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
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:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from USCoreCoverageProfile
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
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 | |
relationship | ||||
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 | |
Documentation for this format |
Path | Conformance | ValueSet | URI |
Coverage.relationship.coding:X12Code | required | https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069 |
Id | Grade | Path(s) | Details | Requirements |
self-beneficiary | error | Coverage | If relationship does not equal 'self', then subscriber SHALL be present. : $this.relationship.coding.where(code='18').count() = 0 implies $this.subscriber.exists() |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
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 | |
status | ?!SΣ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. ele-1: All FHIR elements must have a @value or children 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 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 |
Documentation for this format |
Path | Conformance | ValueSet / Code | URI |
Coverage.identifier:memberid.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard | |
Coverage.identifier:memberid.type | extensible | Pattern: MBhttp://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard | |
Coverage.status | required | Pattern: activehttp://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard | |
Coverage.type | extensible | PayerType (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.relationship | extensible | SubscriberRelationshipCodeshttp://hl7.org/fhir/ValueSet/subscriber-relationship from the FHIR Standard | |
Coverage.relationship.coding:X12Code | required | https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069 | |
Coverage.class.type | extensible | CoverageClassCodeshttp://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard | |
Coverage.class:group.type | extensible | Pattern: grouphttp://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard | |
Coverage.class:plan.type | extensible | Pattern: planhttp://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
self-beneficiary | error | Coverage | If relationship does not equal 'self', then subscriber SHALL be present. : $this.relationship.coding.where(code='18').count() = 0 implies $this.subscriber.exists() |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
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 | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
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 | |||||
Documentation for this format |
Path | Conformance | ValueSet / Code | URI | |||
Coverage.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languages from the FHIR Standard
| ||||
Coverage.identifier:memberid.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard | ||||
Coverage.identifier:memberid.type | extensible | Pattern: MBhttp://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard | ||||
Coverage.status | required | Pattern: activehttp://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard | ||||
Coverage.type | extensible | PayerType (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.relationship | extensible | SubscriberRelationshipCodeshttp://hl7.org/fhir/ValueSet/subscriber-relationship from the FHIR Standard | ||||
Coverage.relationship.coding:X12Code | required | https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069 | ||||
Coverage.class.type | extensible | CoverageClassCodeshttp://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard | ||||
Coverage.class:group.type | extensible | Pattern: grouphttp://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard | ||||
Coverage.class:plan.type | extensible | Pattern: planhttp://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard | ||||
Coverage.costToBeneficiary.type | extensible | CoverageCopayTypeCodeshttp://hl7.org/fhir/ValueSet/coverage-copay-type from the FHIR Standard | ||||
Coverage.costToBeneficiary.exception.type | example | ExampleCoverageFinancialExceptionCodeshttp://hl7.org/fhir/ValueSet/coverage-financial-exception from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
self-beneficiary | error | Coverage | If relationship does not equal 'self', then subscriber SHALL be present. : $this.relationship.coding.where(code='18').count() = 0 implies $this.subscriber.exists() |
This structure is derived from USCoreCoverageProfile
Summary
Must-Support: 2 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Maturity: 3
Differential View
This structure is derived from USCoreCoverageProfile
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Coverage | C | 0..* | USCoreCoverageProfile(7.0.0) | Insurance or medical plan or a payment agreement This profile also complies with the profile US Core Coverage Profile (6.1.0) self-beneficiary: If relationship does not equal 'self', then subscriber SHALL be present. |
status | 1..1 | code | active | cancelled | draft | entered-in-error Required Pattern: active | |
subscriber | S | 0..1 | Reference(PAS Subscriber Patient) | Subscriber to the policy |
beneficiary | 1..1 | Reference(PAS Beneficiary Patient) | Plan beneficiary | |
relationship | ||||
Slices for coding | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:$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 | |
Documentation for this format |
Path | Conformance | ValueSet | URI |
Coverage.relationship.coding:X12Code | required | https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069 |
Id | Grade | Path(s) | Details | Requirements |
self-beneficiary | error | Coverage | If 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
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
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 | |
status | ?!SΣ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. ele-1: All FHIR elements must have a @value or children 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 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 |
Documentation for this format |
Path | Conformance | ValueSet / Code | URI |
Coverage.identifier:memberid.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard | |
Coverage.identifier:memberid.type | extensible | Pattern: MBhttp://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard | |
Coverage.status | required | Pattern: activehttp://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard | |
Coverage.type | extensible | PayerType (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.relationship | extensible | SubscriberRelationshipCodeshttp://hl7.org/fhir/ValueSet/subscriber-relationship from the FHIR Standard | |
Coverage.relationship.coding:X12Code | required | https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069 | |
Coverage.class.type | extensible | CoverageClassCodeshttp://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard | |
Coverage.class:group.type | extensible | Pattern: grouphttp://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard | |
Coverage.class:plan.type | extensible | Pattern: planhttp://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
self-beneficiary | error | Coverage | If relationship does not equal 'self', then subscriber SHALL be present. : $this.relationship.coding.where(code='18').count() = 0 implies $this.subscriber.exists() |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
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 | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
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 | |||||
Documentation for this format |
Path | Conformance | ValueSet / Code | URI | |||
Coverage.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languages from the FHIR Standard
| ||||
Coverage.identifier:memberid.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard | ||||
Coverage.identifier:memberid.type | extensible | Pattern: MBhttp://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard | ||||
Coverage.status | required | Pattern: activehttp://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard | ||||
Coverage.type | extensible | PayerType (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.relationship | extensible | SubscriberRelationshipCodeshttp://hl7.org/fhir/ValueSet/subscriber-relationship from the FHIR Standard | ||||
Coverage.relationship.coding:X12Code | required | https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069 | ||||
Coverage.class.type | extensible | CoverageClassCodeshttp://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard | ||||
Coverage.class:group.type | extensible | Pattern: grouphttp://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard | ||||
Coverage.class:plan.type | extensible | Pattern: planhttp://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard | ||||
Coverage.costToBeneficiary.type | extensible | CoverageCopayTypeCodeshttp://hl7.org/fhir/ValueSet/coverage-copay-type from the FHIR Standard | ||||
Coverage.costToBeneficiary.exception.type | example | ExampleCoverageFinancialExceptionCodeshttp://hl7.org/fhir/ValueSet/coverage-financial-exception from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
self-beneficiary | error | Coverage | If 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:
Maturity: 3
Other representations of profile: CSV, Excel, Schematron