Da Vinci Prior Authorization Support (PAS) FHIR IG
2.2.0-ballot - STU 2.2 - Ballot

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

## Resource Profile: PAS Coverage

Official URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-coverage | Version: 2.2.0-ballot
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

Usages:

- Refer to this Profile: 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 of Profiles, Differentials, Snapshots and how the different presentations work.

- 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
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
Slices for identifier | S Σ | 0..* | Identifier | Member ID and other identifiers Slice: Unordered, Open by pattern:type
identifier:memberid | S Σ C | 0..1 | Identifier | Member ID
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type | S Σ | 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
status | ?!S Σ | 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 | S Σ | 0..1 | CodeableConcept | Coverage category such as medical or accident Binding: Payer Type (extensible): US Public Health Data Consortium Source of Payment Codes
subscriber | S Σ | 0..1 | Reference(PAS Subscriber Patient) | Subscriber to the policy
subscriberId | S Σ C | 0..1 | string | ID assigned to the subscriber
beneficiary | S Σ | 1..1 | Reference(PAS Beneficiary Patient) | Plan beneficiary
relationship | S | 1..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible)
Slices for coding | Σ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:$this
coding:X12Code | S Σ | 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.
period | S Σ | 0..1 | Period | Coverage start and end dates
payor | S Σ | 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
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
class:group | S | 0..1 | BackboneElement | Group
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 | S Σ | 1..1 | string | Group Number
name | S Σ | 0..1 | string | Group Name
class:plan | S | 0..1 | BackboneElement | Plan
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 | S Σ | 1..1 | string | Plan Number
name | S Σ | 0..1 | string | Plan Name
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet / Code | URI
Coverage.identifier:memberid.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` From the FHIR Standard
Coverage.identifier:memberid.type | extensible | Pattern Value: MB `http://hl7.org/fhir/ValueSet/identifier-type` From the FHIR Standard
Coverage.status | required | Pattern Value: active `http://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` From https://vsac.nlm.nih.gov
Coverage.relationship | extensible | SubscriberRelationshipCodes `http://hl7.org/fhir/ValueSet/subscriber-relationship` From the FHIR Standard
Coverage.relationship.coding:X12Code | required | https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069 `https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069`
Coverage.class.type | extensible | CoverageClassCodes `http://hl7.org/fhir/ValueSet/coverage-class` From the FHIR Standard
Coverage.class:group.type | extensible | Pattern Value: group `http://hl7.org/fhir/ValueSet/coverage-class` From the FHIR Standard
Coverage.class:plan.type | extensible | Pattern Value: plan `http://hl7.org/fhir/ValueSet/coverage-class` From the FHIR Standard

#### Constraints

Id | Grade | Path(s) | Details | Requirements
dom-2 | error | Coverage | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() |
dom-3 | error | Coverage | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() |
dom-4 | error | Coverage | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() |
dom-5 | error | Coverage | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() |
dom-6 | best practice | Coverage | A resource should have narrative for robust management : text.`div`.exists() |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
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() |
us-core-15 | error | Coverage | Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present : identifier.type.coding.where(system='http://terminology.hl7.org/CodeSystem/v2-0203' and code='MB').exists() or subscriberId.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) Constraints: self-beneficiary
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

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet | URI
Coverage.relationship.coding:X12Code | required | https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069 `https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069`

#### Constraints

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 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
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.
Additional Bindings | Purpose
AllLanguages | Max Binding
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
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 | S Σ | 0..* | Identifier | Member ID and other identifiers Slice: Unordered, Open by pattern:type
identifier:memberid | S Σ C | 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 | S Σ | 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 | ?!S Σ | 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 | S Σ | 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 | S Σ | 0..1 | Reference(PAS Subscriber Patient) | Subscriber to the policy
subscriberId | S Σ C | 0..1 | string | ID assigned to the subscriber
beneficiary | S Σ | 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 | S Σ | 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 | S Σ | 0..1 | Period | Coverage start and end dates
payor | S Σ | 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 | S Σ | 1..1 | string | Group Number
name | S Σ | 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 | S Σ | 1..1 | string | Plan Number
name | S Σ | 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

#### Terminology Bindings

Path | Conformance | ValueSet / Code | URI
Coverage.language | preferred | CommonLanguages `http://hl7.org/fhir/ValueSet/languages` From the FHIR Standard
Additional Bindings | Purpose
AllLanguages | Max Binding
Coverage.identifier:memberid.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` From the FHIR Standard
Coverage.identifier:memberid.type | extensible | Pattern Value: MB `http://hl7.org/fhir/ValueSet/identifier-type` From the FHIR Standard
Coverage.status | required | Pattern Value: active `http://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` From https://vsac.nlm.nih.gov
Coverage.relationship | extensible | SubscriberRelationshipCodes `http://hl7.org/fhir/ValueSet/subscriber-relationship` From the FHIR Standard
Coverage.relationship.coding:X12Code | required | https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069 `https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069`
Coverage.class.type | extensible | CoverageClassCodes `http://hl7.org/fhir/ValueSet/coverage-class` From the FHIR Standard
Coverage.class:group.type | extensible | Pattern Value: group `http://hl7.org/fhir/ValueSet/coverage-class` From the FHIR Standard
Coverage.class:plan.type | extensible | Pattern Value: plan `http://hl7.org/fhir/ValueSet/coverage-class` From the FHIR Standard
Coverage.costToBeneficiary.type | extensible | CoverageCopayTypeCodes `http://hl7.org/fhir/ValueSet/coverage-copay-type` From the FHIR Standard
Coverage.costToBeneficiary.exception.type | example | ExampleCoverageFinancialExceptionCodes `http://hl7.org/fhir/ValueSet/coverage-financial-exception` From the FHIR Standard

#### Constraints

Id | Grade | Path(s) | Details | Requirements
dom-2 | error | Coverage | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() |
dom-3 | error | Coverage | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() |
dom-4 | error | Coverage | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() |
dom-5 | error | Coverage | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() |
dom-6 | best practice | Coverage | A resource should have narrative for robust management : text.`div`.exists() |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
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() |
us-core-15 | error | Coverage | Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present : identifier.type.coding.where(system='http://terminology.hl7.org/CodeSystem/v2-0203' and code='MB').exists() or subscriberId.exists() |

This structure is derived from USCoreCoverageProfile

Summary

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

Slices

This structure defines the following Slices:

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

Maturity: 3

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
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
Slices for identifier | S Σ | 0..* | Identifier | Member ID and other identifiers Slice: Unordered, Open by pattern:type
identifier:memberid | S Σ C | 0..1 | Identifier | Member ID
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type | S Σ | 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
status | ?!S Σ | 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 | S Σ | 0..1 | CodeableConcept | Coverage category such as medical or accident Binding: Payer Type (extensible): US Public Health Data Consortium Source of Payment Codes
subscriber | S Σ | 0..1 | Reference(PAS Subscriber Patient) | Subscriber to the policy
subscriberId | S Σ C | 0..1 | string | ID assigned to the subscriber
beneficiary | S Σ | 1..1 | Reference(PAS Beneficiary Patient) | Plan beneficiary
relationship | S | 1..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible)
Slices for coding | Σ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:$this
coding:X12Code | S Σ | 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.
period | S Σ | 0..1 | Period | Coverage start and end dates
payor | S Σ | 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
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
class:group | S | 0..1 | BackboneElement | Group
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 | S Σ | 1..1 | string | Group Number
name | S Σ | 0..1 | string | Group Name
class:plan | S | 0..1 | BackboneElement | Plan
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 | S Σ | 1..1 | string | Plan Number
name | S Σ | 0..1 | string | Plan Name
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet / Code | URI
Coverage.identifier:memberid.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` From the FHIR Standard
Coverage.identifier:memberid.type | extensible | Pattern Value: MB `http://hl7.org/fhir/ValueSet/identifier-type` From the FHIR Standard
Coverage.status | required | Pattern Value: active `http://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` From https://vsac.nlm.nih.gov
Coverage.relationship | extensible | SubscriberRelationshipCodes `http://hl7.org/fhir/ValueSet/subscriber-relationship` From the FHIR Standard
Coverage.relationship.coding:X12Code | required | https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069 `https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069`
Coverage.class.type | extensible | CoverageClassCodes `http://hl7.org/fhir/ValueSet/coverage-class` From the FHIR Standard
Coverage.class:group.type | extensible | Pattern Value: group `http://hl7.org/fhir/ValueSet/coverage-class` From the FHIR Standard
Coverage.class:plan.type | extensible | Pattern Value: plan `http://hl7.org/fhir/ValueSet/coverage-class` From the FHIR Standard

#### Constraints

Id | Grade | Path(s) | Details | Requirements
dom-2 | error | Coverage | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() |
dom-3 | error | Coverage | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() |
dom-4 | error | Coverage | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() |
dom-5 | error | Coverage | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() |
dom-6 | best practice | Coverage | A resource should have narrative for robust management : text.`div`.exists() |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
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() |
us-core-15 | error | Coverage | Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present : identifier.type.coding.where(system='http://terminology.hl7.org/CodeSystem/v2-0203' and code='MB').exists() or subscriberId.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) Constraints: self-beneficiary
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

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet | URI
Coverage.relationship.coding:X12Code | required | https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069 `https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069`

#### Constraints

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 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
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.
Additional Bindings | Purpose
AllLanguages | Max Binding
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
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 | S Σ | 0..* | Identifier | Member ID and other identifiers Slice: Unordered, Open by pattern:type
identifier:memberid | S Σ C | 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 | S Σ | 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 | ?!S Σ | 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 | S Σ | 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 | S Σ | 0..1 | Reference(PAS Subscriber Patient) | Subscriber to the policy
subscriberId | S Σ C | 0..1 | string | ID assigned to the subscriber
beneficiary | S Σ | 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 | S Σ | 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 | S Σ | 0..1 | Period | Coverage start and end dates
payor | S Σ | 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 | S Σ | 1..1 | string | Group Number
name | S Σ | 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 | S Σ | 1..1 | string | Plan Number
name | S Σ | 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

#### Terminology Bindings

Path | Conformance | ValueSet / Code | URI
Coverage.language | preferred | CommonLanguages `http://hl7.org/fhir/ValueSet/languages` From the FHIR Standard
Additional Bindings | Purpose
AllLanguages | Max Binding
Coverage.identifier:memberid.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` From the FHIR Standard
Coverage.identifier:memberid.type | extensible | Pattern Value: MB `http://hl7.org/fhir/ValueSet/identifier-type` From the FHIR Standard
Coverage.status | required | Pattern Value: active `http://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` From https://vsac.nlm.nih.gov
Coverage.relationship | extensible | SubscriberRelationshipCodes `http://hl7.org/fhir/ValueSet/subscriber-relationship` From the FHIR Standard
Coverage.relationship.coding:X12Code | required | https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069 `https://valueset.x12.org/x217/005010/request/2000D/INS/1/02/00/1069`
Coverage.class.type | extensible | CoverageClassCodes `http://hl7.org/fhir/ValueSet/coverage-class` From the FHIR Standard
Coverage.class:group.type | extensible | Pattern Value: group `http://hl7.org/fhir/ValueSet/coverage-class` From the FHIR Standard
Coverage.class:plan.type | extensible | Pattern Value: plan `http://hl7.org/fhir/ValueSet/coverage-class` From the FHIR Standard
Coverage.costToBeneficiary.type | extensible | CoverageCopayTypeCodes `http://hl7.org/fhir/ValueSet/coverage-copay-type` From the FHIR Standard
Coverage.costToBeneficiary.exception.type | example | ExampleCoverageFinancialExceptionCodes `http://hl7.org/fhir/ValueSet/coverage-financial-exception` From the FHIR Standard

#### Constraints

Id | Grade | Path(s) | Details | Requirements
dom-2 | error | Coverage | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() |
dom-3 | error | Coverage | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() |
dom-4 | error | Coverage | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() |
dom-5 | error | Coverage | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() |
dom-6 | best practice | Coverage | A resource should have narrative for robust management : text.`div`.exists() |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
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() |
us-core-15 | error | Coverage | Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present : identifier.type.coding.where(system='http://terminology.hl7.org/CodeSystem/v2-0203' and code='MB').exists() or subscriberId.exists() |

This structure is derived from USCoreCoverageProfile

Summary

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

Slices

This structure defines the following Slices:

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

Maturity: 3

Other representations of profile: CSV, Excel, Schematron