Da Vinci - Coverage Requirements Discovery
1.0.0 - STU 1
Da Vinci - Coverage Requirements Discovery
1.0.0 - STU 1
This page is part of the Da Vinci Coverage Requirements Discovery (CRD) FHIR IG (v1.0.0: STU 1) based on FHIR R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions 
| Defining URL: | http://hl7.org/fhir/us/davinci-crd/StructureDefinition/profile-coverage |
| Version: | 1.0.0 |
| Name: | Coverage |
| Status: | Draft as of 2018-07-25 |
| Definition: | This profile specifies constraints on the Coverage resource to support coverage requirements discovery. |
| Publisher: | HL7 International - Financial Management Work Group |
| Source Resource: | XML / JSON / Turtle |
The official URL for this profile is:
http://hl7.org/fhir/us/davinci-crd/StructureDefinition/profile-coverage
CRD Clients SHALL use this profile to resolve references to insurance Coverage resources passed to CRD Services.
Information provided in Must Support elements will commonly be required for CRD Services to perform coverage requirements discovery.
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Coverage
This structure is derived from Coverage
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Coverage | 0..* | Coverage | Insurance or medical plan or a payment agreement | |
  identifier | S | 0..* | Identifier | Business Identifier for the coverage |
| status | S | 1..1 | code | active | cancelled | draft | entered-in-error |
| type | S | 0..1 | CodeableConcept | Coverage category such as medical or accident |
 policyHolder | S | 0..1 | Reference(Patient | Organization) | Owner of the policy |
| subscriber | S | 0..1 | Reference(Patient) | Subscriber to the policy |
| subscriberId | S | 0..1 | string | ID assigned to the subscriber |
| beneficiary | S | 1..1 | Reference(Patient) | Plan beneficiary |
| dependent | S | 0..1 | string | Dependent number |
| relationship | S | 0..1 | CodeableConcept | Beneficiary relationship to the subscriber |
| period | S | 0..1 | Period | Coverage start and end dates |
| payor | S | 1..* | Reference(Patient | Organization) | Issuer of the policy |
 class | S | 0..1 | BackboneElement | Additional coverage classifications |
  type | S | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CRD Coverage Classes (required): CRD Coverage Classes |
| value | S | 1..1 | string | Value associated with the type |
 name | S | 0..1 | string | Human readable description of the type and value |
| order | S | 0..1 | positiveInt | Relative order of the coverage |
| network | S | 0..1 | string | Insurer network |
| costToBeneficiary | 0..0 | |||
| 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 | SΣ | 0..* | Identifier | Business Identifier for the coverage |
| status | ?!SΣ | 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: 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 | SΣ | 0..1 | Reference(Patient | Organization) | Owner of the policy |
| subscriber | SΣ | 0..1 | Reference(Patient) | Subscriber to the policy |
| subscriberId | SΣ | 0..1 | string | ID assigned to the subscriber |
| beneficiary | SΣ | 1..1 | Reference(Patient) | Plan beneficiary |
| dependent | SΣ | 0..1 | string | Dependent number |
| relationship | S | 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(Patient | Organization) | Issuer of the policy |
| class | S | 0..1 | 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 | SΣ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CRD Coverage Classes (required): CRD Coverage Classes |
| value | SΣ | 1..1 | string | Value associated with the type |
| name | SΣ | 0..1 | string | Human readable description of the type and value |
| order | SΣ | 0..1 | positiveInt | Relative order of the coverage |
| network | SΣ | 0..1 | string | Insurer network |
| 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 | |
| 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 | Σ | 0..1 | CodeableConcept | Coverage 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 | Σ | 0..1 | Reference(Patient | Organization) | Owner of the policy |
| subscriber | Σ | 0..1 | Reference(Patient) | Subscriber to the policy |
| subscriberId | Σ | 0..1 | string | ID assigned to the subscriber |
| beneficiary | Σ | 1..1 | Reference(Patient) | 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 | Σ | 0..1 | Period | Coverage start and end dates |
| payor | Σ | 1..* | Reference(Patient | Organization) | Issuer of the policy |
| class | 0..1 | BackboneElement | Additional coverage classifications | |
| type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CRD Coverage Classes (required): CRD Coverage Classes |
| 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 |
| Documentation for this format | ||||
This structure is derived from Coverage
Differential View
This structure is derived from Coverage
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Coverage | 0..* | Coverage | Insurance or medical plan or a payment agreement | |
| identifier | S | 0..* | Identifier | Business Identifier for the coverage |
| status | S | 1..1 | code | active | cancelled | draft | entered-in-error |
| type | S | 0..1 | CodeableConcept | Coverage category such as medical or accident |
| policyHolder | S | 0..1 | Reference(Patient | Organization) | Owner of the policy |
| subscriber | S | 0..1 | Reference(Patient) | Subscriber to the policy |
| subscriberId | S | 0..1 | string | ID assigned to the subscriber |
| beneficiary | S | 1..1 | Reference(Patient) | Plan beneficiary |
| dependent | S | 0..1 | string | Dependent number |
| relationship | S | 0..1 | CodeableConcept | Beneficiary relationship to the subscriber |
| period | S | 0..1 | Period | Coverage start and end dates |
| payor | S | 1..* | Reference(Patient | Organization) | Issuer of the policy |
| class | S | 0..1 | BackboneElement | Additional coverage classifications |
| type | S | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CRD Coverage Classes (required): CRD Coverage Classes |
| value | S | 1..1 | string | Value associated with the type |
| name | S | 0..1 | string | Human readable description of the type and value |
| order | S | 0..1 | positiveInt | Relative order of the coverage |
| network | S | 0..1 | string | Insurer network |
| costToBeneficiary | 0..0 | |||
| 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 | SΣ | 0..* | Identifier | Business Identifier for the coverage |
| status | ?!SΣ | 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: 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 | SΣ | 0..1 | Reference(Patient | Organization) | Owner of the policy |
| subscriber | SΣ | 0..1 | Reference(Patient) | Subscriber to the policy |
| subscriberId | SΣ | 0..1 | string | ID assigned to the subscriber |
| beneficiary | SΣ | 1..1 | Reference(Patient) | Plan beneficiary |
| dependent | SΣ | 0..1 | string | Dependent number |
| relationship | S | 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(Patient | Organization) | Issuer of the policy |
| class | S | 0..1 | 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 | SΣ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CRD Coverage Classes (required): CRD Coverage Classes |
| value | SΣ | 1..1 | string | Value associated with the type |
| name | SΣ | 0..1 | string | Human readable description of the type and value |
| order | SΣ | 0..1 | positiveInt | Relative order of the coverage |
| network | SΣ | 0..1 | string | Insurer network |
| subrogation | 0..1 | boolean | Reimbursement to insurer | |
| contract | 0..* | Reference(Contract) | Contract details | |
| Documentation for this format | ||||
Other representations of profile: Schematron
| Path | Conformance | ValueSet |
| Coverage.language | preferred | CommonLanguages Max Binding: AllLanguages |
| Coverage.status | required | FinancialResourceStatusCodes |
| Coverage.type | preferred | CoverageTypeAndSelf-PayCodes |
| Coverage.relationship | extensible | SubscriberRelationshipCodes |
| Coverage.class.type | required | CRDCoverageClasses |
| Coverage.costToBeneficiary.type | extensible | CoverageCopayTypeCodes |
| Coverage.costToBeneficiary.exception.type | example | ExampleCoverageFinancialExceptionCodes |
| Id | Path | Details | Requirements |
| dom-2 | Coverage | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | 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 | 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 | Coverage | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | Coverage | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | Coverage.meta | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.implicitRules | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.language | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Coverage.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Coverage.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Coverage.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Coverage.identifier | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.status | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.type | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.policyHolder | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.subscriber | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.subscriberId | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.beneficiary | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.dependent | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.relationship | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.period | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.payor | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.class | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.class.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Coverage.class.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Coverage.class.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Coverage.class.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Coverage.class.type | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.class.value | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.class.name | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.order | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.network | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.costToBeneficiary.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Coverage.costToBeneficiary.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Coverage.costToBeneficiary.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Coverage.costToBeneficiary.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Coverage.costToBeneficiary.type | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.costToBeneficiary.value[x] | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.costToBeneficiary.exception | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.costToBeneficiary.exception.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Coverage.costToBeneficiary.exception.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Coverage.costToBeneficiary.exception.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Coverage.costToBeneficiary.exception.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Coverage.costToBeneficiary.exception.type | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.costToBeneficiary.exception.period | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.subrogation | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Coverage.contract | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
IG © 2019+ HL7 International - Financial Management Work Group. Package hl7.fhir.us.davinci-crd#1.0.0 based on FHIR 4.0.1. Generated 2020-12-22
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