Patient Cost Transparency Implementation Guide
2.0.0-ballot - STU 2 Ballot United States of America flag

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-ballot 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

Resource Profile: PCT Coverage

Official URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-coverage Version: 2.0.0-ballot
Standards status: Trial-use Maturity Level: 2 Computable Name: PCTCoverage
Other Identifiers: OID:2.16.840.1.113883.4.642.40.4.42.8

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:

Formal Views of Profile Content

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

This structure is derived from HRexCoverage

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
... 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)

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Coverage.costToBeneficiary.typerequiredCoverageCopayTypeCodes
http://terminology.hl7.org/ValueSet/coverage-copay-type
NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage C 0..* HRexCoverage Insurance or medical plan or a payment agreement
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
... 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
..... 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
.... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

.... value SΣ 1..1 string The value that is unique within the system.
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.

... 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.
.... 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
..... 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
..... 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
...... 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
..... name Σ 1..1 string Human readable description of the type and value
.... class:plan S 0..1 BackboneElement Additional coverage classifications
..... 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
...... 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
..... value Σ 1..1 string Value associated with the type

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Coverage.identifier.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
Coverage.statusrequiredFinancialResourceStatusCodes
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
from the FHIR Standard
Coverage.relationshipextensibleSubscriberRelationshipCodes
http://hl7.org/fhir/ValueSet/subscriber-relationship
from the FHIR Standard
Coverage.class.typeextensibleCoverageClassCodes
http://hl7.org/fhir/ValueSet/coverage-class
from the FHIR Standard
Coverage.class:group.typeextensiblePattern: group
http://hl7.org/fhir/ValueSet/coverage-class
from the FHIR Standard
Coverage.class:plan.typeextensiblePattern: plan
http://hl7.org/fhir/ValueSet/coverage-class
from the FHIR Standard
NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
... 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 0..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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Coverage.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Coverage.identifier.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
Coverage.identifier.typeextensibleIdentifier Type Codes
http://hl7.org/fhir/ValueSet/identifier-type
from the FHIR Standard
Coverage.statusrequiredFinancialResourceStatusCodes
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
from the FHIR Standard
Coverage.typepreferredCoverageTypeAndSelf-PayCodes
http://hl7.org/fhir/ValueSet/coverage-type
from the FHIR Standard
Coverage.subscriber.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
Coverage.relationshipextensibleSubscriberRelationshipCodes
http://hl7.org/fhir/ValueSet/subscriber-relationship
from the FHIR Standard
Coverage.class.typeextensibleCoverageClassCodes
http://hl7.org/fhir/ValueSet/coverage-class
from the FHIR Standard
Coverage.class:group.typeextensiblePattern: group
http://hl7.org/fhir/ValueSet/coverage-class
from the FHIR Standard
Coverage.class:plan.typeextensiblePattern: plan
http://hl7.org/fhir/ValueSet/coverage-class
from the FHIR Standard
Coverage.costToBeneficiary.typerequiredCoverageCopayTypeCodes
http://terminology.hl7.org/ValueSet/coverage-copay-type
Coverage.costToBeneficiary.exception.typeexampleExampleCoverageFinancialExceptionCodes
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:

Extensions

This structure refers to these extensions:

Slices

This structure defines the following Slices:

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

Maturity: 2

Differential View

This structure is derived from HRexCoverage

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
... 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)

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Coverage.costToBeneficiary.typerequiredCoverageCopayTypeCodes
http://terminology.hl7.org/ValueSet/coverage-copay-type

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage C 0..* HRexCoverage Insurance or medical plan or a payment agreement
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
... 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
..... 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
.... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

.... value SΣ 1..1 string The value that is unique within the system.
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.

... 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.
.... 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
..... 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
..... 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
...... 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
..... name Σ 1..1 string Human readable description of the type and value
.... class:plan S 0..1 BackboneElement Additional coverage classifications
..... 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
...... 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
..... value Σ 1..1 string Value associated with the type

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Coverage.identifier.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
Coverage.statusrequiredFinancialResourceStatusCodes
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
from the FHIR Standard
Coverage.relationshipextensibleSubscriberRelationshipCodes
http://hl7.org/fhir/ValueSet/subscriber-relationship
from the FHIR Standard
Coverage.class.typeextensibleCoverageClassCodes
http://hl7.org/fhir/ValueSet/coverage-class
from the FHIR Standard
Coverage.class:group.typeextensiblePattern: group
http://hl7.org/fhir/ValueSet/coverage-class
from the FHIR Standard
Coverage.class:plan.typeextensiblePattern: plan
http://hl7.org/fhir/ValueSet/coverage-class
from the FHIR Standard

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
... 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 0..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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Coverage.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Coverage.identifier.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
Coverage.identifier.typeextensibleIdentifier Type Codes
http://hl7.org/fhir/ValueSet/identifier-type
from the FHIR Standard
Coverage.statusrequiredFinancialResourceStatusCodes
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
from the FHIR Standard
Coverage.typepreferredCoverageTypeAndSelf-PayCodes
http://hl7.org/fhir/ValueSet/coverage-type
from the FHIR Standard
Coverage.subscriber.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
Coverage.relationshipextensibleSubscriberRelationshipCodes
http://hl7.org/fhir/ValueSet/subscriber-relationship
from the FHIR Standard
Coverage.class.typeextensibleCoverageClassCodes
http://hl7.org/fhir/ValueSet/coverage-class
from the FHIR Standard
Coverage.class:group.typeextensiblePattern: group
http://hl7.org/fhir/ValueSet/coverage-class
from the FHIR Standard
Coverage.class:plan.typeextensiblePattern: plan
http://hl7.org/fhir/ValueSet/coverage-class
from the FHIR Standard
Coverage.costToBeneficiary.typerequiredCoverageCopayTypeCodes
http://terminology.hl7.org/ValueSet/coverage-copay-type
Coverage.costToBeneficiary.exception.typeexampleExampleCoverageFinancialExceptionCodes
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:

Extensions

This structure refers to these extensions:

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