US Core Implementation Guide
8.0.0-ballot - Ballot United States of America flag

US Core Implementation Guide, published by HL7 International / Cross-Group Projects. This guide is not an authorized publication; it is the continuous build for version 8.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/US-Core/ and changes regularly. See the Directory of published versions

Resource Profile: US Core Coverage Profile

Official URL: http://hl7.org/fhir/us/core/StructureDefinition/us-core-coverage Version: 8.0.0-ballot
Standards status: Trial-use Maturity Level: 3 Computable Name: USCoreCoverageProfile
Other Identifiers: OID:2.16.840.1.113883.4.642.40.2.42.19

Copyright/Legal: Used by permission of HL7 International, all rights reserved Creative Commons License

The US Core Coverage Profile inherits from the FHIR Coverage resource; refer to it for scope and usage definitions. This profile meets the requirements of the US Core Data for Interoperability (USCDI) Health Insurance Information Data Class. It sets minimum expectations for the Coverage resource to record, search, and fetch data related to an individual's insurance coverage for health care. It specifies which core elements, extensions, vocabularies, and value sets SHALL be present in the resource and constrains how the elements are used. Providing the floor for standards development for specific use cases promotes interoperability and adoption.

Example Usage Scenarios:

The following are example usage scenarios for this profile:

  • Query for a patient's insurance coverage
  • Record or update a past or present insurance coverage

Mandatory and Must Support Data Elements

The following data elements must always be present (Mandatory definition) or must be supported if the data is present in the sending system (Must Support definition). They are presented below in a simple human-readable explanation. Profile-specific guidance and examples are provided as well. The Formal Views below provides the formal summary, definitions, and terminology requirements.

Each Coverage Must Have:

  1. health insurance member identifier or subscriber id
  2. a status
  3. the health insurance beneficiary (patient)
  4. beneficiary's relationship to the subscriber
  5. the health insurance issuer (payer)

Each Coverage Must Support:

  1. health insurance coverage type (e.g., Medicare)
  2. coverage start or end date
  3. health insurance group or plan

Profile Specific Implementation Guidance:

  • There is no single way to indicate that the patient has no coverage using the Coverage resource:
    • Coverage.status alone may not indicate whether an individual is covered. The Coverage.period needs to be considered as well. For example, the coverage may be expired with a status of "active", or conversely, it may be "canceled" but still have covered claims.
    • The absence of a Coverage resource instance may mean the patient has no coverage or the healthcare provider may not know it.
    • A coverage.type of "81" (Self-pay) MAY be used to imply that the patient has no coverage or that an individual or organization other than an insurer is taking responsibility for payment for a portion of the health care costs.

  • The hierarchical nature of the Coverage.type code system "Payer" (also known as the US Public Health Data Consortium Source of Payment Codes) may be unclear in the expansion, and some codes may be inappropriate for the use case. Implementers should refer to the PHDSC Payer Type Committee User's Guide for the Source of Payment Typology when selecting codes.

    • To differentiate Medicare Parts A, B, C, and D systems can use the following codes:

      Medicare Plan SOP Code (Description) Comment
      Part A and B 121 (Medicare Fee For Service) Part A and B. Part A alone cannot be represented (see "Note to Balloters" below). Part B alone does not need to be represented because Part B enrollment requires enrollment in Part A
      Part C (Medicare Advantage Plan) 111 (Medicare HMO)
      112 (Medicare PPO)
      113 (Medicare POS)      		 These are the most common types of Medicare Advantage Plans
      Part D 122 (Medicare Drug Benefit)  

      The US Core team requested a stand-alone code for Medicare Part A from NAHDO. If this request is not approved, systems SHOULD use the X12 concept for Medicare Part A as a code translation to the SOP code "121" (see Using multiple codes with CodeableConcept Datatype).

  • If Insurers issue unique member IDs for dependents, then the memberId Coverage.identifier should be used instead of Coverage.dependent to uniquely refer to the dependent with respect to their insurance.

Usage:

Changes since version 7.0.0:

  • No changes

    • 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 C 0..* Coverage Insurance or medical plan or a payment agreement
    us-core-15: Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present
    ... Slices for identifier S 0..* Identifier Member ID and other identifiers
    Slice: Unordered, Open by value:type
    .... identifier:memberid SC 0..1 Identifier Member ID
    ..... type S 1..1 CodeableConcept Member Number identifier type
    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 S 1..1 code active | cancelled | draft | entered-in-error
    ... type S 0..1 CodeableConcept Coverage category such as medical or accident
    Binding: Payer Type . (extensible): US Public Health Data Consortium Source of Payment Codes

    ... subscriberId SC 0..1 string ID assigned to the subscriber
    ... beneficiary S 1..1 Reference(US Core Patient Profile) Plan beneficiary
    ... relationship S 1..1 CodeableConcept Beneficiary relationship to the subscriber
    Binding: SubscriberRelationshipCodes (extensible)
    ... period S 0..1 Period Coverage start and end dates
    ... payor S 1..1 Reference(US Core Organization Profile S | US Core Patient Profile | US Core RelatedPerson Profile) Issuer of the policy
    ... Slices for class S 0..* BackboneElement Additional coverage classifications
    Slice: Unordered, Open by value:type
    .... class:group S 0..1 BackboneElement Group
    ..... type 1..1 CodeableConcept Type of class such as 'group' or 'plan'
    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 S 1..1 string Group Number
    ..... name S 0..1 string Group Name
    .... class:plan S 0..1 BackboneElement Plan
    ..... type 1..1 CodeableConcept Type of class such as 'group' or 'plan'
    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 S 1..1 string Plan Number
    ..... name S 0..1 string Plan Name

    doco Documentation for this format

    Terminology Bindings (Differential)

    PathConformanceValueSetURI
    Coverage.typeextensiblePayerType . (a valid code from Source of Payment Typology (https://nahdo.org/sopt)
    http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591
    Coverage.relationshipextensibleSubscriberRelationshipCodes
    http://hl7.org/fhir/ValueSet/subscriber-relationship
    from the FHIR Standard

    Constraints

    IdGradePath(s)DetailsRequirements
    us-core-15errorCoverageMember 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()
    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Coverage C 0..* Coverage 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 Member ID and other identifiers
    Slice: Unordered, Open by value:type
    .... identifier:memberid SΣC 0..1 Identifier 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 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 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: Payer Type . (extensible): US Public Health Data Consortium Source of Payment Codes

    ... subscriberId SΣC 0..1 string ID assigned to the subscriber
    ... beneficiary SΣ 1..1 Reference(US Core Patient Profile) Plan beneficiary
    ... relationship S 1..1 CodeableConcept Beneficiary relationship to the subscriber
    Binding: SubscriberRelationshipCodes (extensible)
    ... period SΣ 0..1 Period Coverage start and end dates
    ... payor SΣ 1..1 Reference(US Core Organization Profile) Issuer of the policy
    ... Slices for class S 0..* BackboneElement Additional coverage classifications
    Slice: Unordered, Open by value: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 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 Group Number
    ..... name SΣ 0..1 string Group Name
    .... class:plan S 0..1 BackboneElement 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 Plan Number
    ..... name SΣ 0..1 string Plan Name

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSet / CodeURI
    Coverage.identifier:memberid.userequiredIdentifierUse
    http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
    from the FHIR Standard
    Coverage.identifier:memberid.typeextensiblePattern: MB
    http://hl7.org/fhir/ValueSet/identifier-type
    from the FHIR Standard
    Coverage.statusrequiredFinancialResourceStatusCodes
    http://hl7.org/fhir/ValueSet/fm-status|4.0.1
    from the FHIR Standard
    Coverage.typeextensiblePayerType . (a valid code from Source of Payment Typology (https://nahdo.org/sopt)
    http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591
    Coverage.relationshipextensibleSubscriberRelationshipCodes
    http://hl7.org/fhir/ValueSet/subscriber-relationship
    from the FHIR Standard
    Coverage.class.typeextensibleCoverageClassCodes
    http://hl7.org/fhir/ValueSet/coverage-class
    from the FHIR Standard
    Coverage.class:group.typeextensiblePattern: group
    http://hl7.org/fhir/ValueSet/coverage-class
    from the FHIR Standard
    Coverage.class:plan.typeextensiblePattern: plan
    http://hl7.org/fhir/ValueSet/coverage-class
    from the FHIR Standard

    Constraints

    IdGradePath(s)DetailsRequirements
    us-core-15errorCoverageMember 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()
    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Coverage C 0..* Coverage 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.

    Additional BindingsPurpose
    AllLanguages Max Binding
    ... 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 Member ID and other identifiers
    Slice: Unordered, Open by value:type
    .... identifier:memberid SΣC 0..1 Identifier 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 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 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: Payer Type . (extensible): US Public Health Data Consortium Source of Payment Codes

    ... policyHolder Σ 0..1 Reference(Patient | RelatedPerson | Organization) Owner of the policy
    ... subscriber Σ 0..1 Reference(Patient | RelatedPerson) Subscriber to the policy
    ... subscriberId SΣC 0..1 string ID assigned to the subscriber
    ... beneficiary SΣ 1..1 Reference(US Core Patient Profile) Plan beneficiary
    ... dependent Σ 0..1 string Dependent number
    ... relationship S 1..1 CodeableConcept Beneficiary relationship to the subscriber
    Binding: SubscriberRelationshipCodes (extensible)
    ... period SΣ 0..1 Period Coverage start and end dates
    ... payor SΣ 1..1 Reference(US Core Organization Profile S | US Core Patient Profile | US Core RelatedPerson Profile) Issuer of the policy
    ... Slices for class S 0..* BackboneElement Additional coverage classifications
    Slice: Unordered, Open by value: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 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 Group Number
    ..... name SΣ 0..1 string Group Name
    .... class:plan S 0..1 BackboneElement 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 Plan Number
    ..... name SΣ 0..1 string 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

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSet / CodeURI
    Coverage.languagepreferredCommonLanguages
    Additional Bindings Purpose
    AllLanguages Max Binding
    http://hl7.org/fhir/ValueSet/languages
    from the FHIR Standard
    Coverage.identifier:memberid.userequiredIdentifierUse
    http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
    from the FHIR Standard
    Coverage.identifier:memberid.typeextensiblePattern: MB
    http://hl7.org/fhir/ValueSet/identifier-type
    from the FHIR Standard
    Coverage.statusrequiredFinancialResourceStatusCodes
    http://hl7.org/fhir/ValueSet/fm-status|4.0.1
    from the FHIR Standard
    Coverage.typeextensiblePayerType . (a valid code from Source of Payment Typology (https://nahdo.org/sopt)
    http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591
    Coverage.relationshipextensibleSubscriberRelationshipCodes
    http://hl7.org/fhir/ValueSet/subscriber-relationship
    from the FHIR Standard
    Coverage.class.typeextensibleCoverageClassCodes
    http://hl7.org/fhir/ValueSet/coverage-class
    from the FHIR Standard
    Coverage.class:group.typeextensiblePattern: group
    http://hl7.org/fhir/ValueSet/coverage-class
    from the FHIR Standard
    Coverage.class:plan.typeextensiblePattern: plan
    http://hl7.org/fhir/ValueSet/coverage-class
    from the FHIR Standard
    Coverage.costToBeneficiary.typeextensibleCoverageCopayTypeCodes
    http://hl7.org/fhir/ValueSet/coverage-copay-type
    from the FHIR Standard
    Coverage.costToBeneficiary.exception.typeexampleExampleCoverageFinancialExceptionCodes
    http://hl7.org/fhir/ValueSet/coverage-financial-exception
    from the FHIR Standard

    Constraints

    IdGradePath(s)DetailsRequirements
    us-core-15errorCoverageMember 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 Coverage

    Summary

    Mandatory: 1 element(1 nested mandatory element)
    Must-Support: 17 elements

    Structures

    This structure refers to these other structures:

    Slices

    This structure defines the following Slices:

    • The element 1 is sliced based on the value of Coverage.identifier
    • The element 1 is sliced based on the value of Coverage.class

    Maturity: 3

    Differential View

    This structure is derived from Coverage

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Coverage C 0..* Coverage Insurance or medical plan or a payment agreement
    us-core-15: Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present
    ... Slices for identifier S 0..* Identifier Member ID and other identifiers
    Slice: Unordered, Open by value:type
    .... identifier:memberid SC 0..1 Identifier Member ID
    ..... type S 1..1 CodeableConcept Member Number identifier type
    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 S 1..1 code active | cancelled | draft | entered-in-error
    ... type S 0..1 CodeableConcept Coverage category such as medical or accident
    Binding: Payer Type . (extensible): US Public Health Data Consortium Source of Payment Codes

    ... subscriberId SC 0..1 string ID assigned to the subscriber
    ... beneficiary S 1..1 Reference(US Core Patient Profile) Plan beneficiary
    ... relationship S 1..1 CodeableConcept Beneficiary relationship to the subscriber
    Binding: SubscriberRelationshipCodes (extensible)
    ... period S 0..1 Period Coverage start and end dates
    ... payor S 1..1 Reference(US Core Organization Profile S | US Core Patient Profile | US Core RelatedPerson Profile) Issuer of the policy
    ... Slices for class S 0..* BackboneElement Additional coverage classifications
    Slice: Unordered, Open by value:type
    .... class:group S 0..1 BackboneElement Group
    ..... type 1..1 CodeableConcept Type of class such as 'group' or 'plan'
    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 S 1..1 string Group Number
    ..... name S 0..1 string Group Name
    .... class:plan S 0..1 BackboneElement Plan
    ..... type 1..1 CodeableConcept Type of class such as 'group' or 'plan'
    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 S 1..1 string Plan Number
    ..... name S 0..1 string Plan Name

    doco Documentation for this format

    Terminology Bindings (Differential)

    PathConformanceValueSetURI
    Coverage.typeextensiblePayerType . (a valid code from Source of Payment Typology (https://nahdo.org/sopt)
    http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591
    Coverage.relationshipextensibleSubscriberRelationshipCodes
    http://hl7.org/fhir/ValueSet/subscriber-relationship
    from the FHIR Standard

    Constraints

    IdGradePath(s)DetailsRequirements
    us-core-15errorCoverageMember 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()

    Key Elements View

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Coverage C 0..* Coverage 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 Member ID and other identifiers
    Slice: Unordered, Open by value:type
    .... identifier:memberid SΣC 0..1 Identifier 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 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 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: Payer Type . (extensible): US Public Health Data Consortium Source of Payment Codes

    ... subscriberId SΣC 0..1 string ID assigned to the subscriber
    ... beneficiary SΣ 1..1 Reference(US Core Patient Profile) Plan beneficiary
    ... relationship S 1..1 CodeableConcept Beneficiary relationship to the subscriber
    Binding: SubscriberRelationshipCodes (extensible)
    ... period SΣ 0..1 Period Coverage start and end dates
    ... payor SΣ 1..1 Reference(US Core Organization Profile) Issuer of the policy
    ... Slices for class S 0..* BackboneElement Additional coverage classifications
    Slice: Unordered, Open by value: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 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 Group Number
    ..... name SΣ 0..1 string Group Name
    .... class:plan S 0..1 BackboneElement 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 Plan Number
    ..... name SΣ 0..1 string Plan Name

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSet / CodeURI
    Coverage.identifier:memberid.userequiredIdentifierUse
    http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
    from the FHIR Standard
    Coverage.identifier:memberid.typeextensiblePattern: MB
    http://hl7.org/fhir/ValueSet/identifier-type
    from the FHIR Standard
    Coverage.statusrequiredFinancialResourceStatusCodes
    http://hl7.org/fhir/ValueSet/fm-status|4.0.1
    from the FHIR Standard
    Coverage.typeextensiblePayerType . (a valid code from Source of Payment Typology (https://nahdo.org/sopt)
    http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591
    Coverage.relationshipextensibleSubscriberRelationshipCodes
    http://hl7.org/fhir/ValueSet/subscriber-relationship
    from the FHIR Standard
    Coverage.class.typeextensibleCoverageClassCodes
    http://hl7.org/fhir/ValueSet/coverage-class
    from the FHIR Standard
    Coverage.class:group.typeextensiblePattern: group
    http://hl7.org/fhir/ValueSet/coverage-class
    from the FHIR Standard
    Coverage.class:plan.typeextensiblePattern: plan
    http://hl7.org/fhir/ValueSet/coverage-class
    from the FHIR Standard

    Constraints

    IdGradePath(s)DetailsRequirements
    us-core-15errorCoverageMember 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

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Coverage C 0..* Coverage 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.

    Additional BindingsPurpose
    AllLanguages Max Binding
    ... 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 Member ID and other identifiers
    Slice: Unordered, Open by value:type
    .... identifier:memberid SΣC 0..1 Identifier 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 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 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: Payer Type . (extensible): US Public Health Data Consortium Source of Payment Codes

    ... policyHolder Σ 0..1 Reference(Patient | RelatedPerson | Organization) Owner of the policy
    ... subscriber Σ 0..1 Reference(Patient | RelatedPerson) Subscriber to the policy
    ... subscriberId SΣC 0..1 string ID assigned to the subscriber
    ... beneficiary SΣ 1..1 Reference(US Core Patient Profile) Plan beneficiary
    ... dependent Σ 0..1 string Dependent number
    ... relationship S 1..1 CodeableConcept Beneficiary relationship to the subscriber
    Binding: SubscriberRelationshipCodes (extensible)
    ... period SΣ 0..1 Period Coverage start and end dates
    ... payor SΣ 1..1 Reference(US Core Organization Profile S | US Core Patient Profile | US Core RelatedPerson Profile) Issuer of the policy
    ... Slices for class S 0..* BackboneElement Additional coverage classifications
    Slice: Unordered, Open by value: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 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 Group Number
    ..... name SΣ 0..1 string Group Name
    .... class:plan S 0..1 BackboneElement 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 Plan Number
    ..... name SΣ 0..1 string 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

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSet / CodeURI
    Coverage.languagepreferredCommonLanguages
    Additional Bindings Purpose
    AllLanguages Max Binding
    http://hl7.org/fhir/ValueSet/languages
    from the FHIR Standard
    Coverage.identifier:memberid.userequiredIdentifierUse
    http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
    from the FHIR Standard
    Coverage.identifier:memberid.typeextensiblePattern: MB
    http://hl7.org/fhir/ValueSet/identifier-type
    from the FHIR Standard
    Coverage.statusrequiredFinancialResourceStatusCodes
    http://hl7.org/fhir/ValueSet/fm-status|4.0.1
    from the FHIR Standard
    Coverage.typeextensiblePayerType . (a valid code from Source of Payment Typology (https://nahdo.org/sopt)
    http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591
    Coverage.relationshipextensibleSubscriberRelationshipCodes
    http://hl7.org/fhir/ValueSet/subscriber-relationship
    from the FHIR Standard
    Coverage.class.typeextensibleCoverageClassCodes
    http://hl7.org/fhir/ValueSet/coverage-class
    from the FHIR Standard
    Coverage.class:group.typeextensiblePattern: group
    http://hl7.org/fhir/ValueSet/coverage-class
    from the FHIR Standard
    Coverage.class:plan.typeextensiblePattern: plan
    http://hl7.org/fhir/ValueSet/coverage-class
    from the FHIR Standard
    Coverage.costToBeneficiary.typeextensibleCoverageCopayTypeCodes
    http://hl7.org/fhir/ValueSet/coverage-copay-type
    from the FHIR Standard
    Coverage.costToBeneficiary.exception.typeexampleExampleCoverageFinancialExceptionCodes
    http://hl7.org/fhir/ValueSet/coverage-financial-exception
    from the FHIR Standard

    Constraints

    IdGradePath(s)DetailsRequirements
    us-core-15errorCoverageMember 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 Coverage

    Summary

    Mandatory: 1 element(1 nested mandatory element)
    Must-Support: 17 elements

    Structures

    This structure refers to these other structures:

    Slices

    This structure defines the following Slices:

    • The element 1 is sliced based on the value of Coverage.identifier
    • The element 1 is sliced based on the value of Coverage.class

    Maturity: 3

     

    Other representations of profile: CSV, Excel, Schematron

    Notes:

    Quick Start

    Below is an overview of the required Server RESTful FHIR interactions for this profile - for example, search and read operations - when supporting the US Core interactions to access this profile's information (Profile Support + Interaction Support). Note that systems that support only US Core Profiles (Profile Only Support) are not required to support these interactions. See the US Core Server CapabilityStatement for a complete list of supported RESTful interactions for this IG.

    • See the Scopes Format section for a description of the SMART scopes syntax.
    • See the Search Syntax section for a description of the US Core search syntax.
    • See the General Requirements section for additional rules and expectations when a server requires status parameters.
    • See the General Guidance section for additional guidance on searching for multiple patients.

    US Core Scopes

    Servers providing access to coverage data SHALL support these US Core SMART Scopes:

    Mandatory Search Parameters:

    1. SHALL support searching for all coverages for a patient using the patient search parameter:

      GET [base]/Coverage?patient={Type/}[id]

      Example:

      1. GET [base]/Coverage?patient=1137192

      Implementation Notes: Fetches a bundle of all Coverage resources for the specified patient (how to search by reference)