Profile Comparison between http://hl7.org/fhir/us/core/StructureDefinition/us-core-coverage vs http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage

Messages

Metadata

Name	Value		Comments
abstract	false
baseDefinition	http://hl7.org/fhir/StructureDefinition/Coverage	http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/hrex-coverage	Values Differ
copyright	Used by permission of HL7 International, all rights reserved Creative Commons License		Removed the item 'Used by permission of HL7 International, all rights reserved Creative Commons License'
date	2022-09-24	2023-03-30T13:34:22+00:00	Values Differ
description	The US Core CoverageProfile is based upon the core FHIR Coverage Resource and implements the US Core Data for Interoperability (USCDI) v3 Health Insurance Information requirements. To promote interoperability and adoption through common implementation, this profile sets minimum expectations for the Observation resource to record, search, and fetch the "data related to an individual's insurance coverage for health care". It identifies which core elements, extensions, vocabularies, and value sets **SHALL** be present in the resource when using this profile. It provides the floor for standards development for specific use cases.	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.	Values Differ
experimental	false		Removed the item 'false'
fhirVersion	4.0.1
jurisdiction
jurisdiction[0]	urn:iso:std:iso:3166#US
kind	resource
name	USCoreCoverageProfile	PCTCoverage	Values Differ
publisher	HL7 International - Cross-Group Projects	HL7 International - Financial Management Work Group	Values Differ
purpose
status	active
title	US Core Coverage Profile	PCT Coverage	Values Differ
type	Coverage
url	http://hl7.org/fhir/us/core/StructureDefinition/us-core-coverage	http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage	Values Differ
version	6.0.0-ballot	1.0.0	Values Differ

Structure

Name	L Flags	L Card.	L Type	L Description & Constraints	R Flags	R Card.	L Type	L Description & Constraints	Comments
Coverage	C	0..*	Coverage	Insurance or medical plan or a payment agreement us-core-15: Coverage.identifier or Coverage.subscriberId SHALL be present	C	0..*	HRexCoverage	Insurance or medical plan or a payment agreement	Elements differ in definition: 'Financial instrument which may be used to reimburse or pay for health care products and services. Includes both insurance and self-payment.' vs 'This is the Coverage profile which is used to provide insurance information for scheduling an appointment and/or registering a patient.'
id	Σ	0..1	id	Logical id of this artifact	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: ?? (preferred): A human language. Additional Bindings Purpose ?? Max Binding		0..1	code	Language of the resource content Binding: ?? (preferred): A human language. Additional Bindings Purpose ?? Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored	?!	0..*	Extension	Extensions that cannot be ignored
identifier	SΣC	0..*	Identifier	Member ID and other identifiers	SΣ	0..1	Identifier	Also known as Member identifier	Elements differ in short: 'Member ID and other identifiers' vs 'Also known as Member identifier' Elements differ in comments: 'The main (and possibly only) identifier for the coverage - often referred to as a Member Id, Certificate number, Personal Health Number or Case ID. May be constructed as the concatenation of the Coverage.SubscriberID and the Coverage.dependant.' vs 'This must be filled in when known' Element maximum cardinalities differ: '2147483647' vs '1'
id		0..1	string	Unique id for inter-element referencing		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: ?? (required): Identifies the purpose for this identifier, if known .	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: ?? (required): Identifies the purpose for this identifier, if known .
type	Σ	0..1	CodeableConcept	Description of identifier Binding: ?? (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.	Σ	0..1	CodeableConcept	Description of identifier Binding: ?? (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
system	Σ	0..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient	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	SΣ	1..1	string	The value that is unique within the system. Example General: 123456	Elements differ in short: 'The value that is unique' vs 'The value that is unique within the system.' Elements differ in definition for mustSupport: 'false' vs 'true' Element minimum cardinalities differ: '0' vs '1'
period	Σ	0..1	Period	Time period when id is/was valid for use	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)	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: ?? (required): A code specifying the state of the resource instance.	?!Σ	1..1	code	active | cancelled | draft | entered-in-error Binding: ?? (required): A code specifying the state of the resource instance.	Elements differ in comments: 'The `Coverage.status` alone does not indicate whether an individual's coverage is terminated or that the individual is not covered. The `Coverage.period` needs to be considered as well.' vs 'This element is labeled as a modifier because the status contains the code entered-in-error that marks the coverage as not currently valid.' Elements differ in definition for mustSupport: 'true' vs 'false'
type	SΣ	0..1	CodeableConcept	Coverage category such as medical or accident Binding: ?? (extensible): US Public Health Data Consortium Source of Payment Codes	Σ	0..1	CodeableConcept	Coverage category such as medical or accident Binding: ?? (preferred): The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization.	Elements differ in definition for mustSupport: 'true' vs 'false' Elements differ in binding.description: 'US Public Health Data Consortium Source of Payment Codes' vs '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	Σ	0..1	Reference(US Core Patient Profile | HRex Organization Profile | RelatedPerson)	Owner of the policy
subscriber	Σ	0..1	Reference(Patient | RelatedPerson)	Subscriber to the policy	Σ	0..1	Reference(US Core Patient Profile)	Required if subscriber is a person that is not the beneficiary. When date of birth or gender are not known, omit Patient.birthDate and set Patient.gender to unknown.	Elements differ in short: 'Subscriber to the policy' vs 'Required if subscriber is a person that is not the beneficiary. When date of birth or gender are not known, omit Patient.birthDate and set Patient.gender to unknown.'
id		0..1	string	Unique id for inter-element referencing		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	0..1	string	Literal reference, Relative, internal or absolute URL	ΣC	0..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ?? (extensible): Aa resource (or, for logical models, the URI of the logical model).	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ?? (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource	Σ	1..1	string	Provide the name of the subscriber in Coverage.subscriber.display concatenating the subscriber’s prefix, given name, family name and suffix (in this order), each separated by a single space. If discrete name parts are required, a Patient resource SHALL be pointed to in Coverage.subscriber.reference.	Elements differ in short: 'Text alternative for the resource' vs 'Provide the name of the subscriber in Coverage.subscriber.display concatenating the subscriber’s prefix, given name, family name and suffix (in this order), each separated by a single space. If discrete name parts are required, a Patient resource SHALL be pointed to in Coverage.subscriber.reference.' Element minimum cardinalities differ: '0' vs '1'
subscriberId	SΣC	0..1	string	ID assigned to the subscriber	SΣ	1..1	string	Subscriber ID	Elements differ in short: 'ID assigned to the subscriber' vs 'Subscriber ID' Elements differ in requirements: 'The insurer requires this identifier on correspondance and claims (digital and otherwise).' vs 'The subscriber Id is a number that is needed by the payer to associate the attestation with the member in their system.' Element minimum cardinalities differ: '0' vs '1'
beneficiary	SΣ	1..1	Reference(US Core Patient Profile)	Plan beneficiary	SΣ	1..1	Reference(HRex Patient Demographics)	Plan beneficiary	Elements differ in requirements: 'This is the party who receives treatment for which the costs are reimbursed under the coverage.' vs 'This would usually be the US Core Patient Resource for which the service was performed.'
dependent	Σ	0..1	string	Dependent number	SΣ	0..1	string	Dependent number	Elements differ in definition for mustSupport: 'false' vs 'true'
relationship	S	1..1	CodeableConcept	Beneficiary relationship to the subscriber Binding: ?? (extensible)		1..1	CodeableConcept	Beneficiary relationship to the subscriber Binding: ?? (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).	Elements differ in comments: 'Relationship of the member to the person insured (subscriber)' vs 'Typically, an individual uses policies which are theirs (relationship='self') before policies owned by others.' Elements differ in definition for mustSupport: 'true' vs 'false'
period	SΣ	0..1	Period	Coverage start and end dates	Σ	1..1	Period	Coverage start and end dates	Elements differ in definition for mustSupport: 'true' vs 'false' Element minimum cardinalities differ: '0' vs '1'
payor	SΣ	1..1	Reference(US Core Organization Profile S | US Core Patient Profile | US Core RelatedPerson Profile)	Issuer of the policy	SΣ	1..1	Reference(PCT Organization)	Issuer of the policy	Elements differ in comments: 'Issuer of the Policy' vs 'May provide multiple identifiers such as insurance company identifier or business identifier (BIN number). For selfpay it may provide multiple paying persons and/or organizations. When sending payer, it may either be a reference to a record stored on a mutually accessible registry, or the Reference.display and Reference.identifier elements can be used to convey the payer's name and identifer.'
Slices for class	S	0..*	BackboneElement	Additional coverage classifications Slice: Unordered, Open by pattern:type		1..*	BackboneElement	Additional coverage classifications Slice: Unordered, Open by pattern:type	Elements differ in definition for mustSupport: 'true' vs 'false' Element minimum cardinalities differ: '0' vs '1'
id		0..1	string	Unique id for inter-element referencing		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	Σ	1..1	CodeableConcept	Type of class such as 'group' or 'plan' Binding: ?? (extensible): The policy classifications, eg. Group, Plan, Class, etc.	Σ	1..1	CodeableConcept	Type of class such as 'group' or 'plan' Binding: ?? (extensible): The policy classifications, eg. Group, Plan, Class, etc.
value	Σ	1..1	string	Value associated with the type	Σ	1..1	string	Value associated with the type
name	Σ	0..1	string	Human readable description of the type and value	Σ	1..1	string	Human readable description of the type and value	Element minimum cardinalities differ: '0' vs '1'
order	Σ	0..1	positiveInt	Relative order of the coverage	Σ	0..1	positiveInt	Relative order of the coverage
network	Σ	0..1	string	Insurer network	Σ	0..1	string	Insurer network
costToBeneficiary		0..*	BackboneElement	Patient payments for services/products		0..*	BackboneElement	Patient payments for services/products
id		0..1	string	Unique id for inter-element referencing		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	Σ	0..1	CodeableConcept	Cost category Binding: ?? (extensible): The types of services to which patient copayments are specified.	Σ	0..1	CodeableConcept	Cost category Binding: ?? (required)
value[x]	Σ	1..1	??, Money	The amount or percentage due from the beneficiary	Σ	1..1	??, Money	The amount or percentage due from the beneficiary
exception		0..*	BackboneElement	Exceptions for patient payments		0..*	BackboneElement	Exceptions for patient payments
id		0..1	string	Unique id for inter-element referencing		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	Σ	1..1	CodeableConcept	Exception category Binding: ?? (example): The types of exceptions from the part or full value of financial obligations such as copays.	Σ	1..1	CodeableConcept	Exception category Binding: ?? (example): The types of exceptions from the part or full value of financial obligations such as copays.
period	Σ	0..1	Period	The effective period of the exception	Σ	0..1	Period	The effective period of the exception
subrogation		0..1	boolean	Reimbursement to insurer		0..1	boolean	Reimbursement to insurer
contract		0..*	Reference(Contract)	Contract details		0..*	Reference(Contract)	Contract details
Documentation for this format