QI-Core Implementation Guide
4.1.0 - release

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## Resource Profile: QICoreCoverage

Defining URL: | http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-coverage
Version: | 4.1.0
Name: | QICoreCoverage
Status: | Draft as of 8/22/18
Definition: | Profile of Coverage for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.
Publisher: | http://www.hl7.org/Special/committees/cqi/index.cfm
Source Resource: | XML / JSON / Turtle

The official URL for this profile is:

    http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-coverage

Usage

See the patterns page for implementation and usage patterns.

    define "SDE Payer":
      [Coverage: type in "Payer"] Payer
        return {
          code: Payer.type,
          period: Payer.period
        }

### Examples

General Person Primary Coverage Example

### Formal Views of Profile Content

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

- Text Summary
- Differential Table
- Snapshot Table
- Snapshot Table (Must Support)
- All

This structure is derived from Coverage

Summary

Must-Support: 5 elements

Structures

This structure refers to these other structures:

- QICorePatient (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-patient)
- QICoreOrganization (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-organization)
- QICoreRelatedPerson (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-relatedperson)

This structure is derived from Coverage

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Coverage |  | 0..* | Coverage | Insurance or medical plan or a payment agreement
type | S | 0..1 | CodeableConcept | Coverage category such as medical or accident Binding: https://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 (required): Categories of types of health care payor entities as defined by the US Public Health Data Consortium SOP code system
policyHolder | S | 0..1 | Reference(QICorePatient | QICoreOrganization | QICoreRelatedPerson) | Owner of the policy
beneficiary | S | 1..1 | Reference(QICorePatient) | Plan beneficiary
period | S | 0..1 | Period | Coverage start and end dates
payor | S | 1..* | Reference(QICorePatient | QICoreOrganization | QICoreRelatedPerson) | Issuer of the policy
Documentation for this format

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Coverage |  | 0..* | Coverage | Insurance or medical plan or a payment agreement
id | Σ | 0..1 | string | Logical id of this artifact
meta | Σ | 0..1 | Meta | Metadata about the resource
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
language |  | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages: A human language.
text |  | 0..1 | Narrative | Text summary of the resource, for human interpretation
contained |  | 0..* | Resource | Contained, inline Resources
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | Σ | 0..* | Identifier | Business Identifier for the coverage
status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
type | S Σ | 0..1 | CodeableConcept | Coverage category such as medical or accident Binding: https://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 (required): Categories of types of health care payor entities as defined by the US Public Health Data Consortium SOP code system
policyHolder | S Σ | 0..1 | Reference(QICorePatient | QICoreOrganization | QICoreRelatedPerson) | Owner of the policy
subscriber | Σ | 0..1 | Reference(Patient | RelatedPerson) | Subscriber to the policy
subscriberId | Σ | 0..1 | string | ID assigned to the subscriber
beneficiary | S Σ | 1..1 | Reference(QICorePatient) | Plan beneficiary
dependent | Σ | 0..1 | string | Dependent number
relationship |  | 0..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).
period | S Σ | 0..1 | Period | Coverage start and end dates
payor | S Σ | 1..* | Reference(QICorePatient | QICoreOrganization | QICoreRelatedPerson) | Issuer of the policy
class |  | 0..* | BackboneElement | Additional coverage classifications
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
order | Σ | 0..1 | positiveInt | Relative order of the coverage
network | Σ | 0..1 | string | Insurer network
costToBeneficiary |  | 0..* | BackboneElement | Patient payments for services/products
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 0..1 | CodeableConcept | Cost category Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified.
value[x] | Σ | 1..1 |  | The amount or percentage due from the beneficiary
valueQuantity |  |  | Quantity(SimpleQuantity) |
valueMoney |  |  | Money |
exception |  | 0..* | BackboneElement | Exceptions for patient payments
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 1..1 | CodeableConcept | Exception category Binding: ExampleCoverageFinancialExceptionCodes (example): The types of exceptions from the part or full value of financial obligations such as copays.
period | Σ | 0..1 | Period | The effective period of the exception
subrogation |  | 0..1 | boolean | Reimbursement to insurer
contract |  | 0..* | Reference(Contract) | Contract details
Documentation for this format

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Coverage |  | 0..* | Coverage | Insurance or medical plan or a payment agreement
type | Σ | 0..1 | CodeableConcept | Coverage category such as medical or accident Binding: https://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 (required): Categories of types of health care payor entities as defined by the US Public Health Data Consortium SOP code system
policyHolder | Σ | 0..1 | Reference(QICorePatient | QICoreOrganization | QICoreRelatedPerson) | Owner of the policy
beneficiary | Σ | 1..1 | Reference(QICorePatient) | Plan beneficiary
period | Σ | 0..1 | Period | Coverage start and end dates
payor | Σ | 1..* | Reference(QICorePatient | QICoreOrganization | QICoreRelatedPerson) | Issuer of the policy
Documentation for this format

This structure is derived from Coverage

Summary

Must-Support: 5 elements

Structures

This structure refers to these other structures:

- QICorePatient (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-patient)
- QICoreOrganization (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-organization)
- QICoreRelatedPerson (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-relatedperson)

Differential View

This structure is derived from Coverage

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Coverage |  | 0..* | Coverage | Insurance or medical plan or a payment agreement
type | S | 0..1 | CodeableConcept | Coverage category such as medical or accident Binding: https://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 (required): Categories of types of health care payor entities as defined by the US Public Health Data Consortium SOP code system
policyHolder | S | 0..1 | Reference(QICorePatient | QICoreOrganization | QICoreRelatedPerson) | Owner of the policy
beneficiary | S | 1..1 | Reference(QICorePatient) | Plan beneficiary
period | S | 0..1 | Period | Coverage start and end dates
payor | S | 1..* | Reference(QICorePatient | QICoreOrganization | QICoreRelatedPerson) | Issuer of the policy
Documentation for this format

Snapshot View

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
Coverage |  | 0..* | Coverage | Insurance or medical plan or a payment agreement
id | Σ | 0..1 | string | Logical id of this artifact
meta | Σ | 0..1 | Meta | Metadata about the resource
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
language |  | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages: A human language.
text |  | 0..1 | Narrative | Text summary of the resource, for human interpretation
contained |  | 0..* | Resource | Contained, inline Resources
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | Σ | 0..* | Identifier | Business Identifier for the coverage
status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
type | S Σ | 0..1 | CodeableConcept | Coverage category such as medical or accident Binding: https://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 (required): Categories of types of health care payor entities as defined by the US Public Health Data Consortium SOP code system
policyHolder | S Σ | 0..1 | Reference(QICorePatient | QICoreOrganization | QICoreRelatedPerson) | Owner of the policy
subscriber | Σ | 0..1 | Reference(Patient | RelatedPerson) | Subscriber to the policy
subscriberId | Σ | 0..1 | string | ID assigned to the subscriber
beneficiary | S Σ | 1..1 | Reference(QICorePatient) | Plan beneficiary
dependent | Σ | 0..1 | string | Dependent number
relationship |  | 0..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).
period | S Σ | 0..1 | Period | Coverage start and end dates
payor | S Σ | 1..* | Reference(QICorePatient | QICoreOrganization | QICoreRelatedPerson) | Issuer of the policy
class |  | 0..* | BackboneElement | Additional coverage classifications
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
order | Σ | 0..1 | positiveInt | Relative order of the coverage
network | Σ | 0..1 | string | Insurer network
costToBeneficiary |  | 0..* | BackboneElement | Patient payments for services/products
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 0..1 | CodeableConcept | Cost category Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified.
value[x] | Σ | 1..1 |  | The amount or percentage due from the beneficiary
valueQuantity |  |  | Quantity(SimpleQuantity) |
valueMoney |  |  | Money |
exception |  | 0..* | BackboneElement | Exceptions for patient payments
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 1..1 | CodeableConcept | Exception category Binding: ExampleCoverageFinancialExceptionCodes (example): The types of exceptions from the part or full value of financial obligations such as copays.
period | Σ | 0..1 | Period | The effective period of the exception
subrogation |  | 0..1 | boolean | Reimbursement to insurer
contract |  | 0..* | Reference(Contract) | Contract details
Documentation for this format

Other representations of profile: CSV, Excel, Schematron

#### Terminology Bindings

Path | Conformance | ValueSet
Coverage.language | preferred | CommonLanguages Max Binding: AllLanguages
Coverage.status | required | FinancialResourceStatusCodes
Coverage.type | required | https://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591
Coverage.relationship | extensible | SubscriberRelationshipCodes
Coverage.class.type | extensible | CoverageClassCodes
Coverage.costToBeneficiary.type | extensible | CoverageCopayTypeCodes
Coverage.costToBeneficiary.exception.type | example | ExampleCoverageFinancialExceptionCodes

#### Constraints

Id | Grade | Path | Details | Requirements
dom-2 | error | Coverage | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() |
dom-3 | error | Coverage | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() |
dom-4 | error | Coverage | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() |
dom-5 | error | Coverage | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() |
dom-6 | Best Practice | Coverage | A resource should have narrative for robust management : text.`div`.exists() |
ele-1 | error | Coverage.meta | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Coverage.implicitRules | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Coverage.language | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Coverage.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Coverage.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | error | Coverage.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
ele-1 | error | Coverage.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | error | Coverage.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
ele-1 | error | Coverage.identifier | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Coverage.status | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Coverage.type | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Coverage.policyHolder | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Coverage.subscriber | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Coverage.subscriberId | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Coverage.beneficiary | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Coverage.dependent | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Coverage.relationship | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Coverage.period | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Coverage.payor | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Coverage.class | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Coverage.class.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | error | Coverage.class.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
ele-1 | error | Coverage.class.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | error | Coverage.class.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
ele-1 | error | Coverage.class.type | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Coverage.class.value | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Coverage.class.name | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Coverage.order | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Coverage.network | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Coverage.costToBeneficiary | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Coverage.costToBeneficiary.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | error | Coverage.costToBeneficiary.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
ele-1 | error | Coverage.costToBeneficiary.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | error | Coverage.costToBeneficiary.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
ele-1 | error | Coverage.costToBeneficiary.type | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Coverage.costToBeneficiary.value[x] | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Coverage.costToBeneficiary.exception | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Coverage.costToBeneficiary.exception.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | error | Coverage.costToBeneficiary.exception.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
ele-1 | error | Coverage.costToBeneficiary.exception.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | error | Coverage.costToBeneficiary.exception.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
ele-1 | error | Coverage.costToBeneficiary.exception.type | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Coverage.costToBeneficiary.exception.period | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Coverage.subrogation | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ele-1 | error | Coverage.contract | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |