This page is part of the Da Vinci Prior Authorization Support (PAS) FHIR IG (v2.1.0: STU 2) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

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Resource Profile: PAS Coverage

PAS constraints on Coverage resource mandating support for insurance elements relevant to the prior authorization request

Usage:

• Refer to this Resource Profile: PAS Claim Base
• Examples for this Resource Profile: Coverage/InsuranceExample

Formal Views of Profile Content

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

• Differential Table
• Key Elements Table
• Snapshot Table
• Statistics/References
• All

This structure is derived from USCoreCoverageProfile

Name	Flags	Card.	Type	Description & Constraints
Coverage	C	0..*	USCoreCoverageProfile(7.0.0)	Insurance or medical plan or a payment agreement This profile also complies with the profile US Core Coverage Profile (6.1.0) self-beneficiary: If relationship does not equal 'self', then subscriber SHALL be present.
status		1..1	code	active | cancelled | draft | entered-in-error Required Pattern: active
subscriber	S	0..1	Reference(PAS Subscriber Patient)	Subscriber to the policy
beneficiary		1..1	Reference(PAS Beneficiary Patient)	Plan beneficiary
relationship
Slices for coding		0..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:$this
coding:X12Code	S	0..1	Coding	Code defined by a terminology system Binding: https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069 (required): Codes indicating the relationship between two individuals or entities. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
payor		1..1	Reference(PAS Insurer Organization)	Issuer of the policy
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Coverage.relationship.coding:X12Code	required	https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069 https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069

Constraints

Id	Grade	Path(s)	Details	Requirements
self-beneficiary	error	Coverage	If relationship does not equal 'self', then subscriber SHALL be present. : $this.relationship.coding.where(code='18').count() = 0 implies $this.subscriber.exists()

Name	Flags	Card.	Type	Description & Constraints
Coverage	C	0..*	USCoreCoverageProfile(7.0.0)	Insurance or medical plan or a payment agreement This profile also complies with the profile US Core Coverage Profile (6.1.0) dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: 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 dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management us-core-15: Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present self-beneficiary: If relationship does not equal 'self', then subscriber SHALL be present.
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
Slices for identifier	SΣ	0..*	Identifier	Member ID and other identifiers Slice: Unordered, Open by pattern:type ele-1: All FHIR elements must have a @value or children
identifier:memberid	SΣC	0..1	Identifier	Member ID ele-1: All FHIR elements must have a @value or children
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . ele-1: All FHIR elements must have a @value or children
type	SΣ	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. ele-1: All FHIR elements must have a @value or children 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
status	?!SΣ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. ele-1: All FHIR elements must have a @value or children Required Pattern: active
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 ele-1: All FHIR elements must have a @value or children
subscriber	SΣ	0..1	Reference(PAS Subscriber Patient)	Subscriber to the policy ele-1: All FHIR elements must have a @value or children
subscriberId	SΣC	0..1	string	ID assigned to the subscriber ele-1: All FHIR elements must have a @value or children
beneficiary	SΣ	1..1	Reference(PAS Beneficiary Patient)	Plan beneficiary ele-1: All FHIR elements must have a @value or children
relationship	S	1..1	CodeableConcept	Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible) ele-1: All FHIR elements must have a @value or children
Slices for coding	Σ	0..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:$this ele-1: All FHIR elements must have a @value or children
coding:X12Code	SΣ	0..1	Coding	Code defined by a terminology system Binding: https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069 (required): Codes indicating the relationship between two individuals or entities. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions. ele-1: All FHIR elements must have a @value or children
period	SΣ	0..1	Period	Coverage start and end dates ele-1: All FHIR elements must have a @value or children
payor	SΣ	1..1	Reference(PAS Insurer Organization)	Issuer of the policy ele-1: All FHIR elements must have a @value or children
Slices for class	S	0..*	BackboneElement	Additional coverage classifications Slice: Unordered, Open by pattern:type ele-1: All FHIR elements must have a @value or children
class:All Slices				Content/Rules for all slices
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
type	Σ	1..1	CodeableConcept	Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. ele-1: All FHIR elements must have a @value or children
value	Σ	1..1	string	Value associated with the type ele-1: All FHIR elements must have a @value or children
class:group	S	0..1	BackboneElement	Group ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
type	Σ	1..1	CodeableConcept	Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. ele-1: All FHIR elements must have a @value or children 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 ele-1: All FHIR elements must have a @value or children
name	SΣ	0..1	string	Group Name ele-1: All FHIR elements must have a @value or children
class:plan	S	0..1	BackboneElement	Plan ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
type	Σ	1..1	CodeableConcept	Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. ele-1: All FHIR elements must have a @value or children 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 ele-1: All FHIR elements must have a @value or children
name	SΣ	0..1	string	Plan Name ele-1: All FHIR elements must have a @value or children
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Coverage.identifier:memberid.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard
Coverage.identifier:memberid.type	extensible	Pattern: MB http://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard
Coverage.status	required	Pattern: active http://hl7.org/fhir/ValueSet/fm-status|4.0.1 from 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 from https://vsac.nlm.nih.gov
Coverage.relationship	extensible	SubscriberRelationshipCodes http://hl7.org/fhir/ValueSet/subscriber-relationship from the FHIR Standard
Coverage.relationship.coding:X12Code	required	https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069 https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069
Coverage.class.type	extensible	CoverageClassCodes http://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard
Coverage.class:group.type	extensible	Pattern: group http://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard
Coverage.class:plan.type	extensible	Pattern: plan http://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
self-beneficiary	error	Coverage	If relationship does not equal 'self', then subscriber SHALL be present. : $this.relationship.coding.where(code='18').count() = 0 implies $this.subscriber.exists()

Name	Flags	Card.	Type	Description & Constraints
Coverage	C	0..*	USCoreCoverageProfile(7.0.0)	Insurance or medical plan or a payment agreement This profile also complies with the profile US Core Coverage Profile (6.1.0) us-core-15: Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present self-beneficiary: If relationship does not equal 'self', then subscriber 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. Additional Bindings Purpose AllLanguages Max Binding
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 pattern: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	SΣ	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	Σ	0..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. Required Pattern: active
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	Σ	0..1	Reference(Patient | RelatedPerson | Organization)	Owner of the policy
subscriber	SΣ	0..1	Reference(PAS Subscriber Patient)	Subscriber to the policy
subscriberId	SΣC	0..1	string	ID assigned to the subscriber
beneficiary	SΣ	1..1	Reference(PAS Beneficiary Patient)	Plan beneficiary
dependent	Σ	0..1	string	Dependent number
relationship	S	1..1	CodeableConcept	Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
Slices for coding	Σ	0..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:$this
coding:X12Code	SΣ	0..1	Coding	Code defined by a terminology system Binding: https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069 (required): Codes indicating the relationship between two individuals or entities. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
text	Σ	0..1	string	Plain text representation of the concept
period	SΣ	0..1	Period	Coverage start and end dates
payor	SΣ	1..1	Reference(PAS Insurer Organization)	Issuer of the policy
Slices for class	S	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	Σ	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	SΣ	0..1	string	Group Name
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	Σ	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

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Coverage.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
Coverage.identifier:memberid.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard
Coverage.identifier:memberid.type	extensible	Pattern: MB http://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard
Coverage.status	required	Pattern: active http://hl7.org/fhir/ValueSet/fm-status|4.0.1 from 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 from https://vsac.nlm.nih.gov
Coverage.relationship	extensible	SubscriberRelationshipCodes http://hl7.org/fhir/ValueSet/subscriber-relationship from the FHIR Standard
Coverage.relationship.coding:X12Code	required	https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069 https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069
Coverage.class.type	extensible	CoverageClassCodes http://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard
Coverage.class:group.type	extensible	Pattern: group http://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard
Coverage.class:plan.type	extensible	Pattern: plan http://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard
Coverage.costToBeneficiary.type	extensible	CoverageCopayTypeCodes http://hl7.org/fhir/ValueSet/coverage-copay-type from the FHIR Standard
Coverage.costToBeneficiary.exception.type	example	ExampleCoverageFinancialExceptionCodes http://hl7.org/fhir/ValueSet/coverage-financial-exception from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
self-beneficiary	error	Coverage	If relationship does not equal 'self', then subscriber SHALL be present. : $this.relationship.coding.where(code='18').count() = 0 implies $this.subscriber.exists()

This structure is derived from USCoreCoverageProfile

Summary

Must-Support: 2 elements

Structures

This structure refers to these other structures:

• PAS Subscriber Patient (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-subscriber)
• PAS Beneficiary Patient (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-beneficiary)
• PAS Insurer Organization (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-insurer)

Slices

This structure defines the following Slices:

• The element 1 is sliced based on the value of Coverage.relationship.coding

Maturity: 3

Differential View

This structure is derived from USCoreCoverageProfile

Name	Flags	Card.	Type	Description & Constraints
Coverage	C	0..*	USCoreCoverageProfile(7.0.0)	Insurance or medical plan or a payment agreement This profile also complies with the profile US Core Coverage Profile (6.1.0) self-beneficiary: If relationship does not equal 'self', then subscriber SHALL be present.
status		1..1	code	active | cancelled | draft | entered-in-error Required Pattern: active
subscriber	S	0..1	Reference(PAS Subscriber Patient)	Subscriber to the policy
beneficiary		1..1	Reference(PAS Beneficiary Patient)	Plan beneficiary
relationship
Slices for coding		0..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:$this
coding:X12Code	S	0..1	Coding	Code defined by a terminology system Binding: https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069 (required): Codes indicating the relationship between two individuals or entities. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
payor		1..1	Reference(PAS Insurer Organization)	Issuer of the policy
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Coverage.relationship.coding:X12Code	required	https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069 https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069

Constraints

Id	Grade	Path(s)	Details	Requirements
self-beneficiary	error	Coverage	If relationship does not equal 'self', then subscriber SHALL be present. : $this.relationship.coding.where(code='18').count() = 0 implies $this.subscriber.exists()

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
Coverage	C	0..*	USCoreCoverageProfile(7.0.0)	Insurance or medical plan or a payment agreement This profile also complies with the profile US Core Coverage Profile (6.1.0) dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: 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 dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management us-core-15: Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present self-beneficiary: If relationship does not equal 'self', then subscriber SHALL be present.
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
Slices for identifier	SΣ	0..*	Identifier	Member ID and other identifiers Slice: Unordered, Open by pattern:type ele-1: All FHIR elements must have a @value or children
identifier:memberid	SΣC	0..1	Identifier	Member ID ele-1: All FHIR elements must have a @value or children
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . ele-1: All FHIR elements must have a @value or children
type	SΣ	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. ele-1: All FHIR elements must have a @value or children 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
status	?!SΣ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. ele-1: All FHIR elements must have a @value or children Required Pattern: active
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 ele-1: All FHIR elements must have a @value or children
subscriber	SΣ	0..1	Reference(PAS Subscriber Patient)	Subscriber to the policy ele-1: All FHIR elements must have a @value or children
subscriberId	SΣC	0..1	string	ID assigned to the subscriber ele-1: All FHIR elements must have a @value or children
beneficiary	SΣ	1..1	Reference(PAS Beneficiary Patient)	Plan beneficiary ele-1: All FHIR elements must have a @value or children
relationship	S	1..1	CodeableConcept	Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible) ele-1: All FHIR elements must have a @value or children
Slices for coding	Σ	0..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:$this ele-1: All FHIR elements must have a @value or children
coding:X12Code	SΣ	0..1	Coding	Code defined by a terminology system Binding: https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069 (required): Codes indicating the relationship between two individuals or entities. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions. ele-1: All FHIR elements must have a @value or children
period	SΣ	0..1	Period	Coverage start and end dates ele-1: All FHIR elements must have a @value or children
payor	SΣ	1..1	Reference(PAS Insurer Organization)	Issuer of the policy ele-1: All FHIR elements must have a @value or children
Slices for class	S	0..*	BackboneElement	Additional coverage classifications Slice: Unordered, Open by pattern:type ele-1: All FHIR elements must have a @value or children
class:All Slices				Content/Rules for all slices
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
type	Σ	1..1	CodeableConcept	Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. ele-1: All FHIR elements must have a @value or children
value	Σ	1..1	string	Value associated with the type ele-1: All FHIR elements must have a @value or children
class:group	S	0..1	BackboneElement	Group ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
type	Σ	1..1	CodeableConcept	Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. ele-1: All FHIR elements must have a @value or children 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 ele-1: All FHIR elements must have a @value or children
name	SΣ	0..1	string	Group Name ele-1: All FHIR elements must have a @value or children
class:plan	S	0..1	BackboneElement	Plan ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
type	Σ	1..1	CodeableConcept	Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. ele-1: All FHIR elements must have a @value or children 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 ele-1: All FHIR elements must have a @value or children
name	SΣ	0..1	string	Plan Name ele-1: All FHIR elements must have a @value or children
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Coverage.identifier:memberid.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard
Coverage.identifier:memberid.type	extensible	Pattern: MB http://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard
Coverage.status	required	Pattern: active http://hl7.org/fhir/ValueSet/fm-status|4.0.1 from 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 from https://vsac.nlm.nih.gov
Coverage.relationship	extensible	SubscriberRelationshipCodes http://hl7.org/fhir/ValueSet/subscriber-relationship from the FHIR Standard
Coverage.relationship.coding:X12Code	required	https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069 https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069
Coverage.class.type	extensible	CoverageClassCodes http://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard
Coverage.class:group.type	extensible	Pattern: group http://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard
Coverage.class:plan.type	extensible	Pattern: plan http://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
self-beneficiary	error	Coverage	If relationship does not equal 'self', then subscriber SHALL be present. : $this.relationship.coding.where(code='18').count() = 0 implies $this.subscriber.exists()

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
Coverage	C	0..*	USCoreCoverageProfile(7.0.0)	Insurance or medical plan or a payment agreement This profile also complies with the profile US Core Coverage Profile (6.1.0) us-core-15: Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present self-beneficiary: If relationship does not equal 'self', then subscriber 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. Additional Bindings Purpose AllLanguages Max Binding
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 pattern: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	SΣ	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	Σ	0..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. Required Pattern: active
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	Σ	0..1	Reference(Patient | RelatedPerson | Organization)	Owner of the policy
subscriber	SΣ	0..1	Reference(PAS Subscriber Patient)	Subscriber to the policy
subscriberId	SΣC	0..1	string	ID assigned to the subscriber
beneficiary	SΣ	1..1	Reference(PAS Beneficiary Patient)	Plan beneficiary
dependent	Σ	0..1	string	Dependent number
relationship	S	1..1	CodeableConcept	Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
Slices for coding	Σ	0..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:$this
coding:X12Code	SΣ	0..1	Coding	Code defined by a terminology system Binding: https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069 (required): Codes indicating the relationship between two individuals or entities. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
text	Σ	0..1	string	Plain text representation of the concept
period	SΣ	0..1	Period	Coverage start and end dates
payor	SΣ	1..1	Reference(PAS Insurer Organization)	Issuer of the policy
Slices for class	S	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	Σ	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	SΣ	0..1	string	Group Name
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	Σ	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

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Coverage.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
Coverage.identifier:memberid.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard
Coverage.identifier:memberid.type	extensible	Pattern: MB http://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard
Coverage.status	required	Pattern: active http://hl7.org/fhir/ValueSet/fm-status|4.0.1 from 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 from https://vsac.nlm.nih.gov
Coverage.relationship	extensible	SubscriberRelationshipCodes http://hl7.org/fhir/ValueSet/subscriber-relationship from the FHIR Standard
Coverage.relationship.coding:X12Code	required	https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069 https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069
Coverage.class.type	extensible	CoverageClassCodes http://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard
Coverage.class:group.type	extensible	Pattern: group http://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard
Coverage.class:plan.type	extensible	Pattern: plan http://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard
Coverage.costToBeneficiary.type	extensible	CoverageCopayTypeCodes http://hl7.org/fhir/ValueSet/coverage-copay-type from the FHIR Standard
Coverage.costToBeneficiary.exception.type	example	ExampleCoverageFinancialExceptionCodes http://hl7.org/fhir/ValueSet/coverage-financial-exception from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
self-beneficiary	error	Coverage	If relationship does not equal 'self', then subscriber SHALL be present. : $this.relationship.coding.where(code='18').count() = 0 implies $this.subscriber.exists()

This structure is derived from USCoreCoverageProfile

Summary

Must-Support: 2 elements

Structures

This structure refers to these other structures:

• PAS Subscriber Patient (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-subscriber)
• PAS Beneficiary Patient (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-beneficiary)
• PAS Insurer Organization (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-insurer)

Slices

This structure defines the following Slices:

• The element 1 is sliced based on the value of Coverage.relationship.coding

Maturity: 3

Other representations of profile: CSV, Excel, Schematron