Profile Comparison between http://hl7.org/fhir/us/core/StructureDefinition/us-core-coverage vs http://hl7.org/fhir/us/specialty-rx/StructureDefinition/specialty-rx-coverage

Messages

Metadata

Name	Value		Comments
abstract	false
baseDefinition	http://hl7.org/fhir/StructureDefinition/Coverage
copyright	Used by permission of HL7 International, all rights reserved Creative Commons License		Removed the item 'Used by permission of HL7 International, all rights reserved Creative Commons License'
date	2022-09-24	2023-04-30T00:00:00-05:00	Values Differ
description	The US Core Coverage Profile is based upon the core FHIR Coverage Resource and implements the US Core Data for Interoperability (USCDI) v3 Health Insurance Information requirements. To promote interoperability and adoption through common implementation, this profile sets minimum expectations for the Coverage resource to record, search, and fetch the "data related to an individual's insurance coverage for health care". It identifies which core elements, extensions, vocabularies, and value sets **SHALL** be present in the resource and constrains the way the elements are used when using this profile. It provides the floor for standards development for specific use cases.	This profile constrains the Coverage resource for carrying insurance coverage information in the specialty medication enrollment process	Values Differ
experimental	false
fhirVersion	4.0.1
jurisdiction
jurisdiction[0]	urn:iso:std:iso:3166#US
kind	resource
name	USCoreCoverageProfile	SpecialtyRxCoverage	Values Differ
publisher	HL7 International - Cross-Group Projects	HL7 International - Pharmacy	Values Differ
purpose
status	active
title	US Core Coverage Profile	Specialty Rx Coverage	Values Differ
type	Coverage
url	http://hl7.org/fhir/us/core/StructureDefinition/us-core-coverage	http://hl7.org/fhir/us/specialty-rx/StructureDefinition/specialty-rx-coverage	Values Differ
version	6.0.0	2.1.0	Values Differ

Structure

Name	L Flags	L Card.	L Type	L Description & Constraints	R Flags	R Card.	L Type	L 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		0..*	Coverage	Insurance or medical plan or a payment agreement
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. Additional Bindings Purpose ?? Max Binding		0..1	code	Language of the resource content Binding: ?? (preferred): A human language. Additional Bindings Purpose ?? Max Binding
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		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	SΣ	0..*	Identifier	(USCDI) Member ID and other identifiers Slice: Unordered, Open by pattern:type	SΣ	0..*	Identifier	Member ID and other identifiers Slice: Unordered, Open by pattern:type	Elements differ in short: '(USCDI) Member ID and other identifiers' vs 'Member ID and other identifiers'
status	?!SΣ	1..1	code	(USCDI) 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.	Elements differ in short: '(USCDI) active | cancelled | draft | entered-in-error' vs 'active | cancelled | draft | entered-in-error' Elements differ in comments: '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.' Elements differ in definition for mustSupport: 'true' vs 'false'
type	SΣ	0..1	CodeableConcept	(USCDI) 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.	Elements differ in short: '(USCDI) Coverage category such as medical or accident' vs 'Coverage category such as medical or accident' Elements differ in definition for mustSupport: 'true' vs 'false' Elements differ in binding.description: 'US Public Health Data Consortium Source of Payment Codes' vs '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(Patient | RelatedPerson | Organization)	Owner of the policy
subscriber	Σ	0..1	Reference(Patient | RelatedPerson)	Subscriber to the policy	Σ	0..1	Reference(Patient | RelatedPerson)	Subscriber to the policy
subscriberId	SΣC	0..1	string	(USCDI) ID assigned to the subscriber	SΣ	0..1	string	ID assigned to the subscriber by the health plan	Elements differ in short: '(USCDI) ID assigned to the subscriber' vs 'ID assigned to the subscriber by the health plan'
beneficiary	SΣ	1..1	Reference(US Core Patient Profile)	(USCDI) Plan beneficiary	Σ	1..1	Reference(Patient)	Plan beneficiary	Elements differ in short: '(USCDI) Plan beneficiary' vs 'Plan beneficiary' Elements differ in definition for mustSupport: 'true' vs 'false'
dependent	Σ	0..1	string	Dependent number	Σ	0..1	string	Dependent number
relationship	S	1..1	CodeableConcept	(USCDI) 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).	Elements differ in short: '(USCDI) Beneficiary relationship to the subscriber' vs 'Beneficiary relationship to the subscriber' Elements differ in comments: '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.' Elements differ in definition for mustSupport: 'true' vs 'false' Element minimum cardinalities differ: '1' vs '0'
period	SΣ	0..1	Period	(USCDI) Coverage start and end dates	Σ	0..1	Period	Coverage start and end dates	Elements differ in short: '(USCDI) Coverage start and end dates' vs 'Coverage start and end dates' Elements differ in definition for mustSupport: 'true' vs 'false'
payor	SΣ	1..1	Reference(US Core Organization Profile S | US Core Patient Profile | US Core RelatedPerson Profile)	(USCDI) Issuer of the policy	SΣ	1..*	Reference(Organization | Patient | RelatedPerson)	Issuer of the policy	Elements differ in short: '(USCDI) Issuer of the policy' vs 'Issuer of the policy' Elements differ in comments: '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.' Element maximum cardinalities differ: '1' vs '2147483647'
Slices for class	S	0..*	BackboneElement	(USCDI) Additional coverage classifications Slice: Unordered, Open by pattern:type	S	0..*	BackboneElement	Pharmacy coverage identifiers Slice: Unordered, Open by value:type	Elements differ in short: '(USCDI) Additional coverage classifications' vs 'Pharmacy coverage identifiers' Elements differ in definition: 'A suite of underwriter specific classifiers.' vs 'Identifiers related to a patient's pharmacy coverage. IIN (BIN) number, Processor Control Number (PCN), pharmacy benefit Group ID and patient's PBM Member ID.'
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): Coverage Class Codes	Elements differ in description: 'The policy classifications, eg. Group, Plan, Class, etc.' vs 'Coverage Class Codes' Elements differ in description: 'The policy classifications, eg. Group, Plan, Class, etc.' vs 'Coverage Class Codes'
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	0..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: ?? (extensible): The types of services to which patient copayments are specified.
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