Patient Cost Transparency Implementation Guide
2.0.0 - STU 2 United States of America flag

This page is part of the Da Vinci Patient Cost Transparency Implementation Guide (v2.0.0: 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

Resource Profile: PCT Coverage

Official URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage Version: 2.0.0
Standards status: Trial-use Maturity Level: 2 Computable Name: PCTCoverage
Other Identifiers: OID:2.16.840.1.113883.4.642.40.4.42.8

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.

Usages:

You can also check for usages in the FHIR IG Statistics

Changes since version 1.1.0:

  • The resource metadata has changed (description)
  • The data elements list has changed
  • One or more text definitions, invariants or bindings have changed

    • Formal Views of Profile Content

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

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Coverage C 0..* USCoreCoverageProfile(7.0.0) Insurance or medical plan or a payment agreement
    Constraints: us-core-15, pct-coverage-1, pct-coverage-2
    ... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
    ... Slices for extension 1..* Extension Extension
    Slice: Unordered, Open by value:url
    .... extension:coverage-kind S 1..1 (Complex) Optional Extensions Element
    URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind
    ..... extension 0..0
    ..... url 1..1 uri "http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind"
    ..... value[x] 1..1 code Value of extension
    .... extension:self-pay-declared S 0..1 boolean Self-Pay Declared
    URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/selfPayDeclared
    ... 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
    ..... 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
    ... status ?!SΣ 1..1 code active | cancelled | draft | entered-in-error
    Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
    ... type SΣ 0..1 CodeableConcept Coverage category such as medical or accident. A coverage.type of `81` (Self-pay) MAY be used to imply that the patient has no coverage or that an individual or organization other than an insurer is taking responsibility for payment for a portion of the health care costs.
    Binding: Payer Type . (extensible): US Public Health Data Consortium Source of Payment Codes
    ... subscriber Σ 0..1 Reference(Patient | RelatedPerson) 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.
    .... display Σ 0..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.
    ... subscriberId SΣC 1..1 string ID assigned to the subscriber
    .... Slices for extension 0..* Extension Extension
    Slice: Unordered, Open by value:url
    ..... extension:dataAbsentReason 0..1 (Complex) unknown | asked | temp | notasked | masked | unsupported | astext | error
    URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
    ...... extension 0..0
    ...... url 1..1 uri "http://hl7.org/fhir/StructureDefinition/data-absent-reason"
    ...... value[x] 1..1 code Use Data Absent Reason (DAR) extension with a value of 'not-applicable' for self-pay or uninsured
    Binding: DataAbsentReason (required)
    Required Pattern: not-applicable
    ... beneficiary SΣ 1..1 Reference(US Core Patient Profile(7.0.0)) Patient or Plan Beneficiary
    ... relationship S 1..1 CodeableConcept Beneficiary relationship to the subscriber
    Binding: SubscriberRelationshipCodes (extensible)
    ... period SΣ 0..1 Period Coverage start and end dates
    ... payor SΣ 1..1 Reference(PCT Organization | US Core Patient Profile(7.0.0) | US Core RelatedPerson Profile(7.0.0)) Issuer of the policy. For Self-pay or uninsured this should be a reference to a patient or related person resource
    ... Slices for class S 0..* BackboneElement Additional coverage classifications
    Slice: Unordered, Open by pattern:type
    .... class:All Slices Content/Rules for all slices
    ..... 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 1..1 string Human readable description of the type and value
    .... class:group S 0..1 BackboneElement Group
    ..... 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 1..1 string Group Name
    .... class:plan S 0..1 BackboneElement Plan
    ..... 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 1..1 string Plan Name

    doco Documentation for this format

    Terminology Bindings

    Path Status Usage ValueSet Version Source
    Coverage.identifier:memberid.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
    Coverage.identifier:memberid.​type Base extensible IdentifierType 📦4.0.1 FHIR Std.
    Coverage.status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
    Coverage.type Base extensible Payer Type . 📦20221118 VSAC v0.19
    Coverage.subscriberId.​extension:dataAbsentReason.​value[x] Base required DataAbsentReason 📦4.0.1 FHIR Std.
    Coverage.relationship Base extensible SubscriberPolicyholder Relationship Codes 📦4.0.1 FHIR Std.
    Coverage.class.type Base extensible Coverage Class Codes 📦4.0.1 FHIR Std.
    Coverage.class:group.​type Base extensible Coverage Class Codes 📦4.0.1 FHIR Std.
    Coverage.class:plan.​type Base extensible Coverage Class Codes 📦4.0.1 FHIR Std.

    Constraints

    Id Grade Path(s) Description Expression
    dom-2 error Coverage If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
    dom-3 error 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 error 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 error Coverage If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
    dom-6 best practice Coverage A resource should have narrative for robust management text.`div`.exists()
    ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
    ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
    pct-coverage-1 error Coverage Coverage: class element SHALL be present if coverage-0kind is insurance extension.where(url='http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind'and value = 'insurance').exists() implies class.exists()
    pct-coverage-2 error Coverage Coverage: period element SHALL be present if coverage-0kind is insurance extension.where(url='http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind'and value = 'insurance').exists() implies period.exists()
    us-core-15 error Coverage Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present identifier.type.coding.where(system='http://terminology.hl7.org/CodeSystem/v2-0203' and code='MB').exists() or subscriberId.exists()

    This structure is derived from USCoreCoverageProfile

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Coverage C 0..* USCoreCoverageProfile(7.0.0) Insurance or medical plan or a payment agreement
    Constraints: pct-coverage-1, pct-coverage-2
    ... Slices for extension 1..* Extension Extension
    Slice: Unordered, Open by value:url
    .... extension:coverage-kind S 1..1 (Complex) Optional Extensions Element
    URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind
    ..... value[x] 1..1 code Value of extension
    .... extension:self-pay-declared S 0..1 boolean Self-Pay Declared
    URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/selfPayDeclared
    ... type 0..1 CodeableConcept Coverage category such as medical or accident. A coverage.type of `81` (Self-pay) MAY be used to imply that the patient has no coverage or that an individual or organization other than an insurer is taking responsibility for payment for a portion of the health care costs.
    ... subscriber 0..1 Reference(Patient | RelatedPerson) 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.
    .... display 0..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.
    ... subscriberId 1..1 string ID assigned to the subscriber
    .... Slices for extension 0..* Extension Extension
    Slice: Unordered, Open by value:url
    ..... extension:dataAbsentReason 0..1 (Complex) unknown | asked | temp | notasked | masked | unsupported | astext | error
    URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
    ...... value[x] 1..1 code Use Data Absent Reason (DAR) extension with a value of 'not-applicable' for self-pay or uninsured
    Required Pattern: not-applicable
    ... beneficiary 1..1 Reference(US Core Patient Profile(7.0.0)) Patient or Plan Beneficiary
    ... payor 1..1 Reference(PCT Organization | US Core Patient Profile(7.0.0) | US Core RelatedPerson Profile(7.0.0)) Issuer of the policy. For Self-pay or uninsured this should be a reference to a patient or related person resource
    ... class 0..* BackboneElement Additional coverage classifications
    .... name 1..1 string Human readable description of the type and value
    ... Slices for class Content/Rules for all slices
    .... class:group 0..1 BackboneElement Group
    ..... name 1..1 string Group Name
    .... class:plan 0..1 BackboneElement Plan
    ..... name 1..1 string Plan Name
    ... costToBeneficiary
    .... type 0..1 CodeableConcept Cost category
    Binding: CoverageCopayTypeCodes (1.0.1) (required)

    doco Documentation for this format

    Terminology Bindings (Differential)

    Path Status Usage ValueSet Version Source
    Coverage.costToBeneficiary.​type Base required Coverage Copay Type Codes 📍1.0.1 THO v6.5

    Constraints

    Id Grade Path(s) Description Expression
    pct-coverage-1 error Coverage Coverage: class element SHALL be present if coverage-0kind is insurance extension.where(url='http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind'and value = 'insurance').exists() implies class.exists()
    pct-coverage-2 error Coverage Coverage: period element SHALL be present if coverage-0kind is insurance extension.where(url='http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind'and value = 'insurance').exists() implies period.exists()
    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Coverage C 0..* USCoreCoverageProfile(7.0.0) Insurance or medical plan or a payment agreement
    Constraints: us-core-15, pct-coverage-1, pct-coverage-2
    ... 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 BindingsPurpose
    AllLanguages Max Binding
    ... text 0..1 Narrative Text summary of the resource, for human interpretation
    This profile does not constrain the narrative in regard to content, language, or traceability to data elements
    ... contained 0..* Resource Contained, inline Resources
    ... Slices for extension 1..* Extension Extension
    Slice: Unordered, Open by value:url
    .... extension:coverage-kind S 1..1 (Complex) Optional Extensions Element
    URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind
    ..... id 0..1 string Unique id for inter-element referencing
    ..... extension 0..0
    ..... url 1..1 uri "http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind"
    ..... value[x] 1..1 code Value of extension
    .... extension:self-pay-declared S 0..1 boolean Self-Pay Declared
    URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/selfPayDeclared
    ... 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.
    ... type SΣ 0..1 CodeableConcept Coverage category such as medical or accident. A coverage.type of `81` (Self-pay) MAY be used to imply that the patient has no coverage or that an individual or organization other than an insurer is taking responsibility for payment for a portion of the health care costs.
    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 Σ 0..1 Reference(Patient | RelatedPerson) 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
    .... extension 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
    .... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
    Binding: ResourceType (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
    .... display Σ 0..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.
    ... subscriberId SΣC 1..1 string ID assigned to the subscriber
    .... id 0..1 string xml:id (or equivalent in JSON)
    .... Slices for extension 0..* Extension Extension
    Slice: Unordered, Open by value:url
    ..... extension:dataAbsentReason 0..1 (Complex) unknown | asked | temp | notasked | masked | unsupported | astext | error
    URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
    ...... id 0..1 id Unique id for inter-element referencing
    ...... extension 0..0
    ...... url 1..1 uri "http://hl7.org/fhir/StructureDefinition/data-absent-reason"
    ...... value[x] 1..1 code Use Data Absent Reason (DAR) extension with a value of 'not-applicable' for self-pay or uninsured
    Binding: DataAbsentReason (required)
    Required Pattern: not-applicable
    .... value 0..1 string Primitive value for string
    Max Length:1048576
    ... beneficiary SΣ 1..1 Reference(US Core Patient Profile(7.0.0)) Patient or Plan Beneficiary
    ... dependent Σ 0..1 string Dependent number
    ... relationship S 1..1 CodeableConcept Beneficiary relationship to the subscriber
    Binding: SubscriberRelationshipCodes (extensible)
    ... period SΣ 0..1 Period Coverage start and end dates
    ... payor SΣ 1..1 Reference(PCT Organization | US Core Patient Profile(7.0.0) | US Core RelatedPerson Profile(7.0.0)) Issuer of the policy. For Self-pay or uninsured this should be a reference to a patient or related person resource
    ... 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 1..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 1..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 1..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 (1.0.1) (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

    doco Documentation for this format

    Terminology Bindings

    Path Status Usage ValueSet Version Source
    Coverage.language Base preferred Common Languages 📦4.0.1 FHIR Std.
    Coverage.identifier:memberid.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
    Coverage.identifier:memberid.​type Base extensible IdentifierType 📦4.0.1 FHIR Std.
    Coverage.status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
    Coverage.type Base extensible Payer Type . 📦20221118 VSAC v0.19
    Coverage.subscriber.​type Base extensible ResourceType 📍4.0.1 FHIR Std.
    Coverage.subscriberId.​extension:dataAbsentReason.​value[x] Base required DataAbsentReason 📦4.0.1 FHIR Std.
    Coverage.relationship Base extensible SubscriberPolicyholder Relationship Codes 📦4.0.1 FHIR Std.
    Coverage.class.type Base extensible Coverage Class Codes 📦4.0.1 FHIR Std.
    Coverage.class:group.​type Base extensible Coverage Class Codes 📦4.0.1 FHIR Std.
    Coverage.class:plan.​type Base extensible Coverage Class Codes 📦4.0.1 FHIR Std.
    Coverage.costToBeneficiary.​type Base required Coverage Copay Type Codes 📍1.0.1 THO v6.5
    Coverage.costToBeneficiary.​exception.type Base example Example Coverage Financial Exception Codes 📦4.0.1 FHIR Std.

    Constraints

    Id Grade Path(s) Description Expression
    dom-2 error Coverage If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
    dom-3 error 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 error 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 error Coverage If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
    dom-6 best practice Coverage A resource should have narrative for robust management text.`div`.exists()
    ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
    ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
    pct-coverage-1 error Coverage Coverage: class element SHALL be present if coverage-0kind is insurance extension.where(url='http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind'and value = 'insurance').exists() implies class.exists()
    pct-coverage-2 error Coverage Coverage: period element SHALL be present if coverage-0kind is insurance extension.where(url='http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind'and value = 'insurance').exists() implies period.exists()
    us-core-15 error Coverage Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present identifier.type.coding.where(system='http://terminology.hl7.org/CodeSystem/v2-0203' and code='MB').exists() or subscriberId.exists()

    Key Elements View

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Coverage C 0..* USCoreCoverageProfile(7.0.0) Insurance or medical plan or a payment agreement
    Constraints: us-core-15, pct-coverage-1, pct-coverage-2
    ... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
    ... Slices for extension 1..* Extension Extension
    Slice: Unordered, Open by value:url
    .... extension:coverage-kind S 1..1 (Complex) Optional Extensions Element
    URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind
    ..... extension 0..0
    ..... url 1..1 uri "http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind"
    ..... value[x] 1..1 code Value of extension
    .... extension:self-pay-declared S 0..1 boolean Self-Pay Declared
    URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/selfPayDeclared
    ... 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
    ..... 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
    ... status ?!SΣ 1..1 code active | cancelled | draft | entered-in-error
    Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
    ... type SΣ 0..1 CodeableConcept Coverage category such as medical or accident. A coverage.type of `81` (Self-pay) MAY be used to imply that the patient has no coverage or that an individual or organization other than an insurer is taking responsibility for payment for a portion of the health care costs.
    Binding: Payer Type . (extensible): US Public Health Data Consortium Source of Payment Codes
    ... subscriber Σ 0..1 Reference(Patient | RelatedPerson) 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.
    .... display Σ 0..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.
    ... subscriberId SΣC 1..1 string ID assigned to the subscriber
    .... Slices for extension 0..* Extension Extension
    Slice: Unordered, Open by value:url
    ..... extension:dataAbsentReason 0..1 (Complex) unknown | asked | temp | notasked | masked | unsupported | astext | error
    URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
    ...... extension 0..0
    ...... url 1..1 uri "http://hl7.org/fhir/StructureDefinition/data-absent-reason"
    ...... value[x] 1..1 code Use Data Absent Reason (DAR) extension with a value of 'not-applicable' for self-pay or uninsured
    Binding: DataAbsentReason (required)
    Required Pattern: not-applicable
    ... beneficiary SΣ 1..1 Reference(US Core Patient Profile(7.0.0)) Patient or Plan Beneficiary
    ... relationship S 1..1 CodeableConcept Beneficiary relationship to the subscriber
    Binding: SubscriberRelationshipCodes (extensible)
    ... period SΣ 0..1 Period Coverage start and end dates
    ... payor SΣ 1..1 Reference(PCT Organization | US Core Patient Profile(7.0.0) | US Core RelatedPerson Profile(7.0.0)) Issuer of the policy. For Self-pay or uninsured this should be a reference to a patient or related person resource
    ... Slices for class S 0..* BackboneElement Additional coverage classifications
    Slice: Unordered, Open by pattern:type
    .... class:All Slices Content/Rules for all slices
    ..... 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 1..1 string Human readable description of the type and value
    .... class:group S 0..1 BackboneElement Group
    ..... 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 1..1 string Group Name
    .... class:plan S 0..1 BackboneElement Plan
    ..... 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 1..1 string Plan Name

    doco Documentation for this format

    Terminology Bindings

    Path Status Usage ValueSet Version Source
    Coverage.identifier:memberid.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
    Coverage.identifier:memberid.​type Base extensible IdentifierType 📦4.0.1 FHIR Std.
    Coverage.status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
    Coverage.type Base extensible Payer Type . 📦20221118 VSAC v0.19
    Coverage.subscriberId.​extension:dataAbsentReason.​value[x] Base required DataAbsentReason 📦4.0.1 FHIR Std.
    Coverage.relationship Base extensible SubscriberPolicyholder Relationship Codes 📦4.0.1 FHIR Std.
    Coverage.class.type Base extensible Coverage Class Codes 📦4.0.1 FHIR Std.
    Coverage.class:group.​type Base extensible Coverage Class Codes 📦4.0.1 FHIR Std.
    Coverage.class:plan.​type Base extensible Coverage Class Codes 📦4.0.1 FHIR Std.

    Constraints

    Id Grade Path(s) Description Expression
    dom-2 error Coverage If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
    dom-3 error 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 error 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 error Coverage If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
    dom-6 best practice Coverage A resource should have narrative for robust management text.`div`.exists()
    ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
    ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
    pct-coverage-1 error Coverage Coverage: class element SHALL be present if coverage-0kind is insurance extension.where(url='http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind'and value = 'insurance').exists() implies class.exists()
    pct-coverage-2 error Coverage Coverage: period element SHALL be present if coverage-0kind is insurance extension.where(url='http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind'and value = 'insurance').exists() implies period.exists()
    us-core-15 error Coverage Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present identifier.type.coding.where(system='http://terminology.hl7.org/CodeSystem/v2-0203' and code='MB').exists() or subscriberId.exists()

    Differential View

    This structure is derived from USCoreCoverageProfile

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Coverage C 0..* USCoreCoverageProfile(7.0.0) Insurance or medical plan or a payment agreement
    Constraints: pct-coverage-1, pct-coverage-2
    ... Slices for extension 1..* Extension Extension
    Slice: Unordered, Open by value:url
    .... extension:coverage-kind S 1..1 (Complex) Optional Extensions Element
    URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind
    ..... value[x] 1..1 code Value of extension
    .... extension:self-pay-declared S 0..1 boolean Self-Pay Declared
    URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/selfPayDeclared
    ... type 0..1 CodeableConcept Coverage category such as medical or accident. A coverage.type of `81` (Self-pay) MAY be used to imply that the patient has no coverage or that an individual or organization other than an insurer is taking responsibility for payment for a portion of the health care costs.
    ... subscriber 0..1 Reference(Patient | RelatedPerson) 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.
    .... display 0..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.
    ... subscriberId 1..1 string ID assigned to the subscriber
    .... Slices for extension 0..* Extension Extension
    Slice: Unordered, Open by value:url
    ..... extension:dataAbsentReason 0..1 (Complex) unknown | asked | temp | notasked | masked | unsupported | astext | error
    URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
    ...... value[x] 1..1 code Use Data Absent Reason (DAR) extension with a value of 'not-applicable' for self-pay or uninsured
    Required Pattern: not-applicable
    ... beneficiary 1..1 Reference(US Core Patient Profile(7.0.0)) Patient or Plan Beneficiary
    ... payor 1..1 Reference(PCT Organization | US Core Patient Profile(7.0.0) | US Core RelatedPerson Profile(7.0.0)) Issuer of the policy. For Self-pay or uninsured this should be a reference to a patient or related person resource
    ... class 0..* BackboneElement Additional coverage classifications
    .... name 1..1 string Human readable description of the type and value
    ... Slices for class Content/Rules for all slices
    .... class:group 0..1 BackboneElement Group
    ..... name 1..1 string Group Name
    .... class:plan 0..1 BackboneElement Plan
    ..... name 1..1 string Plan Name
    ... costToBeneficiary
    .... type 0..1 CodeableConcept Cost category
    Binding: CoverageCopayTypeCodes (1.0.1) (required)

    doco Documentation for this format

    Terminology Bindings (Differential)

    Path Status Usage ValueSet Version Source
    Coverage.costToBeneficiary.​type Base required Coverage Copay Type Codes 📍1.0.1 THO v6.5

    Constraints

    Id Grade Path(s) Description Expression
    pct-coverage-1 error Coverage Coverage: class element SHALL be present if coverage-0kind is insurance extension.where(url='http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind'and value = 'insurance').exists() implies class.exists()
    pct-coverage-2 error Coverage Coverage: period element SHALL be present if coverage-0kind is insurance extension.where(url='http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind'and value = 'insurance').exists() implies period.exists()

    Snapshot View

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Coverage C 0..* USCoreCoverageProfile(7.0.0) Insurance or medical plan or a payment agreement
    Constraints: us-core-15, pct-coverage-1, pct-coverage-2
    ... 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 BindingsPurpose
    AllLanguages Max Binding
    ... text 0..1 Narrative Text summary of the resource, for human interpretation
    This profile does not constrain the narrative in regard to content, language, or traceability to data elements
    ... contained 0..* Resource Contained, inline Resources
    ... Slices for extension 1..* Extension Extension
    Slice: Unordered, Open by value:url
    .... extension:coverage-kind S 1..1 (Complex) Optional Extensions Element
    URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind
    ..... id 0..1 string Unique id for inter-element referencing
    ..... extension 0..0
    ..... url 1..1 uri "http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind"
    ..... value[x] 1..1 code Value of extension
    .... extension:self-pay-declared S 0..1 boolean Self-Pay Declared
    URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/selfPayDeclared
    ... 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.
    ... type SΣ 0..1 CodeableConcept Coverage category such as medical or accident. A coverage.type of `81` (Self-pay) MAY be used to imply that the patient has no coverage or that an individual or organization other than an insurer is taking responsibility for payment for a portion of the health care costs.
    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 Σ 0..1 Reference(Patient | RelatedPerson) 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
    .... extension 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
    .... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
    Binding: ResourceType (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
    .... display Σ 0..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.
    ... subscriberId SΣC 1..1 string ID assigned to the subscriber
    .... id 0..1 string xml:id (or equivalent in JSON)
    .... Slices for extension 0..* Extension Extension
    Slice: Unordered, Open by value:url
    ..... extension:dataAbsentReason 0..1 (Complex) unknown | asked | temp | notasked | masked | unsupported | astext | error
    URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
    ...... id 0..1 id Unique id for inter-element referencing
    ...... extension 0..0
    ...... url 1..1 uri "http://hl7.org/fhir/StructureDefinition/data-absent-reason"
    ...... value[x] 1..1 code Use Data Absent Reason (DAR) extension with a value of 'not-applicable' for self-pay or uninsured
    Binding: DataAbsentReason (required)
    Required Pattern: not-applicable
    .... value 0..1 string Primitive value for string
    Max Length:1048576
    ... beneficiary SΣ 1..1 Reference(US Core Patient Profile(7.0.0)) Patient or Plan Beneficiary
    ... dependent Σ 0..1 string Dependent number
    ... relationship S 1..1 CodeableConcept Beneficiary relationship to the subscriber
    Binding: SubscriberRelationshipCodes (extensible)
    ... period SΣ 0..1 Period Coverage start and end dates
    ... payor SΣ 1..1 Reference(PCT Organization | US Core Patient Profile(7.0.0) | US Core RelatedPerson Profile(7.0.0)) Issuer of the policy. For Self-pay or uninsured this should be a reference to a patient or related person resource
    ... 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 1..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 1..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 1..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 (1.0.1) (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

    doco Documentation for this format

    Terminology Bindings

    Path Status Usage ValueSet Version Source
    Coverage.language Base preferred Common Languages 📦4.0.1 FHIR Std.
    Coverage.identifier:memberid.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
    Coverage.identifier:memberid.​type Base extensible IdentifierType 📦4.0.1 FHIR Std.
    Coverage.status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
    Coverage.type Base extensible Payer Type . 📦20221118 VSAC v0.19
    Coverage.subscriber.​type Base extensible ResourceType 📍4.0.1 FHIR Std.
    Coverage.subscriberId.​extension:dataAbsentReason.​value[x] Base required DataAbsentReason 📦4.0.1 FHIR Std.
    Coverage.relationship Base extensible SubscriberPolicyholder Relationship Codes 📦4.0.1 FHIR Std.
    Coverage.class.type Base extensible Coverage Class Codes 📦4.0.1 FHIR Std.
    Coverage.class:group.​type Base extensible Coverage Class Codes 📦4.0.1 FHIR Std.
    Coverage.class:plan.​type Base extensible Coverage Class Codes 📦4.0.1 FHIR Std.
    Coverage.costToBeneficiary.​type Base required Coverage Copay Type Codes 📍1.0.1 THO v6.5
    Coverage.costToBeneficiary.​exception.type Base example Example Coverage Financial Exception Codes 📦4.0.1 FHIR Std.

    Constraints

    Id Grade Path(s) Description Expression
    dom-2 error Coverage If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
    dom-3 error 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 error 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 error Coverage If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
    dom-6 best practice Coverage A resource should have narrative for robust management text.`div`.exists()
    ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
    ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
    pct-coverage-1 error Coverage Coverage: class element SHALL be present if coverage-0kind is insurance extension.where(url='http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind'and value = 'insurance').exists() implies class.exists()
    pct-coverage-2 error Coverage Coverage: period element SHALL be present if coverage-0kind is insurance extension.where(url='http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind'and value = 'insurance').exists() implies period.exists()
    us-core-15 error Coverage Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present identifier.type.coding.where(system='http://terminology.hl7.org/CodeSystem/v2-0203' and code='MB').exists() or subscriberId.exists()

     

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