| Left: | US Core Coverage Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-coverage) |
| Right: | PCT Coverage (http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage) |
| Error | StructureDefinition.url | Values for url differ: 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-coverage' vs 'http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage' |
| Error | StructureDefinition.version | Values for version differ: '7.0.0' vs '2.0.0-ballot' |
| Information | StructureDefinition.name | Values for name differ: 'USCoreCoverageProfile' vs 'PCTCoverage' |
| Information | StructureDefinition.title | Values for title differ: 'US Core Coverage Profile' vs 'PCT Coverage' |
| Information | StructureDefinition.date | Values for date differ: '2023-10-17' vs '2024-11-20T18:01:40+00:00' |
| Information | StructureDefinition.publisher | Values for publisher differ: 'HL7 International / Cross-Group Projects' vs 'HL7 International / Financial Management' |
| Error | StructureDefinition.baseDefinition | Values for baseDefinition differ: 'http://hl7.org/fhir/StructureDefinition/Coverage' vs 'http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/hrex-coverage' |
| Information | StructureDefinition.definition | Values for definition differ: 'Financial instrument which may be used to reimburse or pay for health care products and services. Includes both insurance and self-payment.' vs 'This is the Coverage profile which is used to provide insurance information for scheduling an appointment and/or registering a patient.' |
| Information | StructureDefinition.short | Values for short differ: 'Additional content defined by implementations' vs 'Extension' |
| Information | StructureDefinition.definition | Values for definition differ: 'May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.' vs 'An Extension' |
| Information | Coverage.extension | Element minimum cardinalities differ: '0' vs '1' |
| Information | StructureDefinition.short | Values for short differ: 'Member ID and other identifiers' vs 'Also known as Member identifier' |
| Information | StructureDefinition.comment | Values for comment differ: 'The main (and possibly only) identifier for the coverage - often referred to as a Member Id, Certificate number, Personal Health Number or Case ID. May be constructed as the concatenation of the Coverage.SubscriberID and the Coverage.dependant.' vs 'This must be filled in when known' |
| Information | Coverage.identifier | Element maximum cardinalities differ: '2147483647' vs '1' |
| Information | StructureDefinition.comment | Values for comment differ: 'The `Coverage.status` alone does not indicate whether an individual's coverage is terminated or that the individual is not covered. The `Coverage.period` needs to be considered as well.' vs 'This element is labeled as a modifier because the status contains the code entered-in-error that marks the coverage as not currently valid.' |
| Warning | Coverage.status | Elements differ in definition for mustSupport: 'true' vs 'false' |
| Warning | Coverage.type | Elements differ in definition for mustSupport: 'true' vs 'false' |
| Information | StructureDefinition.short | Values for short differ: 'Subscriber to the policy' vs '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.' |
| Information | StructureDefinition.short | Values for short differ: 'ID assigned to the subscriber' vs 'Subscriber ID' |
| Information | StructureDefinition.requirements | Values for requirements differ: 'The insurer requires this identifier on correspondance and claims (digital and otherwise).' vs 'The subscriber Id is a number that is needed by the payer to associate the attestation with the member in their system.' |
| Information | Coverage.subscriberId | Element minimum cardinalities differ: '0' vs '1' |
| Information | StructureDefinition.requirements | Values for requirements differ: 'This is the party who receives treatment for which the costs are reimbursed under the coverage.' vs 'This would usually be the US Core Patient Resource for which the service was performed.' |
| Warning | Coverage.dependent | Elements differ in definition for mustSupport: 'false' vs 'true' |
| Information | StructureDefinition.comment | Values for comment differ: 'Relationship of the member to the person insured (subscriber)' vs 'Typically, an individual uses policies which are theirs (relationship='self') before policies owned by others.' |
| Warning | Coverage.relationship | Elements differ in definition for mustSupport: 'true' vs 'false' |
| Warning | Coverage.period | Elements differ in definition for mustSupport: 'true' vs 'false' |
| Information | Coverage.period | Element minimum cardinalities differ: '0' vs '1' |
| Information | StructureDefinition.comment | Values for comment differ: 'Issuer of the Policy' vs 'May provide multiple identifiers such as insurance company identifier or business identifier (BIN number). For selfpay it may provide multiple paying persons and/or organizations. When sending payer, it may either be a reference to a record stored on a mutually accessible registry, or the Reference.display and Reference.identifier elements can be used to convey the payer's name and identifer.' |
| Warning | Coverage.class | Elements differ in definition for mustSupport: 'true' vs 'false' |
| Information | Coverage.class | Element minimum cardinalities differ: '0' vs '1' |
| Information | Coverage.class.name | Element minimum cardinalities differ: '0' vs '1' |
| Name | Value | Comments | |
|---|---|---|---|
 abstract | false | ||
| baseDefinition | http://hl7.org/fhir/StructureDefinition/Coverage | http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/hrex-coverage |
|
| copyright | Used by permission of HL7 International, all rights reserved Creative Commons License |
| |
| date | 2023-10-17 | 2024-11-20T18:01:40+00:00 |
|
| description | The US Core Coverage Profile inherits from the FHIR [Coverage](https://hl7.org/fhir/R4/coverage.html) resource; refer to it for scope and usage definitions. This profile meets the requirements of the US Core Data for Interoperability (USCDI) *Health Insurance Information* Data Class. It sets minimum expectations for the Coverage resource to record, search, and fetch data related to an individual's insurance coverage for health care. It specifies which core elements, extensions, vocabularies, and value sets **SHALL** be present in the resource and constrains how the elements are used. Providing the floor for standards development for specific use cases promotes interoperability and adoption. | 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. |
|
| experimental | false |
| |
| fhirVersion | 4.0.1 | ||
| jurisdiction | |||
 jurisdiction[0] | urn:iso:std:iso:3166#US | ||
| kind | resource | ||
| name | USCoreCoverageProfile | PCTCoverage |
|
| publisher | HL7 International / Cross-Group Projects | HL7 International / Financial Management |
|
| purpose | |||
| status | active | ||
| title | US Core Coverage Profile | PCT Coverage |
|
| type | Coverage | ||
| url | http://hl7.org/fhir/us/core/StructureDefinition/us-core-coverage | http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage |
|
| version | 7.0.0 | 2.0.0-ballot |
|
| Name | L Flags | L Card. | L Type | L Description & Constraints | R Flags | R Card. | R Type | R Description & Constraints | Comments | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
 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 | C | 0..* | HRexCoverage | Insurance or medical plan or a payment agreement hrex-cov-1: Coverage.identifier or Coverage.subscriberId SHALL be present | |||||||||
 id | Σ | 0..1 | id | Logical id of this artifact | Σ | 0..1 | id | Logical id of this artifact | |||||||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | Σ | 0..1 | Meta | Metadata about the resource | |||||||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ?!Σ | 0..1 | uri | A set of rules under which this content was created | |||||||||
| language | 0..1 | code | Language of the resource content Binding: ?? (preferred): A human language.
| 0..1 | code | Language of the resource content Binding: ?? (preferred): A human language.
| |||||||||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||||||||
| contained | 0..* | Resource | Contained, inline Resources | 0..* | Resource | Contained, inline Resources | |||||||||||
 extension | 0..* | Extension | Additional content defined by implementations | 1..* | Extension | Extension Slice: Unordered, Open by value:url |
| ||||||||||
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ?! | 0..* | Extension | Extensions that cannot be ignored | |||||||||
 Slices for identifier | SΣ | 0..* | Identifier | Member ID and other identifiers Slice: Unordered, Open by pattern:type | SΣ | 0..1 | Identifier | Also known as Member identifier |
| ||||||||
 id | 0..1 | string | Unique id for inter-element referencing |
| |||||||||||||
| Slices for 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: ?? (required): Identifies the purpose for this identifier, if known . |
| ||||||||||||
| type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: ?? (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. |
| ||||||||||||
| system | Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient |
| ||||||||||||
| value | SΣ | 1..1 | string | The value that is unique within the system. 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: ?? (required): A code specifying the state of the resource instance. | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ?? (required): A code specifying the state of the resource instance. |
| ||||||||
| type | SΣ | 0..1 | CodeableConcept | Coverage category such as medical or accident Binding: ?? (extensible): US Public Health Data Consortium Source of Payment Codes | Σ | 0..1 | CodeableConcept | Coverage category such as medical or accident Binding: ?? (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 | Σ | 0..1 | Reference(Patient | RelatedPerson | Organization) | Owner of the policy | Σ | 0..1 | Reference(US Core Patient Profile | HRex Organization Profile | RelatedPerson) | Owner of the policy | |||||||||
| subscriber | Σ | 0..1 | Reference(Patient | RelatedPerson) | Subscriber to the policy | Σ | 0..1 | Reference(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..1 | string | Unique id for inter-element referencing |
| |||||||||||||
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| |||||||||||||
| reference | ΣC | 0..1 | string | Literal reference, Relative, internal or absolute URL |
| ||||||||||||
| type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ?? (extensible): Aa resource (or, for logical models, the URI of the logical model). |
| ||||||||||||
| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known |
| ||||||||||||
| display | Σ | 1..1 | string | Provide 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 | SΣC | 0..1 | string | ID assigned to the subscriber | SΣ | 1..1 | string | Subscriber ID |
| ||||||||
| beneficiary | SΣ | 1..1 | Reference(US Core Patient Profile) | Plan beneficiary | SΣ | 1..1 | Reference(HRex Patient Demographics) | Plan beneficiary | |||||||||
| dependent | Σ | 0..1 | string | Dependent number | SΣ | 0..1 | string | Dependent number |
| ||||||||
| relationship | S | 1..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: ?? (extensible) | 1..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: ?? (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient). |
| |||||||||
| period | SΣ | 0..1 | Period | Coverage start and end dates | Σ | 1..1 | Period | Coverage start and end dates |
| ||||||||
| payor | SΣ | 1..1 | Reference(US Core Organization Profile S | US Core Patient Profile | US Core RelatedPerson Profile) | Issuer of the policy | SΣ | 1..1 | Reference(PCT Organization) | Issuer of the policy | |||||||||
| Slices for class | S | 0..* | BackboneElement | Additional coverage classifications Slice: Unordered, Open by pattern:type | 1..* | BackboneElement | Additional coverage classifications Slice: Unordered, Open by pattern:type |
| |||||||||
| id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
| extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!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: ?? (extensible): The policy classifications, eg. Group, Plan, Class, etc. | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: ?? (extensible): The policy classifications, eg. Group, Plan, Class, etc. | |||||||||
| value | Σ | 1..1 | string | Value associated with the type | Σ | 1..1 | string | Value associated with the type | |||||||||
| name | Σ | 0..1 | string | Human readable description of the type and value | Σ | 1..1 | string | Human readable description of the type and value |
| ||||||||
| order | Σ | 0..1 | positiveInt | Relative order of the coverage | Σ | 0..1 | positiveInt | Relative order of the coverage | |||||||||
| network | Σ | 0..1 | string | Insurer network | Σ | 0..1 | string | Insurer network | |||||||||
| costToBeneficiary | 0..* | BackboneElement | Patient payments for services/products | 0..* | BackboneElement | Patient payments for services/products | |||||||||||
| id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
| extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||||||
| type | Σ | 0..1 | CodeableConcept | Cost category Binding: ?? (extensible): The types of services to which patient copayments are specified. | Σ | 0..1 | CodeableConcept | Cost category Binding: ?? (required) | |||||||||
| value[x] | Σ | 1..1 | ??, Money | The amount or percentage due from the beneficiary | Σ | 1..1 | ??, Money | The amount or percentage due from the beneficiary | |||||||||
 exception | 0..* | BackboneElement | Exceptions for patient payments | 0..* | BackboneElement | Exceptions for patient payments | |||||||||||
 id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
| extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||||||
| type | Σ | 1..1 | CodeableConcept | Exception category Binding: ?? (example): The types of exceptions from the part or full value of financial obligations such as copays. | Σ | 1..1 | CodeableConcept | Exception category Binding: ?? (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 | Σ | 0..1 | Period | The effective period of the exception | |||||||||
| subrogation | 0..1 | boolean | Reimbursement to insurer | 0..1 | boolean | Reimbursement to insurer | |||||||||||
| contract | 0..* | Reference(Contract) | Contract details | 0..* | Reference(Contract) | Contract details | |||||||||||
| Documentation for this format | |||||||||||||||||