US Quality Core Implementation Guide
1.0.0-ballot - STU 1 - ballot United States of America flag

US Quality Core Implementation Guide, published by HL7 International / Clinical Quality Information. This guide is not an authorized publication; it is the continuous build for version 1.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-us-quality-core/ and changes regularly. See the Directory of published versions

Resource Profile: US Quality Core Coverage

Official URL: http://hl7.org/fhir/us/quality-core/StructureDefinition/us-quality-core-coverage Version: 1.0.0-ballot
Standards status: Trial-use Maturity Level: 4 Computable Name: USQualityCoreCoverage
Other Identifiers: OID:2.16.840.1.113883.4.642.40.78.42.10

Profile of Coverage for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.

USCDI+ Quality Element Support Expectations

Systems are expected to support this profile as part of implementing USCDI+ Quality V2 in FHIR and meeting the conformance requirements of this guide.

The following elements are specifically relevant to USCDI+ Quality V2 data classes and elements. Systems are expected to support these elements as applicable to their role in US Quality Core data exchange. See the Must Support section of this guide for more information. These elements are flagged as (USCDI+ Quality) in the formal profile views.

USCDI+ Quality Elements:

Profile element Description USCDI+ Quality Data Element(s)
beneficiary Plan beneficiary Health Insurance Information: Health Insurance Beneficiary
class Additional coverage classifications Health Insurance Information: Group Identifier
class:group Group Health Insurance Information: Group Identifier
class:group.name Human readable description of the type and value Health Insurance Information: Group Identifier
class:group.value Group Identifier Health Insurance Information: Group Identifier
class:plan Plan Health Insurance Information: Insurance Plan Name
class:plan.name Plan Name Health Insurance Information: Insurance Plan Name
class:plan.value Plan Number Health Insurance Information: Health Insurance Plan Identifier
identifier Member ID and other identifiers Health Insurance Information: Member Identifier
identifier:memberid Member ID Health Insurance Information: Member Identifier
identifier:memberid.type Member Number identifier type Health Insurance Information: Member Identifier
payor Issuer of the policy Health Insurance Information: Health Insurance Payer, Health Insurance Information: Payer Identifier
period Coverage start and end dates Health Insurance Information: Coverage Status, Health Insurance Information: Health Insurance Coverage Period
relationship Beneficiary relationship to the subscriber Health Insurance Information: Relationship to Subscriber
status active | cancelled | draft | entered-in-error Health Insurance Information: Coverage Status
subscriberId ID assigned to the subscriber Health Insurance Information: Subscriber Identifier
type Coverage category such as medical or accident Health Insurance Information: Coverage Type

Because this profile is derived directly or indirectly from US Core, systems are also expected to support the Must Support and Additional USCDI requirements specified by the US Core profile this profile inherits from. For more information about those requirements, refer to the US Core Coverage Profile. The Formal Views section also provides the formal summary, definitions, terminology requirements, and mandatory element requirements.

Usages:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

Description Differentials, Snapshots, and other representations.

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Coverage C 0..* USCoreCoverageProfile(9.0.0) Insurance or medical plan or a payment agreement
Constraints: us-core-15
... 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 (USCDI+ Quality) Member ID and other identifiers
Slice: Unordered, Open by value:type
.... identifier:memberid SΣC 0..1 Identifier (USCDI+ Quality) Member ID
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
..... type SΣ 1..1 CodeableConcept (USCDI+ Quality) 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
... type SΣ 0..1 CodeableConcept (USCDI+ Quality) Coverage category such as medical or accident
Binding: Payer Type . (extensible): Categories of types of health care payor entities as defined by the US Public Health Data Consortium SOP code system
... policyHolder Σ 0..1 Reference(US Quality Core Patient | US Quality Core Organization | US Quality Core RelatedPerson) Owner of the policy
... subscriberId SΣC 0..1 string (USCDI+ Quality) ID assigned to the subscriber
... beneficiary SΣ 1..1 Reference(US Quality Core Patient) (USCDI+ Quality) Plan beneficiary
... relationship S 1..1 CodeableConcept (USCDI+ Quality) Beneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible)
... period SΣ 0..1 Period (USCDI+ Quality) Coverage start and end dates
... payor SΣ 1..1 Reference(US Quality Core Patient | US Quality Core Organization | US Quality Core RelatedPerson) (USCDI+ Quality) Issuer of the policy
... Slices for class S 0..* BackboneElement (USCDI+ Quality) Additional coverage classifications
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): The policy classifications, eg. Group, Plan, Class, etc.
..... value Σ 1..1 string Value associated with the type
.... class:group S 0..1 BackboneElement (USCDI+ Quality) Group
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... type Σ 1..1 CodeableConcept Type of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: group
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... value SΣ 1..1 string (USCDI+ Quality) Group Identifier
..... name Σ 0..1 string (USCDI+ Quality) Human readable description of the type and value
.... class:plan S 0..1 BackboneElement (USCDI+ Quality) Plan
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... type Σ 1..1 CodeableConcept Type of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: plan
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... value SΣ 1..1 string (USCDI+ Quality) Plan Number
..... name SΣ 0..1 string (USCDI+ Quality) Plan Name

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Coverage.identifier:memberid.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
Coverage.identifier:memberid.​type Base extensible IdentifierType 📍4.0.1 FHIR Std.
Coverage.status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
Coverage.type Base extensible Payer Type . ⏿20250419 tx.fhir.org
Coverage.relationship Base extensible SubscriberPolicyholder Relationship Codes 📦4.0.1 FHIR Std.
Coverage.class.type Base extensible Coverage Class Codes 📍4.0.1 FHIR Std.
Coverage.class:group.​type Base extensible Coverage Class Codes 📍4.0.1 FHIR Std.
Coverage.class:plan.​type Base extensible Coverage Class Codes 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error Coverage If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Coverage If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error Coverage If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error Coverage If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Coverage A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
us-core-15 error Coverage Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present identifier.type.coding.where(system='http://terminology.hl7.org/CodeSystem/v2-0203' and code='MB').exists() or subscriberId.exists()

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Coverage 0..* USCoreCoverageProfile(9.0.0) Insurance or medical plan or a payment agreement
... identifier 0..* Identifier (USCDI+ Quality) Member ID and other identifiers
... Slices for identifier Content/Rules for all slices
.... identifier:memberid 0..1 Identifier (USCDI+ Quality) Member ID
..... type 1..1 CodeableConcept (USCDI+ Quality) Member Number identifier type
... status 1..1 code (USCDI+ Quality) active | cancelled | draft | entered-in-error
... policyHolder 0..1 Reference(US Quality Core Patient | US Quality Core Organization | US Quality Core RelatedPerson) Owner of the policy
... subscriberId 0..1 string (USCDI+ Quality) ID assigned to the subscriber
... beneficiary 1..1 Reference(US Quality Core Patient) (USCDI+ Quality) Plan beneficiary
... relationship 1..1 CodeableConcept (USCDI+ Quality) Beneficiary relationship to the subscriber
... period 0..1 Period (USCDI+ Quality) Coverage start and end dates
... payor 1..1 Reference(US Quality Core Patient | US Quality Core Organization | US Quality Core RelatedPerson) (USCDI+ Quality) Issuer of the policy
... class 0..* BackboneElement (USCDI+ Quality) Additional coverage classifications
... Slices for class Content/Rules for all slices
.... class:group 0..1 BackboneElement (USCDI+ Quality) Group
..... value 1..1 string (USCDI+ Quality) Group Identifier
..... name 0..1 string (USCDI+ Quality) Human readable description of the type and value
.... class:plan 0..1 BackboneElement (USCDI+ Quality) Plan
..... value 1..1 string (USCDI+ Quality) Plan Number
..... name 0..1 string (USCDI+ Quality) Plan Name

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
Coverage.type Base extensible Payer Type . ⏿20250419 tx.fhir.org
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Coverage C 0..* USCoreCoverageProfile(9.0.0) Insurance or medical plan or a payment agreement
Constraints: us-core-15
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... 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 (USCDI+ Quality) Member ID and other identifiers
Slice: Unordered, Open by value:type
.... identifier:memberid SΣC 0..1 Identifier (USCDI+ Quality) Member ID
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
..... type SΣ 1..1 CodeableConcept (USCDI+ Quality) 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 ?!SΣ 1..1 code (USCDI+ Quality) active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
... type SΣ 0..1 CodeableConcept (USCDI+ Quality) Coverage category such as medical or accident
Binding: Payer Type . (extensible): Categories of types of health care payor entities as defined by the US Public Health Data Consortium SOP code system
... policyHolder Σ 0..1 Reference(US Quality Core Patient | US Quality Core Organization | US Quality Core RelatedPerson) Owner of the policy
... subscriber Σ 0..1 Reference(Patient | RelatedPerson) Subscriber to the policy
... subscriberId SΣC 0..1 string (USCDI+ Quality) ID assigned to the subscriber
... beneficiary SΣ 1..1 Reference(US Quality Core Patient) (USCDI+ Quality) Plan beneficiary
... dependent Σ 0..1 string Dependent number
... relationship S 1..1 CodeableConcept (USCDI+ Quality) Beneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible)
... period SΣ 0..1 Period (USCDI+ Quality) Coverage start and end dates
... payor SΣ 1..1 Reference(US Quality Core Patient | US Quality Core Organization | US Quality Core RelatedPerson) (USCDI+ Quality) Issuer of the policy
... Slices for class S 0..* BackboneElement (USCDI+ Quality) Additional coverage classifications
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): The policy classifications, eg. Group, Plan, Class, etc.
..... value Σ 1..1 string Value associated with the type
..... name Σ 0..1 string Human readable description of the type and value
.... class:group S 0..1 BackboneElement (USCDI+ Quality) Group
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... type Σ 1..1 CodeableConcept Type of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: group
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... value SΣ 1..1 string (USCDI+ Quality) Group Identifier
..... name Σ 0..1 string (USCDI+ Quality) Human readable description of the type and value
.... class:plan S 0..1 BackboneElement (USCDI+ Quality) Plan
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... type Σ 1..1 CodeableConcept Type of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: plan
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... value SΣ 1..1 string (USCDI+ Quality) Plan Number
..... name SΣ 0..1 string (USCDI+ Quality) Plan Name
... order Σ 0..1 positiveInt Relative order of the coverage
... network Σ 0..1 string Insurer network
... costToBeneficiary 0..* BackboneElement Patient payments for services/products
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type Σ 0..1 CodeableConcept Cost category
Binding: CoverageCopayTypeCodes (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

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.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 . ⏿20250419 tx.fhir.org
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 extensible Coverage Copay Type Codes 📍4.0.1 FHIR Std.
Coverage.costToBeneficiary.​exception.type Base example Example Coverage Financial Exception Codes 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error Coverage If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Coverage If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error Coverage If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error Coverage If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Coverage A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
us-core-15 error Coverage Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present identifier.type.coding.where(system='http://terminology.hl7.org/CodeSystem/v2-0203' and code='MB').exists() or subscriberId.exists()

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Coverage C 0..* USCoreCoverageProfile(9.0.0) Insurance or medical plan or a payment agreement
Constraints: us-core-15
... 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 (USCDI+ Quality) Member ID and other identifiers
Slice: Unordered, Open by value:type
.... identifier:memberid SΣC 0..1 Identifier (USCDI+ Quality) Member ID
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
..... type SΣ 1..1 CodeableConcept (USCDI+ Quality) 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
... type SΣ 0..1 CodeableConcept (USCDI+ Quality) Coverage category such as medical or accident
Binding: Payer Type . (extensible): Categories of types of health care payor entities as defined by the US Public Health Data Consortium SOP code system
... policyHolder Σ 0..1 Reference(US Quality Core Patient | US Quality Core Organization | US Quality Core RelatedPerson) Owner of the policy
... subscriberId SΣC 0..1 string (USCDI+ Quality) ID assigned to the subscriber
... beneficiary SΣ 1..1 Reference(US Quality Core Patient) (USCDI+ Quality) Plan beneficiary
... relationship S 1..1 CodeableConcept (USCDI+ Quality) Beneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible)
... period SΣ 0..1 Period (USCDI+ Quality) Coverage start and end dates
... payor SΣ 1..1 Reference(US Quality Core Patient | US Quality Core Organization | US Quality Core RelatedPerson) (USCDI+ Quality) Issuer of the policy
... Slices for class S 0..* BackboneElement (USCDI+ Quality) Additional coverage classifications
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): The policy classifications, eg. Group, Plan, Class, etc.
..... value Σ 1..1 string Value associated with the type
.... class:group S 0..1 BackboneElement (USCDI+ Quality) Group
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... type Σ 1..1 CodeableConcept Type of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: group
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... value SΣ 1..1 string (USCDI+ Quality) Group Identifier
..... name Σ 0..1 string (USCDI+ Quality) Human readable description of the type and value
.... class:plan S 0..1 BackboneElement (USCDI+ Quality) Plan
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... type Σ 1..1 CodeableConcept Type of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: plan
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... value SΣ 1..1 string (USCDI+ Quality) Plan Number
..... name SΣ 0..1 string (USCDI+ Quality) Plan Name

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Coverage.identifier:memberid.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
Coverage.identifier:memberid.​type Base extensible IdentifierType 📍4.0.1 FHIR Std.
Coverage.status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
Coverage.type Base extensible Payer Type . ⏿20250419 tx.fhir.org
Coverage.relationship Base extensible SubscriberPolicyholder Relationship Codes 📦4.0.1 FHIR Std.
Coverage.class.type Base extensible Coverage Class Codes 📍4.0.1 FHIR Std.
Coverage.class:group.​type Base extensible Coverage Class Codes 📍4.0.1 FHIR Std.
Coverage.class:plan.​type Base extensible Coverage Class Codes 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error Coverage If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Coverage If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error Coverage If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error Coverage If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Coverage A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
us-core-15 error Coverage Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present identifier.type.coding.where(system='http://terminology.hl7.org/CodeSystem/v2-0203' and code='MB').exists() or subscriberId.exists()

Differential View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Coverage 0..* USCoreCoverageProfile(9.0.0) Insurance or medical plan or a payment agreement
... identifier 0..* Identifier (USCDI+ Quality) Member ID and other identifiers
... Slices for identifier Content/Rules for all slices
.... identifier:memberid 0..1 Identifier (USCDI+ Quality) Member ID
..... type 1..1 CodeableConcept (USCDI+ Quality) Member Number identifier type
... status 1..1 code (USCDI+ Quality) active | cancelled | draft | entered-in-error
... policyHolder 0..1 Reference(US Quality Core Patient | US Quality Core Organization | US Quality Core RelatedPerson) Owner of the policy
... subscriberId 0..1 string (USCDI+ Quality) ID assigned to the subscriber
... beneficiary 1..1 Reference(US Quality Core Patient) (USCDI+ Quality) Plan beneficiary
... relationship 1..1 CodeableConcept (USCDI+ Quality) Beneficiary relationship to the subscriber
... period 0..1 Period (USCDI+ Quality) Coverage start and end dates
... payor 1..1 Reference(US Quality Core Patient | US Quality Core Organization | US Quality Core RelatedPerson) (USCDI+ Quality) Issuer of the policy
... class 0..* BackboneElement (USCDI+ Quality) Additional coverage classifications
... Slices for class Content/Rules for all slices
.... class:group 0..1 BackboneElement (USCDI+ Quality) Group
..... value 1..1 string (USCDI+ Quality) Group Identifier
..... name 0..1 string (USCDI+ Quality) Human readable description of the type and value
.... class:plan 0..1 BackboneElement (USCDI+ Quality) Plan
..... value 1..1 string (USCDI+ Quality) Plan Number
..... name 0..1 string (USCDI+ Quality) Plan Name

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
Coverage.type Base extensible Payer Type . ⏿20250419 tx.fhir.org

Snapshot ViewView

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Coverage C 0..* USCoreCoverageProfile(9.0.0) Insurance or medical plan or a payment agreement
Constraints: us-core-15
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... 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 (USCDI+ Quality) Member ID and other identifiers
Slice: Unordered, Open by value:type
.... identifier:memberid SΣC 0..1 Identifier (USCDI+ Quality) Member ID
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
..... type SΣ 1..1 CodeableConcept (USCDI+ Quality) 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 ?!SΣ 1..1 code (USCDI+ Quality) active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
... type SΣ 0..1 CodeableConcept (USCDI+ Quality) Coverage category such as medical or accident
Binding: Payer Type . (extensible): Categories of types of health care payor entities as defined by the US Public Health Data Consortium SOP code system
... policyHolder Σ 0..1 Reference(US Quality Core Patient | US Quality Core Organization | US Quality Core RelatedPerson) Owner of the policy
... subscriber Σ 0..1 Reference(Patient | RelatedPerson) Subscriber to the policy
... subscriberId SΣC 0..1 string (USCDI+ Quality) ID assigned to the subscriber
... beneficiary SΣ 1..1 Reference(US Quality Core Patient) (USCDI+ Quality) Plan beneficiary
... dependent Σ 0..1 string Dependent number
... relationship S 1..1 CodeableConcept (USCDI+ Quality) Beneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible)
... period SΣ 0..1 Period (USCDI+ Quality) Coverage start and end dates
... payor SΣ 1..1 Reference(US Quality Core Patient | US Quality Core Organization | US Quality Core RelatedPerson) (USCDI+ Quality) Issuer of the policy
... Slices for class S 0..* BackboneElement (USCDI+ Quality) Additional coverage classifications
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): The policy classifications, eg. Group, Plan, Class, etc.
..... value Σ 1..1 string Value associated with the type
..... name Σ 0..1 string Human readable description of the type and value
.... class:group S 0..1 BackboneElement (USCDI+ Quality) Group
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... type Σ 1..1 CodeableConcept Type of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: group
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... value SΣ 1..1 string (USCDI+ Quality) Group Identifier
..... name Σ 0..1 string (USCDI+ Quality) Human readable description of the type and value
.... class:plan S 0..1 BackboneElement (USCDI+ Quality) Plan
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... type Σ 1..1 CodeableConcept Type of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/coverage-class
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: plan
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... value SΣ 1..1 string (USCDI+ Quality) Plan Number
..... name SΣ 0..1 string (USCDI+ Quality) Plan Name
... order Σ 0..1 positiveInt Relative order of the coverage
... network Σ 0..1 string Insurer network
... costToBeneficiary 0..* BackboneElement Patient payments for services/products
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type Σ 0..1 CodeableConcept Cost category
Binding: CoverageCopayTypeCodes (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

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.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 . ⏿20250419 tx.fhir.org
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 extensible Coverage Copay Type Codes 📍4.0.1 FHIR Std.
Coverage.costToBeneficiary.​exception.type Base example Example Coverage Financial Exception Codes 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error Coverage If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Coverage If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error Coverage If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error Coverage If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Coverage A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
us-core-15 error Coverage Member Id in Coverage.identifier or Coverage.subscriberId SHALL be present identifier.type.coding.where(system='http://terminology.hl7.org/CodeSystem/v2-0203' and code='MB').exists() or subscriberId.exists()

 

Other representations of profile: CSV, Excel, Schematron

Notes:

Element Conformance Indicators by Profile Layer

Badges identify the profile layer where each conformance indicator is first introduced. Indicators introduced in an earlier layer remain applicable in later derived profiles.

Element conformance indicators organized by the profile layer where they are first introduced
Profile element FHIR US Core US Quality Core
identifier Must Support USCDI+ Quality
identifier:memberid Must Support USCDI+ Quality
identifier:memberid.type Mandatory Must Support USCDI+ Quality
status Mandatory Must Support USCDI+ Quality
type Must Support USCDI+ Quality
subscriberId Must Support USCDI+ Quality
beneficiary Mandatory Must Support USCDI+ Quality
relationship Mandatory Must Support USCDI+ Quality
period Must Support USCDI+ Quality
payor Mandatory Must Support USCDI+ Quality
class Must Support USCDI+ Quality
class.type Mandatory
class.value Mandatory
class:group Must Support USCDI+ Quality
class:group.type Mandatory
class:group.value Mandatory Must Support USCDI+ Quality
class:group.name USCDI+ Quality
class:plan Must Support USCDI+ Quality
class:plan.type Mandatory
class:plan.value Mandatory Must Support USCDI+ Quality
class:plan.name Must Support USCDI+ Quality
costToBeneficiary.value[x] Mandatory
costToBeneficiary.exception.type Mandatory

Cardinality note: “Mandatory” means the element has a minimum cardinality greater than zero. For nested elements, the cardinality indicator applies when the containing element is present.

Mandatory US Quality Core Server Search Parameters

The searches below are the focused set identified by US Quality Core as needed to retrieve USCDI+ Quality data for quality measurement and reporting. See the US Core FHIR RESTful Search API Requirements for detailed information on requirements by search parameter type.

Because this profile derives directly or indirectly from US Core, servers SHALL also support all mandatory searches described in the US Core Server CapabilityStatement requirements for Coverage. When possible, this guide reuses mandatory searches from US Core and notes them with the EXISTING US CORE REQUIREMENT flag. While US Quality Core may restate US Core requirements to highlight searches directly relevant to USCDI+ Quality data access, US Core requirements not restated here remain applicable.

See the US Quality Core Server CapabilityStatement for complete requirements for the underlying Coverage resource and Search Requirement Selection for how this focused set was selected.

Servers supporting this profile SHALL support the following search parameters and search parameter combinations:

  1. SHALL support searching for all Coverage resources for a patient using the patient search parameter. EXISTING US CORE REQUIREMENT

    GET [base]/Coverage?patient={Patient/}[id]

    Example:

    GET [base]/Coverage?patient=Patient/example

    Implementation Notes: Fetches a bundle of US Quality Core Coverage resources matching the specified search criteria. See how to search by reference.

    Rationale for inclusion: Supports patient-scoped retrieval of Coverage resources for USCDI+ Quality workflows.