Da Vinci Prior Authorization Support (PAS) FHIR IG
2.0.1 - STU 2 United States of America flag

Da Vinci Prior Authorization Support (PAS) FHIR IG, published by HL7 International / Financial Management. This guide is not an authorized publication; it is the continuous build for version 2.0.1 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/davinci-pas/ and changes regularly. See the Directory of published versions

Resource Profile: PASCoverage - Detailed Descriptions

Page standards status: Trial-use Maturity Level: 3

Definitions for the profile-coverage resource profile.

Guidance on how to interpret the contents of this table can be found here

0. Coverage
2. Coverage.identifier
NoteThis is a business identifier, not a resource identifier (see discussion)
Must Supporttrue
4. Coverage.status
Must Supporttrue
Pattern Valueactive
6. Coverage.subscriber
TypeReference(PAS Subscriber Patient)
Must Supporttrue
8. Coverage.subscriberId
Must Supporttrue
10. Coverage.beneficiary
TypeReference(PAS Beneficiary Patient)
Must Supporttrue
12. Coverage.relationship
Must Supporttrue
14. Coverage.relationship.coding
SlicingThis element introduces a set of slices on Coverage.relationship.coding. The slices areUnordered and Open, and can be differentiated using the following discriminators:
  • value @ $this
  • 16. Coverage.relationship.coding:X12Code
    Slice NameX12Code
    Control0..1
    BindingThe codes SHALL be taken from https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069
    (required to https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069)

    Codes indicating the relationship between two individuals or entities. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.

    Must Supporttrue
    18. Coverage.payor
    TypeReference(PAS Insurer Organization)
    Must Supporttrue

    Guidance on how to interpret the contents of this table can be found here

    0. Coverage
    Definition

    Financial instrument which may be used to reimburse or pay for health care products and services. Includes both insurance and self-payment.

    ShortInsurance or medical plan or a payment agreement
    Comments

    The Coverage resource contains the insurance card level information, which is customary to provide on claims and other communications between providers and insurers.

    Control0..*
    Is Modifierfalse
    Summaryfalse
    Invariantsdom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty())
    dom-3: 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: 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: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty())
    dom-6: A resource should have narrative for robust management (text.`div`.exists())
    2. Coverage.implicitRules
    Definition

    A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

    ShortA set of rules under which this content was created
    Comments

    Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

    Control0..1
    Typeuri
    Is Modifiertrue because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summarytrue
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    4. Coverage.modifierExtension
    Definition

    May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

    Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

    ShortExtensions that cannot be ignored
    Comments

    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

    Control0..*
    TypeExtension
    Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
    Summaryfalse
    Requirements

    Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

    Alternate Namesextensions, user content
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    6. Coverage.identifier
    Definition

    A unique identifier assigned to this coverage.

    ShortBusiness Identifier for the coverage
    Comments

    The main (and possibly only) identifier for the coverage - often referred to as a Member Id, Certificate number, Personal Health Number or Case ID. May be constructed as the concatenation of the Coverage.SubscriberID and the Coverage.dependant.

    NoteThis is a business identifier, not a resource identifier (see discussion)
    Control0..*
    TypeIdentifier
    Is Modifierfalse
    Must Supporttrue
    Summarytrue
    Requirements

    Allows coverages to be distinguished and referenced.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    8. Coverage.status
    Definition

    The status of the resource instance.

    Shortactive | cancelled | draft | entered-in-error
    Comments

    This element is labeled as a modifier because the status contains the code entered-in-error that marks the coverage as not currently valid.

    Control1..1
    BindingThe codes SHALL be taken from FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|4.0.1
    (required to http://hl7.org/fhir/ValueSet/fm-status|4.0.1)

    A code specifying the state of the resource instance.

    Typecode
    Is Modifiertrue because This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Must Supporttrue
    Summarytrue
    Requirements

    Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.

    Pattern Valueactive
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    10. Coverage.subscriber
    Definition

    The party who has signed-up for or 'owns' the contractual relationship to the policy or to whom the benefit of the policy for services rendered to them or their family is due.

    ShortSubscriber to the policy
    Comments

    May be self or a parent in the case of dependants.

    Control0..1
    TypeReference(PAS Subscriber Patient, Patient, RelatedPerson)
    Is Modifierfalse
    Must Supporttrue
    Summarytrue
    Requirements

    This is the party who is entitled to the benfits under the policy.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    12. Coverage.subscriberId
    Definition

    The insurer assigned ID for the Subscriber.

    ShortID assigned to the subscriber
    Control0..1
    Typestring
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Must Supporttrue
    Summarytrue
    Requirements

    The insurer requires this identifier on correspondance and claims (digital and otherwise).

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    14. Coverage.beneficiary
    Definition

    The party who benefits from the insurance coverage; the patient when products and/or services are provided.

    ShortPlan beneficiary
    Control1..1
    TypeReference(PAS Beneficiary Patient, Patient)
    Is Modifierfalse
    Must Supporttrue
    Summarytrue
    Requirements

    This is the party who receives treatment for which the costs are reimbursed under the coverage.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    16. Coverage.relationship
    Definition

    The relationship of beneficiary (patient) to the subscriber.

    ShortBeneficiary relationship to the subscriber
    Comments

    Typically, an individual uses policies which are theirs (relationship='self') before policies owned by others.

    Control0..1
    BindingUnless not suitable, these codes SHALL be taken from SubscriberRelationshipCodeshttp://hl7.org/fhir/ValueSet/subscriber-relationship
    (extensible to http://hl7.org/fhir/ValueSet/subscriber-relationship)

    The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).

    TypeCodeableConcept
    Is Modifierfalse
    Must Supporttrue
    Summaryfalse
    Requirements

    To determine relationship between the patient and the subscriber to determine coordination of benefits.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    18. Coverage.relationship.coding
    Definition

    A reference to a code defined by a terminology system.

    ShortCode defined by a terminology system
    Comments

    Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

    Control0..*
    TypeCoding
    Is Modifierfalse
    Summarytrue
    Requirements

    Allows for alternative encodings within a code system, and translations to other code systems.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    SlicingThis element introduces a set of slices on Coverage.relationship.coding. The slices areUnordered and Open, and can be differentiated using the following discriminators:
    • value @ $this
    • 20. Coverage.relationship.coding:X12Code
      Slice NameX12Code
      Definition

      A reference to a code defined by a terminology system.

      ShortCode defined by a terminology system
      Comments

      Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

      Control0..1*
      BindingThe codes SHALL be taken from For codes, see https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069
      (required to https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069)

      Codes indicating the relationship between two individuals or entities. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.

      TypeCoding
      Is Modifierfalse
      Must Supporttrue
      Summarytrue
      Requirements

      Allows for alternative encodings within a code system, and translations to other code systems.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      22. Coverage.payor
      Definition

      The program or plan underwriter or payor including both insurance and non-insurance agreements, such as patient-pay agreements.

      ShortIssuer of the policy
      Comments

      May provide multiple identifiers such as insurance company identifier or business identifier (BIN number). For selfpay it may provide multiple paying persons and/or organizations.

      Control1..*
      TypeReference(PAS Insurer Organization, Organization, Patient, RelatedPerson)
      Is Modifierfalse
      Must Supporttrue
      Summarytrue
      Requirements

      Need to identify the issuer to target for claim processing and for coordination of benefit processing.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

      Guidance on how to interpret the contents of this table can be found here

      0. Coverage
      Definition

      Financial instrument which may be used to reimburse or pay for health care products and services. Includes both insurance and self-payment.

      ShortInsurance or medical plan or a payment agreement
      Comments

      The Coverage resource contains the insurance card level information, which is customary to provide on claims and other communications between providers and insurers.

      Control0..*
      Is Modifierfalse
      Summaryfalse
      Invariantsdom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty())
      dom-3: 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: 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: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty())
      dom-6: A resource should have narrative for robust management (text.`div`.exists())
      2. Coverage.id
      Definition

      The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

      ShortLogical id of this artifact
      Comments

      The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

      Control0..1
      Typeid
      Is Modifierfalse
      Summarytrue
      4. Coverage.meta
      Definition

      The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

      ShortMetadata about the resource
      Control0..1
      TypeMeta
      Is Modifierfalse
      Summarytrue
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      6. Coverage.implicitRules
      Definition

      A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

      ShortA set of rules under which this content was created
      Comments

      Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

      Control0..1
      Typeuri
      Is Modifiertrue because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Summarytrue
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      8. Coverage.language
      Definition

      The base language in which the resource is written.

      ShortLanguage of the resource content
      Comments

      Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

      Control0..1
      BindingThe codes SHOULD be taken from CommonLanguages
      (preferred to http://hl7.org/fhir/ValueSet/languages)

      A human language.

      Additional BindingsPurpose
      AllLanguagesMax Binding
      Typecode
      Is Modifierfalse
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Summaryfalse
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      10. Coverage.text
      Definition

      A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

      ShortText summary of the resource, for human interpretation
      Comments

      Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.

      Control0..1
      TypeNarrative
      Is Modifierfalse
      Summaryfalse
      Alternate Namesnarrative, html, xhtml, display
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      12. Coverage.contained
      Definition

      These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

      ShortContained, inline Resources
      Comments

      This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.

      Control0..*
      TypeResource
      Is Modifierfalse
      Summaryfalse
      Alternate Namesinline resources, anonymous resources, contained resources
      14. Coverage.extension
      Definition

      May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

      ShortAdditional content defined by implementations
      Comments

      There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

      Control0..*
      TypeExtension
      Is Modifierfalse
      Summaryfalse
      Alternate Namesextensions, user content
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
      16. Coverage.modifierExtension
      Definition

      May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

      Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

      ShortExtensions that cannot be ignored
      Comments

      There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

      Control0..*
      TypeExtension
      Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
      Summaryfalse
      Requirements

      Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

      Alternate Namesextensions, user content
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
      18. Coverage.identifier
      Definition

      A unique identifier assigned to this coverage.

      ShortBusiness Identifier for the coverage
      Comments

      The main (and possibly only) identifier for the coverage - often referred to as a Member Id, Certificate number, Personal Health Number or Case ID. May be constructed as the concatenation of the Coverage.SubscriberID and the Coverage.dependant.

      NoteThis is a business identifier, not a resource identifier (see discussion)
      Control0..*
      TypeIdentifier
      Is Modifierfalse
      Must Supporttrue
      Summarytrue
      Requirements

      Allows coverages to be distinguished and referenced.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      20. Coverage.status
      Definition

      The status of the resource instance.

      Shortactive | cancelled | draft | entered-in-error
      Comments

      This element is labeled as a modifier because the status contains the code entered-in-error that marks the coverage as not currently valid.

      Control1..1
      BindingThe codes SHALL be taken from FinancialResourceStatusCodes
      (required to http://hl7.org/fhir/ValueSet/fm-status|4.0.1)

      A code specifying the state of the resource instance.

      Typecode
      Is Modifiertrue because This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Must Supporttrue
      Summarytrue
      Requirements

      Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.

      Pattern Valueactive
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      22. Coverage.type
      Definition

      The type of coverage: social program, medical plan, accident coverage (workers compensation, auto), group health or payment by an individual or organization.

      ShortCoverage category such as medical or accident
      Control0..1
      BindingThe codes SHOULD be taken from CoverageTypeAndSelf-PayCodes
      (preferred to http://hl7.org/fhir/ValueSet/coverage-type)

      The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization.

      TypeCodeableConcept
      Is Modifierfalse
      Summarytrue
      Requirements

      The order of application of coverages is dependent on the types of coverage.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      24. Coverage.policyHolder
      Definition

      The party who 'owns' the insurance policy.

      ShortOwner of the policy
      Comments

      For example: may be an individual, corporation or the subscriber's employer.

      Control0..1
      TypeReference(Patient, RelatedPerson, Organization)
      Is Modifierfalse
      Summarytrue
      Requirements

      This provides employer information in the case of Worker's Compensation and other policies.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      26. Coverage.subscriber
      Definition

      The party who has signed-up for or 'owns' the contractual relationship to the policy or to whom the benefit of the policy for services rendered to them or their family is due.

      ShortSubscriber to the policy
      Comments

      May be self or a parent in the case of dependants.

      Control0..1
      TypeReference(PAS Subscriber Patient)
      Is Modifierfalse
      Must Supporttrue
      Summarytrue
      Requirements

      This is the party who is entitled to the benfits under the policy.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      28. Coverage.subscriberId
      Definition

      The insurer assigned ID for the Subscriber.

      ShortID assigned to the subscriber
      Control0..1
      Typestring
      Is Modifierfalse
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Must Supporttrue
      Summarytrue
      Requirements

      The insurer requires this identifier on correspondance and claims (digital and otherwise).

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      30. Coverage.beneficiary
      Definition

      The party who benefits from the insurance coverage; the patient when products and/or services are provided.

      ShortPlan beneficiary
      Control1..1
      TypeReference(PAS Beneficiary Patient)
      Is Modifierfalse
      Must Supporttrue
      Summarytrue
      Requirements

      This is the party who receives treatment for which the costs are reimbursed under the coverage.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      32. Coverage.dependent
      Definition

      A unique identifier for a dependent under the coverage.

      ShortDependent number
      Comments

      Periodically the member number is constructed from the subscriberId and the dependant number.

      Control0..1
      Typestring
      Is Modifierfalse
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Summarytrue
      Requirements

      For some coverages a single identifier is issued to the Subscriber and then a unique dependent number is issued to each beneficiary.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      34. Coverage.relationship
      Definition

      The relationship of beneficiary (patient) to the subscriber.

      ShortBeneficiary relationship to the subscriber
      Comments

      Typically, an individual uses policies which are theirs (relationship='self') before policies owned by others.

      Control0..1
      BindingUnless not suitable, these codes SHALL be taken from SubscriberRelationshipCodes
      (extensible to http://hl7.org/fhir/ValueSet/subscriber-relationship)

      The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).

      TypeCodeableConcept
      Is Modifierfalse
      Must Supporttrue
      Summaryfalse
      Requirements

      To determine relationship between the patient and the subscriber to determine coordination of benefits.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      36. Coverage.relationship.id
      Definition

      Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

      ShortUnique id for inter-element referencing
      Control0..1
      Typestring
      Is Modifierfalse
      XML FormatIn the XML format, this property is represented as an attribute.
      Summaryfalse
      38. Coverage.relationship.extension
      Definition

      May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

      ShortAdditional content defined by implementations
      Comments

      There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

      Control0..*
      TypeExtension
      Is Modifierfalse
      Summaryfalse
      Alternate Namesextensions, user content
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
      SlicingThis element introduces a set of slices on Coverage.relationship.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
      • value @ url
      • 40. Coverage.relationship.coding
        Definition

        A reference to a code defined by a terminology system.

        ShortCode defined by a terminology system
        Comments

        Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

        Control0..*
        TypeCoding
        Is Modifierfalse
        Summarytrue
        Requirements

        Allows for alternative encodings within a code system, and translations to other code systems.

        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        SlicingThis element introduces a set of slices on Coverage.relationship.coding. The slices areUnordered and Open, and can be differentiated using the following discriminators:
        • value @ $this
        • 42. Coverage.relationship.coding:X12Code
          Slice NameX12Code
          Definition

          A reference to a code defined by a terminology system.

          ShortCode defined by a terminology system
          Comments

          Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

          Control0..1
          BindingThe codes SHALL be taken from https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069
          (required to https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069)

          Codes indicating the relationship between two individuals or entities. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.

          TypeCoding
          Is Modifierfalse
          Must Supporttrue
          Summarytrue
          Requirements

          Allows for alternative encodings within a code system, and translations to other code systems.

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          44. Coverage.relationship.text
          Definition

          A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

          ShortPlain text representation of the concept
          Comments

          Very often the text is the same as a displayName of one of the codings.

          Control0..1
          Typestring
          Is Modifierfalse
          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
          Summarytrue
          Requirements

          The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          46. Coverage.period
          Definition

          Time period during which the coverage is in force. A missing start date indicates the start date isn't known, a missing end date means the coverage is continuing to be in force.

          ShortCoverage start and end dates
          Control0..1
          TypePeriod
          Is Modifierfalse
          Summarytrue
          Requirements

          Some insurers require the submission of the coverage term.

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          48. Coverage.payor
          Definition

          The program or plan underwriter or payor including both insurance and non-insurance agreements, such as patient-pay agreements.

          ShortIssuer of the policy
          Comments

          May provide multiple identifiers such as insurance company identifier or business identifier (BIN number). For selfpay it may provide multiple paying persons and/or organizations.

          Control1..*
          TypeReference(PAS Insurer Organization)
          Is Modifierfalse
          Must Supporttrue
          Summarytrue
          Requirements

          Need to identify the issuer to target for claim processing and for coordination of benefit processing.

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          50. Coverage.class
          Definition

          A suite of underwriter specific classifiers.

          ShortAdditional coverage classifications
          Comments

          For example may be used to identify a class of coverage or employer group, Policy, Plan.

          Control0..*
          TypeBackboneElement
          Is Modifierfalse
          Summaryfalse
          Requirements

          The codes provided on the health card which identify or confirm the specific policy for the insurer.

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          52. Coverage.class.id
          Definition

          Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

          ShortUnique id for inter-element referencing
          Control0..1
          Typestring
          Is Modifierfalse
          XML FormatIn the XML format, this property is represented as an attribute.
          Summaryfalse
          54. Coverage.class.extension
          Definition

          May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

          ShortAdditional content defined by implementations
          Comments

          There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

          Control0..*
          TypeExtension
          Is Modifierfalse
          Summaryfalse
          Alternate Namesextensions, user content
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
          56. Coverage.class.modifierExtension
          Definition

          May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

          Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

          ShortExtensions that cannot be ignored even if unrecognized
          Comments

          There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

          Control0..*
          TypeExtension
          Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
          Summarytrue
          Requirements

          Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

          Alternate Namesextensions, user content, modifiers
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
          58. Coverage.class.type
          Definition

          The type of classification for which an insurer-specific class label or number and optional name is provided, for example may be used to identify a class of coverage or employer group, Policy, Plan.

          ShortType of class such as 'group' or 'plan'
          Control1..1
          BindingUnless not suitable, these codes SHALL be taken from CoverageClassCodes
          (extensible to http://hl7.org/fhir/ValueSet/coverage-class)

          The policy classifications, eg. Group, Plan, Class, etc.

          TypeCodeableConcept
          Is Modifierfalse
          Summarytrue
          Requirements

          The insurer issued label for a specific health card value.

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          60. Coverage.class.value
          Definition

          The alphanumeric string value associated with the insurer issued label.

          ShortValue associated with the type
          Comments

          For example, the Group or Plan number.

          Control1..1
          Typestring
          Is Modifierfalse
          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
          Summarytrue
          Requirements

          The insurer issued label and value are necessary to identify the specific policy.

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          62. Coverage.class.name
          Definition

          A short description for the class.

          ShortHuman readable description of the type and value
          Control0..1
          Typestring
          Is Modifierfalse
          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
          Summarytrue
          Requirements

          Used to provide a meaningful description in correspondence to the patient.

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          64. Coverage.order
          Definition

          The order of applicability of this coverage relative to other coverages which are currently in force. Note, there may be gaps in the numbering and this does not imply primary, secondary etc. as the specific positioning of coverages depends upon the episode of care.

          ShortRelative order of the coverage
          Control0..1
          TypepositiveInt
          Is Modifierfalse
          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
          Summarytrue
          Requirements

          Used in managing the coordination of benefits.

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          66. Coverage.network
          Definition

          The insurer-specific identifier for the insurer-defined network of providers to which the beneficiary may seek treatment which will be covered at the 'in-network' rate, otherwise 'out of network' terms and conditions apply.

          ShortInsurer network
          Control0..1
          Typestring
          Is Modifierfalse
          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
          Summarytrue
          Requirements

          Used in referral for treatment and in claims processing.

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          68. Coverage.costToBeneficiary
          Definition

          A suite of codes indicating the cost category and associated amount which have been detailed in the policy and may have been included on the health card.

          ShortPatient payments for services/products
          Comments

          For example by knowing the patient visit co-pay, the provider can collect the amount prior to undertaking treatment.

          Control0..*
          TypeBackboneElement
          Is Modifierfalse
          Summaryfalse
          Requirements

          Required by providers to manage financial transaction with the patient.

          Alternate NamesCoPay, Deductible, Exceptions
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          70. Coverage.costToBeneficiary.id
          Definition

          Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

          ShortUnique id for inter-element referencing
          Control0..1
          Typestring
          Is Modifierfalse
          XML FormatIn the XML format, this property is represented as an attribute.
          Summaryfalse
          72. Coverage.costToBeneficiary.extension
          Definition

          May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

          ShortAdditional content defined by implementations
          Comments

          There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

          Control0..*
          TypeExtension
          Is Modifierfalse
          Summaryfalse
          Alternate Namesextensions, user content
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
          74. Coverage.costToBeneficiary.modifierExtension
          Definition

          May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

          Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

          ShortExtensions that cannot be ignored even if unrecognized
          Comments

          There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

          Control0..*
          TypeExtension
          Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
          Summarytrue
          Requirements

          Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

          Alternate Namesextensions, user content, modifiers
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
          76. Coverage.costToBeneficiary.type
          Definition

          The category of patient centric costs associated with treatment.

          ShortCost category
          Comments

          For example visit, specialist visits, emergency, inpatient care, etc.

          Control0..1
          BindingUnless not suitable, these codes SHALL be taken from CoverageCopayTypeCodes
          (extensible to http://hl7.org/fhir/ValueSet/coverage-copay-type)

          The types of services to which patient copayments are specified.

          TypeCodeableConcept
          Is Modifierfalse
          Summarytrue
          Requirements

          Needed to identify the category associated with the amount for the patient.

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          78. Coverage.costToBeneficiary.value[x]
          Definition

          The amount due from the patient for the cost category.

          ShortThe amount or percentage due from the beneficiary
          Comments

          Amount may be expressed as a percentage of the service/product cost or a fixed amount of currency.

          Control1..1
          TypeChoice of: Quantity(SimpleQuantity), Money
          [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
          Is Modifierfalse
          Summarytrue
          Requirements

          Needed to identify the amount for the patient associated with the category.

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          80. Coverage.costToBeneficiary.exception
          Definition

          A suite of codes indicating exceptions or reductions to patient costs and their effective periods.

          ShortExceptions for patient payments
          Control0..*
          TypeBackboneElement
          Is Modifierfalse
          Summaryfalse
          Requirements

          Required by providers to manage financial transaction with the patient.

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          82. Coverage.costToBeneficiary.exception.id
          Definition

          Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

          ShortUnique id for inter-element referencing
          Control0..1
          Typestring
          Is Modifierfalse
          XML FormatIn the XML format, this property is represented as an attribute.
          Summaryfalse
          84. Coverage.costToBeneficiary.exception.extension
          Definition

          May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

          ShortAdditional content defined by implementations
          Comments

          There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

          Control0..*
          TypeExtension
          Is Modifierfalse
          Summaryfalse
          Alternate Namesextensions, user content
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
          86. Coverage.costToBeneficiary.exception.modifierExtension
          Definition

          May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

          Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

          ShortExtensions that cannot be ignored even if unrecognized
          Comments

          There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

          Control0..*
          TypeExtension
          Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
          Summarytrue
          Requirements

          Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

          Alternate Namesextensions, user content, modifiers
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
          88. Coverage.costToBeneficiary.exception.type
          Definition

          The code for the specific exception.

          ShortException category
          Control1..1
          BindingFor example codes, see ExampleCoverageFinancialExceptionCodes
          (example to http://hl7.org/fhir/ValueSet/coverage-financial-exception)

          The types of exceptions from the part or full value of financial obligations such as copays.

          TypeCodeableConcept
          Is Modifierfalse
          Summarytrue
          Requirements

          Needed to identify the exception associated with the amount for the patient.

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          90. Coverage.costToBeneficiary.exception.period
          Definition

          The timeframe during when the exception is in force.

          ShortThe effective period of the exception
          Control0..1
          TypePeriod
          Is Modifierfalse
          Summarytrue
          Requirements

          Needed to identify the applicable timeframe for the exception for the correct calculation of patient costs.

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          92. Coverage.subrogation
          Definition

          When 'subrogation=true' this insurance instance has been included not for adjudication but to provide insurers with the details to recover costs.

          ShortReimbursement to insurer
          Comments

          Typically, automotive and worker's compensation policies would be flagged with 'subrogation=true' to enable healthcare payors to collect against accident claims.

          Control0..1
          Typeboolean
          Is Modifierfalse
          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
          Summaryfalse
          Requirements

          See definition for when to be used.

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          94. Coverage.contract
          Definition

          The policy(s) which constitute this insurance coverage.

          ShortContract details
          Control0..*
          TypeReference(Contract)
          Is Modifierfalse
          Summaryfalse
          Requirements

          To reference the legally binding contract between the policy holder and the insurer.

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))