet/coverage-class
from the FHIR Standard
Coverage.class:plan.typeextensiblePattern: plan
http://hl7.org/fhir/ValueSet/coverage-class
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
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-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
us-core-15errorCoverageMember 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()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage C 0..* USCoreCoverageProfile(7.0.0) Insurance or medical plan or a payment agreement
This profile also complies with the profile US Core Coverage Profile (6.1.0)
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
... 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 Member ID and other identifiers
Slice: Unordered, Open by pattern:type
.... identifier:memberid SΣC 0..1 Identifier 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 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 active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... type SΣ 0..1 CodeableConcept Coverage category such as medical or accident
Binding: Payer Type . (extensible): US Public Health Data Consortium Source of Payment Codes

... policyHolder SΣ 0..1 Reference(CRD Patient | CRD Organization) Owner of the policy
... subscriber SΣ 0..1 Reference(CRD Patient) Subscriber to the policy
... subscriberId SΣC 0..1 string ID assigned to the subscriber
... beneficiary SΣ 1..1 Reference(CRD Patient) Plan beneficiary
... dependent SΣ 0..1 string Dependent number
... relationship S 1..1 CodeableConcept Beneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible)
... period SΣ 0..1 Period Coverage start and end dates
... payor SΣ 1..1 Reference(CRD Patient | CRD Organization) Issuer of the policy
... Slices for class S 0..* BackboneElement 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 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 Group Number
..... name SΣ 0..1 string Group Name
.... class:plan S 0..1 BackboneElement 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 Plan Number
..... name SΣ 0..1 string Plan Name
... order SΣ 0..1 positiveInt Relative order of the coverage
... network SΣ 0..1 string Insurer network
... subrogation 0..1 boolean Reimbursement to insurer
... contract 0..* Reference(Contract) Contract details

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Coverage.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
Coverage.identifier:memberid.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
Coverage.identifier:memberid.typeextensiblePattern: MB
http://hl7.org/fhir/ValueSet/identifier-type
from the FHIR Standard
Coverage.statusrequiredFinancialResourceStatusCodes
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
from the FHIR Standard
Coverage.typeextensiblePayerType . (a valid code from Source of Payment Typology (https://nahdo.org/sopt)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591
Coverage.relationshipextensibleSubscriberRelationshipCodes
http://hl7.org/fhir/ValueSet/subscriber-relationship
from the FHIR Standard
Coverage.class.typeextensibleCoverageClassCodes
http://hl7.org/fhir/ValueSet/coverage-class
from the FHIR Standard
Coverage.class:group.typeextensiblePattern: group
http://hl7.org/fhir/ValueSet/coverage-class
from the FHIR Standard
Coverage.class:plan.typeextensiblePattern: plan
http://hl7.org/fhir/ValueSet/coverage-class
from the FHIR Standard
Coverage.costToBeneficiary.typeextensibleCoverageCopayTypeCodes
http://hl7.org/fhir/ValueSet/coverage-copay-type
from the FHIR Standard
Coverage.costToBeneficiary.exception.typeexampleExampleCoverageFinancialExceptionCodes
http://hl7.org/fhir/ValueSet/coverage-financial-exception
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
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-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
us-core-15errorCoverageMember 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()

This structure is derived from USCoreCoverageProfile

Differential View

This structure is derived from USCoreCoverageProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..* USCoreCoverageProfile(7.0.0) Insurance or medical plan or a payment agreement
This profile also complies with the profile US Core Coverage Profile (6.1.0)
... policyHolder S 0..1 Reference(CRD Patient | CRD Organization) Owner of the policy
... subscriber S 0..1 Reference(CRD Patient) Subscriber to the policy
... beneficiary 1..1 Reference(CRD Patient) Plan beneficiary
... payor 1..1 Reference(CRD Patient | CRD Organization) Issuer of the policy
... order S 0..1 positiveInt Relative order of the coverage
... network S 0..1 string Insurer network
... costToBeneficiary 0..0

doco Documentation for this format

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage C 0..* USCoreCoverageProfile(7.0.0) Insurance or medical plan or a payment agreement
This profile also complies with the profile US Core Coverage Profile (6.1.0)
dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
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
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
dom-6: A resource should have narrative for robust management
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
ele-1: All FHIR elements must have a @value or children
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
... Slices for identifier SΣ 0..* Identifier Member ID and other identifiers
Slice: Unordered, Open by pattern:type
ele-1: All FHIR elements must have a @value or children
.... identifier:memberid SΣC 0..1 Identifier Member ID
ele-1: All FHIR elements must have a @value or children
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .


ele-1: All FHIR elements must have a @value or children
..... type SΣ 1..1 CodeableConcept 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.


ele-1: All FHIR elements must have a @value or children
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
... type SΣ 0..1 CodeableConcept Coverage category such as medical or accident
Binding: Payer Type . (extensible): US Public Health Data Consortium Source of Payment Codes


ele-1: All FHIR elements must have a @value or children
... policyHolder SΣ 0..1 Reference(CRD Patient | CRD Organization) Owner of the policy
ele-1: All FHIR elements must have a @value or children
... subscriber SΣ 0..1 Reference(CRD Patient) Subscriber to the policy
ele-1: All FHIR elements must have a @value or children
... subscriberId SΣC 0..1 string ID assigned to the subscriber
ele-1: All FHIR elements must have a @value or children
... beneficiary SΣ 1..1 Reference(CRD Patient) Plan beneficiary
ele-1: All FHIR elements must have a @value or children
... dependent SΣ 0..1 string Dependent number
ele-1: All FHIR elements must have a @value or children
... relationship S 1..1 CodeableConcept Beneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible)
ele-1: All FHIR elements must have a @value or children
... period SΣ 0..1 Period Coverage start and end dates
ele-1: All FHIR elements must have a @value or children
... payor SΣ 1..1 Reference(CRD Patient | CRD Organization) Issuer of the policy
ele-1: All FHIR elements must have a @value or children
... Slices for class S 0..* BackboneElement Additional coverage classifications
Slice: Unordered, Open by pattern:type
ele-1: All FHIR elements must have a @value or children
.... class:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... type Σ 1..1 CodeableConcept Type of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.


ele-1: All FHIR elements must have a @value or children
..... value Σ 1..1 string Value associated with the type
ele-1: All FHIR elements must have a @value or children
.... class:group S 0..1 BackboneElement Group
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... type Σ 1..1 CodeableConcept Type of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.


ele-1: All FHIR elements must have a @value or children
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 Group Number
ele-1: All FHIR elements must have a @value or children
..... name SΣ 0..1 string Group Name
ele-1: All FHIR elements must have a @value or children
.... class:plan S 0..1 BackboneElement Plan
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... type Σ 1..1 CodeableConcept Type of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.


ele-1: All FHIR elements must have a @value or children
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 Plan Number
ele-1: All FHIR elements must have a @value or children
..... name SΣ 0..1 string Plan Name
ele-1: All FHIR elements must have a @value or children
... order SΣ 0..1 positiveInt Relative order of the coverage
ele-1: All FHIR elements must have a @value or children
... network SΣ 0..1 string Insurer network
ele-1: All FHIR elements must have a @value or children

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Coverage.identifier:memberid.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
Coverage.identifier:memberid.typeextensiblePattern: MB
http://hl7.org/fhir/ValueSet/identifier-type
from the FHIR Standard
Coverage.statusrequiredFinancialResourceStatusCodes
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
from the FHIR Standard
Coverage.typeextensiblePayerType . (a valid code from Source of Payment Typology (https://nahdo.org/sopt)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591
Coverage.relationshipextensibleSubscriberRelationshipCodes
http://hl7.org/fhir/ValueSet/subscriber-relationship
from the FHIR Standard
Coverage.class.typeextensibleCoverageClassCodes
http://hl7.org/fhir/ValueSet/coverage-class
from the FHIR Standard
Coverage.class:group.typeextensiblePattern: group
http://hl7.org/fhir/ValueSet/coverage-class
from the FHIR Standard
Coverage.class:plan.typeextensiblePattern: plan
http://hl7.org/fhir/ValueSet/coverage-class
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
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-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
us-core-15errorCoverageMember 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

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage C 0..* USCoreCoverageProfile(7.0.0) Insurance or medical plan or a payment agreement
This profile also complies with the profile US Core Coverage Profile (6.1.0)
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
... 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 Member ID and other identifiers
Slice: Unordered, Open by pattern:type
.... identifier:memberid SΣC 0..1 Identifier 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 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 active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... type SΣ 0..1 CodeableConcept Coverage category such as medical or accident
Binding: Payer Type . (extensible): US Public Health Data Consortium Source of Payment Codes

... policyHolder SΣ 0..1 Reference(CRD Patient | CRD Organization) Owner of the policy
... subscriber SΣ 0..1 Reference(CRD Patient) Subscriber to the policy
... subscriberId SΣC 0..1 string ID assigned to the subscriber
... beneficiary SΣ 1..1 Reference(CRD Patient) Plan beneficiary
... dependent SΣ 0..1 string Dependent number
... relationship S 1..1 CodeableConcept Beneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible)
... period SΣ 0..1 Period Coverage start and end dates
... payor SΣ 1..1 Reference(CRD Patient | CRD Organization) Issuer of the policy
... Slices for class S 0..* BackboneElement 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 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 Group Number
..... name SΣ 0..1 string Group Name
.... class:plan S 0..1 BackboneElement 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 Plan Number
..... name SΣ 0..1 string Plan Name
... order SΣ 0..1 positiveInt Relative order of the coverage
... network SΣ 0..1 string Insurer network
... subrogation 0..1 boolean Reimbursement to insurer
... contract 0..* Reference(Contract) Contract details

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Coverage.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
Coverage.identifier:memberid.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
Coverage.identifier:memberid.typeextensiblePattern: MB
http://hl7.org/fhir/ValueSet/identifier-type
from the FHIR Standard
Coverage.statusrequiredFinancialResourceStatusCodes
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
from the FHIR Standard
Coverage.typeextensiblePayerType . (a valid code from Source of Payment Typology (https://nahdo.org/sopt)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591
Coverage.relationshipextensibleSubscriberRelationshipCodes
http://hl7.org/fhir/ValueSet/subscriber-relationship
from the FHIR Standard
Coverage.class.typeextensibleCoverageClassCodes
http://hl7.org/fhir/ValueSet/coverage-class
from the FHIR Standard
Coverage.class:group.typeextensiblePattern: group
http://hl7.org/fhir/ValueSet/coverage-class
from the FHIR Standard
Coverage.class:plan.typeextensiblePattern: plan
http://hl7.org/fhir/ValueSet/coverage-class
from the FHIR Standard
Coverage.costToBeneficiary.typeextensibleCoverageCopayTypeCodes
http://hl7.org/fhir/ValueSet/coverage-copay-type
from the FHIR Standard
Coverage.costToBeneficiary.exception.typeexampleExampleCoverageFinancialExceptionCodes
http://hl7.org/fhir/ValueSet/coverage-financial-exception
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
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-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
us-core-15errorCoverageMember 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()

This structure is derived from USCoreCoverageProfile

 

Other representations of profile: CSV, Excel, Schematron