HL7® FHIR® New Zealand Base Implementation Guide
1.1.0 - CI Build

HL7® FHIR® New Zealand Base Implementation Guide, published by HL7 New Zealand. This is not an authorized publication; it is the continuous build for version 1.1.0). 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: Coverage resource for use in NZ

Official URL: http://hl7.org.nz/fhir/StructureDefinition/NzCoverage Version: 1.1.0
Standards status: Trial-use Realm: New Zealand flag Computable Name: NzCoverage

Coverage resource for use in NZ

Profile on Coverage for NZ use. Primarily changing the type valueset

Usage:

Formal Views of Profile Content

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

This structure is derived from Coverage

Summary

This structure is derived from Coverage

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..*CoverageInsurance or medical plan or a payment agreement
... type 0..1CodeableConceptCoverage category such as medical or accident
Binding: CoverageType type VS (preferred)
... class
.... type 1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: https://nzhts.digital.health.nz/fhir/ValueSet/coverage-category-code (extensible)

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..*CoverageInsurance or medical plan or a payment agreement
... id Σ0..1stringLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness Identifier for the coverage
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... type Σ0..1CodeableConceptCoverage category such as medical or accident
Binding: CoverageType type VS (preferred)
... policyHolder Σ0..1Reference(Patient | RelatedPerson | Organization)Owner of the policy
... subscriber Σ0..1Reference(Patient | RelatedPerson)Subscriber to the policy
... subscriberId Σ0..1stringID assigned to the subscriber
... beneficiary Σ1..1Reference(Patient)Plan beneficiary
... dependent Σ0..1stringDependent number
... relationship 0..1CodeableConceptBeneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).

... period Σ0..1PeriodCoverage start and end dates
... payor Σ1..*Reference(Organization | Patient | RelatedPerson)Issuer of the policy
... class 0..*BackboneElementAdditional coverage classifications
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type Σ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: https://nzhts.digital.health.nz/fhir/ValueSet/coverage-category-code (extensible)
.... value Σ1..1stringValue associated with the type
.... name Σ0..1stringHuman readable description of the type and value
... order Σ0..1positiveIntRelative order of the coverage
... network Σ0..1stringInsurer network
... costToBeneficiary 0..*BackboneElementPatient payments for services/products
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type Σ0..1CodeableConceptCost category
Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified.

.... value[x] Σ1..1The amount or percentage due from the beneficiary
..... valueQuantityQuantity(SimpleQuantity)
..... valueMoneyMoney
.... exception 0..*BackboneElementExceptions for patient payments
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type Σ1..1CodeableConceptException category
Binding: ExampleCoverageFinancialExceptionCodes (example): The types of exceptions from the part or full value of financial obligations such as copays.

..... period Σ0..1PeriodThe effective period of the exception
... subrogation 0..1booleanReimbursement to insurer
... contract 0..*Reference(Contract)Contract details

doco Documentation for this format

This structure is derived from Coverage

Summary

Differential View

This structure is derived from Coverage

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..*CoverageInsurance or medical plan or a payment agreement
... type 0..1CodeableConceptCoverage category such as medical or accident
Binding: CoverageType type VS (preferred)
... class
.... type 1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: https://nzhts.digital.health.nz/fhir/ValueSet/coverage-category-code (extensible)

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..*CoverageInsurance or medical plan or a payment agreement
... id Σ0..1stringLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness Identifier for the coverage
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... type Σ0..1CodeableConceptCoverage category such as medical or accident
Binding: CoverageType type VS (preferred)
... policyHolder Σ0..1Reference(Patient | RelatedPerson | Organization)Owner of the policy
... subscriber Σ0..1Reference(Patient | RelatedPerson)Subscriber to the policy
... subscriberId Σ0..1stringID assigned to the subscriber
... beneficiary Σ1..1Reference(Patient)Plan beneficiary
... dependent Σ0..1stringDependent number
... relationship 0..1CodeableConceptBeneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).

... period Σ0..1PeriodCoverage start and end dates
... payor Σ1..*Reference(Organization | Patient | RelatedPerson)Issuer of the policy
... class 0..*BackboneElementAdditional coverage classifications
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type Σ1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: https://nzhts.digital.health.nz/fhir/ValueSet/coverage-category-code (extensible)
.... value Σ1..1stringValue associated with the type
.... name Σ0..1stringHuman readable description of the type and value
... order Σ0..1positiveIntRelative order of the coverage
... network Σ0..1stringInsurer network
... costToBeneficiary 0..*BackboneElementPatient payments for services/products
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type Σ0..1CodeableConceptCost category
Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified.

.... value[x] Σ1..1The amount or percentage due from the beneficiary
..... valueQuantityQuantity(SimpleQuantity)
..... valueMoneyMoney
.... exception 0..*BackboneElementExceptions for patient payments
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type Σ1..1CodeableConceptException category
Binding: ExampleCoverageFinancialExceptionCodes (example): The types of exceptions from the part or full value of financial obligations such as copays.

..... period Σ0..1PeriodThe effective period of the exception
... subrogation 0..1booleanReimbursement to insurer
... contract 0..*Reference(Contract)Contract details

doco Documentation for this format

 

Other representations of profile: CSV, Excel, Schematron

Terminology Bindings

PathConformanceValueSet
Coverage.languagepreferredCommonLanguages
Max Binding: AllLanguages
Coverage.statusrequiredFinancialResourceStatusCodes
Coverage.typepreferredCoverageType
Coverage.relationshipextensibleSubscriberRelationshipCodes
Coverage.class.typeextensiblehttps://nzhts.digital.health.nz/fhir/ValueSet/coverage-category-code
Coverage.costToBeneficiary.typeextensibleCoverageCopayTypeCodes
Coverage.costToBeneficiary.exception.typeexampleExampleCoverageFinancialExceptionCodes