Patient Cost Transparency Implementation Guide
2.0.1 - STU 2

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 2.0.1 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: 2.0.1
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.

Usages:

- Use this Profile: PCT AEOB Packet, PCT GFE Bundle, PCT GFE Information Bundle, PCT GFE Missing Bundle and PCT GFE Packet
- Refer to this Profile: PCT Advanced EOB Summary, PCT Advanced EOB, PCT GFE Composition, PCT Good Faith Estimate Institutional... Show 2 more, PCT Good Faith Estimate Professional and PCT Good Faith Estimate Summary
- Examples for this Profile: Coverage/coverage1001 and Coverage/selfpaycoverage2001
- CapabilityStatements using this Profile: Patient Cost Transparency Implementation Guide Payer Capability Statement

You can also check for usages in the FHIR IG Statistics

Changes since version 1.1.0:

- The resource metadata has changed (description)
- The data elements list has changed
- One or more text definitions, invariants or bindings have changed

### 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 Constraints: us-core-15, pct-coverage-1, pct-coverage-2
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
extension:coverage-kind | S | 1..1 | (Complex) | Optional Extensions Element URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind"
value[x] |  | 1..1 | code | Value of extension
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
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.
type | S Σ | 0..1 | CodeableConcept | Coverage category such as medical or accident. A coverage.type of `81` (Self-pay) MAY be used to imply that the patient has no coverage or that an individual or organization other than an insurer is taking responsibility for payment for a portion of the health care costs. Binding: Payer Type (extensible): US Public Health Data Consortium Source of Payment Codes
subscriber | Σ | 0..1 | Reference(Patient | RelatedPerson) | 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 | 0..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 | S Σ C | 1..1 | string | ID assigned to the subscriber
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:dataAbsentReason |  | 0..1 | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/data-absent-reason"
value[x] |  | 1..1 | code | Use Data Absent Reason (DAR) extension with a value of 'not-applicable' for self-pay or uninsured Binding: DataAbsentReason (required) Required Pattern: not-applicable
beneficiary | S Σ | 1..1 | Reference(US Core Patient Profile(7.0.0)) | Patient or Plan Beneficiary
relationship | S | 1..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible)
period | S Σ | 0..1 | Period | Coverage start and end dates
payor | S Σ | 1..1 | Reference(PCT Organization | US Core Patient Profile(7.0.0) | US Core RelatedPerson Profile(7.0.0)) | Issuer of the policy. For Self-pay or uninsured this should be a reference to a patient or related person resource
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
name | Σ | 1..1 | string | Human readable description of the type and value
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 | 1..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 | 1..1 | string | Plan Name
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Coverage.identifier:memberid.​use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std.
Coverage.identifier:memberid.​type | Base | extensible | IdentifierType | 📦4.0.1 | FHIR Std.
Coverage.status | Base | required | Financial Resource Status Codes | 📍4.0.1 | FHIR Std.
Coverage.type | Base | extensible | Payer Type | 📦20221118 | VSAC v0.19
Coverage.subscriberId.​extension:dataAbsentReason.​value[x] | Base | required | DataAbsentReason | 📦4.0.1 | FHIR Std.
Coverage.relationship | Base | extensible | SubscriberPolicyholder Relationship Codes | 📦4.0.1 | FHIR Std.
Coverage.class.type | Base | extensible | Coverage Class Codes | 📦4.0.1 | FHIR Std.
Coverage.class:group.​type | Base | extensible | Coverage Class Codes | 📦4.0.1 | FHIR Std.
Coverage.class:plan.​type | Base | extensible | Coverage Class Codes | 📦4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
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()`
pct-coverage-1 | error | Coverage | Coverage: class element SHALL be present if coverage-0kind is insurance | `extension.where(url='http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind'and value = 'insurance').exists() implies class.exists()`
pct-coverage-2 | error | Coverage | Coverage: period element SHALL be present if coverage-0kind is insurance | `extension.where(url='http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind'and value = 'insurance').exists() implies period.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 Constraints: pct-coverage-1, pct-coverage-2
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:coverage-kind | S | 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
extension:self-pay-declared | S | 0..1 | boolean | Self-Pay Declared URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/selfPayDeclared
type |  | 0..1 | CodeableConcept | Coverage category such as medical or accident. A coverage.type of `81` (Self-pay) MAY be used to imply that the patient has no coverage or that an individual or organization other than an insurer is taking responsibility for payment for a portion of the health care costs.
subscriber |  | 0..1 | Reference(Patient | RelatedPerson) | 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 |  | 0..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 | ID assigned to the subscriber
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:dataAbsentReason |  | 0..1 | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
value[x] |  | 1..1 | code | Use Data Absent Reason (DAR) extension with a value of 'not-applicable' for self-pay or uninsured Required Pattern: not-applicable
beneficiary |  | 1..1 | Reference(US Core Patient Profile(7.0.0)) | Patient or Plan Beneficiary
payor |  | 1..1 | Reference(PCT Organization | US Core Patient Profile(7.0.0) | US Core RelatedPerson Profile(7.0.0)) | Issuer of the policy. For Self-pay or uninsured this should be a reference to a patient or related person resource
class |  | 0..* | BackboneElement | Additional coverage classifications
name |  | 1..1 | string | Human readable description of the type and value
Slices for class |  |  |  | Content/Rules for all slices
class:group |  | 0..1 | BackboneElement | Group
name |  | 1..1 | string | Group Name
class:plan |  | 0..1 | BackboneElement | Plan
name |  | 1..1 | string | Plan Name
costToBeneficiary |  |  |  |
type |  | 0..1 | CodeableConcept | Cost category Binding: CoverageCopayTypeCodes (1.0.1) (required)
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
Coverage.costToBeneficiary.​type | Base | required | Coverage Copay Type Codes | 📍1.0.1 | THO v6.5

#### Constraints

Id | Grade | Path(s) | Description | Expression
pct-coverage-1 | error | Coverage | Coverage: class element SHALL be present if coverage-0kind is insurance | `extension.where(url='http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind'and value = 'insurance').exists() implies class.exists()`
pct-coverage-2 | error | Coverage | Coverage: period element SHALL be present if coverage-0kind is insurance | `extension.where(url='http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind'and value = 'insurance').exists() implies period.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 Constraints: us-core-15, pct-coverage-1, pct-coverage-2
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
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:coverage-kind | S | 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 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind"
value[x] |  | 1..1 | code | Value of extension
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
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.
type | S Σ | 0..1 | CodeableConcept | Coverage category such as medical or accident. A coverage.type of `81` (Self-pay) MAY be used to imply that the patient has no coverage or that an individual or organization other than an insurer is taking responsibility for payment for a portion of the health care costs. 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 | Σ | 0..1 | Reference(Patient | RelatedPerson) | 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 | Σ C | 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 | 0..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 | S Σ C | 1..1 | string | ID assigned to the subscriber
id |  | 0..1 | string | xml:id (or equivalent in JSON)
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:dataAbsentReason |  | 0..1 | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
id |  | 0..1 | id | Unique id for inter-element referencing
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/data-absent-reason"
value[x] |  | 1..1 | code | Use Data Absent Reason (DAR) extension with a value of 'not-applicable' for self-pay or uninsured Binding: DataAbsentReason (required) Required Pattern: not-applicable
value |  | 0..1 | string | Primitive value for string Max Length:1048576
beneficiary | S Σ | 1..1 | Reference(US Core Patient Profile(7.0.0)) | Patient or Plan Beneficiary
dependent | Σ | 0..1 | string | Dependent number
relationship | S | 1..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible)
period | S Σ | 0..1 | Period | Coverage start and end dates
payor | S Σ | 1..1 | Reference(PCT Organization | US Core Patient Profile(7.0.0) | US Core RelatedPerson Profile(7.0.0)) | Issuer of the policy. For Self-pay or uninsured this should be a reference to a patient or related person resource
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 | 1..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 | 1..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 | 1..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 (1.0.1) (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 | Status | Usage | ValueSet | Version | Source
Coverage.language | Base | preferred | Common Languages | 📦4.0.1 | FHIR Std.
Coverage.identifier:memberid.​use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std.
Coverage.identifier:memberid.​type | Base | extensible | IdentifierType | 📦4.0.1 | FHIR Std.
Coverage.status | Base | required | Financial Resource Status Codes | 📍4.0.1 | FHIR Std.
Coverage.type | Base | extensible | Payer Type | 📦20221118 | VSAC v0.19
Coverage.subscriber.​type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std.
Coverage.subscriberId.​extension:dataAbsentReason.​value[x] | Base | required | DataAbsentReason | 📦4.0.1 | FHIR Std.
Coverage.relationship | Base | extensible | SubscriberPolicyholder Relationship Codes | 📦4.0.1 | FHIR Std.
Coverage.class.type | Base | extensible | Coverage Class Codes | 📦4.0.1 | FHIR Std.
Coverage.class:group.​type | Base | extensible | Coverage Class Codes | 📦4.0.1 | FHIR Std.
Coverage.class:plan.​type | Base | extensible | Coverage Class Codes | 📦4.0.1 | FHIR Std.
Coverage.costToBeneficiary.​type | Base | required | Coverage Copay Type Codes | 📍1.0.1 | THO v6.5
Coverage.costToBeneficiary.​exception.type | Base | example | Example Coverage Financial Exception Codes | 📦4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
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()`
pct-coverage-1 | error | Coverage | Coverage: class element SHALL be present if coverage-0kind is insurance | `extension.where(url='http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind'and value = 'insurance').exists() implies class.exists()`
pct-coverage-2 | error | Coverage | Coverage: period element SHALL be present if coverage-0kind is insurance | `extension.where(url='http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind'and value = 'insurance').exists() implies period.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

Mandatory: 4 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)
- US Core Patient Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient|7.0.0)
- US Core RelatedPerson Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-relatedperson|7.0.0)

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
- http://hl7.org/fhir/StructureDefinition/data-absent-reason|5.2.0

Maturity: 2

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 Constraints: us-core-15, pct-coverage-1, pct-coverage-2
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
extension:coverage-kind | S | 1..1 | (Complex) | Optional Extensions Element URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind"
value[x] |  | 1..1 | code | Value of extension
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
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.
type | S Σ | 0..1 | CodeableConcept | Coverage category such as medical or accident. A coverage.type of `81` (Self-pay) MAY be used to imply that the patient has no coverage or that an individual or organization other than an insurer is taking responsibility for payment for a portion of the health care costs. Binding: Payer Type (extensible): US Public Health Data Consortium Source of Payment Codes
subscriber | Σ | 0..1 | Reference(Patient | RelatedPerson) | 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 | 0..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 | S Σ C | 1..1 | string | ID assigned to the subscriber
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:dataAbsentReason |  | 0..1 | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/data-absent-reason"
value[x] |  | 1..1 | code | Use Data Absent Reason (DAR) extension with a value of 'not-applicable' for self-pay or uninsured Binding: DataAbsentReason (required) Required Pattern: not-applicable
beneficiary | S Σ | 1..1 | Reference(US Core Patient Profile(7.0.0)) | Patient or Plan Beneficiary
relationship | S | 1..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible)
period | S Σ | 0..1 | Period | Coverage start and end dates
payor | S Σ | 1..1 | Reference(PCT Organization | US Core Patient Profile(7.0.0) | US Core RelatedPerson Profile(7.0.0)) | Issuer of the policy. For Self-pay or uninsured this should be a reference to a patient or related person resource
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
name | Σ | 1..1 | string | Human readable description of the type and value
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 | 1..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 | 1..1 | string | Plan Name
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Coverage.identifier:memberid.​use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std.
Coverage.identifier:memberid.​type | Base | extensible | IdentifierType | 📦4.0.1 | FHIR Std.
Coverage.status | Base | required | Financial Resource Status Codes | 📍4.0.1 | FHIR Std.
Coverage.type | Base | extensible | Payer Type | 📦20221118 | VSAC v0.19
Coverage.subscriberId.​extension:dataAbsentReason.​value[x] | Base | required | DataAbsentReason | 📦4.0.1 | FHIR Std.
Coverage.relationship | Base | extensible | SubscriberPolicyholder Relationship Codes | 📦4.0.1 | FHIR Std.
Coverage.class.type | Base | extensible | Coverage Class Codes | 📦4.0.1 | FHIR Std.
Coverage.class:group.​type | Base | extensible | Coverage Class Codes | 📦4.0.1 | FHIR Std.
Coverage.class:plan.​type | Base | extensible | Coverage Class Codes | 📦4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
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()`
pct-coverage-1 | error | Coverage | Coverage: class element SHALL be present if coverage-0kind is insurance | `extension.where(url='http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind'and value = 'insurance').exists() implies class.exists()`
pct-coverage-2 | error | Coverage | Coverage: period element SHALL be present if coverage-0kind is insurance | `extension.where(url='http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind'and value = 'insurance').exists() implies period.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 Constraints: pct-coverage-1, pct-coverage-2
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:coverage-kind | S | 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
extension:self-pay-declared | S | 0..1 | boolean | Self-Pay Declared URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/selfPayDeclared
type |  | 0..1 | CodeableConcept | Coverage category such as medical or accident. A coverage.type of `81` (Self-pay) MAY be used to imply that the patient has no coverage or that an individual or organization other than an insurer is taking responsibility for payment for a portion of the health care costs.
subscriber |  | 0..1 | Reference(Patient | RelatedPerson) | 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 |  | 0..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 | ID assigned to the subscriber
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:dataAbsentReason |  | 0..1 | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
value[x] |  | 1..1 | code | Use Data Absent Reason (DAR) extension with a value of 'not-applicable' for self-pay or uninsured Required Pattern: not-applicable
beneficiary |  | 1..1 | Reference(US Core Patient Profile(7.0.0)) | Patient or Plan Beneficiary
payor |  | 1..1 | Reference(PCT Organization | US Core Patient Profile(7.0.0) | US Core RelatedPerson Profile(7.0.0)) | Issuer of the policy. For Self-pay or uninsured this should be a reference to a patient or related person resource
class |  | 0..* | BackboneElement | Additional coverage classifications
name |  | 1..1 | string | Human readable description of the type and value
Slices for class |  |  |  | Content/Rules for all slices
class:group |  | 0..1 | BackboneElement | Group
name |  | 1..1 | string | Group Name
class:plan |  | 0..1 | BackboneElement | Plan
name |  | 1..1 | string | Plan Name
costToBeneficiary |  |  |  |
type |  | 0..1 | CodeableConcept | Cost category Binding: CoverageCopayTypeCodes (1.0.1) (required)
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
Coverage.costToBeneficiary.​type | Base | required | Coverage Copay Type Codes | 📍1.0.1 | THO v6.5

#### Constraints

Id | Grade | Path(s) | Description | Expression
pct-coverage-1 | error | Coverage | Coverage: class element SHALL be present if coverage-0kind is insurance | `extension.where(url='http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind'and value = 'insurance').exists() implies class.exists()`
pct-coverage-2 | error | Coverage | Coverage: period element SHALL be present if coverage-0kind is insurance | `extension.where(url='http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind'and value = 'insurance').exists() implies period.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 Constraints: us-core-15, pct-coverage-1, pct-coverage-2
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
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:coverage-kind | S | 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 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind"
value[x] |  | 1..1 | code | Value of extension
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
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.
type | S Σ | 0..1 | CodeableConcept | Coverage category such as medical or accident. A coverage.type of `81` (Self-pay) MAY be used to imply that the patient has no coverage or that an individual or organization other than an insurer is taking responsibility for payment for a portion of the health care costs. 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 | Σ | 0..1 | Reference(Patient | RelatedPerson) | 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 | Σ C | 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 | 0..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 | S Σ C | 1..1 | string | ID assigned to the subscriber
id |  | 0..1 | string | xml:id (or equivalent in JSON)
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:dataAbsentReason |  | 0..1 | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
id |  | 0..1 | id | Unique id for inter-element referencing
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/data-absent-reason"
value[x] |  | 1..1 | code | Use Data Absent Reason (DAR) extension with a value of 'not-applicable' for self-pay or uninsured Binding: DataAbsentReason (required) Required Pattern: not-applicable
value |  | 0..1 | string | Primitive value for string Max Length:1048576
beneficiary | S Σ | 1..1 | Reference(US Core Patient Profile(7.0.0)) | Patient or Plan Beneficiary
dependent | Σ | 0..1 | string | Dependent number
relationship | S | 1..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible)
period | S Σ | 0..1 | Period | Coverage start and end dates
payor | S Σ | 1..1 | Reference(PCT Organization | US Core Patient Profile(7.0.0) | US Core RelatedPerson Profile(7.0.0)) | Issuer of the policy. For Self-pay or uninsured this should be a reference to a patient or related person resource
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 | 1..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 | 1..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 | 1..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 (1.0.1) (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 | Status | Usage | ValueSet | Version | Source
Coverage.language | Base | preferred | Common Languages | 📦4.0.1 | FHIR Std.
Coverage.identifier:memberid.​use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std.
Coverage.identifier:memberid.​type | Base | extensible | IdentifierType | 📦4.0.1 | FHIR Std.
Coverage.status | Base | required | Financial Resource Status Codes | 📍4.0.1 | FHIR Std.
Coverage.type | Base | extensible | Payer Type | 📦20221118 | VSAC v0.19
Coverage.subscriber.​type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std.
Coverage.subscriberId.​extension:dataAbsentReason.​value[x] | Base | required | DataAbsentReason | 📦4.0.1 | FHIR Std.
Coverage.relationship | Base | extensible | SubscriberPolicyholder Relationship Codes | 📦4.0.1 | FHIR Std.
Coverage.class.type | Base | extensible | Coverage Class Codes | 📦4.0.1 | FHIR Std.
Coverage.class:group.​type | Base | extensible | Coverage Class Codes | 📦4.0.1 | FHIR Std.
Coverage.class:plan.​type | Base | extensible | Coverage Class Codes | 📦4.0.1 | FHIR Std.
Coverage.costToBeneficiary.​type | Base | required | Coverage Copay Type Codes | 📍1.0.1 | THO v6.5
Coverage.costToBeneficiary.​exception.type | Base | example | Example Coverage Financial Exception Codes | 📦4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
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()`
pct-coverage-1 | error | Coverage | Coverage: class element SHALL be present if coverage-0kind is insurance | `extension.where(url='http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind'and value = 'insurance').exists() implies class.exists()`
pct-coverage-2 | error | Coverage | Coverage: period element SHALL be present if coverage-0kind is insurance | `extension.where(url='http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind'and value = 'insurance').exists() implies period.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

Mandatory: 4 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)
- US Core Patient Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient|7.0.0)
- US Core RelatedPerson Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-relatedperson|7.0.0)

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
- http://hl7.org/fhir/StructureDefinition/data-absent-reason|5.2.0

Maturity: 2

Other representations of profile: CSV, Excel, Schematron