Da Vinci Prior Authorization Support (PAS) FHIR IG
2.2.0-snapshot - STU 2.2 - Public Review United States of America flag

Da Vinci Prior Authorization Support (PAS) FHIR IG, published by HL7 International / Financial Management. This guide is not an authorized publication; it is the continuous build for version 2.2.0-snapshot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/davinci-pas/ and changes regularly. See the Directory of published versions

Resource Profile: PAS Coverage

2.2.0-snapshot
Official URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-coverage Version:
Standards status: Trial-use Active as of 2026-01-30 Maturity Level: 4 Computable Name: PASCoverage
Other Identifiers: OID:2.16.840.1.113883.4.642.40.24.42.54

PAS constraints on Coverage resource mandating support for insurance elements relevant to the prior authorization request

Usages:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

Description Differentials, Snapshots, and other representations.

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Coverage C 0..* USCoreCoverageProfile(7.0.0) Insurance or medical plan or a payment agreement
This profile also complies with the profile US Core Coverage Profile (6.1.0)
Constraints: us-core-15, self-beneficiary
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... Slices for identifier SΣ 0..* Identifier Member ID and other identifiers
Slice: Unordered, Open by pattern:type
.... identifier:memberid SΣC 0..1 Identifier Member ID
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
..... type SΣ 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
... type SΣ 0..1 CodeableConcept Coverage category such as medical or accident
Binding: PayerType (20221118) . (extensible): US Public Health Data Consortium Source of Payment Codes
... subscriber SΣ 0..1 Reference(PAS Subscriber Patient(2.2.0-snapshot)) Subscriber to the policy
... subscriberId SΣC 0..1 string ID assigned to the subscriber
... beneficiary SΣ 1..1 Reference(PAS Beneficiary Patient(2.2.0-snapshot)) Plan beneficiary
... relationship S 1..1 CodeableConcept Beneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible)
.... Slices for coding Σ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by value:$this
..... coding:X12Code SΣ 0..1 Coding Code defined by a terminology system
Binding: https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069 (required): Codes indicating the relationship between two individuals or entities. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
... period SΣ 0..1 Period Coverage start and end dates
... payor SΣ 1..1 Reference(PAS Insurer Organization(2.2.0-snapshot)) Issuer of the policy
... Slices for class S 0..* BackboneElement Additional coverage classifications
Slice: Unordered, Open by pattern:type
.... class:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... type Σ 1..1 CodeableConcept Type of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.
..... value Σ 1..1 string Value associated with the type
.... class:group S 0..1 BackboneElement Group
..... 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.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: group
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... value SΣ 1..1 string Group Number
..... name SΣ 0..1 string Group Name
.... class:plan S 0..1 BackboneElement Plan
..... 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.
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 SΣ 1..1 string Plan Number
..... name SΣ 0..1 string Plan Name

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Coverage.identifier:memberid.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
Coverage.identifier:memberid.​type Base extensible IdentifierType 📦4.0.1 FHIR Std.
Coverage.status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
Coverage.type Base extensible Payer Type . 📍20221118 VSAC v0.21
Coverage.relationship Base extensible SubscriberPolicyholder Relationship Codes 📦4.0.1 FHIR Std.
Coverage.relationship.​coding:X12Code Base required https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069 Not State Unknown
Coverage.class.type Base extensible Coverage Class Codes 📦4.0.1 FHIR Std.
Coverage.class:group.​type Base extensible Coverage Class Codes 📦4.0.1 FHIR Std.
Coverage.class:plan.​type Base extensible Coverage Class Codes 📦4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
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()
self-beneficiary error Coverage If relationship does not equal 'self', then subscriber SHALL be present. $this.relationship.coding.where(code='18').count() = 0 implies $this.subscriber.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()

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Coverage C 0..* USCoreCoverageProfile(7.0.0) Insurance or medical plan or a payment agreement
This profile also complies with the profile US Core Coverage Profile (6.1.0)
... status 1..1 code active | cancelled | draft | entered-in-error
Required Pattern: active
... subscriber S 0..1 Reference(PAS Subscriber Patient(2.2.0-snapshot)) Subscriber to the policy
... beneficiary 1..1 Reference(PAS Beneficiary Patient(2.2.0-snapshot)) Plan beneficiary
.... Slices for coding 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by value:$this
..... coding:X12Code S 0..1 Coding Code defined by a terminology system
Binding: https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069 (required): Codes indicating the relationship between two individuals or entities. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
... payor 1..1 Reference(PAS Insurer Organization(2.2.0-snapshot)) Issuer of the policy

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
Coverage.relationship.​coding:X12Code Base required https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069 Not State Unknown

Constraints

Id Grade Path(s) Description Expression
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Coverage C 0..* USCoreCoverageProfile(7.0.0) Insurance or medical plan or a payment agreement
This profile also complies with the profile US Core Coverage Profile (6.1.0)
Constraints: us-core-15, self-beneficiary
... 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
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... 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 SΣ 0..* Identifier Member ID and other identifiers
Slice: Unordered, Open by pattern:type
.... identifier:memberid SΣC 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 SΣ 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 Σ 0..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 ?!SΣ 1..1 code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
Required Pattern: active
... type SΣ 0..1 CodeableConcept Coverage category such as medical or accident
Binding: PayerType (20221118) . (extensible): US Public Health Data Consortium Source of Payment Codes
... policyHolder Σ 0..1 Reference(Patient | RelatedPerson | Organization) Owner of the policy
... subscriber SΣ 0..1 Reference(PAS Subscriber Patient(2.2.0-snapshot)) Subscriber to the policy
... subscriberId SΣC 0..1 string ID assigned to the subscriber
... beneficiary SΣ 1..1 Reference(PAS Beneficiary Patient(2.2.0-snapshot)) Plan beneficiary
... dependent Σ 0..1 string Dependent number
... relationship S 1..1 CodeableConcept Beneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible)
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... Slices for coding Σ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by value:$this
..... coding:X12Code SΣ 0..1 Coding Code defined by a terminology system
Binding: https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069 (required): Codes indicating the relationship between two individuals or entities. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
.... text Σ 0..1 string Plain text representation of the concept
... period SΣ 0..1 Period Coverage start and end dates
... payor SΣ 1..1 Reference(PAS Insurer Organization(2.2.0-snapshot)) Issuer of the policy
... Slices for class S 0..* BackboneElement Additional coverage classifications
Slice: Unordered, Open by pattern:type
.... class:All Slices Content/Rules for all slices
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... type Σ 1..1 CodeableConcept Type of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.
..... value Σ 1..1 string Value associated with the type
..... name Σ 0..1 string Human readable description of the type and value
.... class:group S 0..1 BackboneElement 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 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 SΣ 1..1 string Group Number
..... name SΣ 0..1 string Group Name
.... 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 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 SΣ 1..1 string Plan Number
..... name SΣ 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

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Coverage.language Base preferred Common Languages 📦4.0.1 FHIR Std.
Coverage.identifier:memberid.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
Coverage.identifier:memberid.​type Base extensible IdentifierType 📦4.0.1 FHIR Std.
Coverage.status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
Coverage.type Base extensible Payer Type . 📍20221118 VSAC v0.21
Coverage.relationship Base extensible SubscriberPolicyholder Relationship Codes 📦4.0.1 FHIR Std.
Coverage.relationship.​coding:X12Code Base required https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069 Not State Unknown
Coverage.class.type Base extensible Coverage Class Codes 📦4.0.1 FHIR Std.
Coverage.class:group.​type Base extensible Coverage Class Codes 📦4.0.1 FHIR Std.
Coverage.class:plan.​type Base extensible Coverage Class Codes 📦4.0.1 FHIR Std.
Coverage.costToBeneficiary.​type Base extensible Coverage Copay Type Codes 📦4.0.1 FHIR Std.
Coverage.costToBeneficiary.​exception.type Base example Example Coverage Financial Exception Codes 📦4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
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()
self-beneficiary error Coverage If relationship does not equal 'self', then subscriber SHALL be present. $this.relationship.coding.where(code='18').count() = 0 implies $this.subscriber.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()

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Coverage C 0..* USCoreCoverageProfile(7.0.0) Insurance or medical plan or a payment agreement
This profile also complies with the profile US Core Coverage Profile (6.1.0)
Constraints: us-core-15, self-beneficiary
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... Slices for identifier SΣ 0..* Identifier Member ID and other identifiers
Slice: Unordered, Open by pattern:type
.... identifier:memberid SΣC 0..1 Identifier Member ID
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
..... type SΣ 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
... type SΣ 0..1 CodeableConcept Coverage category such as medical or accident
Binding: PayerType (20221118) . (extensible): US Public Health Data Consortium Source of Payment Codes
... subscriber SΣ 0..1 Reference(PAS Subscriber Patient(2.2.0-snapshot)) Subscriber to the policy
... subscriberId SΣC 0..1 string ID assigned to the subscriber
... beneficiary SΣ 1..1 Reference(PAS Beneficiary Patient(2.2.0-snapshot)) Plan beneficiary
... relationship S 1..1 CodeableConcept Beneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible)
.... Slices for coding Σ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by value:$this
..... coding:X12Code SΣ 0..1 Coding Code defined by a terminology system
Binding: https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069 (required): Codes indicating the relationship between two individuals or entities. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
... period SΣ 0..1 Period Coverage start and end dates
... payor SΣ 1..1 Reference(PAS Insurer Organization(2.2.0-snapshot)) Issuer of the policy
... Slices for class S 0..* BackboneElement Additional coverage classifications
Slice: Unordered, Open by pattern:type
.... class:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... type Σ 1..1 CodeableConcept Type of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.
..... value Σ 1..1 string Value associated with the type
.... class:group S 0..1 BackboneElement Group
..... 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.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: group
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... value SΣ 1..1 string Group Number
..... name SΣ 0..1 string Group Name
.... class:plan S 0..1 BackboneElement Plan
..... 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.
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 SΣ 1..1 string Plan Number
..... name SΣ 0..1 string Plan Name

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Coverage.identifier:memberid.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
Coverage.identifier:memberid.​type Base extensible IdentifierType 📦4.0.1 FHIR Std.
Coverage.status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
Coverage.type Base extensible Payer Type . 📍20221118 VSAC v0.21
Coverage.relationship Base extensible SubscriberPolicyholder Relationship Codes 📦4.0.1 FHIR Std.
Coverage.relationship.​coding:X12Code Base required https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069 Not State Unknown
Coverage.class.type Base extensible Coverage Class Codes 📦4.0.1 FHIR Std.
Coverage.class:group.​type Base extensible Coverage Class Codes 📦4.0.1 FHIR Std.
Coverage.class:plan.​type Base extensible Coverage Class Codes 📦4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
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()
self-beneficiary error Coverage If relationship does not equal 'self', then subscriber SHALL be present. $this.relationship.coding.where(code='18').count() = 0 implies $this.subscriber.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

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Coverage C 0..* USCoreCoverageProfile(7.0.0) Insurance or medical plan or a payment agreement
This profile also complies with the profile US Core Coverage Profile (6.1.0)
... status 1..1 code active | cancelled | draft | entered-in-error
Required Pattern: active
... subscriber S 0..1 Reference(PAS Subscriber Patient(2.2.0-snapshot)) Subscriber to the policy
... beneficiary 1..1 Reference(PAS Beneficiary Patient(2.2.0-snapshot)) Plan beneficiary
.... Slices for coding 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by value:$this
..... coding:X12Code S 0..1 Coding Code defined by a terminology system
Binding: https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069 (required): Codes indicating the relationship between two individuals or entities. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
... payor 1..1 Reference(PAS Insurer Organization(2.2.0-snapshot)) Issuer of the policy

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
Coverage.relationship.​coding:X12Code Base required https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069 Not State Unknown

Constraints

Id Grade Path(s) Description Expression

Snapshot ViewView

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Coverage C 0..* USCoreCoverageProfile(7.0.0) Insurance or medical plan or a payment agreement
This profile also complies with the profile US Core Coverage Profile (6.1.0)
Constraints: us-core-15, self-beneficiary
... 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
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... 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 SΣ 0..* Identifier Member ID and other identifiers
Slice: Unordered, Open by pattern:type
.... identifier:memberid SΣC 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 SΣ 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 Σ 0..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 ?!SΣ 1..1 code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
Required Pattern: active
... type SΣ 0..1 CodeableConcept Coverage category such as medical or accident
Binding: PayerType (20221118) . (extensible): US Public Health Data Consortium Source of Payment Codes
... policyHolder Σ 0..1 Reference(Patient | RelatedPerson | Organization) Owner of the policy
... subscriber SΣ 0..1 Reference(PAS Subscriber Patient(2.2.0-snapshot)) Subscriber to the policy
... subscriberId SΣC 0..1 string ID assigned to the subscriber
... beneficiary SΣ 1..1 Reference(PAS Beneficiary Patient(2.2.0-snapshot)) Plan beneficiary
... dependent Σ 0..1 string Dependent number
... relationship S 1..1 CodeableConcept Beneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible)
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... Slices for coding Σ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by value:$this
..... coding:X12Code SΣ 0..1 Coding Code defined by a terminology system
Binding: https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069 (required): Codes indicating the relationship between two individuals or entities. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
.... text Σ 0..1 string Plain text representation of the concept
... period SΣ 0..1 Period Coverage start and end dates
... payor SΣ 1..1 Reference(PAS Insurer Organization(2.2.0-snapshot)) Issuer of the policy
... Slices for class S 0..* BackboneElement Additional coverage classifications
Slice: Unordered, Open by pattern:type
.... class:All Slices Content/Rules for all slices
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... type Σ 1..1 CodeableConcept Type of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.
..... value Σ 1..1 string Value associated with the type
..... name Σ 0..1 string Human readable description of the type and value
.... class:group S 0..1 BackboneElement 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 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 SΣ 1..1 string Group Number
..... name SΣ 0..1 string Group Name
.... 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 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 SΣ 1..1 string Plan Number
..... name SΣ 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

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Coverage.language Base preferred Common Languages 📦4.0.1 FHIR Std.
Coverage.identifier:memberid.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
Coverage.identifier:memberid.​type Base extensible IdentifierType 📦4.0.1 FHIR Std.
Coverage.status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
Coverage.type Base extensible Payer Type . 📍20221118 VSAC v0.21
Coverage.relationship Base extensible SubscriberPolicyholder Relationship Codes 📦4.0.1 FHIR Std.
Coverage.relationship.​coding:X12Code Base required https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069 Not State Unknown
Coverage.class.type Base extensible Coverage Class Codes 📦4.0.1 FHIR Std.
Coverage.class:group.​type Base extensible Coverage Class Codes 📦4.0.1 FHIR Std.
Coverage.class:plan.​type Base extensible Coverage Class Codes 📦4.0.1 FHIR Std.
Coverage.costToBeneficiary.​type Base extensible Coverage Copay Type Codes 📦4.0.1 FHIR Std.
Coverage.costToBeneficiary.​exception.type Base example Example Coverage Financial Exception Codes 📦4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
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()
self-beneficiary error Coverage If relationship does not equal 'self', then subscriber SHALL be present. $this.relationship.coding.where(code='18').count() = 0 implies $this.subscriber.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()

 

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