Da Vinci - Coverage Requirements Discovery
2.2.1 - STU 2.2

Da Vinci - Coverage Requirements Discovery, published by HL7 International / Financial Management. This guide is not an authorized publication; it is the continuous build for version 2.2.1 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/davinci-crd/ and changes regularly. See the Directory of published versions

## Resource Profile: CRD Coverage

Official URL: http://hl7.org/fhir/us/davinci-crd/StructureDefinition/profile-coverage | Version: 2.2.1 | Highlight text changes?
Standards status: Trial-use Active as of 2026-03-26 | Maturity Level: 4 | Computable Name: CRDCoverage
Other Identifiers: OID:2.16.840.1.113883.4.642.40.18.42.7

This profile specifies constraints on the Coverage resource to support coverage requirements discovery.

### Usage

CRD Clients SHALL use the CRD Coverage profile to resolve references to insurance Coverage resources passed to CRD Servers. §prof-4

Information provided in Must Support elements will commonly be required for CRD Servers to perform coverage requirements discovery.

Usages:

- Use this Profile: CRD CDSHooks Adjust Coverage Response (Logical Definition)
- Refer to this Profile: Coverage Information
- CapabilityStatements using this Profile: CRD Client USCDI 1, CRD Client USCDI 3 and CRD Client USCDI 4

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(7.0.0) | Insurance or medical plan or a payment agreement This profile also complies with the profile US Core Coverage Profile (6.1.0) Constraints: us-core-15
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
Slices for identifier | S Σ | 0..* | Identifier | Member ID and other identifiers Slice: Unordered, Open by pattern:type
identifier:memberid | S Σ C | 0..1 | Identifier | Member ID
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type | S Σ | 1..1 | CodeableConcept | Member Number identifier type Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: MB
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
status | ?!S Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
type | S Σ | 0..1 | CodeableConcept | Coverage category such as medical or accident Binding: Payer Type (extensible): US Public Health Data Consortium Source of Payment Codes
policyHolder | S Σ | 0..1 | Reference(CRD Patient | CRD Organization) | Owner of the policy
subscriber | S Σ | 0..1 | Reference(CRD Patient) | Subscriber to the policy
subscriberId | S Σ C | 0..1 | string | ID assigned to the subscriber
beneficiary | S Σ | 1..1 | Reference(CRD Patient) | Plan beneficiary
dependent | S Σ | 0..1 | string | Dependent number
relationship | S | 1..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible)
period | S Σ | 0..1 | Period | Coverage start and end dates
payor | S Σ | 1..1 | Reference(CRD Organization) | Issuer of the policy
Slices for class | S | 0..* | BackboneElement | Additional coverage classifications Slice: Unordered, Open by pattern: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): The policy classifications, eg. Group, Plan, Class, etc.
value | Σ | 1..1 | string | Value associated with the type
class:group | S | 0..1 | BackboneElement | Group
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: group
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
value | S Σ | 1..1 | string | Group Number
name | S Σ | 0..1 | string | Group Name
class:plan | S | 0..1 | BackboneElement | Plan
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: plan
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
value | S Σ | 1..1 | string | Plan Number
name | S Σ | 0..1 | string | Plan Name
order | S Σ | 0..1 | positiveInt | Relative order of the coverage
network | S Σ | 0..1 | string | Insurer network
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 | 📦20221118 | VSAC v0.19
Coverage.relationship | Base | extensible | SubscriberPolicyholder Relationship Codes | 📦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.

#### 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(7.0.0) | Insurance or medical plan or a payment agreement This profile also complies with the profile US Core Coverage Profile (6.1.0)
policyHolder | S | 0..1 | Reference(CRD Patient | CRD Organization) | Owner of the policy
subscriber | S | 0..1 | Reference(CRD Patient) | Subscriber to the policy
beneficiary |  | 1..1 | Reference(CRD Patient) | Plan beneficiary
dependent | S | 0..1 | string | Dependent number
payor |  | 1..1 | Reference(CRD Organization) | Issuer of the policy
order | S | 0..1 | positiveInt | Relative order of the coverage
network | S | 0..1 | string | Insurer network
costToBeneficiary |  | 0..0 |  | Patient payments for services/products
Documentation for this format

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Coverage | C | 0..* | USCoreCoverageProfile(7.0.0) | Insurance or medical plan or a payment agreement This profile also complies with the profile US Core Coverage Profile (6.1.0) Constraints: us-core-15
id | Σ | 0..1 | id | Logical id of this artifact
meta | Σ | 0..1 | Meta | Metadata about the resource
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
language |  | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
text |  | 0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained |  | 0..* | Resource | Contained, inline Resources
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
Slices for identifier | S Σ | 0..* | Identifier | Member ID and other identifiers Slice: Unordered, Open by pattern:type
identifier:memberid | S Σ C | 0..1 | Identifier | Member ID
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type | S Σ | 1..1 | CodeableConcept | Member Number identifier type Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: MB
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
system | Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value | Σ | 0..1 | string | The value that is unique Example General: 123456
period | Σ | 0..1 | Period | Time period when id is/was valid for use
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text)
status | ?!S Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
type | S Σ | 0..1 | CodeableConcept | Coverage category such as medical or accident Binding: Payer Type (extensible): US Public Health Data Consortium Source of Payment Codes
policyHolder | S Σ | 0..1 | Reference(CRD Patient | CRD Organization) | Owner of the policy
subscriber | S Σ | 0..1 | Reference(CRD Patient) | Subscriber to the policy
subscriberId | S Σ C | 0..1 | string | ID assigned to the subscriber
beneficiary | S Σ | 1..1 | Reference(CRD Patient) | Plan beneficiary
dependent | S Σ | 0..1 | string | Dependent number
relationship | S | 1..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible)
period | S Σ | 0..1 | Period | Coverage start and end dates
payor | S Σ | 1..1 | Reference(CRD Organization) | Issuer of the policy
Slices for class | S | 0..* | BackboneElement | Additional coverage classifications Slice: Unordered, Open by pattern: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): The policy classifications, eg. Group, Plan, Class, etc.
value | Σ | 1..1 | string | Value associated with the type
name | Σ | 0..1 | string | Human readable description of the type and value
class:group | S | 0..1 | BackboneElement | Group
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: group
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
value | S Σ | 1..1 | string | Group Number
name | S Σ | 0..1 | string | Group Name
class:plan | S | 0..1 | BackboneElement | Plan
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: plan
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
value | S Σ | 1..1 | string | Plan Number
name | S Σ | 0..1 | string | Plan Name
order | S Σ | 0..1 | positiveInt | Relative order of the coverage
network | S Σ | 0..1 | string | Insurer network
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 | 📦20221118 | VSAC v0.19
Coverage.relationship | Base | extensible | SubscriberPolicyholder Relationship Codes | 📦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.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

Must-Support: 5 elements
Prohibited: 1 element

Structures

This structure refers to these other structures:

- CRD Patient (http://hl7.org/fhir/us/davinci-crd/StructureDefinition/profile-patient)
- CRD Organization (http://hl7.org/fhir/us/davinci-crd/StructureDefinition/profile-organization)

Maturity: 4

Key Elements View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Coverage | C | 0..* | USCoreCoverageProfile(7.0.0) | Insurance or medical plan or a payment agreement This profile also complies with the profile US Core Coverage Profile (6.1.0) Constraints: us-core-15
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
Slices for identifier | S Σ | 0..* | Identifier | Member ID and other identifiers Slice: Unordered, Open by pattern:type
identifier:memberid | S Σ C | 0..1 | Identifier | Member ID
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type | S Σ | 1..1 | CodeableConcept | Member Number identifier type Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: MB
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
status | ?!S Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
type | S Σ | 0..1 | CodeableConcept | Coverage category such as medical or accident Binding: Payer Type (extensible): US Public Health Data Consortium Source of Payment Codes
policyHolder | S Σ | 0..1 | Reference(CRD Patient | CRD Organization) | Owner of the policy
subscriber | S Σ | 0..1 | Reference(CRD Patient) | Subscriber to the policy
subscriberId | S Σ C | 0..1 | string | ID assigned to the subscriber
beneficiary | S Σ | 1..1 | Reference(CRD Patient) | Plan beneficiary
dependent | S Σ | 0..1 | string | Dependent number
relationship | S | 1..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible)
period | S Σ | 0..1 | Period | Coverage start and end dates
payor | S Σ | 1..1 | Reference(CRD Organization) | Issuer of the policy
Slices for class | S | 0..* | BackboneElement | Additional coverage classifications Slice: Unordered, Open by pattern: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): The policy classifications, eg. Group, Plan, Class, etc.
value | Σ | 1..1 | string | Value associated with the type
class:group | S | 0..1 | BackboneElement | Group
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: group
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
value | S Σ | 1..1 | string | Group Number
name | S Σ | 0..1 | string | Group Name
class:plan | S | 0..1 | BackboneElement | Plan
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: plan
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
value | S Σ | 1..1 | string | Plan Number
name | S Σ | 0..1 | string | Plan Name
order | S Σ | 0..1 | positiveInt | Relative order of the coverage
network | S Σ | 0..1 | string | Insurer network
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 | 📦20221118 | VSAC v0.19
Coverage.relationship | Base | extensible | SubscriberPolicyholder Relationship Codes | 📦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.

#### 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(7.0.0) | Insurance or medical plan or a payment agreement This profile also complies with the profile US Core Coverage Profile (6.1.0)
policyHolder | S | 0..1 | Reference(CRD Patient | CRD Organization) | Owner of the policy
subscriber | S | 0..1 | Reference(CRD Patient) | Subscriber to the policy
beneficiary |  | 1..1 | Reference(CRD Patient) | Plan beneficiary
dependent | S | 0..1 | string | Dependent number
payor |  | 1..1 | Reference(CRD Organization) | Issuer of the policy
order | S | 0..1 | positiveInt | Relative order of the coverage
network | S | 0..1 | string | Insurer network
costToBeneficiary |  | 0..0 |  | Patient payments for services/products
Documentation for this format

Snapshot ViewView

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Coverage | C | 0..* | USCoreCoverageProfile(7.0.0) | Insurance or medical plan or a payment agreement This profile also complies with the profile US Core Coverage Profile (6.1.0) Constraints: us-core-15
id | Σ | 0..1 | id | Logical id of this artifact
meta | Σ | 0..1 | Meta | Metadata about the resource
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
language |  | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
text |  | 0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained |  | 0..* | Resource | Contained, inline Resources
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
Slices for identifier | S Σ | 0..* | Identifier | Member ID and other identifiers Slice: Unordered, Open by pattern:type
identifier:memberid | S Σ C | 0..1 | Identifier | Member ID
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type | S Σ | 1..1 | CodeableConcept | Member Number identifier type Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: MB
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
system | Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value | Σ | 0..1 | string | The value that is unique Example General: 123456
period | Σ | 0..1 | Period | Time period when id is/was valid for use
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text)
status | ?!S Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
type | S Σ | 0..1 | CodeableConcept | Coverage category such as medical or accident Binding: Payer Type (extensible): US Public Health Data Consortium Source of Payment Codes
policyHolder | S Σ | 0..1 | Reference(CRD Patient | CRD Organization) | Owner of the policy
subscriber | S Σ | 0..1 | Reference(CRD Patient) | Subscriber to the policy
subscriberId | S Σ C | 0..1 | string | ID assigned to the subscriber
beneficiary | S Σ | 1..1 | Reference(CRD Patient) | Plan beneficiary
dependent | S Σ | 0..1 | string | Dependent number
relationship | S | 1..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible)
period | S Σ | 0..1 | Period | Coverage start and end dates
payor | S Σ | 1..1 | Reference(CRD Organization) | Issuer of the policy
Slices for class | S | 0..* | BackboneElement | Additional coverage classifications Slice: Unordered, Open by pattern: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): The policy classifications, eg. Group, Plan, Class, etc.
value | Σ | 1..1 | string | Value associated with the type
name | Σ | 0..1 | string | Human readable description of the type and value
class:group | S | 0..1 | BackboneElement | Group
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: group
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
value | S Σ | 1..1 | string | Group Number
name | S Σ | 0..1 | string | Group Name
class:plan | S | 0..1 | BackboneElement | Plan
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: plan
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
value | S Σ | 1..1 | string | Plan Number
name | S Σ | 0..1 | string | Plan Name
order | S Σ | 0..1 | positiveInt | Relative order of the coverage
network | S Σ | 0..1 | string | Insurer network
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 | 📦20221118 | VSAC v0.19
Coverage.relationship | Base | extensible | SubscriberPolicyholder Relationship Codes | 📦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.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

Must-Support: 5 elements
Prohibited: 1 element

Structures

This structure refers to these other structures:

- CRD Patient (http://hl7.org/fhir/us/davinci-crd/StructureDefinition/profile-patient)
- CRD Organization (http://hl7.org/fhir/us/davinci-crd/StructureDefinition/profile-organization)

Maturity: 4

Other representations of profile: CSV, Excel, Schematron