QI-Core Implementation Guide
4.1.1 - STU 4.1.1
US
QI-Core Implementation Guide
4.1.1 - STU 4.1.1
US
This page is part of the Quality Improvement Core Framework (v4.1.1: STU 4) based on FHIR R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions 
| Official URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-coverage | Version: 4.1.1 | |||
| Draft 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.
define "SDE Payer":
[Coverage: type in "Payer"] Payer
return {
code: Payer.type,
period: Payer.period
}
| General Person Primary Coverage Example |
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Coverage
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 |
| beneficiary | S | 1..1 | Reference(QICorePatient) | Plan beneficiary |
| period | S | 0..1 | Period | Coverage start and end dates |
 payor | S | 1..* | Reference(QICorePatient | QICoreOrganization | QICoreRelatedPerson) | Issuer of the policy |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Coverage | 0..* | Coverage | Insurance or medical plan or a payment agreement | |
 id | Σ | 0..1 | string | 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) Max Binding: AllLanguages: A human language. | |
| 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 | Σ | 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..* | 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 | 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 (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 | 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 |
| beneficiary | Σ | 1..1 | Reference(QICorePatient) | Plan beneficiary |
| period | Σ | 0..1 | Period | Coverage start and end dates |
| payor | Σ | 1..* | Reference(QICorePatient | QICoreOrganization | QICoreRelatedPerson) | Issuer of the policy |
| Documentation for this format | ||||
This structure is derived from Coverage
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 |
| beneficiary | S | 1..1 | Reference(QICorePatient) | Plan beneficiary |
| period | S | 0..1 | Period | Coverage start and end dates |
| payor | S | 1..* | Reference(QICorePatient | QICoreOrganization | QICoreRelatedPerson) | Issuer of the policy |
| Documentation for this format | ||||
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Coverage | 0..* | Coverage | Insurance or medical plan or a payment agreement | |
| id | Σ | 0..1 | string | 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) Max Binding: AllLanguages: A human language. | |
| 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 | Σ | 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..* | 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 | 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 (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 | 0..* | Reference(Contract) | Contract details | |
| Documentation for this format | ||||
Other representations of profile: CSV, Excel, Schematron
| 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 |
| 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#4.1.1 based on FHIR 4.0.1. Generated 2022-03-31
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