abstractbaseDefinitioncopyrightdate- Values Differ
description- Values Differ
experimentalfhirVersionjurisdiction
jurisdiction[0]kindnamepublisher- Values Differ
purposestatustitle- Values Differ
typeurlversion- Values Differ
| Left: | HRex Coverage Profile (http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/hrex-coverage) |
| Right: | HRex Member Match Coverage Profile (http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/hrex-coverage) |
| Error | StructureDefinition.version | Values for version differ: '1.0.0' vs '1.1.0' |
| Information | StructureDefinition.title | Values for title differ: 'HRex Coverage Profile' vs 'HRex Member Match Coverage Profile' |
| Information | StructureDefinition.date | Values for date differ: '2022-03-23T18:55:58+00:00' vs '2024-12-10T16:50:09+00:00' |
| Information | StructureDefinition.publisher | Values for publisher differ: 'HL7 International - Clinical Interoperability Council' vs 'HL7 International / Clinical Interoperability Council' |
| Information | StructureDefinition.short | Values for short differ: 'Also known as Member identifier' vs 'Member ID and other identifiers' |
| Information | StructureDefinition.comment | Values for comment differ: 'This must be filled in when known' vs 'The main (and possibly only) identifier for the coverage - often referred to as a Member Id, Certificate number, Personal Health Number or Case ID. May be constructed as the concatenation of the Coverage.SubscriberID and the Coverage.dependant.' |
| Information | Coverage.identifier | Element maximum cardinalities differ: '1' vs '2147483647' |
| Information | StructureDefinition.comment | Values for comment differ: 'This element is labeled as a modifier because the status contains the code entered-in-error that marks the coverage as not currently valid.' vs '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.' |
| Warning | Coverage.status | Elements differ in definition for mustSupport: 'false' vs 'true' |
| Warning | Coverage.type | Elements differ in definition for mustSupport: 'false' vs 'true' |
| Information | StructureDefinition.comment | Values for comment differ: 'For example: may be an individual, corporation or the subscriber's employer.' vs 'When the Coverage pertains to organizations such as Children and Family Services, `policyHolder` should reference Organization (or another suitable entity) representing them. It acts as the holder of the policy and is responsible for the management and oversight of the coverage.' |
| Warning | Coverage.policyHolder | Elements differ in definition for mustSupport: 'false' vs 'true' |
| Information | StructureDefinition.requirements | Values for requirements differ: 'The subscriber Id is a number that is needed by the payer to associate the attestation with the member in their system.' vs 'The insurer requires this identifier on correspondance and claims (digital and otherwise).' |
| Information | StructureDefinition.requirements | Values for requirements differ: 'This would usually be the US Core Patient Resource for which the service was performed.' vs 'This would usually be the US Core Patient Resource for which the service was performed, however US Core requires an identifier, and that won't necessarily be available/relevant when coverage is being between payers' |
| Warning | Coverage.relationship | Elements differ in definition for mustSupport: 'false' vs 'true' |
| Information | Coverage.relationship | Element minimum cardinalities differ: '0' vs '1' |
| Warning | Coverage.period | Elements differ in definition for mustSupport: 'false' vs 'true' |
| Information | StructureDefinition.comment | Values for comment differ: '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. When sending payer, it may either be a reference to a record stored on a mutually accessible registry, or the Reference.display and Reference.identifier elements can be used to convey the payer's name and identifer.' 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. When sending payer, it might either be a reference to a record stored on a mutually accessible registry, or the Reference.display and Reference.identifier elements can be used to convey the payer's name and identifer.' |
| Information | StructureDefinition.requirements | Values for requirements differ: 'Need to identify the issuer to target for claim processing and for coordination of benefit processing.' vs 'Need to identify the issuer to target for claim processing and for coordination of benefit processing. In Da Vinci, we're only concerned with insurance coverage. Because self-pay is not relevant, this is limited to organizations only' |
| Name | Value | Comments | |
|---|---|---|---|
| abstract | false | ||
| baseDefinition | http://hl7.org/fhir/StructureDefinition/Coverage | ||
| copyright | |||
| date | 2022-03-23T18:55:58+00:00 | 2024-12-10T16:50:09+00:00 |
|
| description | 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. | The HRex Coverage Profile defines the constraints for representing a member's healthcare insurance information to the Payer for member match purposes. 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. |
|
| experimental | false | ||
| fhirVersion | 4.0.1 | ||
| jurisdiction | |||
| jurisdiction[0] | urn:iso:std:iso:3166#US | ||
| kind | resource | ||
| name | HRexCoverage | ||
| publisher | HL7 International - Clinical Interoperability Council | HL7 International / Clinical Interoperability Council |
|
| purpose | |||
| status | active | ||
| title | HRex Coverage Profile | HRex Member Match Coverage Profile |
|
| type | Coverage | ||
| url | http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/hrex-coverage | ||
| version | 1.0.0 | 1.1.0 |
|
| Name | L Flags | L Card. | L Type | L Description & Constraints | R Flags | R Card. | R Type | R Description & Constraints | Comments | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
 Coverage | C | 0..* | Coverage | Insurance or medical plan or a payment agreement hrex-cov-1: Coverage.identifier or Coverage.subscriberId SHALL be present | 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 | string | 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: ?? (preferred): A human language.
| 0..1 | code | Language of the resource content Binding: ?? (preferred): A human language.
| |||||||||||
| 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 | SΣ | 0..1 | Identifier | Also known as Member identifier | SΣ | 0..* | Identifier | Member ID and other identifiers Slice: Unordered, Open by value:type |
| ||||||||
 id | 0..1 | string | Unique id for inter-element referencing |
| |||||||||||||
| Slices for 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: ?? (required): Identifies the purpose for this identifier, if known . |
| ||||||||||||
| type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: ?? (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. |
| ||||||||||||
| 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 within the system. 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 | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ?? (required): A code specifying the state of the resource instance. | ?!SΣ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ?? (required): A code specifying the state of the resource instance. |
| ||||||||
| type | Σ | 0..1 | CodeableConcept | Coverage category such as medical or accident Binding: ?? (preferred): The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization. | SΣ | 0..1 | CodeableConcept | Coverage category such as medical or accident Binding: ?? (extensible): US Public Health Data Consortium Source of Payment Codes |
| ||||||||
| policyHolder | Σ | 0..1 | Reference(US Core Patient Profile | HRex Organization Profile | RelatedPerson) | Owner of the policy | SΣ | 0..1 | Reference(US Core Patient Profile(7.0.0) | HRex Organization Profile | US Core RelatedPerson Profile(7.0.0)) | Owner of the policy |
| ||||||||
| subscriber | Σ | 0..1 | Reference(US Core Patient Profile) | Subscriber to the policy | Σ | 0..1 | Reference(Patient | RelatedPerson) | Subscriber to the policy | |||||||||
| subscriberId | SΣ | 0..1 | string | Subscriber ID | SΣC | 0..1 | string | Subscriber ID | |||||||||
| beneficiary | SΣ | 1..1 | Reference(HRex Patient Demographics) | Plan beneficiary | SΣ | 1..1 | Reference(HRex Member Match Patient) | Plan beneficiary | |||||||||
| dependent | SΣ | 0..1 | string | Dependent number | SΣ | 0..1 | string | Dependent number | |||||||||
| relationship | 0..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: ?? (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient). | S | 1..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: ?? (required) |
| |||||||||
| period | Σ | 0..1 | Period | Coverage start and end dates | SΣ | 0..1 | Period | Coverage start and end dates |
| ||||||||
| payor | SΣ | 1..1 | Reference(HRex Organization Profile) | Issuer of the policy | 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 | 0..* | BackboneElement | Additional coverage classifications Slice: Unordered, Open by value:type | |||||||||||
| 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: ?? (extensible): The policy classifications, eg. Group, Plan, Class, etc. | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: ?? (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: ?? (extensible): The types of services to which patient copayments are specified. | Σ | 0..1 | CodeableConcept | Cost category Binding: ?? (extensible): The types of services to which patient copayments are specified. | |||||||||
| value[x] | Σ | 1..1 | ??, Money | The amount or percentage due from the beneficiary | Σ | 1..1 | ??, 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: ?? (example): The types of exceptions from the part or full value of financial obligations such as copays. | Σ | 1..1 | CodeableConcept | Exception category Binding: ?? (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 | |||||||||||||||||