Patient Cost Transparency Implementation Guide
0.1.0 - STU 1 Ballot
Patient Cost Transparency Implementation Guide
0.1.0 - STU 1 Ballot
This page is part of the Da Vinci Patient Cost Transparency Implementation Guide (v0.1.0: STU 1 Draft) based on FHIR (HL7® FHIR® Standard) R4. The current version which supersedes this version is 1.1.0. For a full list of available versions, see the Directory of published versions
| Defining URL: | http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage |
| Version: | 0.1.0 |
| Name: | PCTCoverage |
| Title: | PCT Coverage |
| Status: | Active as of 12/4/21 9:54 PM |
| Definition: | PCT Coverage is a profile for capturing data that reflect a payer’s coverage that was effective as of the proposed date of service or the date of admission of the GFE. |
| Publisher: | HL7 International - Financial Management Work Group |
| Source Resource: | XML / JSON / Turtle |
The official URL for this profile is:
http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from HRexCoverage
This structure is derived from HRexCoverage
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Coverage | 0..* | HRexCoverage | Insurance or medical plan or a payment agreement | |
  subscriber | S | 0..1 | Reference(PCT Patient) | Subscriber to the policy |
 subscriberId | 1..1 | string | Subscriber ID | |
| beneficiary | 1..1 | Reference(PCT Patient) | Plan beneficiary | |
| relationship | S | 1..1 | CodeableConcept | Beneficiary relationship to the subscriber |
| period | S | 1..1 | Period | Coverage start and end dates |
| payor | 1..1 | Reference(PCT Organization) | Issuer of the policy | |
 class | S | 1..* | BackboneElement | Additional coverage classifications |
  name | S | 1..1 | string | Human readable description of the type and value |
 costToBeneficiary | S | 0..* | BackboneElement | Patient payments for services/products |
 type | 0..1 | CodeableConcept | Cost category Binding: PCT Coverage Copay Type Value Set - locally defined for testing purpose; an external FHIR value set will be created through the HL7 Terminology (THO) process to replace this value set (required) | |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Coverage | 0..* | HRexCoverage | Insurance or medical plan or a payment agreement | |
 id | Σ | 0..1 | string | 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) Max Binding: AllLanguages: A human language. | |
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |
| contained | 0..* | Resource | Contained, inline Resources | |
 extension | 0..* | Extension | Additional content defined by implementations | |
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| identifier | SΣ | 0..* | Identifier | Also known as Member identifier |
| status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. |
| 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(US Core Patient Profile | HRex Organization Profile | RelatedPerson) | Owner of the policy |
| subscriber | SΣ | 0..1 | Reference(PCT Patient) | Subscriber to the policy |
| subscriberId | SΣ | 1..1 | string | Subscriber ID |
| beneficiary | SΣ | 1..1 | Reference(PCT Patient) | Plan beneficiary |
| dependent | Σ | 0..1 | string | Dependent number |
| relationship | S | 1..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient). |
| period | SΣ | 1..1 | Period | Coverage start and end dates |
| payor | SΣ | 1..1 | Reference(PCT Organization) | Issuer of the policy |
| class | S | 1..* | 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 | SΣ | 1..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 | S | 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: PCT Coverage Copay Type Value Set - locally defined for testing purpose; an external FHIR value set will be created through the HL7 Terminology (THO) process to replace this value set (required) |
 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 | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Coverage | 0..* | HRexCoverage | Insurance or medical plan or a payment agreement | |
| identifier | Σ | 0..* | Identifier | Also known as Member identifier |
| subscriber | Σ | 0..1 | Reference(PCT Patient) | Subscriber to the policy |
| subscriberId | Σ | 1..1 | string | Subscriber ID |
| beneficiary | Σ | 1..1 | Reference(PCT Patient) | Plan beneficiary |
| relationship | 1..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient). | |
| period | Σ | 1..1 | Period | Coverage start and end dates |
| payor | Σ | 1..1 | Reference(PCT Organization) | Issuer of the policy |
| class | 1..* | BackboneElement | Additional coverage classifications | |
| name | Σ | 1..1 | string | Human readable description of the type and value |
| costToBeneficiary | 0..* | BackboneElement | Patient payments for services/products | |
| Documentation for this format | ||||
This structure is derived from HRexCoverage
Differential View
This structure is derived from HRexCoverage
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Coverage | 0..* | HRexCoverage | Insurance or medical plan or a payment agreement | |
| subscriber | S | 0..1 | Reference(PCT Patient) | Subscriber to the policy |
| subscriberId | 1..1 | string | Subscriber ID | |
| beneficiary | 1..1 | Reference(PCT Patient) | Plan beneficiary | |
| relationship | S | 1..1 | CodeableConcept | Beneficiary relationship to the subscriber |
| period | S | 1..1 | Period | Coverage start and end dates |
| payor | 1..1 | Reference(PCT Organization) | Issuer of the policy | |
| class | S | 1..* | BackboneElement | Additional coverage classifications |
| name | S | 1..1 | string | Human readable description of the type and value |
| costToBeneficiary | S | 0..* | BackboneElement | Patient payments for services/products |
| type | 0..1 | CodeableConcept | Cost category Binding: PCT Coverage Copay Type Value Set - locally defined for testing purpose; an external FHIR value set will be created through the HL7 Terminology (THO) process to replace this value set (required) | |
| Documentation for this format | ||||
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Coverage | 0..* | HRexCoverage | Insurance or medical plan or a payment agreement | |
| id | Σ | 0..1 | string | 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) Max Binding: AllLanguages: A human language. | |
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |
| contained | 0..* | Resource | Contained, inline Resources | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| identifier | SΣ | 0..* | Identifier | Also known as Member identifier |
| status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. |
| 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(US Core Patient Profile | HRex Organization Profile | RelatedPerson) | Owner of the policy |
| subscriber | SΣ | 0..1 | Reference(PCT Patient) | Subscriber to the policy |
| subscriberId | SΣ | 1..1 | string | Subscriber ID |
| beneficiary | SΣ | 1..1 | Reference(PCT Patient) | Plan beneficiary |
| dependent | Σ | 0..1 | string | Dependent number |
| relationship | S | 1..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient). |
| period | SΣ | 1..1 | Period | Coverage start and end dates |
| payor | SΣ | 1..1 | Reference(PCT Organization) | Issuer of the policy |
| class | S | 1..* | 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 | SΣ | 1..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 | S | 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: PCT Coverage Copay Type Value Set - locally defined for testing purpose; an external FHIR value set will be created through the HL7 Terminology (THO) process to replace this value set (required) |
| 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 | ||||
Other representations of profile: CSV, Excel, Schematron
| Path | Conformance | ValueSet |
| Coverage.language | preferred | CommonLanguages Max Binding: AllLanguages |
| Coverage.status | required | FinancialResourceStatusCodes |
| Coverage.type | preferred | CoverageTypeAndSelf-PayCodes |
| Coverage.relationship | extensible | SubscriberRelationshipCodes |
| Coverage.class.type | extensible | CoverageClassCodes |
| Coverage.costToBeneficiary.type | required | PCTCoverageCopayTypeVS |
| Coverage.costToBeneficiary.exception.type | example | ExampleCoverageFinancialExceptionCodes |
| Id | Path | Details | Requirements |
| dom-2 | Coverage | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | 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 | 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 | Coverage | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | Coverage | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | Coverage.meta | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.implicitRules | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.language | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Coverage.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Coverage.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Coverage.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Coverage.identifier | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.status | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.type | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.policyHolder | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.subscriber | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.subscriberId | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.beneficiary | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.dependent | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.relationship | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.period | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.payor | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.class | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.class.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Coverage.class.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Coverage.class.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Coverage.class.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Coverage.class.type | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.class.value | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.class.name | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.order | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.network | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.costToBeneficiary | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.costToBeneficiary.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Coverage.costToBeneficiary.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Coverage.costToBeneficiary.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Coverage.costToBeneficiary.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Coverage.costToBeneficiary.type | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.costToBeneficiary.value[x] | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.costToBeneficiary.exception | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.costToBeneficiary.exception.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Coverage.costToBeneficiary.exception.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Coverage.costToBeneficiary.exception.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Coverage.costToBeneficiary.exception.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Coverage.costToBeneficiary.exception.type | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.costToBeneficiary.exception.period | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.subrogation | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.contract | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
IG © 2021+ HL7 International - Financial Management Work Group. Package hl7.fhir.us.davinci-pct#0.1.0 based on FHIR 4.0.1. Generated 2021-12-04
Links: Table of Contents |
QA Report
| Version History |
Search |
|
Propose a change