Da Vinci Health Record Exchange (HRex)
1.1.0 - STU 1.1
Da Vinci Health Record Exchange (HRex)
1.1.0 - STU 1.1
Da Vinci Health Record Exchange (HRex), published by HL7 International / Clinical Interoperability Council. This guide is not an authorized publication; it is the continuous build for version 1.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/davinci-ehrx/ and changes regularly. See the Directory of published versions
| Official URL: http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/hrex-coverage | Version: 1.1.0 | |||
| Standards status: Trial-use | Maturity Level: 2 | Computable Name: HRexCoverage | ||
| Other Identifiers: OID:2.16.840.1.113883.4.642.40.19.42.7 | ||||
The HRex Coverage Profile defines the constraints for representing a member's healthcare insurance information to the Payer for member match purposes. 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. It aligns with the equivalent US Core profile, but diverges in that it does not require Patient.identifier for the beneficiary.
In most cases, Da Vinci will use the US Core Coverage profile when communicating Coverage.
This profile is intended for use ONLY during the $member-match operation. It differs from the US Core profile in that the referenced 'Patient' resource does not need to have an identifier (as when calling $member-match, no identifier will be known).
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Coverage |
C | 0..* | Coverage | Insurance or medical plan or a payment agreement dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: 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 dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management us-core-15: Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present |
  implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children |
 modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
  Slices for identifier |
SΣ | 0..* | Identifier | Member ID and other identifiers Slice: Unordered, Open by value:type ele-1: All FHIR elements must have a @value or children |
   identifier:memberid |
SΣC | 0..1 | Identifier | Member ID ele-1: All FHIR elements must have a @value or children |
  use |
?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . ele-1: All FHIR elements must have a @value or children |
  type |
Σ | 1..1 | CodeableConcept | Member Number identifier type Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following |
   coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203 | |
 code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: MB | |
 value |
SΣ | 1..1 | string | The value that is unique ele-1: All FHIR elements must have a @value or children Example General: 123456 |
| status |
?!SΣ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. ele-1: All FHIR elements must have a @value or children |
| type |
SΣ | 0..1 | CodeableConcept | Coverage category such as medical or accident Binding: Payer Type  (extensible): US Public Health Data Consortium Source of Payment Codesele-1: All FHIR elements must have a @value or children |
 policyHolder |
SΣ | 0..1 | Reference(US Core Patient Profile(7.0.0) | HRex Organization Profile | US Core RelatedPerson Profile(7.0.0)) | Owner of the policy ele-1: All FHIR elements must have a @value or children |
| subscriberId |
SΣC | 0..1 | string | Subscriber ID ele-1: All FHIR elements must have a @value or children |
| beneficiary |
SΣ | 1..1 | Reference(HRex Member Match Patient) | Plan beneficiary ele-1: All FHIR elements must have a @value or children |
| dependent |
SΣ | 0..1 | string | Dependent number ele-1: All FHIR elements must have a @value or children |
| relationship |
S | 1..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: HRex Coverage Relationship ValueSet (required) ele-1: All FHIR elements must have a @value or children |
| period |
SΣ | 0..1 | Period | Coverage start and end dates ele-1: All FHIR elements must have a @value or children |
| payor |
SΣ | 1..1 | Reference(HRex Organization Profile) | Issuer of the policy ele-1: All FHIR elements must have a @value or children |
| Slices for class |
0..* | BackboneElement | Additional coverage classifications Slice: Unordered, Open by value:type ele-1: All FHIR elements must have a @value or children | |
  class:All Slices |
Content/Rules for all slices | |||
  modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
| type |
Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. ele-1: All FHIR elements must have a @value or children |
 value |
Σ | 1..1 | string | Value associated with the type ele-1: All FHIR elements must have a @value or children |
| class:group |
S | 0..1 | BackboneElement | Group ele-1: All FHIR elements must have a @value or children |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
| type |
SΣ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. ele-1: All FHIR elements must have a @value or children 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 | Group Number ele-1: All FHIR elements must have a @value or children |
| class:plan |
S | 0..1 | BackboneElement | Plan ele-1: All FHIR elements must have a @value or children |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
| type |
SΣ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: plan | |
| value |
SΣ | 1..1 | string | Plan Number ele-1: All FHIR elements must have a @value or children |
| name |
SΣ | 0..1 | string | Plan Name ele-1: All FHIR elements must have a @value or children |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| Coverage.identifier:memberid.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1from the FHIR Standard | |
| Coverage.identifier:memberid.type | extensible | Pattern: MBhttp://hl7.org/fhir/ValueSet/identifier-typefrom the FHIR Standard | |
| Coverage.status | required | FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|4.0.1from the FHIR Standard | |
| Coverage.type | extensible | PayerType (a valid code from Source of Payment Typology (https://nahdo.org/sopt)http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 | |
| Coverage.relationship | required | HRexCoverageRelationshiphttp://hl7.org/fhir/us/davinci-hrex/ValueSet/hrex-coverage-relationshipfrom this IG | |
| Coverage.class.type | extensible | CoverageClassCodeshttp://hl7.org/fhir/ValueSet/coverage-classfrom the FHIR Standard | |
| Coverage.class:group.type | extensible | Pattern: grouphttp://hl7.org/fhir/ValueSet/coverage-classfrom the FHIR Standard | |
| Coverage.class:plan.type | extensible | Pattern: planhttp://hl7.org/fhir/ValueSet/coverage-classfrom the FHIR Standard |
| 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() | |
| us-core-15 | error | Coverage | Member 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() |
Other representations of profile: CSV, Excel, Schematron
If the member identifier (conveyed in Coverage.identifier) is known, it must 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.)
Additional notes and guidance around how to map real-world insurance card information into the Coverage resource can be found in the CARIN Digital Insurance Card IG. As a rule, all elements available SHOULD be populated, even if not all might be strictly necessary to identify the member because rules can vary from insurer to insurer about which pieces of information are necessary to uniquely identify a member.
IG © 2019+ HL7 International / Clinical Interoperability Council. Package hl7.fhir.us.davinci-hrex#1.1.0 based on FHIR 4.0.1. Generated 2025-01-26
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