Data Exchange For Quality Measures STU1 for FHIR STU3 Implementation Guide (Release 1.0.0)

This page is part of the Da Vinci Data Exchange for Quality Measures (DEQM) FHIR IG (v1.0.0: STU 1) based on FHIR R3. The current version which supercedes this version is 3.1.0. For a full list of available versions, see the Directory of published versions

StructureDefinition-coverage-deqm

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 for which the MRP was performed

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

Each Coverage should have (Must Support):

  1. The beneficiary

Additional Profile specific implementation guidance:

None

Examples

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

    • Formal Views of Profile Content

    Description of Profiles, Differentials, and Snapshots.

    The official URL for this profile is: http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/coverage-deqm

    Published on Tue Jun 19 00:00:00 UTC 2018 as active by Da Vinci Project.

    This profile builds on QICore-Coverage

    Summary

    Mandatory: 1 element
    Must-Support: 2 elements

    Structures

    This structure refers to these other structures:

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Coverage I0..*QICore-CoverageInsurance or medical plan or a payment agreement
    ... id Σ0..1idLogical id of this artifact
    ... meta Σ0..1MetaMetadata about the resource
    ... implicitRules ?!Σ0..1uriA set of rules under which this content was created
    ... language 0..1codeLanguage of the resource content
    Binding: Common Languages (extensible)
    Max Binding: All Languages
    ... text I0..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 Σ0..*IdentifierThe primary coverage ID
    ... status ?!Σ0..1codeactive | cancelled | draft | entered-in-error
    Binding: Financial Resource Status Codes (required)
    ... type Σ0..1CodeableConceptType of coverage such as medical or accident
    Binding: https://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 (required)
    ... policyHolder SΣ0..1Reference(QICore-Patient | QICore-Organization | QICore-RelatedPerson)Owner of the policy
    ... subscriber Σ0..1Reference(Patient | RelatedPerson)Subscriber to the policy
    ... subscriberId SΣ1..1stringSubscriber ID
    ... beneficiary SΣ0..1Reference(QICore-Patient)Plan Beneficiary
    ... relationship 0..1CodeableConceptBeneficiary relationship to the Subscriber
    Binding: Policyholder Relationship Codes (example)
    ... period Σ0..1PeriodCoverage start and end dates
    ... payor SΣ0..*Reference(QICore-Patient | QICore-Organization | QICore-RelatedPerson)Identifier for the plan or agreement issuer
    ... grouping I0..1BackboneElementAdditional coverage classifications
    .... id 0..1stringxml:id (or equivalent in JSON)
    .... extension 0..*ExtensionAdditional Content defined by implementations
    .... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
    .... group Σ0..1stringAn identifier for the group
    .... groupDisplay Σ0..1stringDisplay text for an identifier for the group
    .... subGroup Σ0..1stringAn identifier for the subsection of the group
    .... subGroupDisplay Σ0..1stringDisplay text for the subsection of the group
    .... plan Σ0..1stringAn identifier for the plan
    .... planDisplay Σ0..1stringDisplay text for the plan
    .... subPlan Σ0..1stringAn identifier for the subsection of the plan
    .... subPlanDisplay Σ0..1stringDisplay text for the subsection of the plan
    .... class Σ0..1stringAn identifier for the class
    .... classDisplay Σ0..1stringDisplay text for the class
    .... subClass Σ0..1stringAn identifier for the subsection of the class
    .... subClassDisplay Σ0..1stringDisplay text for the subsection of the subclass
    ... dependent Σ0..1stringDependent number
    ... sequence Σ0..1stringThe plan instance or sequence counter
    ... order Σ0..1positiveIntRelative order of the coverage
    ... network Σ0..1stringInsurer network
    ... contract 0..*Reference(Contract)Contract details

    doco Documentation for this format

    Summary

    Mandatory: 1 element
    Must-Support: 2 elements

    Structures

    This structure refers to these other structures:

    Snapshot View

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Coverage I0..*QICore-CoverageInsurance or medical plan or a payment agreement
    ... id Σ0..1idLogical id of this artifact
    ... meta Σ0..1MetaMetadata about the resource
    ... implicitRules ?!Σ0..1uriA set of rules under which this content was created
    ... language 0..1codeLanguage of the resource content
    Binding: Common Languages (extensible)
    Max Binding: All Languages
    ... text I0..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 Σ0..*IdentifierThe primary coverage ID
    ... status ?!Σ0..1codeactive | cancelled | draft | entered-in-error
    Binding: Financial Resource Status Codes (required)
    ... type Σ0..1CodeableConceptType of coverage such as medical or accident
    Binding: https://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 (required)
    ... policyHolder SΣ0..1Reference(QICore-Patient | QICore-Organization | QICore-RelatedPerson)Owner of the policy
    ... subscriber Σ0..1Reference(Patient | RelatedPerson)Subscriber to the policy
    ... subscriberId SΣ1..1stringSubscriber ID
    ... beneficiary SΣ0..1Reference(QICore-Patient)Plan Beneficiary
    ... relationship 0..1CodeableConceptBeneficiary relationship to the Subscriber
    Binding: Policyholder Relationship Codes (example)
    ... period Σ0..1PeriodCoverage start and end dates
    ... payor SΣ0..*Reference(QICore-Patient | QICore-Organization | QICore-RelatedPerson)Identifier for the plan or agreement issuer
    ... grouping I0..1BackboneElementAdditional coverage classifications
    .... id 0..1stringxml:id (or equivalent in JSON)
    .... extension 0..*ExtensionAdditional Content defined by implementations
    .... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
    .... group Σ0..1stringAn identifier for the group
    .... groupDisplay Σ0..1stringDisplay text for an identifier for the group
    .... subGroup Σ0..1stringAn identifier for the subsection of the group
    .... subGroupDisplay Σ0..1stringDisplay text for the subsection of the group
    .... plan Σ0..1stringAn identifier for the plan
    .... planDisplay Σ0..1stringDisplay text for the plan
    .... subPlan Σ0..1stringAn identifier for the subsection of the plan
    .... subPlanDisplay Σ0..1stringDisplay text for the subsection of the plan
    .... class Σ0..1stringAn identifier for the class
    .... classDisplay Σ0..1stringDisplay text for the class
    .... subClass Σ0..1stringAn identifier for the subsection of the class
    .... subClassDisplay Σ0..1stringDisplay text for the subsection of the subclass
    ... dependent Σ0..1stringDependent number
    ... sequence Σ0..1stringThe plan instance or sequence counter
    ... order Σ0..1positiveIntRelative order of the coverage
    ... network Σ0..1stringInsurer network
    ... contract 0..*Reference(Contract)Contract details

    doco Documentation for this format

    Downloads: StructureDefinition: (XML, JSON), Schema: XML Schematron


    Quick Start

    Below is an overview of the required set of RESTful FHIR interactions - for example, search and read operations - for this profile. See the Conformance requirements for a complete list of supported RESTful interactions for this IG.

    Use cases: