Data Exchange For Quality Measures STU2 for FHIR R4 Implementation Guide (Release 1.1.0 STU2 Ballot)

This page is part of the Da Vinci Data Exchange for Quality Measures (DEQM) FHIR IG (v1.1.0: STU 2 Ballot 1) based on FHIR R4. The current version which supercedes this version is 3.1.0. For a full list of available versions, see the Directory of published versions

StructureDefinition-coverage-deqm

The DEQM Coverage Profile defines the constraints for representing the subscriber information to the Payer. This along with the patient first name, last name, date of birth and gender allows the payer to identify the member in their system.

Mandatory Data Elements and Terminology

The following data-elements are mandatory (i.e data MUST be present).

Each Coverage must have:

  1. A subscriber ID

Each Coverage should have (Must Support):

  1. The beneficiary

Additional Profile specific implementation guidance:

None

Examples

  • Coverage/coverage01
  • Coverage/coverage02
  • Coverage/coverage03

    • Formal Views of Profile Content

    Description of Profiles, Differentials, and Snapshots.

    The official URL for this profile is: http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/coverage-deqm

    Published on Tue Jun 19 00:00:00 UTC 2018 as a active by Da Vinci Project.

    This profile builds on QICoreCoverage

    Summary

    Mandatory: 1 element
    Must-Support: 1 element

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Coverage I0..*QICoreCoverageInsurance or medical plan or a payment agreement
    ... id Σ0..1idLogical id of this artifact
    ... meta Σ0..1MetaMetadata about the resource
    ... implicitRules ?!Σ0..1uriA set of rules under which this content was created
    ... language 0..1codeLanguage of the resource content
    Binding: CommonLanguages (preferred)
    Max Binding: AllLanguages
    ... 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 Σ0..*IdentifierBusiness Identifier for the coverage
    ... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
    Binding: FinancialResourceStatusCodes (required)
    ... type Σ0..1CodeableConceptCoverage category such as medical or accident
    Binding: https://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 (required)
    ... policyHolder SΣ0..1Reference(QICorePatient | QICoreOrganization | QICoreRelatedPerson)Owner of the policy
    ... subscriber Σ0..1Reference(Patient | RelatedPerson)Subscriber to the policy
    ... subscriberId SΣ1..1stringSubscriber ID
    ... beneficiary SΣ1..1Reference(QICorePatient)Plan beneficiary
    ... dependent Σ0..1stringDependent number
    ... relationship 0..1CodeableConceptBeneficiary relationship to the subscriber
    Binding: SubscriberRelationshipCodes (extensible)
    ... period Σ0..1PeriodCoverage start and end dates
    ... payor SΣ1..*Reference(QICorePatient | QICoreOrganization | QICoreRelatedPerson)Issuer of the policy
    ... class I0..*BackboneElementAdditional coverage classifications
    .... 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)
    .... 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 I0..*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)
    .... value[x] Σ1..1The amount or percentage due from the beneficiary
    ..... valueQuantityQuantity(SimpleQuantity)
    ..... valueMoneyMoney
    .... exception I0..*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)
    ..... period Σ0..1PeriodThe effective period of the exception
    ... subrogation 0..1booleanReimbursement to insurer
    ... contract 0..*Reference(Contract)Contract details

    doco Documentation for this format

    Summary

    Mandatory: 1 element
    Must-Support: 1 element

    Snapshot View

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Coverage I0..*QICoreCoverageInsurance or medical plan or a payment agreement
    ... id Σ0..1idLogical id of this artifact
    ... meta Σ0..1MetaMetadata about the resource
    ... implicitRules ?!Σ0..1uriA set of rules under which this content was created
    ... language 0..1codeLanguage of the resource content
    Binding: CommonLanguages (preferred)
    Max Binding: AllLanguages
    ... 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 Σ0..*IdentifierBusiness Identifier for the coverage
    ... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
    Binding: FinancialResourceStatusCodes (required)
    ... type Σ0..1CodeableConceptCoverage category such as medical or accident
    Binding: https://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 (required)
    ... policyHolder SΣ0..1Reference(QICorePatient | QICoreOrganization | QICoreRelatedPerson)Owner of the policy
    ... subscriber Σ0..1Reference(Patient | RelatedPerson)Subscriber to the policy
    ... subscriberId SΣ1..1stringSubscriber ID
    ... beneficiary SΣ1..1Reference(QICorePatient)Plan beneficiary
    ... dependent Σ0..1stringDependent number
    ... relationship 0..1CodeableConceptBeneficiary relationship to the subscriber
    Binding: SubscriberRelationshipCodes (extensible)
    ... period Σ0..1PeriodCoverage start and end dates
    ... payor SΣ1..*Reference(QICorePatient | QICoreOrganization | QICoreRelatedPerson)Issuer of the policy
    ... class I0..*BackboneElementAdditional coverage classifications
    .... 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)
    .... 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 I0..*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)
    .... value[x] Σ1..1The amount or percentage due from the beneficiary
    ..... valueQuantityQuantity(SimpleQuantity)
    ..... valueMoneyMoney
    .... exception I0..*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)
    ..... period Σ0..1PeriodThe effective period of the exception
    ... subrogation 0..1booleanReimbursement to insurer
    ... contract 0..*Reference(Contract)Contract details

    doco Documentation for this format

    Downloads: StructureDefinition: (XML, JSON), Schema: XML Schematron


    Quick Start

    Below is an overview of the required set of RESTful FHIR interactions - for example, search and read operations - for this profile. See the Conformance requirements for a complete list of supported RESTful interactions for this IG.

    Use cases: