CARIN Consumer Directed Payer Data Exchange
0.3.1 - 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 0.3.1). 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: CARINBBCoverage

CARIN Blue Button Coverage Profile.

The official URL for this profile is:

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

Introductory material for CARINBB-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: 10 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(CARIN BB Patient)Subscriber to the policy
... subscriberId S1..1stringIdentifies the subscriber identification (132 )
... beneficiary S1..1Reference(CARIN BB Patient)Plan beneficiary
... relationship S1..1CodeableConceptRelationship of the member to the person insured (subscriber). (72 )
Binding: SubscriberRelationshipCodes (required)
... period 0..1PeriodDate that the contract was terminated or coverage changed (75 )
... payor S1..1Reference(CARIN BB 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
..... name S0..1stringHuman readable description of the type and value
.... 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 1..1stringEmployer account identifier (134 )
..... name 0..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 1..1stringBusiness concept used by a health plan to describe its benefit offerings (154 )
..... name 0..1stringName of the health plan benefit offering assigned to the Plan Identfier (155 )

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage I0..*CoverageInsurance or medical plan or a payment agreement
... id Σ0..1stringLogical id of this artifact
... meta ΣI0..1MetaMetadata about the resource
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId ΣI0..1idVersion specific identifier
.... lastUpdated SΣI1..1instantWhen the resource version last changed
.... source ΣI0..1uriIdentifies where the resource comes from
.... profile SΣI1..*canonical(StructureDefinition)Profiles this resource claims to conform to
.... security ΣI0..*CodingSecurity Labels applied to this resource
Binding: All Security Labels (extensible)
.... tag ΣI0..*CodingTags applied to this resource
Binding: CommonTags (example)
... implicitRules ?!ΣI0..1uriA set of rules under which this content was created
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension I0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!I0..*ExtensionExtensions that cannot be ignored
... identifier SΣI0..*IdentifierBusiness Identifier for the coverage
... status ?!SΣI1..1codeIdentfies the status of the coverage information (default: active) (133 )
Binding: FinancialResourceStatusCodes (required)
... type ΣI0..1CodeableConceptIdentifies if the coverage is PPO, HMO, POS, etc. (3 )
Binding: CoverageTypeAndSelf-PayCodes (preferred)
... policyHolder ΣI0..1Reference(Patient | RelatedPerson | Organization)Owner of the policy
... subscriber ΣI0..1Reference(CARIN BB Patient)Subscriber to the policy
... subscriberId SΣI1..1stringIdentifies the subscriber identification (132 )
... beneficiary SΣI1..1Reference(CARIN BB Patient)Plan beneficiary
... dependent ΣI0..1stringDependent number
... relationship SI1..1CodeableConceptRelationship of the member to the person insured (subscriber). (72 )
Binding: SubscriberRelationshipCodes (required)
... period ΣI0..1PeriodDate that the contract was terminated or coverage changed (75 )
... payor SΣI1..1Reference(CARIN BB Organization)Issuer of the Policy (2 )
... class SI2..*(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 I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type ΣI1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible)
..... value ΣI1..1stringValue associated with the type
..... name SΣI0..1stringHuman readable description of the type and value
.... class:group I1..1BackboneElementAdditional coverage classifications
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type ΣI1..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 ΣI1..1stringEmployer account identifier (134 )
..... name ΣI0..1stringName of the Employer Account (135 )
.... class:plan I1..1BackboneElementAdditional coverage classifications
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type ΣI1..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 ΣI1..1stringBusiness concept used by a health plan to describe its benefit offerings (154 )
..... name ΣI0..1stringName of the health plan benefit offering assigned to the Plan Identfier (155 )
... order ΣI0..1positiveIntRelative order of the coverage
... network ΣI0..1stringInsurer network
... costToBeneficiary I0..*BackboneElementPatient payments for services/products
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type ΣI0..1CodeableConceptCost category
Binding: CoverageCopayTypeCodes (extensible)
.... value[x] ΣI1..1The amount or percentage due from the beneficiary
..... valueQuantityQuantity(SimpleQuantity)
..... valueMoneyMoney
.... exception I0..*BackboneElementExceptions for patient payments
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type ΣI1..1CodeableConceptException category
Binding: ExampleCoverageFinancialExceptionCodes (example)
..... period ΣI0..1PeriodThe effective period of the exception
... subrogation I0..1booleanReimbursement to insurer
... contract I0..*Reference(Contract)Contract details

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage I0..*CoverageInsurance or medical plan or a payment agreement
... meta ΣI0..1MetaMetadata about the resource
.... lastUpdated ΣI1..1instantWhen the resource version last changed
.... profile ΣI1..*canonical(StructureDefinition)Profiles this resource claims to conform to
... identifier ΣI0..*IdentifierBusiness Identifier for the coverage
... status ?!ΣI1..1codeIdentfies the status of the coverage information (default: active) (133 )
Binding: FinancialResourceStatusCodes (required)
... beneficiary ΣI1..1Reference(CARIN BB Patient)Plan beneficiary
... relationship I1..1CodeableConceptRelationship of the member to the person insured (subscriber). (72 )
Binding: SubscriberRelationshipCodes (required)
... payor ΣI1..1Reference(CARIN BB Organization)Issuer of the Policy (2 )
... class I2..*(Slice Definition)Additional coverage classifications
Slice: Unordered, Open by pattern:type
.... class:All Slices Content/Rules for all slices
..... name ΣI0..1stringHuman readable description of the type and value

doco Documentation for this format

This structure is derived from Coverage

Summary

Mandatory: 4 elements (2 nested mandatory elements)
Must-Support: 10 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(CARIN BB Patient)Subscriber to the policy
... subscriberId S1..1stringIdentifies the subscriber identification (132 )
... beneficiary S1..1Reference(CARIN BB Patient)Plan beneficiary
... relationship S1..1CodeableConceptRelationship of the member to the person insured (subscriber). (72 )
Binding: SubscriberRelationshipCodes (required)
... period 0..1PeriodDate that the contract was terminated or coverage changed (75 )
... payor S1..1Reference(CARIN BB 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
..... name S0..1stringHuman readable description of the type and value
.... 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 1..1stringEmployer account identifier (134 )
..... name 0..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 1..1stringBusiness concept used by a health plan to describe its benefit offerings (154 )
..... name 0..1stringName of the health plan benefit offering assigned to the Plan Identfier (155 )

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage I0..*CoverageInsurance or medical plan or a payment agreement
... id Σ0..1stringLogical id of this artifact
... meta ΣI0..1MetaMetadata about the resource
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId ΣI0..1idVersion specific identifier
.... lastUpdated SΣI1..1instantWhen the resource version last changed
.... source ΣI0..1uriIdentifies where the resource comes from
.... profile SΣI1..*canonical(StructureDefinition)Profiles this resource claims to conform to
.... security ΣI0..*CodingSecurity Labels applied to this resource
Binding: All Security Labels (extensible)
.... tag ΣI0..*CodingTags applied to this resource
Binding: CommonTags (example)
... implicitRules ?!ΣI0..1uriA set of rules under which this content was created
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension I0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!I0..*ExtensionExtensions that cannot be ignored
... identifier SΣI0..*IdentifierBusiness Identifier for the coverage
... status ?!SΣI1..1codeIdentfies the status of the coverage information (default: active) (133 )
Binding: FinancialResourceStatusCodes (required)
... type ΣI0..1CodeableConceptIdentifies if the coverage is PPO, HMO, POS, etc. (3 )
Binding: CoverageTypeAndSelf-PayCodes (preferred)
... policyHolder ΣI0..1Reference(Patient | RelatedPerson | Organization)Owner of the policy
... subscriber ΣI0..1Reference(CARIN BB Patient)Subscriber to the policy
... subscriberId SΣI1..1stringIdentifies the subscriber identification (132 )
... beneficiary SΣI1..1Reference(CARIN BB Patient)Plan beneficiary
... dependent ΣI0..1stringDependent number
... relationship SI1..1CodeableConceptRelationship of the member to the person insured (subscriber). (72 )
Binding: SubscriberRelationshipCodes (required)
... period ΣI0..1PeriodDate that the contract was terminated or coverage changed (75 )
... payor SΣI1..1Reference(CARIN BB Organization)Issuer of the Policy (2 )
... class SI2..*(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 I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type ΣI1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible)
..... value ΣI1..1stringValue associated with the type
..... name SΣI0..1stringHuman readable description of the type and value
.... class:group I1..1BackboneElementAdditional coverage classifications
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type ΣI1..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 ΣI1..1stringEmployer account identifier (134 )
..... name ΣI0..1stringName of the Employer Account (135 )
.... class:plan I1..1BackboneElementAdditional coverage classifications
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type ΣI1..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 ΣI1..1stringBusiness concept used by a health plan to describe its benefit offerings (154 )
..... name ΣI0..1stringName of the health plan benefit offering assigned to the Plan Identfier (155 )
... order ΣI0..1positiveIntRelative order of the coverage
... network ΣI0..1stringInsurer network
... costToBeneficiary I0..*BackboneElementPatient payments for services/products
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type ΣI0..1CodeableConceptCost category
Binding: CoverageCopayTypeCodes (extensible)
.... value[x] ΣI1..1The amount or percentage due from the beneficiary
..... valueQuantityQuantity(SimpleQuantity)
..... valueMoneyMoney
.... exception I0..*BackboneElementExceptions for patient payments
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type ΣI1..1CodeableConceptException category
Binding: ExampleCoverageFinancialExceptionCodes (example)
..... period ΣI0..1PeriodThe effective period of the exception
... subrogation I0..1booleanReimbursement to insurer
... contract I0..*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