HL7® FHIR® New Zealand Base Implementation Guide
3.1.0 - Draft

HL7® FHIR® New Zealand Base Implementation Guide, published by HL7 New Zealand. This guide is not an authorized publication; it is the continuous build for version 3.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7NZ/nzbase/ and changes regularly. See the Directory of published versions

Resource Profile: NzCoverage - Detailed Descriptions

Draft as of 2025-02-28

Definitions for the NzCoverage resource profile.

Guidance on how to interpret the contents of this table can be found here

0. Coverage
Definition

Financial instrument which may be used to reimburse or pay for health care products and services. Includes both insurance and self-payment.

ShortInsurance or medical plan or a payment agreement
Comments

The Coverage resource contains the insurance card level information, which is customary to provide on claims and other communications between providers and insurers.

Control0..*
Is Modifierfalse
Summaryfalse
Invariantsdom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty())
dom-3: 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: 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: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty())
dom-6: A resource should have narrative for robust management (text.`div`.exists())
2. Coverage.implicitRules
Definition

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

ShortA set of rules under which this content was created
Comments

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

Control0..1
Typeuri
Is Modifiertrue because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
4. Coverage.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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 is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Summaryfalse
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
6. Coverage.status
Definition

The status of the resource instance.

Shortactive | cancelled | draft | entered-in-error
Comments

This element is labeled as a modifier because the status contains the code entered-in-error that marks the coverage as not currently valid.

Control1..1
BindingThe codes SHALL be taken from FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|4.0.1
(required to http://hl7.org/fhir/ValueSet/fm-status|4.0.1)

A code specifying the state of the resource instance.

Typecode
Is Modifiertrue because This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Requirements

Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
8. Coverage.type
Definition

The type of coverage: social program, medical plan, accident coverage (workers compensation, auto), group health or payment by an individual or organization.

ShortCoverage category such as medical or accident
Control0..1
BindingUnless not suitable, these codes SHALL be taken from The codes SHOULD be taken from Coverage Typehttp://hl7.org/fhir/ValueSet/coverage-type
(extensible to https://nzhts.digital.health.nz/fhir/ValueSet/coverage-type-code)
TypeCodeableConcept
Is Modifierfalse
Summarytrue
Requirements

The order of application of coverages is dependent on the types of coverage.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
10. Coverage.beneficiary
Definition

The party who benefits from the insurance coverage; the patient when products and/or services are provided.

ShortPlan beneficiary
Control1..1
TypeReference(Patient)
Is Modifierfalse
Summarytrue
Requirements

This is the party who receives treatment for which the costs are reimbursed under the coverage.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
12. Coverage.payor
Definition

The program or plan underwriter or payor including both insurance and non-insurance agreements, such as patient-pay agreements.

ShortIssuer of the policy
Comments

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.

Control1..*
TypeReference(Organization, Patient, RelatedPerson)
Is Modifierfalse
Summarytrue
Requirements

Need to identify the issuer to target for claim processing and for coordination of benefit processing.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))