Da Vinci Health Record Exchange (HRex)
0.2.0 - STU R1 - 2nd ballot

Da Vinci Health Record Exchange (HRex), published by HL7 International - Clinical Interoperability Council. This is not an authorized publication; it is the continuous build for version 0.2.0). This version is based on the current content of https://github.com/HL7/davinci-ehrx/ and changes regularly. See the Directory of published versions

Resource Profile: HRexCoverage

The HRex Coverage Profile defines the constraints for representing a member’s healthcare insurance information to the Payer.  Coverage instances complying with this profile, sometimes together with the Patient which this profile references via beneficiary, allows a payer to identify a member in their system.

The official URL for this profile is:

http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/hrex-coverage

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.

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from Coverage

Summary

Must-Support: 4 elements

Structures

This structure refers to these other structures:

This structure is derived from Coverage

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..*CoverageInsurance or medical plan or a payment agreement
... identifier S0..*IdentifierAlso known as Member identifier
... type 0..1CodeableConceptCoverage category such as medical or accident
... policyHolder 0..1Reference(US Core Patient Profile | HRex Organization Profile | RelatedPerson)Owner of the policy
... subscriberId S0..1stringSubscriber ID
... beneficiary S1..1Reference(US Core Patient Profile)Plan beneficiary
... period 0..1PeriodCoverage start and end dates
... payor S1..*Reference(HRex Organization Profile)Issuer of the policy

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage I0..*CoverageInsurance or medical plan or a payment agreement
... id Σ0..1stringLogical id of this artifact
... meta ΣI0..1MetaMetadata about the resource
... implicitRules ?!ΣI0..1uriA set of rules under which this content was created
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension I0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!I0..*ExtensionExtensions that cannot be ignored
... identifier SΣI0..*IdentifierAlso known as Member identifier
... status ?!ΣI1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required)
... type ΣI0..1CodeableConceptCoverage category such as medical or accident
Binding: CoverageTypeAndSelf-PayCodes (preferred)
... policyHolder ΣI0..1Reference(US Core Patient Profile | HRex Organization Profile | RelatedPerson)Owner of the policy
... subscriber ΣI0..1Reference(US Core Patient Profile)Subscriber to the policy
... subscriberId SΣI0..1stringSubscriber ID
... beneficiary SΣI1..1Reference(US Core Patient Profile)Plan beneficiary
... dependent ΣI0..1stringDependent number
... relationship I0..1CodeableConceptBeneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible)
... period ΣI0..1PeriodCoverage start and end dates
... payor SΣI1..*Reference(HRex Organization Profile)Issuer of the policy
... class I0..*BackboneElementAdditional coverage classifications
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type ΣI1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible)
.... value ΣI1..1stringValue associated with the type
.... name ΣI0..1stringHuman readable description of the type and value
... order ΣI0..1positiveIntRelative order of the coverage
... network ΣI0..1stringInsurer network
... costToBeneficiary I0..*BackboneElementPatient payments for services/products
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type ΣI0..1CodeableConceptCost category
Binding: CoverageCopayTypeCodes (extensible)
.... value[x] ΣI1..1The amount or percentage due from the beneficiary
..... valueQuantityQuantity(SimpleQuantity)
..... valueMoneyMoney
.... exception I0..*BackboneElementExceptions for patient payments
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type ΣI1..1CodeableConceptException category
Binding: ExampleCoverageFinancialExceptionCodes (example)
..... period ΣI0..1PeriodThe effective period of the exception
... subrogation I0..1booleanReimbursement to insurer
... contract I0..*Reference(Contract)Contract details

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage I0..*CoverageInsurance or medical plan or a payment agreement
... identifier ΣI0..*IdentifierAlso known as Member identifier
... subscriberId ΣI0..1stringSubscriber ID
... beneficiary ΣI1..1Reference(US Core Patient Profile)Plan beneficiary

doco Documentation for this format

This structure is derived from Coverage

Summary

Must-Support: 4 elements

Structures

This structure refers to these other structures:

Differential View

This structure is derived from Coverage

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage 0..*CoverageInsurance or medical plan or a payment agreement
... identifier S0..*IdentifierAlso known as Member identifier
... type 0..1CodeableConceptCoverage category such as medical or accident
... policyHolder 0..1Reference(US Core Patient Profile | HRex Organization Profile | RelatedPerson)Owner of the policy
... subscriberId S0..1stringSubscriber ID
... beneficiary S1..1Reference(US Core Patient Profile)Plan beneficiary
... period 0..1PeriodCoverage start and end dates
... payor S1..*Reference(HRex Organization Profile)Issuer of the policy

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage I0..*CoverageInsurance or medical plan or a payment agreement
... id Σ0..1stringLogical id of this artifact
... meta ΣI0..1MetaMetadata about the resource
... implicitRules ?!ΣI0..1uriA set of rules under which this content was created
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension I0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!I0..*ExtensionExtensions that cannot be ignored
... identifier SΣI0..*IdentifierAlso known as Member identifier
... status ?!ΣI1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required)
... type ΣI0..1CodeableConceptCoverage category such as medical or accident
Binding: CoverageTypeAndSelf-PayCodes (preferred)
... policyHolder ΣI0..1Reference(US Core Patient Profile | HRex Organization Profile | RelatedPerson)Owner of the policy
... subscriber ΣI0..1Reference(US Core Patient Profile)Subscriber to the policy
... subscriberId SΣI0..1stringSubscriber ID
... beneficiary SΣI1..1Reference(US Core Patient Profile)Plan beneficiary
... dependent ΣI0..1stringDependent number
... relationship I0..1CodeableConceptBeneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible)
... period ΣI0..1PeriodCoverage start and end dates
... payor SΣI1..*Reference(HRex Organization Profile)Issuer of the policy
... class I0..*BackboneElementAdditional coverage classifications
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type ΣI1..1CodeableConceptType of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible)
.... value ΣI1..1stringValue associated with the type
.... name ΣI0..1stringHuman readable description of the type and value
... order ΣI0..1positiveIntRelative order of the coverage
... network ΣI0..1stringInsurer network
... costToBeneficiary I0..*BackboneElementPatient payments for services/products
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type ΣI0..1CodeableConceptCost category
Binding: CoverageCopayTypeCodes (extensible)
.... value[x] ΣI1..1The amount or percentage due from the beneficiary
..... valueQuantityQuantity(SimpleQuantity)
..... valueMoneyMoney
.... exception I0..*BackboneElementExceptions for patient payments
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type ΣI1..1CodeableConceptException category
Binding: ExampleCoverageFinancialExceptionCodes (example)
..... period ΣI0..1PeriodThe effective period of the exception
... subrogation I0..1booleanReimbursement to insurer
... contract I0..*Reference(Contract)Contract details

doco Documentation for this format

 

Other representations of profile: Schematron

Terminology Bindings

PathConformanceValueSet
Coverage.languagepreferredCommonLanguages
Max Binding: AllLanguages
Coverage.statusrequiredFinancialResourceStatusCodes
Coverage.typepreferredCoverageTypeAndSelf-PayCodes
Coverage.relationshipextensibleSubscriberRelationshipCodes
Coverage.class.typeextensibleCoverageClassCodes
Coverage.costToBeneficiary.typeextensibleCoverageCopayTypeCodes
Coverage.costToBeneficiary.exception.typeexampleExampleCoverageFinancialExceptionCodes

Constraints

IdPathDetailsRequirements
dom-2CoverageIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3CoverageIf 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-4CoverageIf 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-5CoverageIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6CoverageA resource should have narrative for robust management
: text.`div`.exists()
ele-1Coverage.metaAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.implicitRulesAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.languageAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.textAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Coverage.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Coverage.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Coverage.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Coverage.identifierAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.statusAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.typeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.policyHolderAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.subscriberAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.subscriberIdAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.beneficiaryAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.dependentAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.relationshipAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.periodAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.payorAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.classAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.class.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Coverage.class.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Coverage.class.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Coverage.class.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Coverage.class.typeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.class.valueAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.class.nameAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.orderAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.networkAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.costToBeneficiaryAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.costToBeneficiary.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Coverage.costToBeneficiary.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Coverage.costToBeneficiary.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Coverage.costToBeneficiary.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Coverage.costToBeneficiary.typeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.costToBeneficiary.value[x]All FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.costToBeneficiary.exceptionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.costToBeneficiary.exception.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Coverage.costToBeneficiary.exception.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Coverage.costToBeneficiary.exception.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Coverage.costToBeneficiary.exception.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Coverage.costToBeneficiary.exception.typeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.costToBeneficiary.exception.periodAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.subrogationAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Coverage.contractAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())

Notes:

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.)