Data Exchange For Quality Measures Implementation Guide
3.1.0 - STU 3.1.0 US

This page is part of the Da Vinci Data Exchange for Quality Measures (DEQM) FHIR IG (v3.1.0: STU 3) based on FHIR R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

Resource Profile: DEQM Coverage Profile

Official URL: http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/coverage-deqm Version: 3.1.0
Active as of 2018-06-19 Computable Name: 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.

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

    • Usage:

    Formal Views of Profile Content

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

    This structure is derived from QICoreCoverage

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Coverage 0..*QICoreCoverageInsurance or medical plan or a payment agreement
    ... implicitRules ?!Σ0..1uriA set of rules under which this content was created
    ... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
    ... status ?!Σ1..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: https://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 (required): Categories of types of health care payor entities as defined by the US Public Health Data Consortium SOP code system

    ... policyHolder SΣ0..1Reference(QICorePatient | QICoreOrganization | QICoreRelatedPerson)Owner of the policy
    ... subscriberId SΣ1..1stringSubscriber ID
    ... beneficiary SΣ1..1Reference(QICorePatient)Plan beneficiary
    ... period SΣ0..1PeriodCoverage start and end dates
    ... payor SΣ1..*Reference(QICorePatient | QICoreOrganization | QICoreRelatedPerson)Issuer of the policy

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSet
    Coverage.statusrequiredFinancialResourceStatusCodes
    Coverage.typerequiredhttps://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591
    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Coverage 0..*QICoreCoverageInsurance 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: CommonLanguages (preferred): A human language.

    Additional BindingsPurpose
    AllLanguagesMax Binding
    ... 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 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 SΣ0..1CodeableConceptCoverage category such as medical or accident
    Binding: https://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 (required): Categories of types of health care payor entities as defined by the US Public Health Data Consortium SOP code system

    ... policyHolder SΣ0..1Reference(QICorePatient | QICoreOrganization | QICoreRelatedPerson)Owner of the policy
    ... subscriber Σ0..1Reference(Patient | RelatedPerson)Subscriber to the policy
    ... subscriberId SΣ1..1stringSubscriber ID
    ... beneficiary SΣ1..1Reference(QICorePatient)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 SΣ0..1PeriodCoverage start and end dates
    ... payor SΣ1..*Reference(QICorePatient | QICoreOrganization | QICoreRelatedPerson)Issuer of the policy
    ... class 0..*BackboneElementAdditional 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 Σ1..1CodeableConceptType of class such as 'group' or 'plan'
    Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.

    .... 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
    ... costToBeneficiary 0..*BackboneElementPatient payments for services/products
    .... 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 Σ0..1CodeableConceptCost category
    Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified.

    .... value[x] Σ1..1The amount or percentage due from the beneficiary
    ..... valueQuantityQuantity(SimpleQuantity)
    ..... valueMoneyMoney
    .... exception 0..*BackboneElementExceptions for patient payments
    ..... 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 Σ1..1CodeableConceptException category
    Binding: ExampleCoverageFinancialExceptionCodes (example): The types of exceptions from the part or full value of financial obligations such as copays.

    ..... period Σ0..1PeriodThe effective period of the exception
    ... subrogation 0..1booleanReimbursement to insurer
    ... contract 0..*Reference(Contract)Contract details

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSet
    Coverage.languagepreferredCommonLanguages
    Additional Bindings Purpose
    AllLanguages Max Binding
    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

    This structure is derived from QICoreCoverage

    Summary

    Mandatory: 1 element
    Must-Support: 1 element

    Differential View

    This structure is derived from QICoreCoverage

    Key Elements View

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Coverage 0..*QICoreCoverageInsurance or medical plan or a payment agreement
    ... implicitRules ?!Σ0..1uriA set of rules under which this content was created
    ... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
    ... status ?!Σ1..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: https://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 (required): Categories of types of health care payor entities as defined by the US Public Health Data Consortium SOP code system

    ... policyHolder SΣ0..1Reference(QICorePatient | QICoreOrganization | QICoreRelatedPerson)Owner of the policy
    ... subscriberId SΣ1..1stringSubscriber ID
    ... beneficiary SΣ1..1Reference(QICorePatient)Plan beneficiary
    ... period SΣ0..1PeriodCoverage start and end dates
    ... payor SΣ1..*Reference(QICorePatient | QICoreOrganization | QICoreRelatedPerson)Issuer of the policy

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSet
    Coverage.statusrequiredFinancialResourceStatusCodes
    Coverage.typerequiredhttps://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591

    Snapshot View

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Coverage 0..*QICoreCoverageInsurance 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: CommonLanguages (preferred): A human language.

    Additional BindingsPurpose
    AllLanguagesMax Binding
    ... 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 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 SΣ0..1CodeableConceptCoverage category such as medical or accident
    Binding: https://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 (required): Categories of types of health care payor entities as defined by the US Public Health Data Consortium SOP code system

    ... policyHolder SΣ0..1Reference(QICorePatient | QICoreOrganization | QICoreRelatedPerson)Owner of the policy
    ... subscriber Σ0..1Reference(Patient | RelatedPerson)Subscriber to the policy
    ... subscriberId SΣ1..1stringSubscriber ID
    ... beneficiary SΣ1..1Reference(QICorePatient)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 SΣ0..1PeriodCoverage start and end dates
    ... payor SΣ1..*Reference(QICorePatient | QICoreOrganization | QICoreRelatedPerson)Issuer of the policy
    ... class 0..*BackboneElementAdditional 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 Σ1..1CodeableConceptType of class such as 'group' or 'plan'
    Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.

    .... 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
    ... costToBeneficiary 0..*BackboneElementPatient payments for services/products
    .... 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 Σ0..1CodeableConceptCost category
    Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified.

    .... value[x] Σ1..1The amount or percentage due from the beneficiary
    ..... valueQuantityQuantity(SimpleQuantity)
    ..... valueMoneyMoney
    .... exception 0..*BackboneElementExceptions for patient payments
    ..... 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 Σ1..1CodeableConceptException category
    Binding: ExampleCoverageFinancialExceptionCodes (example): The types of exceptions from the part or full value of financial obligations such as copays.

    ..... period Σ0..1PeriodThe effective period of the exception
    ... subrogation 0..1booleanReimbursement to insurer
    ... contract 0..*Reference(Contract)Contract details

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSet
    Coverage.languagepreferredCommonLanguages
    Additional Bindings Purpose
    AllLanguages Max Binding
    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

    This structure is derived from QICoreCoverage

    Summary

    Mandatory: 1 element
    Must-Support: 1 element

     

    Other representations of profile: CSV, Excel, Schematron

    Notes:

    This profile is used in the following transactions: