Da Vinci Prior Authorization Support (PAS) FHIR IG
2.1.0 - STU 2.1 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 2.1.0 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: PAS Coverage

Official URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-coverage Version: 2.1.0
Standards status: Trial-use Maturity Level: 3 Computable Name: PASCoverage
Other Identifiers: OID:2.16.840.1.113883.4.642.40.24.42.54

PAS constraints on Coverage resource mandating support for insurance elements relevant to the prior authorization request

Usage:

Formal Views of Profile Content

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

This structure is derived from USCoreCoverageProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage C 0..* USCoreCoverageProfile(7.0.0) Insurance or medical plan or a payment agreement
This profile also complies with the profile US Core Coverage Profile (6.1.0)
self-beneficiary: If relationship does not equal 'self', then subscriber SHALL be present.
... status 1..1 code active | cancelled | draft | entered-in-error
Required Pattern: active
... subscriber S 0..1 Reference(PAS Subscriber Patient) Subscriber to the policy
... beneficiary 1..1 Reference(PAS Beneficiary Patient) Plan beneficiary
.... Slices for coding 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by value:$this
..... coding:X12Code S 0..1 Coding Code defined by a terminology system
Binding: https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069 (required): 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.

... payor 1..1 Reference(PAS Insurer Organization) Issuer of the policy

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Coverage.relationship.coding:X12Coderequiredhttps://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069
https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069

Constraints

IdGradePath(s)DetailsRequirements
self-beneficiaryerrorCoverageIf relationship does not equal 'self', then subscriber SHALL be present.
: $this.relationship.coding.where(code='18').count() = 0 implies $this.subscriber.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage C 0..* USCoreCoverageProfile(7.0.0) Insurance or medical plan or a payment agreement
This profile also complies with the profile US Core Coverage Profile (6.1.0)
dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
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
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
dom-6: A resource should have narrative for robust management
us-core-15: Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present
self-beneficiary: If relationship does not equal 'self', then subscriber SHALL be present.
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
ele-1: All FHIR elements must have a @value or children
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
... Slices for identifier SΣ 0..* Identifier Member ID and other identifiers
Slice: Unordered, Open by pattern:type
ele-1: All FHIR elements must have a @value or children
.... identifier:memberid SΣC 0..1 Identifier Member ID
ele-1: All FHIR elements must have a @value or children
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .


ele-1: All FHIR elements must have a @value or children
..... type SΣ 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.


ele-1: All FHIR elements must have a @value or children
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
... 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


ele-1: All FHIR elements must have a @value or children
... subscriber SΣ 0..1 Reference(PAS Subscriber Patient) Subscriber to the policy
ele-1: All FHIR elements must have a @value or children
... subscriberId SΣC 0..1 string ID assigned to the subscriber
ele-1: All FHIR elements must have a @value or children
... beneficiary SΣ 1..1 Reference(PAS Beneficiary Patient) Plan beneficiary
ele-1: All FHIR elements must have a @value or children
... relationship S 1..1 CodeableConcept Beneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible)
ele-1: All FHIR elements must have a @value or children
.... Slices for coding Σ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by value:$this
ele-1: All FHIR elements must have a @value or children
..... coding:X12Code SΣ 0..1 Coding Code defined by a terminology system
Binding: https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069 (required): 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.


ele-1: All FHIR elements must have a @value or children
... period SΣ 0..1 Period Coverage start and end dates
ele-1: All FHIR elements must have a @value or children
... payor SΣ 1..1 Reference(PAS Insurer Organization) Issuer of the policy
ele-1: All FHIR elements must have a @value or children
... Slices for class S 0..* BackboneElement Additional coverage classifications
Slice: Unordered, Open by pattern:type
ele-1: All FHIR elements must have a @value or children
.... class:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... type Σ 1..1 CodeableConcept Type of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.


ele-1: All FHIR elements must have a @value or children
..... value Σ 1..1 string Value associated with the type
ele-1: All FHIR elements must have a @value or children
.... class:group S 0..1 BackboneElement Group
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... type Σ 1..1 CodeableConcept Type of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.


ele-1: All FHIR elements must have a @value or children
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
ele-1: All FHIR elements must have a @value or children
..... name SΣ 0..1 string Group Name
ele-1: All FHIR elements must have a @value or children
.... class:plan S 0..1 BackboneElement Plan
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... type Σ 1..1 CodeableConcept Type of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.


ele-1: All FHIR elements must have a @value or children
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
ele-1: All FHIR elements must have a @value or children
..... name SΣ 0..1 string Plan Name
ele-1: All FHIR elements must have a @value or children

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Coverage.identifier:memberid.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
Coverage.identifier:memberid.typeextensiblePattern: MB
http://hl7.org/fhir/ValueSet/identifier-type
from the FHIR Standard
Coverage.statusrequiredPattern: active
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
from the FHIR Standard
Coverage.typeextensiblePayerType . (a valid code from Source of Payment Typology (https://nahdo.org/sopt)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591
Coverage.relationshipextensibleSubscriberRelationshipCodes
http://hl7.org/fhir/ValueSet/subscriber-relationship
from the FHIR Standard
Coverage.relationship.coding:X12Coderequiredhttps://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069
https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069
Coverage.class.typeextensibleCoverageClassCodes
http://hl7.org/fhir/ValueSet/coverage-class
from the FHIR Standard
Coverage.class:group.typeextensiblePattern: group
http://hl7.org/fhir/ValueSet/coverage-class
from the FHIR Standard
Coverage.class:plan.typeextensiblePattern: plan
http://hl7.org/fhir/ValueSet/coverage-class
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
self-beneficiaryerrorCoverageIf relationship does not equal 'self', then subscriber SHALL be present.
: $this.relationship.coding.where(code='18').count() = 0 implies $this.subscriber.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage C 0..* USCoreCoverageProfile(7.0.0) Insurance or medical plan or a payment agreement
This profile also complies with the profile US Core Coverage Profile (6.1.0)
us-core-15: Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present
self-beneficiary: If relationship does not equal 'self', then subscriber 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
... 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 pattern: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 SΣ 1..1 CodeableConcept Member Number identifier type
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.


Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: MB
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... system Σ 0..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value Σ 0..1 string The value that is unique
Example General: 123456
..... period Σ 0..1 Period Time period when id is/was valid for use
..... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
... status ?!SΣ 1..1 code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.


Required Pattern: active
... 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 Σ 0..1 Reference(Patient | RelatedPerson | Organization) Owner of the policy
... subscriber SΣ 0..1 Reference(PAS Subscriber Patient) Subscriber to the policy
... subscriberId SΣC 0..1 string ID assigned to the subscriber
... beneficiary SΣ 1..1 Reference(PAS Beneficiary Patient) Plan beneficiary
... dependent Σ 0..1 string Dependent number
... relationship S 1..1 CodeableConcept Beneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible)
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... Slices for coding Σ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by value:$this
..... coding:X12Code SΣ 0..1 Coding Code defined by a terminology system
Binding: https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069 (required): 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.


.... text Σ 0..1 string Plain text representation of the concept
... period SΣ 0..1 Period Coverage start and end dates
... payor SΣ 1..1 Reference(PAS Insurer Organization) Issuer of the policy
... Slices for class S 0..* BackboneElement Additional coverage classifications
Slice: Unordered, Open by pattern:type
.... class:All Slices Content/Rules for all slices
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... type Σ 1..1 CodeableConcept Type of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.

..... value Σ 1..1 string Value associated with the type
..... name Σ 0..1 string Human readable description of the type and value
.... class:group S 0..1 BackboneElement Group
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... type Σ 1..1 CodeableConcept Type of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.


Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: group
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... value SΣ 1..1 string Group Number
..... name SΣ 0..1 string Group Name
.... class:plan S 0..1 BackboneElement Plan
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... type Σ 1..1 CodeableConcept Type of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.


Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: plan
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... value 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Coverage.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
Coverage.identifier:memberid.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
Coverage.identifier:memberid.typeextensiblePattern: MB
http://hl7.org/fhir/ValueSet/identifier-type
from the FHIR Standard
Coverage.statusrequiredPattern: active
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
from the FHIR Standard
Coverage.typeextensiblePayerType . (a valid code from Source of Payment Typology (https://nahdo.org/sopt)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591
Coverage.relationshipextensibleSubscriberRelationshipCodes
http://hl7.org/fhir/ValueSet/subscriber-relationship
from the FHIR Standard
Coverage.relationship.coding:X12Coderequiredhttps://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069
https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069
Coverage.class.typeextensibleCoverageClassCodes
http://hl7.org/fhir/ValueSet/coverage-class
from the FHIR Standard
Coverage.class:group.typeextensiblePattern: group
http://hl7.org/fhir/ValueSet/coverage-class
from the FHIR Standard
Coverage.class:plan.typeextensiblePattern: plan
http://hl7.org/fhir/ValueSet/coverage-class
from the FHIR Standard
Coverage.costToBeneficiary.typeextensibleCoverageCopayTypeCodes
http://hl7.org/fhir/ValueSet/coverage-copay-type
from the FHIR Standard
Coverage.costToBeneficiary.exception.typeexampleExampleCoverageFinancialExceptionCodes
http://hl7.org/fhir/ValueSet/coverage-financial-exception
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
self-beneficiaryerrorCoverageIf relationship does not equal 'self', then subscriber SHALL be present.
: $this.relationship.coding.where(code='18').count() = 0 implies $this.subscriber.exists()

This structure is derived from USCoreCoverageProfile

Summary

Must-Support: 2 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of Coverage.relationship.coding

Maturity: 3

Differential View

This structure is derived from USCoreCoverageProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage C 0..* USCoreCoverageProfile(7.0.0) Insurance or medical plan or a payment agreement
This profile also complies with the profile US Core Coverage Profile (6.1.0)
self-beneficiary: If relationship does not equal 'self', then subscriber SHALL be present.
... status 1..1 code active | cancelled | draft | entered-in-error
Required Pattern: active
... subscriber S 0..1 Reference(PAS Subscriber Patient) Subscriber to the policy
... beneficiary 1..1 Reference(PAS Beneficiary Patient) Plan beneficiary
.... Slices for coding 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by value:$this
..... coding:X12Code S 0..1 Coding Code defined by a terminology system
Binding: https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069 (required): 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.

... payor 1..1 Reference(PAS Insurer Organization) Issuer of the policy

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Coverage.relationship.coding:X12Coderequiredhttps://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069
https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069

Constraints

IdGradePath(s)DetailsRequirements
self-beneficiaryerrorCoverageIf relationship does not equal 'self', then subscriber SHALL be present.
: $this.relationship.coding.where(code='18').count() = 0 implies $this.subscriber.exists()

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage C 0..* USCoreCoverageProfile(7.0.0) Insurance or medical plan or a payment agreement
This profile also complies with the profile US Core Coverage Profile (6.1.0)
dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
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
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
dom-6: A resource should have narrative for robust management
us-core-15: Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present
self-beneficiary: If relationship does not equal 'self', then subscriber SHALL be present.
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
ele-1: All FHIR elements must have a @value or children
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
... Slices for identifier SΣ 0..* Identifier Member ID and other identifiers
Slice: Unordered, Open by pattern:type
ele-1: All FHIR elements must have a @value or children
.... identifier:memberid SΣC 0..1 Identifier Member ID
ele-1: All FHIR elements must have a @value or children
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .


ele-1: All FHIR elements must have a @value or children
..... type SΣ 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.


ele-1: All FHIR elements must have a @value or children
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
... 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


ele-1: All FHIR elements must have a @value or children
... subscriber SΣ 0..1 Reference(PAS Subscriber Patient) Subscriber to the policy
ele-1: All FHIR elements must have a @value or children
... subscriberId SΣC 0..1 string ID assigned to the subscriber
ele-1: All FHIR elements must have a @value or children
... beneficiary SΣ 1..1 Reference(PAS Beneficiary Patient) Plan beneficiary
ele-1: All FHIR elements must have a @value or children
... relationship S 1..1 CodeableConcept Beneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible)
ele-1: All FHIR elements must have a @value or children
.... Slices for coding Σ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by value:$this
ele-1: All FHIR elements must have a @value or children
..... coding:X12Code SΣ 0..1 Coding Code defined by a terminology system
Binding: https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069 (required): 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.


ele-1: All FHIR elements must have a @value or children
... period SΣ 0..1 Period Coverage start and end dates
ele-1: All FHIR elements must have a @value or children
... payor SΣ 1..1 Reference(PAS Insurer Organization) Issuer of the policy
ele-1: All FHIR elements must have a @value or children
... Slices for class S 0..* BackboneElement Additional coverage classifications
Slice: Unordered, Open by pattern:type
ele-1: All FHIR elements must have a @value or children
.... class:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... type Σ 1..1 CodeableConcept Type of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.


ele-1: All FHIR elements must have a @value or children
..... value Σ 1..1 string Value associated with the type
ele-1: All FHIR elements must have a @value or children
.... class:group S 0..1 BackboneElement Group
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... type Σ 1..1 CodeableConcept Type of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.


ele-1: All FHIR elements must have a @value or children
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
ele-1: All FHIR elements must have a @value or children
..... name SΣ 0..1 string Group Name
ele-1: All FHIR elements must have a @value or children
.... class:plan S 0..1 BackboneElement Plan
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... type Σ 1..1 CodeableConcept Type of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.


ele-1: All FHIR elements must have a @value or children
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
ele-1: All FHIR elements must have a @value or children
..... name SΣ 0..1 string Plan Name
ele-1: All FHIR elements must have a @value or children

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Coverage.identifier:memberid.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
Coverage.identifier:memberid.typeextensiblePattern: MB
http://hl7.org/fhir/ValueSet/identifier-type
from the FHIR Standard
Coverage.statusrequiredPattern: active
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
from the FHIR Standard
Coverage.typeextensiblePayerType . (a valid code from Source of Payment Typology (https://nahdo.org/sopt)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591
Coverage.relationshipextensibleSubscriberRelationshipCodes
http://hl7.org/fhir/ValueSet/subscriber-relationship
from the FHIR Standard
Coverage.relationship.coding:X12Coderequiredhttps://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069
https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069
Coverage.class.typeextensibleCoverageClassCodes
http://hl7.org/fhir/ValueSet/coverage-class
from the FHIR Standard
Coverage.class:group.typeextensiblePattern: group
http://hl7.org/fhir/ValueSet/coverage-class
from the FHIR Standard
Coverage.class:plan.typeextensiblePattern: plan
http://hl7.org/fhir/ValueSet/coverage-class
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
self-beneficiaryerrorCoverageIf relationship does not equal 'self', then subscriber SHALL be present.
: $this.relationship.coding.where(code='18').count() = 0 implies $this.subscriber.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage C 0..* USCoreCoverageProfile(7.0.0) Insurance or medical plan or a payment agreement
This profile also complies with the profile US Core Coverage Profile (6.1.0)
us-core-15: Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present
self-beneficiary: If relationship does not equal 'self', then subscriber 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
... 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 pattern: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 SΣ 1..1 CodeableConcept Member Number identifier type
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.


Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: MB
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... system Σ 0..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value Σ 0..1 string The value that is unique
Example General: 123456
..... period Σ 0..1 Period Time period when id is/was valid for use
..... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
... status ?!SΣ 1..1 code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.


Required Pattern: active
... 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 Σ 0..1 Reference(Patient | RelatedPerson | Organization) Owner of the policy
... subscriber SΣ 0..1 Reference(PAS Subscriber Patient) Subscriber to the policy
... subscriberId SΣC 0..1 string ID assigned to the subscriber
... beneficiary SΣ 1..1 Reference(PAS Beneficiary Patient) Plan beneficiary
... dependent Σ 0..1 string Dependent number
... relationship S 1..1 CodeableConcept Beneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible)
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... Slices for coding Σ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by value:$this
..... coding:X12Code SΣ 0..1 Coding Code defined by a terminology system
Binding: https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069 (required): 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.


.... text Σ 0..1 string Plain text representation of the concept
... period SΣ 0..1 Period Coverage start and end dates
... payor SΣ 1..1 Reference(PAS Insurer Organization) Issuer of the policy
... Slices for class S 0..* BackboneElement Additional coverage classifications
Slice: Unordered, Open by pattern:type
.... class:All Slices Content/Rules for all slices
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... type Σ 1..1 CodeableConcept Type of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.

..... value Σ 1..1 string Value associated with the type
..... name Σ 0..1 string Human readable description of the type and value
.... class:group S 0..1 BackboneElement Group
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... type Σ 1..1 CodeableConcept Type of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.


Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: group
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... value SΣ 1..1 string Group Number
..... name SΣ 0..1 string Group Name
.... class:plan S 0..1 BackboneElement Plan
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... type Σ 1..1 CodeableConcept Type of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.


Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: plan
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... value 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Coverage.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
Coverage.identifier:memberid.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
Coverage.identifier:memberid.typeextensiblePattern: MB
http://hl7.org/fhir/ValueSet/identifier-type
from the FHIR Standard
Coverage.statusrequiredPattern: active
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
from the FHIR Standard
Coverage.typeextensiblePayerType . (a valid code from Source of Payment Typology (https://nahdo.org/sopt)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591
Coverage.relationshipextensibleSubscriberRelationshipCodes
http://hl7.org/fhir/ValueSet/subscriber-relationship
from the FHIR Standard
Coverage.relationship.coding:X12Coderequiredhttps://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069
https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069
Coverage.class.typeextensibleCoverageClassCodes
http://hl7.org/fhir/ValueSet/coverage-class
from the FHIR Standard
Coverage.class:group.typeextensiblePattern: group
http://hl7.org/fhir/ValueSet/coverage-class
from the FHIR Standard
Coverage.class:plan.typeextensiblePattern: plan
http://hl7.org/fhir/ValueSet/coverage-class
from the FHIR Standard
Coverage.costToBeneficiary.typeextensibleCoverageCopayTypeCodes
http://hl7.org/fhir/ValueSet/coverage-copay-type
from the FHIR Standard
Coverage.costToBeneficiary.exception.typeexampleExampleCoverageFinancialExceptionCodes
http://hl7.org/fhir/ValueSet/coverage-financial-exception
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
self-beneficiaryerrorCoverageIf relationship does not equal 'self', then subscriber SHALL be present.
: $this.relationship.coding.where(code='18').count() = 0 implies $this.subscriber.exists()

This structure is derived from USCoreCoverageProfile

Summary

Must-Support: 2 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of Coverage.relationship.coding

Maturity: 3

 

Other representations of profile: CSV, Excel, Schematron