HL7.FHIR.US.QICORE\QICore Coverage

QI-Core Implementation Guide
5.0.0-ballot - STU Ballot US

This page is part of the Quality Improvement Core Framework (v5.0.0-ballot: STU 5 Ballot 1) based on FHIR R4. The current version which supercedes this version is 4.1.1. For a full list of available versions, see the Directory of published versions

Resource Profile: QICore Coverage

Official URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-coverage				Version: 5.0.0-ballot
Active as of 2018-08-22				Computable Name: QICoreCoverage

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

Usage

See the patterns page for implementation and usage patterns.

define "SDE Payer":
  [Coverage: type in "Payer"] Payer
    return {
      code: Payer.type,
      period: Payer.period
    }

Examples

General Person Primary Coverage Example

General Subscriber ID Coverage Example

Usage:

Examples for this Resource Profile: Coverage/example-new, Coverage/example

Formal Views of Profile Content

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

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

This structure is derived from Coverage

Summary

Mandatory: 1 element
Must-Support: 8 elements

Structures

This structure refers to these other structures:

This structure is derived from Coverage

Name	Flags	Card.	Type	Description & Constraints
Coverage		0..*	Coverage	Insurance or medical plan or a payment agreement
type	S	0..1	CodeableConcept	Coverage category such as medical or accident Binding: https://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 (required): Categories of types of health care payor entities as defined by the US Public Health Data Consortium SOP code system
policyHolder	S	0..1	Reference(QICorePatient \| QICoreOrganization \| QICoreRelatedPerson)	Owner of the policy
subscriberId	S	0..1	string	ID assigned to the subscriber
beneficiary	S	1..1	Reference(QICorePatient)	Plan beneficiary
period	S	0..1	Period	Coverage start and end dates
payor	S	1..1	Reference(QICorePatient \| QICoreOrganization \| QICoreRelatedPerson)	Issuer of the policy
order	S	0..1	positiveInt	Relative order of the coverage
contract	S	0..*	Reference(Contract)	Contract details
Documentation for this format

Description & Constraints

Coverage

0..*

Coverage

Insurance or medical plan or a payment agreement

id

Σ

0..1

string

Logical id of this artifact

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 Bindings

Purpose

AllLanguages

Max Binding

text

0..1

Narrative

Text summary of the resource, for human interpretation

contained

0..*

Resource

Contained, inline Resources

extension

0..*

Extension

Additional content defined by implementations

modifierExtension

?!

0..*

Extension

Extensions that cannot be ignored

identifier

Σ

0..*

Identifier

Business Identifier for the coverage

status

?!Σ

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
Binding: https://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 (required): Categories of types of health care payor entities as defined by the US Public Health Data Consortium SOP code system

policyHolder

SΣ

0..1

Reference(QICorePatient | QICoreOrganization | QICoreRelatedPerson)

Owner of the policy

subscriber

Σ

0..1

Reference(Patient | RelatedPerson)

Subscriber to the policy

subscriberId

SΣ

0..1

string

ID assigned to the subscriber

beneficiary

SΣ

1..1

Reference(QICorePatient)

Plan beneficiary

dependent

Σ

0..1

string

Dependent number

relationship

0..1

CodeableConcept

Beneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).

period

SΣ

0..1

Period

Coverage start and end dates

payor

SΣ

1..1

Reference(QICorePatient | QICoreOrganization | QICoreRelatedPerson)

Issuer of the policy

class

0..*

BackboneElement

Additional coverage classifications

id

0..1

string

Unique id for inter-element referencing

extension

0..*

Extension

Additional content defined by implementations

modifierExtension

?!Σ

0..*

Extension

Extensions that cannot be ignored even if unrecognized

type

Σ

1..1

CodeableConcept

Type of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.

value

Σ

1..1

string

Value associated with the type

name

Σ

0..1

string

Human readable description of the type and value

order

SΣ

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 (extensible): The types of services to which patient copayments are specified.

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

S

0..*

Reference(Contract)

Contract details

Documentation for this format

Name	Flags	Card.	Type	Description & Constraints
Coverage		0..*	Coverage	Insurance or medical plan or a payment agreement
type	Σ	0..1	CodeableConcept	Coverage category such as medical or accident Binding: https://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 (required): Categories of types of health care payor entities as defined by the US Public Health Data Consortium SOP code system
policyHolder	Σ	0..1	Reference(QICorePatient \| QICoreOrganization \| QICoreRelatedPerson)	Owner of the policy
subscriberId	Σ	0..1	string	ID assigned to the subscriber
beneficiary	Σ	1..1	Reference(QICorePatient)	Plan beneficiary
period	Σ	0..1	Period	Coverage start and end dates
payor	Σ	1..1	Reference(QICorePatient \| QICoreOrganization \| QICoreRelatedPerson)	Issuer of the policy
order	Σ	0..1	positiveInt	Relative order of the coverage
contract		0..*	Reference(Contract)	Contract details
Documentation for this format

This structure is derived from Coverage

Summary

Mandatory: 1 element
Must-Support: 8 elements

Structures

This structure refers to these other structures:

Differential View

This structure is derived from Coverage

Name	Flags	Card.	Type	Description & Constraints
Coverage		0..*	Coverage	Insurance or medical plan or a payment agreement
type	S	0..1	CodeableConcept	Coverage category such as medical or accident Binding: https://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 (required): Categories of types of health care payor entities as defined by the US Public Health Data Consortium SOP code system
policyHolder	S	0..1	Reference(QICorePatient \| QICoreOrganization \| QICoreRelatedPerson)	Owner of the policy
subscriberId	S	0..1	string	ID assigned to the subscriber
beneficiary	S	1..1	Reference(QICorePatient)	Plan beneficiary
period	S	0..1	Period	Coverage start and end dates
payor	S	1..1	Reference(QICorePatient \| QICoreOrganization \| QICoreRelatedPerson)	Issuer of the policy
order	S	0..1	positiveInt	Relative order of the coverage
contract	S	0..*	Reference(Contract)	Contract details
Documentation for this format

Snapshot View

Description & Constraints

Coverage

0..*

Coverage

Insurance or medical plan or a payment agreement

id

Σ

0..1

string

Logical id of this artifact

Terminology Bindings

Path	Conformance	ValueSet
Coverage.language	preferred	CommonLanguages Max Binding: AllLanguages
Coverage.status	required	FinancialResourceStatusCodes
Coverage.type	required	https://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591
Coverage.relationship	extensible	SubscriberRelationshipCodes
Coverage.class.type	extensible	CoverageClassCodes
Coverage.costToBeneficiary.type	extensible	CoverageCopayTypeCodes
Coverage.costToBeneficiary.exception.type	example	ExampleCoverageFinancialExceptionCodes

Constraints

Id	Grade	Path	Details	Requirements
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	Coverage.meta	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Coverage.implicitRules	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Coverage.language	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Coverage.text	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Coverage.extension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	Coverage.extension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	error	Coverage.modifierExtension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	Coverage.modifierExtension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	error	Coverage.identifier	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Coverage.status	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Coverage.type	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Coverage.policyHolder	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Coverage.subscriber	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Coverage.subscriberId	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Coverage.beneficiary	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Coverage.dependent	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Coverage.relationship	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Coverage.period	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Coverage.payor	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Coverage.class	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Coverage.class.extension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	Coverage.class.extension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	error	Coverage.class.modifierExtension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	Coverage.class.modifierExtension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	error	Coverage.class.type	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Coverage.class.value	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Coverage.class.name	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Coverage.order	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Coverage.network	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Coverage.costToBeneficiary	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Coverage.costToBeneficiary.extension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	Coverage.costToBeneficiary.extension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	error	Coverage.costToBeneficiary.modifierExtension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	Coverage.costToBeneficiary.modifierExtension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	error	Coverage.costToBeneficiary.type	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Coverage.costToBeneficiary.value[x]	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Coverage.costToBeneficiary.exception	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Coverage.costToBeneficiary.exception.extension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	Coverage.costToBeneficiary.exception.extension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	error	Coverage.costToBeneficiary.exception.modifierExtension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	Coverage.costToBeneficiary.exception.modifierExtension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	error	Coverage.costToBeneficiary.exception.type	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Coverage.costToBeneficiary.exception.period	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Coverage.subrogation	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Coverage.contract	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())

IG © 2019+ http://www.hl7.org/Special/committees/cqi/index.cfm. Package hl7.fhir.us.qicore#5.0.0-ballot based on FHIR 4.0.1. Generated 2022-08-08
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