Da Vinci - Coverage Requirements Discovery
2.0.1 - STU 2 United States of America flag

Da Vinci - Coverage Requirements Discovery, published by HL7 International / Financial Management. This guide is not an authorized publication; it is the continuous build for version 2.0.1 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/davinci-crd/ and changes regularly. See the Directory of published versions

Resource Profile: CRD Coverage

Official URL: http://hl7.org/fhir/us/davinci-crd/StructureDefinition/profile-coverage Version: 2.0.1
Standards status: Trial-use Maturity Level: 2 Computable Name: Coverage

This profile specifies constraints on the Coverage resource to support coverage requirements discovery.

Usage


CRD Clients SHALL use this profile to resolve references to insurance Coverage resources passed to CRD Servers.

Information provided in Must Support elements will commonly be required for CRD Servers to perform coverage requirements discovery.

Usage:

Formal Views of Profile Content

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

This structure is derived from Coverage

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage C0..*CoverageInsurance or medical plan or a payment agreement
us-core-15: Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present
... Slices for identifier S0..*IdentifierBusiness Identifier for the coverage
Slice: Unordered, Open by pattern:type
.... identifier:MBIdentifier S0..1IdentifierEMR Identifier for MB
..... type S1..1CodeableConceptDescription of identifier
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: MB
... status S1..1codeactive | cancelled | draft | entered-in-error
... type S0..1CodeableConceptCoverage category such as medical or accident
Binding: Payer Type . (extensible)
... subscriber S0..1Reference(CRD Patient)Subscriber to the policy
... subscriberId S0..1stringID assigned to the subscriber
... beneficiary S1..1Reference(CRD Patient)Plan beneficiary
... dependent S0..1stringDependent number
... relationship S0..1CodeableConceptBeneficiary relationship to the subscriber
... period S0..1PeriodCoverage start and end dates
... payor S1..*Reference(CRD Patient | CRD Organization)Issuer of the policy
... Slices for class S0..*BackboneElementAdditional coverage classifications
Slice: Unordered, Open by pattern:type
.... class:group S0..1BackboneElementAdditional coverage classifications
..... type 1..1CodeableConceptType of class such as 'group' or 'plan'
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: group
..... value S1..1stringGroup Number
..... name S0..1stringGroup Name
.... class:plan S0..1BackboneElementAdditional coverage classifications
..... type 1..1CodeableConceptType of class such as 'group' or 'plan'
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: plan
..... value S1..1stringPlan Number
..... name S0..1stringPlan Name
... order S0..1positiveIntRelative order of the coverage
... network S0..1stringInsurer network
... costToBeneficiary 0..0

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Coverage.typeextensiblePayerType .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591

Constraints

IdGradePath(s)DetailsRequirements
us-core-15errorCoverageMember Id in Coverage.identifier or Coverage.subscriberId SHALL be present
: identifier.type.coding.where(system='http://terminology.hl7.org/CodeSystem/v2-0203' and code='MB').exists() or subscriberId.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage C0..*CoverageInsurance or medical plan or a payment agreement
us-core-15: Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... Slices for identifier SΣ0..*IdentifierBusiness Identifier for the coverage
Slice: Unordered, Open by pattern:type
.... identifier:MBIdentifier SΣ0..1IdentifierEMR Identifier for MB
..... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... type SΣ1..1CodeableConceptDescription 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.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: MB
... type SΣ0..1CodeableConceptCoverage category such as medical or accident
Binding: Payer Type . (extensible)
... policyHolder SΣ0..1Reference(CRD Patient | CRD Organization)Owner of the policy
... subscriber SΣ0..1Reference(CRD Patient)Subscriber to the policy
... subscriberId SΣ0..1stringID assigned to the subscriber
... beneficiary SΣ1..1Reference(CRD Patient)Plan beneficiary
... dependent SΣ0..1stringDependent number
... relationship S0..1CodeableConceptBeneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).

... period SΣ0..1PeriodCoverage start and end dates
... payor SΣ1..*Reference(CRD Patient | CRD Organization)Issuer of the policy
... Slices for class S0..*BackboneElementAdditional coverage classifications
Slice: Unordered, Open by pattern:type
.... class:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type Σ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.

..... value Σ1..1stringValue associated with the type
.... class:group S0..1BackboneElementAdditional coverage classifications
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type Σ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: group
..... value SΣ1..1stringGroup Number
..... name SΣ0..1stringGroup Name
.... class:plan S0..1BackboneElementAdditional coverage classifications
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type Σ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: plan
..... value SΣ1..1stringPlan Number
..... name SΣ0..1stringPlan Name
... order SΣ0..1positiveIntRelative order of the coverage
... network SΣ0..1stringInsurer network

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Coverage.identifier:MBIdentifier.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
Coverage.identifier:MBIdentifier.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.relationshipextensibleSubscriberRelationshipCodes
http://hl7.org/fhir/ValueSet/subscriber-relationship
from the FHIR Standard
Coverage.class.typeextensibleCoverageClassCodes
http://hl7.org/fhir/ValueSet/coverage-class
from the FHIR Standard
Coverage.class:group.typeextensiblePattern: group
http://hl7.org/fhir/ValueSet/coverage-class
from the FHIR Standard
Coverage.class:plan.typeextensiblePattern: plan
http://hl7.org/fhir/ValueSet/coverage-class
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorCoverageIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorCoverageIf 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-4errorCoverageIf 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-5errorCoverageIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceCoverageA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
us-core-15errorCoverageMember Id in Coverage.identifier or Coverage.subscriberId SHALL be present
: identifier.type.coding.where(system='http://terminology.hl7.org/CodeSystem/v2-0203' and code='MB').exists() or subscriberId.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage C0..*CoverageInsurance or medical plan or a payment agreement
us-core-15: Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... Slices for identifier SΣ0..*IdentifierBusiness Identifier for the coverage
Slice: Unordered, Open by pattern:type
.... identifier:MBIdentifier SΣ0..1IdentifierEMR Identifier for MB
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... type SΣ1..1CodeableConceptDescription 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.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: MB
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... system Σ0..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value Σ0..1stringThe value that is unique
Example General: 123456
..... period Σ0..1PeriodTime period when id is/was valid for use
..... assigner Σ0..1Reference(Organization)Organization that issued id (may be just text)
... status ?!SΣ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... type SΣ0..1CodeableConceptCoverage category such as medical or accident
Binding: Payer Type . (extensible)
... policyHolder SΣ0..1Reference(CRD Patient | CRD Organization)Owner of the policy
... subscriber SΣ0..1Reference(CRD Patient)Subscriber to the policy
... subscriberId SΣ0..1stringID assigned to the subscriber
... beneficiary SΣ1..1Reference(CRD Patient)Plan beneficiary
... dependent SΣ0..1stringDependent number
... relationship S0..1CodeableConceptBeneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).

... period SΣ0..1PeriodCoverage start and end dates
... payor SΣ1..*Reference(CRD Patient | CRD Organization)Issuer of the policy
... Slices for class S0..*BackboneElementAdditional coverage classifications
Slice: Unordered, Open by pattern:type
.... class:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type Σ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.

..... value Σ1..1stringValue associated with the type
..... name Σ0..1stringHuman readable description of the type and value
.... class:group S0..1BackboneElementAdditional coverage classifications
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type Σ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: group
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... value SΣ1..1stringGroup Number
..... name SΣ0..1stringGroup Name
.... class:plan S0..1BackboneElementAdditional coverage classifications
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type Σ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: plan
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... value SΣ1..1stringPlan Number
..... name SΣ0..1stringPlan Name
... order SΣ0..1positiveIntRelative order of the coverage
... network SΣ0..1stringInsurer network
... subrogation 0..1booleanReimbursement to insurer
... contract 0..*Reference(Contract)Contract details

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Coverage.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Coverage.identifier:MBIdentifier.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
Coverage.identifier:MBIdentifier.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.relationshipextensibleSubscriberRelationshipCodes
http://hl7.org/fhir/ValueSet/subscriber-relationship
from the FHIR Standard
Coverage.class.typeextensibleCoverageClassCodes
http://hl7.org/fhir/ValueSet/coverage-class
from the FHIR Standard
Coverage.class:group.typeextensiblePattern: group
http://hl7.org/fhir/ValueSet/coverage-class
from the FHIR Standard
Coverage.class:plan.typeextensiblePattern: plan
http://hl7.org/fhir/ValueSet/coverage-class
from the FHIR Standard
Coverage.costToBeneficiary.typeextensibleCoverageCopayTypeCodes
http://hl7.org/fhir/ValueSet/coverage-copay-type
from the FHIR Standard
Coverage.costToBeneficiary.exception.typeexampleExampleCoverageFinancialExceptionCodes
http://hl7.org/fhir/ValueSet/coverage-financial-exception
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorCoverageIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorCoverageIf 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-4errorCoverageIf 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-5errorCoverageIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceCoverageA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
us-core-15errorCoverageMember Id in Coverage.identifier or Coverage.subscriberId SHALL be present
: identifier.type.coding.where(system='http://terminology.hl7.org/CodeSystem/v2-0203' and code='MB').exists() or subscriberId.exists()

This structure is derived from Coverage

Summary

Mandatory: 0 element (1 nested mandatory element)
Must-Support: 22 elements
Prohibited: 1 element

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Coverage.identifier is sliced based on the value of pattern:type
  • The element Coverage.class is sliced based on the value of pattern:type

Maturity: 2

Differential View

This structure is derived from Coverage

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage C0..*CoverageInsurance or medical plan or a payment agreement
us-core-15: Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present
... Slices for identifier S0..*IdentifierBusiness Identifier for the coverage
Slice: Unordered, Open by pattern:type
.... identifier:MBIdentifier S0..1IdentifierEMR Identifier for MB
..... type S1..1CodeableConceptDescription of identifier
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: MB
... status S1..1codeactive | cancelled | draft | entered-in-error
... type S0..1CodeableConceptCoverage category such as medical or accident
Binding: Payer Type . (extensible)
... subscriber S0..1Reference(CRD Patient)Subscriber to the policy
... subscriberId S0..1stringID assigned to the subscriber
... beneficiary S1..1Reference(CRD Patient)Plan beneficiary
... dependent S0..1stringDependent number
... relationship S0..1CodeableConceptBeneficiary relationship to the subscriber
... period S0..1PeriodCoverage start and end dates
... payor S1..*Reference(CRD Patient | CRD Organization)Issuer of the policy
... Slices for class S0..*BackboneElementAdditional coverage classifications
Slice: Unordered, Open by pattern:type
.... class:group S0..1BackboneElementAdditional coverage classifications
..... type 1..1CodeableConceptType of class such as 'group' or 'plan'
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: group
..... value S1..1stringGroup Number
..... name S0..1stringGroup Name
.... class:plan S0..1BackboneElementAdditional coverage classifications
..... type 1..1CodeableConceptType of class such as 'group' or 'plan'
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: plan
..... value S1..1stringPlan Number
..... name S0..1stringPlan Name
... order S0..1positiveIntRelative order of the coverage
... network S0..1stringInsurer network
... costToBeneficiary 0..0

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Coverage.typeextensiblePayerType .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591

Constraints

IdGradePath(s)DetailsRequirements
us-core-15errorCoverageMember Id in Coverage.identifier or Coverage.subscriberId SHALL be present
: identifier.type.coding.where(system='http://terminology.hl7.org/CodeSystem/v2-0203' and code='MB').exists() or subscriberId.exists()

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage C0..*CoverageInsurance or medical plan or a payment agreement
us-core-15: Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... Slices for identifier SΣ0..*IdentifierBusiness Identifier for the coverage
Slice: Unordered, Open by pattern:type
.... identifier:MBIdentifier SΣ0..1IdentifierEMR Identifier for MB
..... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... type SΣ1..1CodeableConceptDescription 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.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: MB
... type SΣ0..1CodeableConceptCoverage category such as medical or accident
Binding: Payer Type . (extensible)
... policyHolder SΣ0..1Reference(CRD Patient | CRD Organization)Owner of the policy
... subscriber SΣ0..1Reference(CRD Patient)Subscriber to the policy
... subscriberId SΣ0..1stringID assigned to the subscriber
... beneficiary SΣ1..1Reference(CRD Patient)Plan beneficiary
... dependent SΣ0..1stringDependent number
... relationship S0..1CodeableConceptBeneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).

... period SΣ0..1PeriodCoverage start and end dates
... payor SΣ1..*Reference(CRD Patient | CRD Organization)Issuer of the policy
... Slices for class S0..*BackboneElementAdditional coverage classifications
Slice: Unordered, Open by pattern:type
.... class:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type Σ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.

..... value Σ1..1stringValue associated with the type
.... class:group S0..1BackboneElementAdditional coverage classifications
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type Σ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: group
..... value SΣ1..1stringGroup Number
..... name SΣ0..1stringGroup Name
.... class:plan S0..1BackboneElementAdditional coverage classifications
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type Σ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: plan
..... value SΣ1..1stringPlan Number
..... name SΣ0..1stringPlan Name
... order SΣ0..1positiveIntRelative order of the coverage
... network SΣ0..1stringInsurer network

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Coverage.identifier:MBIdentifier.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
Coverage.identifier:MBIdentifier.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.relationshipextensibleSubscriberRelationshipCodes
http://hl7.org/fhir/ValueSet/subscriber-relationship
from the FHIR Standard
Coverage.class.typeextensibleCoverageClassCodes
http://hl7.org/fhir/ValueSet/coverage-class
from the FHIR Standard
Coverage.class:group.typeextensiblePattern: group
http://hl7.org/fhir/ValueSet/coverage-class
from the FHIR Standard
Coverage.class:plan.typeextensiblePattern: plan
http://hl7.org/fhir/ValueSet/coverage-class
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorCoverageIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorCoverageIf 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-4errorCoverageIf 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-5errorCoverageIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceCoverageA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
us-core-15errorCoverageMember Id in Coverage.identifier or Coverage.subscriberId SHALL be present
: identifier.type.coding.where(system='http://terminology.hl7.org/CodeSystem/v2-0203' and code='MB').exists() or subscriberId.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage C0..*CoverageInsurance or medical plan or a payment agreement
us-core-15: Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... Slices for identifier SΣ0..*IdentifierBusiness Identifier for the coverage
Slice: Unordered, Open by pattern:type
.... identifier:MBIdentifier SΣ0..1IdentifierEMR Identifier for MB
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... type SΣ1..1CodeableConceptDescription 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.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: MB
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... system Σ0..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value Σ0..1stringThe value that is unique
Example General: 123456
..... period Σ0..1PeriodTime period when id is/was valid for use
..... assigner Σ0..1Reference(Organization)Organization that issued id (may be just text)
... status ?!SΣ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... type SΣ0..1CodeableConceptCoverage category such as medical or accident
Binding: Payer Type . (extensible)
... policyHolder SΣ0..1Reference(CRD Patient | CRD Organization)Owner of the policy
... subscriber SΣ0..1Reference(CRD Patient)Subscriber to the policy
... subscriberId SΣ0..1stringID assigned to the subscriber
... beneficiary SΣ1..1Reference(CRD Patient)Plan beneficiary
... dependent SΣ0..1stringDependent number
... relationship S0..1CodeableConceptBeneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).

... period SΣ0..1PeriodCoverage start and end dates
... payor SΣ1..*Reference(CRD Patient | CRD Organization)Issuer of the policy
... Slices for class S0..*BackboneElementAdditional coverage classifications
Slice: Unordered, Open by pattern:type
.... class:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type Σ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.

..... value Σ1..1stringValue associated with the type
..... name Σ0..1stringHuman readable description of the type and value
.... class:group S0..1BackboneElementAdditional coverage classifications
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type Σ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: group
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... value SΣ1..1stringGroup Number
..... name SΣ0..1stringGroup Name
.... class:plan S0..1BackboneElementAdditional coverage classifications
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type Σ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: plan
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... value SΣ1..1stringPlan Number
..... name SΣ0..1stringPlan Name
... order SΣ0..1positiveIntRelative order of the coverage
... network SΣ0..1stringInsurer network
... subrogation 0..1booleanReimbursement to insurer
... contract 0..*Reference(Contract)Contract details

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Coverage.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Coverage.identifier:MBIdentifier.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
Coverage.identifier:MBIdentifier.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.relationshipextensibleSubscriberRelationshipCodes
http://hl7.org/fhir/ValueSet/subscriber-relationship
from the FHIR Standard
Coverage.class.typeextensibleCoverageClassCodes
http://hl7.org/fhir/ValueSet/coverage-class
from the FHIR Standard
Coverage.class:group.typeextensiblePattern: group
http://hl7.org/fhir/ValueSet/coverage-class
from the FHIR Standard
Coverage.class:plan.typeextensiblePattern: plan
http://hl7.org/fhir/ValueSet/coverage-class
from the FHIR Standard
Coverage.costToBeneficiary.typeextensibleCoverageCopayTypeCodes
http://hl7.org/fhir/ValueSet/coverage-copay-type
from the FHIR Standard
Coverage.costToBeneficiary.exception.typeexampleExampleCoverageFinancialExceptionCodes
http://hl7.org/fhir/ValueSet/coverage-financial-exception
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorCoverageIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorCoverageIf 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-4errorCoverageIf 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-5errorCoverageIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceCoverageA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
us-core-15errorCoverageMember Id in Coverage.identifier or Coverage.subscriberId SHALL be present
: identifier.type.coding.where(system='http://terminology.hl7.org/CodeSystem/v2-0203' and code='MB').exists() or subscriberId.exists()

This structure is derived from Coverage

Summary

Mandatory: 0 element (1 nested mandatory element)
Must-Support: 22 elements
Prohibited: 1 element

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Coverage.identifier is sliced based on the value of pattern:type
  • The element Coverage.class is sliced based on the value of pattern:type

Maturity: 2

 

Other representations of profile: CSV, Excel, Schematron