Da Vinci - Prior Authorization Support
0.1.0 - STU Ballot

This page is part of the Da Vinci Prior Authorization Support (PAS) FHIR IG (v0.1.0: STU 1 Ballot 1) based on FHIR R4. The current version which supercedes this version is 1.1.0. For a full list of available versions, see the Directory of published versions

StructureDefinition: Coverage

The official URL for this profile is: 

http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-coverage

Formal Views of Profile Content

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

This structure is derived from Coverage

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage I0..*Insurance 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: CoverageTypeAndSelf-PayCodes (preferred)
... policyHolder Σ0..1Reference(Patient | RelatedPerson | Organization)Owner of the policy
... subscriber SΣ0..1Reference(SubscriberPatient)Subscriber to the policy
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... extension-militaryStatus S0..*codeMilitary Status
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-militaryStatus
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... url 1..1uri"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-militaryStatus"
..... value[x] (Slice Definition)Value of extension
Slice: Unordered, Closed by type:$this
...... valueCode 0..1codeValue of extension
.... reference ΣI0..1stringLiteral reference, Relative, internal or absolute URL
.... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible)
.... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
.... display Σ0..1stringText alternative for the resource
... subscriberId Σ0..1stringID assigned to the subscriber
... beneficiary SΣ1..1Reference(BeneficiaryPatient)Plan beneficiary
... dependent Σ0..1stringDependent number
... relationship S0..1CodeableConceptBeneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible)
... period Σ0..1PeriodCoverage start and end dates
... payor Σ1..*Reference(Organization | Patient | RelatedPerson)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
..... 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

This structure is derived from Coverage

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage I0..*Insurance 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: CoverageTypeAndSelf-PayCodes (preferred)
... policyHolder Σ0..1Reference(Patient | RelatedPerson | Organization)Owner of the policy
... subscriber SΣ0..1Reference(SubscriberPatient)Subscriber to the policy
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... extension-militaryStatus S0..*codeMilitary Status
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-militaryStatus
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... url 1..1uri"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-militaryStatus"
..... value[x] (Slice Definition)Value of extension
Slice: Unordered, Closed by type:$this
...... valueCode 0..1codeValue of extension
.... reference ΣI0..1stringLiteral reference, Relative, internal or absolute URL
.... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible)
.... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
.... display Σ0..1stringText alternative for the resource
... subscriberId Σ0..1stringID assigned to the subscriber
... beneficiary SΣ1..1Reference(BeneficiaryPatient)Plan beneficiary
... dependent Σ0..1stringDependent number
... relationship S0..1CodeableConceptBeneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible)
... period Σ0..1PeriodCoverage start and end dates
... payor Σ1..*Reference(Organization | Patient | RelatedPerson)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
..... 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

 

Other representations of profile: Schematron

Terminology Bindings

PathConformanceValueSet
Coverage.languagepreferredCommonLanguages
Max Binding: AllLanguages
Coverage.statusrequiredFinancialResourceStatusCodes
Coverage.typepreferredCoverageTypeAndSelf-PayCodes
Coverage.subscriber.typeextensibleResourceType
Coverage.relationshipextensibleSubscriberRelationshipCodes
Coverage.class.typeextensibleCoverageClassCodes
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-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-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-6CoverageA resource should have narrative for robust management
: text.div.exists()
dom-5CoverageIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
ele-1Coverage.classAll 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.exceptionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())