HL7.FHIR.US.QICORE\QICoreCoverage

QI-Core Implementation Guide
4.1.0 - release

This page is part of the Quality Improvement Core Framework (v4.1.0: STU 4) 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: QICoreCoverage

Defining URL:

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

Version:

4.1.0

Name:

QICoreCoverage

Status:

Draft as of 8/22/18

Definition:

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

Publisher:

http://www.hl7.org/Special/committees/cqi/index.cfm

Source Resource:

XML / JSON / Turtle

The official URL for this profile is:

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

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

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

Must-Support: 5 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
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

Summary

Must-Support: 5 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
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

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#4.1.0 based on FHIR 4.0.1. Generated 2022-01-18
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