CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®), published by HL7 International / Financial Management. This guide is not an authorized publication; it is the continuous build for version 2.1.0-snapshot1 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/carin-bb/ and changes regularly. See the Directory of published versions
Official URL: http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Coverage | Version: 2.1.0-snapshot1 | |||
Standards status: Trial-use | Computable Name: C4BBCoverage |
Data that reflect a payer’s coverage that was effective as of the date of service or the date of admission of the claim.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from USCoreCoverageProfile
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Coverage | C | 0..* | USCoreCoverageProfile | Insurance or medical plan or a payment agreement coverage-meta-profile-version: Coverage: meta.profile with canonical and major.minor. version required. |
meta | S | 1..1 | Meta | Metadata about the resource |
lastUpdated | S | 1..1 | instant | When the resource version last changed |
profile | 1..* | canonical(StructureDefinition) | Profiles this resource claims to conform to | |
identifier | 0..* | Identifier | Member ID and other identifiers | |
status | 1..1 | code | (USCDI) active | cancelled | draft | entered-in-error | |
type | 0..1 | CodeableConcept | (USCDI) Coverage category such as medical or accident | |
subscriberId | 1..1 | string | (USCDI) ID assigned to the subscriber | |
beneficiary | 1..1 | Reference(C4BB Patient) | (USCDI) Plan beneficiary | |
relationship | 1..1 | CodeableConcept | (USCDI) Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (required) | |
period | 0..1 | Period | (USCDI) Coverage start and end dates | |
payor | 1..1 | Reference(C4BB Organization) | (USCDI) Issuer of the policy | |
Slices for class | Content/Rules for all slices | |||
class:group | 0..1 | BackboneElement | (USCDI) Group | |
value | 1..1 | string | (USCDI) Group Number | |
class:plan | 0..1 | BackboneElement | (USCDI) Plan | |
value | 1..1 | string | (USCDI) Plan Number | |
name | 0..1 | string | (USCDI) Plan Name | |
Documentation for this format |
Path | Conformance | ValueSet | URI |
Coverage.relationship | required | SubscriberRelationshipCodeshttp://hl7.org/fhir/ValueSet/subscriber-relationship from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
coverage-meta-profile-version | warning | Coverage | Coverage: meta.profile with canonical and major.minor. version required. : meta.profile.exists($this.startsWith('http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Coverage|2.1')) |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Coverage | C | 0..* | USCoreCoverageProfile | Insurance or medical plan or a payment agreement us-core-15: Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present coverage-meta-profile-version: Coverage: meta.profile with canonical and major.minor. version required. |
meta | SΣ | 1..1 | Meta | Metadata about the resource |
lastUpdated | SΣ | 1..1 | instant | When the resource version last changed |
profile | Σ | 1..* | canonical(StructureDefinition) | Profiles this resource claims to conform to |
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 pattern:type |
identifier:memberid | SΣC | 0..1 | Identifier | (USCDI) 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 | (USCDI) 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 | (USCDI) active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. |
type | SΣ | 0..1 | CodeableConcept | (USCDI) Coverage category such as medical or accident Binding: Payer Type (extensible): US Public Health Data Consortium Source of Payment Codes |
subscriberId | SΣC | 1..1 | string | (USCDI) ID assigned to the subscriber |
beneficiary | SΣ | 1..1 | Reference(C4BB Patient) | (USCDI) Plan beneficiary |
relationship | S | 1..1 | CodeableConcept | (USCDI) Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (required) |
period | SΣ | 0..1 | Period | (USCDI) Coverage start and end dates |
payor | SΣ | 1..1 | Reference(C4BB Organization) | (USCDI) Issuer of the policy |
Slices for class | S | 0..* | BackboneElement | (USCDI) Additional coverage classifications Slice: Unordered, Open by pattern: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 | (USCDI) 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 | (USCDI) Group Number |
name | SΣ | 0..1 | string | (USCDI) Group Name |
class:plan | S | 0..1 | BackboneElement | (USCDI) 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 | (USCDI) Plan Number |
name | SΣ | 0..1 | string | (USCDI) Plan Name |
Documentation for this format |
Path | Conformance | ValueSet / Code | URI |
Coverage.identifier:memberid.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard | |
Coverage.identifier:memberid.type | extensible | Pattern: MBhttp://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard | |
Coverage.status | required | FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard | |
Coverage.type | extensible | PayerType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 | |
Coverage.relationship | required | SubscriberRelationshipCodeshttp://hl7.org/fhir/ValueSet/subscriber-relationship from the FHIR Standard | |
Coverage.class.type | extensible | CoverageClassCodeshttp://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard | |
Coverage.class:group.type | extensible | Pattern: grouphttp://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard | |
Coverage.class:plan.type | extensible | Pattern: planhttp://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
coverage-meta-profile-version | warning | Coverage | Coverage: meta.profile with canonical and major.minor. version required. : meta.profile.exists($this.startsWith('http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Coverage|2.1')) |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Coverage | C | 0..* | USCoreCoverageProfile | Insurance or medical plan or a payment agreement us-core-15: Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present coverage-meta-profile-version: Coverage: meta.profile with canonical and major.minor. version required. | ||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | SΣ | 1..1 | Meta | Metadata about the resource | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
versionId | Σ | 0..1 | id | Version specific identifier | ||||
lastUpdated | SΣ | 1..1 | instant | When the resource version last changed | ||||
source | Σ | 0..1 | uri | Identifies where the resource comes from | ||||
profile | Σ | 1..* | canonical(StructureDefinition) | Profiles this resource claims to conform to | ||||
security | Σ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
tag | Σ | 0..* | Coding | Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
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.
| |||||
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 pattern:type | ||||
identifier:memberid | SΣC | 0..1 | Identifier | (USCDI) 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 | (USCDI) 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 | (USCDI) active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. | ||||
type | SΣ | 0..1 | CodeableConcept | (USCDI) 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 | 1..1 | string | (USCDI) ID assigned to the subscriber | ||||
beneficiary | SΣ | 1..1 | Reference(C4BB Patient) | (USCDI) Plan beneficiary | ||||
dependent | Σ | 0..1 | string | Dependent number | ||||
relationship | S | 1..1 | CodeableConcept | (USCDI) Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (required) | ||||
period | SΣ | 0..1 | Period | (USCDI) Coverage start and end dates | ||||
payor | SΣ | 1..1 | Reference(C4BB Organization) | (USCDI) Issuer of the policy | ||||
Slices for class | S | 0..* | BackboneElement | (USCDI) Additional coverage classifications Slice: Unordered, Open by pattern: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 | (USCDI) 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 | (USCDI) Group Number | ||||
name | SΣ | 0..1 | string | (USCDI) Group Name | ||||
class:plan | S | 0..1 | BackboneElement | (USCDI) 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 | (USCDI) Plan Number | ||||
name | SΣ | 0..1 | string | (USCDI) 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 | |||||
Documentation for this format |
Path | Conformance | ValueSet / Code | URI | |||
Coverage.meta.security | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels from the FHIR Standard | ||||
Coverage.meta.tag | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tags from the FHIR Standard | ||||
Coverage.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
Coverage.identifier:memberid.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard | ||||
Coverage.identifier:memberid.type | extensible | Pattern: MBhttp://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard | ||||
Coverage.status | required | FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard | ||||
Coverage.type | extensible | PayerType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 | ||||
Coverage.relationship | required | SubscriberRelationshipCodeshttp://hl7.org/fhir/ValueSet/subscriber-relationship from the FHIR Standard | ||||
Coverage.class.type | extensible | CoverageClassCodeshttp://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard | ||||
Coverage.class:group.type | extensible | Pattern: grouphttp://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard | ||||
Coverage.class:plan.type | extensible | Pattern: planhttp://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard | ||||
Coverage.costToBeneficiary.type | extensible | CoverageCopayTypeCodeshttp://hl7.org/fhir/ValueSet/coverage-copay-type from the FHIR Standard | ||||
Coverage.costToBeneficiary.exception.type | example | ExampleCoverageFinancialExceptionCodeshttp://hl7.org/fhir/ValueSet/coverage-financial-exception from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
coverage-meta-profile-version | warning | Coverage | Coverage: meta.profile with canonical and major.minor. version required. : meta.profile.exists($this.startsWith('http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Coverage|2.1')) |
This structure is derived from USCoreCoverageProfile
Differential View
This structure is derived from USCoreCoverageProfile
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Coverage | C | 0..* | USCoreCoverageProfile | Insurance or medical plan or a payment agreement coverage-meta-profile-version: Coverage: meta.profile with canonical and major.minor. version required. |
meta | S | 1..1 | Meta | Metadata about the resource |
lastUpdated | S | 1..1 | instant | When the resource version last changed |
profile | 1..* | canonical(StructureDefinition) | Profiles this resource claims to conform to | |
identifier | 0..* | Identifier | Member ID and other identifiers | |
status | 1..1 | code | (USCDI) active | cancelled | draft | entered-in-error | |
type | 0..1 | CodeableConcept | (USCDI) Coverage category such as medical or accident | |
subscriberId | 1..1 | string | (USCDI) ID assigned to the subscriber | |
beneficiary | 1..1 | Reference(C4BB Patient) | (USCDI) Plan beneficiary | |
relationship | 1..1 | CodeableConcept | (USCDI) Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (required) | |
period | 0..1 | Period | (USCDI) Coverage start and end dates | |
payor | 1..1 | Reference(C4BB Organization) | (USCDI) Issuer of the policy | |
Slices for class | Content/Rules for all slices | |||
class:group | 0..1 | BackboneElement | (USCDI) Group | |
value | 1..1 | string | (USCDI) Group Number | |
class:plan | 0..1 | BackboneElement | (USCDI) Plan | |
value | 1..1 | string | (USCDI) Plan Number | |
name | 0..1 | string | (USCDI) Plan Name | |
Documentation for this format |
Path | Conformance | ValueSet | URI |
Coverage.relationship | required | SubscriberRelationshipCodeshttp://hl7.org/fhir/ValueSet/subscriber-relationship from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
coverage-meta-profile-version | warning | Coverage | Coverage: meta.profile with canonical and major.minor. version required. : meta.profile.exists($this.startsWith('http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Coverage|2.1')) |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Coverage | C | 0..* | USCoreCoverageProfile | Insurance or medical plan or a payment agreement us-core-15: Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present coverage-meta-profile-version: Coverage: meta.profile with canonical and major.minor. version required. |
meta | SΣ | 1..1 | Meta | Metadata about the resource |
lastUpdated | SΣ | 1..1 | instant | When the resource version last changed |
profile | Σ | 1..* | canonical(StructureDefinition) | Profiles this resource claims to conform to |
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 pattern:type |
identifier:memberid | SΣC | 0..1 | Identifier | (USCDI) 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 | (USCDI) 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 | (USCDI) active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. |
type | SΣ | 0..1 | CodeableConcept | (USCDI) Coverage category such as medical or accident Binding: Payer Type (extensible): US Public Health Data Consortium Source of Payment Codes |
subscriberId | SΣC | 1..1 | string | (USCDI) ID assigned to the subscriber |
beneficiary | SΣ | 1..1 | Reference(C4BB Patient) | (USCDI) Plan beneficiary |
relationship | S | 1..1 | CodeableConcept | (USCDI) Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (required) |
period | SΣ | 0..1 | Period | (USCDI) Coverage start and end dates |
payor | SΣ | 1..1 | Reference(C4BB Organization) | (USCDI) Issuer of the policy |
Slices for class | S | 0..* | BackboneElement | (USCDI) Additional coverage classifications Slice: Unordered, Open by pattern: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 | (USCDI) 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 | (USCDI) Group Number |
name | SΣ | 0..1 | string | (USCDI) Group Name |
class:plan | S | 0..1 | BackboneElement | (USCDI) 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 | (USCDI) Plan Number |
name | SΣ | 0..1 | string | (USCDI) Plan Name |
Documentation for this format |
Path | Conformance | ValueSet / Code | URI |
Coverage.identifier:memberid.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard | |
Coverage.identifier:memberid.type | extensible | Pattern: MBhttp://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard | |
Coverage.status | required | FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard | |
Coverage.type | extensible | PayerType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 | |
Coverage.relationship | required | SubscriberRelationshipCodeshttp://hl7.org/fhir/ValueSet/subscriber-relationship from the FHIR Standard | |
Coverage.class.type | extensible | CoverageClassCodeshttp://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard | |
Coverage.class:group.type | extensible | Pattern: grouphttp://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard | |
Coverage.class:plan.type | extensible | Pattern: planhttp://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
coverage-meta-profile-version | warning | Coverage | Coverage: meta.profile with canonical and major.minor. version required. : meta.profile.exists($this.startsWith('http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Coverage|2.1')) |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Coverage | C | 0..* | USCoreCoverageProfile | Insurance or medical plan or a payment agreement us-core-15: Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present coverage-meta-profile-version: Coverage: meta.profile with canonical and major.minor. version required. | ||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | SΣ | 1..1 | Meta | Metadata about the resource | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
versionId | Σ | 0..1 | id | Version specific identifier | ||||
lastUpdated | SΣ | 1..1 | instant | When the resource version last changed | ||||
source | Σ | 0..1 | uri | Identifies where the resource comes from | ||||
profile | Σ | 1..* | canonical(StructureDefinition) | Profiles this resource claims to conform to | ||||
security | Σ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
tag | Σ | 0..* | Coding | Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
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.
| |||||
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 pattern:type | ||||
identifier:memberid | SΣC | 0..1 | Identifier | (USCDI) 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 | (USCDI) 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 | (USCDI) active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. | ||||
type | SΣ | 0..1 | CodeableConcept | (USCDI) 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 | 1..1 | string | (USCDI) ID assigned to the subscriber | ||||
beneficiary | SΣ | 1..1 | Reference(C4BB Patient) | (USCDI) Plan beneficiary | ||||
dependent | Σ | 0..1 | string | Dependent number | ||||
relationship | S | 1..1 | CodeableConcept | (USCDI) Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (required) | ||||
period | SΣ | 0..1 | Period | (USCDI) Coverage start and end dates | ||||
payor | SΣ | 1..1 | Reference(C4BB Organization) | (USCDI) Issuer of the policy | ||||
Slices for class | S | 0..* | BackboneElement | (USCDI) Additional coverage classifications Slice: Unordered, Open by pattern: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 | (USCDI) 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 | (USCDI) Group Number | ||||
name | SΣ | 0..1 | string | (USCDI) Group Name | ||||
class:plan | S | 0..1 | BackboneElement | (USCDI) 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 | (USCDI) Plan Number | ||||
name | SΣ | 0..1 | string | (USCDI) 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 | |||||
Documentation for this format |
Path | Conformance | ValueSet / Code | URI | |||
Coverage.meta.security | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels from the FHIR Standard | ||||
Coverage.meta.tag | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tags from the FHIR Standard | ||||
Coverage.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
Coverage.identifier:memberid.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard | ||||
Coverage.identifier:memberid.type | extensible | Pattern: MBhttp://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard | ||||
Coverage.status | required | FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard | ||||
Coverage.type | extensible | PayerType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 | ||||
Coverage.relationship | required | SubscriberRelationshipCodeshttp://hl7.org/fhir/ValueSet/subscriber-relationship from the FHIR Standard | ||||
Coverage.class.type | extensible | CoverageClassCodeshttp://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard | ||||
Coverage.class:group.type | extensible | Pattern: grouphttp://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard | ||||
Coverage.class:plan.type | extensible | Pattern: planhttp://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard | ||||
Coverage.costToBeneficiary.type | extensible | CoverageCopayTypeCodeshttp://hl7.org/fhir/ValueSet/coverage-copay-type from the FHIR Standard | ||||
Coverage.costToBeneficiary.exception.type | example | ExampleCoverageFinancialExceptionCodeshttp://hl7.org/fhir/ValueSet/coverage-financial-exception from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
coverage-meta-profile-version | warning | Coverage | Coverage: meta.profile with canonical and major.minor. version required. : meta.profile.exists($this.startsWith('http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Coverage|2.1')) |
This structure is derived from USCoreCoverageProfile
Other representations of profile: CSV, Excel, Schematron