Patient Cost Transparency Implementation Guide, published by HL7 International / Financial Management. This guide is not an authorized publication; it is the continuous build for version 2.0.0-draft built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/davinci-pct/ and changes regularly. See the Directory of published versions

• Content
• Detailed Descriptions
• Mappings
• Examples
• XML
• JSON
• TTL

Resource Profile: PCT Coverage

PCT Coverage is a profile for capturing data that reflect a payer’s coverage that was effective as of the proposed date of service or the date of admission of the GFE.

Usage:

• Use this Resource Profile: PCT AEOB Bundle, PCT AEOB Document Bundle, PCT GFE Bundle, PCT GFE Collection Bundle... Show 3 more, PCT GFE Document Bundle, PCT GFE Information Bundle and PCT GFE Missing Bundle
• Refer to this Resource Profile: PCT Advanced EOB Summary, PCT Advanced EOB, PCT Good Faith Estimate Institutional, PCT Good Faith Estimate Professional and PCT Good Faith Estimate Summary
• Examples for this Resource Profile: Coverage/coverage1001
• CapabilityStatements using this Resource Profile: Patient Cost Transparency Implementation Guide Payer Capability Statement

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
Coverage	C	0..*	HRexCoverage	Insurance or medical plan or a payment agreement dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management hrex-cov-1: Coverage.identifier or Coverage.subscriberId SHALL be present
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
coverage-kind		1..1	(Complex)	Optional Extensions Element URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
extension		0..0
url		1..1	uri	"http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind"
value[x]		1..1	code	Value of extension ele-1: All FHIR elements must have a @value or children
self-pay-declared	S	0..1	boolean	Self-Pay Declared URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/selfPayDeclared ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
identifier	SΣ	0..1	Identifier	Also known as Member identifier ele-1: All FHIR elements must have a @value or children
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . ele-1: All FHIR elements must have a @value or children
value	SΣ	1..1	string	The value that is unique within the system. ele-1: All FHIR elements must have a @value or children Example General: 123456
status	?!Σ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. ele-1: All FHIR elements must have a @value or children
subscriber	Σ	0..1	Reference(US Core Patient Profile)	Required if subscriber is a person that is not the beneficiary. When date of birth or gender are not known, omit Patient.birthDate and set Patient.gender to unknown. ele-1: All FHIR elements must have a @value or children
display	Σ	1..1	string	Provide the name of the subscriber in Coverage.subscriber.display concatenating the subscriber’s prefix, given name, family name and suffix (in this order), each separated by a single space. If discrete name parts are required, a Patient resource SHALL be pointed to in Coverage.subscriber.reference. ele-1: All FHIR elements must have a @value or children
subscriberId	SΣ	1..1	string	Subscriber ID ele-1: All FHIR elements must have a @value or children
beneficiary	SΣ	1..1	Reference(HRex Patient Demographics)	Plan beneficiary ele-1: All FHIR elements must have a @value or children
dependent	SΣ	0..1	string	Dependent number ele-1: All FHIR elements must have a @value or children
relationship		1..1	CodeableConcept	Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient). ele-1: All FHIR elements must have a @value or children
period	Σ	1..1	Period	Coverage start and end dates ele-1: All FHIR elements must have a @value or children
payor	SΣ	1..1	Reference(PCT Organization)	Issuer of the policy ele-1: All FHIR elements must have a @value or children
Slices for class		1..*	BackboneElement	Additional coverage classifications Slice: Unordered, Open by pattern:type ele-1: All FHIR elements must have a @value or children
class:All Slices				Content/Rules for all slices
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
type	Σ	1..1	CodeableConcept	Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. ele-1: All FHIR elements must have a @value or children
value	Σ	1..1	string	Value associated with the type ele-1: All FHIR elements must have a @value or children
name	Σ	1..1	string	Human readable description of the type and value ele-1: All FHIR elements must have a @value or children
class:group	S	0..1	BackboneElement	Additional coverage classifications ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
type	SΣ	1..1	CodeableConcept	Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
code		1..1	code	Symbol in syntax defined by the system Fixed Value: group
value	SΣ	1..1	string	Value associated with the type ele-1: All FHIR elements must have a @value or children
name	Σ	1..1	string	Human readable description of the type and value ele-1: All FHIR elements must have a @value or children
class:plan	S	0..1	BackboneElement	Additional coverage classifications ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
type	Σ	1..1	CodeableConcept	Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
code		1..1	code	Symbol in syntax defined by the system Fixed Value: plan
coding	Σ	1..*	Coding	Code defined by a terminology system ele-1: All FHIR elements must have a @value or children
value	Σ	1..1	string	Value associated with the type ele-1: All FHIR elements must have a @value or children
name	Σ	1..1	string	Human readable description of the type and value ele-1: All FHIR elements must have a @value or children
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Coverage.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard
Coverage.status	required	FinancialResourceStatusCodes http://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard
Coverage.relationship	extensible	SubscriberRelationshipCodes http://hl7.org/fhir/ValueSet/subscriber-relationship from the FHIR Standard
Coverage.class.type	extensible	CoverageClassCodes http://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard
Coverage.class:group.type	extensible	Pattern: group http://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard
Coverage.class:plan.type	extensible	Pattern: plan http://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard

This structure is derived from HRexCoverage

Name	Flags	Card.	Type	Description & Constraints
Coverage			HRexCoverage
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
coverage-kind		1..1	(Complex)	Optional Extensions Element URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind
value[x]		1..1	code	Value of extension
self-pay-declared	S	0..1	boolean	Self-Pay Declared URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/selfPayDeclared
subscriber		0..1	Reference(US Core Patient Profile)	Required if subscriber is a person that is not the beneficiary. When date of birth or gender are not known, omit Patient.birthDate and set Patient.gender to unknown.
display		1..1	string	Provide the name of the subscriber in Coverage.subscriber.display concatenating the subscriber’s prefix, given name, family name and suffix (in this order), each separated by a single space. If discrete name parts are required, a Patient resource SHALL be pointed to in Coverage.subscriber.reference.
subscriberId		1..1	string	Subscriber ID
relationship		1..1	CodeableConcept	Beneficiary relationship to the subscriber
period		1..1	Period	Coverage start and end dates
payor		1..1	Reference(PCT Organization)	Issuer of the policy
Slices for class		1..*	BackboneElement	Additional coverage classifications Slice: Unordered, Open by pattern:type
class:All Slices				Content/Rules for all slices
name		1..1	string	Human readable description of the type and value
class:group		0..1	BackboneElement	Additional coverage classifications
name		1..1	string	Human readable description of the type and value
class:plan	S	0..1	BackboneElement	Additional coverage classifications
type		1..1	CodeableConcept	Type of class such as 'group' or 'plan' Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
code		1..1	code	Symbol in syntax defined by the system Fixed Value: plan
coding		1..*	Coding	Code defined by a terminology system
costToBeneficiary
type		0..1	CodeableConcept	Cost category Binding: Coverage Copay Type Codes (required)
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Coverage.costToBeneficiary.type	required	CoverageCopayTypeCodes http://terminology.hl7.org/ValueSet/coverage-copay-type

Name	Flags	Card.	Type	Description & Constraints
Coverage	C	0..*	HRexCoverage	Insurance or medical plan or a payment agreement hrex-cov-1: Coverage.identifier or Coverage.subscriberId SHALL be present
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
coverage-kind		1..1	(Complex)	Optional Extensions Element URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind
id		0..1	string	Unique id for inter-element referencing
extension		0..0
url		1..1	uri	"http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind"
value[x]		1..1	code	Value of extension
self-pay-declared	S	0..1	boolean	Self-Pay Declared URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/selfPayDeclared
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	SΣ	0..1	Identifier	Also known as Member identifier
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	Σ	0..1	CodeableConcept	Description of identifier 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.
system	Σ	0..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value	SΣ	1..1	string	The value that is unique within the system. 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	?!Σ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
type	Σ	0..1	CodeableConcept	Coverage category such as medical or accident Binding: CoverageTypeAndSelf-PayCodes (preferred): The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization.
policyHolder	Σ	0..1	Reference(US Core Patient Profile | HRex Organization Profile | RelatedPerson)	Owner of the policy
subscriber	Σ	0..1	Reference(US Core Patient Profile)	Required if subscriber is a person that is not the beneficiary. When date of birth or gender are not known, omit Patient.birthDate and set Patient.gender to unknown.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	0..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	1..1	string	Provide the name of the subscriber in Coverage.subscriber.display concatenating the subscriber’s prefix, given name, family name and suffix (in this order), each separated by a single space. If discrete name parts are required, a Patient resource SHALL be pointed to in Coverage.subscriber.reference.
subscriberId	SΣ	1..1	string	Subscriber ID
beneficiary	SΣ	1..1	Reference(HRex Patient Demographics)	Plan beneficiary
dependent	SΣ	0..1	string	Dependent number
relationship		1..1	CodeableConcept	Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).
period	Σ	1..1	Period	Coverage start and end dates
payor	SΣ	1..1	Reference(PCT Organization)	Issuer of the policy
Slices for class		1..*	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	1..1	string	Human readable description of the type and value
class:group	S	0..1	BackboneElement	Additional coverage classifications
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	SΣ	1..1	CodeableConcept	Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: group
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
value	SΣ	1..1	string	Value associated with the type
name	Σ	1..1	string	Human readable description of the type and value
class:plan	S	0..1	BackboneElement	Additional coverage classifications
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
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	1..*	Coding	Code defined by a terminology system
text	Σ	0..1	string	Plain text representation of the concept
value	Σ	1..1	string	Value associated with the type
name	Σ	1..1	string	Human readable description of the type and value
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: Coverage Copay Type Codes (required)
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.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard
Coverage.identifier.type	extensible	Identifier Type Codes http://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard
Coverage.status	required	FinancialResourceStatusCodes http://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard
Coverage.type	preferred	CoverageTypeAndSelf-PayCodes http://hl7.org/fhir/ValueSet/coverage-type from the FHIR Standard
Coverage.subscriber.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard
Coverage.relationship	extensible	SubscriberRelationshipCodes http://hl7.org/fhir/ValueSet/subscriber-relationship from the FHIR Standard
Coverage.class.type	extensible	CoverageClassCodes http://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard
Coverage.class:group.type	extensible	Pattern: group http://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard
Coverage.class:plan.type	extensible	Pattern: plan http://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard
Coverage.costToBeneficiary.type	required	CoverageCopayTypeCodes http://terminology.hl7.org/ValueSet/coverage-copay-type
Coverage.costToBeneficiary.exception.type	example	ExampleCoverageFinancialExceptionCodes http://hl7.org/fhir/ValueSet/coverage-financial-exception from the FHIR Standard

This structure is derived from HRexCoverage

Summary

Mandatory: 8 elements(3 nested mandatory elements)
Must-Support: 2 elements

Structures

This structure refers to these other structures:

• PCT Organization (http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization)

Extensions

This structure refers to these extensions:

• http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind
• http://hl7.org/fhir/us/davinci-pct/StructureDefinition/selfPayDeclared

Slices

This structure defines the following Slices:

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

Maturity: 2

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
Coverage	C	0..*	HRexCoverage	Insurance or medical plan or a payment agreement dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management hrex-cov-1: Coverage.identifier or Coverage.subscriberId SHALL be present
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
coverage-kind		1..1	(Complex)	Optional Extensions Element URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
extension		0..0
url		1..1	uri	"http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind"
value[x]		1..1	code	Value of extension ele-1: All FHIR elements must have a @value or children
self-pay-declared	S	0..1	boolean	Self-Pay Declared URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/selfPayDeclared ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
identifier	SΣ	0..1	Identifier	Also known as Member identifier ele-1: All FHIR elements must have a @value or children
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . ele-1: All FHIR elements must have a @value or children
value	SΣ	1..1	string	The value that is unique within the system. ele-1: All FHIR elements must have a @value or children Example General: 123456
status	?!Σ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. ele-1: All FHIR elements must have a @value or children
subscriber	Σ	0..1	Reference(US Core Patient Profile)	Required if subscriber is a person that is not the beneficiary. When date of birth or gender are not known, omit Patient.birthDate and set Patient.gender to unknown. ele-1: All FHIR elements must have a @value or children
display	Σ	1..1	string	Provide the name of the subscriber in Coverage.subscriber.display concatenating the subscriber’s prefix, given name, family name and suffix (in this order), each separated by a single space. If discrete name parts are required, a Patient resource SHALL be pointed to in Coverage.subscriber.reference. ele-1: All FHIR elements must have a @value or children
subscriberId	SΣ	1..1	string	Subscriber ID ele-1: All FHIR elements must have a @value or children
beneficiary	SΣ	1..1	Reference(HRex Patient Demographics)	Plan beneficiary ele-1: All FHIR elements must have a @value or children
dependent	SΣ	0..1	string	Dependent number ele-1: All FHIR elements must have a @value or children
relationship		1..1	CodeableConcept	Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient). ele-1: All FHIR elements must have a @value or children
period	Σ	1..1	Period	Coverage start and end dates ele-1: All FHIR elements must have a @value or children
payor	SΣ	1..1	Reference(PCT Organization)	Issuer of the policy ele-1: All FHIR elements must have a @value or children
Slices for class		1..*	BackboneElement	Additional coverage classifications Slice: Unordered, Open by pattern:type ele-1: All FHIR elements must have a @value or children
class:All Slices				Content/Rules for all slices
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
type	Σ	1..1	CodeableConcept	Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. ele-1: All FHIR elements must have a @value or children
value	Σ	1..1	string	Value associated with the type ele-1: All FHIR elements must have a @value or children
name	Σ	1..1	string	Human readable description of the type and value ele-1: All FHIR elements must have a @value or children
class:group	S	0..1	BackboneElement	Additional coverage classifications ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
type	SΣ	1..1	CodeableConcept	Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
code		1..1	code	Symbol in syntax defined by the system Fixed Value: group
value	SΣ	1..1	string	Value associated with the type ele-1: All FHIR elements must have a @value or children
name	Σ	1..1	string	Human readable description of the type and value ele-1: All FHIR elements must have a @value or children
class:plan	S	0..1	BackboneElement	Additional coverage classifications ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
type	Σ	1..1	CodeableConcept	Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
code		1..1	code	Symbol in syntax defined by the system Fixed Value: plan
coding	Σ	1..*	Coding	Code defined by a terminology system ele-1: All FHIR elements must have a @value or children
value	Σ	1..1	string	Value associated with the type ele-1: All FHIR elements must have a @value or children
name	Σ	1..1	string	Human readable description of the type and value ele-1: All FHIR elements must have a @value or children
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Coverage.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard
Coverage.status	required	FinancialResourceStatusCodes http://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard
Coverage.relationship	extensible	SubscriberRelationshipCodes http://hl7.org/fhir/ValueSet/subscriber-relationship from the FHIR Standard
Coverage.class.type	extensible	CoverageClassCodes http://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard
Coverage.class:group.type	extensible	Pattern: group http://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard
Coverage.class:plan.type	extensible	Pattern: plan http://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard

Differential View

This structure is derived from HRexCoverage

Name	Flags	Card.	Type	Description & Constraints
Coverage			HRexCoverage
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
coverage-kind		1..1	(Complex)	Optional Extensions Element URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind
value[x]		1..1	code	Value of extension
self-pay-declared	S	0..1	boolean	Self-Pay Declared URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/selfPayDeclared
subscriber		0..1	Reference(US Core Patient Profile)	Required if subscriber is a person that is not the beneficiary. When date of birth or gender are not known, omit Patient.birthDate and set Patient.gender to unknown.
display		1..1	string	Provide the name of the subscriber in Coverage.subscriber.display concatenating the subscriber’s prefix, given name, family name and suffix (in this order), each separated by a single space. If discrete name parts are required, a Patient resource SHALL be pointed to in Coverage.subscriber.reference.
subscriberId		1..1	string	Subscriber ID
relationship		1..1	CodeableConcept	Beneficiary relationship to the subscriber
period		1..1	Period	Coverage start and end dates
payor		1..1	Reference(PCT Organization)	Issuer of the policy
Slices for class		1..*	BackboneElement	Additional coverage classifications Slice: Unordered, Open by pattern:type
class:All Slices				Content/Rules for all slices
name		1..1	string	Human readable description of the type and value
class:group		0..1	BackboneElement	Additional coverage classifications
name		1..1	string	Human readable description of the type and value
class:plan	S	0..1	BackboneElement	Additional coverage classifications
type		1..1	CodeableConcept	Type of class such as 'group' or 'plan' Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
code		1..1	code	Symbol in syntax defined by the system Fixed Value: plan
coding		1..*	Coding	Code defined by a terminology system
costToBeneficiary
type		0..1	CodeableConcept	Cost category Binding: Coverage Copay Type Codes (required)
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Coverage.costToBeneficiary.type	required	CoverageCopayTypeCodes http://terminology.hl7.org/ValueSet/coverage-copay-type

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
Coverage	C	0..*	HRexCoverage	Insurance or medical plan or a payment agreement hrex-cov-1: Coverage.identifier or Coverage.subscriberId SHALL be present
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
coverage-kind		1..1	(Complex)	Optional Extensions Element URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind
id		0..1	string	Unique id for inter-element referencing
extension		0..0
url		1..1	uri	"http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind"
value[x]		1..1	code	Value of extension
self-pay-declared	S	0..1	boolean	Self-Pay Declared URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/selfPayDeclared
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	SΣ	0..1	Identifier	Also known as Member identifier
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	Σ	0..1	CodeableConcept	Description of identifier 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.
system	Σ	0..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value	SΣ	1..1	string	The value that is unique within the system. 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	?!Σ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
type	Σ	0..1	CodeableConcept	Coverage category such as medical or accident Binding: CoverageTypeAndSelf-PayCodes (preferred): The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization.
policyHolder	Σ	0..1	Reference(US Core Patient Profile | HRex Organization Profile | RelatedPerson)	Owner of the policy
subscriber	Σ	0..1	Reference(US Core Patient Profile)	Required if subscriber is a person that is not the beneficiary. When date of birth or gender are not known, omit Patient.birthDate and set Patient.gender to unknown.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	0..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	1..1	string	Provide the name of the subscriber in Coverage.subscriber.display concatenating the subscriber’s prefix, given name, family name and suffix (in this order), each separated by a single space. If discrete name parts are required, a Patient resource SHALL be pointed to in Coverage.subscriber.reference.
subscriberId	SΣ	1..1	string	Subscriber ID
beneficiary	SΣ	1..1	Reference(HRex Patient Demographics)	Plan beneficiary
dependent	SΣ	0..1	string	Dependent number
relationship		1..1	CodeableConcept	Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).
period	Σ	1..1	Period	Coverage start and end dates
payor	SΣ	1..1	Reference(PCT Organization)	Issuer of the policy
Slices for class		1..*	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	1..1	string	Human readable description of the type and value
class:group	S	0..1	BackboneElement	Additional coverage classifications
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	SΣ	1..1	CodeableConcept	Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: group
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
value	SΣ	1..1	string	Value associated with the type
name	Σ	1..1	string	Human readable description of the type and value
class:plan	S	0..1	BackboneElement	Additional coverage classifications
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
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	1..*	Coding	Code defined by a terminology system
text	Σ	0..1	string	Plain text representation of the concept
value	Σ	1..1	string	Value associated with the type
name	Σ	1..1	string	Human readable description of the type and value
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: Coverage Copay Type Codes (required)
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.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard
Coverage.identifier.type	extensible	Identifier Type Codes http://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard
Coverage.status	required	FinancialResourceStatusCodes http://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard
Coverage.type	preferred	CoverageTypeAndSelf-PayCodes http://hl7.org/fhir/ValueSet/coverage-type from the FHIR Standard
Coverage.subscriber.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard
Coverage.relationship	extensible	SubscriberRelationshipCodes http://hl7.org/fhir/ValueSet/subscriber-relationship from the FHIR Standard
Coverage.class.type	extensible	CoverageClassCodes http://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard
Coverage.class:group.type	extensible	Pattern: group http://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard
Coverage.class:plan.type	extensible	Pattern: plan http://hl7.org/fhir/ValueSet/coverage-class from the FHIR Standard
Coverage.costToBeneficiary.type	required	CoverageCopayTypeCodes http://terminology.hl7.org/ValueSet/coverage-copay-type
Coverage.costToBeneficiary.exception.type	example	ExampleCoverageFinancialExceptionCodes http://hl7.org/fhir/ValueSet/coverage-financial-exception from the FHIR Standard

This structure is derived from HRexCoverage

Summary

Mandatory: 8 elements(3 nested mandatory elements)
Must-Support: 2 elements

Structures

This structure refers to these other structures:

• PCT Organization (http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-organization)

Extensions

This structure refers to these extensions:

• http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind
• http://hl7.org/fhir/us/davinci-pct/StructureDefinition/selfPayDeclared

Slices

This structure defines the following Slices:

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

Maturity: 2

Other representations of profile: CSV, Excel, Schematron