This page is part of the Da Vinci Prior Authorization Support (PAS) FHIR IG (v2.0.1: STU 2) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. 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 Coverage

Name	Flags	Card.	Type	Description & Constraints
Coverage			Coverage
identifier	S	0..*	Identifier	Business Identifier for the coverage
status	S	1..1	code	active | cancelled | draft | entered-in-error Required Pattern: active
subscriber	S	0..1	Reference(PAS Subscriber Patient)	Subscriber to the policy
subscriberId	S	0..1	string	ID assigned to the subscriber
beneficiary	S	1..1	Reference(PAS Beneficiary Patient)	Plan beneficiary
relationship	S	0..1	CodeableConcept	Beneficiary relationship to the subscriber
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	S	1..*	Reference(PAS Insurer Organization)	Issuer of the policy
Documentation for this format

Terminology Bindings (Differential)

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

Name	Flags	Card.	Type	Description & Constraints
Coverage		0..*	Coverage	Insurance or medical plan or a payment agreement
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	SΣ	0..*	Identifier	Business Identifier for the coverage
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
subscriber	SΣ	0..1	Reference(PAS Subscriber Patient)	Subscriber to the policy
subscriberId	SΣ	0..1	string	ID assigned to the subscriber
beneficiary	SΣ	1..1	Reference(PAS Beneficiary Patient)	Plan beneficiary
relationship	S	0..1	CodeableConcept	Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).
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.
payor	SΣ	1..*	Reference(PAS Insurer Organization)	Issuer of the policy
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
Coverage.status	required	Pattern: active
Coverage.relationship	extensible	SubscriberRelationshipCodes
Coverage.relationship.coding:X12Code	required	https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069

Name	Flags	Card.	Type	Description & Constraints
Coverage		0..*	Coverage	Insurance or medical plan or a payment agreement
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. 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
identifier	SΣ	0..*	Identifier	Business Identifier for the coverage
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	Σ	0..1	CodeableConcept	Coverage category such as medical or accident Binding: CoverageTypeAndSelf-PayCodes (preferred): The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization.
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	SΣ	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	0..1	CodeableConcept	Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).
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	Σ	0..1	Period	Coverage start and end dates
payor	SΣ	1..*	Reference(PAS Insurer Organization)	Issuer of the policy
class		0..*	BackboneElement	Additional coverage classifications
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	Σ	1..1	CodeableConcept	Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.
value	Σ	1..1	string	Value associated with the type
name	Σ	0..1	string	Human readable description of the type and value
order	Σ	0..1	positiveInt	Relative order of the coverage
network	Σ	0..1	string	Insurer network
costToBeneficiary		0..*	BackboneElement	Patient payments for services/products
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	Σ	0..1	CodeableConcept	Cost category Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified.
value[x]	Σ	1..1		The amount or percentage due from the beneficiary
valueQuantity			Quantity(SimpleQuantity)
valueMoney			Money
exception		0..*	BackboneElement	Exceptions for patient payments
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	Σ	1..1	CodeableConcept	Exception category Binding: ExampleCoverageFinancialExceptionCodes (example): The types of exceptions from the part or full value of financial obligations such as copays.
period	Σ	0..1	Period	The effective period of the exception
subrogation		0..1	boolean	Reimbursement to insurer
contract		0..*	Reference(Contract)	Contract details
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
Coverage.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
Coverage.status	required	Pattern: active
Coverage.type	preferred	CoverageTypeAndSelf-PayCodes
Coverage.relationship	extensible	SubscriberRelationshipCodes
Coverage.relationship.coding:X12Code	required	https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069
Coverage.class.type	extensible	CoverageClassCodes
Coverage.costToBeneficiary.type	extensible	CoverageCopayTypeCodes
Coverage.costToBeneficiary.exception.type	example	ExampleCoverageFinancialExceptionCodes

This structure is derived from Coverage

Summary

Must-Support: 8 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 Coverage.relationship.coding is sliced based on the value of value:$this

Maturity: 3

Differential View

This structure is derived from Coverage

Name	Flags	Card.	Type	Description & Constraints
Coverage			Coverage
identifier	S	0..*	Identifier	Business Identifier for the coverage
status	S	1..1	code	active | cancelled | draft | entered-in-error Required Pattern: active
subscriber	S	0..1	Reference(PAS Subscriber Patient)	Subscriber to the policy
subscriberId	S	0..1	string	ID assigned to the subscriber
beneficiary	S	1..1	Reference(PAS Beneficiary Patient)	Plan beneficiary
relationship	S	0..1	CodeableConcept	Beneficiary relationship to the subscriber
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	S	1..*	Reference(PAS Insurer Organization)	Issuer of the policy
Documentation for this format

Terminology Bindings (Differential)

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

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
Coverage		0..*	Coverage	Insurance or medical plan or a payment agreement
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	SΣ	0..*	Identifier	Business Identifier for the coverage
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
subscriber	SΣ	0..1	Reference(PAS Subscriber Patient)	Subscriber to the policy
subscriberId	SΣ	0..1	string	ID assigned to the subscriber
beneficiary	SΣ	1..1	Reference(PAS Beneficiary Patient)	Plan beneficiary
relationship	S	0..1	CodeableConcept	Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).
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.
payor	SΣ	1..*	Reference(PAS Insurer Organization)	Issuer of the policy
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
Coverage.status	required	Pattern: active
Coverage.relationship	extensible	SubscriberRelationshipCodes
Coverage.relationship.coding:X12Code	required	https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
Coverage		0..*	Coverage	Insurance or medical plan or a payment agreement
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. 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
identifier	SΣ	0..*	Identifier	Business Identifier for the coverage
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	Σ	0..1	CodeableConcept	Coverage category such as medical or accident Binding: CoverageTypeAndSelf-PayCodes (preferred): The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization.
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	SΣ	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	0..1	CodeableConcept	Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).
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	Σ	0..1	Period	Coverage start and end dates
payor	SΣ	1..*	Reference(PAS Insurer Organization)	Issuer of the policy
class		0..*	BackboneElement	Additional coverage classifications
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	Σ	1..1	CodeableConcept	Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.
value	Σ	1..1	string	Value associated with the type
name	Σ	0..1	string	Human readable description of the type and value
order	Σ	0..1	positiveInt	Relative order of the coverage
network	Σ	0..1	string	Insurer network
costToBeneficiary		0..*	BackboneElement	Patient payments for services/products
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	Σ	0..1	CodeableConcept	Cost category Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified.
value[x]	Σ	1..1		The amount or percentage due from the beneficiary
valueQuantity			Quantity(SimpleQuantity)
valueMoney			Money
exception		0..*	BackboneElement	Exceptions for patient payments
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	Σ	1..1	CodeableConcept	Exception category Binding: ExampleCoverageFinancialExceptionCodes (example): The types of exceptions from the part or full value of financial obligations such as copays.
period	Σ	0..1	Period	The effective period of the exception
subrogation		0..1	boolean	Reimbursement to insurer
contract		0..*	Reference(Contract)	Contract details
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
Coverage.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
Coverage.status	required	Pattern: active
Coverage.type	preferred	CoverageTypeAndSelf-PayCodes
Coverage.relationship	extensible	SubscriberRelationshipCodes
Coverage.relationship.coding:X12Code	required	https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069
Coverage.class.type	extensible	CoverageClassCodes
Coverage.costToBeneficiary.type	extensible	CoverageCopayTypeCodes
Coverage.costToBeneficiary.exception.type	example	ExampleCoverageFinancialExceptionCodes

This structure is derived from Coverage

Summary

Must-Support: 8 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 Coverage.relationship.coding is sliced based on the value of value:$this

Maturity: 3

Other representations of profile: CSV, Excel, Schematron