DHIN 2025Connectathon FHIR IG
            
            0.1.0 - draft
            
          
DHIN 2025Connectathon FHIR IG, published by DHIN. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/Nigeria-FHIR-Community/2025Connectathon/ and changes regularly. See the Directory of published versions
| Official URL: https://sandbox.dhin-hie.org/ig/StructureDefinition/ng-claim-coverage | Version: 0.1.0 | |||
| Draft as of 2025-10-21 | Computable Name: NgCoverage | |||
A profile capturing a patient's insurance coverage details.
Usages:
You can also check for usages in the FHIR IG Statistics
Description of Profiles, Differentials, Snapshots and how the different presentations work.
| Name | Flags | Card. | Type | Description & Constraints    Filter:   | 
|---|---|---|---|---|
|   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 | 
|    status | ?!SΣ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. | 
|    type | SΣ | 1..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. | 
|    subscriber | SΣ | 0..1 | Reference(Patient | RelatedPerson) | Subscriber to the policy | 
|    beneficiary | SΣ | 1..1 | Reference(Patient) | Plan beneficiary | 
|    payor | SΣ | 1..1 | Reference(Organization | Patient | RelatedPerson) | Issuer of the policy | 
|  Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source | 
| Coverage.status | Base | required | Financial Resource Status Codes | 📍4.0.1 | FHIR Std. | 
| Coverage.type | Base | preferred | Coverage Type and Self-Pay Codes | 📍4.0.1 | FHIR Std. | 
| 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() | 
This structure is derived from Coverage
| Name | Flags | Card. | Type | Description & Constraints    Filter:   | 
|---|---|---|---|---|
|   Coverage | 0..* | Coverage | Insurance or medical plan or a payment agreement | |
|    status | S | 1..1 | code | active | cancelled | draft | entered-in-error | 
|    type | S | 1..1 | CodeableConcept | Coverage category such as medical or accident | 
|    subscriber | S | 0..1 | Reference(Patient | RelatedPerson) | Subscriber to the policy | 
|    beneficiary | S | 1..1 | Reference(Patient) | Plan beneficiary | 
|    payor | S | 1..1 | Reference(Organization | Patient | RelatedPerson) | Issuer of the policy | 
|  Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints    Filter:   | ||||
|---|---|---|---|---|---|---|---|---|
|   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 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 | ||||
|    identifier | Σ | 0..* | Identifier | Business Identifier for the coverage | ||||
|    status | ?!SΣ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. | ||||
|    type | SΣ | 1..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 | SΣ | 0..1 | Reference(Patient | RelatedPerson) | Subscriber to the policy | ||||
|    subscriberId | Σ | 0..1 | string | ID assigned to the subscriber | ||||
|    beneficiary | SΣ | 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..1 | Reference(Organization | Patient | RelatedPerson) | Issuer of the policy | ||||
|    class | 0..* | BackboneElement | Additional coverage classifications | |||||
|     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 | ||||
|    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 | Status | Usage | ValueSet | Version | Source | 
| Coverage.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std. | 
| Coverage.status | Base | required | Financial Resource Status Codes | 📍4.0.1 | FHIR Std. | 
| Coverage.type | Base | preferred | Coverage Type and Self-Pay Codes | 📍4.0.1 | FHIR Std. | 
| Coverage.relationship | Base | extensible | SubscriberPolicyholder Relationship Codes | 📍4.0.1 | FHIR Std. | 
| Coverage.class.type | Base | extensible | Coverage Class Codes | 📍4.0.1 | FHIR Std. | 
| Coverage.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. | 
| 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() | 
This structure is derived from Coverage
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints    Filter:   | 
|---|---|---|---|---|
|   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 | 
|    status | ?!SΣ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. | 
|    type | SΣ | 1..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. | 
|    subscriber | SΣ | 0..1 | Reference(Patient | RelatedPerson) | Subscriber to the policy | 
|    beneficiary | SΣ | 1..1 | Reference(Patient) | Plan beneficiary | 
|    payor | SΣ | 1..1 | Reference(Organization | Patient | RelatedPerson) | Issuer of the policy | 
|  Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source | 
| Coverage.status | Base | required | Financial Resource Status Codes | 📍4.0.1 | FHIR Std. | 
| Coverage.type | Base | preferred | Coverage Type and Self-Pay Codes | 📍4.0.1 | FHIR Std. | 
| 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() | 
Differential View
This structure is derived from Coverage
| Name | Flags | Card. | Type | Description & Constraints    Filter:   | 
|---|---|---|---|---|
|   Coverage | 0..* | Coverage | Insurance or medical plan or a payment agreement | |
|    status | S | 1..1 | code | active | cancelled | draft | entered-in-error | 
|    type | S | 1..1 | CodeableConcept | Coverage category such as medical or accident | 
|    subscriber | S | 0..1 | Reference(Patient | RelatedPerson) | Subscriber to the policy | 
|    beneficiary | S | 1..1 | Reference(Patient) | Plan beneficiary | 
|    payor | S | 1..1 | Reference(Organization | Patient | RelatedPerson) | Issuer of the policy | 
|  Documentation for this format | ||||
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints    Filter:   | ||||
|---|---|---|---|---|---|---|---|---|
|   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 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 | ||||
|    identifier | Σ | 0..* | Identifier | Business Identifier for the coverage | ||||
|    status | ?!SΣ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. | ||||
|    type | SΣ | 1..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 | SΣ | 0..1 | Reference(Patient | RelatedPerson) | Subscriber to the policy | ||||
|    subscriberId | Σ | 0..1 | string | ID assigned to the subscriber | ||||
|    beneficiary | SΣ | 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..1 | Reference(Organization | Patient | RelatedPerson) | Issuer of the policy | ||||
|    class | 0..* | BackboneElement | Additional coverage classifications | |||||
|     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 | ||||
|    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 | Status | Usage | ValueSet | Version | Source | 
| Coverage.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std. | 
| Coverage.status | Base | required | Financial Resource Status Codes | 📍4.0.1 | FHIR Std. | 
| Coverage.type | Base | preferred | Coverage Type and Self-Pay Codes | 📍4.0.1 | FHIR Std. | 
| Coverage.relationship | Base | extensible | SubscriberPolicyholder Relationship Codes | 📍4.0.1 | FHIR Std. | 
| Coverage.class.type | Base | extensible | Coverage Class Codes | 📍4.0.1 | FHIR Std. | 
| Coverage.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. | 
| 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() | 
This structure is derived from Coverage
Other representations of profile: CSV, Excel, Schematron