Data Exchange For Quality Measures STU3 for FHIR R4
2.1.0 - Ballot

This page is part of the Da Vinci Data Exchange for Quality Measures (DEQM) FHIR IG (v2.1.0: STU 3) based on FHIR R4. The current version which supercedes this version is 3.1.0. For a full list of available versions, see the Directory of published versions

Resource Profile: DEQMCoverageProfile

The DEQM Coverage Profile defines the constraints for representing the subscriber information to the Payer. This along with the patient first name, last name, date of birth and gender allows the payer to identify the member in their system.

The official URL for this profile is: 

http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/coverage-deqm

Mandatory Data Elements and Terminology

The following data-elements are mandatory (i.e data MUST be present).

Each Coverage must have:

  1. A subscriber ID

Additional Profile specific implementation guidance:

None

Examples

  • Coverage/coverage01
  • Coverage/coverage02
  • Coverage/coverage03

    • Formal Views of Profile Content

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

    This structure is derived from QICoreCoverage

    Summary

    Mandatory: 1 element
    Must-Support: 1 element

    This structure is derived from QICoreCoverage

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Coverage I0..*QICoreCoverageInsurance or medical plan or a payment agreement
    ... id Σ0..1stringLogical id of this artifact
    ... meta ΣI0..1MetaMetadata about the resource
    ... implicitRules ?!ΣI0..1uriA set of rules under which this content was created
    ... language I0..1codeLanguage of the resource content
    Binding: CommonLanguages (preferred)
    Max Binding: AllLanguages
    ... text I0..1NarrativeText summary of the resource, for human interpretation
    ... contained 0..*ResourceContained, inline Resources
    ... extension I0..*ExtensionAdditional content defined by implementations
    ... modifierExtension ?!I0..*ExtensionExtensions that cannot be ignored
    ... identifier ΣI0..*IdentifierBusiness Identifier for the coverage
    ... status ?!ΣI1..1codeactive | cancelled | draft | entered-in-error
    Binding: FinancialResourceStatusCodes (required)
    ... type ΣI0..1CodeableConceptCoverage category such as medical or accident
    Binding: https://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 (required)
    ... policyHolder SΣI0..1Reference(QICorePatient | QICoreOrganization | QICoreRelatedPerson)Owner of the policy
    ... subscriber ΣI0..1Reference(Patient | RelatedPerson)Subscriber to the policy
    ... subscriberId SΣI1..1stringSubscriber ID
    ... beneficiary SΣI1..1Reference(QICorePatient)Plan beneficiary
    ... dependent ΣI0..1stringDependent number
    ... relationship I0..1CodeableConceptBeneficiary relationship to the subscriber
    Binding: SubscriberRelationshipCodes (extensible)
    ... period ΣI0..1PeriodCoverage start and end dates
    ... payor SΣI1..*Reference(QICorePatient | QICoreOrganization | QICoreRelatedPerson)Issuer of the policy
    ... class I0..*BackboneElementAdditional coverage classifications
    .... id 0..1stringUnique id for inter-element referencing
    .... extension I0..*ExtensionAdditional content defined by implementations
    .... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
    .... type ΣI1..1CodeableConceptType of class such as 'group' or 'plan'
    Binding: CoverageClassCodes (extensible)
    .... value ΣI1..1stringValue associated with the type
    .... name ΣI0..1stringHuman readable description of the type and value
    ... order ΣI0..1positiveIntRelative order of the coverage
    ... network ΣI0..1stringInsurer network
    ... costToBeneficiary I0..*BackboneElementPatient payments for services/products
    .... id 0..1stringUnique id for inter-element referencing
    .... extension I0..*ExtensionAdditional content defined by implementations
    .... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
    .... type ΣI0..1CodeableConceptCost category
    Binding: CoverageCopayTypeCodes (extensible)
    .... value[x] ΣI1..1The amount or percentage due from the beneficiary
    ..... valueQuantityQuantity(SimpleQuantity)
    ..... valueMoneyMoney
    .... exception I0..*BackboneElementExceptions for patient payments
    ..... id 0..1stringUnique id for inter-element referencing
    ..... extension I0..*ExtensionAdditional content defined by implementations
    ..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
    ..... type ΣI1..1CodeableConceptException category
    Binding: ExampleCoverageFinancialExceptionCodes (example)
    ..... period ΣI0..1PeriodThe effective period of the exception
    ... subrogation I0..1booleanReimbursement to insurer
    ... contract I0..*Reference(Contract)Contract details

    doco Documentation for this format

    This structure is derived from QICoreCoverage

    Summary

    Mandatory: 1 element
    Must-Support: 1 element

    Differential View

    This structure is derived from QICoreCoverage

    Snapshot View

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Coverage I0..*QICoreCoverageInsurance or medical plan or a payment agreement
    ... id Σ0..1stringLogical id of this artifact
    ... meta ΣI0..1MetaMetadata about the resource
    ... implicitRules ?!ΣI0..1uriA set of rules under which this content was created
    ... language I0..1codeLanguage of the resource content
    Binding: CommonLanguages (preferred)
    Max Binding: AllLanguages
    ... text I0..1NarrativeText summary of the resource, for human interpretation
    ... contained 0..*ResourceContained, inline Resources
    ... extension I0..*ExtensionAdditional content defined by implementations
    ... modifierExtension ?!I0..*ExtensionExtensions that cannot be ignored
    ... identifier ΣI0..*IdentifierBusiness Identifier for the coverage
    ... status ?!ΣI1..1codeactive | cancelled | draft | entered-in-error
    Binding: FinancialResourceStatusCodes (required)
    ... type ΣI0..1CodeableConceptCoverage category such as medical or accident
    Binding: https://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 (required)
    ... policyHolder SΣI0..1Reference(QICorePatient | QICoreOrganization | QICoreRelatedPerson)Owner of the policy
    ... subscriber ΣI0..1Reference(Patient | RelatedPerson)Subscriber to the policy
    ... subscriberId SΣI1..1stringSubscriber ID
    ... beneficiary SΣI1..1Reference(QICorePatient)Plan beneficiary
    ... dependent ΣI0..1stringDependent number
    ... relationship I0..1CodeableConceptBeneficiary relationship to the subscriber
    Binding: SubscriberRelationshipCodes (extensible)
    ... period ΣI0..1PeriodCoverage start and end dates
    ... payor SΣI1..*Reference(QICorePatient | QICoreOrganization | QICoreRelatedPerson)Issuer of the policy
    ... class I0..*BackboneElementAdditional coverage classifications
    .... id 0..1stringUnique id for inter-element referencing
    .... extension I0..*ExtensionAdditional content defined by implementations
    .... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
    .... type ΣI1..1CodeableConceptType of class such as 'group' or 'plan'
    Binding: CoverageClassCodes (extensible)
    .... value ΣI1..1stringValue associated with the type
    .... name ΣI0..1stringHuman readable description of the type and value
    ... order ΣI0..1positiveIntRelative order of the coverage
    ... network ΣI0..1stringInsurer network
    ... costToBeneficiary I0..*BackboneElementPatient payments for services/products
    .... id 0..1stringUnique id for inter-element referencing
    .... extension I0..*ExtensionAdditional content defined by implementations
    .... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
    .... type ΣI0..1CodeableConceptCost category
    Binding: CoverageCopayTypeCodes (extensible)
    .... value[x] ΣI1..1The amount or percentage due from the beneficiary
    ..... valueQuantityQuantity(SimpleQuantity)
    ..... valueMoneyMoney
    .... exception I0..*BackboneElementExceptions for patient payments
    ..... id 0..1stringUnique id for inter-element referencing
    ..... extension I0..*ExtensionAdditional content defined by implementations
    ..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
    ..... type ΣI1..1CodeableConceptException category
    Binding: ExampleCoverageFinancialExceptionCodes (example)
    ..... period ΣI0..1PeriodThe effective period of the exception
    ... subrogation I0..1booleanReimbursement to insurer
    ... contract I0..*Reference(Contract)Contract details

    doco Documentation for this format

     

    Other representations of profile: Schematron

    Terminology Bindings

    PathConformanceValueSet
    Coverage.languagepreferredCommonLanguages
    Max Binding: AllLanguages
    Coverage.statusrequiredFinancialResourceStatusCodes
    Coverage.typerequiredhttps://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591
    Coverage.relationshipextensibleSubscriberRelationshipCodes
    Coverage.class.typeextensibleCoverageClassCodes
    Coverage.costToBeneficiary.typeextensibleCoverageCopayTypeCodes
    Coverage.costToBeneficiary.exception.typeexampleExampleCoverageFinancialExceptionCodes

    Notes:

    This profile is used in the following transactions: