Consumer Real-Time Pharmacy Benefit Check FHIR IG, published by HL7 International / Pharmacy. This guide is not an authorized publication; it is the continuous build for version 2.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/carin-rtpbc/ and changes regularly. See the Directory of published versions
Official URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-coverage | Version: 2.0.0 | |||
Standards status: Trial-use | Maturity Level: 4 | Computable Name: RtpbcCoverage |
This profile constrains the Coverage resource for carrying the pharmacy benefit information required in the consumer real-time pharmacy benefit check process
This profile constrains the Coverage resource to carry the member and and coverage identifiers that insurers use to locate the patient's specific plan coverage rules.
(Note: When the responder is a medication pricing source, the Coverage resource is not required).
The Coverage elements available to be used by the RTPBC process are:
Different insurers PBMs or other responders may require just a subset of these elements. Implementers may populate all elements for which information is available, or scope the population based the particular responder’s requirements.
Client and Responding systems
The elements identified as Must Support are the typical set used in US pharmacy benefit processing; client systems must enable these to be submitted in requests, and responders must be able to accept them to be used as appropriate during processing.
Usages:
You can also check for usages in the FHIR IG Statistics
Description of Profiles, Differentials, Snapshots and how the different presentations work.
Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() |
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0..* | Coverage | Insurance or medical plan or a payment agreement | |
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?!Σ | 0..1 | uri | A set of rules under which this content was created |
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?! | 0..* | Extension | Extensions that cannot be ignored |
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?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. |
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SΣ | 0..1 | string | Health Plan Cardholder ID |
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SΣ | 1..1 | Reference(Patient) | Plan beneficiary |
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SΣ | 1..1 | Reference(Organization | Patient | RelatedPerson) | Payer ID |
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SΣ | 0..1 | Identifier | Payer ID |
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?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . |
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SΣ | 1..1 | string | Payer ID Value Example General: 123456 |
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S | 0..* | BackboneElement | Pharmacy coverage identifiers Slice: Unordered, Open by value:type |
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Content/Rules for all slices | |||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
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Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): Coverage Class Codes |
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Σ | 1..1 | string | Value associated with the type |
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S | 0..1 | BackboneElement | IIN (BIN) number |
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
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Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): Coverage Class Codes Required Pattern: At least the following |
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0..1 | string | Unique id for inter-element referencing | |
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0..* | Extension | Additional content defined by implementations | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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0..1 | string | Unique id for inter-element referencing | |
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0..* | Extension | Additional content defined by implementations | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
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0..1 | string | Version of the system - if relevant | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: rxbin | |
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0..1 | string | Representation defined by the system | |
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0..1 | boolean | If this coding was chosen directly by the user | |
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0..1 | string | Plain text representation of the concept | |
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Σ | 1..1 | string | Value associated with the type |
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S | 0..1 | BackboneElement | Processor Control Number (PCN) |
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
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Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): Coverage Class Codes Required Pattern: At least the following |
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0..1 | string | Unique id for inter-element referencing | |
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0..* | Extension | Additional content defined by implementations | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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0..1 | string | Unique id for inter-element referencing | |
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0..* | Extension | Additional content defined by implementations | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
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0..1 | string | Version of the system - if relevant | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: rxpcn | |
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0..1 | string | Representation defined by the system | |
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0..1 | boolean | If this coding was chosen directly by the user | |
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0..1 | string | Plain text representation of the concept | |
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Σ | 1..1 | string | Value associated with the type |
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S | 0..1 | BackboneElement | Pharmacy Benefit Group ID |
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
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Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): Coverage Class Codes Required Pattern: At least the following |
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0..1 | string | Unique id for inter-element referencing | |
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0..* | Extension | Additional content defined by implementations | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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0..1 | string | Unique id for inter-element referencing | |
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0..* | Extension | Additional content defined by implementations | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
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0..1 | string | Version of the system - if relevant | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: rxgroup | |
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0..1 | string | Representation defined by the system | |
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0..1 | boolean | If this coding was chosen directly by the user | |
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0..1 | string | Plain text representation of the concept | |
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Σ | 1..1 | string | Value associated with the type |
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S | 0..1 | BackboneElement | PBM Member ID |
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
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Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): Coverage Class Codes Required Pattern: At least the following |
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0..1 | string | Unique id for inter-element referencing | |
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0..* | Extension | Additional content defined by implementations | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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0..1 | string | Unique id for inter-element referencing | |
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0..* | Extension | Additional content defined by implementations | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
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0..1 | string | Version of the system - if relevant | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: rxid | |
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0..1 | string | Representation defined by the system | |
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0..1 | boolean | If this coding was chosen directly by the user | |
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0..1 | string | Plain text representation of the concept | |
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Σ | 1..1 | string | Value associated with the type |
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Path | Conformance | ValueSet / Code | URI |
Coverage.status | required | FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|4.0.1 From the FHIR Standard | |
Coverage.payor.identifier.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 From the FHIR Standard | |
Coverage.class.type | extensible | CoverageClassCodeshttp://hl7.org/fhir/ValueSet/coverage-class From the FHIR Standard | |
Coverage.class:bin.type | extensible | Pattern Value: rxbinhttp://hl7.org/fhir/ValueSet/coverage-class From the FHIR Standard | |
Coverage.class:pcn.type | extensible | Pattern Value: rxpcnhttp://hl7.org/fhir/ValueSet/coverage-class From the FHIR Standard | |
Coverage.class:rxgroup-id.type | extensible | Pattern Value: rxgrouphttp://hl7.org/fhir/ValueSet/coverage-class From the FHIR Standard | |
Coverage.class:pbm-member-id.type | extensible | Pattern Value: rxidhttp://hl7.org/fhir/ValueSet/coverage-class From the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
dom-2 | error | Coverage | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Coverage | 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 | error | Coverage | 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 | error | Coverage | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Coverage | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from Coverage
Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() |
---|---|---|---|---|
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0..* | Coverage | Insurance or medical plan or a payment agreement | |
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S | 0..1 | string | Health Plan Cardholder ID |
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S | 1..1 | Reference(Patient) | Plan beneficiary |
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S | 1..1 | Reference(Organization | Patient | RelatedPerson) | Payer ID |
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S | 0..1 | Identifier | Payer ID |
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S | 1..1 | string | Payer ID Value |
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S | 0..* | BackboneElement | Pharmacy coverage identifiers Slice: Unordered, Open by value:type |
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Content/Rules for all slices | |||
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1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): Coverage Class Codes | |
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S | 0..1 | BackboneElement | IIN (BIN) number |
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1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: rxbin | |
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S | 0..1 | BackboneElement | Processor Control Number (PCN) |
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1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: rxpcn | |
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S | 0..1 | BackboneElement | Pharmacy Benefit Group ID |
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1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: rxgroup | |
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S | 0..1 | BackboneElement | PBM Member ID |
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1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Required Pattern: At least the following | |
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
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1..1 | code | Symbol in syntax defined by the system Fixed Value: rxid | |
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Path | Conformance | ValueSet | URI |
Coverage.class.type | extensible | CoverageClassCodeshttp://hl7.org/fhir/ValueSet/coverage-class From the FHIR Standard |
Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() | ||||
---|---|---|---|---|---|---|---|---|
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0..* | Coverage | Insurance or medical plan or a payment agreement | |||||
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Σ | 0..1 | id | Logical id of this artifact | ||||
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Σ | 0..1 | Meta | Metadata about the resource | ||||
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?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
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0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
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0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||
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0..* | Resource | Contained, inline Resources | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?! | 0..* | Extension | Extensions that cannot be ignored | ||||
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Σ | 0..* | Identifier | Business Identifier for the coverage | ||||
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?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. | ||||
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Σ | 0..1 | CodeableConcept | Coverage category such as medical or accident Binding: CoverageTypeAndSelf-PayCodes (preferred): The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization. | ||||
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Σ | 0..1 | Reference(Patient | RelatedPerson | Organization) | Owner of the policy | ||||
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Σ | 0..1 | Reference(Patient | RelatedPerson) | Subscriber to the policy | ||||
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SΣ | 0..1 | string | Health Plan Cardholder ID | ||||
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SΣ | 1..1 | Reference(Patient) | Plan beneficiary | ||||
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Σ | 0..1 | string | Dependent number | ||||
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0..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient). | |||||
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Σ | 0..1 | Period | Coverage start and end dates | ||||
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SΣ | 1..1 | Reference(Organization | Patient | RelatedPerson) | Payer ID | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
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ΣC | 0..1 | string | Literal reference, Relative, internal or absolute URL | ||||
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Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
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SΣ | 0..1 | Identifier | Payer ID | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
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?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
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Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. | ||||
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Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
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SΣ | 1..1 | string | Payer ID Value Example General: 123456 | ||||
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Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
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Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||
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Σ | 0..1 | string | Text alternative for the resource | ||||
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S | 0..* | BackboneElement | Pharmacy coverage identifiers Slice: Unordered, Open by value:type | ||||
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Content/Rules for all slices | |||||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): Coverage Class Codes | ||||
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Σ | 1..1 | string | Value associated with the type | ||||
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Σ | 0..1 | string | Human readable description of the type and value | ||||
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S | 0..1 | BackboneElement | IIN (BIN) number | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): Coverage Class Codes Required Pattern: At least the following | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |||||
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0..1 | string | Version of the system - if relevant | |||||
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1..1 | code | Symbol in syntax defined by the system Fixed Value: rxbin | |||||
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0..1 | string | Representation defined by the system | |||||
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0..1 | boolean | If this coding was chosen directly by the user | |||||
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0..1 | string | Plain text representation of the concept | |||||
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Σ | 1..1 | string | Value associated with the type | ||||
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Σ | 0..1 | string | Human readable description of the type and value | ||||
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S | 0..1 | BackboneElement | Processor Control Number (PCN) | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): Coverage Class Codes Required Pattern: At least the following | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |||||
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0..1 | string | Version of the system - if relevant | |||||
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1..1 | code | Symbol in syntax defined by the system Fixed Value: rxpcn | |||||
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0..1 | string | Representation defined by the system | |||||
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0..1 | boolean | If this coding was chosen directly by the user | |||||
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0..1 | string | Plain text representation of the concept | |||||
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Σ | 1..1 | string | Value associated with the type | ||||
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Σ | 0..1 | string | Human readable description of the type and value | ||||
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S | 0..1 | BackboneElement | Pharmacy Benefit Group ID | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): Coverage Class Codes Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: rxgroup | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | string | Value associated with the type | ||||
![]() ![]() ![]() ![]() ![]() |
Σ | 0..1 | string | Human readable description of the type and value | ||||
![]() ![]() ![]() ![]() |
S | 0..1 | BackboneElement | PBM Member ID | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): Coverage Class Codes Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: rxid | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |||||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |||||
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | string | Value associated with the type | ||||
![]() ![]() ![]() ![]() ![]() |
Σ | 0..1 | string | Human readable description of the type and value | ||||
![]() ![]() ![]() |
Σ | 0..1 | positiveInt | Relative order of the coverage | ||||
![]() ![]() ![]() |
Σ | 0..1 | string | Insurer network | ||||
![]() ![]() ![]() |
0..* | BackboneElement | Patient payments for services/products | |||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() |
Σ | 0..1 | CodeableConcept | Cost category Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified. | ||||
![]() ![]() ![]() ![]() |
Σ | 1..1 | The amount or percentage due from the beneficiary | |||||
![]() ![]() ![]() ![]() ![]() |
Quantity(SimpleQuantity) | |||||||
![]() ![]() ![]() ![]() ![]() |
Money | |||||||
![]() ![]() ![]() ![]() |
0..* | BackboneElement | Exceptions for patient payments | |||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | CodeableConcept | Exception category Binding: ExampleCoverageFinancialExceptionCodes (example): The types of exceptions from the part or full value of financial obligations such as copays. | ||||
![]() ![]() ![]() ![]() ![]() |
Σ | 0..1 | Period | The effective period of the exception | ||||
![]() ![]() ![]() |
0..1 | boolean | Reimbursement to insurer | |||||
![]() ![]() ![]() |
0..* | Reference(Contract) | Contract details | |||||
![]() |
Path | Conformance | ValueSet / Code | URI | |||
Coverage.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languages From the FHIR Standard
| ||||
Coverage.status | required | FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|4.0.1 From the FHIR Standard | ||||
Coverage.type | preferred | CoverageTypeAndSelf-PayCodeshttp://hl7.org/fhir/ValueSet/coverage-type From the FHIR Standard | ||||
Coverage.relationship | extensible | SubscriberRelationshipCodeshttp://hl7.org/fhir/ValueSet/subscriber-relationship From the FHIR Standard | ||||
Coverage.payor.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types From the FHIR Standard | ||||
Coverage.payor.identifier.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 From the FHIR Standard | ||||
Coverage.payor.identifier.type | extensible | Identifier Type Codeshttp://hl7.org/fhir/ValueSet/identifier-type From the FHIR Standard | ||||
Coverage.class.type | extensible | CoverageClassCodeshttp://hl7.org/fhir/ValueSet/coverage-class From the FHIR Standard | ||||
Coverage.class:bin.type | extensible | Pattern Value: rxbinhttp://hl7.org/fhir/ValueSet/coverage-class From the FHIR Standard | ||||
Coverage.class:pcn.type | extensible | Pattern Value: rxpcnhttp://hl7.org/fhir/ValueSet/coverage-class From the FHIR Standard | ||||
Coverage.class:rxgroup-id.type | extensible | Pattern Value: rxgrouphttp://hl7.org/fhir/ValueSet/coverage-class From the FHIR Standard | ||||
Coverage.class:pbm-member-id.type | extensible | Pattern Value: rxidhttp://hl7.org/fhir/ValueSet/coverage-class From the FHIR Standard | ||||
Coverage.costToBeneficiary.type | extensible | CoverageCopayTypeCodeshttp://hl7.org/fhir/ValueSet/coverage-copay-type From the FHIR Standard | ||||
Coverage.costToBeneficiary.exception.type | example | ExampleCoverageFinancialExceptionCodeshttp://hl7.org/fhir/ValueSet/coverage-financial-exception From the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
dom-2 | error | Coverage | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Coverage | 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 | error | Coverage | 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 | error | Coverage | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Coverage | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() |
---|---|---|---|---|
![]() ![]() |
0..* | Coverage | Insurance or medical plan or a payment agreement | |
![]() ![]() ![]() |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
![]() ![]() ![]() |
?! | 0..* | Extension | Extensions that cannot be ignored |
![]() ![]() ![]() |
?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. |
![]() ![]() ![]() |
SΣ | 0..1 | string | Health Plan Cardholder ID |
![]() ![]() ![]() |
SΣ | 1..1 | Reference(Patient) | Plan beneficiary |
![]() ![]() ![]() |
SΣ | 1..1 | Reference(Organization | Patient | RelatedPerson) | Payer ID |
![]() ![]() ![]() ![]() |
SΣ | 0..1 | Identifier | Payer ID |
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . |
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | string | Payer ID Value Example General: 123456 |
![]() ![]() ![]() |
S | 0..* | BackboneElement | Pharmacy coverage identifiers Slice: Unordered, Open by value:type |
![]() ![]() ![]() ![]() |
Content/Rules for all slices | |||
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): Coverage Class Codes |
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | string | Value associated with the type |
![]() ![]() ![]() ![]() |
S | 0..1 | BackboneElement | IIN (BIN) number |
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): Coverage Class Codes Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: rxbin | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | string | Value associated with the type |
![]() ![]() ![]() ![]() |
S | 0..1 | BackboneElement | Processor Control Number (PCN) |
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): Coverage Class Codes Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: rxpcn | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | string | Value associated with the type |
![]() ![]() ![]() ![]() |
S | 0..1 | BackboneElement | Pharmacy Benefit Group ID |
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): Coverage Class Codes Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: rxgroup | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | string | Value associated with the type |
![]() ![]() ![]() ![]() |
S | 0..1 | BackboneElement | PBM Member ID |
![]() ![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): Coverage Class Codes Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: rxid | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Plain text representation of the concept | |
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | string | Value associated with the type |
![]() |
Path | Conformance | ValueSet / Code | URI |
Coverage.status | required | FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|4.0.1 From the FHIR Standard | |
Coverage.payor.identifier.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 From the FHIR Standard | |
Coverage.class.type | extensible | CoverageClassCodeshttp://hl7.org/fhir/ValueSet/coverage-class From the FHIR Standard | |
Coverage.class:bin.type | extensible | Pattern Value: rxbinhttp://hl7.org/fhir/ValueSet/coverage-class From the FHIR Standard | |
Coverage.class:pcn.type | extensible | Pattern Value: rxpcnhttp://hl7.org/fhir/ValueSet/coverage-class From the FHIR Standard | |
Coverage.class:rxgroup-id.type | extensible | Pattern Value: rxgrouphttp://hl7.org/fhir/ValueSet/coverage-class From the FHIR Standard | |
Coverage.class:pbm-member-id.type | extensible | Pattern Value: rxidhttp://hl7.org/fhir/ValueSet/coverage-class From the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
dom-2 | error | Coverage | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Coverage | 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 | error | Coverage | 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 | error | Coverage | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Coverage | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Differential View
This structure is derived from Coverage
Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() |
---|---|---|---|---|
![]() ![]() |
0..* | Coverage | Insurance or medical plan or a payment agreement | |
![]() ![]() ![]() |
S | 0..1 | string | Health Plan Cardholder ID |
![]() ![]() ![]() |
S | 1..1 | Reference(Patient) | Plan beneficiary |
![]() ![]() ![]() |
S | 1..1 | Reference(Organization | Patient | RelatedPerson) | Payer ID |
![]() ![]() ![]() ![]() |
S | 0..1 | Identifier | Payer ID |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | string | Payer ID Value |
![]() ![]() ![]() |
S | 0..* | BackboneElement | Pharmacy coverage identifiers Slice: Unordered, Open by value:type |
![]() ![]() ![]() ![]() |
Content/Rules for all slices | |||
![]() ![]() ![]() ![]() ![]() |
1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): Coverage Class Codes | |
![]() ![]() ![]() ![]() |
S | 0..1 | BackboneElement | IIN (BIN) number |
![]() ![]() ![]() ![]() ![]() |
1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Required Pattern: At least the following | |
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: rxbin | |
![]() ![]() ![]() ![]() |
S | 0..1 | BackboneElement | Processor Control Number (PCN) |
![]() ![]() ![]() ![]() ![]() |
1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Required Pattern: At least the following | |
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: rxpcn | |
![]() ![]() ![]() ![]() |
S | 0..1 | BackboneElement | Pharmacy Benefit Group ID |
![]() ![]() ![]() ![]() ![]() |
1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Required Pattern: At least the following | |
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: rxgroup | |
![]() ![]() ![]() ![]() |
S | 0..1 | BackboneElement | PBM Member ID |
![]() ![]() ![]() ![]() ![]() |
1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Required Pattern: At least the following | |
![]() ![]() ![]() ![]() ![]() ![]() |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system Fixed Value: rxid | |
![]() |
Path | Conformance | ValueSet | URI |
Coverage.class.type | extensible | CoverageClassCodeshttp://hl7.org/fhir/ValueSet/coverage-class From the FHIR Standard |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() | ||||
---|---|---|---|---|---|---|---|---|
![]() ![]() |
0..* | Coverage | Insurance or medical plan or a payment agreement | |||||
![]() ![]() ![]() |
Σ | 0..1 | id | Logical id of this artifact | ||||
![]() ![]() ![]() |
Σ | 0..1 | Meta | Metadata about the resource | ||||
![]() ![]() ![]() |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
![]() ![]() ![]() |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
![]() ![]() ![]() |
0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||
![]() ![]() ![]() |
0..* | Resource | Contained, inline Resources | |||||
![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
![]() ![]() ![]() |
Σ | 0..* | Identifier | Business Identifier for the coverage | ||||
![]() ![]() ![]() |
?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. | ||||
![]() ![]() ![]() |
Σ | 0..1 | CodeableConcept | Coverage category such as medical or accident Binding: CoverageTypeAndSelf-PayCodes (preferred): The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization. | ||||
![]() ![]() ![]() |
Σ | 0..1 | Reference(Patient | RelatedPerson | Organization) | Owner of the policy | ||||
![]() ![]() ![]() |
Σ | 0..1 | Reference(Patient | RelatedPerson) | Subscriber to the policy | ||||
![]() ![]() ![]() |
SΣ | 0..1 | string | Health Plan Cardholder ID | ||||
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SΣ | 1..1 | Reference(Patient) | Plan beneficiary | ||||
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Σ | 0..1 | string | Dependent number | ||||
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0..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient). | |||||
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Σ | 0..1 | Period | Coverage start and end dates | ||||
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SΣ | 1..1 | Reference(Organization | Patient | RelatedPerson) | Payer ID | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
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ΣC | 0..1 | string | Literal reference, Relative, internal or absolute URL | ||||
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Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
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SΣ | 0..1 | Identifier | Payer ID | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
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?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
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Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. | ||||
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Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
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SΣ | 1..1 | string | Payer ID Value Example General: 123456 | ||||
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Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
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Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||
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Σ | 0..1 | string | Text alternative for the resource | ||||
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S | 0..* | BackboneElement | Pharmacy coverage identifiers Slice: Unordered, Open by value:type | ||||
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Content/Rules for all slices | |||||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): Coverage Class Codes | ||||
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Σ | 1..1 | string | Value associated with the type | ||||
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Σ | 0..1 | string | Human readable description of the type and value | ||||
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S | 0..1 | BackboneElement | IIN (BIN) number | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): Coverage Class Codes Required Pattern: At least the following | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |||||
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0..1 | string | Version of the system - if relevant | |||||
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1..1 | code | Symbol in syntax defined by the system Fixed Value: rxbin | |||||
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0..1 | string | Representation defined by the system | |||||
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0..1 | boolean | If this coding was chosen directly by the user | |||||
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0..1 | string | Plain text representation of the concept | |||||
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Σ | 1..1 | string | Value associated with the type | ||||
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Σ | 0..1 | string | Human readable description of the type and value | ||||
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S | 0..1 | BackboneElement | Processor Control Number (PCN) | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): Coverage Class Codes Required Pattern: At least the following | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |||||
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0..1 | string | Version of the system - if relevant | |||||
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1..1 | code | Symbol in syntax defined by the system Fixed Value: rxpcn | |||||
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0..1 | string | Representation defined by the system | |||||
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0..1 | boolean | If this coding was chosen directly by the user | |||||
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0..1 | string | Plain text representation of the concept | |||||
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Σ | 1..1 | string | Value associated with the type | ||||
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Σ | 0..1 | string | Human readable description of the type and value | ||||
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S | 0..1 | BackboneElement | Pharmacy Benefit Group ID | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): Coverage Class Codes Required Pattern: At least the following | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |||||
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0..1 | string | Version of the system - if relevant | |||||
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1..1 | code | Symbol in syntax defined by the system Fixed Value: rxgroup | |||||
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0..1 | string | Representation defined by the system | |||||
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0..1 | boolean | If this coding was chosen directly by the user | |||||
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0..1 | string | Plain text representation of the concept | |||||
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Σ | 1..1 | string | Value associated with the type | ||||
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Σ | 0..1 | string | Human readable description of the type and value | ||||
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S | 0..1 | BackboneElement | PBM Member ID | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): Coverage Class Codes Required Pattern: At least the following | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |||||
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0..1 | string | Version of the system - if relevant | |||||
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1..1 | code | Symbol in syntax defined by the system Fixed Value: rxid | |||||
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0..1 | string | Representation defined by the system | |||||
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0..1 | boolean | If this coding was chosen directly by the user | |||||
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0..1 | string | Plain text representation of the concept | |||||
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Σ | 1..1 | string | Value associated with the type | ||||
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Σ | 0..1 | string | Human readable description of the type and value | ||||
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Σ | 0..1 | positiveInt | Relative order of the coverage | ||||
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Σ | 0..1 | string | Insurer network | ||||
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0..* | BackboneElement | Patient payments for services/products | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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Σ | 0..1 | CodeableConcept | Cost category Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified. | ||||
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Σ | 1..1 | The amount or percentage due from the beneficiary | |||||
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Quantity(SimpleQuantity) | |||||||
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Money | |||||||
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0..* | BackboneElement | Exceptions for patient payments | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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Σ | 1..1 | CodeableConcept | Exception category Binding: ExampleCoverageFinancialExceptionCodes (example): The types of exceptions from the part or full value of financial obligations such as copays. | ||||
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Σ | 0..1 | Period | The effective period of the exception | ||||
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0..1 | boolean | Reimbursement to insurer | |||||
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0..* | Reference(Contract) | Contract details | |||||
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Path | Conformance | ValueSet / Code | URI | |||
Coverage.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languages From the FHIR Standard
| ||||
Coverage.status | required | FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|4.0.1 From the FHIR Standard | ||||
Coverage.type | preferred | CoverageTypeAndSelf-PayCodeshttp://hl7.org/fhir/ValueSet/coverage-type From the FHIR Standard | ||||
Coverage.relationship | extensible | SubscriberRelationshipCodeshttp://hl7.org/fhir/ValueSet/subscriber-relationship From the FHIR Standard | ||||
Coverage.payor.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types From the FHIR Standard | ||||
Coverage.payor.identifier.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 From the FHIR Standard | ||||
Coverage.payor.identifier.type | extensible | Identifier Type Codeshttp://hl7.org/fhir/ValueSet/identifier-type From the FHIR Standard | ||||
Coverage.class.type | extensible | CoverageClassCodeshttp://hl7.org/fhir/ValueSet/coverage-class From the FHIR Standard | ||||
Coverage.class:bin.type | extensible | Pattern Value: rxbinhttp://hl7.org/fhir/ValueSet/coverage-class From the FHIR Standard | ||||
Coverage.class:pcn.type | extensible | Pattern Value: rxpcnhttp://hl7.org/fhir/ValueSet/coverage-class From the FHIR Standard | ||||
Coverage.class:rxgroup-id.type | extensible | Pattern Value: rxgrouphttp://hl7.org/fhir/ValueSet/coverage-class From the FHIR Standard | ||||
Coverage.class:pbm-member-id.type | extensible | Pattern Value: rxidhttp://hl7.org/fhir/ValueSet/coverage-class From the FHIR Standard | ||||
Coverage.costToBeneficiary.type | extensible | CoverageCopayTypeCodeshttp://hl7.org/fhir/ValueSet/coverage-copay-type From the FHIR Standard | ||||
Coverage.costToBeneficiary.exception.type | example | ExampleCoverageFinancialExceptionCodeshttp://hl7.org/fhir/ValueSet/coverage-financial-exception From the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
dom-2 | error | Coverage | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Coverage | 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 | error | Coverage | 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 | error | Coverage | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Coverage | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
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