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

• Content
• Detailed Descriptions
• Mappings
• Examples
• XML
• JSON
• TTL

Resource Profile: RTPBC Coverage - Non-PHI

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

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	SΣ	0..*	Identifier	Member ID and other identifiers Slice: Unordered, Open by value:type
identifier:memberid	SΣC	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	SΣ	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	?!SΣ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
type	SΣ	0..1	CodeableConcept	Coverage category such as medical or accident Binding: Payer Type (extensible): US Public Health Data Consortium Source of Payment Codes
subscriberId	SΣC	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	SΣ	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	SΣ	0..1	Period	Coverage start and end dates
payor	SΣ	1..1	Reference(US Core Organization Profile S | US Core Patient Profile | US Core RelatedPerson Profile)	Issuer of the policy
identifier	SΣ	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	SΣ	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	SΣ	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	SΣ	1..1	string	Plan Number
name	SΣ	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	SΣ	0..*	Identifier	Member ID and other identifiers Slice: Unordered, Open by value:type
identifier:memberid	SΣC	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	SΣ	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	?!SΣ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
type	SΣ	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	SΣC	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	SΣ	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	SΣ	0..1	Period	Coverage start and end dates
payor	SΣ	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	ΣC	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	SΣ	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	SΣ	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	SΣ	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	SΣ	1..1	string	Plan Number
name	SΣ	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	SΣ	0..*	Identifier	Member ID and other identifiers Slice: Unordered, Open by value:type
identifier:memberid	SΣC	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	SΣ	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	?!SΣ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
type	SΣ	0..1	CodeableConcept	Coverage category such as medical or accident Binding: Payer Type (extensible): US Public Health Data Consortium Source of Payment Codes
subscriberId	SΣC	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	SΣ	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	SΣ	0..1	Period	Coverage start and end dates
payor	SΣ	1..1	Reference(US Core Organization Profile S | US Core Patient Profile | US Core RelatedPerson Profile)	Issuer of the policy
identifier	SΣ	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	SΣ	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	SΣ	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	SΣ	1..1	string	Plan Number
name	SΣ	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	SΣ	0..*	Identifier	Member ID and other identifiers Slice: Unordered, Open by value:type
identifier:memberid	SΣC	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	SΣ	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	?!SΣ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
type	SΣ	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	SΣC	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	SΣ	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	SΣ	0..1	Period	Coverage start and end dates
payor	SΣ	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	ΣC	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	SΣ	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	SΣ	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	SΣ	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	SΣ	1..1	string	Plan Number
name	SΣ	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