Specialty Medication Enrollment
2.1.0 - CI Build
Specialty Medication Enrollment
2.1.0 - CI Build
Specialty Medication Enrollment, published by HL7 International - Pharmacy. This is not an authorized publication; it is the continuous build for version 2.1.0). This version is based on the current content of https://github.com/HL7/fhir-specialty-rx/ and changes regularly. See the Directory of published versions
| Official URL: http://hl7.org/fhir/us/specialty-rx/StructureDefinition/specialty-rx-coverage | Version: 2.1.0 | |||
| Active as of 2023-04-30 | Computable Name: SpecialtyRxCoverage | |||
This profile constrains the Coverage resource for carrying insurance coverage information in the specialty medication enrollment process
The Coverage elements available to be used by the Specialty Rx process include:
Must Support elements. The elements identified as Must Support are the typical set used in US pharmacy benefit processing.
Note: This Coverage profile is pharmacy benefits-focused. For additional guidance on population of health plan benefits see the US Core Coverage profile.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Coverage
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Coverage | 0..* | Coverage | Insurance or medical plan or a payment agreement | |
  Slices for identifier | S | 0..* | Identifier | Member ID and other identifiers Slice: Unordered, Open by pattern:type |
   identifier:memberid | S | 0..1 | Identifier | Member ID assigned by health plan |
   type | 1..1 | CodeableConcept | Member Number identifier type 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 | |
| subscriberId | S | 0..1 | string | ID assigned to the subscriber by the health plan |
| payor | S | 1..* | Reference(Organization | Patient | RelatedPerson) | Issuer of the policy |
| Slices for class | S | 0..* | BackboneElement | Pharmacy coverage identifiers Slice: Unordered, Open by value:type |
 class:All Slices | Content/Rules for all slices | |||
  type | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): Coverage Class Codes | |
| class:bin | S | 0..1 | BackboneElement | IIN (BIN) number |
| type | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxbin | |
| class:pcn | S | 0..1 | BackboneElement | Processor Control Number (PCN) |
| type | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxpcn | |
| class:rxgroup-id | S | 0..1 | BackboneElement | Pharmacy Benefit Group ID |
| type | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxgroup | |
| class:pbm-member-id | S | 0..1 | BackboneElement | Member ID assigned by the pharmacy benefit manager (PBM) |
| type | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxid | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Coverage.class.type | extensible | CoverageClassCodes |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Coverage | 0..* | Coverage | Insurance or medical plan or a payment agreement | |
 implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| Slices for identifier | SΣ | 0..* | Identifier | Member ID and other identifiers Slice: Unordered, Open by pattern:type |
| identifier:memberid | SΣ | 0..1 | Identifier | Member ID assigned by health plan |
 use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . |
 type | Σ | 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 |
| 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 | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. |
| subscriberId | SΣ | 0..1 | string | ID assigned to the subscriber by the health plan |
 beneficiary | Σ | 1..1 | Reference(Patient) | Plan beneficiary |
| payor | SΣ | 1..* | Reference(Organization | Patient | RelatedPerson) | Issuer of the policy |
| Slices for class | S | 0..* | BackboneElement | Pharmacy coverage identifiers Slice: Unordered, Open by value: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): Coverage Class Codes |
| value | Σ | 1..1 | string | Value associated with the type |
| class:bin | S | 0..1 | BackboneElement | IIN (BIN) number |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
 type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following |
 coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxbin | |
 value | Σ | 1..1 | string | Value associated with the type |
| class:pcn | S | 0..1 | BackboneElement | Processor Control Number (PCN) |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxpcn | |
| value | Σ | 1..1 | string | Value associated with the type |
| class:rxgroup-id | S | 0..1 | BackboneElement | Pharmacy Benefit Group ID |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxgroup | |
| value | Σ | 1..1 | string | Value associated with the type |
| class:pbm-member-id | S | 0..1 | BackboneElement | Member ID assigned by the pharmacy benefit manager (PBM) |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxid | |
| value | Σ | 1..1 | string | Value associated with the type |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Coverage.identifier:memberid.use | required | IdentifierUse |
| Coverage.identifier:memberid.type | extensible | Pattern: MB |
| Coverage.status | required | FinancialResourceStatusCodes |
| Coverage.class.type | extensible | CoverageClassCodes |
| Coverage.class:bin.type | extensible | Pattern: rxbin |
| Coverage.class:pcn.type | extensible | Pattern: rxpcn |
| Coverage.class:rxgroup-id.type | extensible | Pattern: rxgroup |
| Coverage.class:pbm-member-id.type | extensible | Pattern: rxid |
| Id | Grade | Path(s) | Details | Requirements |
| 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() |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Coverage | 0..* | Coverage | Insurance or medical plan or a payment agreement | |||||
| 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.
| |||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
 extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| Slices for identifier | SΣ | 0..* | Identifier | Member ID and other identifiers Slice: Unordered, Open by pattern:type | ||||
| identifier:memberid | SΣ | 0..1 | Identifier | Member ID assigned by health plan | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
| type | Σ | 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 | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. | ||||
| type | Σ | 0..1 | CodeableConcept | Coverage category such as medical or accident Binding: CoverageTypeAndSelf-PayCodes (preferred): The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization. | ||||
| policyHolder | Σ | 0..1 | Reference(Patient | RelatedPerson | Organization) | Owner of the policy | ||||
| subscriber | Σ | 0..1 | Reference(Patient | RelatedPerson) | Subscriber to the policy | ||||
| subscriberId | SΣ | 0..1 | string | ID assigned to the subscriber by the health plan | ||||
| beneficiary | Σ | 1..1 | Reference(Patient) | Plan beneficiary | ||||
| dependent | Σ | 0..1 | string | Dependent number | ||||
| relationship | 0..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient). | |||||
| period | Σ | 0..1 | Period | Coverage start and end dates | ||||
| payor | SΣ | 1..* | Reference(Organization | Patient | RelatedPerson) | Issuer of the policy | ||||
| Slices for class | S | 0..* | BackboneElement | Pharmacy coverage identifiers Slice: Unordered, Open by value: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): Coverage Class Codes | ||||
| value | Σ | 1..1 | string | Value associated with the type | ||||
| name | Σ | 0..1 | string | Human readable description of the type and value | ||||
| class:bin | S | 0..1 | BackboneElement | IIN (BIN) number | ||||
| 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: rxbin | |||||
| 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 | Σ | 1..1 | string | Value associated with the type | ||||
| name | Σ | 0..1 | string | Human readable description of the type and value | ||||
| class:pcn | S | 0..1 | BackboneElement | Processor Control Number (PCN) | ||||
| 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: rxpcn | |||||
| 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 | Σ | 1..1 | string | Value associated with the type | ||||
| name | Σ | 0..1 | string | Human readable description of the type and value | ||||
| class:rxgroup-id | S | 0..1 | BackboneElement | Pharmacy Benefit Group ID | ||||
| 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: rxgroup | |||||
| 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 | Σ | 1..1 | string | Value associated with the type | ||||
| name | Σ | 0..1 | string | Human readable description of the type and value | ||||
| class:pbm-member-id | S | 0..1 | BackboneElement | Member ID assigned by the pharmacy benefit manager (PBM) | ||||
| 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: rxid | |||||
| 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 | Σ | 1..1 | string | Value associated with the type | ||||
| name | Σ | 0..1 | string | Human readable description of the type and value | ||||
| order | Σ | 0..1 | positiveInt | Relative order of the coverage | ||||
| network | Σ | 0..1 | string | Insurer network | ||||
| costToBeneficiary | 0..* | BackboneElement | Patient payments for services/products | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| type | Σ | 0..1 | CodeableConcept | Cost category Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified. | ||||
 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 | ||||||||
| Path | Conformance | ValueSet / Code | ||||
| Coverage.language | preferred | CommonLanguages
| ||||
| Coverage.identifier:memberid.use | required | IdentifierUse | ||||
| Coverage.identifier:memberid.type | extensible | Pattern: MB | ||||
| Coverage.status | required | FinancialResourceStatusCodes | ||||
| Coverage.type | preferred | CoverageTypeAndSelf-PayCodes | ||||
| Coverage.relationship | extensible | SubscriberRelationshipCodes | ||||
| Coverage.class.type | extensible | CoverageClassCodes | ||||
| Coverage.class:bin.type | extensible | Pattern: rxbin | ||||
| Coverage.class:pcn.type | extensible | Pattern: rxpcn | ||||
| Coverage.class:rxgroup-id.type | extensible | Pattern: rxgroup | ||||
| Coverage.class:pbm-member-id.type | extensible | Pattern: rxid | ||||
| Coverage.costToBeneficiary.type | extensible | CoverageCopayTypeCodes | ||||
| Coverage.costToBeneficiary.exception.type | example | ExampleCoverageFinancialExceptionCodes |
| Id | Grade | Path(s) | Details | Requirements |
| 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() |
This structure is derived from Coverage
Summary
Mandatory: 0 element (5 nested mandatory elements)
Must-Support: 9 elements
Slices
This structure defines the following Slices:
Differential View
This structure is derived from Coverage
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Coverage | 0..* | Coverage | Insurance or medical plan or a payment agreement | |
| Slices for identifier | S | 0..* | Identifier | Member ID and other identifiers Slice: Unordered, Open by pattern:type |
| identifier:memberid | S | 0..1 | Identifier | Member ID assigned by health plan |
| type | 1..1 | CodeableConcept | Member Number identifier type 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 | |
| subscriberId | S | 0..1 | string | ID assigned to the subscriber by the health plan |
| payor | S | 1..* | Reference(Organization | Patient | RelatedPerson) | Issuer of the policy |
| Slices for class | S | 0..* | BackboneElement | Pharmacy coverage identifiers Slice: Unordered, Open by value:type |
| class:All Slices | Content/Rules for all slices | |||
| type | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): Coverage Class Codes | |
| class:bin | S | 0..1 | BackboneElement | IIN (BIN) number |
| type | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxbin | |
| class:pcn | S | 0..1 | BackboneElement | Processor Control Number (PCN) |
| type | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxpcn | |
| class:rxgroup-id | S | 0..1 | BackboneElement | Pharmacy Benefit Group ID |
| type | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxgroup | |
| class:pbm-member-id | S | 0..1 | BackboneElement | Member ID assigned by the pharmacy benefit manager (PBM) |
| type | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxid | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Coverage.class.type | extensible | CoverageClassCodes |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Coverage | 0..* | Coverage | Insurance or medical plan or a payment agreement | |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| Slices for identifier | SΣ | 0..* | Identifier | Member ID and other identifiers Slice: Unordered, Open by pattern:type |
| identifier:memberid | SΣ | 0..1 | Identifier | Member ID assigned by health plan |
| use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . |
| type | Σ | 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 |
| 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 | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. |
| subscriberId | SΣ | 0..1 | string | ID assigned to the subscriber by the health plan |
| beneficiary | Σ | 1..1 | Reference(Patient) | Plan beneficiary |
| payor | SΣ | 1..* | Reference(Organization | Patient | RelatedPerson) | Issuer of the policy |
| Slices for class | S | 0..* | BackboneElement | Pharmacy coverage identifiers Slice: Unordered, Open by value: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): Coverage Class Codes |
| value | Σ | 1..1 | string | Value associated with the type |
| class:bin | S | 0..1 | BackboneElement | IIN (BIN) number |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxbin | |
| value | Σ | 1..1 | string | Value associated with the type |
| class:pcn | S | 0..1 | BackboneElement | Processor Control Number (PCN) |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxpcn | |
| value | Σ | 1..1 | string | Value associated with the type |
| class:rxgroup-id | S | 0..1 | BackboneElement | Pharmacy Benefit Group ID |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxgroup | |
| value | Σ | 1..1 | string | Value associated with the type |
| class:pbm-member-id | S | 0..1 | BackboneElement | Member ID assigned by the pharmacy benefit manager (PBM) |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | Σ | 1..1 | CodeableConcept | Type of class such as 'group' or 'plan' Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc. Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: rxid | |
| value | Σ | 1..1 | string | Value associated with the type |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Coverage.identifier:memberid.use | required | IdentifierUse |
| Coverage.identifier:memberid.type | extensible | Pattern: MB |
| Coverage.status | required | FinancialResourceStatusCodes |
| Coverage.class.type | extensible | CoverageClassCodes |
| Coverage.class:bin.type | extensible | Pattern: rxbin |
| Coverage.class:pcn.type | extensible | Pattern: rxpcn |
| Coverage.class:rxgroup-id.type | extensible | Pattern: rxgroup |
| Coverage.class:pbm-member-id.type | extensible | Pattern: rxid |
| Id | Grade | Path(s) | Details | Requirements |
| 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() |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Coverage | 0..* | Coverage | Insurance or medical plan or a payment agreement | |||||
| 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.
| |||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| Slices for identifier | SΣ | 0..* | Identifier | Member ID and other identifiers Slice: Unordered, Open by pattern:type | ||||
| identifier:memberid | SΣ | 0..1 | Identifier | Member ID assigned by health plan | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
| type | Σ | 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 | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. | ||||
| type | Σ | 0..1 | CodeableConcept | Coverage category such as medical or accident Binding: CoverageTypeAndSelf-PayCodes (preferred): The type of insurance: public health, worker compensation; private accident, auto, private health, etc.) or a direct payment by an individual or organization. | ||||
| policyHolder | Σ | 0..1 | Reference(Patient | RelatedPerson | Organization) | Owner of the policy | ||||
| subscriber | Σ | 0..1 | Reference(Patient | RelatedPerson) | Subscriber to the policy | ||||
| subscriberId | SΣ | 0..1 | string | ID assigned to the subscriber by the health plan | ||||
| beneficiary | Σ | 1..1 | Reference(Patient) | Plan beneficiary | ||||
| dependent | Σ | 0..1 | string | Dependent number | ||||
| relationship | 0..1 | CodeableConcept | Beneficiary relationship to the subscriber Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient). | |||||
| period | Σ | 0..1 | Period | Coverage start and end dates | ||||
| payor | SΣ | 1..* | Reference(Organization | Patient | RelatedPerson) | Issuer of the policy | ||||
| Slices for class | S | 0..* | BackboneElement | Pharmacy coverage identifiers Slice: Unordered, Open by value: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): Coverage Class Codes | ||||
| value | Σ | 1..1 | string | Value associated with the type | ||||
| name | Σ | 0..1 | string | Human readable description of the type and value | ||||
| class:bin | S | 0..1 | BackboneElement | IIN (BIN) number | ||||
| 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: rxbin | |||||
| 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 | Σ | 1..1 | string | Value associated with the type | ||||
| name | Σ | 0..1 | string | Human readable description of the type and value | ||||
| class:pcn | S | 0..1 | BackboneElement | Processor Control Number (PCN) | ||||
| 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: rxpcn | |||||
| 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 | Σ | 1..1 | string | Value associated with the type | ||||
| name | Σ | 0..1 | string | Human readable description of the type and value | ||||
| class:rxgroup-id | S | 0..1 | BackboneElement | Pharmacy Benefit Group ID | ||||
| 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: rxgroup | |||||
| 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 | Σ | 1..1 | string | Value associated with the type | ||||
| name | Σ | 0..1 | string | Human readable description of the type and value | ||||
| class:pbm-member-id | S | 0..1 | BackboneElement | Member ID assigned by the pharmacy benefit manager (PBM) | ||||
| 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: rxid | |||||
| 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 | Σ | 1..1 | string | Value associated with the type | ||||
| name | Σ | 0..1 | string | Human readable description of the type and value | ||||
| order | Σ | 0..1 | positiveInt | Relative order of the coverage | ||||
| network | Σ | 0..1 | string | Insurer network | ||||
| costToBeneficiary | 0..* | BackboneElement | Patient payments for services/products | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| type | Σ | 0..1 | CodeableConcept | Cost category Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified. | ||||
| 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 | ||||||||
| Path | Conformance | ValueSet / Code | ||||
| Coverage.language | preferred | CommonLanguages
| ||||
| Coverage.identifier:memberid.use | required | IdentifierUse | ||||
| Coverage.identifier:memberid.type | extensible | Pattern: MB | ||||
| Coverage.status | required | FinancialResourceStatusCodes | ||||
| Coverage.type | preferred | CoverageTypeAndSelf-PayCodes | ||||
| Coverage.relationship | extensible | SubscriberRelationshipCodes | ||||
| Coverage.class.type | extensible | CoverageClassCodes | ||||
| Coverage.class:bin.type | extensible | Pattern: rxbin | ||||
| Coverage.class:pcn.type | extensible | Pattern: rxpcn | ||||
| Coverage.class:rxgroup-id.type | extensible | Pattern: rxgroup | ||||
| Coverage.class:pbm-member-id.type | extensible | Pattern: rxid | ||||
| Coverage.costToBeneficiary.type | extensible | CoverageCopayTypeCodes | ||||
| Coverage.costToBeneficiary.exception.type | example | ExampleCoverageFinancialExceptionCodes |
| Id | Grade | Path(s) | Details | Requirements |
| 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() |
This structure is derived from Coverage
Summary
Mandatory: 0 element (5 nested mandatory elements)
Must-Support: 9 elements
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron
IG © 2021+ HL7 International - Pharmacy. Package hl7.fhir.us.specialty-rx#2.1.0 based on FHIR 4.0.1. Generated 2023-05-09
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