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. For a full list of available versions, see the Directory of published versions
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.
The following data-elements are mandatory (i.e data MUST be present).
Each Coverage must have:
Additional Profile specific implementation guidance:
None
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from QICoreCoverage
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Coverage | 0..* | QICoreCoverage | Insurance or medical plan or a payment agreement | |
subscriberId | S | 1..1 | string | Subscriber ID |
Documentation for this format |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Coverage | 0..* | QICoreCoverage | Insurance or medical plan or a payment agreement | |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
status | ?!Σ | 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: 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 | SΣ | 0..1 | Reference(QICorePatient | QICoreOrganization | QICoreRelatedPerson) | Owner of the policy |
subscriberId | SΣ | 1..1 | string | Subscriber ID |
beneficiary | SΣ | 1..1 | Reference(QICorePatient) | Plan beneficiary |
period | SΣ | 0..1 | Period | Coverage start and end dates |
payor | SΣ | 1..* | Reference(QICorePatient | QICoreOrganization | QICoreRelatedPerson) | Issuer of the policy |
Documentation for this format |
Path | Conformance | ValueSet |
Coverage.status | required | FinancialResourceStatusCodes |
Coverage.type | required | https://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Coverage | 0..* | QICoreCoverage | Insurance or medical plan or a payment agreement | |||||
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 | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
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 | ||||
identifier | Σ | 0..* | Identifier | Business Identifier for the coverage | ||||
status | ?!Σ | 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: 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 | SΣ | 0..1 | Reference(QICorePatient | QICoreOrganization | QICoreRelatedPerson) | Owner of the policy | ||||
subscriber | Σ | 0..1 | Reference(Patient | RelatedPerson) | Subscriber to the policy | ||||
subscriberId | SΣ | 1..1 | string | Subscriber ID | ||||
beneficiary | SΣ | 1..1 | Reference(QICorePatient) | Plan beneficiary | ||||
dependent | Σ | 0..1 | string | Dependent number | ||||
relationship | 0..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient). | |||||
period | SΣ | 0..1 | Period | Coverage start and end dates | ||||
payor | SΣ | 1..* | Reference(QICorePatient | QICoreOrganization | QICoreRelatedPerson) | Issuer of the policy | ||||
class | 0..* | BackboneElement | Additional coverage classifications | |||||
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 | ||||
order | Σ | 0..1 | positiveInt | Relative order of the coverage | ||||
network | Σ | 0..1 | string | Insurer network | ||||
costToBeneficiary | 0..* | BackboneElement | Patient payments for services/products | |||||
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 | 0..1 | CodeableConcept | Cost category Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified. | ||||
value[x] | Σ | 1..1 | The amount or percentage due from the beneficiary | |||||
valueQuantity | Quantity(SimpleQuantity) | |||||||
valueMoney | Money | |||||||
exception | 0..* | BackboneElement | Exceptions for patient payments | |||||
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 | 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 | ||||
subrogation | 0..1 | boolean | Reimbursement to insurer | |||||
contract | 0..* | Reference(Contract) | Contract details | |||||
Documentation for this format |
Path | Conformance | ValueSet | ||||
Coverage.language | preferred | CommonLanguages
| ||||
Coverage.status | required | FinancialResourceStatusCodes | ||||
Coverage.type | required | https://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 | ||||
Coverage.relationship | extensible | SubscriberRelationshipCodes | ||||
Coverage.class.type | extensible | CoverageClassCodes | ||||
Coverage.costToBeneficiary.type | extensible | CoverageCopayTypeCodes | ||||
Coverage.costToBeneficiary.exception.type | example | ExampleCoverageFinancialExceptionCodes |
This structure is derived from QICoreCoverage
Differential View
This structure is derived from QICoreCoverage
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Coverage | 0..* | QICoreCoverage | Insurance or medical plan or a payment agreement | |
subscriberId | S | 1..1 | string | Subscriber ID |
Documentation for this format |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Coverage | 0..* | QICoreCoverage | Insurance or medical plan or a payment agreement | |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
status | ?!Σ | 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: 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 | SΣ | 0..1 | Reference(QICorePatient | QICoreOrganization | QICoreRelatedPerson) | Owner of the policy |
subscriberId | SΣ | 1..1 | string | Subscriber ID |
beneficiary | SΣ | 1..1 | Reference(QICorePatient) | Plan beneficiary |
period | SΣ | 0..1 | Period | Coverage start and end dates |
payor | SΣ | 1..* | Reference(QICorePatient | QICoreOrganization | QICoreRelatedPerson) | Issuer of the policy |
Documentation for this format |
Path | Conformance | ValueSet |
Coverage.status | required | FinancialResourceStatusCodes |
Coverage.type | required | https://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Coverage | 0..* | QICoreCoverage | Insurance or medical plan or a payment agreement | |||||
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 | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
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 | ||||
identifier | Σ | 0..* | Identifier | Business Identifier for the coverage | ||||
status | ?!Σ | 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: 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 | SΣ | 0..1 | Reference(QICorePatient | QICoreOrganization | QICoreRelatedPerson) | Owner of the policy | ||||
subscriber | Σ | 0..1 | Reference(Patient | RelatedPerson) | Subscriber to the policy | ||||
subscriberId | SΣ | 1..1 | string | Subscriber ID | ||||
beneficiary | SΣ | 1..1 | Reference(QICorePatient) | Plan beneficiary | ||||
dependent | Σ | 0..1 | string | Dependent number | ||||
relationship | 0..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient). | |||||
period | SΣ | 0..1 | Period | Coverage start and end dates | ||||
payor | SΣ | 1..* | Reference(QICorePatient | QICoreOrganization | QICoreRelatedPerson) | Issuer of the policy | ||||
class | 0..* | BackboneElement | Additional coverage classifications | |||||
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 | ||||
order | Σ | 0..1 | positiveInt | Relative order of the coverage | ||||
network | Σ | 0..1 | string | Insurer network | ||||
costToBeneficiary | 0..* | BackboneElement | Patient payments for services/products | |||||
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 | 0..1 | CodeableConcept | Cost category Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified. | ||||
value[x] | Σ | 1..1 | The amount or percentage due from the beneficiary | |||||
valueQuantity | Quantity(SimpleQuantity) | |||||||
valueMoney | Money | |||||||
exception | 0..* | BackboneElement | Exceptions for patient payments | |||||
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 | 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 | ||||
subrogation | 0..1 | boolean | Reimbursement to insurer | |||||
contract | 0..* | Reference(Contract) | Contract details | |||||
Documentation for this format |
Path | Conformance | ValueSet | ||||
Coverage.language | preferred | CommonLanguages
| ||||
Coverage.status | required | FinancialResourceStatusCodes | ||||
Coverage.type | required | https://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 | ||||
Coverage.relationship | extensible | SubscriberRelationshipCodes | ||||
Coverage.class.type | extensible | CoverageClassCodes | ||||
Coverage.costToBeneficiary.type | extensible | CoverageCopayTypeCodes | ||||
Coverage.costToBeneficiary.exception.type | example | ExampleCoverageFinancialExceptionCodes |
This structure is derived from QICoreCoverage
Other representations of profile: CSV, Excel, Schematron