Patient Cost Transparency Implementation Guide
2.0.0-ballot - STU 2 Ballot United States of America flag

Patient Cost Transparency Implementation Guide, published by HL7 International / Financial Management. This guide is not an authorized publication; it is the continuous build for version 2.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/davinci-pct/ and changes regularly. See the Directory of published versions

Resource Profile: PCT Coverage

Official URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage Version: 2.0.0-ballot
Standards status: Trial-use Computable Name: PCTCoverage
Other Identifiers: OID:2.16.840.1.113883.4.642.40.4.42.8

PCT Coverage is a profile for capturing data that reflect a payer’s coverage that was effective as of the proposed date of service or the date of admission of the GFE.

Usage:

Changes since version true:

  • No changes
  • Formal Views of Profile Content

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

    This structure is derived from HRexCoverage

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Coverage HRexCoverage
    ... Slices for extension 1..*ExtensionExtension
    Slice: Unordered, Open by value:url
    ... coverage-kind 1..1codeOptional Extensions Element
    URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind
    .... value[x] 1..1codeValue of extension
    ... self-pay-declared S0..1booleanSelf-Pay Declared
    URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/selfPayDeclared
    .... display 1..1stringProvide the name of the subscriber in Coverage.subscriber.display concatenating the subscriber’s prefix, given name, family name and suffix (in this order), each separated by a single space. If discrete name parts are required, a Patient resource SHALL be pointed to in Coverage.subscriber.reference.
    ... subscriberId 1..1stringSubscriber ID
    ... relationship 1..1CodeableConceptBeneficiary relationship to the subscriber
    ... period 1..1PeriodCoverage start and end dates
    ... payor 1..1Reference(PCT Organization)Issuer of the policy
    ... Slices for class 1..*BackboneElementAdditional coverage classifications
    Slice: Unordered, Open by pattern:type
    .... class:All Slices Content/Rules for all slices
    ..... name 1..1stringHuman readable description of the type and value
    .... class:group 0..1BackboneElementAdditional coverage classifications
    ..... name 1..1stringHuman readable description of the type and value
    .... class:plan S0..1BackboneElementAdditional coverage classifications
    ..... type 1..1CodeableConceptType of class such as 'group' or 'plan'
    Required Pattern: At least the following
    ...... coding1..*CodingCode defined by a terminology system
    Fixed Value: (complex)
    ....... system1..1uriIdentity of the terminology system
    Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
    ....... code1..1codeSymbol in syntax defined by the system
    Fixed Value: plan
    ...... coding 1..*CodingCode defined by a terminology system
    ... costToBeneficiary
    .... type 0..1CodeableConceptCost category
    Binding: Coverage Copay Type Codes (required)

    doco Documentation for this format

    Terminology Bindings (Differential)

    PathConformanceValueSetURI
    Coverage.costToBeneficiary.typerequiredCoverageCopayTypeCodes
    http://terminology.hl7.org/ValueSet/coverage-copay-type
    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Coverage C0..*HRexCoverageInsurance or medical plan or a payment agreement
    hrex-cov-1: Coverage.identifier or Coverage.subscriberId SHALL be present
    ... implicitRules ?!Σ0..1uriA set of rules under which this content was created
    ... Slices for extension 1..*ExtensionExtension
    Slice: Unordered, Open by value:url
    ... coverage-kind 1..1codeOptional Extensions Element
    URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind
    .... extension 0..0
    .... url 1..1uri"http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind"
    .... value[x] 1..1codeValue of extension
    ... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
    ... identifier SΣ0..1IdentifierAlso known as Member identifier
    .... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
    Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

    .... value SΣ1..1stringThe value that is unique within the system.
    Example General: 123456
    ... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
    Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

    ... subscriber Σ0..1Reference(US Core Patient Profile)Required if subscriber is a person that is not the beneficiary. When date of birth or gender are not known, omit Patient.birthDate and set Patient.gender to unknown.
    .... display Σ1..1stringProvide the name of the subscriber in Coverage.subscriber.display concatenating the subscriber’s prefix, given name, family name and suffix (in this order), each separated by a single space. If discrete name parts are required, a Patient resource SHALL be pointed to in Coverage.subscriber.reference.
    ... subscriberId SΣ1..1stringSubscriber ID
    ... beneficiary SΣ1..1Reference(HRex Patient Demographics)Plan beneficiary
    ... dependent SΣ0..1stringDependent number
    ... relationship 1..1CodeableConceptBeneficiary relationship to the subscriber
    Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).

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

    ..... value Σ1..1stringValue associated with the type
    ..... name Σ1..1stringHuman readable description of the type and value
    .... class:group S0..1BackboneElementAdditional coverage classifications
    ..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
    ..... type SΣ1..1CodeableConceptType of class such as 'group' or 'plan'
    Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.


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


    Required Pattern: At least the following
    ...... coding1..*CodingCode defined by a terminology system
    Fixed Value: (complex)
    ....... system1..1uriIdentity of the terminology system
    Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
    ....... code1..1codeSymbol in syntax defined by the system
    Fixed Value: plan
    ...... coding Σ1..*CodingCode defined by a terminology system
    ..... value Σ1..1stringValue associated with the type

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSet / CodeURI
    Coverage.identifier.userequiredIdentifierUse
    http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
    from the FHIR Standard
    Coverage.statusrequiredFinancialResourceStatusCodes
    http://hl7.org/fhir/ValueSet/fm-status|4.0.1
    from the FHIR Standard
    Coverage.relationshipextensibleSubscriberRelationshipCodes
    http://hl7.org/fhir/ValueSet/subscriber-relationship
    from the FHIR Standard
    Coverage.class.typeextensibleCoverageClassCodes
    http://hl7.org/fhir/ValueSet/coverage-class
    from the FHIR Standard
    Coverage.class:group.typeextensiblePattern: group
    http://hl7.org/fhir/ValueSet/coverage-class
    from the FHIR Standard
    Coverage.class:plan.typeextensiblePattern: plan
    http://hl7.org/fhir/ValueSet/coverage-class
    from the FHIR Standard
    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Coverage C0..*HRexCoverageInsurance or medical plan or a payment agreement
    hrex-cov-1: Coverage.identifier or Coverage.subscriberId SHALL be present
    ... id Σ0..1idLogical id of this artifact
    ... meta Σ0..1MetaMetadata about the resource
    ... implicitRules ?!Σ0..1uriA set of rules under which this content was created
    ... language 0..1codeLanguage of the resource content
    Binding: CommonLanguages (preferred): A human language.

    Additional BindingsPurpose
    AllLanguagesMax Binding
    ... text 0..1NarrativeText summary of the resource, for human interpretation
    ... contained 0..*ResourceContained, inline Resources
    ... Slices for extension 1..*ExtensionExtension
    Slice: Unordered, Open by value:url
    ... coverage-kind 1..1codeOptional Extensions Element
    URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind
    .... id 0..1stringUnique id for inter-element referencing
    .... extension 0..0
    .... url 1..1uri"http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind"
    .... value[x] 1..1codeValue of extension
    ... self-pay-declared S0..1booleanSelf-Pay Declared
    URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/selfPayDeclared
    ... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
    ... identifier SΣ0..1IdentifierAlso known as Member identifier
    .... id 0..1stringUnique id for inter-element referencing
    .... extension 0..*ExtensionAdditional content defined by implementations
    Slice: Unordered, Open by value:url
    .... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
    Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

    .... type Σ0..1CodeableConceptDescription of identifier
    Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

    .... system Σ0..1uriThe namespace for the identifier value
    Example General: http://www.acme.com/identifiers/patient
    .... value SΣ1..1stringThe value that is unique within the system.
    Example General: 123456
    .... period Σ0..1PeriodTime period when id is/was valid for use
    .... assigner Σ0..1Reference(Organization)Organization that issued id (may be just text)
    ... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
    Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

    ... type Σ0..1CodeableConceptCoverage category such as medical or accident
    Binding: CoverageTypeAndSelf-PayCodes (preferred): The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization.

    ... policyHolder Σ0..1Reference(US Core Patient Profile | HRex Organization Profile | RelatedPerson)Owner of the policy
    ... subscriber Σ0..1Reference(US Core Patient Profile)Required if subscriber is a person that is not the beneficiary. When date of birth or gender are not known, omit Patient.birthDate and set Patient.gender to unknown.
    .... id 0..1stringUnique id for inter-element referencing
    .... extension 0..*ExtensionAdditional content defined by implementations
    Slice: Unordered, Open by value:url
    .... reference ΣC0..1stringLiteral reference, Relative, internal or absolute URL
    .... type Σ0..1uriType the reference refers to (e.g. "Patient")
    Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

    .... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
    .... display Σ1..1stringProvide the name of the subscriber in Coverage.subscriber.display concatenating the subscriber’s prefix, given name, family name and suffix (in this order), each separated by a single space. If discrete name parts are required, a Patient resource SHALL be pointed to in Coverage.subscriber.reference.
    ... subscriberId SΣ1..1stringSubscriber ID
    ... beneficiary SΣ1..1Reference(HRex Patient Demographics)Plan beneficiary
    ... dependent SΣ0..1stringDependent number
    ... relationship 1..1CodeableConceptBeneficiary relationship to the subscriber
    Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).

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

    ..... value Σ1..1stringValue associated with the type
    ..... name Σ1..1stringHuman readable description of the type and value
    .... class:group S0..1BackboneElementAdditional coverage classifications
    ..... id 0..1stringUnique id for inter-element referencing
    ..... extension 0..*ExtensionAdditional content defined by implementations
    ..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
    ..... type SΣ1..1CodeableConceptType of class such as 'group' or 'plan'
    Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.


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


    Required Pattern: At least the following
    ...... id0..1stringUnique id for inter-element referencing
    ...... extension0..*ExtensionAdditional content defined by implementations
    ...... coding1..*CodingCode defined by a terminology system
    Fixed Value: (complex)
    ....... id0..1stringUnique id for inter-element referencing
    ....... extension0..*ExtensionAdditional content defined by implementations
    ....... system1..1uriIdentity of the terminology system
    Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
    ....... version0..1stringVersion of the system - if relevant
    ....... code1..1codeSymbol in syntax defined by the system
    Fixed Value: plan
    ....... display0..1stringRepresentation defined by the system
    ....... userSelected0..1booleanIf this coding was chosen directly by the user
    ...... text0..1stringPlain text representation of the concept
    ...... id 0..1stringUnique id for inter-element referencing
    ...... extension 0..*ExtensionAdditional content defined by implementations
    Slice: Unordered, Open by value:url
    ...... coding Σ1..*CodingCode defined by a terminology system
    ...... text Σ0..1stringPlain text representation of the concept
    ..... value Σ1..1stringValue associated with the type
    ..... name Σ0..1stringHuman readable description of the type and value
    ... order Σ0..1positiveIntRelative order of the coverage
    ... network Σ0..1stringInsurer network
    ... costToBeneficiary 0..*BackboneElementPatient payments for services/products
    .... id 0..1stringUnique id for inter-element referencing
    .... extension 0..*ExtensionAdditional content defined by implementations
    .... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
    .... type Σ0..1CodeableConceptCost category
    Binding: Coverage Copay Type Codes (required)
    .... value[x] Σ1..1The amount or percentage due from the beneficiary
    ..... valueQuantityQuantity(SimpleQuantity)
    ..... valueMoneyMoney
    .... exception 0..*BackboneElementExceptions for patient payments
    ..... id 0..1stringUnique id for inter-element referencing
    ..... extension 0..*ExtensionAdditional content defined by implementations
    ..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
    ..... type Σ1..1CodeableConceptException category
    Binding: ExampleCoverageFinancialExceptionCodes (example): The types of exceptions from the part or full value of financial obligations such as copays.

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

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSet / CodeURI
    Coverage.languagepreferredCommonLanguages
    Additional Bindings Purpose
    AllLanguages Max Binding
    http://hl7.org/fhir/ValueSet/languages
    from the FHIR Standard
    Coverage.identifier.userequiredIdentifierUse
    http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
    from the FHIR Standard
    Coverage.identifier.typeextensibleIdentifier Type Codes
    http://hl7.org/fhir/ValueSet/identifier-type
    from the FHIR Standard
    Coverage.statusrequiredFinancialResourceStatusCodes
    http://hl7.org/fhir/ValueSet/fm-status|4.0.1
    from the FHIR Standard
    Coverage.typepreferredCoverageTypeAndSelf-PayCodes
    http://hl7.org/fhir/ValueSet/coverage-type
    from the FHIR Standard
    Coverage.subscriber.typeextensibleResourceType
    http://hl7.org/fhir/ValueSet/resource-types
    from the FHIR Standard
    Coverage.relationshipextensibleSubscriberRelationshipCodes
    http://hl7.org/fhir/ValueSet/subscriber-relationship
    from the FHIR Standard
    Coverage.class.typeextensibleCoverageClassCodes
    http://hl7.org/fhir/ValueSet/coverage-class
    from the FHIR Standard
    Coverage.class:group.typeextensiblePattern: group
    http://hl7.org/fhir/ValueSet/coverage-class
    from the FHIR Standard
    Coverage.class:plan.typeextensiblePattern: plan
    http://hl7.org/fhir/ValueSet/coverage-class
    from the FHIR Standard
    Coverage.costToBeneficiary.typerequiredCoverageCopayTypeCodes
    http://terminology.hl7.org/ValueSet/coverage-copay-type
    Coverage.costToBeneficiary.exception.typeexampleExampleCoverageFinancialExceptionCodes
    http://hl7.org/fhir/ValueSet/coverage-financial-exception
    from the FHIR Standard

    This structure is derived from HRexCoverage

    Summary

    Mandatory: 8 elements (3 nested mandatory elements)
    Must-Support: 2 elements

    Structures

    This structure refers to these other structures:

    Extensions

    This structure refers to these extensions:

    Slices

    This structure defines the following Slices:

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

    Differential View

    This structure is derived from HRexCoverage

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Coverage HRexCoverage
    ... Slices for extension 1..*ExtensionExtension
    Slice: Unordered, Open by value:url
    ... coverage-kind 1..1codeOptional Extensions Element
    URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind
    .... value[x] 1..1codeValue of extension
    ... self-pay-declared S0..1booleanSelf-Pay Declared
    URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/selfPayDeclared
    .... display 1..1stringProvide the name of the subscriber in Coverage.subscriber.display concatenating the subscriber’s prefix, given name, family name and suffix (in this order), each separated by a single space. If discrete name parts are required, a Patient resource SHALL be pointed to in Coverage.subscriber.reference.
    ... subscriberId 1..1stringSubscriber ID
    ... relationship 1..1CodeableConceptBeneficiary relationship to the subscriber
    ... period 1..1PeriodCoverage start and end dates
    ... payor 1..1Reference(PCT Organization)Issuer of the policy
    ... Slices for class 1..*BackboneElementAdditional coverage classifications
    Slice: Unordered, Open by pattern:type
    .... class:All Slices Content/Rules for all slices
    ..... name 1..1stringHuman readable description of the type and value
    .... class:group 0..1BackboneElementAdditional coverage classifications
    ..... name 1..1stringHuman readable description of the type and value
    .... class:plan S0..1BackboneElementAdditional coverage classifications
    ..... type 1..1CodeableConceptType of class such as 'group' or 'plan'
    Required Pattern: At least the following
    ...... coding1..*CodingCode defined by a terminology system
    Fixed Value: (complex)
    ....... system1..1uriIdentity of the terminology system
    Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
    ....... code1..1codeSymbol in syntax defined by the system
    Fixed Value: plan
    ...... coding 1..*CodingCode defined by a terminology system
    ... costToBeneficiary
    .... type 0..1CodeableConceptCost category
    Binding: Coverage Copay Type Codes (required)

    doco Documentation for this format

    Terminology Bindings (Differential)

    PathConformanceValueSetURI
    Coverage.costToBeneficiary.typerequiredCoverageCopayTypeCodes
    http://terminology.hl7.org/ValueSet/coverage-copay-type

    Key Elements View

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Coverage C0..*HRexCoverageInsurance or medical plan or a payment agreement
    hrex-cov-1: Coverage.identifier or Coverage.subscriberId SHALL be present
    ... implicitRules ?!Σ0..1uriA set of rules under which this content was created
    ... Slices for extension 1..*ExtensionExtension
    Slice: Unordered, Open by value:url
    ... coverage-kind 1..1codeOptional Extensions Element
    URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind
    .... extension 0..0
    .... url 1..1uri"http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind"
    .... value[x] 1..1codeValue of extension
    ... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
    ... identifier SΣ0..1IdentifierAlso known as Member identifier
    .... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
    Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

    .... value SΣ1..1stringThe value that is unique within the system.
    Example General: 123456
    ... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
    Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

    ... subscriber Σ0..1Reference(US Core Patient Profile)Required if subscriber is a person that is not the beneficiary. When date of birth or gender are not known, omit Patient.birthDate and set Patient.gender to unknown.
    .... display Σ1..1stringProvide the name of the subscriber in Coverage.subscriber.display concatenating the subscriber’s prefix, given name, family name and suffix (in this order), each separated by a single space. If discrete name parts are required, a Patient resource SHALL be pointed to in Coverage.subscriber.reference.
    ... subscriberId SΣ1..1stringSubscriber ID
    ... beneficiary SΣ1..1Reference(HRex Patient Demographics)Plan beneficiary
    ... dependent SΣ0..1stringDependent number
    ... relationship 1..1CodeableConceptBeneficiary relationship to the subscriber
    Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).

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

    ..... value Σ1..1stringValue associated with the type
    ..... name Σ1..1stringHuman readable description of the type and value
    .... class:group S0..1BackboneElementAdditional coverage classifications
    ..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
    ..... type SΣ1..1CodeableConceptType of class such as 'group' or 'plan'
    Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.


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


    Required Pattern: At least the following
    ...... coding1..*CodingCode defined by a terminology system
    Fixed Value: (complex)
    ....... system1..1uriIdentity of the terminology system
    Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
    ....... code1..1codeSymbol in syntax defined by the system
    Fixed Value: plan
    ...... coding Σ1..*CodingCode defined by a terminology system
    ..... value Σ1..1stringValue associated with the type

    doco Documentation for this format

    Terminology Bindings

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

    Snapshot View

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Coverage C0..*HRexCoverageInsurance or medical plan or a payment agreement
    hrex-cov-1: Coverage.identifier or Coverage.subscriberId SHALL be present
    ... id Σ0..1idLogical id of this artifact
    ... meta Σ0..1MetaMetadata about the resource
    ... implicitRules ?!Σ0..1uriA set of rules under which this content was created
    ... language 0..1codeLanguage of the resource content
    Binding: CommonLanguages (preferred): A human language.

    Additional BindingsPurpose
    AllLanguagesMax Binding
    ... text 0..1NarrativeText summary of the resource, for human interpretation
    ... contained 0..*ResourceContained, inline Resources
    ... Slices for extension 1..*ExtensionExtension
    Slice: Unordered, Open by value:url
    ... coverage-kind 1..1codeOptional Extensions Element
    URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind
    .... id 0..1stringUnique id for inter-element referencing
    .... extension 0..0
    .... url 1..1uri"http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind"
    .... value[x] 1..1codeValue of extension
    ... self-pay-declared S0..1booleanSelf-Pay Declared
    URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/selfPayDeclared
    ... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
    ... identifier SΣ0..1IdentifierAlso known as Member identifier
    .... id 0..1stringUnique id for inter-element referencing
    .... extension 0..*ExtensionAdditional content defined by implementations
    Slice: Unordered, Open by value:url
    .... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
    Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

    .... type Σ0..1CodeableConceptDescription of identifier
    Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

    .... system Σ0..1uriThe namespace for the identifier value
    Example General: http://www.acme.com/identifiers/patient
    .... value SΣ1..1stringThe value that is unique within the system.
    Example General: 123456
    .... period Σ0..1PeriodTime period when id is/was valid for use
    .... assigner Σ0..1Reference(Organization)Organization that issued id (may be just text)
    ... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
    Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

    ... type Σ0..1CodeableConceptCoverage category such as medical or accident
    Binding: CoverageTypeAndSelf-PayCodes (preferred): The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization.

    ... policyHolder Σ0..1Reference(US Core Patient Profile | HRex Organization Profile | RelatedPerson)Owner of the policy
    ... subscriber Σ0..1Reference(US Core Patient Profile)Required if subscriber is a person that is not the beneficiary. When date of birth or gender are not known, omit Patient.birthDate and set Patient.gender to unknown.
    .... id 0..1stringUnique id for inter-element referencing
    .... extension 0..*ExtensionAdditional content defined by implementations
    Slice: Unordered, Open by value:url
    .... reference ΣC0..1stringLiteral reference, Relative, internal or absolute URL
    .... type Σ0..1uriType the reference refers to (e.g. "Patient")
    Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

    .... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
    .... display Σ1..1stringProvide the name of the subscriber in Coverage.subscriber.display concatenating the subscriber’s prefix, given name, family name and suffix (in this order), each separated by a single space. If discrete name parts are required, a Patient resource SHALL be pointed to in Coverage.subscriber.reference.
    ... subscriberId SΣ1..1stringSubscriber ID
    ... beneficiary SΣ1..1Reference(HRex Patient Demographics)Plan beneficiary
    ... dependent SΣ0..1stringDependent number
    ... relationship 1..1CodeableConceptBeneficiary relationship to the subscriber
    Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).

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

    ..... value Σ1..1stringValue associated with the type
    ..... name Σ1..1stringHuman readable description of the type and value
    .... class:group S0..1BackboneElementAdditional coverage classifications
    ..... id 0..1stringUnique id for inter-element referencing
    ..... extension 0..*ExtensionAdditional content defined by implementations
    ..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
    ..... type SΣ1..1CodeableConceptType of class such as 'group' or 'plan'
    Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.


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


    Required Pattern: At least the following
    ...... id0..1stringUnique id for inter-element referencing
    ...... extension0..*ExtensionAdditional content defined by implementations
    ...... coding1..*CodingCode defined by a terminology system
    Fixed Value: (complex)
    ....... id0..1stringUnique id for inter-element referencing
    ....... extension0..*ExtensionAdditional content defined by implementations
    ....... system1..1uriIdentity of the terminology system
    Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
    ....... version0..1stringVersion of the system - if relevant
    ....... code1..1codeSymbol in syntax defined by the system
    Fixed Value: plan
    ....... display0..1stringRepresentation defined by the system
    ....... userSelected0..1booleanIf this coding was chosen directly by the user
    ...... text0..1stringPlain text representation of the concept
    ...... id 0..1stringUnique id for inter-element referencing
    ...... extension 0..*ExtensionAdditional content defined by implementations
    Slice: Unordered, Open by value:url
    ...... coding Σ1..*CodingCode defined by a terminology system
    ...... text Σ0..1stringPlain text representation of the concept
    ..... value Σ1..1stringValue associated with the type
    ..... name Σ0..1stringHuman readable description of the type and value
    ... order Σ0..1positiveIntRelative order of the coverage
    ... network Σ0..1stringInsurer network
    ... costToBeneficiary 0..*BackboneElementPatient payments for services/products
    .... id 0..1stringUnique id for inter-element referencing
    .... extension 0..*ExtensionAdditional content defined by implementations
    .... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
    .... type Σ0..1CodeableConceptCost category
    Binding: Coverage Copay Type Codes (required)
    .... value[x] Σ1..1The amount or percentage due from the beneficiary
    ..... valueQuantityQuantity(SimpleQuantity)
    ..... valueMoneyMoney
    .... exception 0..*BackboneElementExceptions for patient payments
    ..... id 0..1stringUnique id for inter-element referencing
    ..... extension 0..*ExtensionAdditional content defined by implementations
    ..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
    ..... type Σ1..1CodeableConceptException category
    Binding: ExampleCoverageFinancialExceptionCodes (example): The types of exceptions from the part or full value of financial obligations such as copays.

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

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSet / CodeURI
    Coverage.languagepreferredCommonLanguages
    Additional Bindings Purpose
    AllLanguages Max Binding
    http://hl7.org/fhir/ValueSet/languages
    from the FHIR Standard
    Coverage.identifier.userequiredIdentifierUse
    http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
    from the FHIR Standard
    Coverage.identifier.typeextensibleIdentifier Type Codes
    http://hl7.org/fhir/ValueSet/identifier-type
    from the FHIR Standard
    Coverage.statusrequiredFinancialResourceStatusCodes
    http://hl7.org/fhir/ValueSet/fm-status|4.0.1
    from the FHIR Standard
    Coverage.typepreferredCoverageTypeAndSelf-PayCodes
    http://hl7.org/fhir/ValueSet/coverage-type
    from the FHIR Standard
    Coverage.subscriber.typeextensibleResourceType
    http://hl7.org/fhir/ValueSet/resource-types
    from the FHIR Standard
    Coverage.relationshipextensibleSubscriberRelationshipCodes
    http://hl7.org/fhir/ValueSet/subscriber-relationship
    from the FHIR Standard
    Coverage.class.typeextensibleCoverageClassCodes
    http://hl7.org/fhir/ValueSet/coverage-class
    from the FHIR Standard
    Coverage.class:group.typeextensiblePattern: group
    http://hl7.org/fhir/ValueSet/coverage-class
    from the FHIR Standard
    Coverage.class:plan.typeextensiblePattern: plan
    http://hl7.org/fhir/ValueSet/coverage-class
    from the FHIR Standard
    Coverage.costToBeneficiary.typerequiredCoverageCopayTypeCodes
    http://terminology.hl7.org/ValueSet/coverage-copay-type
    Coverage.costToBeneficiary.exception.typeexampleExampleCoverageFinancialExceptionCodes
    http://hl7.org/fhir/ValueSet/coverage-financial-exception
    from the FHIR Standard

    This structure is derived from HRexCoverage

    Summary

    Mandatory: 8 elements (3 nested mandatory elements)
    Must-Support: 2 elements

    Structures

    This structure refers to these other structures:

    Extensions

    This structure refers to these extensions:

    Slices

    This structure defines the following Slices:

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

     

    Other representations of profile: CSV, Excel, Schematron