Da Vinci Health Record Exchange (HRex)
1.1.0-ballot - STU 1.1 Ballot
Da Vinci Health Record Exchange (HRex)
1.1.0-ballot - STU 1.1 Ballot
This page is part of the Da Vinci Health Record Exchange (v1.1.0-ballot: STU 1.1 Ballot 1) based on FHIR (HL7® FHIR® Standard) R4. The current version which supersedes this version is 1.0.0. For a full list of available versions, see the Directory of published versions
| Official URL: http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/hrex-coverage | Version: 1.1.0-ballot | |||
| Standards status: Trial-use | Maturity Level: 2 | Computable Name: HRexCoverage | ||
| Other Identifiers: OID:2.16.840.1.113883.4.642.40.19.42.7 | ||||
The HRex Coverage Profile defines the constraints for representing a member's healthcare insurance information to the Payer. Coverage instances complying with this profile, sometimes together with the Patient which this profile references via beneficiary, allows a payer to identify a member in their system. It aligns with the equivalent US Core profile, but diverges in that it does not require Patient.identifier for the beneficiary
Coverage is central to most Da Vinci use-cases. The resource provides the information that identifies the type of insurance, the payer who provides it and the member who is covered. As such, it forms the justification or focus for almost all data exchanges in the payer space. While the resource is complex, the Da Vinci profile focuses on capturing only the minimum data necessary to identify both payer and member.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Coverage
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Coverage |
C | 0..* | Coverage | Insurance or medical plan or a payment agreement us-core-15: Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present |
  Slices for identifier |
S | 0..* | Identifier | Member ID and other identifiers Slice: Unordered, Open by value:type |
   identifier:memberid |
SC | 0..1 | Identifier | Member ID |
   type |
1..1 | CodeableConcept | Member Number identifier type Required Pattern: At least the following | |
   coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
 system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203 | |
 code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: MB | |
 value |
S | 1..1 | string | The value that is unique |
| status |
S | 1..1 | code | active | cancelled | draft | entered-in-error |
| type |
S | 0..1 | CodeableConcept | Coverage category such as medical or accident Binding: Payer Type  (extensible): US Public Health Data Consortium Source of Payment Codes |
 policyHolder |
S | 0..1 | Reference(US Core Patient Profile(6.1.0) | HRex Organization Profile | US Core RelatedPerson Profile(6.1.0)) | Owner of the policy |
| subscriberId |
SC | 0..1 | string | Subscriber ID |
| beneficiary |
S | 1..1 | Reference(HRex Patient Demographics) | Plan beneficiary |
| dependent |
S | 0..1 | string | Dependent number |
| relationship |
S | 1..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: HRex Coverage Relationship ValueSet (required) |
| period |
S | 0..1 | Period | Coverage start and end dates |
| payor |
S | 1..1 | Reference(HRex Organization Profile) | Issuer of the policy |
| Slices for class |
0..* | BackboneElement | Additional coverage classifications Slice: Unordered, Open by pattern:type | |
 class:group |
S | 0..1 | BackboneElement | Group |
 type |
S | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: group | |
| value |
S | 1..1 | string | Group Number |
| class:plan |
S | 0..1 | BackboneElement | Plan |
| type |
S | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: plan | |
 value |
S | 1..1 | string | Plan Number |
| name |
S | 0..1 | string | Plan Name |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Coverage.type | extensible | PayerType (a valid code from Source of Payment Typology (https://nahdo.org/sopt)http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 | |
| Coverage.relationship | required | HRexCoverageRelationshiphttp://hl7.org/fhir/us/davinci-hrex/ValueSet/hrex-coverage-relationshipfrom this IG |
| Id | Grade | Path(s) | Details | Requirements |
| us-core-15 | error | Coverage | Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present : identifier.type.coding.where(system='http://terminology.hl7.org/CodeSystem/v2-0203' and code='MB').exists() or subscriberId.exists() |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Coverage |
C | 0..* | Coverage | Insurance or medical plan or a payment agreement us-core-15: Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present |
 implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
 modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored |
| Slices for identifier |
SΣ | 0..* | Identifier | Member ID and other identifiers Slice: Unordered, Open by value:type |
| identifier:memberid |
SΣC | 0..1 | Identifier | Member ID |
| use |
?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . |
 type |
Σ | 1..1 | CodeableConcept | Member Number identifier type Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203 | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: MB | |
| value |
SΣ | 1..1 | string | The value that is unique Example General: 123456 |
| status |
?!SΣ | 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: Payer Type (extensible): US Public Health Data Consortium Source of Payment Codes |
| policyHolder |
SΣ | 0..1 | Reference(US Core Patient Profile(6.1.0) | HRex Organization Profile | US Core RelatedPerson Profile(6.1.0)) | Owner of the policy |
| subscriberId |
SΣC | 0..1 | string | Subscriber ID |
| beneficiary |
SΣ | 1..1 | Reference(HRex Patient Demographics) | Plan beneficiary |
| dependent |
SΣ | 0..1 | string | Dependent number |
| relationship |
S | 1..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: HRex Coverage Relationship ValueSet (required) |
| period |
SΣ | 0..1 | Period | Coverage start and end dates |
| payor |
SΣ | 1..1 | Reference(HRex Organization Profile) | Issuer of the policy |
| Slices for class |
0..* | BackboneElement | Additional coverage classifications Slice: Unordered, Open by pattern:type | |
| class:All Slices |
Content/Rules for all slices | |||
 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 |
| class:group |
S | 0..1 | BackboneElement | Group |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type |
SΣ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: group | |
| value |
SΣ | 1..1 | string | Group Number |
| class:plan |
S | 0..1 | BackboneElement | Plan |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type |
SΣ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: plan | |
| value |
SΣ | 1..1 | string | Plan Number |
| name |
SΣ | 0..1 | string | Plan Name |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| Coverage.identifier:memberid.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1from the FHIR Standard | |
| Coverage.identifier:memberid.type | extensible | Pattern: MBhttp://hl7.org/fhir/ValueSet/identifier-typefrom the FHIR Standard | |
| Coverage.status | required | FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|4.0.1from the FHIR Standard | |
| Coverage.type | extensible | PayerType (a valid code from Source of Payment Typology (https://nahdo.org/sopt)http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 | |
| Coverage.relationship | required | HRexCoverageRelationshiphttp://hl7.org/fhir/us/davinci-hrex/ValueSet/hrex-coverage-relationshipfrom this IG | |
| Coverage.class.type | extensible | CoverageClassCodeshttp://hl7.org/fhir/ValueSet/coverage-classfrom the FHIR Standard | |
| Coverage.class:group.type | extensible | Pattern: grouphttp://hl7.org/fhir/ValueSet/coverage-classfrom the FHIR Standard | |
| Coverage.class:plan.type | extensible | Pattern: planhttp://hl7.org/fhir/ValueSet/coverage-classfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Coverage | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Coverage | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Coverage | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Coverage | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Coverage | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| us-core-15 | error | Coverage | Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present : identifier.type.coding.where(system='http://terminology.hl7.org/CodeSystem/v2-0203' and code='MB').exists() or subscriberId.exists() |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Coverage |
C | 0..* | Coverage | Insurance or medical plan or a payment agreement us-core-15: Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present | ||||
| 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 | ||||
| Slices for identifier |
SΣ | 0..* | Identifier | Member ID and other identifiers Slice: Unordered, Open by value:type | ||||
| identifier:memberid |
SΣC | 0..1 | Identifier | Member ID | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| use |
?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
| type |
Σ | 1..1 | CodeableConcept | Member Number identifier type Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203 | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: MB | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| system |
Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
| value |
SΣ | 1..1 | string | The value that is unique Example General: 123456 | ||||
| period |
Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
| assigner |
Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||
| status |
?!SΣ | 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: Payer Type (extensible): US Public Health Data Consortium Source of Payment Codes | ||||
| policyHolder |
SΣ | 0..1 | Reference(US Core Patient Profile(6.1.0) | HRex Organization Profile | US Core RelatedPerson Profile(6.1.0)) | Owner of the policy | ||||
| subscriber |
Σ | 0..1 | Reference(Patient | RelatedPerson) | Subscriber to the policy | ||||
| subscriberId |
SΣC | 0..1 | string | Subscriber ID | ||||
| beneficiary |
SΣ | 1..1 | Reference(HRex Patient Demographics) | Plan beneficiary | ||||
| dependent |
SΣ | 0..1 | string | Dependent number | ||||
| relationship |
S | 1..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: HRex Coverage Relationship ValueSet (required) | ||||
| period |
SΣ | 0..1 | Period | Coverage start and end dates | ||||
| payor |
SΣ | 1..1 | Reference(HRex Organization Profile) | Issuer of the policy | ||||
| Slices for class |
0..* | BackboneElement | Additional coverage classifications Slice: Unordered, Open by pattern:type | |||||
| class:All Slices |
Content/Rules for all slices | |||||||
| 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 | ||||
| class:group |
S | 0..1 | BackboneElement | Group | ||||
| 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 |
SΣ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: group | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| value |
SΣ | 1..1 | string | Group Number | ||||
| name |
Σ | 0..1 | string | Human readable description of the type and value | ||||
| class:plan |
S | 0..1 | BackboneElement | Plan | ||||
| 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 |
SΣ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: plan | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| value |
SΣ | 1..1 | string | Plan Number | ||||
| name |
SΣ | 0..1 | string | Plan Name | ||||
| 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 / Code | URI | |||
| Coverage.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| Coverage.identifier:memberid.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1from the FHIR Standard | ||||
| Coverage.identifier:memberid.type | extensible | Pattern: MBhttp://hl7.org/fhir/ValueSet/identifier-typefrom the FHIR Standard | ||||
| Coverage.status | required | FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|4.0.1from the FHIR Standard | ||||
| Coverage.type | extensible | PayerType (a valid code from Source of Payment Typology (https://nahdo.org/sopt)http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 | ||||
| Coverage.relationship | required | HRexCoverageRelationshiphttp://hl7.org/fhir/us/davinci-hrex/ValueSet/hrex-coverage-relationshipfrom this IG | ||||
| Coverage.class.type | extensible | CoverageClassCodeshttp://hl7.org/fhir/ValueSet/coverage-classfrom the FHIR Standard | ||||
| Coverage.class:group.type | extensible | Pattern: grouphttp://hl7.org/fhir/ValueSet/coverage-classfrom the FHIR Standard | ||||
| Coverage.class:plan.type | extensible | Pattern: planhttp://hl7.org/fhir/ValueSet/coverage-classfrom the FHIR Standard | ||||
| Coverage.costToBeneficiary.type | extensible | CoverageCopayTypeCodeshttp://hl7.org/fhir/ValueSet/coverage-copay-typefrom the FHIR Standard | ||||
| Coverage.costToBeneficiary.exception.type | example | ExampleCoverageFinancialExceptionCodeshttp://hl7.org/fhir/ValueSet/coverage-financial-exceptionfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Coverage | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Coverage | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Coverage | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Coverage | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Coverage | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| us-core-15 | error | Coverage | Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present : identifier.type.coding.where(system='http://terminology.hl7.org/CodeSystem/v2-0203' and code='MB').exists() or subscriberId.exists() |
This structure is derived from Coverage
Summary
Mandatory: 1 element(2 nested mandatory elements)
Must-Support: 19 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Maturity: 2
Differential View
This structure is derived from Coverage
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Coverage |
C | 0..* | Coverage | Insurance or medical plan or a payment agreement us-core-15: Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present |
| Slices for identifier |
S | 0..* | Identifier | Member ID and other identifiers Slice: Unordered, Open by value:type |
| identifier:memberid |
SC | 0..1 | Identifier | Member ID |
| type |
1..1 | CodeableConcept | Member Number identifier type Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203 | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: MB | |
| value |
S | 1..1 | string | The value that is unique |
| status |
S | 1..1 | code | active | cancelled | draft | entered-in-error |
| type |
S | 0..1 | CodeableConcept | Coverage category such as medical or accident Binding: Payer Type (extensible): US Public Health Data Consortium Source of Payment Codes |
| policyHolder |
S | 0..1 | Reference(US Core Patient Profile(6.1.0) | HRex Organization Profile | US Core RelatedPerson Profile(6.1.0)) | Owner of the policy |
| subscriberId |
SC | 0..1 | string | Subscriber ID |
| beneficiary |
S | 1..1 | Reference(HRex Patient Demographics) | Plan beneficiary |
| dependent |
S | 0..1 | string | Dependent number |
| relationship |
S | 1..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: HRex Coverage Relationship ValueSet (required) |
| period |
S | 0..1 | Period | Coverage start and end dates |
| payor |
S | 1..1 | Reference(HRex Organization Profile) | Issuer of the policy |
| Slices for class |
0..* | BackboneElement | Additional coverage classifications Slice: Unordered, Open by pattern:type | |
| class:group |
S | 0..1 | BackboneElement | Group |
| type |
S | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: group | |
| value |
S | 1..1 | string | Group Number |
| class:plan |
S | 0..1 | BackboneElement | Plan |
| type |
S | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: plan | |
| value |
S | 1..1 | string | Plan Number |
| name |
S | 0..1 | string | Plan Name |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Coverage.type | extensible | PayerType (a valid code from Source of Payment Typology (https://nahdo.org/sopt)http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 | |
| Coverage.relationship | required | HRexCoverageRelationshiphttp://hl7.org/fhir/us/davinci-hrex/ValueSet/hrex-coverage-relationshipfrom this IG |
| Id | Grade | Path(s) | Details | Requirements |
| us-core-15 | error | Coverage | Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present : identifier.type.coding.where(system='http://terminology.hl7.org/CodeSystem/v2-0203' and code='MB').exists() or subscriberId.exists() |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Coverage |
C | 0..* | Coverage | Insurance or medical plan or a payment agreement us-core-15: Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present |
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored |
| Slices for identifier |
SΣ | 0..* | Identifier | Member ID and other identifiers Slice: Unordered, Open by value:type |
| identifier:memberid |
SΣC | 0..1 | Identifier | Member ID |
| use |
?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . |
| type |
Σ | 1..1 | CodeableConcept | Member Number identifier type Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203 | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: MB | |
| value |
SΣ | 1..1 | string | The value that is unique Example General: 123456 |
| status |
?!SΣ | 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: Payer Type (extensible): US Public Health Data Consortium Source of Payment Codes |
| policyHolder |
SΣ | 0..1 | Reference(US Core Patient Profile(6.1.0) | HRex Organization Profile | US Core RelatedPerson Profile(6.1.0)) | Owner of the policy |
| subscriberId |
SΣC | 0..1 | string | Subscriber ID |
| beneficiary |
SΣ | 1..1 | Reference(HRex Patient Demographics) | Plan beneficiary |
| dependent |
SΣ | 0..1 | string | Dependent number |
| relationship |
S | 1..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: HRex Coverage Relationship ValueSet (required) |
| period |
SΣ | 0..1 | Period | Coverage start and end dates |
| payor |
SΣ | 1..1 | Reference(HRex Organization Profile) | Issuer of the policy |
| Slices for class |
0..* | BackboneElement | Additional coverage classifications Slice: Unordered, Open by pattern:type | |
| class:All Slices |
Content/Rules for all slices | |||
| 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 |
| class:group |
S | 0..1 | BackboneElement | Group |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type |
SΣ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: group | |
| value |
SΣ | 1..1 | string | Group Number |
| class:plan |
S | 0..1 | BackboneElement | Plan |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type |
SΣ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: plan | |
| value |
SΣ | 1..1 | string | Plan Number |
| name |
SΣ | 0..1 | string | Plan Name |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| Coverage.identifier:memberid.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1from the FHIR Standard | |
| Coverage.identifier:memberid.type | extensible | Pattern: MBhttp://hl7.org/fhir/ValueSet/identifier-typefrom the FHIR Standard | |
| Coverage.status | required | FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|4.0.1from the FHIR Standard | |
| Coverage.type | extensible | PayerType (a valid code from Source of Payment Typology (https://nahdo.org/sopt)http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 | |
| Coverage.relationship | required | HRexCoverageRelationshiphttp://hl7.org/fhir/us/davinci-hrex/ValueSet/hrex-coverage-relationshipfrom this IG | |
| Coverage.class.type | extensible | CoverageClassCodeshttp://hl7.org/fhir/ValueSet/coverage-classfrom the FHIR Standard | |
| Coverage.class:group.type | extensible | Pattern: grouphttp://hl7.org/fhir/ValueSet/coverage-classfrom the FHIR Standard | |
| Coverage.class:plan.type | extensible | Pattern: planhttp://hl7.org/fhir/ValueSet/coverage-classfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Coverage | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Coverage | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Coverage | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Coverage | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Coverage | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| us-core-15 | error | Coverage | Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present : identifier.type.coding.where(system='http://terminology.hl7.org/CodeSystem/v2-0203' and code='MB').exists() or subscriberId.exists() |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Coverage |
C | 0..* | Coverage | Insurance or medical plan or a payment agreement us-core-15: Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present | ||||
| 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 | ||||
| Slices for identifier |
SΣ | 0..* | Identifier | Member ID and other identifiers Slice: Unordered, Open by value:type | ||||
| identifier:memberid |
SΣC | 0..1 | Identifier | Member ID | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| use |
?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
| type |
Σ | 1..1 | CodeableConcept | Member Number identifier type Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203 | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: MB | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| system |
Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
| value |
SΣ | 1..1 | string | The value that is unique Example General: 123456 | ||||
| period |
Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
| assigner |
Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||
| status |
?!SΣ | 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: Payer Type (extensible): US Public Health Data Consortium Source of Payment Codes | ||||
| policyHolder |
SΣ | 0..1 | Reference(US Core Patient Profile(6.1.0) | HRex Organization Profile | US Core RelatedPerson Profile(6.1.0)) | Owner of the policy | ||||
| subscriber |
Σ | 0..1 | Reference(Patient | RelatedPerson) | Subscriber to the policy | ||||
| subscriberId |
SΣC | 0..1 | string | Subscriber ID | ||||
| beneficiary |
SΣ | 1..1 | Reference(HRex Patient Demographics) | Plan beneficiary | ||||
| dependent |
SΣ | 0..1 | string | Dependent number | ||||
| relationship |
S | 1..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: HRex Coverage Relationship ValueSet (required) | ||||
| period |
SΣ | 0..1 | Period | Coverage start and end dates | ||||
| payor |
SΣ | 1..1 | Reference(HRex Organization Profile) | Issuer of the policy | ||||
| Slices for class |
0..* | BackboneElement | Additional coverage classifications Slice: Unordered, Open by pattern:type | |||||
| class:All Slices |
Content/Rules for all slices | |||||||
| 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 | ||||
| class:group |
S | 0..1 | BackboneElement | Group | ||||
| 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 |
SΣ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: group | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| value |
SΣ | 1..1 | string | Group Number | ||||
| name |
Σ | 0..1 | string | Human readable description of the type and value | ||||
| class:plan |
S | 0..1 | BackboneElement | Plan | ||||
| 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 |
SΣ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: plan | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| value |
SΣ | 1..1 | string | Plan Number | ||||
| name |
SΣ | 0..1 | string | Plan Name | ||||
| 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 / Code | URI | |||
| Coverage.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| Coverage.identifier:memberid.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1from the FHIR Standard | ||||
| Coverage.identifier:memberid.type | extensible | Pattern: MBhttp://hl7.org/fhir/ValueSet/identifier-typefrom the FHIR Standard | ||||
| Coverage.status | required | FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|4.0.1from the FHIR Standard | ||||
| Coverage.type | extensible | PayerType (a valid code from Source of Payment Typology (https://nahdo.org/sopt)http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 | ||||
| Coverage.relationship | required | HRexCoverageRelationshiphttp://hl7.org/fhir/us/davinci-hrex/ValueSet/hrex-coverage-relationshipfrom this IG | ||||
| Coverage.class.type | extensible | CoverageClassCodeshttp://hl7.org/fhir/ValueSet/coverage-classfrom the FHIR Standard | ||||
| Coverage.class:group.type | extensible | Pattern: grouphttp://hl7.org/fhir/ValueSet/coverage-classfrom the FHIR Standard | ||||
| Coverage.class:plan.type | extensible | Pattern: planhttp://hl7.org/fhir/ValueSet/coverage-classfrom the FHIR Standard | ||||
| Coverage.costToBeneficiary.type | extensible | CoverageCopayTypeCodeshttp://hl7.org/fhir/ValueSet/coverage-copay-typefrom the FHIR Standard | ||||
| Coverage.costToBeneficiary.exception.type | example | ExampleCoverageFinancialExceptionCodeshttp://hl7.org/fhir/ValueSet/coverage-financial-exceptionfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Coverage | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Coverage | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Coverage | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Coverage | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Coverage | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| us-core-15 | error | Coverage | Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present : identifier.type.coding.where(system='http://terminology.hl7.org/CodeSystem/v2-0203' and code='MB').exists() or subscriberId.exists() |
This structure is derived from Coverage
Summary
Mandatory: 1 element(2 nested mandatory elements)
Must-Support: 19 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Maturity: 2
Other representations of profile: CSV, Excel, Schematron
If the member identifier (conveyed in Coverage.identifier) is known, it should be sent as this uniquely identifies a covered individual. If not, then the Coverage.subscriberId can be used together with demographic information found by resolving Coverage.beneficiary to identify the member. (There can be multiple members associated with a single subscriber - e.g. family members of an individual who is covered under a work-based policy.)
Additional notes and guidance around how to map real-world insurance card information into the Coverage resource can be found in the CARIN Digital Insurance Card IG. As a rule, all elements available should be populated, even if not all might be strictly necessary to identify the member because rules can vary from insurer to insurer about which pieces of information are necessary to uniquely identify a member.
IG © 2019+ HL7 International / Clinical Interoperability Council. Package hl7.fhir.us.davinci-hrex#1.1.0-ballot based on FHIR 4.0.1. Generated 2024-08-13
Links: Table of Contents |
QA Report
| Version History |
|
Propose a change