HL7.FHIR.US.DAVINCI-PCT\PCT Coverage

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 R4. . For a full list of available versions, see the Directory of published versions

Resource Profile: PCT Coverage

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

Formal Views of Profile Content

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

Text Summary
Differential Table
Snapshot Table
Snapshot Table (Must Support)
All

This structure is derived from HRexCoverage

Summary

Mandatory: 5 elements
Must-Support: 6 elements

Structures

This structure refers to these other structures:

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

Summary

Mandatory: 5 elements
Must-Support: 6 elements

Structures

This structure refers to these other structures:

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

Terminology Bindings

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

Constraints

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
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