Consumer Real-Time Pharmacy Benefit Check FHIR IG
2.0.0-ballot - STU 2 Ballot

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-ballot 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

## Resource Profile: RTPBC Coverage - Non-PHI

Official URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-coverage-non-phi | Version: 2.0.0-ballot | Highlight text changes?
Standards status: Trial-use Active as of 2026-03-03 | Maturity Level: 2 | Computable Name: RtpbcCoverageNonPHI

Coverage resource in which no personally-identifiable information is included. Used for representing non-patient-specific payment sources such as medication discount cards.

This profile constrains the Coverage resource to contain non-patient-specific coverage information related to an RTPBC response entry conveyed in a Claim.item or Claim.addItem element.

Data population is based on the RTPBC Coverage but excludes content that could contain information about the patient.

### Masked information

The following element is unavailable in this profile:

- beneficiary

To conform with the Non-PHI Coverage profile, the Data Absent Reason extension SHALL be used in the Coverage.beneficiary element, populated with the code, "masked".§PHI-COV-1

Usages:

- Use this Profile: RTPBC Response Bundle Non-PHI
- Refer to this Profile: RTPBC relatedCoverage Extension
- Examples for this Profile: Coverage/rtpbc-coverage-non-phi-01

You can also check for usages in the FHIR IG Statistics

### Formal Views of Profile Content

Description Differentials, Snapshots, and other representations.

- Key Elements Table
- Differential Table
- Snapshot Table
- Statistics/References
- All

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Coverage | C | 0..* | USCoreCoverageProfile | Insurance or medical plan or a payment agreement Constraints: us-core-15
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
Slices for identifier | S Σ | 0..* | Identifier | Member ID and other identifiers Slice: Unordered, Open by value:type
identifier:memberid | S Σ C | 0..1 | Identifier | Member ID
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type | S Σ | 1..1 | CodeableConcept | Member Number identifier type 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. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: MB
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
status | ?!S Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
type | S Σ | 0..1 | CodeableConcept | Coverage category such as medical or accident Binding: Payer Type (extensible): US Public Health Data Consortium Source of Payment Codes
subscriberId | S Σ C | 0..1 | string | Subscriber ID (masked)
Slices for extension | S | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:data-masked | S | 1..1 | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/data-absent-reason"
value[x] |  | 1..1 | code | Value of extension Binding: DataAbsentReason (required) Fixed Value: masked
beneficiary | S Σ | 1..1 | Reference(US Core Patient Profile) | Patient information (masked)
Slices for extension | S | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:data-masked | S | 1..1 | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/data-absent-reason"
value[x] |  | 1..1 | code | Value of extension Binding: DataAbsentReason (required) Fixed Value: masked
identifier | Σ | 0..1 | Identifier | Unique, non-personally identifiable code
relationship | S | 1..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible)
period | S Σ | 0..1 | Period | Coverage start and end dates
payor | S Σ | 1..1 | Reference(US Core Organization Profile S | US Core Patient Profile | US Core RelatedPerson Profile) | Issuer of the policy
identifier | S Σ | 0..1 | Identifier | Payer ID
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
value | S Σ | 1..1 | string | Payer ID Value Example General: 123456
Slices for class | S | 0..* | BackboneElement | Pharmacy coverage identifiers Slice: Unordered, Open by value:type
class:All Slices |  |  |  | Content/Rules for all slices
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): Coverage Class Codes
value | Σ | 1..1 | string | Value associated with the type
class:group | S | 0..1 | BackboneElement | Group
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: group
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
value | S Σ | 1..1 | string | Group Identifier
class:plan | S | 0..1 | BackboneElement | Plan
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: plan
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
value | S Σ | 1..1 | string | Plan Number
name | S Σ | 0..1 | string | Plan Name
class:bin | S | 0..1 | BackboneElement | IIN (BIN) number
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): Coverage Class Codes Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxbin
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
value | Σ | 1..1 | string | Value associated with the type
class:pcn | S | 0..1 | BackboneElement | Processor Control Number (PCN)
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): Coverage Class Codes Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxpcn
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
value | Σ | 1..1 | string | Value associated with the type
class:rxgroup-id | S | 0..1 | BackboneElement | Pharmacy Benefit Group ID
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): Coverage Class Codes Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxgroup
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
value | Σ | 1..1 | string | Value associated with the type
class:member-id | S | 0..1 | BackboneElement | PBM Member ID
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): Coverage Class Codes Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxid
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
value | Σ | 1..1 | string | Value associated with the type
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Coverage.identifier:memberid.​use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std.
Coverage.identifier:memberid.​type | Base | extensible | IdentifierType | 📍4.0.1 | FHIR Std.
Coverage.status | Base | required | Financial Resource Status Codes | 📍4.0.1 | FHIR Std.
Coverage.type | Base | extensible | Payer Type | 📦20250419 | VSAC v0.24
Coverage.subscriberId.​extension:data-masked.​value[x] | Base | required | DataAbsentReason | 📦4.0.1 | FHIR Std.
Coverage.beneficiary.​extension:data-masked.​value[x] | Base | required | DataAbsentReason | 📦4.0.1 | FHIR Std.
Coverage.relationship | Base | extensible | SubscriberPolicyholder Relationship Codes | 📦4.0.1 | FHIR Std.
Coverage.payor.identifier.​use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std.
Coverage.class.type | Base | extensible | Coverage Class Codes | 📦4.0.1 | FHIR Std.
Coverage.class:group.​type | Base | extensible | Coverage Class Codes | 📍4.0.1 | FHIR Std.
Coverage.class:plan.​type | Base | extensible | Coverage Class Codes | 📍4.0.1 | FHIR Std.
Coverage.class:bin.type | Base | extensible | Coverage Class Codes | 📦4.0.1 | FHIR Std.
Coverage.class:pcn.type | Base | extensible | Coverage Class Codes | 📦4.0.1 | FHIR Std.
Coverage.class:rxgroup-id.​type | Base | extensible | Coverage Class Codes | 📦4.0.1 | FHIR Std.
Coverage.class:member-id.​type | Base | extensible | Coverage Class Codes | 📦4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
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()`
us-core-15 | error | Coverage | Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present | `identifier.type.coding.where(system='http://terminology.hl7.org/CodeSystem/v2-0203' and code='MB').exists() or subscriberId.exists()`

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Coverage |  | 0..* | USCoreCoverageProfile | Insurance or medical plan or a payment agreement
subscriberId |  | 0..1 | string | Subscriber ID (masked)
Slices for extension | S | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:data-masked | S | 1..1 | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
value[x] |  | 1..1 | code | Value of extension Fixed Value: masked
beneficiary |  | 1..1 | Reference(US Core Patient Profile) | Patient information (masked)
extension | S | 1..* | Extension | Extension
Slices for extension |  |  |  | Content/Rules for all slices
extension:data-masked | S | 1..1 | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
value[x] |  | 1..1 | code | Value of extension Fixed Value: masked
reference |  | 0..0 |  | Literal reference, Relative, internal or absolute URL
type |  | 0..0 |  | Type the reference refers to (e.g. "Patient")
identifier |  | 0..1 | Identifier | Unique, non-personally identifiable code
display |  | 0..0 |  | Text alternative for the resource
relationship |  | 1..1 | CodeableConcept | Beneficiary relationship to the subscriber
coding |  |  |  |
system |  | 0..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/subscriber-relationship
code |  | 0..1 | code | Symbol in syntax defined by the system Fixed Value: self
payor |  |  |  |
identifier | S | 0..1 | Identifier | Payer ID
value | S | 1..1 | string | Payer ID Value
Slices for class |  | 0..* | BackboneElement | Pharmacy coverage identifiers Slice: Unordered, Open by value:type
class:All Slices |  |  |  | Content/Rules for all slices
type |  | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): Coverage Class Codes
class:bin | S | 0..1 | BackboneElement | IIN (BIN) number
type |  | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxbin
class:pcn | S | 0..1 | BackboneElement | Processor Control Number (PCN)
type |  | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxpcn
class:rxgroup-id | S | 0..1 | BackboneElement | Pharmacy Benefit Group ID
type |  | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxgroup
class:member-id | S | 0..1 | BackboneElement | PBM Member ID
type |  | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxid
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
Coverage.class.type | Base | extensible | Coverage Class Codes | 📦4.0.1 | FHIR Std.

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Coverage | C | 0..* | USCoreCoverageProfile | Insurance or medical plan or a payment agreement Constraints: us-core-15
id | Σ | 0..1 | id | Logical id of this artifact
meta | Σ | 0..1 | Meta | Metadata about the resource
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
language |  | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
text |  | 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
contained |  | 0..* | Resource | Contained, inline Resources
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
Slices for identifier | S Σ | 0..* | Identifier | Member ID and other identifiers Slice: Unordered, Open by value:type
identifier:memberid | S Σ C | 0..1 | Identifier | Member ID
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type | S Σ | 1..1 | CodeableConcept | Member Number identifier type 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. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: MB
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
system | Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value | Σ | 0..1 | string | The value that is unique Example General: 123456
period | Σ | 0..1 | Period | Time period when id is/was valid for use
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text)
status | ?!S Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
type | S Σ | 0..1 | CodeableConcept | Coverage category such as medical or accident Binding: Payer Type (extensible): US Public Health Data Consortium Source of Payment Codes
policyHolder | Σ | 0..1 | Reference(Patient | RelatedPerson | Organization) | Owner of the policy
subscriber | Σ | 0..1 | Reference(Patient | RelatedPerson) | Subscriber to the policy
subscriberId | S Σ C | 0..1 | string | Subscriber ID (masked)
id |  | 0..1 | string | xml:id (or equivalent in JSON)
Slices for extension | S | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:data-masked | S | 1..1 | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
id |  | 0..1 | id | Unique id for inter-element referencing
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/data-absent-reason"
value[x] |  | 1..1 | code | Value of extension Binding: DataAbsentReason (required) Fixed Value: masked
value |  | 0..1 | string | Primitive value for string Max Length:1048576
beneficiary | S Σ | 1..1 | Reference(US Core Patient Profile) | Patient information (masked)
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension | S | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:data-masked | S | 1..1 | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
id |  | 0..1 | id | Unique id for inter-element referencing
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/data-absent-reason"
value[x] |  | 1..1 | code | Value of extension Binding: DataAbsentReason (required) Fixed Value: masked
identifier | Σ | 0..1 | Identifier | Unique, non-personally identifiable code
dependent | Σ | 0..1 | string | Dependent number
relationship | S | 1..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
coding | Σ | 0..* | Coding | Code defined by a terminology system
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
system | Σ | 0..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/subscriber-relationship
version | Σ | 0..1 | string | Version of the system - if relevant
code | Σ | 0..1 | code | Symbol in syntax defined by the system Fixed Value: self
display | Σ | 0..1 | string | Representation defined by the system
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user
text | Σ | 0..1 | string | Plain text representation of the concept
period | S Σ | 0..1 | Period | Coverage start and end dates
payor | S Σ | 1..1 | Reference(US Core Organization Profile S | US Core Patient Profile | US Core RelatedPerson Profile) | Issuer of the policy
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
reference | Σ C | 0..1 | string | Literal reference, Relative, internal or absolute URL
type | 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).
identifier | S Σ | 0..1 | Identifier | Payer ID
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type | 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.
system | Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value | S Σ | 1..1 | string | Payer ID Value Example General: 123456
period | Σ | 0..1 | Period | Time period when id is/was valid for use
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text)
display | Σ | 0..1 | string | Text alternative for the resource
Slices for class | S | 0..* | BackboneElement | Pharmacy coverage identifiers Slice: Unordered, Open by value:type
class:All Slices |  |  |  | Content/Rules for all slices
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): Coverage Class Codes
value | Σ | 1..1 | string | Value associated with the type
name | Σ | 0..1 | string | Human readable description of the type and value
class:group | S | 0..1 | BackboneElement | Group
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: group
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
value | S Σ | 1..1 | string | Group Identifier
name | Σ | 0..1 | string | Human readable description of the type and value
class:plan | S | 0..1 | BackboneElement | Plan
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: plan
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
value | S Σ | 1..1 | string | Plan Number
name | S Σ | 0..1 | string | Plan Name
class:bin | S | 0..1 | BackboneElement | IIN (BIN) number
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): Coverage Class Codes Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxbin
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
value | Σ | 1..1 | string | Value associated with the type
name | Σ | 0..1 | string | Human readable description of the type and value
class:pcn | S | 0..1 | BackboneElement | Processor Control Number (PCN)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): Coverage Class Codes Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxpcn
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
value | Σ | 1..1 | string | Value associated with the type
name | Σ | 0..1 | string | Human readable description of the type and value
class:rxgroup-id | S | 0..1 | BackboneElement | Pharmacy Benefit Group ID
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): Coverage Class Codes Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxgroup
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
value | Σ | 1..1 | string | Value associated with the type
name | Σ | 0..1 | string | Human readable description of the type and value
class:member-id | S | 0..1 | BackboneElement | PBM Member ID
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): Coverage Class Codes Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxid
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
value | Σ | 1..1 | string | Value associated with the type
name | Σ | 0..1 | string | Human readable description of the type and value
order | Σ | 0..1 | positiveInt | Relative order of the coverage
network | Σ | 0..1 | string | Insurer network
costToBeneficiary |  | 0..* | BackboneElement | Patient payments for services/products
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 0..1 | CodeableConcept | Cost category Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified.
value[x] | Σ | 1..1 |  | The amount or percentage due from the beneficiary
valueQuantity |  |  | Quantity(SimpleQuantity) |
valueMoney |  |  | Money |
exception |  | 0..* | BackboneElement | Exceptions for patient payments
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | 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.
period | Σ | 0..1 | Period | The effective period of the exception
subrogation |  | 0..1 | boolean | Reimbursement to insurer
contract |  | 0..* | Reference(Contract) | Contract details
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Coverage.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
Coverage.identifier:memberid.​use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std.
Coverage.identifier:memberid.​type | Base | extensible | IdentifierType | 📍4.0.1 | FHIR Std.
Coverage.status | Base | required | Financial Resource Status Codes | 📍4.0.1 | FHIR Std.
Coverage.type | Base | extensible | Payer Type | 📦20250419 | VSAC v0.24
Coverage.subscriberId.​extension:data-masked.​value[x] | Base | required | DataAbsentReason | 📦4.0.1 | FHIR Std.
Coverage.beneficiary.​extension:data-masked.​value[x] | Base | required | DataAbsentReason | 📦4.0.1 | FHIR Std.
Coverage.relationship | Base | extensible | SubscriberPolicyholder Relationship Codes | 📦4.0.1 | FHIR Std.
Coverage.payor.type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std.
Coverage.payor.identifier.​use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std.
Coverage.payor.identifier.​type | Base | extensible | IdentifierType | 📍4.0.1 | FHIR Std.
Coverage.class.type | Base | extensible | Coverage Class Codes | 📦4.0.1 | FHIR Std.
Coverage.class:group.​type | Base | extensible | Coverage Class Codes | 📍4.0.1 | FHIR Std.
Coverage.class:plan.​type | Base | extensible | Coverage Class Codes | 📍4.0.1 | FHIR Std.
Coverage.class:bin.type | Base | extensible | Coverage Class Codes | 📦4.0.1 | FHIR Std.
Coverage.class:pcn.type | Base | extensible | Coverage Class Codes | 📦4.0.1 | FHIR Std.
Coverage.class:rxgroup-id.​type | Base | extensible | Coverage Class Codes | 📦4.0.1 | FHIR Std.
Coverage.class:member-id.​type | Base | extensible | Coverage Class Codes | 📦4.0.1 | FHIR Std.
Coverage.costToBeneficiary.​type | Base | extensible | Coverage Copay Type Codes | 📍4.0.1 | FHIR Std.
Coverage.costToBeneficiary.​exception.type | Base | example | Example Coverage Financial Exception Codes | 📍4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
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()`
us-core-15 | error | Coverage | Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present | `identifier.type.coding.where(system='http://terminology.hl7.org/CodeSystem/v2-0203' and code='MB').exists() or subscriberId.exists()`

Summary

Mandatory: 2 elements(3 nested mandatory elements)
Must-Support: 10 elements
Fixed: 4 elements
Prohibited: 3 elements

Extensions

This structure refers to these extensions:

- http://hl7.org/fhir/StructureDefinition/data-absent-reason|5.2.0

Slices

This structure defines the following Slices:

- The element 1 is sliced based on the value of Coverage.class

Maturity: 2

Key Elements View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Coverage | C | 0..* | USCoreCoverageProfile | Insurance or medical plan or a payment agreement Constraints: us-core-15
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
Slices for identifier | S Σ | 0..* | Identifier | Member ID and other identifiers Slice: Unordered, Open by value:type
identifier:memberid | S Σ C | 0..1 | Identifier | Member ID
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type | S Σ | 1..1 | CodeableConcept | Member Number identifier type 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. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: MB
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
status | ?!S Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
type | S Σ | 0..1 | CodeableConcept | Coverage category such as medical or accident Binding: Payer Type (extensible): US Public Health Data Consortium Source of Payment Codes
subscriberId | S Σ C | 0..1 | string | Subscriber ID (masked)
Slices for extension | S | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:data-masked | S | 1..1 | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/data-absent-reason"
value[x] |  | 1..1 | code | Value of extension Binding: DataAbsentReason (required) Fixed Value: masked
beneficiary | S Σ | 1..1 | Reference(US Core Patient Profile) | Patient information (masked)
Slices for extension | S | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:data-masked | S | 1..1 | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/data-absent-reason"
value[x] |  | 1..1 | code | Value of extension Binding: DataAbsentReason (required) Fixed Value: masked
identifier | Σ | 0..1 | Identifier | Unique, non-personally identifiable code
relationship | S | 1..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible)
period | S Σ | 0..1 | Period | Coverage start and end dates
payor | S Σ | 1..1 | Reference(US Core Organization Profile S | US Core Patient Profile | US Core RelatedPerson Profile) | Issuer of the policy
identifier | S Σ | 0..1 | Identifier | Payer ID
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
value | S Σ | 1..1 | string | Payer ID Value Example General: 123456
Slices for class | S | 0..* | BackboneElement | Pharmacy coverage identifiers Slice: Unordered, Open by value:type
class:All Slices |  |  |  | Content/Rules for all slices
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): Coverage Class Codes
value | Σ | 1..1 | string | Value associated with the type
class:group | S | 0..1 | BackboneElement | Group
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: group
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
value | S Σ | 1..1 | string | Group Identifier
class:plan | S | 0..1 | BackboneElement | Plan
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: plan
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
value | S Σ | 1..1 | string | Plan Number
name | S Σ | 0..1 | string | Plan Name
class:bin | S | 0..1 | BackboneElement | IIN (BIN) number
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): Coverage Class Codes Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxbin
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
value | Σ | 1..1 | string | Value associated with the type
class:pcn | S | 0..1 | BackboneElement | Processor Control Number (PCN)
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): Coverage Class Codes Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxpcn
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
value | Σ | 1..1 | string | Value associated with the type
class:rxgroup-id | S | 0..1 | BackboneElement | Pharmacy Benefit Group ID
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): Coverage Class Codes Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxgroup
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
value | Σ | 1..1 | string | Value associated with the type
class:member-id | S | 0..1 | BackboneElement | PBM Member ID
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): Coverage Class Codes Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxid
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
value | Σ | 1..1 | string | Value associated with the type
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Coverage.identifier:memberid.​use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std.
Coverage.identifier:memberid.​type | Base | extensible | IdentifierType | 📍4.0.1 | FHIR Std.
Coverage.status | Base | required | Financial Resource Status Codes | 📍4.0.1 | FHIR Std.
Coverage.type | Base | extensible | Payer Type | 📦20250419 | VSAC v0.24
Coverage.subscriberId.​extension:data-masked.​value[x] | Base | required | DataAbsentReason | 📦4.0.1 | FHIR Std.
Coverage.beneficiary.​extension:data-masked.​value[x] | Base | required | DataAbsentReason | 📦4.0.1 | FHIR Std.
Coverage.relationship | Base | extensible | SubscriberPolicyholder Relationship Codes | 📦4.0.1 | FHIR Std.
Coverage.payor.identifier.​use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std.
Coverage.class.type | Base | extensible | Coverage Class Codes | 📦4.0.1 | FHIR Std.
Coverage.class:group.​type | Base | extensible | Coverage Class Codes | 📍4.0.1 | FHIR Std.
Coverage.class:plan.​type | Base | extensible | Coverage Class Codes | 📍4.0.1 | FHIR Std.
Coverage.class:bin.type | Base | extensible | Coverage Class Codes | 📦4.0.1 | FHIR Std.
Coverage.class:pcn.type | Base | extensible | Coverage Class Codes | 📦4.0.1 | FHIR Std.
Coverage.class:rxgroup-id.​type | Base | extensible | Coverage Class Codes | 📦4.0.1 | FHIR Std.
Coverage.class:member-id.​type | Base | extensible | Coverage Class Codes | 📦4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
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()`
us-core-15 | error | Coverage | Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present | `identifier.type.coding.where(system='http://terminology.hl7.org/CodeSystem/v2-0203' and code='MB').exists() or subscriberId.exists()`

Differential View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Coverage |  | 0..* | USCoreCoverageProfile | Insurance or medical plan or a payment agreement
subscriberId |  | 0..1 | string | Subscriber ID (masked)
Slices for extension | S | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:data-masked | S | 1..1 | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
value[x] |  | 1..1 | code | Value of extension Fixed Value: masked
beneficiary |  | 1..1 | Reference(US Core Patient Profile) | Patient information (masked)
extension | S | 1..* | Extension | Extension
Slices for extension |  |  |  | Content/Rules for all slices
extension:data-masked | S | 1..1 | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
value[x] |  | 1..1 | code | Value of extension Fixed Value: masked
reference |  | 0..0 |  | Literal reference, Relative, internal or absolute URL
type |  | 0..0 |  | Type the reference refers to (e.g. "Patient")
identifier |  | 0..1 | Identifier | Unique, non-personally identifiable code
display |  | 0..0 |  | Text alternative for the resource
relationship |  | 1..1 | CodeableConcept | Beneficiary relationship to the subscriber
coding |  |  |  |
system |  | 0..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/subscriber-relationship
code |  | 0..1 | code | Symbol in syntax defined by the system Fixed Value: self
payor |  |  |  |
identifier | S | 0..1 | Identifier | Payer ID
value | S | 1..1 | string | Payer ID Value
Slices for class |  | 0..* | BackboneElement | Pharmacy coverage identifiers Slice: Unordered, Open by value:type
class:All Slices |  |  |  | Content/Rules for all slices
type |  | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): Coverage Class Codes
class:bin | S | 0..1 | BackboneElement | IIN (BIN) number
type |  | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxbin
class:pcn | S | 0..1 | BackboneElement | Processor Control Number (PCN)
type |  | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxpcn
class:rxgroup-id | S | 0..1 | BackboneElement | Pharmacy Benefit Group ID
type |  | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxgroup
class:member-id | S | 0..1 | BackboneElement | PBM Member ID
type |  | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxid
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
Coverage.class.type | Base | extensible | Coverage Class Codes | 📦4.0.1 | FHIR Std.

Snapshot ViewView

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Coverage | C | 0..* | USCoreCoverageProfile | Insurance or medical plan or a payment agreement Constraints: us-core-15
id | Σ | 0..1 | id | Logical id of this artifact
meta | Σ | 0..1 | Meta | Metadata about the resource
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
language |  | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
text |  | 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
contained |  | 0..* | Resource | Contained, inline Resources
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
Slices for identifier | S Σ | 0..* | Identifier | Member ID and other identifiers Slice: Unordered, Open by value:type
identifier:memberid | S Σ C | 0..1 | Identifier | Member ID
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type | S Σ | 1..1 | CodeableConcept | Member Number identifier type 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. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: MB
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
system | Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value | Σ | 0..1 | string | The value that is unique Example General: 123456
period | Σ | 0..1 | Period | Time period when id is/was valid for use
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text)
status | ?!S Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
type | S Σ | 0..1 | CodeableConcept | Coverage category such as medical or accident Binding: Payer Type (extensible): US Public Health Data Consortium Source of Payment Codes
policyHolder | Σ | 0..1 | Reference(Patient | RelatedPerson | Organization) | Owner of the policy
subscriber | Σ | 0..1 | Reference(Patient | RelatedPerson) | Subscriber to the policy
subscriberId | S Σ C | 0..1 | string | Subscriber ID (masked)
id |  | 0..1 | string | xml:id (or equivalent in JSON)
Slices for extension | S | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:data-masked | S | 1..1 | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
id |  | 0..1 | id | Unique id for inter-element referencing
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/data-absent-reason"
value[x] |  | 1..1 | code | Value of extension Binding: DataAbsentReason (required) Fixed Value: masked
value |  | 0..1 | string | Primitive value for string Max Length:1048576
beneficiary | S Σ | 1..1 | Reference(US Core Patient Profile) | Patient information (masked)
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension | S | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:data-masked | S | 1..1 | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
id |  | 0..1 | id | Unique id for inter-element referencing
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/data-absent-reason"
value[x] |  | 1..1 | code | Value of extension Binding: DataAbsentReason (required) Fixed Value: masked
identifier | Σ | 0..1 | Identifier | Unique, non-personally identifiable code
dependent | Σ | 0..1 | string | Dependent number
relationship | S | 1..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
coding | Σ | 0..* | Coding | Code defined by a terminology system
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
system | Σ | 0..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/subscriber-relationship
version | Σ | 0..1 | string | Version of the system - if relevant
code | Σ | 0..1 | code | Symbol in syntax defined by the system Fixed Value: self
display | Σ | 0..1 | string | Representation defined by the system
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user
text | Σ | 0..1 | string | Plain text representation of the concept
period | S Σ | 0..1 | Period | Coverage start and end dates
payor | S Σ | 1..1 | Reference(US Core Organization Profile S | US Core Patient Profile | US Core RelatedPerson Profile) | Issuer of the policy
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
reference | Σ C | 0..1 | string | Literal reference, Relative, internal or absolute URL
type | 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).
identifier | S Σ | 0..1 | Identifier | Payer ID
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type | 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.
system | Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value | S Σ | 1..1 | string | Payer ID Value Example General: 123456
period | Σ | 0..1 | Period | Time period when id is/was valid for use
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text)
display | Σ | 0..1 | string | Text alternative for the resource
Slices for class | S | 0..* | BackboneElement | Pharmacy coverage identifiers Slice: Unordered, Open by value:type
class:All Slices |  |  |  | Content/Rules for all slices
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): Coverage Class Codes
value | Σ | 1..1 | string | Value associated with the type
name | Σ | 0..1 | string | Human readable description of the type and value
class:group | S | 0..1 | BackboneElement | Group
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: group
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
value | S Σ | 1..1 | string | Group Identifier
name | Σ | 0..1 | string | Human readable description of the type and value
class:plan | S | 0..1 | BackboneElement | Plan
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: plan
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
value | S Σ | 1..1 | string | Plan Number
name | S Σ | 0..1 | string | Plan Name
class:bin | S | 0..1 | BackboneElement | IIN (BIN) number
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): Coverage Class Codes Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxbin
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
value | Σ | 1..1 | string | Value associated with the type
name | Σ | 0..1 | string | Human readable description of the type and value
class:pcn | S | 0..1 | BackboneElement | Processor Control Number (PCN)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): Coverage Class Codes Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxpcn
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
value | Σ | 1..1 | string | Value associated with the type
name | Σ | 0..1 | string | Human readable description of the type and value
class:rxgroup-id | S | 0..1 | BackboneElement | Pharmacy Benefit Group ID
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): Coverage Class Codes Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxgroup
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
value | Σ | 1..1 | string | Value associated with the type
name | Σ | 0..1 | string | Human readable description of the type and value
class:member-id | S | 0..1 | BackboneElement | PBM Member ID
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): Coverage Class Codes Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxid
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
value | Σ | 1..1 | string | Value associated with the type
name | Σ | 0..1 | string | Human readable description of the type and value
order | Σ | 0..1 | positiveInt | Relative order of the coverage
network | Σ | 0..1 | string | Insurer network
costToBeneficiary |  | 0..* | BackboneElement | Patient payments for services/products
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 0..1 | CodeableConcept | Cost category Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified.
value[x] | Σ | 1..1 |  | The amount or percentage due from the beneficiary
valueQuantity |  |  | Quantity(SimpleQuantity) |
valueMoney |  |  | Money |
exception |  | 0..* | BackboneElement | Exceptions for patient payments
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | 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.
period | Σ | 0..1 | Period | The effective period of the exception
subrogation |  | 0..1 | boolean | Reimbursement to insurer
contract |  | 0..* | Reference(Contract) | Contract details
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Coverage.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
Coverage.identifier:memberid.​use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std.
Coverage.identifier:memberid.​type | Base | extensible | IdentifierType | 📍4.0.1 | FHIR Std.
Coverage.status | Base | required | Financial Resource Status Codes | 📍4.0.1 | FHIR Std.
Coverage.type | Base | extensible | Payer Type | 📦20250419 | VSAC v0.24
Coverage.subscriberId.​extension:data-masked.​value[x] | Base | required | DataAbsentReason | 📦4.0.1 | FHIR Std.
Coverage.beneficiary.​extension:data-masked.​value[x] | Base | required | DataAbsentReason | 📦4.0.1 | FHIR Std.
Coverage.relationship | Base | extensible | SubscriberPolicyholder Relationship Codes | 📦4.0.1 | FHIR Std.
Coverage.payor.type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std.
Coverage.payor.identifier.​use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std.
Coverage.payor.identifier.​type | Base | extensible | IdentifierType | 📍4.0.1 | FHIR Std.
Coverage.class.type | Base | extensible | Coverage Class Codes | 📦4.0.1 | FHIR Std.
Coverage.class:group.​type | Base | extensible | Coverage Class Codes | 📍4.0.1 | FHIR Std.
Coverage.class:plan.​type | Base | extensible | Coverage Class Codes | 📍4.0.1 | FHIR Std.
Coverage.class:bin.type | Base | extensible | Coverage Class Codes | 📦4.0.1 | FHIR Std.
Coverage.class:pcn.type | Base | extensible | Coverage Class Codes | 📦4.0.1 | FHIR Std.
Coverage.class:rxgroup-id.​type | Base | extensible | Coverage Class Codes | 📦4.0.1 | FHIR Std.
Coverage.class:member-id.​type | Base | extensible | Coverage Class Codes | 📦4.0.1 | FHIR Std.
Coverage.costToBeneficiary.​type | Base | extensible | Coverage Copay Type Codes | 📍4.0.1 | FHIR Std.
Coverage.costToBeneficiary.​exception.type | Base | example | Example Coverage Financial Exception Codes | 📍4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
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()`
us-core-15 | error | Coverage | Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present | `identifier.type.coding.where(system='http://terminology.hl7.org/CodeSystem/v2-0203' and code='MB').exists() or subscriberId.exists()`

Summary

Mandatory: 2 elements(3 nested mandatory elements)
Must-Support: 10 elements
Fixed: 4 elements
Prohibited: 3 elements

Extensions

This structure refers to these extensions:

- http://hl7.org/fhir/StructureDefinition/data-absent-reason|5.2.0

Slices

This structure defines the following Slices:

- The element 1 is sliced based on the value of Coverage.class

Maturity: 2

Other representations of profile: CSV, Excel, Schematron