| Left: | US Core Coverage Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-coverage) |
| Right: | Davinci ATR Coverage 3.1 (http://hl7.org/fhir/us/davinci-atr/StructureDefinition/atr-coverage) |
| Error | StructureDefinition.url | Values for url differ: 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-coverage' vs 'http://hl7.org/fhir/us/davinci-atr/StructureDefinition/atr-coverage' |
| Error | StructureDefinition.version | Values for version differ: '7.0.0' vs '2.1.0-preview' |
| Information | StructureDefinition.name | Values for name differ: 'USCoreCoverageProfile' vs 'ATRCoverage31' |
| Information | StructureDefinition.title | Values for title differ: 'US Core Coverage Profile' vs 'Davinci ATR Coverage 3.1' |
| Information | StructureDefinition.date | Values for date differ: '2023-10-17' vs '2019-09-01' |
| Information | StructureDefinition.publisher | Values for publisher differ: 'HL7 International / Cross-Group Projects' vs 'HL7 International / Financial Management' |
| Information | StructureDefinition.short | Values for short differ: 'Insurance or medical plan or a payment agreement' vs 'Davinci ATR Coverage 3.1' |
| Information | StructureDefinition.definition | Values for definition differ: 'Financial instrument which may be used to reimburse or pay for health care products and services. Includes both insurance and self-payment.' vs 'Sets expectations for supported capabilities for Coverage resource in Member Attribution Lists.' |
| Information | StructureDefinition.short | Values for short differ: 'Additional content defined by implementations' vs 'Extension' |
| Information | StructureDefinition.definition | Values for definition differ: 'May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.' vs 'An Extension' |
| Information | StructureDefinition.short | Values for short differ: 'Member ID and other identifiers' vs 'Business Identifier for the coverage' |
| Information | StructureDefinition.comment | Values for comment differ: 'The `Coverage.status` alone does not indicate whether an individual's coverage is terminated or that the individual is not covered. The `Coverage.period` needs to be considered as well.' vs 'This element is labeled as a modifier because the status contains the code entered-in-error that marks the coverage as not currently valid.' |
| Warning | Coverage.type | Elements differ in definition for mustSupport: 'true' vs 'false' |
| Warning | Coverage.policyHolder | Elements differ in definition for mustSupport: 'false' vs 'true' |
| Warning | Coverage.subscriber | Elements differ in definition for mustSupport: 'false' vs 'true' |
| Information | Coverage.subscriberId | Element minimum cardinalities differ: '0' vs '1' |
| Warning | Coverage.dependent | Elements differ in definition for mustSupport: 'false' vs 'true' |
| Information | StructureDefinition.comment | Values for comment differ: 'Relationship of the member to the person insured (subscriber)' vs 'Typically, an individual uses policies which are theirs (relationship='self') before policies owned by others.' |
| Information | Coverage.relationship | Element minimum cardinalities differ: '1' vs '0' |
| Information | Coverage.period | Element minimum cardinalities differ: '0' vs '1' |
| Information | StructureDefinition.comment | Values for comment differ: 'Issuer of the Policy' vs 'May provide multiple identifiers such as insurance company identifier or business identifier (BIN number). For selfpay it may provide multiple paying persons and/or organizations.' |
| Error | Coverage.payor | Type Mismatch: Reference([CanonicalType[http://hl7.org/fhir/us/core/StructureDefinition/us-core-organization], CanonicalType[http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient], CanonicalType[http://hl7.org/fhir/us/core/StructureDefinition/us-core-relatedperson]]) vs Reference([CanonicalType[http://hl7.org/fhir/us/davinci-atr/StructureDefinition/atr-patient], CanonicalType[http://hl7.org/fhir/us/davinci-atr/StructureDefinition/atr-relatedperson], CanonicalType[http://hl7.org/fhir/us/core/StructureDefinition/us-core-relatedperson], CanonicalType[http://hl7.org/fhir/us/davinci-atr/StructureDefinition/atr-organization]]) |
| Name | Value | Comments | |
|---|---|---|---|
 abstract | false | ||
| baseDefinition | http://hl7.org/fhir/StructureDefinition/Coverage | ||
| copyright | Used by permission of HL7 International, all rights reserved Creative Commons License |
| |
| date | 2023-10-17 | 2019-09-01 |
|
| description | The US Core Coverage Profile inherits from the FHIR [Coverage](https://hl7.org/fhir/R4/coverage.html) resource; refer to it for scope and usage definitions. This profile meets the requirements of the US Core Data for Interoperability (USCDI) *Health Insurance Information* Data Class. It sets minimum expectations for the Coverage resource to record, search, and fetch data related to an individual's insurance coverage for health care. It specifies which core elements, extensions, vocabularies, and value sets **SHALL** be present in the resource and constrains how the elements are used. Providing the floor for standards development for specific use cases promotes interoperability and adoption. | This is the Coverage Resource profile for the IG to be used when vendors are implementing US Core 3.1.1 |
|
| experimental | false | ||
| fhirVersion | 4.0.1 | ||
| jurisdiction | |||
 jurisdiction[0] | urn:iso:std:iso:3166#US | ||
| kind | resource | ||
| name | USCoreCoverageProfile | ATRCoverage31 |
|
| publisher | HL7 International / Cross-Group Projects | HL7 International / Financial Management |
|
| purpose | |||
| status | active | ||
| title | US Core Coverage Profile | Davinci ATR Coverage 3.1 |
|
| type | Coverage | ||
| url | http://hl7.org/fhir/us/core/StructureDefinition/us-core-coverage | http://hl7.org/fhir/us/davinci-atr/StructureDefinition/atr-coverage |
|
| version | 7.0.0 | 2.1.0-preview |
|
| Name | L Flags | L Card. | L Type | L Description & Constraints | R Flags | R Card. | R Type | R Description & Constraints | Comments | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
 Coverage | C | 0..* | Coverage | Insurance or medical plan or a payment agreement us-core-15: Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present | 0..* | Coverage | Davinci ATR Coverage 3.1 | ||||||||||
 id | Σ | 0..1 | id | Logical id of this artifact | Σ | 0..1 | id | Logical id of this artifact | |||||||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | Σ | 0..1 | Meta | Metadata about the resource | |||||||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ?!Σ | 0..1 | uri | A set of rules under which this content was created | |||||||||
| language | 0..1 | code | Language of the resource content Binding: ?? (preferred): A human language.
| 0..1 | code | Language of the resource content Binding: ?? (preferred): A human language.
| |||||||||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||||||||
| contained | 0..* | Resource | Contained, inline Resources | 0..* | Resource | Contained, inline Resources | |||||||||||
 extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||||
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ?! | 0..* | Extension | Extensions that cannot be ignored | |||||||||
| Slices for identifier | SΣ | 0..* | Identifier | Member ID and other identifiers Slice: Unordered, Open by pattern:type | SΣ | 0..* | Identifier | Business Identifier for the coverage Slice: Unordered, Open by value:type.coding.system, value:type.coding.code | |||||||||
| status | ?!SΣ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ?? (required): A code specifying the state of the resource instance. | ?!SΣ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ?? (required): A code specifying the state of the resource instance. Fixed Value: active | |||||||||
| type | SΣ | 0..1 | CodeableConcept | Coverage category such as medical or accident Binding: ?? (extensible): US Public Health Data Consortium Source of Payment Codes | Σ | 0..1 | CodeableConcept | Coverage category such as medical or accident Binding: ?? (preferred): The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization. |
| ||||||||
| policyHolder | Σ | 0..1 | Reference(Patient | RelatedPerson | Organization) | Owner of the policy | SΣ | 0..1 | Reference(Davinci ATR Patient | Davinci ATR RelatedPerson 3.1 | US Core RelatedPerson Profile(7.0.0) | Davinci ATR Organization) | Owner of the policy |
| ||||||||
| subscriber | Σ | 0..1 | Reference(Patient | RelatedPerson) | Subscriber to the policy | SΣ | 0..1 | Reference(Davinci ATR Patient | Davinci ATR RelatedPerson 3.1 | US Core RelatedPerson Profile(7.0.0)) | Subscriber to the policy |
| ||||||||
| subscriberId | SΣC | 0..1 | string | ID assigned to the subscriber | SΣ | 1..1 | string | ID assigned to the subscriber |
| ||||||||
| beneficiary | SΣ | 1..1 | Reference(US Core Patient Profile(7.0.0)) | Plan beneficiary | SΣ | 1..1 | Reference(Davinci ATR Patient) | Plan beneficiary | |||||||||
| dependent | Σ | 0..1 | string | Dependent number | SΣ | 0..1 | string | Dependent number |
| ||||||||
| relationship | S | 1..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: ?? (extensible) | S | 0..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: ?? (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient). |
| ||||||||
| period | SΣ | 0..1 | Period | Coverage start and end dates | SΣ | 1..1 | Period | Coverage start and end dates |
| ||||||||
| payor | SΣ | 1..1 | Reference(US Core Organization Profile(7.0.0) S | US Core Patient Profile(7.0.0) | US Core RelatedPerson Profile(7.0.0)) | Issuer of the policy | SΣ | 1..1 | Reference(Davinci ATR Patient | Davinci ATR RelatedPerson 3.1 | US Core RelatedPerson Profile(7.0.0) | Davinci ATR Organization) | Issuer of the policy |
| ||||||||
 Slices for class | S | 0..* | BackboneElement | Additional coverage classifications Slice: Unordered, Open by pattern:type | S | 0..* | BackboneElement | Additional coverage classifications Slice: Unordered, Open by value:type.coding.system, value:type.coding.code | |||||||||
 id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
| extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!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: ?? (extensible): The policy classifications, eg. Group, Plan, Class, etc. | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: ?? (extensible): The policy classifications, eg. Group, Plan, Class, etc. | |||||||||
| value | Σ | 1..1 | string | Value associated with the type | Σ | 1..1 | string | Value associated with the type | |||||||||
| name | Σ | 0..1 | string | Human readable description of the type and value | Σ | 0..1 | string | Human readable description of the type and value | |||||||||
| order | Σ | 0..1 | positiveInt | Relative order of the coverage | Σ | 0..1 | positiveInt | Relative order of the coverage | |||||||||
| network | Σ | 0..1 | string | Insurer network | Σ | 0..1 | string | Insurer network | |||||||||
| costToBeneficiary | 0..* | BackboneElement | Patient payments for services/products | 0..* | BackboneElement | Patient payments for services/products | |||||||||||
| id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
| extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||||||
| type | Σ | 0..1 | CodeableConcept | Cost category Binding: ?? (extensible): The types of services to which patient copayments are specified. | Σ | 0..1 | CodeableConcept | Cost category Binding: ?? (extensible): The types of services to which patient copayments are specified. | |||||||||
| value[x] | Σ | 1..1 | ??, Money | The amount or percentage due from the beneficiary | Σ | 1..1 | ??, Money | The amount or percentage due from the beneficiary | |||||||||
 exception | 0..* | BackboneElement | Exceptions for patient payments | 0..* | BackboneElement | Exceptions for patient payments | |||||||||||
 id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
| extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||||||
| type | Σ | 1..1 | CodeableConcept | Exception category Binding: ?? (example): The types of exceptions from the part or full value of financial obligations such as copays. | Σ | 1..1 | CodeableConcept | Exception category Binding: ?? (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 | Σ | 0..1 | Period | The effective period of the exception | |||||||||
| subrogation | 0..1 | boolean | Reimbursement to insurer | 0..1 | boolean | Reimbursement to insurer | |||||||||||
| contract | 0..* | Reference(Contract) | Contract details | 0..* | Reference(Contract) | Contract details | |||||||||||
| Documentation for this format | |||||||||||||||||