Qi-Core Implementation Guide (Release 2.1 Trial-Use Ballot)

This page is part of the Quality Improvement Core Framework (v2.1.0: STU 3 Ballot 1) based on FHIR R3. The current version which supercedes this version is 4.1.1. For a full list of available versions, see the Directory of published versions

D.4.1 StructureDefinition: qicore-coverage

Examples:

General Person Primary Coverage Example

D.4.1.1 Formal Views of Profile Content

The official URL for this profile is: 

http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-coverage

Profile of Coverage for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.

This profile builds on Coverage.

This profile was published on Mon Aug 21 00:00:00 AEST 2017 as a draft by Health Level Seven International (Clinical Quality Information - QICore).

Description of Profiles, Differentials, and Snapshots.

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage I0..*Insurance or medical plan or a payment agreement
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: Common Languages (extensible)
... text I0..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 Σ0..*IdentifierThe primary coverage ID
... status ?!Σ0..1codeactive | cancelled | draft | entered-in-error
Binding: Financial Resource Status Codes (required)
... type Σ0..1CodeableConceptType of coverage such as medical or accident
Binding: Coverage Type and Self-Pay Codes (preferred)
... policyHolder SΣ0..1Reference(QICore-Patient), Reference(QICore-Organization), Reference(QICore-RelatedPerson)Owner of the policy
... subscriber Σ0..1Reference(Patient), Reference(RelatedPerson)Subscriber to the policy
... subscriberId Σ0..1stringID assigned to the Subscriber
... beneficiary SΣ0..1Reference(QICore-Patient)Plan Beneficiary
... relationship 0..1CodeableConceptBeneficiary relationship to the Subscriber
Binding: Policyholder Relationship Codes (example)
... period Σ0..1PeriodCoverage start and end dates
... payor SΣ0..*Reference(QICore-Patient), Reference(QICore-Organization), Reference(QICore-RelatedPerson)Identifier for the plan or agreement issuer
... grouping I0..1BackboneElementAdditional coverage classifications
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... group Σ0..1stringAn identifier for the group
.... groupDisplay Σ0..1stringDisplay text for an identifier for the group
.... subGroup Σ0..1stringAn identifier for the subsection of the group
.... subGroupDisplay Σ0..1stringDisplay text for the subsection of the group
.... plan Σ0..1stringAn identifier for the plan
.... planDisplay Σ0..1stringDisplay text for the plan
.... subPlan Σ0..1stringAn identifier for the subsection of the plan
.... subPlanDisplay Σ0..1stringDisplay text for the subsection of the plan
.... class Σ0..1stringAn identifier for the class
.... classDisplay Σ0..1stringDisplay text for the class
.... subClass Σ0..1stringAn identifier for the subsection of the class
.... subClassDisplay Σ0..1stringDisplay text for the subsection of the subclass
... dependent Σ0..1stringDependent number
... sequence Σ0..1stringThe plan instance or sequence counter
... order Σ0..1positiveIntRelative order of the coverage
... network Σ0..1stringInsurer network
... contract 0..*Reference(Contract)Contract details

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage I0..*Insurance or medical plan or a payment agreement
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: Common Languages (extensible)
... text I0..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 Σ0..*IdentifierThe primary coverage ID
... status ?!Σ0..1codeactive | cancelled | draft | entered-in-error
Binding: Financial Resource Status Codes (required)
... type Σ0..1CodeableConceptType of coverage such as medical or accident
Binding: Coverage Type and Self-Pay Codes (preferred)
... policyHolder SΣ0..1Reference(QICore-Patient), Reference(QICore-Organization), Reference(QICore-RelatedPerson)Owner of the policy
... subscriber Σ0..1Reference(Patient), Reference(RelatedPerson)Subscriber to the policy
... subscriberId Σ0..1stringID assigned to the Subscriber
... beneficiary SΣ0..1Reference(QICore-Patient)Plan Beneficiary
... relationship 0..1CodeableConceptBeneficiary relationship to the Subscriber
Binding: Policyholder Relationship Codes (example)
... period Σ0..1PeriodCoverage start and end dates
... payor SΣ0..*Reference(QICore-Patient), Reference(QICore-Organization), Reference(QICore-RelatedPerson)Identifier for the plan or agreement issuer
... grouping I0..1BackboneElementAdditional coverage classifications
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... group Σ0..1stringAn identifier for the group
.... groupDisplay Σ0..1stringDisplay text for an identifier for the group
.... subGroup Σ0..1stringAn identifier for the subsection of the group
.... subGroupDisplay Σ0..1stringDisplay text for the subsection of the group
.... plan Σ0..1stringAn identifier for the plan
.... planDisplay Σ0..1stringDisplay text for the plan
.... subPlan Σ0..1stringAn identifier for the subsection of the plan
.... subPlanDisplay Σ0..1stringDisplay text for the subsection of the plan
.... class Σ0..1stringAn identifier for the class
.... classDisplay Σ0..1stringDisplay text for the class
.... subClass Σ0..1stringAn identifier for the subsection of the class
.... subClassDisplay Σ0..1stringDisplay text for the subsection of the subclass
... dependent Σ0..1stringDependent number
... sequence Σ0..1stringThe plan instance or sequence counter
... order Σ0..1positiveIntRelative order of the coverage
... network Σ0..1stringInsurer network
... contract 0..*Reference(Contract)Contract details

doco Documentation for this format

 

D.4.1.2 Terminology Bindings

Terminology Bindings

PathNameConformanceValueSet
Coverage.languageCommon LanguagesextensibleCommon Languages
Coverage.statusFinancial Resource Status CodesrequiredFinancial Resource Status Codes
Coverage.typeCoverage Type and Self-Pay CodespreferredCoverage Type and Self-Pay Codes
Coverage.relationshipPolicyholder Relationship CodesexamplePolicyholder Relationship Codes

D.4.1.3 Constraints

Constraints

IdPathDetailsRequirements
dom-2CoverageIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-1CoverageIf the resource is contained in another resource, it SHALL NOT contain any narrative
: contained.text.empty()
dom-4CoverageIf 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-3CoverageIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource
: contained.where(('#'+id in %resource.descendants().reference).not()).empty()
ele-1Coverage.groupingAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())