Profile Comparison between http://hl7.org/fhir/us/core/StructureDefinition/us-core-coverage vs http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/coverage-deqm

Messages

Metadata

Name	Value		Comments
abstract	false
baseDefinition	http://hl7.org/fhir/StructureDefinition/Coverage	http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-coverage	Values Differ
copyright	Used by permission of HL7 International, all rights reserved Creative Commons License		Removed the item 'Used by permission of HL7 International, all rights reserved Creative Commons License'
date	2022-09-24	2018-06-19T00:00:00-07:00	Values Differ
description	The US Core CoverageProfile is based upon the core FHIR Coverage Resource and implements the US Core Data for Interoperability (USCDI) v3 Health Insurance Information requirements. To promote interoperability and adoption through common implementation, this profile sets minimum expectations for the Observation resource to record, search, and fetch the "data related to an individual's insurance coverage for health care". It identifies which core elements, extensions, vocabularies, and value sets **SHALL** be present in the resource when using this profile. It provides the floor for standards development for specific use cases.	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.	Values Differ
experimental	false
fhirVersion	4.0.1
jurisdiction
jurisdiction[0]	urn:iso:std:iso:3166#US
kind	resource
name	USCoreCoverageProfile	DEQMCoverageProfile	Values Differ
publisher	HL7 International - Cross-Group Projects	HL7 International - Clinical Quality Information Work Group	Values Differ
purpose
status	active
title	US Core Coverage Profile	DEQM Coverage Profile	Values Differ
type	Coverage
url	http://hl7.org/fhir/us/core/StructureDefinition/us-core-coverage	http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/coverage-deqm	Values Differ
version	6.0.0-ballot	3.1.0	Values Differ

Structure

Name	L Flags	L Card.	L Type	L Description & Constraints	R Flags	R Card.	L Type	L Description & Constraints	Comments
Coverage	C	0..*	Coverage	Insurance or medical plan or a payment agreement us-core-15: Coverage.identifier or Coverage.subscriberId SHALL be present		0..*	QICoreCoverage	Insurance or medical plan or a payment agreement	Elements differ in definition: 'Financial instrument which may be used to reimburse or pay for health care products and services. Includes both insurance and self-payment.' vs 'This is the Coverage profile which is used to provide insurance information for scheduling an appointment and or registering a patient.'
id	Σ	0..1	id	Logical id of this artifact	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored	?!	0..*	Extension	Extensions that cannot be ignored
identifier	SΣC	0..*	Identifier	Member ID and other identifiers	Σ	0..*	Identifier	Business Identifier for the coverage	Elements differ in short: 'Member ID and other identifiers' vs 'Business Identifier for the coverage' Elements differ in definition for mustSupport: 'true' vs 'false'
status	?!SΣ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.	?!Σ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.	Elements differ in comments: 'The `Coverage.status` alone does not indicate whether an individual's coverage is terminated or that the individual is not covered. The `Coverage.period` needs to be considered as well.' vs 'This element is labeled as a modifier because the status contains the code entered-in-error that marks the coverage as not currently valid.' Elements differ in definition for mustSupport: 'true' vs 'false'
type	SΣ	0..1	CodeableConcept	Coverage category such as medical or accident Binding: https://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 (extensible): US Public Health Data Consortium Source of Payment Codes	SΣ	0..1	CodeableConcept	Coverage 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	Elements differ in description: 'US Public Health Data Consortium Source of Payment Codes' vs 'Categories of types of health care payor entities as defined by the US Public Health Data Consortium SOP code system' Elements differ in description: 'US Public Health Data Consortium Source of Payment Codes' vs 'Categories of types of health care payor entities as defined by the US Public Health Data Consortium SOP code system'
policyHolder	Σ	0..1	Reference(Patient | RelatedPerson | Organization)	Owner of the policy	SΣ	0..1	Reference(QICorePatient | QICoreOrganization | QICoreRelatedPerson)	Owner of the policy	Elements differ in definition for mustSupport: 'false' vs 'true'
subscriber	Σ	0..1	Reference(Patient | RelatedPerson)	Subscriber to the policy	Σ	0..1	Reference(Patient | RelatedPerson)	Subscriber to the policy
subscriberId	SΣC	0..1	string	ID assigned to the subscriber	SΣ	1..1	string	Subscriber ID	Elements differ in short: 'ID assigned to the subscriber' vs 'Subscriber ID' Elements differ in requirements: 'The insurer requires this identifier on correspondance and claims (digital and otherwise).' vs 'The subscriber Id is a number that is needed by the payor to associate the attestation with the meber in their system.' Element minimum cardinalities differ: '0' vs '1'
beneficiary	SΣ	1..1	Reference(US Core Patient Profile)	Plan beneficiary	SΣ	1..1	Reference(QICorePatient)	Plan beneficiary
dependent	Σ	0..1	string	Dependent number	Σ	0..1	string	Dependent number
relationship	S	1..1	CodeableConcept	Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible)		0..1	CodeableConcept	Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).	Elements differ in comments: 'Relationship of the member to the person insured (subscriber)' vs 'Typically, an individual uses policies which are theirs (relationship='self') before policies owned by others.' Elements differ in definition for mustSupport: 'true' vs 'false' Element minimum cardinalities differ: '1' vs '0'
period	SΣ	0..1	Period	Coverage start and end dates	SΣ	0..1	Period	Coverage start and end dates
payor	SΣ	1..1	Reference(US Core Organization Profile S | US Core Patient Profile | US Core RelatedPerson Profile)	Issuer of the policy	SΣ	1..*	Reference(QICorePatient | QICoreOrganization | QICoreRelatedPerson)	Issuer of the policy	Elements differ in comments: 'Issuer of the Policy' vs 'May provide multiple identifiers such as insurance company identifier or business identifier (BIN number). For selfpay it may provide multiple paying persons and/or organizations.' Element maximum cardinalities differ: '1' vs '2147483647' Type Mismatch: Reference([CanonicalType[http://hl7.org/fhir/us/core/StructureDefinition/us-core-organization], CanonicalType[http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient], CanonicalType[http://hl7.org/fhir/us/core/StructureDefinition/us-core-relatedperson]]) vs Reference([CanonicalType[http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-patient], CanonicalType[http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-organization], CanonicalType[http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-relatedperson]])
Slices for class	S	0..*	BackboneElement	Additional coverage classifications Slice: Unordered, Open by pattern:type		0..*	BackboneElement	Additional coverage classifications	Elements differ in definition for mustSupport: 'true' vs 'false'
id		0..1	string	Unique id for inter-element referencing		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized	?!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.	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	Σ	1..1	string	Value associated with the type
name	Σ	0..1	string	Human readable description of the type and value	Σ	0..1	string	Human readable description of the type and value
order	Σ	0..1	positiveInt	Relative order of the coverage	Σ	0..1	positiveInt	Relative order of the coverage
network	Σ	0..1	string	Insurer network	Σ	0..1	string	Insurer network
costToBeneficiary		0..*	BackboneElement	Patient payments for services/products		0..*	BackboneElement	Patient payments for services/products
id		0..1	string	Unique id for inter-element referencing		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	Σ	0..1	CodeableConcept	Cost category Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified.	Σ	0..1	CodeableConcept	Cost category Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified.
value[x]	Σ	1..1	SimpleQuantity, Money	The amount or percentage due from the beneficiary	Σ	1..1	SimpleQuantity, Money	The amount or percentage due from the beneficiary
exception		0..*	BackboneElement	Exceptions for patient payments		0..*	BackboneElement	Exceptions for patient payments
id		0..1	string	Unique id for inter-element referencing		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	Σ	1..1	CodeableConcept	Exception category Binding: ExampleCoverageFinancialExceptionCodes (example): The types of exceptions from the part or full value of financial obligations such as copays.	Σ	1..1	CodeableConcept	Exception category Binding: ExampleCoverageFinancialExceptionCodes (example): The types of exceptions from the part or full value of financial obligations such as copays.
period	Σ	0..1	Period	The effective period of the exception	Σ	0..1	Period	The effective period of the exception
subrogation		0..1	boolean	Reimbursement to insurer		0..1	boolean	Reimbursement to insurer
contract		0..*	Reference(Contract)	Contract details		0..*	Reference(Contract)	Contract details
Documentation for this format