Da Vinci Health Record Exchange (HRex)
1.0.0 - STU R1 United States of America flag

Da Vinci Health Record Exchange (HRex), published by HL7 International - Clinical Interoperability Council. This is not an authorized publication; it is the continuous build for version 1.0.0). This version is based on the current content of https://github.com/HL7/davinci-ehrx/ and changes regularly. See the Directory of published versions

Resource Profile: HRex Coverage Profile

Official URL: http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/hrex-coverage Version: 1.0.0
Standards status: Trial-use Maturity Level: 2 Computable Name: HRexCoverage

The HRex Coverage Profile defines the constraints for representing a member’s healthcare insurance information to the Payer.  Coverage instances complying with this profile, sometimes together with the Patient which this profile references via beneficiary, allows a payer to identify a member in their system.

Coverage is central to most Da Vinci use-cases. The resource provides the information that identifies the type of insurance, the payer who provides it and the member who is covered. As such, it forms the justification or focus for almost all data exchanges in the payer space. While the resource is complex, the Da Vinci profile focuses on capturing only the minimum data necessary to identify both payer and member.

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
hrex-cov-1: Coverage.identifier or Coverage.subscriberId SHALL be present
... identifier S0..1IdentifierAlso known as Member identifier
.... value S1..1stringThe value that is unique within the system.
... policyHolder 0..1Reference(US Core Patient Profile | HRex Organization Profile | RelatedPerson)Owner of the policy
... subscriber 0..1Reference(US Core Patient Profile)Subscriber to the policy
... beneficiary S1..1Reference(HRex Patient Demographics)Plan beneficiary
... dependent S0..1stringDependent number
... payor S1..1Reference(HRex Organization Profile)Issuer of the policy
... Slices for class 0..*BackboneElementAdditional coverage classifications
Slice: Unordered, Open by pattern:type
.... class:group S0..1BackboneElementAdditional coverage classifications
..... type S1..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..1stringValue associated with the type

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
hrex-cov-1errorCoverageCoverage.identifier or Coverage.subscriberId SHALL be present
: identifier.exists() or subscriberId.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage C0..*CoverageInsurance or medical plan or a payment agreement
hrex-cov-1: 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
... identifier SΣ0..1IdentifierAlso known as Member identifier
.... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

.... value SΣ1..1stringThe value that is unique within the system.
Example General: 123456
... policyHolder Σ0..1Reference(US Core Patient Profile | HRex Organization Profile | RelatedPerson)Owner of the policy
... subscriber Σ0..1Reference(US Core Patient Profile)Subscriber to the policy
... subscriberId SΣ0..1stringSubscriber ID
... beneficiary SΣ1..1Reference(HRex Patient Demographics)Plan beneficiary
... dependent SΣ0..1stringDependent number
... payor SΣ1..1Reference(HRex Organization Profile)Issuer of the policy
... Slices for class 0..*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 SΣ1..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..1stringValue associated with the type

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Coverage.identifier.userequiredIdentifierUse
Coverage.statusrequiredFinancialResourceStatusCodes
Coverage.class.typeextensibleCoverageClassCodes
Coverage.class:group.typeextensiblePattern: group

Constraints

IdGradePath(s)DetailsRequirements
hrex-cov-1errorCoverageCoverage.identifier or Coverage.subscriberId SHALL be present
: identifier.exists() or subscriberId.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage C0..*CoverageInsurance or medical plan or a payment agreement
hrex-cov-1: 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
... identifier SΣ0..1IdentifierAlso known as Member identifier
.... 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 Σ0..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.

.... system Σ0..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
.... value SΣ1..1stringThe value that is unique within the system.
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 ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... type Σ0..1CodeableConceptCoverage 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 Σ0..1Reference(US Core Patient Profile | HRex Organization Profile | RelatedPerson)Owner of the policy
... subscriber Σ0..1Reference(US Core Patient Profile)Subscriber to the policy
... subscriberId SΣ0..1stringSubscriber ID
... beneficiary SΣ1..1Reference(HRex Patient Demographics)Plan beneficiary
... dependent SΣ0..1stringDependent number
... relationship 0..1CodeableConceptBeneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).

... period Σ0..1PeriodCoverage start and end dates
... payor SΣ1..1Reference(HRex Organization Profile)Issuer of the policy
... Slices for class 0..*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 SΣ1..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..1stringValue associated with the type
..... name Σ0..1stringHuman readable description of the type and value
... order Σ0..1positiveIntRelative order of the coverage
... network Σ0..1stringInsurer network
... costToBeneficiary 0..*BackboneElementPatient payments for services/products
.... 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 Σ0..1CodeableConceptCost category
Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified.

.... value[x] Σ1..1The amount or percentage due from the beneficiary
..... valueQuantityQuantity(SimpleQuantity)
..... valueMoneyMoney
.... exception 0..*BackboneElementExceptions for patient payments
..... 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..1CodeableConceptException category
Binding: ExampleCoverageFinancialExceptionCodes (example): The types of exceptions from the part or full value of financial obligations such as copays.

..... period Σ0..1PeriodThe effective period of the exception
... subrogation 0..1booleanReimbursement to insurer
... contract 0..*Reference(Contract)Contract details

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Coverage.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Coverage.identifier.userequiredIdentifierUse
Coverage.identifier.typeextensibleIdentifier Type Codes
Coverage.statusrequiredFinancialResourceStatusCodes
Coverage.typepreferredCoverageTypeAndSelf-PayCodes
Coverage.relationshipextensibleSubscriberRelationshipCodes
Coverage.class.typeextensibleCoverageClassCodes
Coverage.class:group.typeextensiblePattern: group
Coverage.costToBeneficiary.typeextensibleCoverageCopayTypeCodes
Coverage.costToBeneficiary.exception.typeexampleExampleCoverageFinancialExceptionCodes

Constraints

IdGradePath(s)DetailsRequirements
hrex-cov-1errorCoverageCoverage.identifier or Coverage.subscriberId SHALL be present
: identifier.exists() or subscriberId.exists()

This structure is derived from Coverage

Summary

Mandatory: 0 element (1 nested mandatory element)
Must-Support: 9 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • 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
hrex-cov-1: Coverage.identifier or Coverage.subscriberId SHALL be present
... identifier S0..1IdentifierAlso known as Member identifier
.... value S1..1stringThe value that is unique within the system.
... policyHolder 0..1Reference(US Core Patient Profile | HRex Organization Profile | RelatedPerson)Owner of the policy
... subscriber 0..1Reference(US Core Patient Profile)Subscriber to the policy
... beneficiary S1..1Reference(HRex Patient Demographics)Plan beneficiary
... dependent S0..1stringDependent number
... payor S1..1Reference(HRex Organization Profile)Issuer of the policy
... Slices for class 0..*BackboneElementAdditional coverage classifications
Slice: Unordered, Open by pattern:type
.... class:group S0..1BackboneElementAdditional coverage classifications
..... type S1..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..1stringValue associated with the type

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
hrex-cov-1errorCoverageCoverage.identifier or Coverage.subscriberId SHALL be present
: identifier.exists() or subscriberId.exists()

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage C0..*CoverageInsurance or medical plan or a payment agreement
hrex-cov-1: 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
... identifier SΣ0..1IdentifierAlso known as Member identifier
.... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

.... value SΣ1..1stringThe value that is unique within the system.
Example General: 123456
... policyHolder Σ0..1Reference(US Core Patient Profile | HRex Organization Profile | RelatedPerson)Owner of the policy
... subscriber Σ0..1Reference(US Core Patient Profile)Subscriber to the policy
... subscriberId SΣ0..1stringSubscriber ID
... beneficiary SΣ1..1Reference(HRex Patient Demographics)Plan beneficiary
... dependent SΣ0..1stringDependent number
... payor SΣ1..1Reference(HRex Organization Profile)Issuer of the policy
... Slices for class 0..*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 SΣ1..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..1stringValue associated with the type

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Coverage.identifier.userequiredIdentifierUse
Coverage.statusrequiredFinancialResourceStatusCodes
Coverage.class.typeextensibleCoverageClassCodes
Coverage.class:group.typeextensiblePattern: group

Constraints

IdGradePath(s)DetailsRequirements
hrex-cov-1errorCoverageCoverage.identifier or Coverage.subscriberId SHALL be present
: identifier.exists() or subscriberId.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage C0..*CoverageInsurance or medical plan or a payment agreement
hrex-cov-1: 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
... identifier SΣ0..1IdentifierAlso known as Member identifier
.... 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 Σ0..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.

.... system Σ0..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
.... value SΣ1..1stringThe value that is unique within the system.
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 ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... type Σ0..1CodeableConceptCoverage 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 Σ0..1Reference(US Core Patient Profile | HRex Organization Profile | RelatedPerson)Owner of the policy
... subscriber Σ0..1Reference(US Core Patient Profile)Subscriber to the policy
... subscriberId SΣ0..1stringSubscriber ID
... beneficiary SΣ1..1Reference(HRex Patient Demographics)Plan beneficiary
... dependent SΣ0..1stringDependent number
... relationship 0..1CodeableConceptBeneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).

... period Σ0..1PeriodCoverage start and end dates
... payor SΣ1..1Reference(HRex Organization Profile)Issuer of the policy
... Slices for class 0..*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 SΣ1..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..1stringValue associated with the type
..... name Σ0..1stringHuman readable description of the type and value
... order Σ0..1positiveIntRelative order of the coverage
... network Σ0..1stringInsurer network
... costToBeneficiary 0..*BackboneElementPatient payments for services/products
.... 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 Σ0..1CodeableConceptCost category
Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified.

.... value[x] Σ1..1The amount or percentage due from the beneficiary
..... valueQuantityQuantity(SimpleQuantity)
..... valueMoneyMoney
.... exception 0..*BackboneElementExceptions for patient payments
..... 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..1CodeableConceptException category
Binding: ExampleCoverageFinancialExceptionCodes (example): The types of exceptions from the part or full value of financial obligations such as copays.

..... period Σ0..1PeriodThe effective period of the exception
... subrogation 0..1booleanReimbursement to insurer
... contract 0..*Reference(Contract)Contract details

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Coverage.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Coverage.identifier.userequiredIdentifierUse
Coverage.identifier.typeextensibleIdentifier Type Codes
Coverage.statusrequiredFinancialResourceStatusCodes
Coverage.typepreferredCoverageTypeAndSelf-PayCodes
Coverage.relationshipextensibleSubscriberRelationshipCodes
Coverage.class.typeextensibleCoverageClassCodes
Coverage.class:group.typeextensiblePattern: group
Coverage.costToBeneficiary.typeextensibleCoverageCopayTypeCodes
Coverage.costToBeneficiary.exception.typeexampleExampleCoverageFinancialExceptionCodes

Constraints

IdGradePath(s)DetailsRequirements
hrex-cov-1errorCoverageCoverage.identifier or Coverage.subscriberId SHALL be present
: identifier.exists() or subscriberId.exists()

This structure is derived from Coverage

Summary

Mandatory: 0 element (1 nested mandatory element)
Must-Support: 9 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

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

Maturity: 2

 

Other representations of profile: CSV, Excel, Schematron

Notes:

If the member identifier (conveyed in Coverage.identifier) is known, it should be sent as this uniquely identifies a covered individual. If not, then the Coverage.subscriberId can be used together with demographic information found by resolving Coverage.beneficiary to identify the member. (There can be multiple members associated with a single subscriber - e.g. family members of an individual who is covered under a work-based policy.)