Da Vinci Payer Data Exchange
1.0.0 - STU1

This page is part of the Da Vinci Payer Data Exchange (v1.0.0: STU1) based on FHIR R4. This is the current published version. For a full list of available versions, see the Directory of published versions

Resource Profile: HRex Coverage Profile

Defining URL:http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/hrex-coverage
Version:1.0.0
Name:HrexCoverage
Title:HRex Coverage Profile
Status:Draft as of 2020-12-22T14:19:47+00:00
Definition:

The HRex Coverage Profile defines the constraints for representing a member's healthcare insurance information to the Payer. Coverage instances complying with this profile, sometimes together with the Patient which this profile references via beneficiary, allows a payer to identify a member in their system.

Publisher:HL7 International
Source Resource:XML / JSON / Turtle

The official URL for this profile is: 

http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/hrex-coverage

Future Development of Coverage

Coverage is a resource that is used by a number of use cases and Implementation Guides. The Coverage resource included in the PDex Implementation Guide will be superceded by the Coverage profile that is defined in the HRex Implementation Guide.

Check the Da Vinci Health Record Exchange IG Directory of Published Versions History Page> for release information: http://hl7.org/fhir/us/davinci-hrex/2020Sep

Formal Views of Profile Content

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

This structure is derived from Coverage

Summary

Must-Support: 4 elements

Structures

This structure refers to these other structures:

This structure is derived from Coverage

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..*CoverageInsurance or medical plan or a payment agreement
... identifier S0..*IdentifierBusiness Identifier for the coverage
... type 0..1CodeableConceptCoverage category such as medical or accident
Binding: CoverageTypeAndSelf-PayCodes (required)
... policyHolder 0..1Reference(US Core Patient Profile | US Core Organization Profile | RelatedPerson)Owner of the policy
... subscriberId S0..1stringID assigned to the subscriber
... beneficiary S1..1Reference(US Core Patient Profile)Plan beneficiary
... payor S1..*Reference(US Core Organization Profile)Issuer of the policy

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..*CoverageInsurance or medical plan or a payment agreement
... id Σ0..1stringLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier SΣ0..*IdentifierBusiness Identifier for the coverage
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... type Σ0..1CodeableConceptCoverage category such as medical or accident
Binding: CoverageTypeAndSelf-PayCodes (required)
... policyHolder Σ0..1Reference(US Core Patient Profile | US Core Organization Profile | RelatedPerson)Owner of the policy
... subscriber Σ0..1Reference(US Core Patient Profile)Subscriber to the policy
... subscriberId SΣ0..1stringID assigned to the subscriber
... beneficiary SΣ1..1Reference(US Core Patient Profile)Plan beneficiary
... dependent Σ0..1stringDependent number
... relationship 0..1CodeableConceptBeneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).

... period Σ0..1PeriodCoverage start and end dates
... payor SΣ1..*Reference(US Core Organization Profile)Issuer of the policy
... class 0..*BackboneElementAdditional coverage classifications
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type Σ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.

.... value Σ1..1stringValue associated with the type
.... name Σ0..1stringHuman readable description of the type and value
... order Σ0..1positiveIntRelative order of the coverage
... network Σ0..1stringInsurer network
... costToBeneficiary 0..*BackboneElementPatient payments for services/products
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type Σ0..1CodeableConceptCost category
Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified.

.... value[x] Σ1..1The amount or percentage due from the beneficiary
..... valueQuantityQuantity(SimpleQuantity)
..... valueMoneyMoney
.... exception 0..*BackboneElementExceptions for patient payments
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type Σ1..1CodeableConceptException category
Binding: ExampleCoverageFinancialExceptionCodes (example): The types of exceptions from the part or full value of financial obligations such as copays.

..... period Σ0..1PeriodThe effective period of the exception
... subrogation 0..1booleanReimbursement to insurer
... contract 0..*Reference(Contract)Contract details

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..*CoverageInsurance or medical plan or a payment agreement
... identifier Σ0..*IdentifierBusiness Identifier for the coverage
... subscriberId Σ0..1stringID assigned to the subscriber
... beneficiary Σ1..1Reference(US Core Patient Profile)Plan beneficiary

doco Documentation for this format

This structure is derived from Coverage

Summary

Must-Support: 4 elements

Structures

This structure refers to these other structures:

Differential View

This structure is derived from Coverage

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..*CoverageInsurance or medical plan or a payment agreement
... identifier S0..*IdentifierBusiness Identifier for the coverage
... type 0..1CodeableConceptCoverage category such as medical or accident
Binding: CoverageTypeAndSelf-PayCodes (required)
... policyHolder 0..1Reference(US Core Patient Profile | US Core Organization Profile | RelatedPerson)Owner of the policy
... subscriberId S0..1stringID assigned to the subscriber
... beneficiary S1..1Reference(US Core Patient Profile)Plan beneficiary
... payor S1..*Reference(US Core Organization Profile)Issuer of the policy

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..*CoverageInsurance or medical plan or a payment agreement
... id Σ0..1stringLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier SΣ0..*IdentifierBusiness Identifier for the coverage
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... type Σ0..1CodeableConceptCoverage category such as medical or accident
Binding: CoverageTypeAndSelf-PayCodes (required)
... policyHolder Σ0..1Reference(US Core Patient Profile | US Core Organization Profile | RelatedPerson)Owner of the policy
... subscriber Σ0..1Reference(US Core Patient Profile)Subscriber to the policy
... subscriberId SΣ0..1stringID assigned to the subscriber
... beneficiary SΣ1..1Reference(US Core Patient Profile)Plan beneficiary
... dependent Σ0..1stringDependent number
... relationship 0..1CodeableConceptBeneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).

... period Σ0..1PeriodCoverage start and end dates
... payor SΣ1..*Reference(US Core Organization Profile)Issuer of the policy
... class 0..*BackboneElementAdditional coverage classifications
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type Σ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.

.... value Σ1..1stringValue associated with the type
.... name Σ0..1stringHuman readable description of the type and value
... order Σ0..1positiveIntRelative order of the coverage
... network Σ0..1stringInsurer network
... costToBeneficiary 0..*BackboneElementPatient payments for services/products
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type Σ0..1CodeableConceptCost category
Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified.

.... value[x] Σ1..1The amount or percentage due from the beneficiary
..... valueQuantityQuantity(SimpleQuantity)
..... valueMoneyMoney
.... exception 0..*BackboneElementExceptions for patient payments
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type Σ1..1CodeableConceptException category
Binding: ExampleCoverageFinancialExceptionCodes (example): The types of exceptions from the part or full value of financial obligations such as copays.

..... period Σ0..1PeriodThe effective period of the exception
... subrogation 0..1booleanReimbursement to insurer
... contract 0..*Reference(Contract)Contract details

doco Documentation for this format

 

Other representations of profile: Schematron

Terminology Bindings

PathConformanceValueSet
Coverage.languagepreferredCommonLanguages
Max Binding: AllLanguages
Coverage.statusrequiredFinancialResourceStatusCodes
Coverage.typerequiredCoverageTypeAndSelf-PayCodes
Coverage.relationshipextensibleSubscriberRelationshipCodes
Coverage.class.typeextensibleCoverageClassCodes
Coverage.costToBeneficiary.typeextensibleCoverageCopayTypeCodes
Coverage.costToBeneficiary.exception.typeexampleExampleCoverageFinancialExceptionCodes