CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
2.1.0-snapshot1 - STU 2.1 prepublication draft United States of America flag

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

Resource Profile: C4BB Coverage

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.

Notes on Fields

  • The Coverage FHIR Resource defines a comprehensive set of data elements.  Many of them are not relevant to this use case.  When reviewing the Profile Snapshot, several data elements previously hidden are now exposed.  Fields intended for consideration to be provided in the API are marked as Must Support; i.e., a red S or have a minimum cardinality of 1.  All other data elements are not expected to be sent by a Responder; if they are sent a Requestor can choose to ignore them
  • The Coverage Reference Resource shall be returned with data that was effective as of the date of service of the claim
  • The numbers, e.g. (1), following the data element descriptions correlate to the MapID in the CPCDS Data Dictionary and the Mapping Worksheet as described here.
  • meta.profile is required as a matter of convenience of receiving systems. The meta.profile should be used by the Server to hint/assert/declare that this instance conforms to one (or more) stated profiles (with business versions). meta.profile does not capture any business logic, processing directives, or semantics (for example, inpatient or outpatient). Clients should not assume that the Server will exhaustively indicate all profiles with all versions that this instance conforms to. Clients can (and should) perform their own validation of conformance to the indicated profile(s) and to any other profiles of interest.

Usage:

Formal Views of Profile Content

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

This structure is derived from USCoreCoverageProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
... 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

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Coverage.relationshiprequiredSubscriberRelationshipCodes
http://hl7.org/fhir/ValueSet/subscriber-relationship
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
coverage-meta-profile-versionwarningCoverageCoverage: 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'))
NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
.... 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

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 .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591
Coverage.relationshiprequiredSubscriberRelationshipCodes
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
coverage-meta-profile-versionwarningCoverageCoverage: 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'))
NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
... 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Coverage.meta.securityextensibleAll Security Labels
http://hl7.org/fhir/ValueSet/security-labels
from the FHIR Standard
Coverage.meta.tagexampleCommonTags
http://hl7.org/fhir/ValueSet/common-tags
from the FHIR Standard
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 .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591
Coverage.relationshiprequiredSubscriberRelationshipCodes
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
coverage-meta-profile-versionwarningCoverageCoverage: 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

Summary

Mandatory: 4 elements
Must-Support: 2 elements

Structures

This structure refers to these other structures:

Differential View

This structure is derived from USCoreCoverageProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
... 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

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Coverage.relationshiprequiredSubscriberRelationshipCodes
http://hl7.org/fhir/ValueSet/subscriber-relationship
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
coverage-meta-profile-versionwarningCoverageCoverage: 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

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
.... 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

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 .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591
Coverage.relationshiprequiredSubscriberRelationshipCodes
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
coverage-meta-profile-versionwarningCoverageCoverage: 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

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
... 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Coverage.meta.securityextensibleAll Security Labels
http://hl7.org/fhir/ValueSet/security-labels
from the FHIR Standard
Coverage.meta.tagexampleCommonTags
http://hl7.org/fhir/ValueSet/common-tags
from the FHIR Standard
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 .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591
Coverage.relationshiprequiredSubscriberRelationshipCodes
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
coverage-meta-profile-versionwarningCoverageCoverage: 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

Summary

Mandatory: 4 elements
Must-Support: 2 elements

Structures

This structure refers to these other structures:

 

Other representations of profile: CSV, Excel, Schematron