QI-Core Implementation Guide
6.0.0 - STU6
QI-Core Implementation Guide
6.0.0 - STU6
This page is part of the Quality Improvement Core Framework (v6.0.0: STU6 (v6.0.0)) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. 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: 6.0.0 | |||
| 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.
define "SDE Payer":
[Coverage: type in "Payer"] Payer
return {
code: Payer.type,
period: Payer.period
}
| General Person Primary Coverage Example |
| General Subscriber ID Coverage Example |
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from USCoreCoverageProfile
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Coverage | 0..* | USCoreCoverageProfile | Insurance or medical plan or a payment agreement | |
  type | 0..1 | CodeableConcept | (QI-Core)(USCDI) Coverage category such as medical or accident Binding: Payer  (extensible): Categories of types of health care payor entities as defined by the US Public Health Data Consortium SOP code system | |
 policyHolder | 0..1 | Reference(QICore Patient | QICore Organization | QICore RelatedPerson) | (QI-Core) Owner of the policy | |
| subscriberId | 0..1 | string | (QI-Core)(USCDI) ID assigned to the subscriber | |
| beneficiary | 1..1 | Reference(QICore Patient) | (QI-Core)(USCDI) Plan beneficiary | |
| period | 0..1 | Period | (QI-Core)(USCDI) Coverage start and end dates | |
 payor | 1..1 | Reference(QICore Patient | QICore Organization | QICore RelatedPerson) | (QI-Core)(USCDI) Issuer of the policy | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Coverage.type | extensible | Payer http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Coverage | C | 0..* | USCoreCoverageProfile | Insurance or medical plan or a payment agreement us-core-15: Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present |
 implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
  Slices for identifier | SΣ | 0..* | Identifier | (USCDI) Member ID and other identifiers Slice: Unordered, Open by pattern:type |
   identifier:memberid | SΣC | 0..1 | Identifier | (USCDI) Member ID |
  use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . |
  type | SΣ | 1..1 | CodeableConcept | (USCDI) Member Number identifier type Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following |
  coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203 | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: MB | |
| status | ?!SΣ | 1..1 | code | (USCDI) active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. |
| type | SΣ | 0..1 | CodeableConcept | (QI-Core)(USCDI) Coverage category such as medical or accident Binding: Payer (extensible): 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(QICore Patient | QICore Organization | QICore RelatedPerson) | (QI-Core) Owner of the policy |
| subscriberId | SΣC | 0..1 | string | (QI-Core)(USCDI) ID assigned to the subscriber |
| beneficiary | SΣ | 1..1 | Reference(QICore Patient) | (QI-Core)(USCDI) Plan beneficiary |
| relationship | S | 1..1 | CodeableConcept | (USCDI) Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible) |
| period | SΣ | 0..1 | Period | (QI-Core)(USCDI) Coverage start and end dates |
| payor | SΣ | 1..1 | Reference(QICore Patient | QICore Organization | QICore RelatedPerson) | (QI-Core)(USCDI) Issuer of the policy |
| Slices for class | S | 0..* | BackboneElement | (USCDI) Additional coverage classifications Slice: Unordered, Open by pattern:type |
 class:All Slices | Content/Rules for all slices | |||
  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 |
| class:group | S | 0..1 | BackboneElement | (USCDI) Group |
| 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. Required Pattern: At least the following |
 coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: group | |
| value | SΣ | 1..1 | string | (USCDI) Group Number |
 name | SΣ | 0..1 | string | (USCDI) Group Name |
| class:plan | S | 0..1 | BackboneElement | (USCDI) Plan |
| 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. Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: plan | |
| value | SΣ | 1..1 | string | (USCDI) Plan Number |
| name | SΣ | 0..1 | string | (USCDI) Plan Name |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| Coverage.identifier:memberid.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1from the FHIR Standard | |
| Coverage.identifier:memberid.type | extensible | Pattern: MBhttp://hl7.org/fhir/ValueSet/identifier-typefrom the FHIR Standard | |
| Coverage.status | required | FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|4.0.1from the FHIR Standard | |
| Coverage.type | extensible | Payer http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 | |
| Coverage.relationship | extensible | SubscriberRelationshipCodeshttp://hl7.org/fhir/ValueSet/subscriber-relationshipfrom the FHIR Standard | |
| Coverage.class.type | extensible | CoverageClassCodeshttp://hl7.org/fhir/ValueSet/coverage-classfrom the FHIR Standard | |
| Coverage.class:group.type | extensible | Pattern: grouphttp://hl7.org/fhir/ValueSet/coverage-classfrom the FHIR Standard | |
| Coverage.class:plan.type | extensible | Pattern: planhttp://hl7.org/fhir/ValueSet/coverage-classfrom the FHIR Standard |
| Id | Grade | Path(s) | 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 | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| us-core-15 | error | Coverage | Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present : identifier.type.coding.where(system='http://terminology.hl7.org/CodeSystem/v2-0203' and code='MB').exists() or subscriberId.exists() |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Coverage | C | 0..* | USCoreCoverageProfile | Insurance or medical plan or a payment agreement us-core-15: Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present | ||||
| id | Σ | 0..1 | id | 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): 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 | ||||
| Slices for identifier | SΣ | 0..* | Identifier | (USCDI) Member ID and other identifiers Slice: Unordered, Open by pattern:type | ||||
| identifier:memberid | SΣC | 0..1 | Identifier | (USCDI) Member ID | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
| type | SΣ | 1..1 | CodeableConcept | (USCDI) Member Number identifier type Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203 | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: MB | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| system | Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
| value | Σ | 0..1 | string | The value that is unique Example General: 123456 | ||||
| period | Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
| assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||
| status | ?!SΣ | 1..1 | code | (USCDI) active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. | ||||
| type | SΣ | 0..1 | CodeableConcept | (QI-Core)(USCDI) Coverage category such as medical or accident Binding: Payer (extensible): 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(QICore Patient | QICore Organization | QICore RelatedPerson) | (QI-Core) Owner of the policy | ||||
| subscriber | Σ | 0..1 | Reference(Patient | RelatedPerson) | Subscriber to the policy | ||||
| subscriberId | SΣC | 0..1 | string | (QI-Core)(USCDI) ID assigned to the subscriber | ||||
| beneficiary | SΣ | 1..1 | Reference(QICore Patient) | (QI-Core)(USCDI) Plan beneficiary | ||||
| dependent | Σ | 0..1 | string | Dependent number | ||||
| relationship | S | 1..1 | CodeableConcept | (USCDI) Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible) | ||||
| period | SΣ | 0..1 | Period | (QI-Core)(USCDI) Coverage start and end dates | ||||
| payor | SΣ | 1..1 | Reference(QICore Patient | QICore Organization | QICore RelatedPerson) | (QI-Core)(USCDI) Issuer of the policy | ||||
| Slices for class | S | 0..* | BackboneElement | (USCDI) Additional coverage classifications Slice: Unordered, Open by pattern:type | ||||
| class:All Slices | Content/Rules for all slices | |||||||
| 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 | ||||
| class:group | S | 0..1 | BackboneElement | (USCDI) Group | ||||
| 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. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: group | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| value | SΣ | 1..1 | string | (USCDI) Group Number | ||||
| name | SΣ | 0..1 | string | (USCDI) Group Name | ||||
| class:plan | S | 0..1 | BackboneElement | (USCDI) Plan | ||||
| 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. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: plan | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| value | SΣ | 1..1 | string | (USCDI) Plan Number | ||||
| name | SΣ | 0..1 | string | (USCDI) Plan Name | ||||
| 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 | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| Coverage.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| Coverage.identifier:memberid.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1from the FHIR Standard | ||||
| Coverage.identifier:memberid.type | extensible | Pattern: MBhttp://hl7.org/fhir/ValueSet/identifier-typefrom the FHIR Standard | ||||
| Coverage.status | required | FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|4.0.1from the FHIR Standard | ||||
| Coverage.type | extensible | Payer http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 | ||||
| Coverage.relationship | extensible | SubscriberRelationshipCodeshttp://hl7.org/fhir/ValueSet/subscriber-relationshipfrom the FHIR Standard | ||||
| Coverage.class.type | extensible | CoverageClassCodeshttp://hl7.org/fhir/ValueSet/coverage-classfrom the FHIR Standard | ||||
| Coverage.class:group.type | extensible | Pattern: grouphttp://hl7.org/fhir/ValueSet/coverage-classfrom the FHIR Standard | ||||
| Coverage.class:plan.type | extensible | Pattern: planhttp://hl7.org/fhir/ValueSet/coverage-classfrom the FHIR Standard | ||||
| Coverage.costToBeneficiary.type | extensible | CoverageCopayTypeCodeshttp://hl7.org/fhir/ValueSet/coverage-copay-typefrom the FHIR Standard | ||||
| Coverage.costToBeneficiary.exception.type | example | ExampleCoverageFinancialExceptionCodeshttp://hl7.org/fhir/ValueSet/coverage-financial-exceptionfrom the FHIR Standard |
| Id | Grade | Path(s) | 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 | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| us-core-15 | error | Coverage | Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present : identifier.type.coding.where(system='http://terminology.hl7.org/CodeSystem/v2-0203' and code='MB').exists() or subscriberId.exists() |
This structure is derived from USCoreCoverageProfile
Differential View
This structure is derived from USCoreCoverageProfile
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Coverage | 0..* | USCoreCoverageProfile | Insurance or medical plan or a payment agreement | |
| type | 0..1 | CodeableConcept | (QI-Core)(USCDI) Coverage category such as medical or accident Binding: Payer (extensible): Categories of types of health care payor entities as defined by the US Public Health Data Consortium SOP code system | |
| policyHolder | 0..1 | Reference(QICore Patient | QICore Organization | QICore RelatedPerson) | (QI-Core) Owner of the policy | |
| subscriberId | 0..1 | string | (QI-Core)(USCDI) ID assigned to the subscriber | |
| beneficiary | 1..1 | Reference(QICore Patient) | (QI-Core)(USCDI) Plan beneficiary | |
| period | 0..1 | Period | (QI-Core)(USCDI) Coverage start and end dates | |
| payor | 1..1 | Reference(QICore Patient | QICore Organization | QICore RelatedPerson) | (QI-Core)(USCDI) Issuer of the policy | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Coverage.type | extensible | Payer http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Coverage | C | 0..* | USCoreCoverageProfile | Insurance or medical plan or a payment agreement us-core-15: Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| Slices for identifier | SΣ | 0..* | Identifier | (USCDI) Member ID and other identifiers Slice: Unordered, Open by pattern:type |
| identifier:memberid | SΣC | 0..1 | Identifier | (USCDI) Member ID |
| use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . |
| type | SΣ | 1..1 | CodeableConcept | (USCDI) Member Number identifier type Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203 | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: MB | |
| status | ?!SΣ | 1..1 | code | (USCDI) active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. |
| type | SΣ | 0..1 | CodeableConcept | (QI-Core)(USCDI) Coverage category such as medical or accident Binding: Payer (extensible): 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(QICore Patient | QICore Organization | QICore RelatedPerson) | (QI-Core) Owner of the policy |
| subscriberId | SΣC | 0..1 | string | (QI-Core)(USCDI) ID assigned to the subscriber |
| beneficiary | SΣ | 1..1 | Reference(QICore Patient) | (QI-Core)(USCDI) Plan beneficiary |
| relationship | S | 1..1 | CodeableConcept | (USCDI) Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible) |
| period | SΣ | 0..1 | Period | (QI-Core)(USCDI) Coverage start and end dates |
| payor | SΣ | 1..1 | Reference(QICore Patient | QICore Organization | QICore RelatedPerson) | (QI-Core)(USCDI) Issuer of the policy |
| Slices for class | S | 0..* | BackboneElement | (USCDI) Additional coverage classifications Slice: Unordered, Open by pattern:type |
| class:All Slices | Content/Rules for all slices | |||
| 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 |
| class:group | S | 0..1 | BackboneElement | (USCDI) Group |
| 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. Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: group | |
| value | SΣ | 1..1 | string | (USCDI) Group Number |
| name | SΣ | 0..1 | string | (USCDI) Group Name |
| class:plan | S | 0..1 | BackboneElement | (USCDI) Plan |
| 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. Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: plan | |
| value | SΣ | 1..1 | string | (USCDI) Plan Number |
| name | SΣ | 0..1 | string | (USCDI) Plan Name |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| Coverage.identifier:memberid.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1from the FHIR Standard | |
| Coverage.identifier:memberid.type | extensible | Pattern: MBhttp://hl7.org/fhir/ValueSet/identifier-typefrom the FHIR Standard | |
| Coverage.status | required | FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|4.0.1from the FHIR Standard | |
| Coverage.type | extensible | Payer http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 | |
| Coverage.relationship | extensible | SubscriberRelationshipCodeshttp://hl7.org/fhir/ValueSet/subscriber-relationshipfrom the FHIR Standard | |
| Coverage.class.type | extensible | CoverageClassCodeshttp://hl7.org/fhir/ValueSet/coverage-classfrom the FHIR Standard | |
| Coverage.class:group.type | extensible | Pattern: grouphttp://hl7.org/fhir/ValueSet/coverage-classfrom the FHIR Standard | |
| Coverage.class:plan.type | extensible | Pattern: planhttp://hl7.org/fhir/ValueSet/coverage-classfrom the FHIR Standard |
| Id | Grade | Path(s) | 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 | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| us-core-15 | error | Coverage | Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present : identifier.type.coding.where(system='http://terminology.hl7.org/CodeSystem/v2-0203' and code='MB').exists() or subscriberId.exists() |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Coverage | C | 0..* | USCoreCoverageProfile | Insurance or medical plan or a payment agreement us-core-15: Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present | ||||
| id | Σ | 0..1 | id | 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): 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 | ||||
| Slices for identifier | SΣ | 0..* | Identifier | (USCDI) Member ID and other identifiers Slice: Unordered, Open by pattern:type | ||||
| identifier:memberid | SΣC | 0..1 | Identifier | (USCDI) Member ID | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
| type | SΣ | 1..1 | CodeableConcept | (USCDI) Member Number identifier type Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203 | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: MB | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| system | Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
| value | Σ | 0..1 | string | The value that is unique Example General: 123456 | ||||
| period | Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
| assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||
| status | ?!SΣ | 1..1 | code | (USCDI) active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. | ||||
| type | SΣ | 0..1 | CodeableConcept | (QI-Core)(USCDI) Coverage category such as medical or accident Binding: Payer (extensible): 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(QICore Patient | QICore Organization | QICore RelatedPerson) | (QI-Core) Owner of the policy | ||||
| subscriber | Σ | 0..1 | Reference(Patient | RelatedPerson) | Subscriber to the policy | ||||
| subscriberId | SΣC | 0..1 | string | (QI-Core)(USCDI) ID assigned to the subscriber | ||||
| beneficiary | SΣ | 1..1 | Reference(QICore Patient) | (QI-Core)(USCDI) Plan beneficiary | ||||
| dependent | Σ | 0..1 | string | Dependent number | ||||
| relationship | S | 1..1 | CodeableConcept | (USCDI) Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible) | ||||
| period | SΣ | 0..1 | Period | (QI-Core)(USCDI) Coverage start and end dates | ||||
| payor | SΣ | 1..1 | Reference(QICore Patient | QICore Organization | QICore RelatedPerson) | (QI-Core)(USCDI) Issuer of the policy | ||||
| Slices for class | S | 0..* | BackboneElement | (USCDI) Additional coverage classifications Slice: Unordered, Open by pattern:type | ||||
| class:All Slices | Content/Rules for all slices | |||||||
| 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 | ||||
| class:group | S | 0..1 | BackboneElement | (USCDI) Group | ||||
| 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. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: group | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| value | SΣ | 1..1 | string | (USCDI) Group Number | ||||
| name | SΣ | 0..1 | string | (USCDI) Group Name | ||||
| class:plan | S | 0..1 | BackboneElement | (USCDI) Plan | ||||
| 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. Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: plan | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| value | SΣ | 1..1 | string | (USCDI) Plan Number | ||||
| name | SΣ | 0..1 | string | (USCDI) Plan Name | ||||
| 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 | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| Coverage.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| Coverage.identifier:memberid.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1from the FHIR Standard | ||||
| Coverage.identifier:memberid.type | extensible | Pattern: MBhttp://hl7.org/fhir/ValueSet/identifier-typefrom the FHIR Standard | ||||
| Coverage.status | required | FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|4.0.1from the FHIR Standard | ||||
| Coverage.type | extensible | Payer http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 | ||||
| Coverage.relationship | extensible | SubscriberRelationshipCodeshttp://hl7.org/fhir/ValueSet/subscriber-relationshipfrom the FHIR Standard | ||||
| Coverage.class.type | extensible | CoverageClassCodeshttp://hl7.org/fhir/ValueSet/coverage-classfrom the FHIR Standard | ||||
| Coverage.class:group.type | extensible | Pattern: grouphttp://hl7.org/fhir/ValueSet/coverage-classfrom the FHIR Standard | ||||
| Coverage.class:plan.type | extensible | Pattern: planhttp://hl7.org/fhir/ValueSet/coverage-classfrom the FHIR Standard | ||||
| Coverage.costToBeneficiary.type | extensible | CoverageCopayTypeCodeshttp://hl7.org/fhir/ValueSet/coverage-copay-typefrom the FHIR Standard | ||||
| Coverage.costToBeneficiary.exception.type | example | ExampleCoverageFinancialExceptionCodeshttp://hl7.org/fhir/ValueSet/coverage-financial-exceptionfrom the FHIR Standard |
| Id | Grade | Path(s) | 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 | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| us-core-15 | error | Coverage | Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present : identifier.type.coding.where(system='http://terminology.hl7.org/CodeSystem/v2-0203' and code='MB').exists() or subscriberId.exists() |
This structure is derived from USCoreCoverageProfile
Other representations of profile: CSV, Excel, Schematron
IG © 2019+ HL7 International / Clinical Quality Information. Package hl7.fhir.us.qicore#6.0.0 based on FHIR 4.0.1. Generated 2024-03-01
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