| Left: | US Core Coverage Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-coverage) |
| Right: | Coverage - Principal Payer for Delivery (http://hl7.org/fhir/us/bfdr/StructureDefinition/Coverage-principal-payer-delivery) |
| Error | StructureDefinition.url | Values for url differ: 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-coverage' vs 'http://hl7.org/fhir/us/bfdr/StructureDefinition/Coverage-principal-payer-delivery' |
| Error | StructureDefinition.version | Values for version differ: '9.0.0' vs '2.0.0' |
| Information | StructureDefinition.name | Values for name differ: 'USCoreCoverageProfile' vs 'CoveragePrincipalPayerDelivery' |
| Information | StructureDefinition.title | Values for title differ: 'US Core Coverage Profile' vs 'Coverage - Principal Payer for Delivery' |
| Information | StructureDefinition.date | Values for date differ: '2023-10-17' vs '2026-11-09T21:59:25+00:00' |
| Information | StructureDefinition.publisher | Values for publisher differ: 'HL7 International / Cross-Group Projects' vs 'HL7 International / Public Health' |
| Information | StructureDefinition.short | Values for short differ: 'Member ID and other identifiers' vs 'Business Identifier for the coverage' |
| Warning | Coverage.identifier | Elements differ in definition for mustSupport: 'true' vs 'false' |
| 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' |
| Information | StructureDefinition.short | Values for short differ: 'Coverage category such as medical or accident' vs 'The value set contains the list of values used to indicate the principle source of payment for the labor and delivery (from codesystem https://nahdo.org/sopt).' |
| Warning | Coverage.type | Elements differ in definition for mustSupport: 'true' vs 'false' |
| Information | Coverage.type | Element minimum cardinalities differ: '0' vs '1' |
| Warning | Coverage.subscriberId | Elements differ in definition for mustSupport: 'true' vs 'false' |
| Warning | Coverage.beneficiary | Elements differ in definition for mustSupport: 'true' vs 'false' |
| 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' |
| Information | Coverage.relationship | Element minimum cardinalities differ: '1' vs '0' |
| Warning | Coverage.period | Elements differ in definition for mustSupport: 'true' vs 'false' |
| 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.' |
| Warning | Coverage.payor | Elements differ in definition for mustSupport: 'true' vs 'false' |
| Information | Coverage.payor | Element maximum cardinalities differ: '1' vs '2147483647' |
| Warning | Coverage.class | Elements differ in definition for mustSupport: 'true' vs 'false' |
| Name | Value | Comments | |
|---|---|---|---|
 abstract | false | ||
| baseDefinition | http://hl7.org/fhir/StructureDefinition/Coverage | ||
| copyright | |||
| date | 2023-10-17 | 2026-11-09T21:59:25+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. | This Coverage profile represents the principal payer for this delivery. |
|
| experimental | false |
| |
| fhirVersion | 4.0.1 | ||
| jurisdiction | |||
 jurisdiction[0] | urn:iso:std:iso:3166#US | ||
| kind | resource | ||
| name | USCoreCoverageProfile | CoveragePrincipalPayerDelivery |
|
| publisher | HL7 International / Cross-Group Projects | HL7 International / Public Health |
|
| purpose | |||
| status | active | ||
| title | US Core Coverage Profile | Coverage - Principal Payer for Delivery |
|
| type | Coverage | ||
| url | http://hl7.org/fhir/us/core/StructureDefinition/us-core-coverage | http://hl7.org/fhir/us/bfdr/StructureDefinition/Coverage-principal-payer-delivery |
|
| version | 9.0.0 | 2.0.0 |
|
| 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 Constraints: us-core-15 | 0..* | Coverage | Insurance or medical plan or a payment agreement | ||||||||||
 id | 0..1 | id | Logical id of this artifact | 0..1 | id | Logical id of this artifact | |||||||||||
| meta | 0..1 | Meta | Metadata about the resource | 0..1 | Meta | Metadata about the resource | |||||||||||
| implicitRules | 0..1 | uri | A set of rules under which this content was created | 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 This profile does not constrain the narrative in regard to content, language, or traceability to data elements | 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 | 0..* | Resource | Contained, inline Resources | |||||||||||
 extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
 modifierExtension | 0..* | Extension | Extensions that cannot be ignored | 0..* | Extension | Extensions that cannot be ignored | |||||||||||
| Slices for identifier | 0..* | Identifier | Member ID and other identifiers Slice: Unordered, Open by value:type Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | 0..* | Identifier | Business Identifier for the coverage |
| ||||||||||
| status | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ?? (required): A code specifying the state of the resource instance. | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ?? (required): A code specifying the state of the resource instance. |
| ||||||||||
| type | 0..1 | CodeableConcept | Coverage category such as medical or accident Binding: ?? (extensible): Centers for Disease Control and Prevention National Center for Health Statistics Source of Payment Codes | 1..1 | CodeableConcept | The value set contains the list of values used to indicate the principle source of payment for the labor and delivery (from codesystem https://nahdo.org/sopt). Binding: ?? (required): Birth and Fetal Death Financial Class (NCHS) |
| ||||||||||
| policyHolder | 0..1 | Reference(Patient | RelatedPerson | Organization) | Owner of the policy | 0..1 | Reference(Patient | RelatedPerson | Organization) | Owner of the policy | |||||||||||
| subscriber | 0..1 | Reference(Patient | RelatedPerson) | Subscriber to the policy | 0..1 | Reference(Patient | RelatedPerson) | Subscriber to the policy | |||||||||||
| subscriberId | C | 0..1 | string | ID assigned to the subscriber | 0..1 | string | ID assigned to the subscriber |
| |||||||||
| beneficiary | 1..1 | Reference(US Core Patient Profile) | Plan beneficiary | 1..1 | Reference(Patient) | Plan beneficiary |
| ||||||||||
| dependent | 0..1 | string | Dependent number | 0..1 | string | Dependent number | |||||||||||
| relationship | 1..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: ?? (extensible) | 0..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: ?? (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient). |
| ||||||||||
| period | 0..1 | Period | Coverage start and end dates | 0..1 | Period | Coverage start and end dates |
| ||||||||||
 payor | 1..1 | Reference(US Core Organization Profile | US Core Patient Profile | US Core RelatedPerson Profile) | Issuer of the policy | 1..* | Reference(Organization | Patient | RelatedPerson) | Issuer of the policy |
| ||||||||||
 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 | C | 0..1 | string | Literal reference, Relative, internal or absolute URL |
| ||||||||||||
| type | 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 | 0..1 | Identifier | Logical reference, when literal reference is not known |
| |||||||||||||
| display | 0..1 | string | Text alternative for the resource |
| |||||||||||||
| Slices for class | 0..* | BackboneElement | Additional coverage classifications Slice: Unordered, Open by value:type Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | 0..* | BackboneElement | Additional coverage classifications |
| ||||||||||
| 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 | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||||||||
| type | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: ?? (extensible): The policy classifications, eg. Group, Plan, Class, etc. | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: ?? (extensible): The policy classifications, eg. Group, Plan, Class, etc. | |||||||||||
| value | 1..1 | string | Value associated with the type | 1..1 | string | Value associated with the type | |||||||||||
| name | 0..1 | string | Human readable description of the type and value | 0..1 | string | Human readable description of the type and value | |||||||||||
| order | 0..1 | positiveInt | Relative order of the coverage | 0..1 | positiveInt | Relative order of the coverage | |||||||||||
| network | 0..1 | string | Insurer network | 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 | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||||||||
| type | 0..1 | CodeableConcept | Cost category Binding: ?? (extensible): The types of services to which patient copayments are specified. | 0..1 | CodeableConcept | Cost category Binding: ?? (extensible): The types of services to which patient copayments are specified. | |||||||||||
| value[x] | 1..1 | ??  , Money | The amount or percentage due from the beneficiary | 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 | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||||||||
| type | 1..1 | CodeableConcept | Exception category Binding: ?? (example): The types of exceptions from the part or full value of financial obligations such as copays. | 1..1 | CodeableConcept | Exception category Binding: ?? (example): The types of exceptions from the part or full value of financial obligations such as copays. | |||||||||||
| period | 0..1 | Period | The effective period of the exception | 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 | |||||||||||||||||