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 2.2.1 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/davinci-pas/ and changes regularly. See the Directory of published versions

• Content
• Detailed Descriptions
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Resource Profile: PAS Coverage

Usages:

• Refer to this Profile: PAS Claim Base and PAS Claim Base
• Examples for this Profile: Coverage/InsuranceExample

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

Description Differentials, Snapshots, and other representations.

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

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
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) Constraints: us-core-15, self-beneficiary
Coverage.implicitRules	?! This element is a modifier element. Σ This element is included in summaries.	0..1	uri	A set of rules under which this content was created
Coverage.modifierExtension	?! This element is a modifier element.	0..*	Extension	Extensions that cannot be ignored
Coverage.Slices for identifier	S This element must be supported. Σ This element is included in summaries.	1..*	Identifier	Member ID and other identifiers Slice: Unordered, Open by pattern:type Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
Coverage.Slices for identifier.identifier:memberid	S This element must be supported. Σ This element is included in summaries. C	1..1	Identifier	Member ID
Coverage.Slices for identifier.identifier:memberid.use	?! This element is a modifier element. Σ This element is included in summaries.	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
Coverage.Slices for identifier.identifier:memberid.type	S This element must be supported. Σ This element is included in summaries.	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
Coverage.Slices for identifier.identifier:memberid.type.id		0..1	string	Unique id for inter-element referencing
Coverage.Slices for identifier.identifier:memberid.type.extension		0..*	Extension	Additional content defined by implementations
Coverage.Slices for identifier.identifier:memberid.type.coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
Coverage.Slices for identifier.identifier:memberid.type.coding.id		0..1	string	Unique id for inter-element referencing
Coverage.Slices for identifier.identifier:memberid.type.coding.extension		0..*	Extension	Additional content defined by implementations
Coverage.Slices for identifier.identifier:memberid.type.coding.system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
Coverage.Slices for identifier.identifier:memberid.type.coding.version		0..1	string	Version of the system - if relevant
Coverage.Slices for identifier.identifier:memberid.type.coding.code		1..1	code	Symbol in syntax defined by the system Fixed Value: MB
Coverage.Slices for identifier.identifier:memberid.type.coding.display		0..1	string	Representation defined by the system
Coverage.Slices for identifier.identifier:memberid.type.coding.userSelected		0..1	boolean	If this coding was chosen directly by the user
Coverage.Slices for identifier.identifier:memberid.type.text		0..1	string	Plain text representation of the concept
Coverage.status	?! This element is a modifier element. S This element must be supported. Σ This element is included in summaries.	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Required Pattern: active
Coverage.type	S This element must be supported. Σ This element is included in summaries.	0..1	CodeableConcept	Coverage category such as medical or accident Binding: PayerType (20221118) (extensible): US Public Health Data Consortium Source of Payment Codes
Coverage.subscriber	S This element must be supported. Σ This element is included in summaries.	0..1	Reference(PAS Subscriber Patient(2.2.1))	Subscriber to the policy
Coverage.subscriberId	S This element must be supported. Σ This element is included in summaries. C	0..1	string	ID assigned to the subscriber
Coverage.beneficiary	S This element must be supported. Σ This element is included in summaries.	1..1	Reference(PAS Beneficiary Patient(2.2.1))	Plan beneficiary
Coverage.relationship	S This element must be supported.	1..1	CodeableConcept	Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible)
Coverage.relationship.Slices for coding	Σ This element is included in summaries.	0..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:$this Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
Coverage.relationship.Slices for coding.coding:X12Code	S This element must be supported. Σ This element is included in summaries.	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.
Coverage.period	S This element must be supported. Σ This element is included in summaries.	0..1	Period	Coverage start and end dates
Coverage.payor	S This element must be supported. Σ This element is included in summaries.	1..1	Reference(PAS Insurer Organization(2.2.1))	Issuer of the policy
Coverage.Slices for class	S This element must be supported.	0..*	BackboneElement	Additional coverage classifications Slice: Unordered, Open by pattern:type Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
Coverage.Slices for class.class:All Slices				Content/Rules for all slices
Coverage.Slices for class.class:All Slices.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Coverage.Slices for class.class:All Slices.type	Σ This element is included in summaries.	1..1	CodeableConcept	Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.
Coverage.Slices for class.class:All Slices.value	Σ This element is included in summaries.	1..1	string	Value associated with the type
Coverage.Slices for class.class:group	S This element must be supported.	0..1	BackboneElement	Group
Coverage.Slices for class.class:group.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Coverage.Slices for class.class:group.type	Σ This element is included in summaries.	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
Coverage.Slices for class.class:group.type.id		0..1	string	Unique id for inter-element referencing
Coverage.Slices for class.class:group.type.extension		0..*	Extension	Additional content defined by implementations
Coverage.Slices for class.class:group.type.coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
Coverage.Slices for class.class:group.type.coding.id		0..1	string	Unique id for inter-element referencing
Coverage.Slices for class.class:group.type.coding.extension		0..*	Extension	Additional content defined by implementations
Coverage.Slices for class.class:group.type.coding.system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
Coverage.Slices for class.class:group.type.coding.version		0..1	string	Version of the system - if relevant
Coverage.Slices for class.class:group.type.coding.code		1..1	code	Symbol in syntax defined by the system Fixed Value: group
Coverage.Slices for class.class:group.type.coding.display		0..1	string	Representation defined by the system
Coverage.Slices for class.class:group.type.coding.userSelected		0..1	boolean	If this coding was chosen directly by the user
Coverage.Slices for class.class:group.type.text		0..1	string	Plain text representation of the concept
Coverage.Slices for class.class:group.value	S This element must be supported. Σ This element is included in summaries.	1..1	string	Group Number
Coverage.Slices for class.class:group.name	S This element must be supported. Σ This element is included in summaries.	0..1	string	Group Name
Coverage.Slices for class.class:plan	S This element must be supported.	0..1	BackboneElement	Plan
Coverage.Slices for class.class:plan.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Coverage.Slices for class.class:plan.type	Σ This element is included in summaries.	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
Coverage.Slices for class.class:plan.type.id		0..1	string	Unique id for inter-element referencing
Coverage.Slices for class.class:plan.type.extension		0..*	Extension	Additional content defined by implementations
Coverage.Slices for class.class:plan.type.coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
Coverage.Slices for class.class:plan.type.coding.id		0..1	string	Unique id for inter-element referencing
Coverage.Slices for class.class:plan.type.coding.extension		0..*	Extension	Additional content defined by implementations
Coverage.Slices for class.class:plan.type.coding.system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
Coverage.Slices for class.class:plan.type.coding.version		0..1	string	Version of the system - if relevant
Coverage.Slices for class.class:plan.type.coding.code		1..1	code	Symbol in syntax defined by the system Fixed Value: plan
Coverage.Slices for class.class:plan.type.coding.display		0..1	string	Representation defined by the system
Coverage.Slices for class.class:plan.type.coding.userSelected		0..1	boolean	If this coding was chosen directly by the user
Coverage.Slices for class.class:plan.type.text		0..1	string	Plain text representation of the concept
Coverage.Slices for class.class:plan.value	S This element must be supported. Σ This element is included in summaries.	1..1	string	Plan Number
Coverage.Slices for class.class:plan.name	S This element must be supported. Σ This element is included in summaries.	0..1	string	Plan Name
Documentation for this format

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
Coverage.identifier:memberid.​use	Base	required	IdentifierUse	📍4.0.1	FHIR Std.
Coverage.identifier:memberid.​type	Base	extensible	IdentifierType	📦4.0.1	FHIR Std.
Coverage.status	Base	required	Financial Resource Status Codes	📍4.0.1	FHIR Std.
Coverage.type	Base	extensible	Payer Type	📍20221118	VSAC v0.19
Coverage.relationship	Base	extensible	SubscriberPolicyholder Relationship Codes	📦4.0.1	FHIR Std.
Coverage.relationship.​coding:X12Code	Base	required	https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069	Not State	Unknown
Coverage.class.type	Base	extensible	Coverage Class Codes	📦4.0.1	FHIR Std.
Coverage.class:group.​type	Base	extensible	Coverage Class Codes	📦4.0.1	FHIR Std.
Coverage.class:plan.​type	Base	extensible	Coverage Class Codes	📦4.0.1	FHIR Std.

Constraints

Id	Grade	Path(s)	Description	Expression
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

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
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)
Coverage.identifier		1..*	Identifier	Member ID and other identifiers
Coverage.Slices for identifier				Content/Rules for all slices
Coverage.Slices for identifier.identifier:memberid		1..1	Identifier	Member ID
Coverage.status		1..1	code	active | cancelled | draft | entered-in-error Required Pattern: active
Coverage.subscriber	S This element must be supported.	0..1	Reference(PAS Subscriber Patient(2.2.1))	Subscriber to the policy
Coverage.beneficiary		1..1	Reference(PAS Beneficiary Patient(2.2.1))	Plan beneficiary
Coverage.relationship
Coverage.relationship.Slices for coding		0..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:$this Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
Coverage.relationship.Slices for coding.coding:X12Code	S This element must be supported.	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.
Coverage.payor		1..1	Reference(PAS Insurer Organization(2.2.1))	Issuer of the policy
Documentation for this format

Terminology Bindings (Differential)

Path	Status	Usage	ValueSet	Version	Source
Coverage.relationship.​coding:X12Code	Base	required	https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069	Not State	Unknown

Constraints

Id	Grade	Path(s)	Description	Expression
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    Filter: Bindings Constraints Obligations
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) Constraints: us-core-15, self-beneficiary
Coverage.id	Σ This element is included in summaries.	0..1	id	Logical id of this artifact
Coverage.meta	Σ This element is included in summaries.	0..1	Meta	Metadata about the resource
Coverage.implicitRules	?! This element is a modifier element. Σ This element is included in summaries.	0..1	uri	A set of rules under which this content was created
Coverage.language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
Coverage.text		0..1	Narrative	Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Coverage.contained		0..*	Resource	Contained, inline Resources
Coverage.extension		0..*	Extension	Additional content defined by implementations
Coverage.modifierExtension	?! This element is a modifier element.	0..*	Extension	Extensions that cannot be ignored
Coverage.Slices for identifier	S This element must be supported. Σ This element is included in summaries.	1..*	Identifier	Member ID and other identifiers Slice: Unordered, Open by pattern:type Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
Coverage.Slices for identifier.identifier:memberid	S This element must be supported. Σ This element is included in summaries. C	1..1	Identifier	Member ID
Coverage.Slices for identifier.identifier:memberid.id		0..1	string	Unique id for inter-element referencing
Coverage.Slices for identifier.identifier:memberid.extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
Coverage.Slices for identifier.identifier:memberid.use	?! This element is a modifier element. Σ This element is included in summaries.	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
Coverage.Slices for identifier.identifier:memberid.type	S This element must be supported. Σ This element is included in summaries.	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
Coverage.Slices for identifier.identifier:memberid.type.id		0..1	string	Unique id for inter-element referencing
Coverage.Slices for identifier.identifier:memberid.type.extension		0..*	Extension	Additional content defined by implementations
Coverage.Slices for identifier.identifier:memberid.type.coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
Coverage.Slices for identifier.identifier:memberid.type.coding.id		0..1	string	Unique id for inter-element referencing
Coverage.Slices for identifier.identifier:memberid.type.coding.extension		0..*	Extension	Additional content defined by implementations
Coverage.Slices for identifier.identifier:memberid.type.coding.system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
Coverage.Slices for identifier.identifier:memberid.type.coding.version		0..1	string	Version of the system - if relevant
Coverage.Slices for identifier.identifier:memberid.type.coding.code		1..1	code	Symbol in syntax defined by the system Fixed Value: MB
Coverage.Slices for identifier.identifier:memberid.type.coding.display		0..1	string	Representation defined by the system
Coverage.Slices for identifier.identifier:memberid.type.coding.userSelected		0..1	boolean	If this coding was chosen directly by the user
Coverage.Slices for identifier.identifier:memberid.type.text		0..1	string	Plain text representation of the concept
Coverage.Slices for identifier.identifier:memberid.system	Σ This element is included in summaries.	0..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
Coverage.Slices for identifier.identifier:memberid.value	Σ This element is included in summaries.	0..1	string	The value that is unique Example General: 123456
Coverage.Slices for identifier.identifier:memberid.period	Σ This element is included in summaries.	0..1	Period	Time period when id is/was valid for use
Coverage.Slices for identifier.identifier:memberid.assigner	Σ This element is included in summaries.	0..1	Reference(Organization)	Organization that issued id (may be just text)
Coverage.status	?! This element is a modifier element. S This element must be supported. Σ This element is included in summaries.	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Required Pattern: active
Coverage.type	S This element must be supported. Σ This element is included in summaries.	0..1	CodeableConcept	Coverage category such as medical or accident Binding: PayerType (20221118) (extensible): US Public Health Data Consortium Source of Payment Codes
Coverage.policyHolder	Σ This element is included in summaries.	0..1	Reference(Patient | RelatedPerson | Organization)	Owner of the policy
Coverage.subscriber	S This element must be supported. Σ This element is included in summaries.	0..1	Reference(PAS Subscriber Patient(2.2.1))	Subscriber to the policy
Coverage.subscriberId	S This element must be supported. Σ This element is included in summaries. C	0..1	string	ID assigned to the subscriber
Coverage.beneficiary	S This element must be supported. Σ This element is included in summaries.	1..1	Reference(PAS Beneficiary Patient(2.2.1))	Plan beneficiary
Coverage.dependent	Σ This element is included in summaries.	0..1	string	Dependent number
Coverage.relationship	S This element must be supported.	1..1	CodeableConcept	Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible)
Coverage.relationship.id		0..1	string	Unique id for inter-element referencing
Coverage.relationship.extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
Coverage.relationship.Slices for coding	Σ This element is included in summaries.	0..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:$this Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
Coverage.relationship.Slices for coding.coding:X12Code	S This element must be supported. Σ This element is included in summaries.	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.
Coverage.relationship.text	Σ This element is included in summaries.	0..1	string	Plain text representation of the concept
Coverage.period	S This element must be supported. Σ This element is included in summaries.	0..1	Period	Coverage start and end dates
Coverage.payor	S This element must be supported. Σ This element is included in summaries.	1..1	Reference(PAS Insurer Organization(2.2.1))	Issuer of the policy
Coverage.Slices for class	S This element must be supported.	0..*	BackboneElement	Additional coverage classifications Slice: Unordered, Open by pattern:type Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
Coverage.Slices for class.class:All Slices				Content/Rules for all slices
Coverage.Slices for class.class:All Slices.id		0..1	string	Unique id for inter-element referencing
Coverage.Slices for class.class:All Slices.extension		0..*	Extension	Additional content defined by implementations
Coverage.Slices for class.class:All Slices.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Coverage.Slices for class.class:All Slices.type	Σ This element is included in summaries.	1..1	CodeableConcept	Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.
Coverage.Slices for class.class:All Slices.value	Σ This element is included in summaries.	1..1	string	Value associated with the type
Coverage.Slices for class.class:All Slices.name	Σ This element is included in summaries.	0..1	string	Human readable description of the type and value
Coverage.Slices for class.class:group	S This element must be supported.	0..1	BackboneElement	Group
Coverage.Slices for class.class:group.id		0..1	string	Unique id for inter-element referencing
Coverage.Slices for class.class:group.extension		0..*	Extension	Additional content defined by implementations
Coverage.Slices for class.class:group.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Coverage.Slices for class.class:group.type	Σ This element is included in summaries.	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
Coverage.Slices for class.class:group.type.id		0..1	string	Unique id for inter-element referencing
Coverage.Slices for class.class:group.type.extension		0..*	Extension	Additional content defined by implementations
Coverage.Slices for class.class:group.type.coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
Coverage.Slices for class.class:group.type.coding.id		0..1	string	Unique id for inter-element referencing
Coverage.Slices for class.class:group.type.coding.extension		0..*	Extension	Additional content defined by implementations
Coverage.Slices for class.class:group.type.coding.system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
Coverage.Slices for class.class:group.type.coding.version		0..1	string	Version of the system - if relevant
Coverage.Slices for class.class:group.type.coding.code		1..1	code	Symbol in syntax defined by the system Fixed Value: group
Coverage.Slices for class.class:group.type.coding.display		0..1	string	Representation defined by the system
Coverage.Slices for class.class:group.type.coding.userSelected		0..1	boolean	If this coding was chosen directly by the user
Coverage.Slices for class.class:group.type.text		0..1	string	Plain text representation of the concept
Coverage.Slices for class.class:group.value	S This element must be supported. Σ This element is included in summaries.	1..1	string	Group Number
Coverage.Slices for class.class:group.name	S This element must be supported. Σ This element is included in summaries.	0..1	string	Group Name
Coverage.Slices for class.class:plan	S This element must be supported.	0..1	BackboneElement	Plan
Coverage.Slices for class.class:plan.id		0..1	string	Unique id for inter-element referencing
Coverage.Slices for class.class:plan.extension		0..*	Extension	Additional content defined by implementations
Coverage.Slices for class.class:plan.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Coverage.Slices for class.class:plan.type	Σ This element is included in summaries.	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
Coverage.Slices for class.class:plan.type.id		0..1	string	Unique id for inter-element referencing
Coverage.Slices for class.class:plan.type.extension		0..*	Extension	Additional content defined by implementations
Coverage.Slices for class.class:plan.type.coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
Coverage.Slices for class.class:plan.type.coding.id		0..1	string	Unique id for inter-element referencing
Coverage.Slices for class.class:plan.type.coding.extension		0..*	Extension	Additional content defined by implementations
Coverage.Slices for class.class:plan.type.coding.system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
Coverage.Slices for class.class:plan.type.coding.version		0..1	string	Version of the system - if relevant
Coverage.Slices for class.class:plan.type.coding.code		1..1	code	Symbol in syntax defined by the system Fixed Value: plan
Coverage.Slices for class.class:plan.type.coding.display		0..1	string	Representation defined by the system
Coverage.Slices for class.class:plan.type.coding.userSelected		0..1	boolean	If this coding was chosen directly by the user
Coverage.Slices for class.class:plan.type.text		0..1	string	Plain text representation of the concept
Coverage.Slices for class.class:plan.value	S This element must be supported. Σ This element is included in summaries.	1..1	string	Plan Number
Coverage.Slices for class.class:plan.name	S This element must be supported. Σ This element is included in summaries.	0..1	string	Plan Name
Coverage.order	Σ This element is included in summaries.	0..1	positiveInt	Relative order of the coverage
Coverage.network	Σ This element is included in summaries.	0..1	string	Insurer network
Coverage.costToBeneficiary		0..*	BackboneElement	Patient payments for services/products
Coverage.costToBeneficiary.id		0..1	string	Unique id for inter-element referencing
Coverage.costToBeneficiary.extension		0..*	Extension	Additional content defined by implementations
Coverage.costToBeneficiary.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Coverage.costToBeneficiary.type	Σ This element is included in summaries.	0..1	CodeableConcept	Cost category Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified.
Coverage.costToBeneficiary.value[x]	Σ This element is included in summaries.	1..1		The amount or percentage due from the beneficiary
Coverage.costToBeneficiary.value[x].valueQuantity			Quantity(SimpleQuantity)
Coverage.costToBeneficiary.value[x].valueMoney			Money
Coverage.costToBeneficiary.exception		0..*	BackboneElement	Exceptions for patient payments
Coverage.costToBeneficiary.exception.id		0..1	string	Unique id for inter-element referencing
Coverage.costToBeneficiary.exception.extension		0..*	Extension	Additional content defined by implementations
Coverage.costToBeneficiary.exception.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Coverage.costToBeneficiary.exception.type	Σ This element is included in summaries.	1..1	CodeableConcept	Exception category Binding: ExampleCoverageFinancialExceptionCodes (example): The types of exceptions from the part or full value of financial obligations such as copays.
Coverage.costToBeneficiary.exception.period	Σ This element is included in summaries.	0..1	Period	The effective period of the exception
Coverage.subrogation		0..1	boolean	Reimbursement to insurer
Coverage.contract		0..*	Reference(Contract)	Contract details
Documentation for this format

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
Coverage.language	Base	preferred	Common Languages	📦4.0.1	FHIR Std.
Coverage.identifier:memberid.​use	Base	required	IdentifierUse	📍4.0.1	FHIR Std.
Coverage.identifier:memberid.​type	Base	extensible	IdentifierType	📦4.0.1	FHIR Std.
Coverage.status	Base	required	Financial Resource Status Codes	📍4.0.1	FHIR Std.
Coverage.type	Base	extensible	Payer Type	📍20221118	VSAC v0.19
Coverage.relationship	Base	extensible	SubscriberPolicyholder Relationship Codes	📦4.0.1	FHIR Std.
Coverage.relationship.​coding:X12Code	Base	required	https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069	Not State	Unknown
Coverage.class.type	Base	extensible	Coverage Class Codes	📦4.0.1	FHIR Std.
Coverage.class:group.​type	Base	extensible	Coverage Class Codes	📦4.0.1	FHIR Std.
Coverage.class:plan.​type	Base	extensible	Coverage Class Codes	📦4.0.1	FHIR Std.
Coverage.costToBeneficiary.​type	Base	extensible	Coverage Copay Type Codes	📦4.0.1	FHIR Std.
Coverage.costToBeneficiary.​exception.type	Base	example	Example Coverage Financial Exception Codes	📦4.0.1	FHIR Std.

Constraints

Id	Grade	Path(s)	Description	Expression
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

Mandatory: 2 elements
Must-Support: 2 elements

Structures

This structure refers to these other structures:

• PAS Subscriber Patient (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-subscriber|2.2.1)
• PAS Beneficiary Patient (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-beneficiary|2.2.1)
• PAS Insurer Organization (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-insurer|2.2.1)

Slices

This structure defines the following Slices:

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

Maturity: 4

Key Elements View

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
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) Constraints: us-core-15, self-beneficiary
Coverage.implicitRules	?! This element is a modifier element. Σ This element is included in summaries.	0..1	uri	A set of rules under which this content was created
Coverage.modifierExtension	?! This element is a modifier element.	0..*	Extension	Extensions that cannot be ignored
Coverage.Slices for identifier	S This element must be supported. Σ This element is included in summaries.	1..*	Identifier	Member ID and other identifiers Slice: Unordered, Open by pattern:type Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
Coverage.Slices for identifier.identifier:memberid	S This element must be supported. Σ This element is included in summaries. C	1..1	Identifier	Member ID
Coverage.Slices for identifier.identifier:memberid.use	?! This element is a modifier element. Σ This element is included in summaries.	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
Coverage.Slices for identifier.identifier:memberid.type	S This element must be supported. Σ This element is included in summaries.	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
Coverage.Slices for identifier.identifier:memberid.type.id		0..1	string	Unique id for inter-element referencing
Coverage.Slices for identifier.identifier:memberid.type.extension		0..*	Extension	Additional content defined by implementations
Coverage.Slices for identifier.identifier:memberid.type.coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
Coverage.Slices for identifier.identifier:memberid.type.coding.id		0..1	string	Unique id for inter-element referencing
Coverage.Slices for identifier.identifier:memberid.type.coding.extension		0..*	Extension	Additional content defined by implementations
Coverage.Slices for identifier.identifier:memberid.type.coding.system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
Coverage.Slices for identifier.identifier:memberid.type.coding.version		0..1	string	Version of the system - if relevant
Coverage.Slices for identifier.identifier:memberid.type.coding.code		1..1	code	Symbol in syntax defined by the system Fixed Value: MB
Coverage.Slices for identifier.identifier:memberid.type.coding.display		0..1	string	Representation defined by the system
Coverage.Slices for identifier.identifier:memberid.type.coding.userSelected		0..1	boolean	If this coding was chosen directly by the user
Coverage.Slices for identifier.identifier:memberid.type.text		0..1	string	Plain text representation of the concept
Coverage.status	?! This element is a modifier element. S This element must be supported. Σ This element is included in summaries.	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Required Pattern: active
Coverage.type	S This element must be supported. Σ This element is included in summaries.	0..1	CodeableConcept	Coverage category such as medical or accident Binding: PayerType (20221118) (extensible): US Public Health Data Consortium Source of Payment Codes
Coverage.subscriber	S This element must be supported. Σ This element is included in summaries.	0..1	Reference(PAS Subscriber Patient(2.2.1))	Subscriber to the policy
Coverage.subscriberId	S This element must be supported. Σ This element is included in summaries. C	0..1	string	ID assigned to the subscriber
Coverage.beneficiary	S This element must be supported. Σ This element is included in summaries.	1..1	Reference(PAS Beneficiary Patient(2.2.1))	Plan beneficiary
Coverage.relationship	S This element must be supported.	1..1	CodeableConcept	Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible)
Coverage.relationship.Slices for coding	Σ This element is included in summaries.	0..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:$this Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
Coverage.relationship.Slices for coding.coding:X12Code	S This element must be supported. Σ This element is included in summaries.	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.
Coverage.period	S This element must be supported. Σ This element is included in summaries.	0..1	Period	Coverage start and end dates
Coverage.payor	S This element must be supported. Σ This element is included in summaries.	1..1	Reference(PAS Insurer Organization(2.2.1))	Issuer of the policy
Coverage.Slices for class	S This element must be supported.	0..*	BackboneElement	Additional coverage classifications Slice: Unordered, Open by pattern:type Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
Coverage.Slices for class.class:All Slices				Content/Rules for all slices
Coverage.Slices for class.class:All Slices.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Coverage.Slices for class.class:All Slices.type	Σ This element is included in summaries.	1..1	CodeableConcept	Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.
Coverage.Slices for class.class:All Slices.value	Σ This element is included in summaries.	1..1	string	Value associated with the type
Coverage.Slices for class.class:group	S This element must be supported.	0..1	BackboneElement	Group
Coverage.Slices for class.class:group.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Coverage.Slices for class.class:group.type	Σ This element is included in summaries.	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
Coverage.Slices for class.class:group.type.id		0..1	string	Unique id for inter-element referencing
Coverage.Slices for class.class:group.type.extension		0..*	Extension	Additional content defined by implementations
Coverage.Slices for class.class:group.type.coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
Coverage.Slices for class.class:group.type.coding.id		0..1	string	Unique id for inter-element referencing
Coverage.Slices for class.class:group.type.coding.extension		0..*	Extension	Additional content defined by implementations
Coverage.Slices for class.class:group.type.coding.system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
Coverage.Slices for class.class:group.type.coding.version		0..1	string	Version of the system - if relevant
Coverage.Slices for class.class:group.type.coding.code		1..1	code	Symbol in syntax defined by the system Fixed Value: group
Coverage.Slices for class.class:group.type.coding.display		0..1	string	Representation defined by the system
Coverage.Slices for class.class:group.type.coding.userSelected		0..1	boolean	If this coding was chosen directly by the user
Coverage.Slices for class.class:group.type.text		0..1	string	Plain text representation of the concept
Coverage.Slices for class.class:group.value	S This element must be supported. Σ This element is included in summaries.	1..1	string	Group Number
Coverage.Slices for class.class:group.name	S This element must be supported. Σ This element is included in summaries.	0..1	string	Group Name
Coverage.Slices for class.class:plan	S This element must be supported.	0..1	BackboneElement	Plan
Coverage.Slices for class.class:plan.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Coverage.Slices for class.class:plan.type	Σ This element is included in summaries.	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
Coverage.Slices for class.class:plan.type.id		0..1	string	Unique id for inter-element referencing
Coverage.Slices for class.class:plan.type.extension		0..*	Extension	Additional content defined by implementations
Coverage.Slices for class.class:plan.type.coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
Coverage.Slices for class.class:plan.type.coding.id		0..1	string	Unique id for inter-element referencing
Coverage.Slices for class.class:plan.type.coding.extension		0..*	Extension	Additional content defined by implementations
Coverage.Slices for class.class:plan.type.coding.system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
Coverage.Slices for class.class:plan.type.coding.version		0..1	string	Version of the system - if relevant
Coverage.Slices for class.class:plan.type.coding.code		1..1	code	Symbol in syntax defined by the system Fixed Value: plan
Coverage.Slices for class.class:plan.type.coding.display		0..1	string	Representation defined by the system
Coverage.Slices for class.class:plan.type.coding.userSelected		0..1	boolean	If this coding was chosen directly by the user
Coverage.Slices for class.class:plan.type.text		0..1	string	Plain text representation of the concept
Coverage.Slices for class.class:plan.value	S This element must be supported. Σ This element is included in summaries.	1..1	string	Plan Number
Coverage.Slices for class.class:plan.name	S This element must be supported. Σ This element is included in summaries.	0..1	string	Plan Name
Documentation for this format

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
Coverage.identifier:memberid.​use	Base	required	IdentifierUse	📍4.0.1	FHIR Std.
Coverage.identifier:memberid.​type	Base	extensible	IdentifierType	📦4.0.1	FHIR Std.
Coverage.status	Base	required	Financial Resource Status Codes	📍4.0.1	FHIR Std.
Coverage.type	Base	extensible	Payer Type	📍20221118	VSAC v0.19
Coverage.relationship	Base	extensible	SubscriberPolicyholder Relationship Codes	📦4.0.1	FHIR Std.
Coverage.relationship.​coding:X12Code	Base	required	https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069	Not State	Unknown
Coverage.class.type	Base	extensible	Coverage Class Codes	📦4.0.1	FHIR Std.
Coverage.class:group.​type	Base	extensible	Coverage Class Codes	📦4.0.1	FHIR Std.
Coverage.class:plan.​type	Base	extensible	Coverage Class Codes	📦4.0.1	FHIR Std.

Constraints

Id	Grade	Path(s)	Description	Expression
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()

Differential View

This structure is derived from USCoreCoverageProfile

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
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)
Coverage.identifier		1..*	Identifier	Member ID and other identifiers
Coverage.Slices for identifier				Content/Rules for all slices
Coverage.Slices for identifier.identifier:memberid		1..1	Identifier	Member ID
Coverage.status		1..1	code	active | cancelled | draft | entered-in-error Required Pattern: active
Coverage.subscriber	S This element must be supported.	0..1	Reference(PAS Subscriber Patient(2.2.1))	Subscriber to the policy
Coverage.beneficiary		1..1	Reference(PAS Beneficiary Patient(2.2.1))	Plan beneficiary
Coverage.relationship
Coverage.relationship.Slices for coding		0..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:$this Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
Coverage.relationship.Slices for coding.coding:X12Code	S This element must be supported.	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.
Coverage.payor		1..1	Reference(PAS Insurer Organization(2.2.1))	Issuer of the policy
Documentation for this format

Terminology Bindings (Differential)

Path	Status	Usage	ValueSet	Version	Source
Coverage.relationship.​coding:X12Code	Base	required	https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069	Not State	Unknown

Constraints

Id	Grade	Path(s)	Description	Expression
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 ViewView

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
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) Constraints: us-core-15, self-beneficiary
Coverage.id	Σ This element is included in summaries.	0..1	id	Logical id of this artifact
Coverage.meta	Σ This element is included in summaries.	0..1	Meta	Metadata about the resource
Coverage.implicitRules	?! This element is a modifier element. Σ This element is included in summaries.	0..1	uri	A set of rules under which this content was created
Coverage.language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
Coverage.text		0..1	Narrative	Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Coverage.contained		0..*	Resource	Contained, inline Resources
Coverage.extension		0..*	Extension	Additional content defined by implementations
Coverage.modifierExtension	?! This element is a modifier element.	0..*	Extension	Extensions that cannot be ignored
Coverage.Slices for identifier	S This element must be supported. Σ This element is included in summaries.	1..*	Identifier	Member ID and other identifiers Slice: Unordered, Open by pattern:type Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
Coverage.Slices for identifier.identifier:memberid	S This element must be supported. Σ This element is included in summaries. C	1..1	Identifier	Member ID
Coverage.Slices for identifier.identifier:memberid.id		0..1	string	Unique id for inter-element referencing
Coverage.Slices for identifier.identifier:memberid.extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
Coverage.Slices for identifier.identifier:memberid.use	?! This element is a modifier element. Σ This element is included in summaries.	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
Coverage.Slices for identifier.identifier:memberid.type	S This element must be supported. Σ This element is included in summaries.	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
Coverage.Slices for identifier.identifier:memberid.type.id		0..1	string	Unique id for inter-element referencing
Coverage.Slices for identifier.identifier:memberid.type.extension		0..*	Extension	Additional content defined by implementations
Coverage.Slices for identifier.identifier:memberid.type.coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
Coverage.Slices for identifier.identifier:memberid.type.coding.id		0..1	string	Unique id for inter-element referencing
Coverage.Slices for identifier.identifier:memberid.type.coding.extension		0..*	Extension	Additional content defined by implementations
Coverage.Slices for identifier.identifier:memberid.type.coding.system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
Coverage.Slices for identifier.identifier:memberid.type.coding.version		0..1	string	Version of the system - if relevant
Coverage.Slices for identifier.identifier:memberid.type.coding.code		1..1	code	Symbol in syntax defined by the system Fixed Value: MB
Coverage.Slices for identifier.identifier:memberid.type.coding.display		0..1	string	Representation defined by the system
Coverage.Slices for identifier.identifier:memberid.type.coding.userSelected		0..1	boolean	If this coding was chosen directly by the user
Coverage.Slices for identifier.identifier:memberid.type.text		0..1	string	Plain text representation of the concept
Coverage.Slices for identifier.identifier:memberid.system	Σ This element is included in summaries.	0..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
Coverage.Slices for identifier.identifier:memberid.value	Σ This element is included in summaries.	0..1	string	The value that is unique Example General: 123456
Coverage.Slices for identifier.identifier:memberid.period	Σ This element is included in summaries.	0..1	Period	Time period when id is/was valid for use
Coverage.Slices for identifier.identifier:memberid.assigner	Σ This element is included in summaries.	0..1	Reference(Organization)	Organization that issued id (may be just text)
Coverage.status	?! This element is a modifier element. S This element must be supported. Σ This element is included in summaries.	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Required Pattern: active
Coverage.type	S This element must be supported. Σ This element is included in summaries.	0..1	CodeableConcept	Coverage category such as medical or accident Binding: PayerType (20221118) (extensible): US Public Health Data Consortium Source of Payment Codes
Coverage.policyHolder	Σ This element is included in summaries.	0..1	Reference(Patient | RelatedPerson | Organization)	Owner of the policy
Coverage.subscriber	S This element must be supported. Σ This element is included in summaries.	0..1	Reference(PAS Subscriber Patient(2.2.1))	Subscriber to the policy
Coverage.subscriberId	S This element must be supported. Σ This element is included in summaries. C	0..1	string	ID assigned to the subscriber
Coverage.beneficiary	S This element must be supported. Σ This element is included in summaries.	1..1	Reference(PAS Beneficiary Patient(2.2.1))	Plan beneficiary
Coverage.dependent	Σ This element is included in summaries.	0..1	string	Dependent number
Coverage.relationship	S This element must be supported.	1..1	CodeableConcept	Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible)
Coverage.relationship.id		0..1	string	Unique id for inter-element referencing
Coverage.relationship.extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
Coverage.relationship.Slices for coding	Σ This element is included in summaries.	0..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:$this Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
Coverage.relationship.Slices for coding.coding:X12Code	S This element must be supported. Σ This element is included in summaries.	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.
Coverage.relationship.text	Σ This element is included in summaries.	0..1	string	Plain text representation of the concept
Coverage.period	S This element must be supported. Σ This element is included in summaries.	0..1	Period	Coverage start and end dates
Coverage.payor	S This element must be supported. Σ This element is included in summaries.	1..1	Reference(PAS Insurer Organization(2.2.1))	Issuer of the policy
Coverage.Slices for class	S This element must be supported.	0..*	BackboneElement	Additional coverage classifications Slice: Unordered, Open by pattern:type Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
Coverage.Slices for class.class:All Slices				Content/Rules for all slices
Coverage.Slices for class.class:All Slices.id		0..1	string	Unique id for inter-element referencing
Coverage.Slices for class.class:All Slices.extension		0..*	Extension	Additional content defined by implementations
Coverage.Slices for class.class:All Slices.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Coverage.Slices for class.class:All Slices.type	Σ This element is included in summaries.	1..1	CodeableConcept	Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.
Coverage.Slices for class.class:All Slices.value	Σ This element is included in summaries.	1..1	string	Value associated with the type
Coverage.Slices for class.class:All Slices.name	Σ This element is included in summaries.	0..1	string	Human readable description of the type and value
Coverage.Slices for class.class:group	S This element must be supported.	0..1	BackboneElement	Group
Coverage.Slices for class.class:group.id		0..1	string	Unique id for inter-element referencing
Coverage.Slices for class.class:group.extension		0..*	Extension	Additional content defined by implementations
Coverage.Slices for class.class:group.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Coverage.Slices for class.class:group.type	Σ This element is included in summaries.	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
Coverage.Slices for class.class:group.type.id		0..1	string	Unique id for inter-element referencing
Coverage.Slices for class.class:group.type.extension		0..*	Extension	Additional content defined by implementations
Coverage.Slices for class.class:group.type.coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
Coverage.Slices for class.class:group.type.coding.id		0..1	string	Unique id for inter-element referencing
Coverage.Slices for class.class:group.type.coding.extension		0..*	Extension	Additional content defined by implementations
Coverage.Slices for class.class:group.type.coding.system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
Coverage.Slices for class.class:group.type.coding.version		0..1	string	Version of the system - if relevant
Coverage.Slices for class.class:group.type.coding.code		1..1	code	Symbol in syntax defined by the system Fixed Value: group
Coverage.Slices for class.class:group.type.coding.display		0..1	string	Representation defined by the system
Coverage.Slices for class.class:group.type.coding.userSelected		0..1	boolean	If this coding was chosen directly by the user
Coverage.Slices for class.class:group.type.text		0..1	string	Plain text representation of the concept
Coverage.Slices for class.class:group.value	S This element must be supported. Σ This element is included in summaries.	1..1	string	Group Number
Coverage.Slices for class.class:group.name	S This element must be supported. Σ This element is included in summaries.	0..1	string	Group Name
Coverage.Slices for class.class:plan	S This element must be supported.	0..1	BackboneElement	Plan
Coverage.Slices for class.class:plan.id		0..1	string	Unique id for inter-element referencing
Coverage.Slices for class.class:plan.extension		0..*	Extension	Additional content defined by implementations
Coverage.Slices for class.class:plan.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Coverage.Slices for class.class:plan.type	Σ This element is included in summaries.	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
Coverage.Slices for class.class:plan.type.id		0..1	string	Unique id for inter-element referencing
Coverage.Slices for class.class:plan.type.extension		0..*	Extension	Additional content defined by implementations
Coverage.Slices for class.class:plan.type.coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
Coverage.Slices for class.class:plan.type.coding.id		0..1	string	Unique id for inter-element referencing
Coverage.Slices for class.class:plan.type.coding.extension		0..*	Extension	Additional content defined by implementations
Coverage.Slices for class.class:plan.type.coding.system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
Coverage.Slices for class.class:plan.type.coding.version		0..1	string	Version of the system - if relevant
Coverage.Slices for class.class:plan.type.coding.code		1..1	code	Symbol in syntax defined by the system Fixed Value: plan
Coverage.Slices for class.class:plan.type.coding.display		0..1	string	Representation defined by the system
Coverage.Slices for class.class:plan.type.coding.userSelected		0..1	boolean	If this coding was chosen directly by the user
Coverage.Slices for class.class:plan.type.text		0..1	string	Plain text representation of the concept
Coverage.Slices for class.class:plan.value	S This element must be supported. Σ This element is included in summaries.	1..1	string	Plan Number
Coverage.Slices for class.class:plan.name	S This element must be supported. Σ This element is included in summaries.	0..1	string	Plan Name
Coverage.order	Σ This element is included in summaries.	0..1	positiveInt	Relative order of the coverage
Coverage.network	Σ This element is included in summaries.	0..1	string	Insurer network
Coverage.costToBeneficiary		0..*	BackboneElement	Patient payments for services/products
Coverage.costToBeneficiary.id		0..1	string	Unique id for inter-element referencing
Coverage.costToBeneficiary.extension		0..*	Extension	Additional content defined by implementations
Coverage.costToBeneficiary.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Coverage.costToBeneficiary.type	Σ This element is included in summaries.	0..1	CodeableConcept	Cost category Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified.
Coverage.costToBeneficiary.value[x]	Σ This element is included in summaries.	1..1		The amount or percentage due from the beneficiary
Coverage.costToBeneficiary.value[x].valueQuantity			Quantity(SimpleQuantity)
Coverage.costToBeneficiary.value[x].valueMoney			Money
Coverage.costToBeneficiary.exception		0..*	BackboneElement	Exceptions for patient payments
Coverage.costToBeneficiary.exception.id		0..1	string	Unique id for inter-element referencing
Coverage.costToBeneficiary.exception.extension		0..*	Extension	Additional content defined by implementations
Coverage.costToBeneficiary.exception.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Coverage.costToBeneficiary.exception.type	Σ This element is included in summaries.	1..1	CodeableConcept	Exception category Binding: ExampleCoverageFinancialExceptionCodes (example): The types of exceptions from the part or full value of financial obligations such as copays.
Coverage.costToBeneficiary.exception.period	Σ This element is included in summaries.	0..1	Period	The effective period of the exception
Coverage.subrogation		0..1	boolean	Reimbursement to insurer
Coverage.contract		0..*	Reference(Contract)	Contract details
Documentation for this format

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
Coverage.language	Base	preferred	Common Languages	📦4.0.1	FHIR Std.
Coverage.identifier:memberid.​use	Base	required	IdentifierUse	📍4.0.1	FHIR Std.
Coverage.identifier:memberid.​type	Base	extensible	IdentifierType	📦4.0.1	FHIR Std.
Coverage.status	Base	required	Financial Resource Status Codes	📍4.0.1	FHIR Std.
Coverage.type	Base	extensible	Payer Type	📍20221118	VSAC v0.19
Coverage.relationship	Base	extensible	SubscriberPolicyholder Relationship Codes	📦4.0.1	FHIR Std.
Coverage.relationship.​coding:X12Code	Base	required	https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069	Not State	Unknown
Coverage.class.type	Base	extensible	Coverage Class Codes	📦4.0.1	FHIR Std.
Coverage.class:group.​type	Base	extensible	Coverage Class Codes	📦4.0.1	FHIR Std.
Coverage.class:plan.​type	Base	extensible	Coverage Class Codes	📦4.0.1	FHIR Std.
Coverage.costToBeneficiary.​type	Base	extensible	Coverage Copay Type Codes	📦4.0.1	FHIR Std.
Coverage.costToBeneficiary.​exception.type	Base	example	Example Coverage Financial Exception Codes	📦4.0.1	FHIR Std.

Constraints

Id	Grade	Path(s)	Description	Expression
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

Mandatory: 2 elements
Must-Support: 2 elements

Structures

This structure refers to these other structures:

• PAS Subscriber Patient (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-subscriber|2.2.1)
• PAS Beneficiary Patient (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-beneficiary|2.2.1)
• PAS Insurer Organization (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-insurer|2.2.1)

Slices

This structure defines the following Slices:

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

Maturity: 4

Other representations of profile: CSV, Excel, Schematron