Introduction

The Da Vinci Admit/Discharge/Transfer Notification Coverage Profile is based on the HRex Coverage Profile and constrains the Patient resource referenced by the Coverage.beneficiary element to be found in the same message Bundle.

Mandatory and Must Support Data Elements

The following data-elements are mandatory (i.e., data MUST be present) 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 Profile Definition below provides the formal summary, definitions, and terminology requirements.

Each Coverage must have:

1. A beneficiary
2. A reference to a payor

Each Coverage must support:

1. A business identifier
2. A subscriber id

Additional Profile specific implementation guidance:

• Note that for the admission/transfer/discharge scenario, the Coverage.beneficiary is a “reverse link” to the Patient resource and cannot be traversed from the MessageHeader within the Message Bundle. There is no mechanism to enforce profiles in a message on a reverse link except via GraphDefinition.
• The Coverage.payor references the HRex Organization Profile profile to mandate an identifier and support additional identifier types.

Examples

The following example of this profile is a freestanding resource instance which is technically invalid since the profile is defined to reference other resources within the same Da Vinci Notification Message Bundle. For examples of this profile within a bundle, see the message bundle examples which are listed on the Examples page.

• Coverage Example

• Differential Table
• Key Elements Table
• Snapshot Table
• Statistics/References
• All

This structure is derived from HRexCoverage

Name	Flags	Card.	Type	Description & Constraints
Coverage		0..*	HRexCoverage	Insurance or medical plan or a payment agreement
beneficiary		1..1	Reference() {b}	Plan beneficiary
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints
Coverage	C	0..*	HRexCoverage	Insurance or medical plan or a payment agreement
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	SΣ	0..1	Identifier	Also known as Member identifier
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
value	SΣ	1..1	string	The value that is unique within the system. Example General: 123456
status	?!Σ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
subscriberId	SΣ	0..1	string	Subscriber ID
beneficiary	SΣ	1..1	Reference() {b}	Plan beneficiary
dependent	SΣ	0..1	string	Dependent number
payor	SΣ	1..1	Reference(HRex Organization Profile)	Issuer of the policy
Slices for class		0..*	BackboneElement	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	Additional coverage classifications
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	SΣ	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	Value associated with the type
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
Coverage.identifier.use	required	IdentifierUse
Coverage.status	required	FinancialResourceStatusCodes
Coverage.class.type	extensible	CoverageClassCodes
Coverage.class:group.type	extensible	Pattern: group

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	Coverage	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Coverage	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	Coverage	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	Coverage	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Coverage	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()
hrex-cov-1	error	Coverage	Coverage.identifier or Coverage.subscriberId SHALL be present : identifier.exists() or subscriberId.exists()

Name	Flags	Card.	Type	Description & Constraints
Coverage	C	0..*	HRexCoverage	Insurance or medical plan or a payment agreement
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 Bindings Purpose 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
identifier	SΣ	0..1	Identifier	Also known as Member identifier
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	Σ	0..1	CodeableConcept	Description of identifier 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.
system	Σ	0..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value	SΣ	1..1	string	The value that is unique within the system. 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	?!Σ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
type	Σ	0..1	CodeableConcept	Coverage category such as medical or accident Binding: CoverageTypeAndSelf-PayCodes (preferred): The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization.
policyHolder	Σ	0..1	Reference(US Core Patient Profile | HRex Organization Profile | RelatedPerson)	Owner of the policy
subscriber	Σ	0..1	Reference(US Core Patient Profile)	Subscriber to the policy
subscriberId	SΣ	0..1	string	Subscriber ID
beneficiary	SΣ	1..1	Reference() {b}	Plan beneficiary
dependent	SΣ	0..1	string	Dependent number
relationship		0..1	CodeableConcept	Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).
period	Σ	0..1	Period	Coverage start and end dates
payor	SΣ	1..1	Reference(HRex Organization Profile)	Issuer of the policy
Slices for class		0..*	BackboneElement	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	Additional coverage classifications
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	SΣ	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	Value associated with the type
name	Σ	0..1	string	Human readable description of the type and value
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

Terminology Bindings

Path	Conformance	ValueSet / Code
Coverage.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
Coverage.identifier.use	required	IdentifierUse
Coverage.identifier.type	extensible	Identifier Type Codes
Coverage.status	required	FinancialResourceStatusCodes
Coverage.type	preferred	CoverageTypeAndSelf-PayCodes
Coverage.relationship	extensible	SubscriberRelationshipCodes
Coverage.class.type	extensible	CoverageClassCodes
Coverage.class:group.type	extensible	Pattern: group
Coverage.costToBeneficiary.type	extensible	CoverageCopayTypeCodes
Coverage.costToBeneficiary.exception.type	example	ExampleCoverageFinancialExceptionCodes

Constraints

Id	Grade	Path(s)	Details	Requirements
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

Differential View

This structure is derived from HRexCoverage

Name	Flags	Card.	Type	Description & Constraints
Coverage		0..*	HRexCoverage	Insurance or medical plan or a payment agreement
beneficiary		1..1	Reference() {b}	Plan beneficiary
Documentation for this format

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
Coverage	C	0..*	HRexCoverage	Insurance or medical plan or a payment agreement
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	SΣ	0..1	Identifier	Also known as Member identifier
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
value	SΣ	1..1	string	The value that is unique within the system. Example General: 123456
status	?!Σ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
subscriberId	SΣ	0..1	string	Subscriber ID
beneficiary	SΣ	1..1	Reference() {b}	Plan beneficiary
dependent	SΣ	0..1	string	Dependent number
payor	SΣ	1..1	Reference(HRex Organization Profile)	Issuer of the policy
Slices for class		0..*	BackboneElement	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	Additional coverage classifications
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	SΣ	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	Value associated with the type
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
Coverage.identifier.use	required	IdentifierUse
Coverage.status	required	FinancialResourceStatusCodes
Coverage.class.type	extensible	CoverageClassCodes
Coverage.class:group.type	extensible	Pattern: group

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	Coverage	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Coverage	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	Coverage	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	Coverage	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Coverage	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()
hrex-cov-1	error	Coverage	Coverage.identifier or Coverage.subscriberId SHALL be present : identifier.exists() or subscriberId.exists()

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
Coverage	C	0..*	HRexCoverage	Insurance or medical plan or a payment agreement
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 Bindings Purpose 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
identifier	SΣ	0..1	Identifier	Also known as Member identifier
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	Σ	0..1	CodeableConcept	Description of identifier 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.
system	Σ	0..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value	SΣ	1..1	string	The value that is unique within the system. 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	?!Σ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
type	Σ	0..1	CodeableConcept	Coverage category such as medical or accident Binding: CoverageTypeAndSelf-PayCodes (preferred): The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization.
policyHolder	Σ	0..1	Reference(US Core Patient Profile | HRex Organization Profile | RelatedPerson)	Owner of the policy
subscriber	Σ	0..1	Reference(US Core Patient Profile)	Subscriber to the policy
subscriberId	SΣ	0..1	string	Subscriber ID
beneficiary	SΣ	1..1	Reference() {b}	Plan beneficiary
dependent	SΣ	0..1	string	Dependent number
relationship		0..1	CodeableConcept	Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).
period	Σ	0..1	Period	Coverage start and end dates
payor	SΣ	1..1	Reference(HRex Organization Profile)	Issuer of the policy
Slices for class		0..*	BackboneElement	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	Additional coverage classifications
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	SΣ	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	Value associated with the type
name	Σ	0..1	string	Human readable description of the type and value
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

Terminology Bindings

Path	Conformance	ValueSet / Code
Coverage.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
Coverage.identifier.use	required	IdentifierUse
Coverage.identifier.type	extensible	Identifier Type Codes
Coverage.status	required	FinancialResourceStatusCodes
Coverage.type	preferred	CoverageTypeAndSelf-PayCodes
Coverage.relationship	extensible	SubscriberRelationshipCodes
Coverage.class.type	extensible	CoverageClassCodes
Coverage.class:group.type	extensible	Pattern: group
Coverage.costToBeneficiary.type	extensible	CoverageCopayTypeCodes
Coverage.costToBeneficiary.exception.type	example	ExampleCoverageFinancialExceptionCodes

Constraints

Id	Grade	Path(s)	Details	Requirements
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

This structure is derived from HRexCoverage

Summary