Da Vinci Health Record Exchange (HRex)
1.2.0-cibuild - 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 1.2.0-cibuild 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

## Resource Profile: HRex Member Match Coverage Profile

Official URL: http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/hrex-coverage | Version: 1.2.0-cibuild
Standards status: Trial-use | Maturity Level: 3 | 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:

- Use this Resource Profile: HRex Parameters - Member Match Request Profile
- Refer to this Resource Profile: HRex Task Data Request Profile
- Examples for this Resource Profile: Coverage/full and Coverage/min

### Formal Views of Profile Content

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

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

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 | S Σ | 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 | S Σ C | 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 | S Σ | 1..1 | string | The value that is unique ele-1: All FHIR elements must have a @value or children Example General: 123456
status | ?!S Σ | 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 | S Σ | 0..1 | CodeableConcept | Coverage category such as medical or accident Binding: Payer Type (extensible): US Public Health Data Consortium Source of Payment Codes ele-1: All FHIR elements must have a @value or children
policyHolder | S Σ | 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 | S Σ C | 0..1 | string | Subscriber ID ele-1: All FHIR elements must have a @value or children
beneficiary | S Σ | 1..1 | Reference(HRex Member Match Patient) | Plan beneficiary ele-1: All FHIR elements must have a @value or children
dependent | S Σ | 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 | S Σ | 0..1 | Period | Coverage start and end dates ele-1: All FHIR elements must have a @value or children
payor | S Σ | 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 | S 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 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 | S Σ | 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 | S 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 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 | S Σ | 1..1 | string | Plan Number ele-1: All FHIR elements must have a @value or children
name | S Σ | 0..1 | string | Plan Name ele-1: All FHIR elements must have a @value or children
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet / Code | URI
Coverage.identifier:memberid.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` from the FHIR Standard
Coverage.identifier:memberid.type | extensible | Pattern: MB `http://hl7.org/fhir/ValueSet/identifier-type` from the FHIR Standard
Coverage.status | required | FinancialResourceStatusCodes `http://hl7.org/fhir/ValueSet/fm-status|4.0.1` from 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` from https://vsac.nlm.nih.gov
Coverage.relationship | required | HRexCoverageRelationship `http://hl7.org/fhir/us/davinci-hrex/ValueSet/hrex-coverage-relationship` from this IG
Coverage.class.type | extensible | CoverageClassCodes `http://hl7.org/fhir/ValueSet/coverage-class` from the FHIR Standard
Coverage.class:group.type | extensible | Pattern: group `http://hl7.org/fhir/ValueSet/coverage-class` from the FHIR Standard
Coverage.class:plan.type | extensible | Pattern: plan `http://hl7.org/fhir/ValueSet/coverage-class` from the FHIR Standard

#### 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() |
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() |

This structure is derived from Coverage

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Coverage | C | 0..* | Coverage | Insurance or medical plan or a payment agreement us-core-15: Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present
Slices for identifier | S | 0..* | Identifier | Member ID and other identifiers Slice: Unordered, Open by value:type
identifier:memberid | S C | 0..1 | Identifier | Member ID
type |  | 1..1 | CodeableConcept | Member Number identifier type 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 | S | 1..1 | string | The value that is unique
status | S | 1..1 | code | active | cancelled | draft | entered-in-error
type | S | 0..1 | CodeableConcept | Coverage category such as medical or accident Binding: Payer Type (extensible): US Public Health Data Consortium Source of Payment Codes
policyHolder | S | 0..1 | Reference(US Core Patient Profile(7.0.0) | HRex Organization Profile | US Core RelatedPerson Profile(7.0.0)) | Owner of the policy
subscriberId | S C | 0..1 | string | Subscriber ID
beneficiary | S | 1..1 | Reference(HRex Member Match Patient) | Plan beneficiary
dependent | S | 0..1 | string | Dependent number
relationship | S | 1..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: HRex Coverage Relationship ValueSet (required)
period | S | 0..1 | Period | Coverage start and end dates
payor | S | 1..1 | Reference(HRex Organization Profile) | Issuer of the policy
Slices for class |  | 0..* | BackboneElement | Additional coverage classifications Slice: Unordered, Open by value:type
class:group | S | 0..1 | BackboneElement | Group
type | S | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' 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 | S | 1..1 | string | Group Number
class:plan | S | 0..1 | BackboneElement | Plan
type | S | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' 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 | S | 1..1 | string | Plan Number
name | S | 0..1 | string | Plan Name
Documentation for this format

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet | URI
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` from https://vsac.nlm.nih.gov
Coverage.relationship | required | HRexCoverageRelationship `http://hl7.org/fhir/us/davinci-hrex/ValueSet/hrex-coverage-relationship` from this IG

#### Constraints

Id | Grade | Path(s) | Details | Requirements
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() |

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Coverage | C | 0..* | Coverage | Insurance or medical plan or a payment agreement us-core-15: Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present
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
Slices for identifier | S Σ | 0..* | Identifier | Member ID and other identifiers Slice: Unordered, Open by value:type
identifier:memberid | S Σ C | 0..1 | Identifier | Member ID
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type | 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. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: MB
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
system | Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value | S Σ | 1..1 | string | The value that is unique Example General: 123456
period | Σ | 0..1 | Period | Time period when id is/was valid for use
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text)
status | ?!S Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
type | S Σ | 0..1 | CodeableConcept | Coverage category such as medical or accident Binding: Payer Type (extensible): US Public Health Data Consortium Source of Payment Codes
policyHolder | S Σ | 0..1 | Reference(US Core Patient Profile(7.0.0) | HRex Organization Profile | US Core RelatedPerson Profile(7.0.0)) | Owner of the policy
subscriber | Σ | 0..1 | Reference(Patient | RelatedPerson) | Subscriber to the policy
subscriberId | S Σ C | 0..1 | string | Subscriber ID
beneficiary | S Σ | 1..1 | Reference(HRex Member Match Patient) | Plan beneficiary
dependent | S Σ | 0..1 | string | Dependent number
relationship | S | 1..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: HRex Coverage Relationship ValueSet (required)
period | S Σ | 0..1 | Period | Coverage start and end dates
payor | S Σ | 1..1 | Reference(HRex Organization Profile) | Issuer of the policy
Slices for class |  | 0..* | BackboneElement | Additional coverage classifications Slice: Unordered, Open by value: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 | Group
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | S Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: group
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
value | S Σ | 1..1 | string | Group Number
name | Σ | 0..1 | string | Human readable description of the type and value
class:plan | S | 0..1 | BackboneElement | Plan
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | S Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: plan
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
value | S Σ | 1..1 | string | Plan Number
name | S Σ | 0..1 | string | Plan Name
order | Σ | 0..1 | positiveInt | Relative order of the coverage
network | Σ | 0..1 | string | Insurer network
costToBeneficiary |  | 0..* | BackboneElement | Patient payments for services/products
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 0..1 | CodeableConcept | Cost category Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified.
value[x] | Σ | 1..1 |  | The amount or percentage due from the beneficiary
valueQuantity |  |  | Quantity(SimpleQuantity) |
valueMoney |  |  | Money |
exception |  | 0..* | BackboneElement | Exceptions for patient payments
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 1..1 | CodeableConcept | Exception category Binding: ExampleCoverageFinancialExceptionCodes (example): The types of exceptions from the part or full value of financial obligations such as copays.
period | Σ | 0..1 | Period | The effective period of the exception
subrogation |  | 0..1 | boolean | Reimbursement to insurer
contract |  | 0..* | Reference(Contract) | Contract details
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet / Code | URI
Coverage.language | preferred | CommonLanguages `http://hl7.org/fhir/ValueSet/languages` from the FHIR Standard
Additional Bindings | Purpose
AllLanguages | Max Binding
Coverage.identifier:memberid.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` from the FHIR Standard
Coverage.identifier:memberid.type | extensible | Pattern: MB `http://hl7.org/fhir/ValueSet/identifier-type` from the FHIR Standard
Coverage.status | required | FinancialResourceStatusCodes `http://hl7.org/fhir/ValueSet/fm-status|4.0.1` from 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` from https://vsac.nlm.nih.gov
Coverage.relationship | required | HRexCoverageRelationship `http://hl7.org/fhir/us/davinci-hrex/ValueSet/hrex-coverage-relationship` from this IG
Coverage.class.type | extensible | CoverageClassCodes `http://hl7.org/fhir/ValueSet/coverage-class` from the FHIR Standard
Coverage.class:group.type | extensible | Pattern: group `http://hl7.org/fhir/ValueSet/coverage-class` from the FHIR Standard
Coverage.class:plan.type | extensible | Pattern: plan `http://hl7.org/fhir/ValueSet/coverage-class` from the FHIR Standard
Coverage.costToBeneficiary.type | extensible | CoverageCopayTypeCodes `http://hl7.org/fhir/ValueSet/coverage-copay-type` from the FHIR Standard
Coverage.costToBeneficiary.exception.type | example | ExampleCoverageFinancialExceptionCodes `http://hl7.org/fhir/ValueSet/coverage-financial-exception` from the FHIR Standard

#### 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() |
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() |

This structure is derived from Coverage

Summary

Mandatory: 1 element(2 nested mandatory elements)
Must-Support: 19 elements

Structures

This structure refers to these other structures:

- US Core Patient Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient|7.0.0)
- HRex Organization Profile (http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/hrex-organization)
- US Core RelatedPerson Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-relatedperson|7.0.0)
- HRex Member Match Patient (http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/hrex-patient-demographics)

Slices

This structure defines the following Slices:

- The element 1 is sliced based on the value of Coverage.identifier
- The element 1 is sliced based on the value of Coverage.class

Maturity: 3

Key Elements View

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 | S Σ | 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 | S Σ C | 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 | S Σ | 1..1 | string | The value that is unique ele-1: All FHIR elements must have a @value or children Example General: 123456
status | ?!S Σ | 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 | S Σ | 0..1 | CodeableConcept | Coverage category such as medical or accident Binding: Payer Type (extensible): US Public Health Data Consortium Source of Payment Codes ele-1: All FHIR elements must have a @value or children
policyHolder | S Σ | 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 | S Σ C | 0..1 | string | Subscriber ID ele-1: All FHIR elements must have a @value or children
beneficiary | S Σ | 1..1 | Reference(HRex Member Match Patient) | Plan beneficiary ele-1: All FHIR elements must have a @value or children
dependent | S Σ | 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 | S Σ | 0..1 | Period | Coverage start and end dates ele-1: All FHIR elements must have a @value or children
payor | S Σ | 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 | S 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 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 | S Σ | 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 | S 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 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 | S Σ | 1..1 | string | Plan Number ele-1: All FHIR elements must have a @value or children
name | S Σ | 0..1 | string | Plan Name ele-1: All FHIR elements must have a @value or children
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet / Code | URI
Coverage.identifier:memberid.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` from the FHIR Standard
Coverage.identifier:memberid.type | extensible | Pattern: MB `http://hl7.org/fhir/ValueSet/identifier-type` from the FHIR Standard
Coverage.status | required | FinancialResourceStatusCodes `http://hl7.org/fhir/ValueSet/fm-status|4.0.1` from 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` from https://vsac.nlm.nih.gov
Coverage.relationship | required | HRexCoverageRelationship `http://hl7.org/fhir/us/davinci-hrex/ValueSet/hrex-coverage-relationship` from this IG
Coverage.class.type | extensible | CoverageClassCodes `http://hl7.org/fhir/ValueSet/coverage-class` from the FHIR Standard
Coverage.class:group.type | extensible | Pattern: group `http://hl7.org/fhir/ValueSet/coverage-class` from the FHIR Standard
Coverage.class:plan.type | extensible | Pattern: plan `http://hl7.org/fhir/ValueSet/coverage-class` from the FHIR Standard

#### 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() |
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() |

Differential View

This structure is derived from Coverage

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Coverage | C | 0..* | Coverage | Insurance or medical plan or a payment agreement us-core-15: Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present
Slices for identifier | S | 0..* | Identifier | Member ID and other identifiers Slice: Unordered, Open by value:type
identifier:memberid | S C | 0..1 | Identifier | Member ID
type |  | 1..1 | CodeableConcept | Member Number identifier type 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 | S | 1..1 | string | The value that is unique
status | S | 1..1 | code | active | cancelled | draft | entered-in-error
type | S | 0..1 | CodeableConcept | Coverage category such as medical or accident Binding: Payer Type (extensible): US Public Health Data Consortium Source of Payment Codes
policyHolder | S | 0..1 | Reference(US Core Patient Profile(7.0.0) | HRex Organization Profile | US Core RelatedPerson Profile(7.0.0)) | Owner of the policy
subscriberId | S C | 0..1 | string | Subscriber ID
beneficiary | S | 1..1 | Reference(HRex Member Match Patient) | Plan beneficiary
dependent | S | 0..1 | string | Dependent number
relationship | S | 1..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: HRex Coverage Relationship ValueSet (required)
period | S | 0..1 | Period | Coverage start and end dates
payor | S | 1..1 | Reference(HRex Organization Profile) | Issuer of the policy
Slices for class |  | 0..* | BackboneElement | Additional coverage classifications Slice: Unordered, Open by value:type
class:group | S | 0..1 | BackboneElement | Group
type | S | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' 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 | S | 1..1 | string | Group Number
class:plan | S | 0..1 | BackboneElement | Plan
type | S | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' 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 | S | 1..1 | string | Plan Number
name | S | 0..1 | string | Plan Name
Documentation for this format

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet | URI
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` from https://vsac.nlm.nih.gov
Coverage.relationship | required | HRexCoverageRelationship `http://hl7.org/fhir/us/davinci-hrex/ValueSet/hrex-coverage-relationship` from this IG

#### Constraints

Id | Grade | Path(s) | Details | Requirements
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() |

Snapshot View

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Coverage | C | 0..* | Coverage | Insurance or medical plan or a payment agreement us-core-15: Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present
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
Slices for identifier | S Σ | 0..* | Identifier | Member ID and other identifiers Slice: Unordered, Open by value:type
identifier:memberid | S Σ C | 0..1 | Identifier | Member ID
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type | 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. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: MB
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
system | Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value | S Σ | 1..1 | string | The value that is unique Example General: 123456
period | Σ | 0..1 | Period | Time period when id is/was valid for use
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text)
status | ?!S Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
type | S Σ | 0..1 | CodeableConcept | Coverage category such as medical or accident Binding: Payer Type (extensible): US Public Health Data Consortium Source of Payment Codes
policyHolder | S Σ | 0..1 | Reference(US Core Patient Profile(7.0.0) | HRex Organization Profile | US Core RelatedPerson Profile(7.0.0)) | Owner of the policy
subscriber | Σ | 0..1 | Reference(Patient | RelatedPerson) | Subscriber to the policy
subscriberId | S Σ C | 0..1 | string | Subscriber ID
beneficiary | S Σ | 1..1 | Reference(HRex Member Match Patient) | Plan beneficiary
dependent | S Σ | 0..1 | string | Dependent number
relationship | S | 1..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: HRex Coverage Relationship ValueSet (required)
period | S Σ | 0..1 | Period | Coverage start and end dates
payor | S Σ | 1..1 | Reference(HRex Organization Profile) | Issuer of the policy
Slices for class |  | 0..* | BackboneElement | Additional coverage classifications Slice: Unordered, Open by value: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 | Group
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | S Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: group
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
value | S Σ | 1..1 | string | Group Number
name | Σ | 0..1 | string | Human readable description of the type and value
class:plan | S | 0..1 | BackboneElement | Plan
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | S Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: plan
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
value | S Σ | 1..1 | string | Plan Number
name | S Σ | 0..1 | string | Plan Name
order | Σ | 0..1 | positiveInt | Relative order of the coverage
network | Σ | 0..1 | string | Insurer network
costToBeneficiary |  | 0..* | BackboneElement | Patient payments for services/products
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 0..1 | CodeableConcept | Cost category Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified.
value[x] | Σ | 1..1 |  | The amount or percentage due from the beneficiary
valueQuantity |  |  | Quantity(SimpleQuantity) |
valueMoney |  |  | Money |
exception |  | 0..* | BackboneElement | Exceptions for patient payments
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 1..1 | CodeableConcept | Exception category Binding: ExampleCoverageFinancialExceptionCodes (example): The types of exceptions from the part or full value of financial obligations such as copays.
period | Σ | 0..1 | Period | The effective period of the exception
subrogation |  | 0..1 | boolean | Reimbursement to insurer
contract |  | 0..* | Reference(Contract) | Contract details
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet / Code | URI
Coverage.language | preferred | CommonLanguages `http://hl7.org/fhir/ValueSet/languages` from the FHIR Standard
Additional Bindings | Purpose
AllLanguages | Max Binding
Coverage.identifier:memberid.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` from the FHIR Standard
Coverage.identifier:memberid.type | extensible | Pattern: MB `http://hl7.org/fhir/ValueSet/identifier-type` from the FHIR Standard
Coverage.status | required | FinancialResourceStatusCodes `http://hl7.org/fhir/ValueSet/fm-status|4.0.1` from 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` from https://vsac.nlm.nih.gov
Coverage.relationship | required | HRexCoverageRelationship `http://hl7.org/fhir/us/davinci-hrex/ValueSet/hrex-coverage-relationship` from this IG
Coverage.class.type | extensible | CoverageClassCodes `http://hl7.org/fhir/ValueSet/coverage-class` from the FHIR Standard
Coverage.class:group.type | extensible | Pattern: group `http://hl7.org/fhir/ValueSet/coverage-class` from the FHIR Standard
Coverage.class:plan.type | extensible | Pattern: plan `http://hl7.org/fhir/ValueSet/coverage-class` from the FHIR Standard
Coverage.costToBeneficiary.type | extensible | CoverageCopayTypeCodes `http://hl7.org/fhir/ValueSet/coverage-copay-type` from the FHIR Standard
Coverage.costToBeneficiary.exception.type | example | ExampleCoverageFinancialExceptionCodes `http://hl7.org/fhir/ValueSet/coverage-financial-exception` from the FHIR Standard

#### 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() |
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() |

This structure is derived from Coverage

Summary

Mandatory: 1 element(2 nested mandatory elements)
Must-Support: 19 elements

Structures

This structure refers to these other structures:

- US Core Patient Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient|7.0.0)
- HRex Organization Profile (http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/hrex-organization)
- US Core RelatedPerson Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-relatedperson|7.0.0)
- HRex Member Match Patient (http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/hrex-patient-demographics)

Slices

This structure defines the following Slices:

- The element 1 is sliced based on the value of Coverage.identifier
- The element 1 is sliced based on the value of Coverage.class

Maturity: 3

Other representations of profile: CSV, Excel, Schematron

### Notes:

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.