DaVinci Payer Data Exchange (PDex) US Drug Formulary
2.1.0 - STU2.1 United States of America flag

DaVinci Payer Data Exchange (PDex) US Drug Formulary, published by HL7 International / Pharmacy. This guide is not an authorized publication; it is the continuous build for version 2.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/davinci-pdex-formulary/ and changes regularly. See the Directory of published versions

Resource Profile: Insurance Plan Coverage

Official URL: http://hl7.org/fhir/us/davinci-drug-formulary/StructureDefinition/insurance-plan-coverage Version: 2.1.0
Standards status: Trial-use Computable Name: InsurancePlanCoverage
Other Identifiers: OID:2.25.74595174031514506193398850787025340071.42.1

Coverage for an insurance plan

Usage:

Formal Views of Profile Content

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

NameFlagsCard.TypeDescription & Constraintsdoco
.. Coverage C 0..* USCoreCoverageProfile(7.0.0) Insurance or medical plan or a payment agreement
dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
dom-6: A resource should have narrative for robust management
us-core-15: Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
ele-1: All FHIR elements must have a @value or children
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... insurancePlan S 0..1 Reference(InsurancePlan) Insurance plan details, pre-adopted from FHIR R5
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.insurancePlan
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... identifier:memberid SΣC 0..1 Identifier Member ID
ele-1: All FHIR elements must have a @value or children
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .


ele-1: All FHIR elements must have a @value or children
..... type SΣ 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.


ele-1: All FHIR elements must have a @value or children
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: MB
... status ?!SΣ 1..1 code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.


ele-1: All FHIR elements must have a @value or children
... type SΣ 0..1 CodeableConcept Coverage category such as medical or accident
Binding: Payer Type . (extensible): US Public Health Data Consortium Source of Payment Codes


ele-1: All FHIR elements must have a @value or children
... subscriberId SΣC 0..1 string ID assigned to the subscriber
ele-1: All FHIR elements must have a @value or children
... beneficiary SΣ 1..1 Reference(US Core Patient Profile(7.0.0)) Plan beneficiary
ele-1: All FHIR elements must have a @value or children
... relationship S 1..1 CodeableConcept Beneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible)
ele-1: All FHIR elements must have a @value or children
... period SΣ 0..1 Period Coverage start and end dates
ele-1: All FHIR elements must have a @value or children
... payor SΣ 1..1 Reference(US Core Organization Profile(7.0.0)) Issuer of the policy
ele-1: All FHIR elements must have a @value or children
... Slices for class S 0..* BackboneElement Additional coverage classifications
Slice: Unordered, Open by pattern:type
ele-1: All FHIR elements must have a @value or children
.... class:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... type Σ 1..1 CodeableConcept Type of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.


ele-1: All FHIR elements must have a @value or children
..... value Σ 1..1 string Value associated with the type
ele-1: All FHIR elements must have a @value or children
.... class:group S 0..1 BackboneElement Group
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... type Σ 1..1 CodeableConcept Type of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.


ele-1: All FHIR elements must have a @value or children
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: group
..... value SΣ 1..1 string Group Number
ele-1: All FHIR elements must have a @value or children
..... name SΣ 0..1 string Group Name
ele-1: All FHIR elements must have a @value or children
.... class:plan S 0..1 BackboneElement Plan
ele-1: All FHIR elements must have a @value or children
..... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
...... valueIdentifier S 0..1 Identifier Value associated with the type, pre-adopted from FHIR R5 since it is just a string in R4
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Coverage.class.value
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... type Σ 1..1 CodeableConcept Type of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.


ele-1: All FHIR elements must have a @value or children
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: plan
..... value SΣ 1..1 string Plan Number
ele-1: All FHIR elements must have a @value or children
..... name SΣ 0..1 string Plan Name
ele-1: All FHIR elements must have a @value or children

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Coverage.identifier:memberid.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
Coverage.identifier:memberid.typeextensiblePattern: MB
http://hl7.org/fhir/ValueSet/identifier-type
from the FHIR Standard
Coverage.statusrequiredFinancialResourceStatusCodes
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
from the FHIR Standard
Coverage.typeextensiblePayerType . (a valid code from Source of Payment Typology (https://nahdo.org/sopt)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591
Coverage.relationshipextensibleSubscriberRelationshipCodes
http://hl7.org/fhir/ValueSet/subscriber-relationship
from the FHIR Standard
Coverage.class.typeextensibleCoverageClassCodes
http://hl7.org/fhir/ValueSet/coverage-class
from the FHIR Standard
Coverage.class:group.typeextensiblePattern: group
http://hl7.org/fhir/ValueSet/coverage-class
from the FHIR Standard
Coverage.class:plan.typeextensiblePattern: plan
http://hl7.org/fhir/ValueSet/coverage-class
from the FHIR Standard

 

Other representations of profile: CSV, Excel, Schematron