CARIN Consumer Directed Payer Data Exchange
0.1.3 - STU1

CARIN Consumer Directed Payer Data Exchange, published by HL7 Financial Management Working Group. This is not an authorized publication; it is the continuous build for version 0.1.3). This version is based on the current content of https://github.com/HL7/carin-bb/ and changes regularly. See the Directory of published versions

Resource Profile: C4BBCoverage

Data that reflect a payer’s coverage that was effective as of the date of service or the date of admission of the claim will be added to the Coverage Profile overview.

The official URL for this profile is:

http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-Coverage

Formal Views of Profile Content

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

This structure is derived from Coverage

Summary

Mandatory: 4 elements (2 nested mandatory elements)
Must-Support: 15 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Coverage.class is sliced based on the value of pattern:type

This structure is derived from Coverage

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..*CoverageInsurance or medical plan or a payment agreement
... meta
.... lastUpdated S1..1instantWhen the resource version last changed
.... profile S1..*canonical(StructureDefinition)Profiles this resource claims to conform to
... identifier S0..*IdentifierBusiness Identifier for the coverage
... status S1..1codeIdentfies the status of the coverage information (default: active) (133)
... subscriber 0..1Reference(C4BB Patient)Subscriber to the policy
... subscriberId S1..1stringThe identifier assigned by the Payer on the subscriber's ID card. (132)
... beneficiary S1..1Reference(C4BB Patient)Plan beneficiary
... relationship S1..1CodeableConceptRelationship of the member to the person insured (subscriber). (72)
Binding: SubscriberRelationshipCodes (required)
... period S0..1PeriodDate that the contract was terminated or coverage changed (75)
... payor S1..1Reference(C4BB Organization)Issuer of the Policy (2)
... class S2..*(Slice Definition)Additional coverage classifications
Slice: Unordered, Open by pattern:type
.... class:group 1..1BackboneElementAdditional coverage classifications
..... type 1..1CodeableConceptType of class such as 'group' or 'plan'
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: group
..... value S1..1stringEmployer account identifier (134)
..... name S0..1stringName of the Employer Account (135)
.... class:plan 1..1BackboneElementAdditional coverage classifications
..... type 1..1CodeableConceptType of class such as 'group' or 'plan'
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: plan
..... value S1..1stringBusiness concept used by a health plan to describe its benefit offerings (154)
..... name S0..1stringName of the health plan benefit offering assigned to the Plan Identfier (155)

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
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ0..1idVersion specific identifier
.... lastUpdated SΣ1..1instantWhen the resource version last changed
.... source Σ0..1uriIdentifies where the resource comes from
.... profile SΣ1..*canonical(StructureDefinition)Profiles this resource claims to conform to
.... security Σ0..*CodingSecurity Labels applied to this resource
Binding: All Security Labels (extensible)
.... tag Σ0..*CodingTags applied to this resource
Binding: CommonTags (example)
... 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 SΣ0..*IdentifierBusiness Identifier for the coverage
... status ?!SΣ1..1codeIdentfies the status of the coverage information (default: active) (133)
Binding: FinancialResourceStatusCodes (required)
... type SΣ0..1CodeableConceptIdentifies if the coverage is PPO, HMO, POS, etc. (3)
Binding: CoverageTypeAndSelf-PayCodes (preferred)
... policyHolder Σ0..1Reference(Patient | RelatedPerson | Organization)Owner of the policy
... subscriber Σ0..1Reference(C4BB Patient)Subscriber to the policy
... subscriberId SΣ1..1stringThe identifier assigned by the Payer on the subscriber's ID card. (132)
... beneficiary SΣ1..1Reference(C4BB Patient)Plan beneficiary
... dependent Σ0..1stringDependent number
... relationship S1..1CodeableConceptRelationship of the member to the person insured (subscriber). (72)
Binding: SubscriberRelationshipCodes (required)
... period SΣ0..1PeriodDate that the contract was terminated or coverage changed (75)
... payor SΣ1..1Reference(C4BB Organization)Issuer of the Policy (2)
... class S2..*(Slice Definition)Additional coverage classifications
Slice: Unordered, Open by pattern:type
.... class:All Slices Content/Rules for all slices
..... 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: CoverageClassCodes (extensible)
..... value Σ1..1stringValue associated with the type
..... name Σ0..1stringHuman readable description of the type and value
.... class:group 1..1BackboneElementAdditional 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: CoverageClassCodes (extensible)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: group
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... value SΣ1..1stringEmployer account identifier (134)
..... name SΣ0..1stringName of the Employer Account (135)
.... class:plan 1..1BackboneElementAdditional 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: CoverageClassCodes (extensible)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: plan
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... value SΣ1..1stringBusiness concept used by a health plan to describe its benefit offerings (154)
..... name SΣ0..1stringName of the health plan benefit offering assigned to the Plan Identfier (155)
... 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)
.... 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)
..... period Σ0..1PeriodThe effective period of the exception
... subrogation 0..1booleanReimbursement to insurer
... contract 0..*Reference(Contract)Contract details

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..*CoverageInsurance or medical plan or a payment agreement
... meta Σ0..1MetaMetadata about the resource
.... lastUpdated Σ1..1instantWhen the resource version last changed
.... profile Σ1..*canonical(StructureDefinition)Profiles this resource claims to conform to
... identifier Σ0..*IdentifierBusiness Identifier for the coverage
... status ?!Σ1..1codeIdentfies the status of the coverage information (default: active) (133)
Binding: FinancialResourceStatusCodes (required)
... subscriberId Σ1..1stringThe identifier assigned by the Payer on the subscriber's ID card. (132)
... beneficiary Σ1..1Reference(C4BB Patient)Plan beneficiary
... relationship 1..1CodeableConceptRelationship of the member to the person insured (subscriber). (72)
Binding: SubscriberRelationshipCodes (required)
... period Σ0..1PeriodDate that the contract was terminated or coverage changed (75)
... payor Σ1..1Reference(C4BB Organization)Issuer of the Policy (2)
... class 2..*(Slice Definition)Additional coverage classifications
Slice: Unordered, Open by pattern:type
.... class:group 1..1BackboneElementAdditional coverage classifications
..... value Σ1..1stringEmployer account identifier (134)
..... name Σ0..1stringName of the Employer Account (135)
.... class:plan 1..1BackboneElementAdditional coverage classifications
..... value Σ1..1stringBusiness concept used by a health plan to describe its benefit offerings (154)
..... name Σ0..1stringName of the health plan benefit offering assigned to the Plan Identfier (155)

doco Documentation for this format

This structure is derived from Coverage

Summary

Mandatory: 4 elements (2 nested mandatory elements)
Must-Support: 15 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Coverage.class is sliced based on the value of pattern:type

Differential View

This structure is derived from Coverage

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..*CoverageInsurance or medical plan or a payment agreement
... meta
.... lastUpdated S1..1instantWhen the resource version last changed
.... profile S1..*canonical(StructureDefinition)Profiles this resource claims to conform to
... identifier S0..*IdentifierBusiness Identifier for the coverage
... status S1..1codeIdentfies the status of the coverage information (default: active) (133)
... subscriber 0..1Reference(C4BB Patient)Subscriber to the policy
... subscriberId S1..1stringThe identifier assigned by the Payer on the subscriber's ID card. (132)
... beneficiary S1..1Reference(C4BB Patient)Plan beneficiary
... relationship S1..1CodeableConceptRelationship of the member to the person insured (subscriber). (72)
Binding: SubscriberRelationshipCodes (required)
... period S0..1PeriodDate that the contract was terminated or coverage changed (75)
... payor S1..1Reference(C4BB Organization)Issuer of the Policy (2)
... class S2..*(Slice Definition)Additional coverage classifications
Slice: Unordered, Open by pattern:type
.... class:group 1..1BackboneElementAdditional coverage classifications
..... type 1..1CodeableConceptType of class such as 'group' or 'plan'
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: group
..... value S1..1stringEmployer account identifier (134)
..... name S0..1stringName of the Employer Account (135)
.... class:plan 1..1BackboneElementAdditional coverage classifications
..... type 1..1CodeableConceptType of class such as 'group' or 'plan'
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: plan
..... value S1..1stringBusiness concept used by a health plan to describe its benefit offerings (154)
..... name S0..1stringName of the health plan benefit offering assigned to the Plan Identfier (155)

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
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ0..1idVersion specific identifier
.... lastUpdated SΣ1..1instantWhen the resource version last changed
.... source Σ0..1uriIdentifies where the resource comes from
.... profile SΣ1..*canonical(StructureDefinition)Profiles this resource claims to conform to
.... security Σ0..*CodingSecurity Labels applied to this resource
Binding: All Security Labels (extensible)
.... tag Σ0..*CodingTags applied to this resource
Binding: CommonTags (example)
... 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 SΣ0..*IdentifierBusiness Identifier for the coverage
... status ?!SΣ1..1codeIdentfies the status of the coverage information (default: active) (133)
Binding: FinancialResourceStatusCodes (required)
... type SΣ0..1CodeableConceptIdentifies if the coverage is PPO, HMO, POS, etc. (3)
Binding: CoverageTypeAndSelf-PayCodes (preferred)
... policyHolder Σ0..1Reference(Patient | RelatedPerson | Organization)Owner of the policy
... subscriber Σ0..1Reference(C4BB Patient)Subscriber to the policy
... subscriberId SΣ1..1stringThe identifier assigned by the Payer on the subscriber's ID card. (132)
... beneficiary SΣ1..1Reference(C4BB Patient)Plan beneficiary
... dependent Σ0..1stringDependent number
... relationship S1..1CodeableConceptRelationship of the member to the person insured (subscriber). (72)
Binding: SubscriberRelationshipCodes (required)
... period SΣ0..1PeriodDate that the contract was terminated or coverage changed (75)
... payor SΣ1..1Reference(C4BB Organization)Issuer of the Policy (2)
... class S2..*(Slice Definition)Additional coverage classifications
Slice: Unordered, Open by pattern:type
.... class:All Slices Content/Rules for all slices
..... 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: CoverageClassCodes (extensible)
..... value Σ1..1stringValue associated with the type
..... name Σ0..1stringHuman readable description of the type and value
.... class:group 1..1BackboneElementAdditional 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: CoverageClassCodes (extensible)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: group
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... value SΣ1..1stringEmployer account identifier (134)
..... name SΣ0..1stringName of the Employer Account (135)
.... class:plan 1..1BackboneElementAdditional 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: CoverageClassCodes (extensible)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: plan
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... value SΣ1..1stringBusiness concept used by a health plan to describe its benefit offerings (154)
..... name SΣ0..1stringName of the health plan benefit offering assigned to the Plan Identfier (155)
... 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)
.... 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)
..... 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: Schematron

Terminology Bindings

PathConformanceValueSet / Code
Coverage.meta.securityextensibleAll Security Labels
Coverage.meta.tagexampleCommonTags
Coverage.languagepreferredCommonLanguages
Max Binding: AllLanguages
Coverage.statusrequiredFinancialResourceStatusCodes
Coverage.typepreferredCoverageTypeAndSelf-PayCodes
Coverage.relationshiprequiredSubscriberRelationshipCodes
Coverage.class.typeextensibleCoverageClassCodes
Coverage.class:group.typeextensiblePattern: group
Coverage.class:plan.typeextensiblePattern: plan
Coverage.costToBeneficiary.typeextensibleCoverageCopayTypeCodes
Coverage.costToBeneficiary.exception.typeexampleExampleCoverageFinancialExceptionCodes