Specialty Medication Enrollment
1.0.0 - STU 1

This page is part of the Specialty Medication Enrollment (v1.0.0: STU1) based on FHIR R4. . For a full list of available versions, see the Directory of published versions

Resource Profile: Specialty Rx Coverage

Defining URL:http://hl7.org/fhir/us/specialty-rx/StructureDefinition/specialty-rx-coverage
Version:1.0.0
Name:SpecialtyRxCoverage
Title:Specialty Rx Coverage
Status:Active as of 2020-12-11T00:00:00-05:00
Definition:

This profile constrains the Coverage resource for carrying insurance coverage information in the specialty medication enrollment process

Publisher:HL7 International - Pharmacy
Source Resource:XML / JSON / Turtle

The official URL for this profile is: 

http://hl7.org/fhir/us/specialty-rx/StructureDefinition/specialty-rx-coverage

The Coverage elements available to be used by the Specialty Rx process are:

  • Coverage.subscriberId: Health plan subscriber ID
  • Coverage.subscriber: Subscriber demographic information
  • Coverage.identifier: Health plan member ID
  • Coverage.beneficiary: Patient demographic information
  • Coverage.class=rxid. Pharmacy benefit Member ID
  • Coverage.class=rxgroup. Pharmacy benefit Group ID
  • Coverage.class=rxbin. Pharmacy benefit BIN (IIN)
  • Coverage.class=rxpcn. Pharmacy benefit PCN

The elements identified as Must Support are the typical set used in US pharmacy benefit processing.

Formal Views of Profile Content

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

This structure is derived from Coverage

Summary

Mandatory: 0 element (4 nested mandatory elements)
Must-Support: 8 elements

Slices

This structure defines the following Slices:

  • The element Coverage.class is sliced based on the value of value:type

This structure is derived from Coverage

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..*CoverageInsurance or medical plan or a payment agreement
... identifier S0..*IdentifierMember identifier
... subscriberId S0..1stringHealth Plan Subscriber ID
... payor S1..*Reference(Organization | Patient | RelatedPerson)Issuer of the policy
.... class:All Slices Content/Rules for all slices
..... type 1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): Coverage Class Codes

.... class:bin S0..1BackboneElementIIN (BIN) number
..... type 1..1CodeableConceptType of class such as 'group' or 'plan'
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: rxbin
.... class:pcn S0..1BackboneElementProcessor Control Number (PCN)
..... type 1..1CodeableConceptType of class such as 'group' or 'plan'
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: rxpcn
.... class:rxgroup-id S0..1BackboneElementPharmacy Benefit Group ID
..... type 1..1CodeableConceptType of class such as 'group' or 'plan'
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: rxgroup
.... class:pbm-member-id S0..1BackboneElementPBM Member ID
..... type 1..1CodeableConceptType of class such as 'group' or 'plan'
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: rxid

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..*CoverageInsurance or medical plan or a payment agreement
... id Σ0..1stringLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier SΣ0..*IdentifierMember identifier
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... type Σ0..1CodeableConceptCoverage category such as medical or accident
Binding: CoverageTypeAndSelf-PayCodes (preferred): The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization.

... policyHolder Σ0..1Reference(Patient | RelatedPerson | Organization)Owner of the policy
... subscriber Σ0..1Reference(Patient | RelatedPerson)Subscriber to the policy
... subscriberId SΣ0..1stringHealth Plan Subscriber ID
... beneficiary Σ1..1Reference(Patient)Plan beneficiary
... dependent Σ0..1stringDependent number
... relationship 0..1CodeableConceptBeneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).

... period Σ0..1PeriodCoverage start and end dates
... payor SΣ1..*Reference(Organization | Patient | RelatedPerson)Issuer of the policy
... Slices for class S0..*BackboneElementPharmacy coverage identifiers
Slice: Unordered, Open by value:type
.... class:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type Σ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): Coverage Class Codes

..... value Σ1..1stringValue associated with the type
..... name Σ0..1stringHuman readable description of the type and value
.... class:bin S0..1BackboneElementIIN (BIN) number
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type Σ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: rxbin
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... value Σ1..1stringValue associated with the type
..... name Σ0..1stringHuman readable description of the type and value
.... class:pcn S0..1BackboneElementProcessor Control Number (PCN)
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type Σ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: rxpcn
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... value Σ1..1stringValue associated with the type
..... name Σ0..1stringHuman readable description of the type and value
.... class:rxgroup-id S0..1BackboneElementPharmacy Benefit Group ID
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type Σ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: rxgroup
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... value Σ1..1stringValue associated with the type
..... name Σ0..1stringHuman readable description of the type and value
.... class:pbm-member-id S0..1BackboneElementPBM Member ID
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type Σ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: rxid
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... value Σ1..1stringValue associated with the type
..... name Σ0..1stringHuman readable description of the type and value
... order Σ0..1positiveIntRelative order of the coverage
... network Σ0..1stringInsurer network
... costToBeneficiary 0..*BackboneElementPatient payments for services/products
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type Σ0..1CodeableConceptCost category
Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified.

.... value[x] Σ1..1The amount or percentage due from the beneficiary
..... valueQuantityQuantity(SimpleQuantity)
..... valueMoneyMoney
.... exception 0..*BackboneElementExceptions for patient payments
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type Σ1..1CodeableConceptException category
Binding: ExampleCoverageFinancialExceptionCodes (example): The types of exceptions from the part or full value of financial obligations such as copays.

..... period Σ0..1PeriodThe effective period of the exception
... subrogation 0..1booleanReimbursement to insurer
... contract 0..*Reference(Contract)Contract details

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..*CoverageInsurance or medical plan or a payment agreement
... identifier Σ0..*IdentifierMember identifier
... subscriberId Σ0..1stringHealth Plan Subscriber ID
... payor Σ1..*Reference(Organization | Patient | RelatedPerson)Issuer of the policy
.... class:bin 0..1BackboneElementIIN (BIN) number
.... class:pcn 0..1BackboneElementProcessor Control Number (PCN)
.... class:rxgroup-id 0..1BackboneElementPharmacy Benefit Group ID
.... class:pbm-member-id 0..1BackboneElementPBM Member ID

doco Documentation for this format

This structure is derived from Coverage

Summary

Mandatory: 0 element (4 nested mandatory elements)
Must-Support: 8 elements

Slices

This structure defines the following Slices:

  • The element Coverage.class is sliced based on the value of value:type

Differential View

This structure is derived from Coverage

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..*CoverageInsurance or medical plan or a payment agreement
... identifier S0..*IdentifierMember identifier
... subscriberId S0..1stringHealth Plan Subscriber ID
... payor S1..*Reference(Organization | Patient | RelatedPerson)Issuer of the policy
.... class:All Slices Content/Rules for all slices
..... type 1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): Coverage Class Codes

.... class:bin S0..1BackboneElementIIN (BIN) number
..... type 1..1CodeableConceptType of class such as 'group' or 'plan'
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: rxbin
.... class:pcn S0..1BackboneElementProcessor Control Number (PCN)
..... type 1..1CodeableConceptType of class such as 'group' or 'plan'
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: rxpcn
.... class:rxgroup-id S0..1BackboneElementPharmacy Benefit Group ID
..... type 1..1CodeableConceptType of class such as 'group' or 'plan'
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: rxgroup
.... class:pbm-member-id S0..1BackboneElementPBM Member ID
..... type 1..1CodeableConceptType of class such as 'group' or 'plan'
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: rxid

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..*CoverageInsurance or medical plan or a payment agreement
... id Σ0..1stringLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier SΣ0..*IdentifierMember identifier
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... type Σ0..1CodeableConceptCoverage category such as medical or accident
Binding: CoverageTypeAndSelf-PayCodes (preferred): The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization.

... policyHolder Σ0..1Reference(Patient | RelatedPerson | Organization)Owner of the policy
... subscriber Σ0..1Reference(Patient | RelatedPerson)Subscriber to the policy
... subscriberId SΣ0..1stringHealth Plan Subscriber ID
... beneficiary Σ1..1Reference(Patient)Plan beneficiary
... dependent Σ0..1stringDependent number
... relationship 0..1CodeableConceptBeneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).

... period Σ0..1PeriodCoverage start and end dates
... payor SΣ1..*Reference(Organization | Patient | RelatedPerson)Issuer of the policy
... Slices for class S0..*BackboneElementPharmacy coverage identifiers
Slice: Unordered, Open by value:type
.... class:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type Σ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): Coverage Class Codes

..... value Σ1..1stringValue associated with the type
..... name Σ0..1stringHuman readable description of the type and value
.... class:bin S0..1BackboneElementIIN (BIN) number
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type Σ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: rxbin
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... value Σ1..1stringValue associated with the type
..... name Σ0..1stringHuman readable description of the type and value
.... class:pcn S0..1BackboneElementProcessor Control Number (PCN)
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type Σ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: rxpcn
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... value Σ1..1stringValue associated with the type
..... name Σ0..1stringHuman readable description of the type and value
.... class:rxgroup-id S0..1BackboneElementPharmacy Benefit Group ID
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type Σ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: rxgroup
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... value Σ1..1stringValue associated with the type
..... name Σ0..1stringHuman readable description of the type and value
.... class:pbm-member-id S0..1BackboneElementPBM Member ID
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type Σ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: rxid
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... value Σ1..1stringValue associated with the type
..... name Σ0..1stringHuman readable description of the type and value
... order Σ0..1positiveIntRelative order of the coverage
... network Σ0..1stringInsurer network
... costToBeneficiary 0..*BackboneElementPatient payments for services/products
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type Σ0..1CodeableConceptCost category
Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified.

.... value[x] Σ1..1The amount or percentage due from the beneficiary
..... valueQuantityQuantity(SimpleQuantity)
..... valueMoneyMoney
.... exception 0..*BackboneElementExceptions for patient payments
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type Σ1..1CodeableConceptException category
Binding: ExampleCoverageFinancialExceptionCodes (example): The types of exceptions from the part or full value of financial obligations such as copays.

..... period Σ0..1PeriodThe effective period of the exception
... subrogation 0..1booleanReimbursement to insurer
... contract 0..*Reference(Contract)Contract details

doco Documentation for this format

 

Other representations of profile: CSV, Excel, Schematron

Terminology Bindings

PathConformanceValueSet / Code
Coverage.languagepreferredCommonLanguages
Max Binding: AllLanguages
Coverage.statusrequiredFinancialResourceStatusCodes
Coverage.typepreferredCoverageTypeAndSelf-PayCodes
Coverage.relationshipextensibleSubscriberRelationshipCodes
Coverage.class.typeextensibleCoverageClassCodes
Coverage.class:bin.typeextensiblePattern: rxbin
Coverage.class:pcn.typeextensiblePattern: rxpcn
Coverage.class:rxgroup-id.typeextensiblePattern: rxgroup
Coverage.class:pbm-member-id.typeextensiblePattern: rxid
Coverage.costToBeneficiary.typeextensibleCoverageCopayTypeCodes
Coverage.costToBeneficiary.exception.typeexampleExampleCoverageFinancialExceptionCodes

Constraints

IdPathDetailsRequirements
dom-2CoverageIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3CoverageIf 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-4CoverageIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5CoverageIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6CoverageA resource should have narrative for robust management
: text.`div`.exists()
ele-1Coverage.metaAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.implicitRulesAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.languageAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.textAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Coverage.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Coverage.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Coverage.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Coverage.identifierAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.statusAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.typeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.policyHolderAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.subscriberAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.subscriberIdAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.beneficiaryAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.dependentAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.relationshipAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.periodAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.payorAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.classAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.class.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Coverage.class.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Coverage.class.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Coverage.class.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Coverage.class.typeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.class.valueAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.class.nameAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.class:binAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.class:bin.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Coverage.class:bin.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Coverage.class:bin.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Coverage.class:bin.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Coverage.class:bin.typeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.class:bin.valueAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.class:bin.nameAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.class:pcnAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.class:pcn.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Coverage.class:pcn.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Coverage.class:pcn.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Coverage.class:pcn.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Coverage.class:pcn.typeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.class:pcn.valueAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.class:pcn.nameAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.class:rxgroup-idAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.class:rxgroup-id.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Coverage.class:rxgroup-id.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Coverage.class:rxgroup-id.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Coverage.class:rxgroup-id.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Coverage.class:rxgroup-id.typeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.class:rxgroup-id.valueAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.class:rxgroup-id.nameAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.class:pbm-member-idAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.class:pbm-member-id.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Coverage.class:pbm-member-id.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Coverage.class:pbm-member-id.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Coverage.class:pbm-member-id.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Coverage.class:pbm-member-id.typeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.class:pbm-member-id.valueAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.class:pbm-member-id.nameAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.orderAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.networkAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.costToBeneficiaryAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.costToBeneficiary.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Coverage.costToBeneficiary.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Coverage.costToBeneficiary.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Coverage.costToBeneficiary.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Coverage.costToBeneficiary.typeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.costToBeneficiary.value[x]All FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.costToBeneficiary.exceptionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.costToBeneficiary.exception.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Coverage.costToBeneficiary.exception.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Coverage.costToBeneficiary.exception.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Coverage.costToBeneficiary.exception.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Coverage.costToBeneficiary.exception.typeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.costToBeneficiary.exception.periodAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.subrogationAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.contractAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())