Coverage is central to most Da Vinci use-cases. The resource provides the information that identifies the type of insurance, the payer who provides it and the member who is covered. As such, it forms the justification or focus for almost all data exchanges in the payer space. While the resource is complex, the Da Vinci profile focuses on capturing only the minimum data necessary to identify both payer and member.

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

This structure is derived from Coverage

Name	Flags	Card.	Type	Description & Constraints
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
Slices for identifier	S	0..*	Identifier	Member ID and other identifiers Slice: Unordered, Open by value:type
identifier:memberid	SC	0..1	Identifier	Member ID
type		1..1	CodeableConcept	Member Number identifier type 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/v2-0203
code		1..1	code	Symbol in syntax defined by the system Fixed Value: MB
value	S	1..1	string	The value that is unique
status	S	1..1	code	active | cancelled | draft | entered-in-error
type	S	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	0..1	Reference(US Core Patient Profile | HRex Organization Profile | US Core RelatedPerson Profile)	Owner of the policy
subscriberId	SC	0..1	string	Subscriber ID
beneficiary	S	1..1	Reference(HRex Patient Demographics)	Plan beneficiary
dependent	S	0..1	string	Dependent number
relationship	S	1..1	CodeableConcept	Beneficiary relationship to the subscriber Binding: HRex Coverage Relationship ValueSet (required)
period	S	0..1	Period	Coverage start and end dates
payor	S	1..1	Reference(HRex Organization Profile)	Issuer of the policy
Slices for class		0..*	BackboneElement	Additional coverage classifications Slice: Unordered, Open by pattern:type
class:group	S	0..1	BackboneElement	Group
type	S	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: group
value	S	1..1	string	Group Number
class:plan	S	0..1	BackboneElement	Plan
type	S	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: plan
value	S	1..1	string	Plan Number
name	S	0..1	string	Plan Name
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Coverage.type	extensible	PayerType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 from https://vsac.nlm.nih.gov
Coverage.relationship	required	HRexCoverageRelationship http://hl7.org/fhir/us/davinci-hrex/ValueSet/hrex-coverage-relationship from this IG

Constraints

Id	Grade	Path(s)	Details	Requirements
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
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
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	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
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/v2-0203
code		1..1	code	Symbol in syntax defined by the system Fixed Value: MB
value	SΣ	1..1	string	The value that is unique Example General: 123456
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	SΣ	0..1	Reference(US Core Patient Profile | HRex Organization Profile | US Core RelatedPerson Profile)	Owner of the policy
subscriberId	SΣC	0..1	string	Subscriber ID
beneficiary	SΣ	1..1	Reference(HRex Patient Demographics)	Plan beneficiary
dependent	SΣ	0..1	string	Dependent number
relationship	S	1..1	CodeableConcept	Beneficiary relationship to the subscriber Binding: HRex Coverage Relationship ValueSet (required)
period	SΣ	0..1	Period	Coverage start and end dates
payor	SΣ	1..1	Reference(HRex Organization Profile)	Issuer of the policy
Slices for class		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	SΣ	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
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: group
value	SΣ	1..1	string	Group Number
class:plan	S	0..1	BackboneElement	Plan
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	SΣ	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
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: plan
value	SΣ	1..1	string	Plan Number
name	SΣ	0..1	string	Plan Name
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Coverage.identifier:memberid.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard
Coverage.identifier:memberid.type	extensible	Pattern: MB http://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard
Coverage.status	required	FinancialResourceStatusCodes http://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard
Coverage.type	extensible	PayerType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 from https://vsac.nlm.nih.gov
Coverage.relationship	required	HRexCoverageRelationship http://hl7.org/fhir/us/davinci-hrex/ValueSet/hrex-coverage-relationship from this IG
Coverage.class.type	extensible	CoverageClassCodes http://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard
Coverage.class:group.type	extensible	Pattern: group http://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard
Coverage.class:plan.type	extensible	Pattern: plan http://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	Coverage	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Coverage	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	Coverage	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	Coverage	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Coverage	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()
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
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
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
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	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	SΣ	1..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	SΣ	0..1	Reference(US Core Patient Profile | HRex Organization Profile | US Core RelatedPerson Profile)	Owner of the policy
subscriber	Σ	0..1	Reference(Patient | RelatedPerson)	Subscriber to the policy
subscriberId	SΣC	0..1	string	Subscriber ID
beneficiary	SΣ	1..1	Reference(HRex Patient Demographics)	Plan beneficiary
dependent	SΣ	0..1	string	Dependent number
relationship	S	1..1	CodeableConcept	Beneficiary relationship to the subscriber Binding: HRex Coverage Relationship ValueSet (required)
period	SΣ	0..1	Period	Coverage start and end dates
payor	SΣ	1..1	Reference(HRex Organization Profile)	Issuer of the policy
Slices for class		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	SΣ	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 Number
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	SΣ	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
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	Conformance	ValueSet / Code	URI
Coverage.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
Coverage.identifier:memberid.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard
Coverage.identifier:memberid.type	extensible	Pattern: MB http://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard
Coverage.status	required	FinancialResourceStatusCodes http://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard
Coverage.type	extensible	PayerType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 from https://vsac.nlm.nih.gov
Coverage.relationship	required	HRexCoverageRelationship http://hl7.org/fhir/us/davinci-hrex/ValueSet/hrex-coverage-relationship from this IG
Coverage.class.type	extensible	CoverageClassCodes http://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard
Coverage.class:group.type	extensible	Pattern: group http://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard
Coverage.class:plan.type	extensible	Pattern: plan http://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard
Coverage.costToBeneficiary.type	extensible	CoverageCopayTypeCodes http://hl7.org/fhir/ValueSet/coverage-copay-type from the FHIR Standard
Coverage.costToBeneficiary.exception.type	example	ExampleCoverageFinancialExceptionCodes http://hl7.org/fhir/ValueSet/coverage-financial-exception from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	Coverage	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Coverage	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	Coverage	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	Coverage	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Coverage	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()
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

This structure is derived from Coverage

Name	Flags	Card.	Type	Description & Constraints
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
Slices for identifier	S	0..*	Identifier	Member ID and other identifiers Slice: Unordered, Open by value:type
identifier:memberid	SC	0..1	Identifier	Member ID
type		1..1	CodeableConcept	Member Number identifier type 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/v2-0203
code		1..1	code	Symbol in syntax defined by the system Fixed Value: MB
value	S	1..1	string	The value that is unique
status	S	1..1	code	active | cancelled | draft | entered-in-error
type	S	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	0..1	Reference(US Core Patient Profile | HRex Organization Profile | US Core RelatedPerson Profile)	Owner of the policy
subscriberId	SC	0..1	string	Subscriber ID
beneficiary	S	1..1	Reference(HRex Patient Demographics)	Plan beneficiary
dependent	S	0..1	string	Dependent number
relationship	S	1..1	CodeableConcept	Beneficiary relationship to the subscriber Binding: HRex Coverage Relationship ValueSet (required)
period	S	0..1	Period	Coverage start and end dates
payor	S	1..1	Reference(HRex Organization Profile)	Issuer of the policy
Slices for class		0..*	BackboneElement	Additional coverage classifications Slice: Unordered, Open by pattern:type
class:group	S	0..1	BackboneElement	Group
type	S	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: group
value	S	1..1	string	Group Number
class:plan	S	0..1	BackboneElement	Plan
type	S	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: plan
value	S	1..1	string	Plan Number
name	S	0..1	string	Plan Name
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Coverage.type	extensible	PayerType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 from https://vsac.nlm.nih.gov
Coverage.relationship	required	HRexCoverageRelationship http://hl7.org/fhir/us/davinci-hrex/ValueSet/hrex-coverage-relationship from this IG

Constraints

Id	Grade	Path(s)	Details	Requirements
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()

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
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
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	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
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/v2-0203
code		1..1	code	Symbol in syntax defined by the system Fixed Value: MB
value	SΣ	1..1	string	The value that is unique Example General: 123456
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	SΣ	0..1	Reference(US Core Patient Profile | HRex Organization Profile | US Core RelatedPerson Profile)	Owner of the policy
subscriberId	SΣC	0..1	string	Subscriber ID
beneficiary	SΣ	1..1	Reference(HRex Patient Demographics)	Plan beneficiary
dependent	SΣ	0..1	string	Dependent number
relationship	S	1..1	CodeableConcept	Beneficiary relationship to the subscriber Binding: HRex Coverage Relationship ValueSet (required)
period	SΣ	0..1	Period	Coverage start and end dates
payor	SΣ	1..1	Reference(HRex Organization Profile)	Issuer of the policy
Slices for class		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	SΣ	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
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: group
value	SΣ	1..1	string	Group Number
class:plan	S	0..1	BackboneElement	Plan
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	SΣ	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
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: plan
value	SΣ	1..1	string	Plan Number
name	SΣ	0..1	string	Plan Name
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Coverage.identifier:memberid.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard
Coverage.identifier:memberid.type	extensible	Pattern: MB http://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard
Coverage.status	required	FinancialResourceStatusCodes http://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard
Coverage.type	extensible	PayerType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 from https://vsac.nlm.nih.gov
Coverage.relationship	required	HRexCoverageRelationship http://hl7.org/fhir/us/davinci-hrex/ValueSet/hrex-coverage-relationship from this IG
Coverage.class.type	extensible	CoverageClassCodes http://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard
Coverage.class:group.type	extensible	Pattern: group http://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard
Coverage.class:plan.type	extensible	Pattern: plan http://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	Coverage	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Coverage	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	Coverage	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	Coverage	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Coverage	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()
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()

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
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
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
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	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	SΣ	1..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	SΣ	0..1	Reference(US Core Patient Profile | HRex Organization Profile | US Core RelatedPerson Profile)	Owner of the policy
subscriber	Σ	0..1	Reference(Patient | RelatedPerson)	Subscriber to the policy
subscriberId	SΣC	0..1	string	Subscriber ID
beneficiary	SΣ	1..1	Reference(HRex Patient Demographics)	Plan beneficiary
dependent	SΣ	0..1	string	Dependent number
relationship	S	1..1	CodeableConcept	Beneficiary relationship to the subscriber Binding: HRex Coverage Relationship ValueSet (required)
period	SΣ	0..1	Period	Coverage start and end dates
payor	SΣ	1..1	Reference(HRex Organization Profile)	Issuer of the policy
Slices for class		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	SΣ	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 Number
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	SΣ	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
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	Conformance	ValueSet / Code	URI
Coverage.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
Coverage.identifier:memberid.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard
Coverage.identifier:memberid.type	extensible	Pattern: MB http://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard
Coverage.status	required	FinancialResourceStatusCodes http://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard
Coverage.type	extensible	PayerType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 from https://vsac.nlm.nih.gov
Coverage.relationship	required	HRexCoverageRelationship http://hl7.org/fhir/us/davinci-hrex/ValueSet/hrex-coverage-relationship from this IG
Coverage.class.type	extensible	CoverageClassCodes http://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard
Coverage.class:group.type	extensible	Pattern: group http://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard
Coverage.class:plan.type	extensible	Pattern: plan http://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard
Coverage.costToBeneficiary.type	extensible	CoverageCopayTypeCodes http://hl7.org/fhir/ValueSet/coverage-copay-type from the FHIR Standard
Coverage.costToBeneficiary.exception.type	example	ExampleCoverageFinancialExceptionCodes http://hl7.org/fhir/ValueSet/coverage-financial-exception from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	Coverage	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Coverage	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	Coverage	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	Coverage	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Coverage	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()
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()

This structure is derived from Coverage

Summary

Mandatory: 1 element(2 nested mandatory elements)
Must-Support: 19 elements

Structures

This structure refers to these other structures:

• US Core Patient Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient|6.1.0)
• HRex Organization Profile (http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/hrex-organization)
• US Core RelatedPerson Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-relatedperson|6.1.0)
• HRex Patient Demographics (http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/hrex-patient-demographics)

Slices

This structure defines the following Slices:

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

Maturity: 2

If the member identifier (conveyed in Coverage.identifier) is known, it should be sent as this uniquely identifies a covered individual. If not, then the Coverage.subscriberId can be used together with demographic information found by resolving Coverage.beneficiary to identify the member. (There can be multiple members associated with a single subscriber - e.g. family members of an individual who is covered under a work-based policy.)

Additional notes and guidance around how to map real-world insurance card information into the Coverage resource can be found in the CARIN Digital Insurance Card IG. As a rule, all elements available should be populated, even if not all might be strictly necessary to identify the member because rules can vary from insurer to insurer about which pieces of information are necessary to uniquely identify a member.