Patient Cost Transparency Implementation Guide
2.0.2 - STU 2 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 2.0.2 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: 2.0.2
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:

You can also check for usages in the FHIR IG Statistics

Changes since version 1.1.0:

  • The data elements list has changed
  • One or more text definitions, invariants or bindings have changed (description, Coverage.subscriber.display, Coverage.payor, Coverage.class:plan, Coverage.type)

    • Formal Views of Profile Content

    Description Differentials, Snapshots, and other representations.

    NameFlagsCard.TypeDescription & Constraints    Filter: doco
    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
    Coverage.implicitRules This element is a modifier element. This element is included in summaries. 0..1 uri A set of rules under which this content was created
    Coverage.Slices for extension 1..* Extension Extension
    Slice: Unordered, Open by value:url
    Coverage.Slices for extension.extension:coverage-kind This element must be supported. 1..1 (Complex) R5: insurance | self-pay | other (new)
    URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind
    Constraints: ext-1
    Coverage.Slices for extension.extension:coverage-kind.extension 0..0 Extension
    Slice: Unordered, Open by value:url
    Constraints: ext-1
    Coverage.Slices for extension.extension:coverage-kind.url 1..1 uri "http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind"
    Coverage.Slices for extension.extension:coverage-kind.value[x] 1..1 code insurance | self-pay | other
    Binding: R5CoverageKindForR4 (0.1.0) (required)
    Coverage.Slices for extension.extension:self-pay-declared This element must be supported. 0..1 boolean Self-Pay Declared
    URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/selfPayDeclared
    Coverage.modifierExtension This element is a modifier element. 0..* Extension Extensions that cannot be ignored
    Coverage.Slices for identifier This element must be supported. This element is included in summaries. 0..* Identifier Member ID and other identifiers
    Slice: Unordered, Open by pattern:type

    Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
    Coverage.Slices for identifier.identifier:memberid This element must be supported. This element is included in summaries. C 0..1 Identifier Member ID
    Coverage.Slices for identifier.identifier:memberid.use This element is a modifier element. This element is included in summaries. 0..1 code usual | official | temp | secondary | old (If known)
    Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
    Coverage.Slices for identifier.identifier:memberid.type This element must be supported. This element is included in summaries. 1..1 CodeableConcept Member Number identifier type
    Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
    Required Pattern: 
    {
  "coding" : [
    {
      "system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
      "code" : "MB"
    }
  ]
}
    Coverage.status This element is a modifier element. This element must be supported. This element is included in summaries. 1..1 code active | cancelled | draft | entered-in-error
    Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
    Coverage.type This element must be supported. This element is included in summaries. 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
    Coverage.subscriber This element is included in summaries. 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.
    Coverage.subscriber.display This element is included in summaries. 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.
    Coverage.subscriberId This element must be supported. This element is included in summaries. C 1..1 string ID assigned to the subscriber
    Coverage.subscriberId.Slices for extension 0..* Extension Extension
    Slice: Unordered, Open by value:url
    Coverage.subscriberId.Slices for extension.extension:dataAbsentReason 0..1 (Complex) unknown | asked | temp | notasked | masked | unsupported | astext | error
    URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
    Coverage.subscriberId.Slices for extension.extension:dataAbsentReason.extension 0..0 Extension
    Slice: Unordered, Open by value:url
    Coverage.subscriberId.Slices for extension.extension:dataAbsentReason.url 1..1 uri "http://hl7.org/fhir/StructureDefinition/data-absent-reason"
    Coverage.subscriberId.Slices for extension.extension:dataAbsentReason.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 (extensions allowed)
    Coverage.beneficiary This element must be supported. This element is included in summaries. 1..1 Reference(US Core Patient Profile(7.0.0)) Patient or Plan Beneficiary
    Coverage.relationship This element must be supported. 1..1 CodeableConcept Beneficiary relationship to the subscriber
    Binding: SubscriberRelationshipCodes (extensible)
    Coverage.period This element must be supported. This element is included in summaries. 0..1 Period Coverage start and end dates
    Coverage.payor This element must be supported. This element is included in summaries. 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
    Coverage.Slices for class This element must be supported. 0..* BackboneElement Additional coverage classifications
    Slice: Unordered, Open by pattern:type

    Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
    Coverage.Slices for class.class:All Slices Content/Rules for all slices
    Coverage.Slices for class.class:All Slices.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    Coverage.Slices for class.class:All Slices.type This element is included in summaries. 1..1 CodeableConcept Type of class such as 'group' or 'plan'
    Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.
    Coverage.Slices for class.class:All Slices.value This element is included in summaries. 1..1 string Value associated with the type
    Coverage.Slices for class.class:All Slices.name This element is included in summaries. 1..1 string Human readable description of the type and value
    Coverage.Slices for class.class:group This element must be supported. 0..1 BackboneElement Group
    Coverage.Slices for class.class:group.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    Coverage.Slices for class.class:group.type This element is included in summaries. 1..1 CodeableConcept Type of class such as 'group' or 'plan'
    Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.
    Required Pattern: 
    {
  "coding" : [
    {
      "system" : "http://terminology.hl7.org/CodeSystem/coverage-class",
      "code" : "group"
    }
  ]
}
    Coverage.Slices for class.class:group.value This element must be supported. This element is included in summaries. 1..1 string Group Number
    Coverage.Slices for class.class:group.name This element must be supported. This element is included in summaries. 1..1 string Group Name
    Coverage.Slices for class.class:plan This element must be supported. 0..1 BackboneElement Plan
    Coverage.Slices for class.class:plan.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    Coverage.Slices for class.class:plan.type This element is included in summaries. 1..1 CodeableConcept Type of class such as 'group' or 'plan'
    Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.
    Required Pattern: 
    {
  "coding" : [
    {
      "system" : "http://terminology.hl7.org/CodeSystem/coverage-class",
      "code" : "plan"
    }
  ]
}
    Coverage.Slices for class.class:plan.value This element must be supported. This element is included in summaries. 1..1 string Plan Number
    Coverage.Slices for class.class:plan.name This element must be supported. This element is included in summaries. 1..1 string Plan Name

    doco Documentation for this format

    Terminology Bindings

    Path Status Usage ValueSet Version Source
    Coverage.extension:coverage-kind.​value[x] Base required Cross-version ValueSet R5.Kind for use in FHIR R4 📍0.1.0 Extensions for Using Data Elements from FHIR R5 in FHIR R4 v0.1
    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
    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-kind is insurance extension.where(url='http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind'and value = 'insurance').exists() implies period.exists()

    This structure is derived from USCoreCoverageProfile

    NameFlagsCard.TypeDescription & Constraints    Filter: doco
    Coverage C 0..* USCoreCoverageProfile(7.0.0) Insurance or medical plan or a payment agreement
    Constraints: pct-coverage-1, pct-coverage-2
    Coverage.Slices for extension 1..* Extension Extension
    Slice: Unordered, Open by value:url
    Coverage.Slices for extension.extension:coverage-kind This element must be supported. 1..1 (Complex) R5: insurance | self-pay | other (new)
    URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind
    Coverage.Slices for extension.extension:coverage-kind.extension 0..0 Extension
    Coverage.Slices for extension.extension:self-pay-declared This element must be supported. 0..1 boolean Self-Pay Declared
    URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/selfPayDeclared
    Coverage.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.
    Coverage.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.
    Coverage.subscriber.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.
    Coverage.subscriberId 1..1 string ID assigned to the subscriber
    Coverage.subscriberId.Slices for extension 0..* Extension Extension
    Slice: Unordered, Open by value:url
    Coverage.subscriberId.Slices for extension.extension:dataAbsentReason 0..1 (Complex) unknown | asked | temp | notasked | masked | unsupported | astext | error
    URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
    Coverage.subscriberId.Slices for extension.extension:dataAbsentReason.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 (extensions allowed)
    Coverage.beneficiary 1..1 Reference(US Core Patient Profile(7.0.0)) Patient or Plan Beneficiary
    Coverage.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
    Coverage.class 0..* BackboneElement Additional coverage classifications
    Coverage.class.name 1..1 string Human readable description of the type and value
    Coverage.Slices for class Content/Rules for all slices
    Coverage.Slices for class.class:group 0..1 BackboneElement Group
    Coverage.Slices for class.class:group.name 1..1 string Group Name
    Coverage.Slices for class.class:plan 0..1 BackboneElement Plan
    Coverage.Slices for class.class:plan.name 1..1 string Plan Name
    Coverage.costToBeneficiary
    Coverage.costToBeneficiary.type 0..1 CodeableConcept Cost category
    Binding: CoverageCopayTypeCodes (1.0.1) (required)

    doco 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 v7.1

    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-kind is insurance extension.where(url='http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind'and value = 'insurance').exists() implies period.exists()
    NameFlagsCard.TypeDescription & Constraints    Filter: doco
    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
    Coverage.id This element is included in summaries. 0..1 id Logical id of this artifact
    Coverage.meta This element is included in summaries. 0..1 Meta Metadata about the resource
    Coverage.implicitRules This element is a modifier element. This element is included in summaries. 0..1 uri A set of rules under which this content was created
    Coverage.language 0..1 code Language of the resource content
    Binding: CommonLanguages (preferred): A human language.
    Additional BindingsPurpose
    AllLanguages Max Binding
    Coverage.text 0..1 Narrative Text summary of the resource, for human interpretation
    This profile does not constrain the narrative in regard to content, language, or traceability to data elements
    Coverage.contained 0..* Resource Contained, inline Resources
    Coverage.Slices for extension 1..* Extension Extension
    Slice: Unordered, Open by value:url
    Coverage.Slices for extension.extension:coverage-kind This element must be supported. 1..1 (Complex) R5: insurance | self-pay | other (new)
    URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind
    Constraints: ext-1
    Coverage.Slices for extension.extension:coverage-kind.id 0..1 string Unique id for inter-element referencing
    Coverage.Slices for extension.extension:coverage-kind.extension 0..0 Extension
    Slice: Unordered, Open by value:url
    Constraints: ext-1
    Coverage.Slices for extension.extension:coverage-kind.url 1..1 uri "http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind"
    Coverage.Slices for extension.extension:coverage-kind.value[x] 1..1 code insurance | self-pay | other
    Binding: R5CoverageKindForR4 (0.1.0) (required)
    Coverage.Slices for extension.extension:self-pay-declared This element must be supported. 0..1 boolean Self-Pay Declared
    URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/selfPayDeclared
    Coverage.modifierExtension This element is a modifier element. 0..* Extension Extensions that cannot be ignored
    Coverage.Slices for identifier This element must be supported. This element is included in summaries. 0..* Identifier Member ID and other identifiers
    Slice: Unordered, Open by pattern:type

    Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
    Coverage.Slices for identifier.identifier:memberid This element must be supported. This element is included in summaries. C 0..1 Identifier Member ID
    Coverage.Slices for identifier.identifier:memberid.id 0..1 string Unique id for inter-element referencing
    Coverage.Slices for identifier.identifier:memberid.extension 0..* Extension Additional content defined by implementations
    Slice: Unordered, Open by value:url
    Coverage.Slices for identifier.identifier:memberid.use This element is a modifier element. This element is included in summaries. 0..1 code usual | official | temp | secondary | old (If known)
    Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
    Coverage.Slices for identifier.identifier:memberid.type This element must be supported. This element is included in summaries. 1..1 CodeableConcept Member Number identifier type
    Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
    Required Pattern: 
    {
  "coding" : [
    {
      "system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
      "code" : "MB"
    }
  ]
}
    Coverage.Slices for identifier.identifier:memberid.system This element is included in summaries. 0..1 uri The namespace for the identifier value
    Example General: http://www.acme.com/identifiers/patient
    Coverage.Slices for identifier.identifier:memberid.value This element is included in summaries. 0..1 string The value that is unique
    Example General: 123456
    Coverage.Slices for identifier.identifier:memberid.period This element is included in summaries. 0..1 Period Time period when id is/was valid for use
    Coverage.Slices for identifier.identifier:memberid.assigner This element is included in summaries. 0..1 Reference(Organization) Organization that issued id (may be just text)
    Coverage.status This element is a modifier element. This element must be supported. This element is included in summaries. 1..1 code active | cancelled | draft | entered-in-error
    Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
    Coverage.type This element must be supported. This element is included in summaries. 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
    Coverage.policyHolder This element is included in summaries. 0..1 Reference(Patient | RelatedPerson | Organization) Owner of the policy
    Coverage.subscriber This element is included in summaries. 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.
    Coverage.subscriber.id 0..1 string Unique id for inter-element referencing
    Coverage.subscriber.extension 0..* Extension Additional content defined by implementations
    Slice: Unordered, Open by value:url
    Coverage.subscriber.reference This element is included in summaries. C 0..1 string Literal reference, Relative, internal or absolute URL
    Coverage.subscriber.type This element is included in summaries. 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).
    Coverage.subscriber.identifier This element is included in summaries. 0..1 Identifier Logical reference, when literal reference is not known
    Coverage.subscriber.display This element is included in summaries. 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.
    Coverage.subscriberId This element must be supported. This element is included in summaries. C 1..1 string ID assigned to the subscriber
    Coverage.subscriberId.id 0..1 string xml:id (or equivalent in JSON)
    Coverage.subscriberId.Slices for extension 0..* Extension Extension
    Slice: Unordered, Open by value:url
    Coverage.subscriberId.Slices for extension.extension:dataAbsentReason 0..1 (Complex) unknown | asked | temp | notasked | masked | unsupported | astext | error
    URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
    Coverage.subscriberId.Slices for extension.extension:dataAbsentReason.id 0..1 string Unique id for inter-element referencing
    Coverage.subscriberId.Slices for extension.extension:dataAbsentReason.extension 0..0 Extension
    Slice: Unordered, Open by value:url
    Coverage.subscriberId.Slices for extension.extension:dataAbsentReason.url 1..1 uri "http://hl7.org/fhir/StructureDefinition/data-absent-reason"
    Coverage.subscriberId.Slices for extension.extension:dataAbsentReason.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 (extensions allowed)
    Coverage.subscriberId.value 0..1 string Primitive value for string
    Max Length:1048576
    Coverage.beneficiary This element must be supported. This element is included in summaries. 1..1 Reference(US Core Patient Profile(7.0.0)) Patient or Plan Beneficiary
    Coverage.dependent This element is included in summaries. 0..1 string Dependent number
    Coverage.relationship This element must be supported. 1..1 CodeableConcept Beneficiary relationship to the subscriber
    Binding: SubscriberRelationshipCodes (extensible)
    Coverage.period This element must be supported. This element is included in summaries. 0..1 Period Coverage start and end dates
    Coverage.payor This element must be supported. This element is included in summaries. 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
    Coverage.Slices for class This element must be supported. 0..* BackboneElement Additional coverage classifications
    Slice: Unordered, Open by pattern:type

    Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
    Coverage.Slices for class.class:All Slices Content/Rules for all slices
    Coverage.Slices for class.class:All Slices.id 0..1 string Unique id for inter-element referencing
    Coverage.Slices for class.class:All Slices.extension 0..* Extension Additional content defined by implementations
    Coverage.Slices for class.class:All Slices.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    Coverage.Slices for class.class:All Slices.type This element is included in summaries. 1..1 CodeableConcept Type of class such as 'group' or 'plan'
    Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.
    Coverage.Slices for class.class:All Slices.value This element is included in summaries. 1..1 string Value associated with the type
    Coverage.Slices for class.class:All Slices.name This element is included in summaries. 1..1 string Human readable description of the type and value
    Coverage.Slices for class.class:group This element must be supported. 0..1 BackboneElement Group
    Coverage.Slices for class.class:group.id 0..1 string Unique id for inter-element referencing
    Coverage.Slices for class.class:group.extension 0..* Extension Additional content defined by implementations
    Coverage.Slices for class.class:group.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    Coverage.Slices for class.class:group.type This element is included in summaries. 1..1 CodeableConcept Type of class such as 'group' or 'plan'
    Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.
    Required Pattern: 
    {
  "coding" : [
    {
      "system" : "http://terminology.hl7.org/CodeSystem/coverage-class",
      "code" : "group"
    }
  ]
}
    Coverage.Slices for class.class:group.value This element must be supported. This element is included in summaries. 1..1 string Group Number
    Coverage.Slices for class.class:group.name This element must be supported. This element is included in summaries. 1..1 string Group Name
    Coverage.Slices for class.class:plan This element must be supported. 0..1 BackboneElement Plan
    Coverage.Slices for class.class:plan.id 0..1 string Unique id for inter-element referencing
    Coverage.Slices for class.class:plan.extension 0..* Extension Additional content defined by implementations
    Coverage.Slices for class.class:plan.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    Coverage.Slices for class.class:plan.type This element is included in summaries. 1..1 CodeableConcept Type of class such as 'group' or 'plan'
    Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.
    Required Pattern: 
    {
  "coding" : [
    {
      "system" : "http://terminology.hl7.org/CodeSystem/coverage-class",
      "code" : "plan"
    }
  ]
}
    Coverage.Slices for class.class:plan.value This element must be supported. This element is included in summaries. 1..1 string Plan Number
    Coverage.Slices for class.class:plan.name This element must be supported. This element is included in summaries. 1..1 string Plan Name
    Coverage.order This element is included in summaries. 0..1 positiveInt Relative order of the coverage
    Coverage.network This element is included in summaries. 0..1 string Insurer network
    Coverage.costToBeneficiary 0..* BackboneElement Patient payments for services/products
    Coverage.costToBeneficiary.id 0..1 string Unique id for inter-element referencing
    Coverage.costToBeneficiary.extension 0..* Extension Additional content defined by implementations
    Coverage.costToBeneficiary.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    Coverage.costToBeneficiary.type This element is included in summaries. 0..1 CodeableConcept Cost category
    Binding: CoverageCopayTypeCodes (1.0.1) (required)
    Coverage.costToBeneficiary.value[x] This element is included in summaries. 1..1 The amount or percentage due from the beneficiary
    Coverage.costToBeneficiary.value[x].valueQuantity Quantity(SimpleQuantity)
    Coverage.costToBeneficiary.value[x].valueMoney Money
    Coverage.costToBeneficiary.exception 0..* BackboneElement Exceptions for patient payments
    Coverage.costToBeneficiary.exception.id 0..1 string Unique id for inter-element referencing
    Coverage.costToBeneficiary.exception.extension 0..* Extension Additional content defined by implementations
    Coverage.costToBeneficiary.exception.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    Coverage.costToBeneficiary.exception.type This element is included in summaries. 1..1 CodeableConcept Exception category
    Binding: ExampleCoverageFinancialExceptionCodes (example): The types of exceptions from the part or full value of financial obligations such as copays.
    Coverage.costToBeneficiary.exception.period This element is included in summaries. 0..1 Period The effective period of the exception
    Coverage.subrogation 0..1 boolean Reimbursement to insurer
    Coverage.contract 0..* Reference(Contract) Contract details

    doco Documentation for this format

    Terminology Bindings

    Path Status Usage ValueSet Version Source
    Coverage.language Base preferred Common Languages 📦4.0.1 FHIR Std.
    Coverage.extension:coverage-kind.​value[x] Base required Cross-version ValueSet R5.Kind for use in FHIR R4 📍0.1.0 Extensions for Using Data Elements from FHIR R5 in FHIR R4 v0.1
    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 v7.1
    Coverage.costToBeneficiary.​exception.type Base example Example Coverage Financial Exception Codes 📦4.0.1 FHIR Std.

    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-kind is insurance extension.where(url='http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind'and value = 'insurance').exists() implies period.exists()

    Key Elements View

    NameFlagsCard.TypeDescription & Constraints    Filter: doco
    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
    Coverage.implicitRules This element is a modifier element. This element is included in summaries. 0..1 uri A set of rules under which this content was created
    Coverage.Slices for extension 1..* Extension Extension
    Slice: Unordered, Open by value:url
    Coverage.Slices for extension.extension:coverage-kind This element must be supported. 1..1 (Complex) R5: insurance | self-pay | other (new)
    URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind
    Constraints: ext-1
    Coverage.Slices for extension.extension:coverage-kind.extension 0..0 Extension
    Slice: Unordered, Open by value:url
    Constraints: ext-1
    Coverage.Slices for extension.extension:coverage-kind.url 1..1 uri "http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind"
    Coverage.Slices for extension.extension:coverage-kind.value[x] 1..1 code insurance | self-pay | other
    Binding: R5CoverageKindForR4 (0.1.0) (required)
    Coverage.Slices for extension.extension:self-pay-declared This element must be supported. 0..1 boolean Self-Pay Declared
    URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/selfPayDeclared
    Coverage.modifierExtension This element is a modifier element. 0..* Extension Extensions that cannot be ignored
    Coverage.Slices for identifier This element must be supported. This element is included in summaries. 0..* Identifier Member ID and other identifiers
    Slice: Unordered, Open by pattern:type

    Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
    Coverage.Slices for identifier.identifier:memberid This element must be supported. This element is included in summaries. C 0..1 Identifier Member ID
    Coverage.Slices for identifier.identifier:memberid.use This element is a modifier element. This element is included in summaries. 0..1 code usual | official | temp | secondary | old (If known)
    Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
    Coverage.Slices for identifier.identifier:memberid.type This element must be supported. This element is included in summaries. 1..1 CodeableConcept Member Number identifier type
    Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
    Required Pattern: 
    {
  "coding" : [
    {
      "system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
      "code" : "MB"
    }
  ]
}
    Coverage.status This element is a modifier element. This element must be supported. This element is included in summaries. 1..1 code active | cancelled | draft | entered-in-error
    Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
    Coverage.type This element must be supported. This element is included in summaries. 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
    Coverage.subscriber This element is included in summaries. 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.
    Coverage.subscriber.display This element is included in summaries. 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.
    Coverage.subscriberId This element must be supported. This element is included in summaries. C 1..1 string ID assigned to the subscriber
    Coverage.subscriberId.Slices for extension 0..* Extension Extension
    Slice: Unordered, Open by value:url
    Coverage.subscriberId.Slices for extension.extension:dataAbsentReason 0..1 (Complex) unknown | asked | temp | notasked | masked | unsupported | astext | error
    URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
    Coverage.subscriberId.Slices for extension.extension:dataAbsentReason.extension 0..0 Extension
    Slice: Unordered, Open by value:url
    Coverage.subscriberId.Slices for extension.extension:dataAbsentReason.url 1..1 uri "http://hl7.org/fhir/StructureDefinition/data-absent-reason"
    Coverage.subscriberId.Slices for extension.extension:dataAbsentReason.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 (extensions allowed)
    Coverage.beneficiary This element must be supported. This element is included in summaries. 1..1 Reference(US Core Patient Profile(7.0.0)) Patient or Plan Beneficiary
    Coverage.relationship This element must be supported. 1..1 CodeableConcept Beneficiary relationship to the subscriber
    Binding: SubscriberRelationshipCodes (extensible)
    Coverage.period This element must be supported. This element is included in summaries. 0..1 Period Coverage start and end dates
    Coverage.payor This element must be supported. This element is included in summaries. 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
    Coverage.Slices for class This element must be supported. 0..* BackboneElement Additional coverage classifications
    Slice: Unordered, Open by pattern:type

    Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
    Coverage.Slices for class.class:All Slices Content/Rules for all slices
    Coverage.Slices for class.class:All Slices.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    Coverage.Slices for class.class:All Slices.type This element is included in summaries. 1..1 CodeableConcept Type of class such as 'group' or 'plan'
    Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.
    Coverage.Slices for class.class:All Slices.value This element is included in summaries. 1..1 string Value associated with the type
    Coverage.Slices for class.class:All Slices.name This element is included in summaries. 1..1 string Human readable description of the type and value
    Coverage.Slices for class.class:group This element must be supported. 0..1 BackboneElement Group
    Coverage.Slices for class.class:group.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    Coverage.Slices for class.class:group.type This element is included in summaries. 1..1 CodeableConcept Type of class such as 'group' or 'plan'
    Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.
    Required Pattern: 
    {
  "coding" : [
    {
      "system" : "http://terminology.hl7.org/CodeSystem/coverage-class",
      "code" : "group"
    }
  ]
}
    Coverage.Slices for class.class:group.value This element must be supported. This element is included in summaries. 1..1 string Group Number
    Coverage.Slices for class.class:group.name This element must be supported. This element is included in summaries. 1..1 string Group Name
    Coverage.Slices for class.class:plan This element must be supported. 0..1 BackboneElement Plan
    Coverage.Slices for class.class:plan.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    Coverage.Slices for class.class:plan.type This element is included in summaries. 1..1 CodeableConcept Type of class such as 'group' or 'plan'
    Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.
    Required Pattern: 
    {
  "coding" : [
    {
      "system" : "http://terminology.hl7.org/CodeSystem/coverage-class",
      "code" : "plan"
    }
  ]
}
    Coverage.Slices for class.class:plan.value This element must be supported. This element is included in summaries. 1..1 string Plan Number
    Coverage.Slices for class.class:plan.name This element must be supported. This element is included in summaries. 1..1 string Plan Name

    doco Documentation for this format

    Terminology Bindings

    Path Status Usage ValueSet Version Source
    Coverage.extension:coverage-kind.​value[x] Base required Cross-version ValueSet R5.Kind for use in FHIR R4 📍0.1.0 Extensions for Using Data Elements from FHIR R5 in FHIR R4 v0.1
    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
    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-kind is insurance extension.where(url='http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind'and value = 'insurance').exists() implies period.exists()

    Differential View

    This structure is derived from USCoreCoverageProfile

    NameFlagsCard.TypeDescription & Constraints    Filter: doco
    Coverage C 0..* USCoreCoverageProfile(7.0.0) Insurance or medical plan or a payment agreement
    Constraints: pct-coverage-1, pct-coverage-2
    Coverage.Slices for extension 1..* Extension Extension
    Slice: Unordered, Open by value:url
    Coverage.Slices for extension.extension:coverage-kind This element must be supported. 1..1 (Complex) R5: insurance | self-pay | other (new)
    URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind
    Coverage.Slices for extension.extension:coverage-kind.extension 0..0 Extension
    Coverage.Slices for extension.extension:self-pay-declared This element must be supported. 0..1 boolean Self-Pay Declared
    URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/selfPayDeclared
    Coverage.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.
    Coverage.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.
    Coverage.subscriber.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.
    Coverage.subscriberId 1..1 string ID assigned to the subscriber
    Coverage.subscriberId.Slices for extension 0..* Extension Extension
    Slice: Unordered, Open by value:url
    Coverage.subscriberId.Slices for extension.extension:dataAbsentReason 0..1 (Complex) unknown | asked | temp | notasked | masked | unsupported | astext | error
    URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
    Coverage.subscriberId.Slices for extension.extension:dataAbsentReason.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 (extensions allowed)
    Coverage.beneficiary 1..1 Reference(US Core Patient Profile(7.0.0)) Patient or Plan Beneficiary
    Coverage.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
    Coverage.class 0..* BackboneElement Additional coverage classifications
    Coverage.class.name 1..1 string Human readable description of the type and value
    Coverage.Slices for class Content/Rules for all slices
    Coverage.Slices for class.class:group 0..1 BackboneElement Group
    Coverage.Slices for class.class:group.name 1..1 string Group Name
    Coverage.Slices for class.class:plan 0..1 BackboneElement Plan
    Coverage.Slices for class.class:plan.name 1..1 string Plan Name
    Coverage.costToBeneficiary
    Coverage.costToBeneficiary.type 0..1 CodeableConcept Cost category
    Binding: CoverageCopayTypeCodes (1.0.1) (required)

    doco 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 v7.1

    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-kind is insurance extension.where(url='http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind'and value = 'insurance').exists() implies period.exists()

    Snapshot ViewView

    NameFlagsCard.TypeDescription & Constraints    Filter: doco
    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
    Coverage.id This element is included in summaries. 0..1 id Logical id of this artifact
    Coverage.meta This element is included in summaries. 0..1 Meta Metadata about the resource
    Coverage.implicitRules This element is a modifier element. This element is included in summaries. 0..1 uri A set of rules under which this content was created
    Coverage.language 0..1 code Language of the resource content
    Binding: CommonLanguages (preferred): A human language.
    Additional BindingsPurpose
    AllLanguages Max Binding
    Coverage.text 0..1 Narrative Text summary of the resource, for human interpretation
    This profile does not constrain the narrative in regard to content, language, or traceability to data elements
    Coverage.contained 0..* Resource Contained, inline Resources
    Coverage.Slices for extension 1..* Extension Extension
    Slice: Unordered, Open by value:url
    Coverage.Slices for extension.extension:coverage-kind This element must be supported. 1..1 (Complex) R5: insurance | self-pay | other (new)
    URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind
    Constraints: ext-1
    Coverage.Slices for extension.extension:coverage-kind.id 0..1 string Unique id for inter-element referencing
    Coverage.Slices for extension.extension:coverage-kind.extension 0..0 Extension
    Slice: Unordered, Open by value:url
    Constraints: ext-1
    Coverage.Slices for extension.extension:coverage-kind.url 1..1 uri "http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind"
    Coverage.Slices for extension.extension:coverage-kind.value[x] 1..1 code insurance | self-pay | other
    Binding: R5CoverageKindForR4 (0.1.0) (required)
    Coverage.Slices for extension.extension:self-pay-declared This element must be supported. 0..1 boolean Self-Pay Declared
    URL: http://hl7.org/fhir/us/davinci-pct/StructureDefinition/selfPayDeclared
    Coverage.modifierExtension This element is a modifier element. 0..* Extension Extensions that cannot be ignored
    Coverage.Slices for identifier This element must be supported. This element is included in summaries. 0..* Identifier Member ID and other identifiers
    Slice: Unordered, Open by pattern:type

    Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
    Coverage.Slices for identifier.identifier:memberid This element must be supported. This element is included in summaries. C 0..1 Identifier Member ID
    Coverage.Slices for identifier.identifier:memberid.id 0..1 string Unique id for inter-element referencing
    Coverage.Slices for identifier.identifier:memberid.extension 0..* Extension Additional content defined by implementations
    Slice: Unordered, Open by value:url
    Coverage.Slices for identifier.identifier:memberid.use This element is a modifier element. This element is included in summaries. 0..1 code usual | official | temp | secondary | old (If known)
    Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
    Coverage.Slices for identifier.identifier:memberid.type This element must be supported. This element is included in summaries. 1..1 CodeableConcept Member Number identifier type
    Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
    Required Pattern: 
    {
  "coding" : [
    {
      "system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
      "code" : "MB"
    }
  ]
}
    Coverage.Slices for identifier.identifier:memberid.system This element is included in summaries. 0..1 uri The namespace for the identifier value
    Example General: http://www.acme.com/identifiers/patient
    Coverage.Slices for identifier.identifier:memberid.value This element is included in summaries. 0..1 string The value that is unique
    Example General: 123456
    Coverage.Slices for identifier.identifier:memberid.period This element is included in summaries. 0..1 Period Time period when id is/was valid for use
    Coverage.Slices for identifier.identifier:memberid.assigner This element is included in summaries. 0..1 Reference(Organization) Organization that issued id (may be just text)
    Coverage.status This element is a modifier element. This element must be supported. This element is included in summaries. 1..1 code active | cancelled | draft | entered-in-error
    Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
    Coverage.type This element must be supported. This element is included in summaries. 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
    Coverage.policyHolder This element is included in summaries. 0..1 Reference(Patient | RelatedPerson | Organization) Owner of the policy
    Coverage.subscriber This element is included in summaries. 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.
    Coverage.subscriber.id 0..1 string Unique id for inter-element referencing
    Coverage.subscriber.extension 0..* Extension Additional content defined by implementations
    Slice: Unordered, Open by value:url
    Coverage.subscriber.reference This element is included in summaries. C 0..1 string Literal reference, Relative, internal or absolute URL
    Coverage.subscriber.type This element is included in summaries. 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).
    Coverage.subscriber.identifier This element is included in summaries. 0..1 Identifier Logical reference, when literal reference is not known
    Coverage.subscriber.display This element is included in summaries. 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.
    Coverage.subscriberId This element must be supported. This element is included in summaries. C 1..1 string ID assigned to the subscriber
    Coverage.subscriberId.id 0..1 string xml:id (or equivalent in JSON)
    Coverage.subscriberId.Slices for extension 0..* Extension Extension
    Slice: Unordered, Open by value:url
    Coverage.subscriberId.Slices for extension.extension:dataAbsentReason 0..1 (Complex) unknown | asked | temp | notasked | masked | unsupported | astext | error
    URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
    Coverage.subscriberId.Slices for extension.extension:dataAbsentReason.id 0..1 string Unique id for inter-element referencing
    Coverage.subscriberId.Slices for extension.extension:dataAbsentReason.extension 0..0 Extension
    Slice: Unordered, Open by value:url
    Coverage.subscriberId.Slices for extension.extension:dataAbsentReason.url 1..1 uri "http://hl7.org/fhir/StructureDefinition/data-absent-reason"
    Coverage.subscriberId.Slices for extension.extension:dataAbsentReason.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 (extensions allowed)
    Coverage.subscriberId.value 0..1 string Primitive value for string
    Max Length:1048576
    Coverage.beneficiary This element must be supported. This element is included in summaries. 1..1 Reference(US Core Patient Profile(7.0.0)) Patient or Plan Beneficiary
    Coverage.dependent This element is included in summaries. 0..1 string Dependent number
    Coverage.relationship This element must be supported. 1..1 CodeableConcept Beneficiary relationship to the subscriber
    Binding: SubscriberRelationshipCodes (extensible)
    Coverage.period This element must be supported. This element is included in summaries. 0..1 Period Coverage start and end dates
    Coverage.payor This element must be supported. This element is included in summaries. 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
    Coverage.Slices for class This element must be supported. 0..* BackboneElement Additional coverage classifications
    Slice: Unordered, Open by pattern:type

    Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
    Coverage.Slices for class.class:All Slices Content/Rules for all slices
    Coverage.Slices for class.class:All Slices.id 0..1 string Unique id for inter-element referencing
    Coverage.Slices for class.class:All Slices.extension 0..* Extension Additional content defined by implementations
    Coverage.Slices for class.class:All Slices.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    Coverage.Slices for class.class:All Slices.type This element is included in summaries. 1..1 CodeableConcept Type of class such as 'group' or 'plan'
    Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.
    Coverage.Slices for class.class:All Slices.value This element is included in summaries. 1..1 string Value associated with the type
    Coverage.Slices for class.class:All Slices.name This element is included in summaries. 1..1 string Human readable description of the type and value
    Coverage.Slices for class.class:group This element must be supported. 0..1 BackboneElement Group
    Coverage.Slices for class.class:group.id 0..1 string Unique id for inter-element referencing
    Coverage.Slices for class.class:group.extension 0..* Extension Additional content defined by implementations
    Coverage.Slices for class.class:group.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    Coverage.Slices for class.class:group.type This element is included in summaries. 1..1 CodeableConcept Type of class such as 'group' or 'plan'
    Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.
    Required Pattern: 
    {
  "coding" : [
    {
      "system" : "http://terminology.hl7.org/CodeSystem/coverage-class",
      "code" : "group"
    }
  ]
}
    Coverage.Slices for class.class:group.value This element must be supported. This element is included in summaries. 1..1 string Group Number
    Coverage.Slices for class.class:group.name This element must be supported. This element is included in summaries. 1..1 string Group Name
    Coverage.Slices for class.class:plan This element must be supported. 0..1 BackboneElement Plan
    Coverage.Slices for class.class:plan.id 0..1 string Unique id for inter-element referencing
    Coverage.Slices for class.class:plan.extension 0..* Extension Additional content defined by implementations
    Coverage.Slices for class.class:plan.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    Coverage.Slices for class.class:plan.type This element is included in summaries. 1..1 CodeableConcept Type of class such as 'group' or 'plan'
    Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.
    Required Pattern: 
    {
  "coding" : [
    {
      "system" : "http://terminology.hl7.org/CodeSystem/coverage-class",
      "code" : "plan"
    }
  ]
}
    Coverage.Slices for class.class:plan.value This element must be supported. This element is included in summaries. 1..1 string Plan Number
    Coverage.Slices for class.class:plan.name This element must be supported. This element is included in summaries. 1..1 string Plan Name
    Coverage.order This element is included in summaries. 0..1 positiveInt Relative order of the coverage
    Coverage.network This element is included in summaries. 0..1 string Insurer network
    Coverage.costToBeneficiary 0..* BackboneElement Patient payments for services/products
    Coverage.costToBeneficiary.id 0..1 string Unique id for inter-element referencing
    Coverage.costToBeneficiary.extension 0..* Extension Additional content defined by implementations
    Coverage.costToBeneficiary.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    Coverage.costToBeneficiary.type This element is included in summaries. 0..1 CodeableConcept Cost category
    Binding: CoverageCopayTypeCodes (1.0.1) (required)
    Coverage.costToBeneficiary.value[x] This element is included in summaries. 1..1 The amount or percentage due from the beneficiary
    Coverage.costToBeneficiary.value[x].valueQuantity Quantity(SimpleQuantity)
    Coverage.costToBeneficiary.value[x].valueMoney Money
    Coverage.costToBeneficiary.exception 0..* BackboneElement Exceptions for patient payments
    Coverage.costToBeneficiary.exception.id 0..1 string Unique id for inter-element referencing
    Coverage.costToBeneficiary.exception.extension 0..* Extension Additional content defined by implementations
    Coverage.costToBeneficiary.exception.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    Coverage.costToBeneficiary.exception.type This element is included in summaries. 1..1 CodeableConcept Exception category
    Binding: ExampleCoverageFinancialExceptionCodes (example): The types of exceptions from the part or full value of financial obligations such as copays.
    Coverage.costToBeneficiary.exception.period This element is included in summaries. 0..1 Period The effective period of the exception
    Coverage.subrogation 0..1 boolean Reimbursement to insurer
    Coverage.contract 0..* Reference(Contract) Contract details

    doco Documentation for this format

    Terminology Bindings

    Path Status Usage ValueSet Version Source
    Coverage.language Base preferred Common Languages 📦4.0.1 FHIR Std.
    Coverage.extension:coverage-kind.​value[x] Base required Cross-version ValueSet R5.Kind for use in FHIR R4 📍0.1.0 Extensions for Using Data Elements from FHIR R5 in FHIR R4 v0.1
    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 v7.1
    Coverage.costToBeneficiary.​exception.type Base example Example Coverage Financial Exception Codes 📦4.0.1 FHIR Std.

    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-kind is insurance extension.where(url='http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.kind'and value = 'insurance').exists() implies period.exists()

     

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